Carol
Procedure:
The patient was placed in the supine position on the fluoroscopy table.
The skin over the left groin, left abdomen, and left upper quadrant was prepped and draped in the usual sterile fashion.
The largest pocket of ascites was identified in the left lower quadrant. 1% lidocaine was used to anesthetize the skin and subcutaneous tissues. Using a micropuncture needle and ultrasound guidance, the peritoneal cavity as accessed. The transitional dilator was placed and a Bentson wire was advanced into the peritoneal cavity under fluoroscopic guidance. Over the Bentson wire, a 5 Fr pigtail catheter was placed. Ascites was aspirated throughout the case. A total of 7.6 Liters of serosanguinous ascites was aspirated. The 5 Fr pigtail catheter was removed at the end of the case with
Attention was then turned to the spleen. Under ultrasound guidance, the inferior pole splenic vein was accessed using a 21 gauge Accustik needle. A splenic venogram was performed through the 21 gauge needle. There were prominent splenic varices. The major outflow was via mesenteric to lumbar collateral veins as well as left chest wall collateral veins. No large gastric varices were noted via the splenic venogram. Therefore, 21 gauge needle was removed and pressure was held for hemostasis.
The left common femoral was accessed using a micropuncture needle under ultrasound guidance and then upsized to a 5 Fr sheath over an Amplatz wire. A left common iliac / IVC venogram was performed which demonstrated a patent venous system.
Through the 5 Fr sheath, a 5 Fr C1 catheter and 0.035" glidewire was used to access the left renal vein and left gastrorenal shunt/phrenic vein. The C1 was exchanged for a 5 Fr glidecath which was used to access the left gastrorenal shunt/phrenic vein. A venogram was performed which demonstrated a small gastrorenal shunt measuring 8 mm into the left renal vein.
The glidecath was advanced to the apex of the left phrenic vein. A venogram was performed which demonstrated the left phrenic venous plexus with small connections to gastric veins. There were no large gastric varices. Additional venograms were performed of the left phrenic vein branches. The left adrenal vein was identified. There was no evidence of large gastric varices.
A 2.4 Fr progreat microcatheter with 0.014" fathom microwire was used to advanced into the phrenic venous plexus in an attempt to cross into the gastric veins. However, due to the tortuosity, this was unsuccessful.
At this point, the decision was made to end the procedure.
All catheters and wires were removed. The right groin sheath was removed and pressure held to hemostasis.
The patient tolerated the procedure well.
There were no apparent immediate complications.
Impression:
1) Splenic venogram with large draining veins/varices into mesenteric/lumbar collaterals as well as left chest wall collaterals. There were no large gastric varices that were amenable to treatment via the splenic venogram.
2) Patent common iliac vein and IVC
3) Gastrorenal shunt measuring 8 mm with connection to small gastric veins via the left phrenic vein venous plexus. There were no large gastric varices that were amenable to treatment via this retrograde venogram.
4) Uncomplicated paracentesis with a total of 7.6 Liters serosanguinous ascites aspirated.
Plan:
1) Continue monitoring for bleeding and transfuse PRN.
2) No indication for additional IR intervention at this time.