Transjugular Intrahepatic Portosystemic Shunt Placement for Cavernous Transformation Through the Gun-Sight Approach

Purpose: Transjugular intrahepatic portosystemic shunt (TIPS) is a well-established treatment for complications associated with portal hypertension. Portal vein thrombosis increases the technical difficulty associated with this procedure because the portal vein fibroses and shrinks over time, making it difficult to access. This report describes a unique technique for successfully completing a TIPS procedure in these patients.

Materials and Methods: A 28-year-old man with a history of sleeve gastrectomy in November 2014 presented within 2 weeks postprocedure with abdominal pain and was found to have portal vein thrombosis. The patient was found to have prothrombin gene mutation. Over time, he developed portal hypertension and esophageal varices. The patient was referred for repeated episodes of bleeding varices.

Results: Under ultrasound guidance, percutaneous transplenic puncture of a peripheral splenic vein with a straight in-line path to the main splenic vein was performed. Antegrade splenic venography was performed using CO₂ given the patient’s allergy to iodinated contrast, which demonstrated multiple collaterals with complete occlusion at the portal confluence. A catheter and glidewire were used to recanalize the thrombosed portal vein. A 10-mm goose-neck snare was advanced into the portal vein. Right internal jugular (IJ) access was obtained. Unsuccessful attempts at snaring the Colapinto needle using the 10-mm snare via the transplenic access were made. A 15-mm goose-neck snare was then advanced via the right IJ sheath. Fluoroscopy-assisted percutaneous midabdominal puncture was made with the needle passing through both snares. This established through-and-through IJ–transhepatic–transplenic access. A Gore Viatorr TIPS endoprosthesis stent was deployed from the middle hepatic vein to the remnant portal vein. A retrograde CO₂ portogram showed minimal flow through the covered stent graft. Using AngioJet, thrombectomy was performed along the length of the portal stent. A repeat retrograde CO₂ portogram demonstrated brisk flow through the TIPS. Transplenic access tract embolization was performed.

Conclusions: Portal hypertension with associated cavernous transformation presents a challenge for the TIPS procedure given the portal vein is often diminutive, making it difficult to perform a standard TIPS. The gun-sight approach provides a method for creating TIPS via through-and-through right IJ–transhepatic–transplenic access.