Hepatic laceration from wedged venography performed before transjugular intrahepatic portosystemic shunt placement

Transjugular intrahepatic portosystemic shunt (TIPS) placement is an increasingly used, nonoperative technique for treating variceal bleeding and refractory ascites secondary to portal hypertension. Since the first clinical TIPS case in 1989, the procedure has undergone significant technical refinement to improve the safety and efficacy of shunt placement. A major technical challenge of TIPS creation is passage of the transjugular needle from the hepatic vein into the portal vein. Perforation of the liver capsule from an errant needle pass can lead to massive intraperitoneal bleeding. To minimize the number of needle passes required to enter the portal vein, investigators have devised a variety of techniques to visualize the portal vein anatomy including direct transhepatic catheterization of the portal vein, superior mesenteric artery (SMA) angiography, real-time ultrasound (US) guidance and refluxing contrast medium into the portal vein with wedged hepatic venography. While these technical improvements have made TIPS a safe and attractive alternative to conventional surgical shunts, the procedure remains technically challenging and lethal hemorrhagic complications can occur when the liver capsule is perforated during the course of the procedure. To our knowledge, there are no reported major complications directly related to the wedged hepatic venogram prior to TIPS. We describe an unusual series of severe liver injuries from wedged hepatic venography during attempts to localize the portal vein.