Transhepatic Access: Alternative Approach for Right Heart Catheterization and Pulmonary Angiography

Peripheral vascular disease, chronic large-bore venous access, and small body habitus can limit traditional venous access methods for right heart catheterization. We present a patient with chronic renal failure, small body habitus due to developmental delay, and multiple central vein stenoses due to chronic indwelling catheters and heparin-induced thrombocytopenia, who required right heart catheterization for workup of possible intracardiac shunt, pulmonary hypertension, and pulmonary embolism. We performed right heart catheterization and pulmonary angiography via transhepatic approach. The hepatic vein was accessed with a Chiba biopsy needle, and hepatic vein access was confirmed by contrast injection under fluoroscopy. A long 8-French sheath was advanced to the cavoatrial junction, and a balloon-tipped right heart catheter was used for pressure measurement, serial oxygen saturations, and angiography. Pulmonary pressures and angiography were normal, and there was no intracardiac shunt. Access-tract hemostasis was achieved with vascular plugs, embolization coils, and manual pressure. We demonstrate successful right heart catheterization and pulmonary angiography via transhepatic access. This is a valuable alternative access for patients with limited traditional options.