Transjugular Intrahepatic Portosytemic Shunt Kevin A. Smith, MD Interventional Radiologist Roper...

Transjugular Intrahepatic Portosytemic Shunt

Kevin A. Smith, MD

Interventional Radiologist

Roper Radiologists, PA

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

Indications TIPSS:

1. Acute uncontrollable esophageal or gastric varices2. Recurrent variceal bleeding despite endoscopic Rx3. Refractory ascites, hydrothorax4. Budd-Chiari syndrome4. Portal Gastropathy

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

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!