TIPSS is a procedure that creates a permanent connection between the portal and hepatic veins to reduce portal hypertension. It has several indications including uncontrolled variceal bleeding and refractory ascites. The procedure involves catheterization of the jugular vein and placement of a stent. Complications can include thrombosis, hemorrhage, and encephalopathy. Success rates are over 80% for variceal bleeding and 50% for ascites, but secondary dysfunction occurs in 40% after 1 year often requiring revision. TIPSS provides immediate reduction in portal pressure and is less invasive than surgical shunting.

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. 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

3. 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

4. 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

5. RELATIVE CONTRAINDICATIONS Anatomic abnormalities of IVC, HV si PV; Recent thrombosis of PV; H ypervascular hepatic tumors; Liver policystic disease

6. 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

7. 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

8. 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

9. 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

10. 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

11. 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

12. Retrograde opacification of RPV (blocked injection of contrast media) Intrahepatic traject Pressure measurements

13. Baloon dilatation of the intrahepatic traject

14. Evaluation of the length needed prothesis

15. 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

16. Portal vein cateterisaton Gastric and oesophageal varices

17. Baloon dilatation Final portography

18. Ultrasound control

19. 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

20. RHV stenose PV and branches permeables

21. baloon dilat ation improvement of the pressure gradient

22. before 24H after dilatation improvement of the flow

23. before 24H after dilatation greater flow speed

24. 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

25. 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

26. 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)

27. 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

28. 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

29. 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