42 - TIPS in a Patient with Situs Inversus: Transcaval Portal Venous Access for Guidance
A. Zians, M. U. Shahid, J. Gans, M. B. Jagust, J. Cynamon
Purpose: Rare and complex variant anatomy complicates routine procedures. The infrequency with which certain anomalies are encountered, emphasizes the importance of utilizing alternative assistive techniques. Situs Inversus is a rare condition in which the internal organs are a mirror image of the usual anatomy. Endovascular procedures, such as TIPS, on such patients can be very challenging.
Material and Methods: An 18-year-old male with PMH notable for situs inversus, biliary atresia status post hepatoportoenterostomy, and liver cirrhosis complicated by portal hypertension and esophageal varices presented with melena and near syncope. IR was consulted for urgent TIPS due to refractory esophageal variceal bleeding.
Results: Standard access was obtained in the right internal jugular vein and a 10-Fr sheath was advanced into a posterior hepatic vein. A 16-gauge Gore TIPS needle (W.L. Gore & Associates Inc, Flagstaff, AZ) was advanced into the hepatic vein via the sheath, and multiple anterior passes were made through the hepatic parenchyma without successful cannulation of the portal vein.
In review of the cross-sectional anatomy it was noted that the SMV was positioned just anterior to the left-sided IVC. The right femoral vein was then accessed and a 7-Fr stiffened TLAB sheath (Argon Medical Devices Inc, Frisco, TX) was placed in the infrahepatic IVC. A long Chiba needle (Cook Medical, Bloomington, IN) was passed through the sheath and directed toward the anterior wall of the IVC and into the SMV. An 0.018in guidewire was advanced into the portal vein to be used as a target for advancement of the TIPS needle. The relationship between the needle and guidewire was examined in multiple planes to determine the best trajectory. Following this assistive maneuver, the TIPS needle was accurately advanced into the portal system. The endograft was deployed and proved to be patent with venograms demonstrating good flow. No recurrent bleeding or evidence of encephalopathy occurred post-procedure. The patient remains well at six months follow-up.
Conclusions: Rare anatomic variants pose a challenge when performing procedures, and a strong understanding of the anatomy and the assistive techniques available can prove invaluable. In this case, a patient with situs inversus underwent a challenging yet successful TIPS placement by utilization of a transcaval to SMV fiducial guidewire approach.