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.

Figure 1

(a) Coeliac arteriography shows all hepatic arterial branches. Note that the A7 hepatic arterial branch accompanies the portal venous branch (P5) that would be punctured (arrow). (b) Posteroanterior screening shows the tip of the 14-gauge curved metal cannula covered by a 10-French Teflon catheter advanced to the right hepatic vein. (c) Lateral-oblique screening shows that the tip of the cannula is directed 1 cm posterior to the tip of the target guidewire in the A7 hepatic arterial branch (arrow). (d) After success in puncturing the portal venous branch (P7), a guidewire (arrowhead) was advanced into the superior mesenteric vein through a 5-French catheter. Note that the micro-guidewire and micro-catheter for targeting is positioned in the right hepatic arterial branch (arrows). (e) Direct portography shows prompt blood flow from the portal vein to the hepatic vein through the transjugular intrahepatic portosystemic shunt tract (arrows) that has just been created. Sufficient patency of the TIPS tract remained on subsequent follow-up with images such as ultrasonography and computed tomography scan.