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PERCUTANEOUS portosystemic shunts are sometimes needed in patients with very small, angulated, or occluded hepatic veins. In these patients, creation of a standard transjugular intrahepatic portosystemic shunt (TIPS) may be difficult or impossible. An alternative method of nonoperative portal decompression is the creation of a transcaval portosystemic shunt. Herein we describe a" gun-sight approach" used to expedite formation of a percutaneous portacaval shunt.