Document30

Institutul Clinic Fundeni - Clinica de Radiologie si Imagistica Medicala

Mihalcea A, Lesaru M, Grasu M, Georgescu SA, Valette Mihalcea A, Lesaru M, Grasu M, Georgescu SA, Valette PJ, Henry L, Gheorghe C, Mihaila MPJ, Henry L, Gheorghe C, Mihaila M

IndicatiIndicationsons, , work-up algorithmwork-up algorithm, re, ressultultss


TIPSS – transjugular intrahepatic TIPSS – transjugular intrahepatic

porto- systemic shuntporto- systemic shunt

interventional therapeutic interventional therapeutic procedureprocedure creates a permanent transhepatic creates a permanent transhepatic communication between the portal communication between the portal and the caval systems and the caval systems equilibration of the pressure in equilibration of the pressure in ththeese two venous systemsse two venous systems


INDICATIONINDICATION

Severe portal hypertension of Severe portal hypertension of various etiology – complicationsvarious etiology – complications

recurentrecurent digestive digestive bleedingbleedingUncontroled variceal bleeding after two Uncontroled variceal bleeding after two sessions of sclerotherapy and sessions of sclerotherapy and haemostasis haemostasis with with Sengstaken Blakemore baloon = TIPSSengstaken Blakemore baloon = TIPSSS emergency indication (in 12-24 hours)emergency indication (in 12-24 hours)

uncontroled ascituncontroled ascitees s hepatorenal syndromehepatorenal syndrome cirrhotic patients with portal cirrhotic patients with portal hypertension waiting for liver transplant hypertension waiting for liver transplant


ABSOLUTE ABSOLUTE CONTRAINDICATIONSCONTRAINDICATIONSPHT not proved PHT not proved

Total bilirubineTotal bilirubine >50 micromol/l or seric >50 micromol/l or seric creatinine > de 180 micromol/lcreatinine > de 180 micromol/l

UncontroleUncontroledd portal encephalopathy portal encephalopathy

Chronic portal obstruction with portal Chronic portal obstruction with portal cavernomacavernoma

Spontaneous shunt with portal inversion Spontaneous shunt with portal inversion

Tumor invasion of the hepatic venous Tumor invasion of the hepatic venous system system

Hemodinamic instability – APACHE II Hemodinamic instability – APACHE II score> 20score> 20

Sepsis, activSepsis, activee infection infection


RELATIVE RELATIVE CONTRAINDICATIONSCONTRAINDICATIONSAnatomic abnormalities of IVC, HV Anatomic abnormalities of IVC, HV si PV;si PV;Recent thrombosis of PV;Recent thrombosis of PV;HHypervascular hepatic tumors;ypervascular hepatic tumors;Liver policystic disease Liver policystic disease


Advantages Advantages

ImmediatImmediatee physphysiopathologic impactiopathologic impacton splahnic and hepatic circulation – reduction of on splahnic and hepatic circulation – reduction of portal pression with loose of the hepatic portal portal pression with loose of the hepatic portal vascularisation vascularisation –– done only by the hepatic artery done only by the hepatic arteryon the systemic circulation on the systemic circulation on the cerebral function - ! encephalopathy riskon the cerebral function - ! encephalopathy risk

Less invasive comparing with surgical Less invasive comparing with surgical shunts – diminishes the postoperatory risk shunts – diminishes the postoperatory risk

Shunt calibration according to the clinical Shunt calibration according to the clinical context context


PRE - TIPSS EVALUATION PRE - TIPSS EVALUATION Clinic Clinic

LaboratoryLaboratory complete liver evaluation complete liver evaluation seric and urinary ionogramseric and urinary ionogram seric creatinine, seric creatinine, coagulation testscoagulation tests hematologic tests hematologic tests respiratory functionrespiratory function ECGECG

ImagingImagingultrasound – liver, venous anatomy - HV, PV; ascitis; ultrasound – liver, venous anatomy - HV, PV; ascitis; spontaneous shuntsspontaneous shuntsCT – liver, PHT, parenchimal lesions CT – liver, PHT, parenchimal lesions Angio-MRI - ficat, topografie venoasa - VH, VP; ascita; Angio-MRI - ficat, topografie venoasa - VH, VP; ascita; shunturi spntane shunturi spntane

Anaesthetic risk evaluationAnaesthetic risk evaluation


General anGeneral anaaesthesiaesthesia2-4 hours !!!2-4 hours !!!Surgical aseptic conditionsSurgical aseptic conditionsUltrasound and radiological Ultrasound and radiological guidanceguidance

Right jugular vein punction - cateterisation Right jugular vein punction - cateterisation Superior vena cava – right atrium – right Superior vena cava – right atrium – right or medium hepatic veinor medium hepatic veinblocked pressure measurement – degree of blocked pressure measurement – degree of PTHPTHCreating a transhepatic communication, Creating a transhepatic communication, dilated with a baloondilated with a baloonMetallic prosthesis between the portal vein Metallic prosthesis between the portal vein and the hepatic veinand the hepatic vein

TTechnical echnical aspectsaspects


Technical Technical aspectsaspects

Final portographyFinal portographyShunt permeabilityShunt permeabilityDecreased hepatic portal flowDecreased hepatic portal flowReduction of collateral circulation Reduction of collateral circulation

Measurement of the venous pressureMeasurement of the venous pressureComplementary proceduresComplementary procedures

Prosthesis dilatation Prosthesis dilatation Varices embolisation – coilsVarices embolisation – coilsIntravenous heparinotherapyIntravenous heparinotherapy


Postoperatory evolutionPostoperatory evolution ICUICU

0-5 days - depending on evolution 0-5 days - depending on evolution

bed drivenbed driven 24 h 24 h

anticoagulation correlated with the degree of anticoagulation correlated with the degree of

hepatic disfunctionhepatic disfunctionplatelets inhibitorsplatelets inhibitorsheparine - d0 – d7heparine - d0 – d7fraxiparine 1 monthfraxiparine 1 month

Doppler ultrasoundDoppler ultrasound24 hours – 24 hours – velocity on portal side: 30 cm/sec si velocity on portal side: 30 cm/sec si velocity on supra-hepatic side: 70-90 cm/secvelocity on supra-hepatic side: 70-90 cm/secDetection of early thrombosisDetection of early thrombosisDays 3, 5, 8, 15 and 30Days 3, 5, 8, 15 and 30Every 3 months after thatEvery 3 months after that


Case 1 – 43 y, MCase 1 – 43 y, M cirrhosis with PHTcirrhosis with PHT

refractory ascitesrefractory ascites

Evolution Evolution ascites reductionascites reduction

clinical and lab tests improvementclinical and lab tests improvement

ultrasound follow-up 4 months – permeable TIPSS, ultrasound follow-up 4 months – permeable TIPSS, minimum ascitesminimum ascites


Retrograde opacification Retrograde opacification of RPV (blocked of RPV (blocked injection of contrast injection of contrast media)media)

Intrahepatic trajectPressure measurements


Baloon dilatation of Baloon dilatation of the intrahepatic the intrahepatic trajecttraject


Evaluation of Evaluation of the length the length needed needed prothesisprothesis


CCasease 22 – 50 – 50yy, , M M – – emergency emergency TIPSTIPSSS alcoholicalcoholic cirrhosis cirrhosis, Child C, , Child C, PTH, ascitesPTH, ascites oesophageal varicesoesophageal varices gr. III, 4 episo gr. III, 4 episodes of des of bleeding treated endoscopicallybleeding treated endoscopically variceal bleeding, uncontroledvariceal bleeding, uncontroled endoscopicendoscopicallyally– – ICUICU

TIPSTIPSSS – – PV pressionPV pression 25 mm H 25 mm H22OO 5 mm H5 mm H22OO

EvolutionEvolutionvariceal bleeding stopsvariceal bleeding stopsimmediate clinical and laboratory tests immediate clinical and laboratory tests improvement improvement ascites reduction (7 kg)ascites reduction (7 kg) ultrasound follow-up 12 months - permeableultrasound follow-up 12 months - permeable TIPSTIPSS, clinically stableS, clinically stable


Portal vein cateterisaton

Gastric and oesophageal varices


Baloon dilatation

Final portography


Ultrasound controlUltrasound control


Case 3 – 24 y, FCase 3 – 24 y, F

Budd Chiari Budd Chiari syndrome syndrome

TIPSS in Italy (2000)TIPSS in Italy (2000)

ascitesascites

prosthesis disfunction – low prosthesis disfunction – low flow in hepatic segment of flow in hepatic segment of the prosthesis and reverse the prosthesis and reverse flow in left portal veinflow in left portal vein

technical aspect: internal technical aspect: internal jugular vein thrombosis jugular vein thrombosis (during the first intervention) (during the first intervention) – external jugular vein – external jugular vein cateterisationcateterisation


RHV stenoseRHV stenose

PV and branches PV and branches permeablespermeables


baloon baloon dilatdilatationation

improvement of the improvement of the pressure pressure gradientgradient


beforebefore

24H 24H after dilatationafter dilatation

improvement of improvement of the flowthe flow


beforebefore

24H 24H after dilatationafter dilatation

greater flow speedgreater flow speed


EvoluEvolutiontion favorable with reduction of the ascites in the next 2 favorable with reduction of the ascites in the next 2 daysdays

ultrasound - persistance of the reverse flow in left ultrasound - persistance of the reverse flow in left portal veinportal vein..

Final solution: liver transplantFinal solution: liver transplant


CComplicationsomplications

CauCauses for technical failureses for technical failurePV thrombosis, HV occlusion or distorsionPV thrombosis, HV occlusion or distorsionfibrous or atrophic liverfibrous or atrophic livermassive ascitesmassive ascites

Procedure complicationsProcedure complications Cardiac arrithmias Cardiac arrithmias Perforation of the liver capsulePerforation of the liver capsulePulmonary emboliPulmonary emboliStent displacementStent displacementAlergic reactions Alergic reactions


Complications Complications Fatal complications -Fatal complications - 1.7%1.7%

Intraperitoneal hemorrhage (PV, HA, capsule)Intraperitoneal hemorrhage (PV, HA, capsule)

Miocardial infarct during the procedureMiocardial infarct during the procedure

Right cardiac failureRight cardiac failure

Evolution complicationsEvolution complicationsPortalPortal encephalophaty encephalophaty

Stent thrombosis Stent thrombosis ((frecquent)frecquent)

inadecquate trans-hepatic trajectinadecquate trans-hepatic traject

low portal flow (spontaneous shunt)low portal flow (spontaneous shunt)


Results Results technical succes:technical succes: 88% - 100% 88% - 100%

Mortality at 30 days:Mortality at 30 days: 3 - 7 % 3 - 7 %

Results correlated with Results correlated with indications :indications :

Variceal haemorrhage: 90% succes – Variceal haemorrhage: 90% succes – rapid and long lasting effect; if rapid and long lasting effect; if incomplete result an embolisation incomplete result an embolisation can be added can be added

refractory ascites: 50% succes at 1-2 refractory ascites: 50% succes at 1-2 months after proceduremonths after procedure


Results Results

Secondary disfunction: Secondary disfunction: 40% at 1 an40% at 1 an

Shunt thrombosis – theoretical risk 100% Shunt thrombosis – theoretical risk 100% at 2 years Doppler survelliance and at 2 years Doppler survelliance and revision when a disfunction sign appears revision when a disfunction sign appears (reduction of flow speed, focal (reduction of flow speed, focal acceleration)acceleration)

Interest for Interest for polytetrafluoroethylene-polytetrafluoroethylene-covered covered and other covered and other covered stentstentss


CConclusionsonclusions

TIPSS have immediat physiopathological impact TIPSS have immediat physiopathological impact – – reduction of PHT and prevention of digestive reduction of PHT and prevention of digestive bleedingsbleedings

The decision for TIPSS must respect the The decision for TIPSS must respect the indications and contraindications in order to indications and contraindications in order to have good results an to reduce the rate of have good results an to reduce the rate of complications complications

TIPSTIPSS is better then surgical shunts, especially S is better then surgical shunts, especially for fragiles patients – lower post-operatory risksfor fragiles patients – lower post-operatory risks

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