Mirror mirror: TIPS in situs inversus with transfemoral transcaval guidance

An 18 year old with history of situs inversus and biliary atresia status post Kasai portoenterostomy in infancy presented with melena and syncope. He continued to bleed despite banding of esophageal varies due to apparent small bowel varices. The patient was referred for TIPS creation. After multiple failed attempts to create a TIPS using standard techniques, another form of portal vein targeting was required. The patient's anatomy contraindicated potential transhepatic, transplenic, and trans-mesenteric portal venous access. A 21-gauge Chiba needle was utilized to puncture the SMV from a transfemoral transcaval approach, and a 0.018 wire advanced into the portal vein to be used as fiducial. A transjugular Colapinto needle was then directed into this portal vein target. The TIPS was completed, and the hepatic venous-portal venous gradient dropped from 21 to 4 mmHg. The patient had no further melena or hepatic encephalopathy at discharge 2 days post-procedure or at 6-month follow-up.