Fig. 1. Hepatic venogram showing the left hepatic vein.	Fig. 2. MCS=metal cannula and 7-F sheath, CN=21-gauge Cope needle, and LPV=left portal vein.

Case Reference No. CC-597-10 The patient is a 37-year-old previously healthy white male presenting with vague upper abdominal pain for several months and new onset of ascites. The diagnosis of Budd-Chiari syndrome was suspected clinically and later confirmed by hepatic venography and transjugular liver biopsy. Initial therapy included an attempt to create a transjugular intrahepatic portosystemic shunt. Hepatic venography revealed typical "spider vein" collaterals and near complete thrombosis of normal hepatic venous structures. The portal veins were widely patent. After partial recanalization of the right hepatic vein, multiple unsuccessful attempts were made to access the portal system. The engorged liver parenchyma was soft and easily compressed by the rigid Colapinto needle, causing downward displacement of the right hepatic vein. This placed the right hepatic vein into the same plane as the right portal vein, making TIPS creation with the standard Colapinto set nearly impossible.

Fig. 3. S=sheath, CN=21-gauge Cope needle, C=4-F catheter, and GW=0.018-inch guide wire. Fig. 4. Hepatic portal shunt following stent placement.

The patient returned for a second TIPS attempt. This time a sheath was seated into the residual stump of the left hepatic vein and the 7-F, blunt-ended metal cannula and sheath of a Cook transjugular liver biopsy set was used instead of the Colapinto needle set. We postulated that the smaller blunt-ended cannula would create less downward force on the hepatic parenchyma and thereby reduce displacement of the hepatic veins. After being directed posteromedially, a long 21-gauge Cope needle was passed through this apparatus, achieving prompt access into the left portal vein. The needle was exchanged over an 0.018-inch guide wire for a 4-F straight catheter that could not be advanced into the portal venous system. Subsequently, the 4-F catheter was mounted onto the Cope needle and readvanced over the wire as a unit. The added support of the needle allowed easy passage of the catheter into the portal system. The TIPS was then completed without any further difficulties.

Questions 1) Has anyone else used this or similar techniques? 2) Are there any other important tricks for these difficult cases or ways to enter the portal vein when it lies in the same cephalocaudal plane as the hepatic vein?