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Transhepatic Puncture of Portal and Hepatic Veins for TIPS Using a Single-Needle Pass Under Sonographic Guidance

Syed A. Raza1,2, Eric Walser3, Alberto Hernandez2, Keven Chen2 and Santiago Marroquin2

1 Department of Radiology, Memorial Herman Hospital, 902 Frostwood, Ste. 275, Houston, TX 77024.
2 University of Texas Medical Branch, Galveston, TX.
3 Mayo Clinic, Jacksonville, FL.


Figure 1
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  		Fig. 1A —49-year-old man with cirrhosis, portal hypertension, and esophageal variceal bleeding on maximum medical management. Initial sonogram showing proposed alignment of right portal vein (RPV) near its bifurcation from main portal vein (MPV) with right hepatic vein (RHV) near its junction with inferior vena cava (IVC).

 

Figure 2
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  		Fig. 1B —49-year-old man with cirrhosis, portal hypertension, and esophageal variceal bleeding on maximum medical management. Needle is passed under sonographic guidance along same plane as initial image along imaginary line between RPV and RHV. Once needle tip punctures RPV, aspiration of blood is recommended for confirmation of IV placement.

 

Figure 3
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  		Fig. 1C —49-year-old man with cirrhosis, portal hypertension, and esophageal variceal bleeding on maximum medical management. Continued advancement of needle under sonographic guidance into RHV. Again, aspiration of blood is recommended to confirm placement.

 

Figure 4
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  		Fig. 1D —49-year-old man with cirrhosis, portal hypertension, and esophageal variceal bleeding on maximum medical management. Continued advancement of needle under sonographic guidance into RHV. Again, aspiration of blood is recommended to confirm placement.

 

Figure 5
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  		Fig. 2A —Fluoroscopic images of same patient as in Figures 1A, 1B, 1C, and 1D. Exchange length guidewire was maneuvered into inferior vena cava (IVC).

 

Figure 6
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  		Fig. 2B —Fluoroscopic images of same patient as in Figures 1A, 1B, 1C, and 1D. Transhepatic guidewire was snared through 6-French transjugular sheath placed in IVC, thus creating transhepatic-transjugular guidewire.

 

Figure 7
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  		Fig. 2C —Fluoroscopic images of same patient as in Figures 1A, 1B, 1C, and 1D. Portovenous tract was dilated with 6-8 mm x 20 mm angioplasty balloon catheter placed over transhepatic-transjugular guidewire, and 6-French sheath was advanced into portal system.

 

Figure 8
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  		Fig. 2D —Fluoroscopic images of same patient as in Figures 1A, 1B, 1C, and 1D. Exchange length hydrophilic guidewire was maneuvered alongside first wire through transjugular sheath into superior mesenteric vein. Transhepatic-transjugular guidewire was then removed.

 

Figure 9
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  		Fig. 2E — Fluoroscopic images of same patient as in Figures 1A, 1B, 1C, and 1D. Procedure continued from transjugular approach with deployment of metal stent across tract between hepatic and portal vein.

 

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