DOI:10.2214/AJR.05.1342
AJR 2006; 187:W87-W91
© American Roentgen Ray Society
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.
Received August 2, 2005;
accepted after revision October 21, 2005.
Address correspondence to S. A. Raza
(asadraza{at}sbcglobal.net).
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Abstract
OBJECTIVE. Creating transjugular intrahepatic portosystemic shunts
(TIPS) requires accessing a portal vein branch from a metal cannula wedged in
a hepatic vein. This initial step in shunt creation often requires multiple
blind intrahepatic punctures and occasionally fails. We describe a method
using sonographic guidance to serially puncture the portal vein and hepatic
vein with a single transhepatic needle pass, after which the TIPS procedure is
completed in the standard transjugular fashion.
CONCLUSION. Sonographically guided transhepatic dual puncture of the
portal and hepatic veins facilitates portosystemic shunt creation in a single
needle pass and allows more controlled selection of the portal vein entry and
hepatic vein landing sites in selected patients.
Keywords: conventional angiography • interventional radiology • liver disease • vascular stents
Introduction
The most commonly practiced technique of transjugular intrahepatic
portosystemic shunt (TIPS) involves a transjugular approach to access one of
the hepatic veins under fluoroscopic guidance. Hepatic venography is performed
to exclude hepatic vein stenosis and localize the junction of the hepatic
veins with the inferior vena cava (IVC). Wedged and free hepatic venous
pressures are recorded to measure the portosystemic gradient.
Mean right atrial pressure is also measured (normal, < 8 mm Hg) to
safeguard against any chance of acute congestive heart failure secondary to
increased blood flow through the TIPS. Subsequently, portal vein localization
is performed with wedged hepatic venography using carbon dioxide or an
iodinated contrast medium, and intrahepatic puncture of the portal vein is
attempted using a long needle through a metal cannula. Despite localizing the
portal vein using the techniques just mentioned, accessing the portal vein
under fluoroscopic guidance is considered to be the most difficult step in the
creation of TIPS. This article describes a technique that involves sonographic
guidance for percutaneous access into the portal and hepatic venous systems.
Once portosystemic access is obtained, the remainder of the procedure is
completed as a transjugular TIPS using the jugular approach.
Materials and Methods
Fifteen patients (4 women and 11 men), age range 41-76 years (mean age, 55
years), with cirrhosis and complications of portal hypertension, recurrent
upper gastrointestinal variceal hemorrhage, unresponsiveness to endoscopic
therapy (n = 9), and refractory ascites (n = 6) were
referred to the interventional radiology department from June 2004 to June
2005 for the TIPS procedure.
An initial screening sonogram was performed to evaluate the anatomy and
patency of the portal and hepatic veins. If a suitable window is available in
which the right portal vein (RPV) and the hepatic veins (right or middle) can
be aligned along a straight imaginary line within the liver parenchyma, the
patient is considered suitable for transhepatic portal venous puncture for
TIPS under sonographic guidance.
After written informed consent, the patients were placed in a supine
position on the fluoroscopy table. With sonographic guidance, the skin was
marked where the RPV and right hepatic vein (RHV) were aligned in one plane
with the portal vein closer to the sonography probe
(Fig. 1A). If any ascites was
present, it was drained before hepatic puncture using a 7-French multipurpose
drainage catheter under sonographic guidance. The patient's neck and abdomen
were prepared for a combined transjugular and transhepatic approach. Using
sonographic guidance, the RPV was punctured with an 18-gauge, 20-cm Chiba
needle (Cook), with the patient quietly breathing under conscious sedation, at
an angle of approximately 60-75° with the anterior abdominal wall just
distal (approximately 2-4 cm) to the bifurcation of the main portal vein
(MPV). Intraportal entry was confirmed with the aspiration of blood
(Fig. 1B). Under continuous
sonographic guidance, the needle was advanced into the RHV close to its
junction with the IVC as would be expected in a conventional TIPS procedure
(Figs. 1C and
1D). Position of the needle
into the hepatic vein was again confirmed by the aspiration of blood. An
Amplatz stiff 0.035-inch exchange guidewire (Cook) was passed through the
hepatic vein and IVC into the right atrium
(Fig. 2A). Then the right
internal jugular vein was accessed using a 21-gauge needle and a 0.018-inch
guidewire under sonographic guidance, and a 55-cm sheath (6-French Flexor
Check-Flo, Cook) was placed in the right atrium. The transhepatic wire was
snared using a 35-mm diameter Amplatz Gooseneck Snare (ev3 Inc.) providing
through-and-through access (Fig.
2B). The transhepatic needle was exchanged with a 4-French
catheter at this point, and the sheath was advanced to the hepatic vein over
the transhepatic-transjugular wire until resistance was met. A 6 x 20 mm
or 8 x 20 mm angioplasty balloon catheter was advanced over the wire,
and the tract between the hepatic and portal veins was dilated
(Fig. 2C). The sheath was
advanced into the dilated tract, and a small amount of contrast material was
injected through the sheath to see the outline of the portal vein. A
0.035-inch, 260-cm-long Glide-wire with stiff shaft (Boston Scientific) was
then introduced through the transjugular sheath and manipulated into the MPV
and then into the superior mesenteric vein (SMV). The
transhepatic-transjugular wire was removed at this stage, and a 6-French
sheath was replaced with a 10-French sheath. The procedure was completed as
conventional TIPS with deployment of a metal stent (15 stents in 11 patients,
Wallstent, Boston Scientific; 14 stents, Luminexx, Bard) across the tract
between the hepatic and portal veins (Figs.
2D and
2E). No immediate complications
were encountered.
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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).
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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.
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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.
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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.
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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.
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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.
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Results
Eleven of 15 patients had suitable hepatic venous anatomy for
sonography-guided puncture of the portal and hepatic veins. Of the four
patients who were unsuitable for this procedure, three had severely distorted
venous anatomy because of advanced cirrhosis, and one had a high hepatic
flexure and transverse colon (Chilaiditi syndrome), which precluded
sonographic guidance to access the portal and hepatic veins. These four
patients then underwent a successful conventional TIPS procedure.
A single-needle pass was used in all cases, and the site of percutaneous
needle entry in all patients was intercostal (except one that was subcostal),
located between the midclavicular and anterior axillary line on the right
side.
We embolized the needle tract empirically at the end of the procedure with
coils in the first three patients (no tract embolization in the last eight
patients); none of the patients showed any clinical evidence of hemorrhage
from the puncture site, however (stable vital signs during postprocedure
monitoring by nursing staff).
The procedure was technically successful in all patients. All patients
showed patent TIPS at 24 hours on color Doppler scanning. The percutaneous
approach under sonographic guidance for creating portosystemic shunt is a safe
and effective step in the creation of TIPS.
Discussion
One of the earliest series of six patients who had the TIPS procedure was
described by Colapinto et al.
[1] in 1983 in which an
intrahepatic portosystemic shunt was created in each case by inflating the
balloon of a Grüntzig dilatation catheter in a needle tract between the
portal and hepatic veins. Colapinto and colleagues did not use metal stents at
the time to cover the tract between the hepatic and portal veins.
The first major study with the use of metal stents (Wallstent, Boston
Scientific) for TIPS in 100 patients was published by LaBerge et al.
[2] in 1993. TIPS has come a
long way in the last two decades and has now gained universal acceptance in
the management of portal hypertension. The basic technique of performing a
TIPS procedure, however, has remained the same except for minor modifications.
The inherent weakness of the TIPS remains the so-called blind puncture of the
portal veins after hepatic venous access is achieved. To minimize the number
of needle passes required to enter the intrahepatic portal venous system,
investigators have devised a variety of techniques to visualize the portal
venous anatomy, including direct transhepatic catheterization of the portal
vein, superior mesenteric artery (SMA) angiography, real-time sonographic
guidance, placement of a metallic marker, and refluxing contrast medium into
the portal vein with wedged hepatic venography
[3,
4]. Although these techniques
help improve the guesswork of puncturing the portal veins, they are associated
with known complications [5].
The metal cannula used to assist the puncture of the portal vein is quite
uncomfortable for patients when it is placed across the IVC and hepatic venous
junction. In addition, the rigidity of the metal cannula makes it prone to
falling out of the hepatic vein during the rotational maneuvering to point
toward the expected location of the portal vein. The femoral venous approach
has also been described but does not offer any significant difference in
technique except the access site in cases of the occluded jugular approach
[6]. Direct visualization with
intravascular sonography has been described in assisting the puncture of the
portal veins in swine models
[7] and creating a direct
portacaval shunt in patients with inaccessible hepatic venous anatomy
[8]. Petersen
[9] in 2003 described a
technique of creating a portacaval shunt in 31 patients that appears to be
promising; however, it requires intravascular sonographic guidance, the
expertise or equipment for which may not be readily available in many
radiology departments.
This article describes a new approach to creating the portosystemic access
with a single-needle pass. Transhepatic puncture and direct visualization
offer significant improvement by eliminating blind puncture of the portal
vein. A sonographic examination of the liver is necessary, either at the start
of the procedure or on a prior visit, to assess for patency and relationship
of the portal and hepatic venous anatomy. If a suitable window is available in
which RPV and hepatic veins (right or middle) can be aligned along a straight
imaginary line within the liver parenchyma (proposed pathway of the needle),
with the portal vein anterior (closer to the sonography probe), the patient is
considered suitable for transhepatic puncture. Although not every patient
would be a candidate, the majority of patients in our series (11 of 15) were
found to have the suitable anatomy.
Eliminating multiple blind punctures to access the portal vein and
real-time sonographic guidance avoids inadvertent puncture of the extrahepatic
portal vein and unnecessary trauma to the liver. The Colapinto needle and
metal cannula were not required in this technique, which reduced discomfort to
patients associated with these devices.
The transhepatic puncture of the portal and hepatic veins for TIPS is an
exciting new approach, although it is more likely to benefit patients in whom
the hepatic venous anatomy is not severely distorted because of advanced
cirrhosis. More recent literature is challenging the concept of only using
TIPS as a rescue treatment in patients with failed sclerotherapy and at the
same time advocating the efficacy of TIPS in the treatment of intractable
ascites and hepatorenal syndrome
[10-13].
This new thinking about not using TIPS as the last option but at an earlier
stage of disease [10] could
bring patients with relatively less deranged liver architecture and function
who would be good candidates for this modified new approach toward TIPS.
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Abstract
Introduction
