Transjugular intrahepatic portosystemic shunt

Contributed by: Ed Boas

History: 59 year old man with alcoholic cirrhosis and a history of upper GI bleeding.

 Right hepatic venogram (5 F MPA catheter)

 Wedged carbon dioxide right hepatic venogram (14 mm Python balloon) shows the right hepatic vein and the portal vein.

 A Colapinto set was advanced from the right hepatic vein anteriorly into the right portal vein, and a portal venogram was performed.

A 5 Fr MPA catheter was then advanced into the SMV.

 Simultaneous contrast injection into the sheath (10 Fr Flexor) and pigtail catheter (5 Fr)

 The tract was pre-dilated (8 mm x 4 cm Conquest  balloon).

 A Viatorr stent graft (7 cm x 10 mm) was then deployed and plastied (10 mm x 4 cm Conquest balloon).

Splenic venogram shows two gastric varices arising from the splenic vein, and draining into the left renal vein.

Contrast injection into the larger gastric varix (7 Fr Python balloon catheter) was used to determine its volume.  6 ml of sclerosant (Ethanolamine, Gelfoam, and Ethiodol) was then injected.  Before deflating the balloon, two Nester coils (14 cm x 6 mm) were deployed at the base of the varix.

Post-embolization venogram shows the smaller gastric varix.

The smaller varix was selected with a microcatheter (Progreat 2.8 Omega), and sclerosant was injected.

 Completion venogram shows no more filling of gastric varices, and shows good flow through the TIPS.