Modified gun--sight transjugular intrahepatic portosystemic shunt technique

Objectives: Conventional transjugular intrahepatic portosystemic shunt (TIPS) stent insertion is an established procedure with high rates of technical success. However, alternative techniques may increase success rates in the setting of challenging anatomy or limited resources. Originally described as a salvage porto--caval approach, we present a modified gun--sight porto-hepatic TIPS technique. Methods: A retrospective review was performed identifying patients who underwent modified gun--sight TIPS over a 1--year period. Six procedures were identified, with snares opened in the target hepatic and portal veins, fluoroscopic percutaneous transhepatic puncture through the snares, and wire pulled through--and--through to establish a parenchymal tract. Five modified gun-sight procedures were primary, and one was salvage. Results: All modified gun--sight TIPS procedures were technically successful with a single needle pass, with patency and appropriate haemodynamic flow at 2 weeks. Advantages of the technique include fluoroscopic-guided transhepatic puncture utilising typically on--shelf low--cost equipment, without requiring a dedicated TIPS set or endovascular ultrasound. Disadvantages include liver capsular puncture. Conclusions: The modified gun--sight TIPS technique is an alternative approach utilising typically on--shelf and low--cost equipment for a targeted fluoroscopic--guided parenchymal puncture. Advances in knowledge: The presented technique is an initial description of a novel alternative TIPS technique, which may be useful to consider in challenging cases.