Transjugular intrahepatic portosystemic shunt (TIPS) - "gun-sight" technique
50 year old woman with refractory ascites due to cirrhosis.
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- General anesthetic
- Left portal vein branch punctured under ultrasound guidance and a 6 Fr sheath inserted
- Wire and catheter access into the right portal vein
- Right internal jugular vein puncture under ultrasound guidance and a 10 Fr sheath inserted
- Wire and catheter access into the middle hepatic vein
- Portal vein to right atrium pressure gradient measured
- In-house 0.018 wire snares were opened in the hepatic venous and portal venous sites and the fluoroscopy machine rotated to bring them into alignment
- Percutaneous puncture performed through both snares under fluoroscopic guidance
- A wire was passed through the needle, snared, and pulled through on both ends to establish through-and-through access across the hepatic parenchymal tract
- The parenchymal tract was then dilated with a 6 mm balloon and the 10 Fr jugular sheath advanced into the portal venous side
- A pigtail catheter was used to measure the length followed by deployment of an 8 cm TIPS stent
- The portal vein to right atrium pressure was again measured and had decreased
- Coil embolization of the left portal venous puncture site
Transjugular intrahepatic portosystemic shunt (TIPS) placement is a complex procedure performed by interventional radiologists. First performed in 19881, the procedure is known to be potentially difficult and time-consuming, particularly the step where hepatic vein to portal vein access is established. First described in 1996, the "gun-sight" technique involves positioning snares in the portal vein and hepatic vein (or IVC)2. The snares are then aligned in the same plane and punctured percutaneously. A wire is inserted and pulled through from the hepatic / IVC and portal venous sides. The remainder of the TIPS procedure can then be performed with usual techniques. "Gun-sight" TIPS was first described as a salvage technique where other techniques have failed or are difficult for anatomical reasons3, but has gained some popularity as a primary technique in certain settings.
- 1. Richter G M, Noeldge G, Palmaz J C, Roessle M. The transjugular intrahepatic portosystemic stent-shunt (TIPSS): results of a pilot study. Cardiovasc Intervent Radiol. 1990;13:200–207.
- 2. Haskal Z J, Duszak R, Jr ,Furth E E. Transjugular intrahepatic transcaval portosystemic shunt: the gun-sight approach. J Vasc Interv Radiol. 1996;7:139–142.
- 3. Hector Ferral, Jose Ignacio Bilbao. The Difficult Transjugular Intrahepatic Portosystemic Shunt: Alternative Techniques and “Tips” to Successful Shunt Creation. (2005) Seminars in Interventional Radiology. 22 (04): 300.