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