Cross-sight transjugular intrahepatic portosystemic shunt (CS-TIPS): combined ultrasound-fluoroscopy guidance for simultaneous percutaneous portal and hepatic vein puncture and access closure with plug deployment.

Transjugular Intrahepatic Portosystemic Shunt (TIPS) is a well-established procedure for managing portal hypertension and its complications that are refractory to medical and endoscopic therapy. However, complex cases may render the conventional approach ineffective. We describe the cross-sight (CS) technique, which combines ultrasound and fluoroscopic guidance to allow simultaneous puncture of the hepatic and portal veins through a single transhepatic needle pass. Following portal access, stent graft deployment is performed via the jugular route, while the percutaneous tract is closed with a vascular plug to minimize bleeding risk. In our experience, this approach enabled safe and effective shunt creation after failed standard TIPS, with no procedure-related complications. The CS technique provides enhanced procedural control and avoids the limitations of alternative strategies such as DIPS or gun-sight methods. By reducing puncture attempts and access points, it represents a feasible salvage option for complex TIPS cases, with potential immediate application in interventional radiology practice.