Hepatic artery-targeting guidewire technique during transjugular intrahepatic portosystemic shunt

Abstract

Objective: This study evaluated the feasibility and safety of the transjugular intrahepatic portosystemic shunt (TIPS) procedure using the hepatic artery-targeting guidewire technique for the puncture step. Methods: We retrospectively reviewed 11 consecutive patients (5 men and 6 women, aged 46-76 years (mean 64 years)) with portal hypertension in whom the TIPS procedure was performed. As the first step in the TIPS procedure in all cases, a micro-guidewire was inserted into the hepatic arterial branch accompanying the portal venous branch through a microcatheter coaxially advanced from a 5-French catheter positioned in the coeliac or common hepatic artery. At the puncture step, the tip of the metallic cannula was aimed 1 cm posterior to the distal part of this micro-guidewire, after which the TIPS procedure was performed. Success rate, number of punctures and complications were evaluated. Results: The TIPS procedure was successfully performed in all 11 patients. The mean number of punctures until success in entering the targeted portal venous branch was 5 (range 1-14). In 3 patients (27%), the right portal venous branch was entered at the first puncture attempt. The hepatic artery was punctured once in one patient and the bile duct was punctured once in another patient. No serious procedure-induced complications occurred. Conclusion: The TIPS procedure can be accomplished safely, precisely and relatively easily using the hepatic artery-targeting guidewire technique. [2,3]. In many institutions, including ours, however, this procedure is rarely performed and it might be difficult to maintain the necessary skills.During the TIPS procedure, the puncture from the proximal portion of the hepatic vein (usually a right hepatic vein) to the proximal portion of a branch of the intrahepatic portal vein (usually the right portal vein) is the most important and difficult step [1,2]. In 1994, Matsui et al [4] introduced a simple technique to assist in this puncture step. This technique was aided by a targeting guidewire in the hepatic arterial branch accompanying the portal venous branch to be punctured. To our knowledge, there has been no subsequent literature on the use of this simple technique, which we have adopted in our institution. This study evaluated the application of the hepatic artery-targeting guidewire technique for the puncture step of the TIPS procedure. We also assessed the occurrence of procedure-induced complications in order to clarify the value of this technique to inexperienced or infrequent operators such as those in our institution. Methods and materials PatientsBetween January 2004 and July 2009, 11 consecutive patients (5 men and 6 women aged 46-76 years (mean 64 years)) with portal hypertension underwent the TIPS procedure at our institution. For these patients, the hepatic artery-targeting guidewire technique was utilised for the puncture step of the TIPS procedure. ProceduresAll procedures were performed after the patient provided written informed consent. The consent form included permission fo...

Intravascular Ultrasound in the Creation of Transhepatic Portosystemic Shunts Reduces Needle Passes, Radiation Dose, and Procedure Time: A Retrospective Study of a Single-Institution Experience

“…Attempts have been made to improve visualization and reduce radiation exposure during the procedure, including the use of biplanar angiography (10); guide wire placement targeting the hepatic artery (11), computed tomography (CT)-guided direct percutaneous transhepatic puncture of the left portal vein through a snare placed in the left hepatic vein (12,13); and the "gun-sight" technique, which involves transhepatic needle puncture through two snares, one placed in the right portal vein with CT guidance and the other placed in the retrohepatic IVC (14). Although these methods have been reported to aid in portal vein puncture, there has been particular interest in the use of ultrasound (US) guidance (15)(16)(17)(18) because it does not involve increased radiation.…”

Ultrasound‐guided portal vein puncture during Transjugular Intrahepatic Portosystemic Shunt: Technique and experience of a quaternary liver transplant hospital

“…These include 'blind' puncture using bony landmarks, guidance using radio-opaque markers placed percutaneously, wedged portography and transabdominal US guidance. 14,[20][21][22][23][24] More novel techniques using magnetic resonanceguidance, cone beam computed tomography and intravascular ultrasound have also been described, although these methods require additional expensive equipment. [11][12][13] Currently, PV puncture during TIPS is most commonly achieved with wedged portography using either iodinated contrast or carbon dioxide.…”

Intrahepatic arterial localizer guided transjugular intrahepatic portosystemic shunt placement

“…The study of arterial targeting for TIPS puncture was first introduced by Osamu Matsui et al in 1994, [19] and then further reported by Yamagami et al [20] In those previous study, the author advocated puncture of the portal vein 1 cm posterior to the targeting guidware placed in celiac trunk which will promote the successful rate of TIPS puncture. In our study, we determined in advance the entry point of the portal side with enhanced CT reconstruction, then we chose the hepatic artery adjacent to the portal entry point for IHAL placement.…”