Under direct ultrasound guidance the left internal jugular vein is accessed with a micropuncture set sonographic documentation is achieved. Over the wire exchanges performed for a fluoroscopic guidance to the level of the inferior venacava. Inferior venacavagram is perfomed to assess caval anomaly and hepatic venous junction.
A catheter is advanced over the wire into the right hepatic vein were selected hepatic venogram was performed. There is appreciated a previosly placed TIPS shunt connecting to the right hepatic vein to the right portal vein. There is no appreciable flow within the TIPS.
The catheter and wire combination are utilized to selectively catheterize the indwelling TIPS. Multiple attempts were made to cross the area of total occlusion within the TIPS. The occlusion is eventually crossed and the wire is advanced into the portal vein. the catheter is advanced over the wire and selective portal venogram is perfomed to evaluate portal hypertension, portal anatomy and collateral vasculature There is again no significant flow appreciated via the indwelling TIPS shunt.
Multiple prominent gastroesophageal varices are appreciated. Three separate gastroesophageal varices are selected and venography perfomed in each vessel. Following this 3 srparate 6 mm coils were utilized for embolization of 2 separate fields a gastroesophageal varices. Residual filling of the varices was treated with embolization utilizing control gelfoam injection under fluoroscopic guidance.
The catheter was then removed over wire and a new catheter was placed into the portal vein. Selective portal venogram was again performed demonstrating no significant filling of the embolized gastric esophageal varices.
Angioplasty of the TIPS shunt an hepatic vein was then perfomed utilizing first a 6mm x 4 cm and subsequently a 9mm x 4 cm angiopasty balloon.Post angioplasty portal venogrqam demonstrates recannulization of the indwelling TIPS with blood flow now crossing the TIPS shunt. The portal systemic gradient was lowered to approximately 6 mmhg.
The catheters wires and jugular sheaths were removed and hemostasis achieved.
Impression:
Successful TIPS revision with TIPS angioplasty
Successful ultrasound guided vascular access of the left internal jugular vein
Successful multiple catheter selective venograms as described.
Successful 2 field coil embolization of multiple prominent gastric esophageal varices.
A catheter is advanced over the wire into the right hepatic vein were selected hepatic venogram was performed. There is appreciated a previosly placed TIPS shunt connecting to the right hepatic vein to the right portal vein. There is no appreciable flow within the TIPS.
The catheter and wire combination are utilized to selectively catheterize the indwelling TIPS. Multiple attempts were made to cross the area of total occlusion within the TIPS. The occlusion is eventually crossed and the wire is advanced into the portal vein. the catheter is advanced over the wire and selective portal venogram is perfomed to evaluate portal hypertension, portal anatomy and collateral vasculature There is again no significant flow appreciated via the indwelling TIPS shunt.
Multiple prominent gastroesophageal varices are appreciated. Three separate gastroesophageal varices are selected and venography perfomed in each vessel. Following this 3 srparate 6 mm coils were utilized for embolization of 2 separate fields a gastroesophageal varices. Residual filling of the varices was treated with embolization utilizing control gelfoam injection under fluoroscopic guidance.
The catheter was then removed over wire and a new catheter was placed into the portal vein. Selective portal venogram was again performed demonstrating no significant filling of the embolized gastric esophageal varices.
Angioplasty of the TIPS shunt an hepatic vein was then perfomed utilizing first a 6mm x 4 cm and subsequently a 9mm x 4 cm angiopasty balloon.Post angioplasty portal venogrqam demonstrates recannulization of the indwelling TIPS with blood flow now crossing the TIPS shunt. The portal systemic gradient was lowered to approximately 6 mmhg.
The catheters wires and jugular sheaths were removed and hemostasis achieved.
Impression:
Successful TIPS revision with TIPS angioplasty
Successful ultrasound guided vascular access of the left internal jugular vein
Successful multiple catheter selective venograms as described.
Successful 2 field coil embolization of multiple prominent gastric esophageal varices.
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