TIPS Creation in Patients with Persistent Left Superior Vena Cava

Abstract

Transjugular intrahepatic portosystemic shunt is a minimally invasive endovascular procedure that has played an important role in the treatment of acute or repeated variceal bleeding or refractory ascites. The standard venous access route for this procedure is the right jugular vein. Sometimes it is better to use the left jugular vein because of lower probability of life threatening complication or technical failure. In this case reports the authors have described their experience with TIPS creation in two patients with persistent left and absent right superior vena cava and recommend using the left jugular vein as an access route in this rare anatomical variant.

Transjugular intrahepatic portosystemic shunt creation via isolated persistent left superior vena cava: a case series

“…A TIPS may be placed in the setting of congenital or acquired anatomic challenges using various methods, including direct transcaval portal access (i.e. direct intrahepatic portocaval shunt) (Petersen and Clark 2008), transfemoral intrahepatic routes for challenging transjugular approaches, and left-sided access in patients with situs inversus (Chovanec et al 2010;Postoak et al 2002;Kundaragi and Ganjoo 2018). Left IJ access, while performed less commonly during TIPS in patients with standard anatomy, may provide trajectory benefits in patients with cirrhosis and cranially situated livers with failed previous right IJ access attempts (Hausegger et al 1998).…”

“…Left IJ access has also been described, and potentially allows for greater engagement of the right hepatic vein, increasing the amount of torque that may be transmitted to the curved cannula for portal vein puncture (Ratliff et al 2006 ). TIPS placement via an isolated PLSVC has been described in single case reports (Petersen and Clark 2008 ; Petridis et al 2010b ; Chovanec et al 2010 ) and is associated with challenges, including an increased risk of arrhythmia, venous injury, and limited device maneuverability (Ratliff et al 2006 ).…”

Absent right superior caval vein in situs solitus

“…16 Furthermore, when the chosen approach of the procedure is impossible due to the anomaly, the necessary adaptation of the procedure may increase the risk of arrhythmias 11,17 or other complications such as puncture of the atrium 16 or the liver capsule. 17 During open-heart surgery, it is important to bear in mind the changed anatomy when selecting perfusion techniques to ensure adequate venous drainage and myocardial protection. 6,7,11,13 With the increased use of central catheters, pacemaker implantation, and cardiac surgery, knowledge of this anomaly is important to prevent future complications and morbidity.…”

“…Positioning the lead in the right atrial appendage is challenging, as the opening into the right atrium from the coronary sinus is very close to the right ventricular inlet, and the procedure requires careful manipulation 16 . Furthermore, when the chosen approach of the procedure is impossible due to the anomaly, the necessary adaptation of the procedure may increase the risk of arrhythmias 11 , 17 or other complications such as puncture of the atrium 16 or the liver capsule 17 . During open-heart surgery, it is important to bear in mind the changed anatomy when selecting perfusion techniques to ensure adequate venous drainage and myocardial protection 6 …”