The risks, benefits and alternatives were discussed and informed consent was obtained. Prior to beginning the procedure, Universal Protocol was performed to confirm the patient's identity and the planned procedure. The fluoroscopy time has been recorded in the electronic medical record. Maximum sterile barriers including cap, mask, hand hygiene, sterile gloves, sterile gown, large sterile drape and 2% chlorhexidine for cutaneous antisepsis were used.
The skin over the right internal jugular access site was infiltrated with 2% plain lidocaine. The vein was accessed using real-time ultrasound guidance. A wire was advanced centrally followed byplacement of a 10 french vascular sheath.
Using fluoroscopic guidance, a MPA catheter was advanced into the right hepatic vein. Over an Amplatz wire the catheter was exchanged for a balloon occlusion catheter. Wedged hepatic venography was done in two projections using carbon dioxide in order to identify the location of the main portal vein branches.
The catheter was exchanged for a Colapinto needle. Passes were made across the liver parenchyma until the right portal vein was entered. A guidewire followed by a catheter was advanced into the portal vein which was confirmed by contrast injection. A marking pigtail catheterwas then advanced into the portal vein. Simultaneous portal and hepatic venography was done to measure the length of the transhepatic tract. Pre-TIPS pressures were measured in the portal vein and right atrium.
The catheter was exchanged over an extra-stiff guidewire for an 8 mm balloon which was used to pre-dilate the parenchymal tract. The long sheath was advanced into the portal vein and through this a 7 x 5 x 2 cm fluency stent was advanced and deployed.
The stent graft was dilated using a 10 mm balloon. The pigtail catheter was re-advanced into the portal vein for post-TIPS venography and pressure measurements. The catheters were removed and hemostasis was achieved at the access site by manual compression
Pre-TIPS portosystemic gradient: 25 mmHg
Post-TIPS portosystemic gradient: 10 mmHg
- DSA (angiography) (TIPS):