37 year old female with a known diagnosis of Budd-Chiari Syndrome who presented originally with a history of recurrent ascites. She experienced an acute upper GI bleeding secondary to varices near the GE junction, resulting in acute hypotension. The patient now presents for an urgent TIPS.
Comment: Attempts were made to place a TIPS in this patient from a hepatic vein approach. However, no recognizable hepatic veins were evident and no collaterals could be accessed percutaneously. As a result, we placed an 18g Chiba needle using a transhepatic approach from the midaxillary line; the needle was directed towards the RA-IVC junction. At the same time, the right internal jugular vein was accessed and a snare was positioned in the upper IVC. The needle was directed towards and passed through the snare. A guidewire was then advanced through the needle and that wire was pulled into the IJ sheath by the snare. A 5F sheath was then advanced from the liver into the IVC and a second wire was placed through the sheath and captured (in order to have a safety wire). At this point, the intrahepatic tract was dilated and a 10F sheath was advanced from the neck into this new tract through the liver. A CO2 venogram was then performed, followed by creation of a TIPS through this tract, extending from the right portal vein into IVC. Note that once the first stent was in place, it was short of the IVC so additional stents had to be placed. In addition, thrombus was noted at the origin of the right portal vein with preferential flow into the left portal vein. Mechanical thrombectomy had to be performed to insure portal vein and TIPS patency. At the conclusion of the procedure, the portosystemic pressure gradient decreased from 39 mm Hg to 10 mm Hg.