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. 2022 Jan 11;45(5):696–702. doi: 10.1007/s00270-021-03054-2

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© The Author(s) 2022

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Fig. 2 — Balloon puncture technique for transsplenic portal vein recanalization–transjugular intrahepatic portosystemic shunt placement. A After successful splenic access was achieved, a 4-F diagnostic catheter was introduced in the splenic vein and a splenoportography the occlusion of > 95% of the portal vein was confirmed. B The obliterated portal vein was gently catheterized with a micro-catheter in this case and filiform original intrahepatic portal vein branches could be detected. C After recanalization of the portal vein, a 6-mm balloon catheter was inflated as the fluoroscopic target in the intrahepatic portal vein branch. The TIPS needle was introduced through a standard transjugular access into the appropriate hepatic vein. D After successful intrahepatic puncture under fluoroscopy guidance from the hepatic vein into the balloon-dilated portal vein branch, a control wire was introduced via the TIPS needle and is captured at the splenic access site. Then, a standard TIPS procedure was performed with gently dilatation of the puncture tract. E The TIPS sheath was advanced in through the TIPS tract and a portography was generated to evaluate the position of the TIPS stent graft. F A final portography was generated to confirm sufficient flow through the TIPS stent graft. In this case, a second TIPS stent graft was placed to cover the complete length of the TIPS tract