Transjugular Intrahepatic Portosytemic Shunt Kevin A. Smith, MD Interventional Radiologist Roper...
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Transcript of Transjugular Intrahepatic Portosytemic Shunt Kevin A. Smith, MD Interventional Radiologist Roper...
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Transjugular Intrahepatic Portosytemic Shunt
Kevin A. Smith, MD
Interventional Radiologist
Roper Radiologists, PA
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What is a TIPSS?
• Transjugular portosystemic shunt• Creation of conduit from portal vein to
hepatic vein to decrease portal pressure
• Stent is placed from portal vein to hepatic vein
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WWho gets a TIPSS?
• Majority of patients have advanced cirrhosis resulting in portal hypertension– Portosystemic gradient normal 3-6mmHg– Corrected Sinosoidal Pressure= free hepatic pressure
minus wedged hepatic pressure (CSP), normally <5mmHg
– Mild 5-10, moderate 10-20, severe >20– Goal TIPS gradient to <12mmHg, <8mmHg ascites
• Budd-Chiari
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The Problem
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Indications TIPSS:
1. Acute uncontrollable esophageal or gastric varices2. Recurrent variceal bleeding despite endoscopic Rx3. Refractory ascites, hydrothorax4. Budd-Chiari syndrome4. Portal Gastropathy
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Absolute Contraindications
1. Severe progressive liver failure2. Severe or uncontrollable encephalopathy3. Severe heart failure
4. Pulmonary hypertension
5. Biliary Sepsis
6. Splenic vein occlusion with isolated gastric varices
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Preprocedure Work-up
• CBC• Coags• MELD score - T bili, creat, albumin• ammonia• MRI/CT
– Anatomy– Portal vein patency– HCC
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Procedure
• Type and cross 4 units PRBCs• General anesthesia versus conscious
sedation• Performed using fluoroscopic guidance• Procedure time 1.5-2hrs• Success rate ~ 96%• 30 day mortality – 4-13%
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Complications
• Acute– hemoperitoneum
– hemobilia
– progressive liver failure
– right heart failure
– hepatic encephalopathy
• Delayed– stenosis
– shunt thrombosis or occlusion
– biliary-shunt fistula formation13
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Post-procedure
• Patient tranferred to PACU or directly to ICU
• Signs of internal hemorrhage• H&H q 4 hours overnight• Fecal blood or hematemesis• Abdominal distension• Hepatic encephalopathy• Hematoma @ access site• Hospital Stay 2-5 days
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Thank You!