BJTRAISTER
Networker
I do not believe this constitutes a TIPS revision - opinions?
REASON FOR EXAM: Tips revision
Procedure: Transjugular intrahepatic portosystemic shunt (TIPS) venogram and embolization of the gastroesophageal varices fed by the recanalized coronary vein
Indications: Portal hypertension due to cirrhosis, recently, the patient was transferred from the VA due to GI bleeding and possible TIPS occlusion. Procedure and
Findings: The procedure was performed in the VIR suite following informed consent and a time out. The patient received approximately 90 minutes of IV moderate sedation under the supervision of the radiologist. 1% lidocaine local anesthesia was used. With the patient in the supine position, the right neck was prepped and draped in the usual sterile fashion.
Vessels injected: Main portal vein/TIPS 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. The right internal jugular vein was accessed using a 21-G needle using ultrasound guidance. 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. A 0.035 inch guidewire was inserted through the micropuncture catheter. Using fluoroscopic guidance, the guidewire was positioned into the IVC. Using fluoroscopic guidance, the TIPS was accessed using a 5-F MPA catheter and a guidewire. The MPA catheter was exchanged for a 5-F pigtail catheter. With the pigtail catheter positioned in the main portal vein, a digital subtraction venogram was performed which demonstrated patent main, right and left portal veins, a patent TIPS and no stenoses. Contrast easily crossed the stent and reached the right atrium. There there are small, with tortuous vessel esophageal varices, fed by a very small recanalized coronary vein. There were no demonstrable feeders from the splenic vein. Using fluoroscopic guidance and over the guidewire, the pigtail catheter was exchanged for a 23 cm, 9-F sheath. The MPA catheter was placed through the sheath into the TIPS. Through the sheath and catheter, pressures were measured simultaneously by manometry in cmH20 and converted to mm
Hg: --Main portal vein, mean 11.6 mmHg. --Right atrium, mean 22.4 mmHg. --Gradient across TIPS 11 mmHg. The small coronary vein off the portal vein was then entered using a Cobra C2 catheter. A microcatheter was then advanced into the varix. A mix of Sotradecol and D-Stat was slowly administered until there was occlusion. Special care was taken to avoid reflux of the sclerosing material into the portal vein. Embolization coils were then placed into the varix. Contrast injection demonstrated stasis. The catheter and sheath were removed and hemostasis was achieved using manual compression. The sheath site was dressed in the usual fashion. There were no immediate complications. Total fluoroscopy time was 13.5 minutes.
Impression: 1. No significant stenosis of the TIPS demonstrated by venography with a portosystemic pressure gradient of 11 mm of mercury. 2. Small tortuous gastroesophageal varices fed by the small recanalized coronary vein which was embolized using a combination of Sotradecol and D-Stat followed by deposition of embolization coils
REASON FOR EXAM: Tips revision
Procedure: Transjugular intrahepatic portosystemic shunt (TIPS) venogram and embolization of the gastroesophageal varices fed by the recanalized coronary vein
Indications: Portal hypertension due to cirrhosis, recently, the patient was transferred from the VA due to GI bleeding and possible TIPS occlusion. Procedure and
Findings: The procedure was performed in the VIR suite following informed consent and a time out. The patient received approximately 90 minutes of IV moderate sedation under the supervision of the radiologist. 1% lidocaine local anesthesia was used. With the patient in the supine position, the right neck was prepped and draped in the usual sterile fashion.
Vessels injected: Main portal vein/TIPS 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. The right internal jugular vein was accessed using a 21-G needle using ultrasound guidance. 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. A 0.035 inch guidewire was inserted through the micropuncture catheter. Using fluoroscopic guidance, the guidewire was positioned into the IVC. Using fluoroscopic guidance, the TIPS was accessed using a 5-F MPA catheter and a guidewire. The MPA catheter was exchanged for a 5-F pigtail catheter. With the pigtail catheter positioned in the main portal vein, a digital subtraction venogram was performed which demonstrated patent main, right and left portal veins, a patent TIPS and no stenoses. Contrast easily crossed the stent and reached the right atrium. There there are small, with tortuous vessel esophageal varices, fed by a very small recanalized coronary vein. There were no demonstrable feeders from the splenic vein. Using fluoroscopic guidance and over the guidewire, the pigtail catheter was exchanged for a 23 cm, 9-F sheath. The MPA catheter was placed through the sheath into the TIPS. Through the sheath and catheter, pressures were measured simultaneously by manometry in cmH20 and converted to mm
Hg: --Main portal vein, mean 11.6 mmHg. --Right atrium, mean 22.4 mmHg. --Gradient across TIPS 11 mmHg. The small coronary vein off the portal vein was then entered using a Cobra C2 catheter. A microcatheter was then advanced into the varix. A mix of Sotradecol and D-Stat was slowly administered until there was occlusion. Special care was taken to avoid reflux of the sclerosing material into the portal vein. Embolization coils were then placed into the varix. Contrast injection demonstrated stasis. The catheter and sheath were removed and hemostasis was achieved using manual compression. The sheath site was dressed in the usual fashion. There were no immediate complications. Total fluoroscopy time was 13.5 minutes.
Impression: 1. No significant stenosis of the TIPS demonstrated by venography with a portosystemic pressure gradient of 11 mm of mercury. 2. Small tortuous gastroesophageal varices fed by the small recanalized coronary vein which was embolized using a combination of Sotradecol and D-Stat followed by deposition of embolization coils