B-28: Tips Catheterization / Revision
  • Indications
    • Established TIPS with Doppler evidence of (impending) malfunction
    • This is generally done as an outpatient procedure
  • Contraindications
    • Contrast allergy (premedicate)
  • Patient Evaluation
    • Able to lie flat on table and cooperate during procedure
  • Preprocedure Orders
  • Tools
    • Micropuncture access set and vascular dilators size 6, 8 and 10 Fr.
    • Bentson and 180cm Amplatz wires
    • 5 Fr. pigtail catheter, pressure transducer set up
    • 9 Fr. x 45cm Cook hemostatic sheath
    • Angioplasty balloons (8mm and 10mm) +/- WallStents for revision
  • Entry site
    • Right or left internal or right external jugular vein
  • Technique
    • TIPS angiogram and hemodynamic evaluation: Micropuncture entry into jugular vein. Dilate entry and place 9 Fr. sheath into IVC. Record IVC and RA pressures through sheath. Perform IVC-gram. Select shunted hepatic vein with curved catheter and advance guide wire into shunt. Traverse shunt with guide wire and catheter and exchange for Amplatz wire. Introduce pigtail into portal vein over Amplatz. Withdraw sheath into RA. Measure simultaneous portal and right atrial pressures. Perform portal venogram.
    • TIPS revision: Give 2000U heparin IV unless patient actively bleeding or has significant coagulopathy. Dilate entire shunt using 8-10mm angioplasty balloon over Amplatz wire. Balloon size is based on final dilatation of original TIPS or last revision. Perform 3 minute inflations at 12 atm. Exchange for pigtail, recheck pressure gradient, and repeat angiogram. Persistent pressure elevation or angiographic defects in shunt or outflow vein will require stenting. Stents added to either end of the shunt should be oversized if possible (i.e., 12mm stents in a 10mm shunt) to avoid migration. After stenting and repeat dilatation with the balloon catheter, recheck pressures and angiogram. When satisfactory result is obtained, remove catheters and sheath and obtain hemostasis.
  • Post-procedure Note
    • Record pre- and post gradients and note interventions performed
  • Post-procedure Orders (inpatient)
    1. Ultrasound with Doppler study of portal vein post procedure
    2. Bed rest x 4hr.with HOB elevated 60·
    3. Check VS (HR, BP, RR), check right IJ or EJ puncture for bleeding or hematoma
      • q 15 min x 2, then
      • q 30 min x 4, then
      • q 1 hour x 2
    4. If bleeding or hematoma at puncture site occurs, elevate hob to 90 degrees, apply light manual compression, and call H/O
    5. Resume other previous orders and medications.
    6. H/O to review and cosign these orders

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