BJTRAISTER
Networker
Okay - this has me perplexed - it reads as though they did everything for a TIPS placement except the stent....thoughts?
Procedure and Findings:
The procedure was performed in the VIR suite following informed consent and a time out. The patient was intubated and received general anesthesia under the care of an anesthesiologist. With the patient in the supine position, the right neck was prepped and draped in the usual sterile fashion.
The right internal jugular vein was evaluated by ultrasound and was
found to be widely patent. An appropriate skin entry site was identified using ultrasound and the right internal jugular vein was accessed using a 21-G needle. A 0.018 inch guidewire was advanced into the vein using fluoroscopic guidance. The access needle was exchanged for a 4-F stiff micropuncture catheter. Using fluoroscopic guidance, a 0.035 inch guidewire was inserted through the micropuncture catheter and positioned into the IVC.
Using fluoroscopic guidance, a 5-F MPA catheter and a 0.035 inch guidewire were used to access the right hepatic vein. A digital subtraction hepatic venogram using iodinated contrast was performed. This venogram demonstrated the catheter position in the right hepatic vein and its relationship to the upper IVC and right atrium.
Using fluoroscopic guidance, a 9-F TIPS introducer sheath was placed
over the guidewire into the right hepatic vein. Using fluoroscopic
guidance, a 5.5 mm Fogarty balloon catheter was placed through the
sheath, over the guidewire, into the right hepatic vein. A wedged
hepatic venogram was performed using carbon dioxide. This venogram
demonstrated the relationship between the right hepatic and portal
veins and identified an appropriate trajectory for TIPS placement.
Using fluoroscopic guidance, the balloon catheter was exchanged over
a 145 cm, 0.035 inch Amplatz guidewire for the 16-F Ross needle.
Through the Ross needle, the 21-G needle and 5-F catheter were
inserted. Using fluoroscopic guidance, the 21-G needle was passed
into the location of the right portal vein as guided by the previous
hepatic venogram. After several passes, the right portal vein was
successfully accessed across the hepatic-portal vein anastomosis, as
confirmed by a small contrast injection. A 0.018 inch Nitrex
guidewire was passed into the right portal vein, the 21-G needle was
removed, and the 5-F catheter was passed over the guidewire into the portal vein.
A 5-F marker pigtail catheter was placed into the splenic vein.
Iodinated contrast was injected through the pigtail catheter and a
digital subtraction venogram of the portal vein system was
performed. This venogram demonstrated the entire portal circulation
of the liver. The main, right, and left portal veins were patent.
Moderate size gastric varices were demonstrated, by a pulmonary
vein. The tract between the right hepatic vein and right portal vein
was dilated with a 4 mm balloon catheter. The 9-F TIPS sheath was then advanced into the portal vein.
The coronary vein was accessed using a Chung B catheter and
Glidewire. A digital subtraction venogram was performed,
demonstrating the gastric varices. A Rosen wire was advanced through
the catheter, positioned within the coronary vein. The catheter was
exchanged for a 5.5-F Fogarty balloon catheter. A digital
subtraction venogram again demonstrated appropriate position of the
catheter within the proximal aspect of the coronary vein varices.
The balloon was inflated to the point of occlusion, preventing
venous back flow. A mixture of contrast, Sotradecol, and collagen
from a D-Stat kit were injected into the varices to the point of
stasis. Three Nester coils were then advanced through the catheter
into the varix. The sclerosant was allowed to set for 30 minutes.
Following 30 minutes, the Fogarty balloon was deflated and the
catheter withdrawn. A marker pigtail catheter was advanced into the
splenic vein over a 0.035 inch guidewire. A digital subtraction
venogram was performed, demonstrating obliteration of the varices.
The right atrial and main portal vein pressures were measured
simultaneously across the hepatic-portal vein anastomosis by
manometry in cmH20 and converted to mmHg.
Right atrium mean pressure: 11mmHg
Main portal vein mean pressure: 33mmHg
Portosystemic gradient: 22mmHg.
The catheter and sheath were removed and hemostasis was achieved
using manual compression. The sheath site was dressed in the usual fashion.
General anesthesia was reversed and the patient was extubated. The
patient was transferred to the PACU under the care of the
anesthesiologist. The patient remained intubated and was transferred back to the MICU.
There were no immediate complications. Total fluoroscopy time was 38
minutes.
Impression:
1. Technically successful TIPS approach balloon-occlusion gastric varices
obliteration.
2. Severe portal hypertension with a portosystemic gradient of 22mmHg.
Procedure and Findings:
The procedure was performed in the VIR suite following informed consent and a time out. The patient was intubated and received general anesthesia under the care of an anesthesiologist. With the patient in the supine position, the right neck was prepped and draped in the usual sterile fashion.
The right internal jugular vein was evaluated by ultrasound and was
found to be widely patent. An appropriate skin entry site was identified using ultrasound and the right internal jugular vein was accessed using a 21-G needle. A 0.018 inch guidewire was advanced into the vein using fluoroscopic guidance. The access needle was exchanged for a 4-F stiff micropuncture catheter. Using fluoroscopic guidance, a 0.035 inch guidewire was inserted through the micropuncture catheter and positioned into the IVC.
Using fluoroscopic guidance, a 5-F MPA catheter and a 0.035 inch guidewire were used to access the right hepatic vein. A digital subtraction hepatic venogram using iodinated contrast was performed. This venogram demonstrated the catheter position in the right hepatic vein and its relationship to the upper IVC and right atrium.
Using fluoroscopic guidance, a 9-F TIPS introducer sheath was placed
over the guidewire into the right hepatic vein. Using fluoroscopic
guidance, a 5.5 mm Fogarty balloon catheter was placed through the
sheath, over the guidewire, into the right hepatic vein. A wedged
hepatic venogram was performed using carbon dioxide. This venogram
demonstrated the relationship between the right hepatic and portal
veins and identified an appropriate trajectory for TIPS placement.
Using fluoroscopic guidance, the balloon catheter was exchanged over
a 145 cm, 0.035 inch Amplatz guidewire for the 16-F Ross needle.
Through the Ross needle, the 21-G needle and 5-F catheter were
inserted. Using fluoroscopic guidance, the 21-G needle was passed
into the location of the right portal vein as guided by the previous
hepatic venogram. After several passes, the right portal vein was
successfully accessed across the hepatic-portal vein anastomosis, as
confirmed by a small contrast injection. A 0.018 inch Nitrex
guidewire was passed into the right portal vein, the 21-G needle was
removed, and the 5-F catheter was passed over the guidewire into the portal vein.
A 5-F marker pigtail catheter was placed into the splenic vein.
Iodinated contrast was injected through the pigtail catheter and a
digital subtraction venogram of the portal vein system was
performed. This venogram demonstrated the entire portal circulation
of the liver. The main, right, and left portal veins were patent.
Moderate size gastric varices were demonstrated, by a pulmonary
vein. The tract between the right hepatic vein and right portal vein
was dilated with a 4 mm balloon catheter. The 9-F TIPS sheath was then advanced into the portal vein.
The coronary vein was accessed using a Chung B catheter and
Glidewire. A digital subtraction venogram was performed,
demonstrating the gastric varices. A Rosen wire was advanced through
the catheter, positioned within the coronary vein. The catheter was
exchanged for a 5.5-F Fogarty balloon catheter. A digital
subtraction venogram again demonstrated appropriate position of the
catheter within the proximal aspect of the coronary vein varices.
The balloon was inflated to the point of occlusion, preventing
venous back flow. A mixture of contrast, Sotradecol, and collagen
from a D-Stat kit were injected into the varices to the point of
stasis. Three Nester coils were then advanced through the catheter
into the varix. The sclerosant was allowed to set for 30 minutes.
Following 30 minutes, the Fogarty balloon was deflated and the
catheter withdrawn. A marker pigtail catheter was advanced into the
splenic vein over a 0.035 inch guidewire. A digital subtraction
venogram was performed, demonstrating obliteration of the varices.
The right atrial and main portal vein pressures were measured
simultaneously across the hepatic-portal vein anastomosis by
manometry in cmH20 and converted to mmHg.
Right atrium mean pressure: 11mmHg
Main portal vein mean pressure: 33mmHg
Portosystemic gradient: 22mmHg.
The catheter and sheath were removed and hemostasis was achieved
using manual compression. The sheath site was dressed in the usual fashion.
General anesthesia was reversed and the patient was extubated. The
patient was transferred to the PACU under the care of the
anesthesiologist. The patient remained intubated and was transferred back to the MICU.
There were no immediate complications. Total fluoroscopy time was 38
minutes.
Impression:
1. Technically successful TIPS approach balloon-occlusion gastric varices
obliteration.
2. Severe portal hypertension with a portosystemic gradient of 22mmHg.