TIPS University Senior Year: Gunsight Technique & Splenic Closure

In this episode, Dr. Emmett Lynskey joins Dr. Chris Beck for the final edition of TIPS University to discuss the gunsight technique and splenic closure. We begin by discussing where to start once the catheter is in the portal vein and you have access, and Dr. Lynskey shares why he likes to use a 8mm balloon for the angioplasty.

We explain the details of the gunsight technique, how to line up the portal and hepatic snare, how to adjust the view, and how to get access to both veins using a 22 gauge chiba needle. We share why it is important to make sure that the cranial caudal difference between the portal and hepatic snare is not significant before you gunsight. We discuss how to work with wires to floss through the splenic vein. Dr. Lynskey tells us why he uses a microcatheter for an extra step instead of snaring the end of the wire. We review some situations where you can throw the snare up and stick it with a colapinto needle and some of the considerations for portal vein thrombosis when doing TIPS.

We discuss splenic access and why it is important to set up for good closure. We explain the different options for splenic access, using a combination of coils, plugs, and gelfoam, and Dr. Lynskey shares which combinations he prefers to use for splenic closure. We review the technique to get images using fluoro and ultrasound.