Figure 2: A 51-year-old man with alcoholic liver cirrhosis who underwent one standard TIPS and two parallel transcaval TIPS.After transcaval portal vein puncture, contrast material injection through a side-arm adapter of a sheath, with simultaneous retraction of the sheath over the wire, demonstrates slight spillage of contrast material (arrow).

Mentions: Direct cavoportal puncture from the intrahepatic segment of the inferior vena cava to the portal vein using a Colapinto transjugular portal venous access needle was attempted. Using the previous TIPS stent as a target, the needle was advanced through the hepatic parenchyma into the portal vein under fluoroscopic guidance. After puncturing the vein, a guidewire was advanced through the needle and manipulated along it and into the splenic vein. The Colapinto needle was then withdrawn and a 5-F multipurpose catheter was passed over the guidewire without dilatation of the parenchymal tract; venography from that position demonstrated large cardiac varices and occlusion of the previous TIPS (Fig. 1). Pressure measurements were obtained, and the portosystemic gradient thus determined. The guidewire was replaced with an Amplatz extra-stiff wire (Cook Inc., Bloomington, U.S.A.), the 9-F sheath with its 9-F dilator was advanced into the portal vein, and the dilator was withdrawn. The sheath was then retracted over the wire from the portal vein to the IVC while simultaneous contrast material injection through a side-arm adapter was performed to confirm the parenchymal location of the tract prior to balloon dilatation (Fig. 2). After evaluating the puncture site, the parenchymal tract was dilated using an Ultrathin Diamond balloon catheter 10 mm in diameter (Medi-Tech/Boston Scientific, Watertown, Mass., U.S.A.) (Fig. 3), and a 10-mm-diameter Wallstent (Schneider USA, Minneapolis, Minn., U.S.A.) was deployed. The stent was then expanded using a 10-mm angioplasty balloon. A 5-F multipurpose catheter was readvanced into the splenic vein; venography from this position was performed and the portosystemic pressure gradient was remeasured.

Seong CK, Kim YJ, Shin TB, Park HY, Kim TH, Kang DS - Korean J Radiol (2001 Oct-Dec)

Bottom Line: After revision of the occluded shunt failed, direct cavoportal puncture at the retrohepatic segment of the IVC was attempted.Transcaval TIPS placement was technically successful in all cases.After the tract was dilated by a bare stent, no patient experienced trans-stent bleeding and no serious procedure-related complications occurred.After successful shunt creation, variceal bleeding ceased in all patients.Transcaval TIPS placement is an effective and safe alternative treatment in patients with occluded previous TIPS and no hepatic veins suitable for new TIPS.

Affiliation: Department of Radiology, Kyungpook National University School of Medicine, Daegu, Korea. sck@knu.ac.kr

Abstract: To determine the feasibility of transcaval transjugular intrahepatic portosystemic shunt (TIPS) in patients with occluded previous TIPS.Between February 1996 and December 2000 we performed five transcaval TIPS procedures in four patients with recurrent gastric cardiac variceal bleeding. All four had occluded TIPS, which was between the hepatic and portal vein. The interval between initial TIPS placement and revisional procedures with transcaval TIPS varied between three and 31 months; one patient underwent transcaval TIPS twice, with a 31-month interval. After revision of the occluded shunt failed, direct cavoportal puncture at the retrohepatic segment of the IVC was attempted.Transcaval TIPS placement was technically successful in all cases. In three, tractography revealed slight leakage of contrast materials into hepatic subcapsular or subdiaphragmatic pericaval space. There was no evidence of propagation of extravasated contrast materials through the retroperitoneal space or spillage into the peritoneal space. After the tract was dilated by a bare stent, no patient experienced trans-stent bleeding and no serious procedure-related complications occurred. After successful shunt creation, variceal bleeding ceased in all patients.Transcaval TIPS placement is an effective and safe alternative treatment in patients with occluded previous TIPS and no hepatic veins suitable for new TIPS.