Technique

Prior to TIBS, computed tomography (CT) or magnetic resonance cholangiopancreatography was performed to evaluate the hepatic anatomy and plan the most appropriate pathway for intervention. TIBS was performed with the patients under conscious sedation with intravenous pethidine hydrochloride (Demerol, Keukdong) and local anesthesia with subcutaneous lidocaine (Jeil Pharmaceuticals) injection. Intravenous antibiotics (Cefotaxime) were administered 2 hours before the procedure and for at least 48 hours after the procedure. The right internal jugular vein was accessed with a micropuncture set under the guidance of ultrasound. Then the venotomy site was serially dilated and a 9 French (F) sheath (Cook Medical) was inserted. A 5 F angiographic catheter was manipulated into the right hepatic vein. Biliary duct was accessed using Ring transjugular intrahepatic access set (RTPS-100, Cook Medical). The location of bile duct was approximated by referring pre-acquired CT. The right intrahepatic bile duct was punctured using a 16-gauge modified Colapinto needle (Cook Medical) under the guidance of fluoroscopy and then was negotiated with a 0.035-inch hydrophilic guidewire (Terumo). After passing the catheter into the biliary system, a cholangiography was performed to determine the location and length of the biliary obstruction. The obstructed biliary segment was traversed with the guidewire. The 9 F sheath was introduced immediately after cannulation of obstructed bile duct with guidewire and 5 F catheter. The 9 F sheath was carefully managed to keep the location during procedure and only removed at the end of the procedure. Pre-balloon dilatation was performed using an 8 mm balloon catheter (Mustang, Boston Scientific) in each of the patients.

Uncovered self-expandable metallic stents with a diameter of 10 mm or 12 mm (Zilver, Cook Medical) were initially deployed across the obstruction so as to cover the biliary duct at a position approximately 2–4 cm proximal to the steno-occlusion to prevent overgrowth of tumor. In all patients, the distal portion of the stent was placed across the papilla to bridge the duodenum. If cholangiogram taken immediately after stent placement did not demonstrate fluent contrast media passage because of immediate tissue ingrowth into the stent, an additional covered stent (GD stents, TaeWoong Medical) was placed. Very little bile reflux to systemic vein seemed to occur during stent placement because of the TIPS sheath tamponading the tract. Prior to sheath removal, we aspirated the remaining bile juice in the biliary system as much as possible. The sheath was removed if completion cholangiography demonstrated good contrast media passage through the stent into the duodenum (Fig. 1). In the first three patients, parenchymal tract embolization was performed using coils prior to sheath removal.

A 40-year-old female with pancreatic cancer and multiple metastases presented with jaundice and ascites (Patient 2). Coronal reconstructed computed tomography image (a) shows diffuse bile duct dilatation and massive ascites. Cholangiography (b) obtained after cannulation of the bile duct using a Colapinto needle shows dilatation of the bile duct and ensures successful biliary access. In image (c), the obstructed bile duct segment was traversed up to the duodenum using a 0.035-inch hydrophilic guidewire and 5 F catheter. Subsequent jejunography showed that the lower intestinal tract was free of obstruction (not shown). A self-expandable bare metallic stent (10×80 mm) was successfully placed across the distal bile duct obstruction (d). Completion radiograph (e) shows good contrast media passage to the jejunum and multiple coils between the hepatic vein and biliary duct for tract embolization.