TIPS in Patients With Cranial Porta Hepatis: Ultrasound-Guided Transhepatic Portohepatic-Portocaval Puncture in Single Needle Pass

Abstract

The purpose of this study was to describe our technique of transhepatic serial puncture of the portal vein and hepatic vein-inferior vena cava in one needle pass under ultrasound guidance to place a transjugular intrahepatic portosystemic shunt (TIPS) in patients with a porta hepatis cranial to the usual location. Six patients (five men, one woman) underwent transhepatic TIPS procedures at our institution. The indications for portal decompression were recurrent variceal bleeding in four patients and refractory ascites and hydrothorax in one patient each. In five patients initial attempts at a classic transjugular approach failed because of an unusual angle between the hepatic vein and the portal vein; in the other patient, revision of an occluded shunt had failed. Two patients had main portal vein thrombosis. Technical success was achieved in all six patients. Two patients received a portohepatic venous shunt and four a portocaval shunt (inferior vena cava to right portal vein in three patients and inferior vena cava to left portal vein in one patient).The portosystemic pressure gradient before TIPS was 17-35 mm Hg and after TIPS was 6-10 mm Hg. No procedure-related complications occurred. One patient had severe hepatic encephalopathy. Two patients had shunt occlusion, which was successfully revised 17 and 10 months after the procedure. Our technique is a safe, effective, and universally applicable method for establishment of a TIPS in patients with either normal venous anatomy or severely distorted liver parenchyma.