Transjugular intrahepatic portosystemic shunt (TIPS) - "gun-sight" technique

Case contributed by Dr Matthew Lukies

Presentation

Refractory ascites due to cirrhosis.

Patient Data

Age: 50 years
Gender: Female
  • General anesthetic
  • Left portal vein branch punctured under ultrasound guidance and a 6 Fr sheath inserted
  • Wire and catheter access into the right portal vein
  • Right internal jugular vein puncture under ultrasound guidance and a 10 Fr sheath inserted
  • Wire and catheter access into the middle hepatic vein
  • Portal vein to right atrium pressure gradient measured
  • In-house 0.018 wire snares were opened in the hepatic venous and portal venous sites and the fluoroscopy machine rotated to bring them into alignment
  • Percutaneous puncture performed through both snares under fluoroscopic guidance
  • A wire was passed through the needle, snared, and pulled through on both ends to establish through-and-through access across the hepatic parenchymal tract
  • The parenchymal tract was then dilated with a 6 mm balloon and the 10 Fr jugular sheath advanced into the portal venous side
  • A pigtail catheter was used to measure the length followed by deployment of an 8 cm TIPS stent
  • The portal vein to right atrium pressure was again measured and had decreased
  • Coil embolization of the left portal venous puncture site

Case Discussion

Transjugular intrahepatic portosystemic shunt (TIPS) placement is a complex procedure performed by interventional radiologists. First performed in 1988 1, the procedure is known to be potentially difficult and time-consuming, particularly the step where hepatic vein to portal vein access is established. First described in 1996, the "gun-sight" technique involves positioning snares in the portal vein and hepatic vein (or IVC2. The snares are then aligned in the same plane and punctured percutaneously. A wire is inserted and pulled through from the hepatic / IVC and portal venous sides. The remainder of the TIPS procedure can then be performed with usual techniques. "Gun-sight" TIPS was first described as a salvage technique where other techniques have failed or are difficult for anatomical reasons 3, but has gained some popularity as a primary technique in certain settings.

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