A 57-year-old male diabetic and alcoholic cirrhotic patient, on transplant list, entered the emergency room with general malaise and dyspnea. After exams collection on admission, leukocytosis and increased C-reactive protein were identified, and antibiotic therapy was started with Piperacillin plus Tazobactam. The patient developed renal dysfunction with hyperkalaemia and acidosis, in addition to hyponatremia, being referred to the intensive care unit with fluctuating level of consciousness, with massive ascites, worsening of ventilatory patterns, but hemodynamically stable. He evolved with the need for orotracheal intubation (OTI) after 5 days of the admission, and the diagnosis of coronavirus (COVID-19) was confirmed, in addition to acute deep vein thrombosis, requiring anticoagulant therapy.
The general condition worsened, with the patient presenting upper gastrointestinal bleeding 7 days after the OTI, requiring transfusion of red blood cells and cryoprecipitate, in addition to the introduction of vasoactive drugs. Terlipressin was started and referred for angiotomography with gastric and esophageal varices of large caliber being identified, and endoscopy band ligation. The patient showed improvement in ventilatory patterns, but continued to have subsequent bleeding with a drop in hematocrit to 24%. In spite of endoscopy treatment, TIPS was indicated to control recurrence of upper digestive bleeding. Liver function was consistent with Child C 10, MELD 30, bilirubin was 3,1mg/dl, platelets 30.000/mm3, INR 2,4 and Albumin 2,1 mg/dl.
Before and after the procedure, all recommended safety and secutiry measures by World Health Organization (WHO) have been adopted.
For the interventional radiologist, the mandatory individual equipment consists of use of appropriate PPE for standard, contact and airborne precautions. N95 or PFF2 standard masks or equivalent, and gowns, gloves, eye protection, aprons and shoes covers. These control measures described are important to minimize intra-institutional spread of SARS-CoV-2 and COVID-19, and should not be underestimated (1).
Standard TIPS access has started from the right internal jugular vein, guided by Ultrasound and fluoroscopy, followed by the 12F introducer implant. Right hepatic vein was catheterized through a MP catheter and a portogram was performed. The access of right portal vein branch was performed with RUPS-100 (Figure 1), followed by catheterization with hydrophilic guidewire and introduction of pigtail catheter to measure the stent and a pre-dilatation of the transhepatic path. IVC pressure was 17 mmHg, and indirect portal vein pressure measured 38 mmHg.
Stent implantation was performed with VIATORR 10mm x 8cm (Gore), followed by dilatation of the TIPS stent with Mustang 10mm balloon (Boston Scientific). A post-venoplasty portogram (Figure 2) showed improvement in IVC pressure (29 mmHg), and direct portal vein pressure (21 mmHg). The portosystemic gradient was 21 mmHg and drop to 8 mmHg.
There were no immediate complications with the procedure. At 2-weeks follow-up, the patient reported no symptoms of portal hypertension, including no further episodes of bleeding, and achieved a significant improvement in lung function, resulting in extubation, as well as in computed tomographic pattern (Figure 3).