Teaching Case

Too central position of primary TIPS puncture

In the patient, a TIPS procedure was performed because of a subacute Budd-Chiari syndrome with reduced liver function, caval compression and ascites. The portal vein was hit in a first attempt close to the bifurcation of the main portal vein into the left portal branch (Fig. 1 a, b). Angiography was performed with a 5 F Pigtail catheter. To avoid complications, it was decided to give up this position. By stepwise withdrawal of the catheter, a tractogram was performed not showing any leakage, so no embolization of the tract was performed. Bleeding may, however, not occur prior to balloon dilatation of the tract so PTA was avoided and a new tract, hitting the portal vein more peripherally was performed (Fig. 1 c).

One of the problems of TIPS is puncture of the portal vein in an extrahepatic position. If the procedure is continued, major bleeding into the peritoneal cavity is a potentially life-threatening complication that should be avoided. If only the small puncture instrument traverses through the free cavity, risk of major bleeding is relatively low. Removal of the needle and repuncture in a more safe position is recommended. In case bleeding occurs already in that stage, transcather embolization by glue or coils is another option. In doubt, a small-sized guidewire may be left in the first tract while a second more safe tract is created. Then, it may be checked both by portography and tractogram whether there is any bleeding evident. Over the small guidewire i place, then instruments for tract embolization can be easily entered into the tract. If bleeding occurs after PTA, this situation can be eventually solved by implantation of a covered stent graft sealing the location of leakage.