# Tips revision



## ramjame (May 18, 2017)

*RP TIPS REVISION*

*37183 is correct code for these report*

Procedure: Transjugular intrahepatic portosystemic shunt (TIPS) revision
Staff: Hunt
Fellow: Browne
Resident: N/A
Contrast: 50 mL Isovue iv
Fluoroscopy time: 44.6 minutes pulsed at 7.5 pulses per second.
Complications: None
Medications: Versed 12 mg iv, Fentanyl 600 mcg iv., Diphenhydramine 50 mg IV, ceftriaxone 1 g IV. Moderate sedation was monitored by radiology nursing staff.
Indication: 67-year-old woman with decompensated nonalcoholic steatohepatitis/cirrhosis can't be gated by ascites, encephalopathy, and recent admission for Flood syndrome. She underwent TIPS placement (8cm/2cm, 10 mm Viatorr, extended by a 10 x 60 mm 
fluency) on 12/16/2016 and anterior abdominal wound closure. Additionally, she was readmitted and underwent a TIPS revision on 1/17/2017 for recurrent ascites. Note that she still demonstrates persistent ascites and she is presenting for a second TIPS 
revision and likely extension of the TIPS further into the IVC.

Procedure: Using real-time ultrasound guidance, the right internal jugular vein was punctured and a sheath was placed. Via this access, the TIPS was selectively catheterized. Note that this required a combination of both catheters and wires, ultimately 
an angled Glidewire and internal mammary catheter were successful. Portography and pressure measurements were performed. Based upon the results of the diagnostic study, angioplasty of the TIPS was performed with a 10 millimeter balloon and placement of a
10 mm x 60 mm covered stent (Fluency) was used to extend the TIPS further into the IVC . Portography and pressures were repeated. The catheter was removed and hemostasis was achieved with manual compression. 

Findings:
1. Ultrasound shows an anechoic and compressible jugular vein. 
2. TIPS venogram demonstrated slow hepatopedal flow in both the right and left intrahepatic portal veins and across the TIPS. The TIPS itself demonstrates a later than 50% stenosis at its junction with the IVC. This resolved with placement of a 10 mm 
covered stent. No large varices are present.
3. Pre-TIPS revision mean pressure measurements:
Right atrium: 13 mmHg
IVC: 13 mmHg
Proximal TIPS (just adjacent to the focal stenosis): 27 mmHg
Portal vein: 26 mmHg
Gradient: 14 mmHg
4. Post-TIPS revision mean pressure measurements:
Right atrium: 16 mmHg
IVC: 16 mmHg
Proximal TIPS: 20 mmHg
Portal vein: 21 mmHg
Final gradient: 5 mmHg

IMPRESSION: 
Successful TIPS revision with extension of TIPS stent. Prerevision gradient was 14 mmHg and post revision gradient was 5 mmHg.


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## Jim Pawloski (May 24, 2017)

ramjame said:


> *RP TIPS REVISION*
> 
> *37183 is correct code for these report*
> 
> ...



Yes, you are correct with that code.
Thanks,
Jim Pawloski, CIRCC


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