Puncture Path Research Articles

CT-guided versus laparoscopic radiofrequency ablation in recurrent small hepatocellular carcinoma against the diaphragmatic dome

Computed tomography-guided radiofrequency ablation (CT-RFA) and laparoscopic RFA (L-RFA) have been used to treat intrahepatic recurrent small hepatocellular carcinoma (HCC) against the diaphragmatic dome. However, the therapeutic safety, efficacy, and hospital fee have never been compared between the two techniques due to scarcity of cases. In this retrospective study, 116 patients were divided into two groups with a total of 151 local recurrent HCC lesions abutting the diaphragm. We compared overall survival (OS), local tumor progression (LTP), postoperative complications, and hospital stay and fee between the two groups. Our findings revealed no significant differences in 5-year OS (36.7% vs. 44.6%, p = 0.4289) or 5-year LTP (73.3% vs. 67.9%, p = 0.8897) between CT-RFA and L-RFA. The overall hospital stay (2.8 days vs. 4.1 days, p < 0.0001) and cost (¥ 19217.6 vs. ¥ 25553.6, p < 0.0001) were significantly lower in the CT-RFA in comparison to that of L-RFA. In addition, we elaborated on the choice of percutaneous puncture paths depending on the locations of the HCC nodules and 11-year experience with CT-RFA. In conclusion, CT-RFA is a relatively easy and economic technique for recurrent small HCC abutting the diaphragm, and both CT-RFA and L-RFA are effective techniques.

Retrospective study of CT-guided radiofrequency ablation and laparoscopic radiofrequency ablation in the treatment of recurrent small hepatocellular carcinoma against the diaphragmatic dome.

272 Background: Radiofrequency ablation (RFA) have been used to treat hepatocellular carcinoma (HCC) in the subphrenic area. Very few studies focus on ablation of recurrent small HCC against the diaphragmatic dome. The therapeutic safety, efficacy, and hospital fee have never been compared between CT guided RFA and laparoscopic RFA (L-RFA) either. Methods: CT guided RFA and L-RFA were performed in totally 116 patients with 151 local recurrent HCC lesions abutting the diaphragm. We compared major and minor postoperative complications, hospital stay and fee, overall survival (OS), and local tumor progression (LTP) between two groups for evaluating respective therapeutic efficacy and safety. Moreover, in CT-guided percutaneous RFA group, depending on the locations of recurrent HCC nodules differentiated puncture paths and ablation methods were used, and intraoperative complications were recorded. Results: There is no significant difference in OS and LTP between CT- guided RFA and LRFA.In recorded postoperative complications, the morbidity in CT-guided RFA group is lower than that of L-RFA group. The average safety margin is 8 and 11 mm in CT-guided RFA and LRFA group, respectively. The shoulder and back pain is significantly high in L-RFA group probably due to pneumoperitoneum. Moreover, overall hospital stay and cost is also lower in CT-guided RFA group. Conclusions: Both CT-guided RFA and L-RFA are considered to be an effective approach for recurrent small HCC abutting diaphragm. Particularly, CT-guided RFA is an easy and economic with less complications if suitable puncture paths and ablation methods can be applied.

Diagnostic yield of a biopsy performed immediately after lung radiofrequency ablation

To evaluate the diagnostic performance of lung biopsies performed immediately after radiofrequency ablation (RFA). Twenty consecutive patients were treated with lung RFA. A biopsy was performed immediately after RFA, through the cannula used to insert the RFA probe to avoid hampering the RFA probe placement. Biopsies were analysed for diagnostic of malignancy and tumour morphological characteristics. Recurrence of RFA and procedure-related complications are reported. Mean tumour size was 17.3mm (±6.2mm). Ninety per cent (18/20) of biopsies were able to help diagnose malignancy. Cancer subtype and origin were determined in 70% (14/20) of tumours, including 12 metastases and two primary lung cancers. During a median follow-up of 24months, one tumour demonstrated local progression (5%). The overall survival, lung disease-free survival and progression-free survival rates at 12months were 100%, 75% and 65%, respectively. Adverse events of the procedure including RFA and biopsy were five pneumothoraces requiring chest tube placement (25%), seven minor pneumothoraces (35%) and one subsegmental intrapulmonary haemorrhage (5%) not requiring any treatment. A biopsy performed immediately after lung RFA allowed diagnosis of malignancy in 90% of cases. This diagnosis is obtained without the need for additional puncture and does not hamper the accuracy of the initial RF probe placement. • Treatment and biopsy are feasible during the same procedure, avoiding multiple punctures. • The best puncture path can be preserved to treat the lung tumour. • Malignancy can be determined on a post-RFA biopsy in 90 % of cases. • Cancer classification can be assessed in 70 % of cases after lung RFA.

Application of stereotactic surgical planning system in foramen ovale puncture for the treatment of trigeminal neuralgia

Objective To investigate the practical application value of stereotactic surgical planning system in the foramen ovale puncture for the treatment of idiopathic trigeminal neuralgia. Methods A total of 112 patients with trigeminal neuralgia admitted at the Department of Neurosurgery, the Second Hospital, Shandong University from October 2008 to March 2013 were enrolled. Using stereotactic techniques to complete the radiofrequency treatment of trigeminal neuralgia after foramen ovale puncture of gasserian ganglion. Different from the traditional mounting of the stereotactic frame, this study used reversed mounting frame. The simulation puncture was conducted after the CT scan dicom data were inputted into the stereotactic surgical planning system. The target coordinates, percutaneous puncture point coordinates, and puncture paths were ultimately determined. Results Using the above methods, 112 patients completed foramen ovale punctures. Twenty-five puncture paths were corrected by the stereotactic surgical planning system before procedure (the correction rate was 22.3%). The one-time success rate of foramen ovale puncture was 100% after setting the paths. No serious complications occurred, such as internal carotid artery injury and bleeding, diplopia, and keratitis. The immediate effective rate was 100%, one-year effective rate was 95.5%%, and two-year effective rate was 90.2%. Conclusion Preoperative setting puncture paths using the stereotactic surgical planning system for the treatment of trigeminal neuralgia is accurate, safe, and effective. Key words: Trigeminal neuralgia; Foramen ovale; Punctures; Stereotaxic techniques; Neuronavigation

Contrast enhanced computed tomography and reconstruction of hepatic vascular system for transjugular intrahepatic portal systemic shunt puncture path planning.

To describe a method for the transjugular intrahepatic portal systemic shunt (TIPS) placement performed with the aid of contrast-enhanced computed tomography (CECT) and three-dimensional reconstructed vascular images (3D RVIs), and to assess its safety and effectiveness. Four hundred and ninety patients were treated with TIPS between January 2005 and December 2012. All patients underwent liver CECT and reconstruction of 3D RVIs of the right hepatic vein to portal vein (PV) prior to the operation. The 3D RVIs were carefully reviewed to plan the puncture path from the start to target points for needle pass through the PV in the TIPS procedure. The improved TIPS procedure was successful in 483 (98.6%) of the 490 patients. The number of punctures attempted was one in 294 (60%) patients, 2 to 3 in 147 (30%) patients, 4 to 6 in 25 (5.1%) patients and more than 6 in 17 (3.5%) patients. Seven patients failed. Of the 490 patients, 12 had punctures into the artery, 15 into the bile duct, eight into the gallbladder, and 18 through the liver capsule. Analysis of the portograms from the 483 successful cases indicated that the puncture points were all located distally to the PV bifurcation on anteroposterior images, while the points were located proximally to the bifurcation in the three cases with intraabdominal bleeding. The complications included three cases of bleeding, of whom one died and two needed surgery. Use of CECT and 3D RVIs to plan the puncture path for TIPS procedure is safe, simple and effective for clinical use.

Clinical application of ultrasound-guided percutaneous tube drainage combined with sclerotherapy to treat the retroperitoneal cystic lymphatic tumor

Objective To evaluate the clinical curative effect of percutaneous tube drainage combined with sclerotherapy guided by ultrasound for treating the retroperitoneal cystic lymphatic tumor.Methods Twenty-seven adult cases with pathologically confirmed retroperitoneal cystic lymphatic tumor were collected from March 2009 to December 2012.All cases were initially diagnosed with retroperitoneal cystic lymphatic tumor by ultrasound,CT or MRI before treating.Firstly,the biopsy of the cyst wall tissues were conducted percutaneously guided by ultrasound for frozen section and the cystic fluid were conducted with the cytological examination.Then local anesthesia were conducted and the 8.5F drainage tube were implanted percutaneously by ultrasound-guided for continuous drainage after which was proved to be cystic lymphatic tumor.When the drainage volume≤10 ml/24 h,the lauromacrogol were injected and retained,and followed by the slow removal of drainage tube in order to observe its clinical curative effect,and analyzed the influence about the number of lesions on the curative effect of the separated comparative.Results All of the 27 patients successfully underwent percutaneous puncture catheter drainage for one time,the operation success rate was 100％.The puncture paths concluded:anterior abdominal approach (3 cases),lateral abdominal approach (7 cases) and retroperitoneal approach (17 cases).At last,22 cases were cured,4 cases were effective and 1 case was improved.The response rate was 100％,and the less partitions of the lesion,the better effect of the treatment(P =0.010).During the process,two patients bleed from the wall of the cyst when the wall was destructed and were controlled immediately after the intravenous injection of the hemostatic and intracapsular injection of lauromacrogol.No other complications occurred.All the 27 patients were followed up for 8 to 24 months(12 months for average).Conclusions The technique of percutaneous tube drainage combined with sclerotherapy guided by ultrasound for treating the retroperitoneal cystic lymphatic tumor is a safe,effective and minimally invasive treatment with small wound and less complications. Key words: Ultrasonography; Lymphangioma; Retroperitoneal neoplasms; Sclerotherapy; Lauromacrogol

The value of artificial pleural effusion for percutaneous microwave ablation of liver tumour in the hepatic dome: A retrospective case-control study

Purpose: The aim of this study was to evaluate the feasibility, safety, and efficiency of percutaneous microwave ablation (MWA) with artificial pleural effusion for liver tumours located in the hepatic dome.Materials and methods: A total of 112 sessions of artificial pleural effusion performed on 102 liver tumour patients were summarised and analysed at our hospital. Among them, 31 hepatocellular carcinoma patients treated by percutaneous MWA were selected as the artificial pleural effusion group. The control group without artificial pleural effusion was matched with tumour size, tumour location and the histological grades of differentiation. The primary technique effectiveness rate, local tumour progression rate and tumour-free survival rate were compared.Results: Artificial pleural effusion was achieved successfully in 110 of 112 sessions (98.2%), which helped to improve the visibility in 98.8% (82/83) and acquire safe puncture path in 96.3% (26/27). There were no statistical differences between the artificial pleural effusion group and the control group in the primary technique effectiveness rate (p = 1.000), the 1-, 2-, and 3-year local tumour progression rates (p = 0.669), and the 1-, 2-, and 3-year tumour-free survival rates (p = 0.979).Conclusions: Percutaneous MWA with artificial pleural effusion could be a feasible, safe, and effective technique for liver tumours located in the hepatic dome.

3:46 PM Abstract No. 54 - Percutaneous vertebroplasty for metastatic lesions of the cervical spine

Purpose To evaluation the effectiveness of the three approaches of percutaneous vertebroplasty for metastatic lytic lesions of the cervical spine. Materials and Methods 40 patients with osteolytic metastases in 65 cervical vertebras received the treatment of PVP. The clinical data were retrospectively analyzed. The WHO standards and Visual Analog Scale were assessed before and after operation, and the three approaches were analyzed and summarized according to the different positions of the cervical body. Results The three groups of puncture path are respectively anterolateral approach, lateral approach, and anterolateral approach through disc space. All the cervical bodies were successfully punctured and injected with bone cement. Follow-up at least 3 months, 13 cases of complete remission (CR), 21 cases of part remission (PR), 2 case of mild remission (MR), 0 is no remission (NR) after operation in data integrity of the 36 patients, while the rate of the clinical effective (CR+PR) reaching 94.44%. Preoperative and postoperative patients with 24h, after one week, 3 months after operation, the VAS differences were statistically significant (P Conclusion Percutaneous vertebroplasty via anterolateral approach is a safe, effective technique in treating the osteolytic metastasis tumor of lower cervical vertebra (C4-C7). While treating metastasis tumor involved in C1, C2 and C3, it’s safe and feasible to choose percutaneous vertebroplasty via lateral approach and anterolateral approach through disc space.

8:08 AM Abstract No. 118 - Clinical evaluation of TIPS procedure guidance software

Purpose TIPS is an effective treatment for portal hypertension. Using fluoroscopic guidance, the target portal vein (PV) is only visible during a CO2 portogram, which cannot be used during PV access. Software has been developed to provide intra-procedural 3D needle guidance from 2 CO2 portograms. The purpose of this study was to demonstrate the utility of this software in creating TIPS shunts. Materials and Methods In 40 patients referred for TIPS (26M/14F, 58±13 yrs), 2 CO2 portograms were acquired at least 20 deg apart. The user then marked the hepatic vein (puncture origin) and PV (target) in each image using prototype software (Siemens Healthcare, Germany). A puncture path connecting these points was displayed on live fluoro and updated in real time with c-arm movement. Puncture attempts, fluoro time and x-ray dose were recorded. Results In 12 subjects the software could not be used: PV not visible on portogram (n=7), technical issues (3), high right heart pressure (2). In 21 of the remaining 28 cases (75%), the procedure was successful using the planned path. When the path was followed, all measured variables were significantly lower than when it was not: puncture attempts (4±5 vs 13±8 p Conclusion In conclusion, software has been developed which provides needle guidance during TIPS procedures. Use of the overlaid path results in significantly fewer puncture attempts and reduced x-ray exposure. Bending the needle according to the software determined angle increased the percentage of patients in whom the path could be followed reliably.

Use of puncture force measurement to investigate the conditions of blood vessel needle insertion

Central venous catheterization involves venous puncture and catheter insertion for transfusions. Quantitative conditions that facilitate insertion of the needle, such as the angle and velocity of insertion, have not been clarified. We previously developed a robotic system for guiding the needle along a specified puncture path with high precision and are currently implementing a hardware design for a robotic system to assist in blood vessel puncture. In this study, we proposed the insertion angle and velocity for stopping the needle in a blood vessel, assuming that a robotic system such as ours is used during the procedure. We inserted a needle into a segment of porcine jugular vein and obtained the puncture reaction force. Evaluation indices were the magnitude of the sudden decrease in reaction force at the point at which the needle advances and the length of time that the needle is present within the vein. Results indicated that the conditions under which it was easiest to stop the needle inside the vein were an insertion angle range of 10–20 and an insertion velocity of 3mm/s.

Percutaneous Punctures with MR Imaging Guidance: Comparison between MR Imaging–enhanced Fluoroscopic Guidance and Real-time MR Imaging Guidance

To evaluate and compare the technical accuracy and feasibility of magnetic resonance (MR) imaging-enhanced fluoroscopic guidance and real-time MR imaging guidance for percutaneous puncture procedures in phantoms and animals. The experimental protocol was approved by the institutional animal care and use committee. Punctures were performed in phantoms, aiming for markers (20 each for MR imaging-enhanced fluoroscopic guidance and real-time MR imaging guidance), and pigs, aiming for anatomic landmarks (10 for MR imaging-enhanced fluoroscopic guidance and five for MR imaging guidance). To guide the punctures, T1-weighted three-dimensional (3D) MR images of the phantom or pig were acquired. Additional axial and coronal T2-weighted images were used to visualize the anatomy in the animals. For MR imaging-enhanced fluoroscopic guidance, phantoms and pigs were transferred to the fluoroscopic system after initial MR imaging and C-arm computed tomography (CT) was performed. C-arm CT and MR imaging data sets were coregistered. Prototype navigation software was used to plan a puncture path with use of MR images and to superimpose it on fluoroscopic images. For real-time MR imaging, an interventional MR imaging prototype for interactive real-time section position navigation was used. Punctures were performed within the magnet bore. After completion, 3D MR imaging was performed to evaluate the accuracy of insertions. Puncture durations were compared by using the log-rank test. The Mann-Whitney U test was applied to compare the spatial errors. In phantoms, the mean total error was 8.6 mm ± 2.8 with MR imaging-enhanced fluoroscopic guidance and 4.0 mm ± 1.2 with real-time MR imaging guidance (P < .001). The mean puncture time was 2 minutes 10 seconds ± 44 seconds with MR imaging-enhanced fluoroscopic guidance and 37 seconds ± 14 with real-time MR imaging guidance (P < .001). In the animal study, a tolerable distance (<1 cm) between target and needle tip was observed for both MR imaging-enhanced fluoroscopic guidance and real-time MR imaging guidance. The mean total error was 7.7 mm ± 2.4 with MR imaging-enhanced fluoroscopic guidance and 7.9 mm ± 4.9 with real-time MR imaging guidance (P = .77). The mean puncture time was 5 minutes 43 seconds ± 2 minutes 7 seconds with MR imaging-enhanced fluoroscopic guidance and 5 minutes 14 seconds ± 2 minutes 25 seconds with real-time MR imaging guidance (P = .68). Both MR imaging-enhanced fluoroscopic guidance and real-time MR imaging guidance demonstrated reasonable and similar accuracy in guiding needle placement to selected targets in phantoms and animals.

An optical tracker based robot registration and servoing method for ultrasound guided percutaneous renal access

BackgroundRobot-assisted needle steering facilitates the percutaneous renal access (PRA) for their accuracy and consistency over manual operation. However, inaccurate image-robot correspondence and uncertainties in robot parameters make the needle track deviate from the intrarenal target. This paper aims to simplify the image-tracker-robot registration procedure and improves the accuracy of needle alignment for robot assisted ultrasound-guided PRA.MethodsFirst, a semi-automatic rigid registration is used for the alignment of the preoperative MR volume and the intraoperative orthogonal US slices. Passive markers are mounted both on US probe and robot end-effector, the planned puncture path is transferred from the MR volume frame into optical tracker frame. Tracker-robot correspondence and robot calibration are performed iteratively using a simplified scheme, both position and orientation information are incorporated to estimate the transformation matrix, only several key structural robot parameters and joint zero-positions are calibrated for simplicity in solving the inverse kinematic. Furthermore, an optical tracker feedback control is designed for compensating inaccuracies in robot parameters and tracker-robot correspondence, and improving the accuracy of needle alignment. The intervention procedure was implemented by a telemanipulated 5R1P robot, two experiments were conducted to validate the efficiency of robot-tracker registration method and the optical tracker feedback control, robot assisted needle insertion experiment was conducted on kidney phantom to evaluate the system performance.ResultsThe relative positioning accuracy of needle alignment is 0.24 ± 0.08 mm, the directional accuracy is 6.78 ± 1.65 × 10-4rad; the needle-target distance of needle insertion is 2.15 ± 0. 17 mm. The optical tracker feedback control method performs stable against wide range of angular disturbance over (0 ~ 0.4) radians, and the length disturbance over (0 ~ 100) mm.ConclusionsThe proposed optical tracker based robot registration and servoing method is capable of accurate three dimension needle operation for PRA procedure with improved precision and shortened time.

ARFI Ultrasound for In Vivo Hemostasis Assessment Postcardiac Catheterization, Part I: Preclinical Studies

The world wide prevalence of cardiovascular disease leads to over seven million annual percutaneous coronary catheterization procedures, the majority of which exploit femoral artery access. Femoral puncture sites ('arteriotomies') can be associated with severe vessel complications after sheath removal if hemostasis is not properly achieved. Hemostasis onset is routinely determined by examination for bleeding at the skin puncture; however, clotting along the puncture path can obscure subcutaneous bleeding, and therefore hemostasis is blindly assessed. We hypothesize that hemostasis assessment can be un-blinded by Acoustic Radiation Force Impulse (ARFI) ultrasound. In this first of a two-part series, we present in vivo ARFI hemostasis imaging data obtained in relevant canine models of femoral artery puncture. Above arteriotomies, ARFI-induced displacements were large (3.5 to >5.0 microm) relative to surrounding soft tissue soon after needle removal, which was consistent with our expectation for pooled extravasated blood. ARFI-induced displacements above arteriotomies decreased in magnitude (to approximately 2 microm) some time after needle removal and suggested the onset of hemostasis. This preclinical investigation served as proof of concept and justification for a pilot human study, which is presented in part two of this series.

Percutaneous Nephrostomy in Supine Position

Introduction Percutaneous nephrostomy has traditionally been performed with the patient in the prone position, probably to reduce the risk of injury to adjacent visceral organs, particularly the colon. The prone position, however, is associated with disadvantages such as patient discomfort and circulatory and ventilatory difficulties, particularly in obese patients. We describe a technique of percutaneous nephrostomy with the patient in the supine anterolateral position using local anesthesia, ultrasound-guided puncture, and fluoroscopy-controlled placement. Technical considerations The supine anterolateral position was obtained by placing towels under the ipsilateral shoulder and gluteus to elevate the flank approximately 30°, thus providing enough space for ultrasound scanning and ultrasound-guided puncture of the collecting system. The ipsilateral arm was placed over the thorax, and the contralateral arm was used for intravenous perfusion. The ipsilateral leg was flexed slightly, and the contralateral leg was flexed and abducted so that its lateral aspect lay on the table, providing adequate space in case of concomitant transurethral manipulation. In this supine position, the colon falls anteromedially and thus well apart from the puncture paths. In contrast, in the prone position, it is pushed against the lateral surface of the kidney in the way of possible puncture paths. Conclusions Our experience with 12 consecutive patients showed this technique to be easy, safe, and effective and to prevent the discomfort and ventilation difficulties of the prone position, particularly in obese patients or those in poor general condition or with respiratory problems.

Tactile feedback and display system for CT-guided, robot-assisted percutaneous procedures

A CT-integrated robot system for interventional procedures is described. A pre-procedure planning screen enabled the radiologist to interactively specify a 3-D virtual needle within a pre-scanned image volume. The virtual needle was specified with a point-and-click interface and included a target and percutaneous insertion points superimposed on transverse axial slices and cross-referenced with multi-planar reformatted views in correlation with the interventional field. After sending the virtual needle's coordinates to the robot, its needle gripper automatically moved to a position congruent with the planned puncture path. The interventionalist then used a remote needle insertion controller with tactile/haptic feedback to insert the needle along the planned path within an abdominal phantom containing simulated targets and critical structures. During needle insertion, the scanner's host computer simultaneously displayed the needle imaged during CT fluoroscopy for comparison with the virtual needle. Forces sensed at the needle gripper are fed back to the remote needle insertion controller for haptic feedback, which provided graded manual sensation from the needle to the operator in a remote location. This technology may facilitate biopsy, ablation, brachytherapy and any needle-based image guided therapy.

Navi-ball: a new guidance device for CT-directed punctures.

A new navigation system (Navi-Ball) for computed tomography (CT)-guided punctures was tested clinically. The device consists of a transparent hemisphere with an angular scale. The hemisphere is fluid filled and contains a bubble indicating the angulation. The system works as a circular spirit level. Adapted to the handle of the needle, it allows needle adjustment according to the planned puncture path on the CT image. The system was tested in 36 patients who had 40 procedures. The needle deviation (in relation to the planned course of the needle) was measured in two rectangular planes. Without requiring preparation time, the guidance system allowed rapid and easy performance of the puncture. First-time needle placement in a double-angulated approach led to a deviation of the needle from the planned path ranging from 0.2 degrees to 4.6 degrees (mean 2.1 degrees, SD 1.4 degrees ) in the axial plane and from 0.4 degrees to 4.0 degrees (mean 2.3 degrees, SD 1.2 degrees). This "low-tech" system offers easy to use guidance by a single operator and provides for adequate accuracy of first-time needle placement.

Circular spirit level guidance system for CT- and MR-guided punctures.

A circular spirit level guidance system was tested for control of CT- and MR-guided punctures. The device consists of a needle holder fixed to a ground plate and two protractors. This allows adjustment of the fixed needle according to the angulation of the supposed puncture path as measured on tomographic images. A circular spirit level is fixed to the needle and leveled. Now the needle can be removed from the needle holder; by leveling the circular spirit level during the puncture, the formerly adjusted angulation is achieved. The system was tested in vitro and in vivo (22 patients) under CT and MR guidance. The average needle deviation was measured to be 1.96 degrees in vitro and 2.51 degrees in vivo. This simple device allows accurate puncture under CT and MR guidance.

Liver anatomy applied to the placement of transjugular intrahepatic portosystemic shunts.

To study the vascular and biliary liver anatomy and its relevance to the creation of a transjugular intrahepatic portosystemic shunt (TIPS). Acrylic casts of 25 normal human livers (necropsy specimens) were obtained. The anatomy of the hepatic veins, portal vein, hepatic artery, and bile ducts and the relationship of structures of the portal triad were evaluated. Diameters of the vessels and distances and relative position of the structures were recorded. Special attention was given to the puncture path used for TIPS. One right hepatic vein (RHV) was seen in 16 cases, two RHVs in one, and an accessory RHV in six. All were posterior to the portal bifurcation. The mean distance between the RHV and the portal bifurcation was 4.4 cm. In 13 cases, the path for TIPS puncture was free of major vascular and biliary structures. In 12 cases, portal, biliary, and/or arterial structures were seen in the puncture path. TIPS puncture should be performed in the postero-inferior aspect of the right portal trunk or at the posterior aspect of the bifurcation of the portal vein. Knowledge of the vascular liver anatomy is imperative to create the TIPS safely.