Creating a transjugular intrahepatic portosystemic shunt is a relatively new technique that may be carried out under local anesthesia. Using a right internal jugular approach, a long needle is placed through the internal jugular vein, the superior vena cava, and the right atrium, into the inferior vena cava. The right hepatic vein is cannulated and, with special steering wires, a needle is passed through the hepatic substance directly into the right branch of the portal vein. A small balloon is passed over the wire and through the hepatic substance and is inflated. After the balloon has been removed, a metallic stent (a flexible wire tube) is placed across this tract in the liver to keep it open. Blood now freely flows from the portal vein into the right hepatic vein, creating a portosystemic shunt.