Technical challenges in TIPS creation via the right subclavian vein

Area of Science:

• Interventional Radiology
• Hepatology
• Surgical Gastroenterology

Background:

• Transjugular intrahepatic portosystemic shunt (TIPS) is a crucial intervention for managing complications of portal hypertension, such as refractory ascites in patients with liver cirrhosis.
• Surgical repair of large umbilical hernias in cirrhotic patients can be complicated by increased intra-abdominal pressure and ascites.
• Pre-operative TIPS placement is sometimes necessary to optimize surgical candidates with severe portal hypertension.

Observation:

• A 64-year-old male with Laennec cirrhosis presented with a large symptomatic umbilical hernia requiring surgical mesh repair.
• Pre-operative management included TIPS placement to address refractory ascites.
• Vascular access for TIPS was challenging due to occlusion of bilateral internal jugular veins and the right external jugular vein.

Findings:

• Successful TIPS creation was achieved by accessing the right subclavian vein.
• The procedure demonstrated the feasibility of TIPS creation from an alternative venous access site when standard routes are unavailable.
• Technical challenges associated with right subclavian vein access for TIPS were encountered and managed.

Implications:

• This case highlights the importance of alternative venous access strategies in interventional radiology procedures like TIPS.
• Successful TIPS placement via the subclavian vein can enable necessary surgical interventions in complex cirrhotic patients.
• Understanding and overcoming anatomical variations and occlusions are critical for successful TIPS outcomes.