A total of 10 TIPS placements supervised by a single interventionalist attending operator were performed from 2007-2012.
Three cases utilized cWHV to target the portal vein,
6 cases utilized hepatic artery guidewire (HAG) technique,
and one utilized both methods.
In cases with HAG (Fig.
2 & 3),
a 5 Fr vascular sheath was placed with a micropuncture kit in the right common femoral artery and celiac +/- mesenteric angiography with delayed portography phase was performed to visualize the portal venous system. The common hepatic artery was then selected by a 4 or 5 Fr catheter,
and a 0.018-inch microguidewire was advanced into the hepatic arterial branch accompanying the portal vein target.
In cases with only cWHV,
no femoral artery puncture was made.
A 5 Fr catheter was advanced from the right transjugular approach and directly wedged against a central portion of the right hepatic vein,
with subsequent injection of carbon dioxide contrast to demonstrate portal venous anatomy for use as a roadmap (Fig.
4).
Once the targeting system was in place for either the HAG or cWHV method,
a Colapinto needle and vascular sheath was advanced from the right hepatic vein towards the central right portal vein,
with either the HAG or cWHV roadmap as the targeting guide.
Successful portal vein cannulation was determined by aspiration of venous blood and contrast injection via the needle that successfully opacified the portal venous system.
Case no. |
Age/Gender |
TIPS indication |
HAG used? |
cWHV used? |
TIPS created? |
Complications |
1 |
64/F |
Refractory variceal bleeding |
No |
Yes |
Yes |
None |
2 |
51/M |
Prevention of variceal bleeding |
Yes |
No |
Yes |
None |
3 |
49/M |
Refractory variceal bleeding |
Yes |
No |
No |
None |
4 |
46/F |
Refractory variceal bleeding |
Yes |
Yes |
Yes |
None |
5 |
65/F |
Refractory variceal bleeding |
No |
Yes |
Yes |
None |
6 |
50/M |
Refractory massive variceal bleeding |
No |
Yes |
Yes |
Nontarget right hepatic artery puncture requiring embolization |
7 |
43/M |
Refractory variceal bleeding |
Yes |
No |
Yes |
None |
8 |
65/M |
Refractory ascites and prevention of variceal bleeding |
Yes |
No |
Yes |
None |
9 |
46/M |
Prevention of variceal bleeding |
Yes |
No |
Yes |
None |
10 |
61/M |
Refractory ascites |
Yes |
No |
Yes |
None |
TIPS creation in 10 patients with complications from cirrhosis-related portal hypertension (notable cases in bold lettering).
The number of passes for portal vein puncture was not documented for any of the cases.
There were no portal vein puncture-related complications in any of the 7 cases utilizing HAG technique.
With respect to the HAG placement,
there were also no complications related to femoral artery puncture or evidence of hepatic artery thrombus formation. However,
in one of the cases utilizing the HAG technique, unusual hepatic venous anatomy precluded successful anterior deployment of the Colapinto needle.
In the 3 cases with cWHV alone,
TIPS was created successfully in all the cases,
with one complication. This complication resulted in symptomatic nontarget puncture of a right hepatic arterial branch,
with postprocedural bleeding (Fig.
5) that required hepatic arterial embolization the next day (Fig.
6).
In the case that utilized both cWHV and HAG,
the HAG was shown to compensate for respiratory motion better than the roadmap,
as depicted by images acquired in inspiration and expiration (Fig.
7).
TIPS was created successfully in this case,
using the HAG as the primary target.