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Transjugular Intrahepatic Portosystemic Shunt (TIPS)

Transjugular Intrahepatic Portosystemic Shunt (TIPS). Presented by R2 吳佳展 2002/10/01. Brief History. 70 y/o male, liver cirrhosis with varices bleeding and chronic left hydrothorax, ascites, mild confusion Uremia with hemodialysis Previous TIPS, but occlusion

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Transjugular Intrahepatic Portosystemic Shunt (TIPS)

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  1. Transjugular Intrahepatic Portosystemic Shunt (TIPS) Presented by R2 吳佳展 2002/10/01

  2. Brief History • 70 y/o male, liver cirrhosis with varices bleeding and chronic left hydrothorax, ascites, mild confusion • Uremia with hemodialysis • Previous TIPS, but occlusion • Incapable to lie still for prolonged procedure • No dyspnea with continuous O2 usage

  3. Evaluation • High aspiration risk: ascites, EV bleeding • The possibility of desaturation under anesthesia or sedation without ventilatory support: ascites, pleural effusion • Limited access to the patient’s airway • Poor liver and renal function

  4. Anesthesia • Rapid sequence induction and intubation • Fluctuating hemodynamics during the procedure • Delayed extubation at POR when the patient was fully awake and breathing with ordinary power ( still dependent on O2)

  5. Indications • Rescue therapy to acute variceal bleeding refractory to medical and endoscopic treatment • Prophylaxis of rebleeding: lower rebleeding rate compared with endoscopic method but higher encephalopathy occurrence, same survival

  6. Indications • Refractory ascites: large volume peritoneocentesis, peritoneovenous shunts, portosystemic shunts, liver transplantation • Refractory hepatic hydrothorax • TIPS improves hepatorenal syndrome, as a bridge to liver transplantation ?

  7. Other indications for non-cirrhotic diseases

  8. Procedure • Patients are positioned as for central venous catheter insertion • The guide wire is threaded into hepatic vein • Puncture into intrahepatic portal system • Stent positioning

  9. Localization of portal system • Wedged hepatic vein angiography • sonography

  10. Procedural Complications • Perforation: heart, vena cava, portal vein, liver capsule, pneumothorax • Fistula creation: arterioportal, arteriobiliary (hemobilia), biliary-stent (bilhemia) • Hemolysis • Stent displacement • Acute stent and portal vein thrombosis • Infection

  11. Shunt-related Complications • Deterioration of liver function • Worsening of hepatic encephalopathy (age, Child class, degree of reduction of pressure gradient) • Exacerbation of the hyperdynamic circulation

  12. Late complications • Follow up with duplex sonography and shunt angiography • Early shunt occlusion <30 days: thrombosis (local thrombolytic treatment, redilation, restenting) • Late: intimal thickening within the stent or hepatic vein ( dilation or another stent)

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