Using a cutaneous approach, a communication tract is created between a hepatic vein and the portal vein to decompress portal hypertension.

The hepatic veins are catheterised using the right internal jugular vein for access (via the SVC and right atrium). A passage is created from the hepatic vein into the portal vein through liver parenchyma. Direct measurement of the systemic and the portal pressures is then made. The tract is then dilated with a balloon. A metallic stent is deployed in order to try and maintain the tract against the recoil of the surrounding liver parenchyma. The resultant reduction in portal venous pressure can then be measured. In general, a gradient of less than 12 mmHg is the target. Serial dilations of the stent can be performed until satisfactory pressure levels have been reached. Varices can be embolised at this stage (if required) using a catheter passing through the stent into the portal veins for access. In patients who may go on to liver transplantation, the stent should occupy less than half of the extrahepatic portal vein.

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