A Method to Prevent Life-threatening Intraperitoneal Bleeding During Transjugular Intrahepatic Portosystemic Shunt Creation

Purpose : To prevent intraperitoneal bleeding, it is critical that the extrahepatic portal vein should not be punctured during transjugular intrahepatic portosystemic shunt(TIPS). There has, however, been no procedure for defining the anatomic relationship between the hepatic capsule and the portal vein segment before shunt formation. To avoid a possibly catastrophic outcome of extrahepatic portal puncture before shunt creation, we therefore devised a new method; the purpose ofthis study is to report its efficacy and feasibility. Materialsand Methods : Whenever a portal vein was punctured, we advanced a 9F sheath over a guidewire into the portal vein before balloon dilatation of the tract. Contrast material was then injected through the sheath as this was slowly withdrawn from the portal vein towards the hepatic vein. When contrast material extravasated or spilled into the peritoneal space, thus suggesting extrahepatic portal vein puncture, a more peripheral segment ofthe portal vein was punctured, and a shunt was created using this new tract. We applied this method to l30 consecutive patients who underwent TIPS to control variceal bleeding due to liver cirrhosis. In all cases, portography and ultrasonography were used for immediate confirmation ofthe procedure. Results : Puncture ofthe extrahepatic portal vein segment occurred in three out l30 (2.3 %) patients. In these three, TIPS was successfully created using the method described above. Clinical and ultrasonographic follow-up showed that no patients suffered intraperitoneal bleeding. Conclusion : For preventing intraperitoneal hemorrhage during TIPS creation, our method is effective and feasible.