Table 1 Tips and Tricks for percutaneous ultrasound-guided DIPS creation

Drainage of ascites shortly before the procedure.

Excess amount of ascites may cause the liver to float within the abdomen subsequently making the puncture of the portal vein difficult. The position of the liver is also more stable when all ascites is drained.

Performing the procedure in general anesthesia.

A longer breath-hold can be achieved with the patient in general anesthesia - this makes especially the initial puncture of the portal vein and vena cava easier to perform.

Careful assessment of site, trajectory and angle of the puncture into the portal vein and the vena cava.

As this is the most important step of the procedure, it is of outmost importance to ensure that the main trunk of the right or left portal vein and subsequently the vena cava are punctured correctly through the caudate lobe of the liver.

Controlling the puncture of the portal vein and vena cava in sonography and fluoroscopy.

It is very important to keep the needle trajectory stable and to ensure a successful access to both vessels – this can be achieved by constant sonographic or fluoroscopic imaging during the puncture. The correct intravascular positioning has to be controlled by angiography once the needle is inside the portal vein and/or the vena cava.

Making sure that the covered parts of the endografts reach sufficiently into both the vena portae and vena cava before deploying them.

The covered parts of the endograft must cover the whole DIPS tract, and this can be achieved by letting the covered parts reach into the vena cava and vena portae. If this is not the case, there is a risk of free-lying uncovered retro- or intraperitoneal stent struts with subsequent risk of major bleeding.

Puncturing the portal vein with a stiff 18-20G needle and then continuing the puncture to the vena cava with a Chiba-needle in coaxial technique.

In order to facilitate access it can be helpful in some patients to perform the initial puncture of the portal vein with a stiff needle. Once access is gained, a Chiba-needle can be introduced coaxially and the vena cava is then punctured under sonographic and fluoroscopic imaging.