Transjugular Intrahepatic Portosystemic Shunt (TIPS) R4 박철기

Introduction  A non-surgical method of portal decompression.  Creation of a low resistant channel through liver parenchyme using stent between hepatic vein and intrahepatic portal vein.  Side to side porto-caval shunt

Procedure  Channel between Rt hepatic vein and Rt intrahepatic portal vein.

Procedure  Hemodynamic Goal  50% decrease of pre-TIPS portal pressure

Indications  Careful patient selection due to no improvement of survival & greater incidence of hepatic encephalopathy

Complication

Procedural Complications  Laceration of vessel  Arrhythmia  Hemobilia  Arterioportal fistula  Hepatic infarction  Hemoperitoneum  Sepsis

TIPS dysfunction & stent related complication  Thrombosis : early event in 10~15% of Pts. leakage of bile into shunt possible cause of PTE early reestablishment & LMWH  Stenosis : pseudointimal hyperplasia  Stent migration & kinking

Tips dysfunction & stent related complication  Hemolytic anemia : mechanical stress to red cells Hb ↓, Reticulocyte ↑, Haptoglobin ↓, autoimmune marker (-) Jaundice : not from worsening of patient’s liver disease resolve within 4 weeks of TIPS placement

Porto-systemic encephalopathy (PSE)  PSE : Shunting of ammonia & other neurotoxines in portal circulation. major drawback of TIPS Risk factors : old age (>65yrs) poor liver function (Child C) prior HE high diameter stent (>10mm) low porto-systemic pressure gradient after TIPS (5mmHG)

Hemodynamic change & associated complication  Hepatic circulatory change Portal flow diversion from terminal venule to main portal vein  sinusoidal perfusion depend on hepatic arterial flow but if hepatic artery cannot provide adequate sinusoidal perfusion  progressive liver failure

Hemodynamic change & associated complication  Extrahepatic circulatory change Increased venous return Increased cardiac output Normal effective arterial volume Decreased RAA system Dramatic Shift of blood to IVC

Hemodynamic change & associated complication  Extrahepatic circulatory change Cardiac output ↑ + systemic vasodilation  Exaggeration of hyperdynamic circulatory state  Induce heart failure

Contraindication  Chronic recurrent hepatic encephalopathy  Severe liver failure (Child score > 11)  Heart failure  Severe pulmonary hypertension  Liver abscess  Old age (>65yrs)  Pre-TIPS evaluation : Exact hepatic function evaluation (Child class & MELD score), EKG, Echocardiography, Chest X-ray, Infection control.

Some possible causes of hyperbilirubinemia after TIPS  Hemolysis  Progressive hepatic failure  Biliary-venous fistula

Some possible causes of hyperbilirubinemia after TIPS  Hemolysis Cause : Direct RBC trauma from stent Clinical manifestation : Jaundice, dyspnea, DOE Lab finding : Hb ↓, Reticulocytosis, Hyperbilirubinemia(indirect>direct), Haptoglobin ↓, Autoimmune hemolytic marker (-) Diagnosis : Lab & clinical finding Tx : usually resolve within 3~4 weeks after TIPS

Some possible causes of hyperbilirubinemia after TIPS  Progressive hepatic failure Cause : Hepatic sinosoidal hypoperfusion Clinical manifestation : Encephalopathy (confusion, disorientation, coma) Lab finding : Hyperbilirubinemia, PT prolongation AST/ALT ↑ Diagnosis : Lab & clinical finding Tx : Liver transplantation

Some possible causes of hyperbilirubinemia after TIPS  Biliary-venous fistula Cause : Procedural sequelae Clinical manifestation : jaundice, recurrent fever, shock Hemobilia, anemia Lab finding : Hyperbilirubinemia, Leukocytosis, ESR/CRP ↑ Recurrent positive blood culture (mainly G(-)) Diagnosis : ERCP (direct visualization of contrast run-off) Tx : broad-spectrum antibiotics embolization of fistula. spontaneous closure by biliary decompression(stenting)

HemolysisProgressive hepatic failure Biliary-venous fistula CauseRBC traumaHepatic hypoperfusionProcedural sequelae Clinical manifestationJaundice Dyspnea/DOE Encephalopathy (confusion, coma) Jaundice, recurrent fever, shock Lab findingHb ↓ Reticulocytosis Hyperbilirubinemia (indirect>direct) Haptoglobin ↓ Autoimmune hemolytic marker (-) Hyperbilirubinemia PT prolongation AST/ALT ↑ Hyperbilirubinemia Leukocytosis ESR/CRP ↑ Recurrent positive blood culture (mainly G(-)) DiagnosisLab & clinical finding  ERCP (direct visualizat ion of contrast run-off) Therapyresolve within 3~4 wks after TIPS LTbroad-spectrum antibio tics embolization of fistula. spontaneous closure by biliary decompressi on(stenting)