Transjugular Intrahepatic Portosystemic Shunt

Date of procedure:

[ ]

Indication:

Refractory Ascites and/or Recurrent Variceal Bleeding

Operators:

Sarel Gaur MD

Medications:

Versed IV:  [ ] ml total

Fentanyl IV:  [ ] ml total

Contrast:

[ ] ml of Omnipaque intravenous

Fluoro time:

[ ] minutes

Access site(s):

[ ]

Device(s):

Gore Tips Viatorr Endoprosthesis

Complications:

None

Technique and Findings:

1. [Risks, benefits, and alternatives to creation of a portosystemic shunt were discussed with the patient and informed written consent was obtained.

2. The patient was brought to fluoroscopy and given general inhalational anesthesia, then placed on the fluoroscopy table supine.

3. Vital signs were monitored continuously by anesthesia workers for 3 hr.

4. The right abdomen was widely prepped with 2 percent chlorhexidine solution, as well as the right neck.  These areas were draped in sterile fashion.

5. Attention was turned first toward access of the portal venous system.

6. Skin entry site at the 10th rib interspace was selected and 1 percent lidocaine was given subcutaneously. 

7. A 21 gauge needle was advanced centrally into the liver under ultrasound guidance.

8. The needle was retracted as contrast was injected.

9. Access to a peripheral right portal vein branch was obtained. 

10. Micro wire traveled into the main portal vein. 

11. Needle was exchanged for a Greb sheath.

12. Portal venogram was obtained.

13. Portal venous pressure was measured. 

14. Attention was now turned toward hepatic vein access.  

15. One percent lidocaine was given at the right neck and right internal jugular vein access was obtained using micropuncture technique under ultrasound guidance.

16. An Amplatz wire was advanced through the micropuncture sheath, then into the inferior vena cava. 

17. The micropuncture sheath was exchanged a 10 French dilator, followed by an 10 French vascular sheath.

18. The sheath was placed in the right atrium and right atrial pressure was measured. Amplatz wire was exchanged for a multipurpose angled catheter and glidewire, which were manipulated into the right hepatic vein.

19. A venogram was obtained through the multipurpose angled catheter.

20. Road map image of the portal veins was created through the portal catheter.

21. Attention was then turned towards intrahepatic portal vein access.  

22. An Amplatz wire was placed through the hepatic vein catheter, and sheath was advanced into the right hepatic vein.

23. Angled catheter was exchanged for a Colapinto needle.

24. Using then road map images, first attempt at accessing the right portal vein to the right hepatic vein was unsuccessful.

25. On the second attempt, access to the right portal vein was gained.

26. Roadrunner was placed through the Colapinto needle and traveled centrally, and into the main portal vein.

27. Glidewire was exchanged for the Lunderquist wire.

28. Attention was now turned toward completion of the shunt.  

29. Colapinto sheath was exchanged for a 8 millimeter x 40 mm Conquest balloon, which initially dilated the parenchymal tract.

30. A 10 millimeter x 40 mm Conquest balloon was then used to further dilate the tract, and the 10 French sheath was advanced over the balloon, then into the main portal vein.

31. A marker pigtail catheter was advanced over the wire through the sheath, and a venogram was obtained.

32. Based on markers, a 2 cm (uncovered) / 8 cm (covered) Viatorr stent was selected.

33. The marker pigtail catheter was exchanged for the Viatorr stent over the Lunderquist wire.

34. The bare portion of the stent was deployed, and the system was brought back until it engaged the parenchymal tract.

35. The 10 French sheath was retracted, and the covered portion of the stent was deployed. The stent was expanded to its final shape using the 10 mm balloon.

36. The sheath was advanced over the balloon, and into the main portal vein.

37. Balloon was removed, contrast run of the shunt was obtained.

38. Portal venous pressure was measured.

39. Sheath was retracted into the right atrium and right atrial pressure was measured.

40. Both venous sheaths were removed and hemostasis was obtained using manual compression.

41. Sterile dressings were applied.

42. The patient was awakened and extubated by anesthesia workers, who brought him back to the postanesthesia care unit having tolerated this procedure well.

Impression:

Technically Successful TIPS creation.

[Venous pressures as follows:

Pre TIPS:  portal vein mmHg, right atrium mmHg.

Post TIPS:  portal vein mmHg, right atrium mmHg.

Plan or Recommendations:

No specific recommendations.

TJ Liver BX (Work in proress)

Clinical History
Alcoholic cirrhosisFor
transjugular liver biopsy with pressures.

Technique
TRANSJUGULAR LIVER BIOPSY

PROCEDURE:

The procedure, possible complications and use of moderate sedation
were explained to the patient in detail and informed consent was
obtained. The patient was brought to the fluoroscopic suite and
placed in the supine position on the fluoroscopic table. Nurse
monitoring was performed throughout the entire procedure. 1%
lidocaine was used for local anesthesia, and moderate sedation was
administered. The patient's right neck was prepped and draped in the
usual sterile fashion. Ultrasound was used to image the right neck,
and a permanent image was stored in the patient record. Using dynamic
ultrasound imaging guidance,the right internal jugular vein was
accessed using standard micropuncture technique. A Bentson wire was
advanced into the inferior vena cava under fluoroscopic guidance. A 5
French angled multipurpose catheter was then advanced over the wire
and used to select the middle hepatic vein under fluoroscopic
guidance, and a small amount of contrast was injected to confirm
position. Free and wedged hepatic venous pressures were recorded and
documented. An Amplatz wire was advanced through the catheter, which
was then removed. A 9 French long angled Ansel sheath was advanced
over the wire, but access was temporarily lost and then
re-established in the right hepatic vein. The Ansel sheath was
positioned centrally within the right hepatic vein. A curved metal
cannula was advanced through the sheath and positioned within the
right hepatic vein just beyond the tip of the sheath. A 19 gauge
Argon TLAB biopsy needle was then advanced through the cannula, and 3
core biopsies were obtained in the usual fashion, directed
anteriorly. Specimens were submitted to pathology in formalin. The
sheath and cannula were removed, and hemostasis was achieved with
manual pressure at the neck. The access site was covered with a dry
sterile dressing,thus terminating the procedure. The patient
tolerated the procedure without immediate complication and was
transferred back to the floor in stable condition. 

Fluoro Time: 7.4 Minutes
Contrast: 10 cc Omni 240
Medications: Versed 2 mg, fentanyl 100 mcg

FINDINGS:

Initial ultrasound demonstrates a widely patent and compressible
right internal jugular vein. The right hepatic vein was successfully
selected under fluoroscopic guidance, and three 18-gauge core
biopsies were obtained in the usual fashion. Pressure transduction in
the hepatic vein resulted in wedge pressure of 23-25 mm Hg and free
hepatic vein pressure of 6-8 mm Hg, corresponding to a portosystemic
gradient of approximately 17 mm Hg. 

Impression
1. Successful transjugular liver biopsy x 3 passes.
2. Portosystemic gradient 17 mm Hg.