• Share
  • Email
  • Embed
  • Like
  • Save
  • Private Content
30
 

30

on

  • 961 views

 

Statistics

Views

Total Views
961
Views on SlideShare
945
Embed Views
16

Actions

Likes
1
Downloads
63
Comments
0

3 Embeds 16

http://www.hepato-gastro-fundeni.ro 14
http://irinel-popescu.i-dl.ru 1
http://irinel-popescu.jugglerdesign.ro 1

Accessibility

Categories

Upload Details

Uploaded via as Microsoft PowerPoint

Usage Rights

© All Rights Reserved

Report content

Flagged as inappropriate Flag as inappropriate
Flag as inappropriate

Select your reason for flagging this presentation as inappropriate.

Cancel
  • Full Name Full Name Comment goes here.
    Are you sure you want to
    Your message goes here
    Processing…
Post Comment
Edit your comment

    30 30 Presentation Transcript

    • T I P S S Mihalcea A, Lesaru M, Grasu M, Georgescu SA, Valette PJ, Henry L, Gheorghe C, Mihaila M Indicati ons , work-up algorithm , re s ult s
    • TIPSS – transjugular intrahepatic porto- systemic shunt
      • interventional therapeutic procedure
      • creates a permanent transhepatic communication between the portal and the caval systems equilibration of the pressure in th e se two venous systems
    • INDICATION
      • Severe portal hypertension of various etiology – complications
        • recurent digestive bleeding
          • Uncontroled variceal bleeding after two sessions of sclerotherapy and haemostasis with Sengstaken Blakemore baloon = TIPS S emergency indication (in 12-24 hours)
        • uncontroled ascit e s
        • hepatorenal syndrome
        • cirrhotic patients with portal hypertension waiting for liver transplant
    • ABSOLUTE CONTRAINDICATIONS
      • PHT not proved
      • Total bilirubine >50 micromol/l or seric creatinine > de 180 micromol/l
      • Uncontrole d portal encephalopathy
      • Chronic portal obstruction with portal cavernoma
      • Spontaneous shunt with portal inversion
      • Tumor invasion of the hepatic venous system
      • Hemodinamic instability – APACHE II score> 20
      • Sepsis, activ e infection
    • RELATIVE CONTRAINDICATIONS
      • Anatomic abnormalities of IVC, HV si PV;
      • Recent thrombosis of PV;
      • H ypervascular hepatic tumors;
      • Liver policystic disease
    • Advantages
      • Immediat e phys iopathologic impact
      • on splahnic and hepatic circulation – reduction of portal pression with loose of the hepatic portal vascularisation – done only by the hepatic artery
      • on the systemic circulation
      • on the cerebral function - ! encephalopathy risk
      • Less invasive comparing with surgical shunts – diminishes the postoperatory risk
      • Shunt calibration according to the clinical context
    • PRE - TIPSS EVALUATION
      • Clinic
      • Laboratory
          • complete liver evaluation
          • seric and urinary ionogram
          • seric creatinine,
          • coagulation tests
          • hematologic tests
          • respiratory function
          • ECG
      • Imaging
          • ultrasound – liver, venous anatomy - HV, PV; ascitis; spontaneous shunts
          • CT – liver, PHT, parenchimal lesions
          • Angio-MRI - ficat, topografie venoasa - VH, VP; ascita; shunturi spntane
      • Anaesthetic risk evaluation
      • General an a esthesia
      • 2-4 hours !!!
      • Surgical aseptic conditions
      • Ultrasound and radiological guidance
        • Right jugular vein punction - cateterisation
        • Superior vena cava – right atrium – right or medium hepatic vein
        • blocked pressure measurement – degree of PTH
        • Creating a transhepatic communication, dilated with a baloon
        • Metallic prosthesis between the portal vein and the hepatic vein
      T echnical aspects
    • Technical aspects
      • Final portography
          • Shunt permeability
          • Decreased hepatic portal flow
          • Reduction of collateral circulation
      • Measurement of the venous pressure
      • Complementary procedures
          • Prosthesis dilatation
          • Varices embolisation – coils
          • Intravenous heparinotherapy
    • Postoperatory evolution
      • ICU
          • 0-5 days - depending on evolution
          • bed driven 24 h
      • anticoagulation correlated with the degree of hepatic disfunction
          • platelets inhibitors
          • heparine -  d0 – d7
          • fraxiparine 1 month
      • Doppler ultrasound
          • 24 hours – velocity on portal side: 30 cm/sec si velocity on supra-hepatic side: 70-90 cm/sec
          • Detection of early thrombosis
          • Days 3, 5, 8, 15 and 30
          • Every 3 months after that
      • Case 1 – 43 y, M
        • cirrhosis with PHT
        • refractory ascites
      • Evolution
        • ascites reduction
        • clinical and lab tests improvement
        • ultrasound follow-up 4 months – permeable TIPSS, minimum ascites
      • Retrograde opacification of RPV (blocked injection of contrast media)
      Intrahepatic traject Pressure measurements
      • Baloon dilatation of the intrahepatic traject
      • Evaluation of the length needed prothesis
      • C ase 2 – 50 y , M – emergency TIPS S
          • alcoholic cirrhosis , Child C, PTH, ascites
          • oesophageal varices gr. III, 4 episo des of bleeding treated endoscopically
          • variceal bleeding, uncontroled endoscopic ally – ICU
          • TIPS S – PV pression 25 mm H 2 O 5 mm H 2 O
        • Evolution
          • variceal bleeding stops
          • immediate clinical and laboratory tests improvement
          • ascites reduction (7 kg)
          • ultrasound follow-up 12 months - permeable TIPS S, clinically stable
    • Portal vein cateterisaton Gastric and oesophageal varices
    • Baloon dilatation Final portography
    • Ultrasound control
      • Case 3 – 24 y, F
        • Budd Chiari syndrome
        • TIPSS in Italy (2000)
        • ascites
        • prosthesis disfunction – low flow in hepatic segment of the prosthesis and reverse flow in left portal vein
        • technical aspect: internal jugular vein thrombosis (during the first intervention) – external jugular vein cateterisation
      • RHV stenose
      • PV and branches permeables
      • baloon dilat ation
      • improvement of the pressure gradient
      • before
      • 24H after dilatation
      • improvement of the flow
      • before
      • 24H after dilatation
      • greater flow speed
      • Evolu tion
        • favorable with reduction of the ascites in the next 2 days
        • ultrasound - persistance of the reverse flow in left portal vein .
      • Final solution: liver transplant
    • C omplications
      • Cau ses for technical failure
        • PV thrombosis, HV occlusion or distorsion
        • fibrous or atrophic liver
        • massive ascites
      • Procedure complications
        • Cardiac arrithmias
        • Perforation of the liver capsule
        • Pulmonary emboli
        • Stent displacement
        • Alergic reactions
    • Complications
        • Fatal complications - 1.7%
        • Intraperitoneal hemorrhage (PV, HA, capsule)
        • Miocardial infarct during the procedure
        • Right cardiac failure
      • Evolution complications
        • Portal encephalophaty
        • Stent thrombosis ( frecquent)
          • inadecquate trans-hepatic traject
          • low portal flow (spontaneous shunt)
    • Results
      • technical succes: 88% - 100%
      • Mortality at 30 days: 3 - 7 %
      • Results correlated with indications :
          • Variceal haemorrhage: 90% succes – rapid and long lasting effect; if incomplete result an embolisation can be added
          • refractory ascites: 50% succes at 1-2 months after procedure
    • Results
      • Secondary disfunction:
          • 40% at 1 an
          • Shunt thrombosis – theoretical risk 100% at 2 years Doppler survelliance and revision when a disfunction sign appears (reduction of flow speed, focal acceleration)
      Interest for polytetrafluoroethylene-covered and other covered stent s
    • C onclusions
      • TIPSS have immediat physiopathological impact – reduction of PHT and prevention of digestive bleedings
      • The decision for TIPSS must respect the indications and contraindications in order to have good results an to reduce the rate of complications
      • TIPS S is better then surgical shunts, especially for fragiles patients – lower post-operatory risks