Barbara Rus Gadžijev Peter Popovič Klinični inštitut za radiologijo UKC Ljubljana

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1 STROKOVNI SESTANEK ZDRUŽENJA HEMATOLOGOV SLOVENIJE IN ZDRUŽENJA ZA TRANSFUZIJSKO MEDICINO, Terme Zreče, Barbara Rus Gadžijev Peter Popovič Klinični inštitut za radiologijo UKC Ljubljana

2 goals, indications and contraindications pre-tips imaging evaluation technique complications and how to provide solutions imaging follow up after TIPS

3

4 creation of minimally invasive portosystemic shunt treat or avoid portal hypertension complications hepatic venous pressure gradient (HVPG) < 12 mmhg

5 liver cirrhosis > 90 % increase in porto-systemic pressure gradient above 6 mmhg complications (> mmhg) variceal bleeding ascites portal hypertensive gastropathy hepatorenal syndrome hepatic hydrothoraks Garcia-Tsao G et al. Hepatology 2007

6 ABSOLUTE Variceal bleeding prophylaxis of recurrent bleeding (controlled trials) Refractory cirrhotic ascites (controlled trials) TIPS efficacy proved by Rand. Control Trials Boyer TD,Haskal ZJ. Hepatology 2010

7 954 pts) ) Raziskava Povprečen čas Št. bolnikov Ponovne krvavitve Jetrna encefalopatija Smrt spremljanja TIPS/ET TIPS/ET TIPS/ET TIPS/ET (meseci) % % % GAIH 1995 Ni podatkov 32/33 41/53 Ni podatkov 50 /12 Escorsell /44 13/39 38/ 14 23/21 Cobrera /32 23/51 33/13 19/15 Sanyal /39 24/39 29/13 29/18 Cello /25 12/48 50/44 33/32 Rosle /65 15/45 29/14 13/12 Sauer /41 25/57 29/13 28/27 Merli /43 24/51 55/26 24/19 Garcia-Villareal /24 9/50 23/25 15/33 Jalan /27 10/52 16/11 42/37 Pomier-Layrorgus /39 18/66 47/44 57/56 Narahara /40 16/28 26/15 29/18 Guiberg /26 25/65 7/4 14/15

8 TIPS EST/EVL +NSBB rebleeding 19% 46,6% Mortality 27,3% 26,5% HE 31% 18,7% Follow up 20 months 19 months According to trials that compared urgent TIPS to endoscopic therapy, TIPS should not be used as a first-line treatment but it should be limited to those who fail pharmacologic and endoscopic therapy Garcia-Tsao G et al. Hepatology 2007 Zheng M et al. J Clin Gastroenterolog 2008 Boyer TD,Haskal ZJ. Hepatology 2010

9 RELATIVE Less Common (efficacy assessed in uncontrolled series) Acute bleeding refractory to endoscopic and therapy (recommended) Budd-Chiari syndrome (recommended) Portal vein thrombosis (unclear) Veno-occlusive disease (unclear) Hepatic hydrothorax (effective) Portal hypertensive gastropathy (effective) Hepatopulmonary syndrome (unclear) Hepatorenal syndrome (type 2) (unclear) medical Boyer T, Haskal Z, Hepatology 2005

10 ABSOLUTE RELATIVE Congestive heart failure Hepatic failure Severe pulmonary hypertension (45 mmhg) Multiple hepatic cysts Hepatoma Portal vein thrombosis Severe coagulopathy Severe encephalopathy Systemic infection or sepsis Boyer T, Haskal Z, Hepatology 2005

11 portal venous anatomy, type of portal bifurcation patency of the portal vein patency of the hepatic veins distortion of the liver anatomy lobar atrophy ascites

12 General anesthesia Internal jugular vein access (Rosh percutaneous set) Hepatic vein catheterization/portography Portal vein puncture (Calapinto) Dilatation/stenting Popovič P et al. J. int. med. res., 2010 Popovič P et al. Gastroenterol. Res. Pract, 2013

13 Recommendations Wedget HV CO2 injection Gas viscosity is 400 X lower than iodinated contrast easily traverses hepatic sinusoids into the portal vein shortens the procedure

14 Recommendations Right atrium Hepatic vein IVC

15 Crucial question: are you in the middle or right hepatic vein?- this change direction of the puncture complications:perforation of the liver capsule, the hepatic artery, puncture, extrahepatic portal vein bifurcationintraperitoneal bleeding

16 Recommendations Performing the intrahepatic tract portography and portal pressure meaurements Parenchimal tract dilatation (8 mm or 10 mm)

17 Self expandable stent/stent graft Stent positioning (proximal edge of the stent at the transition with the IVC) Distal edge not to distaly (go distaly in case of portal vein occlusion) stent diameter 8-10 mm

18 Procedural (major 3%) Intraabdominal bleeding Hemobilia Sepsis Long term PSE Shunt dysfunction Right heart failure

19 5-47%, uncontrolled in 3-7% pre-existing PSE, female, age over 60 y., hypoalbuminemia, Child C protein restriction, lactulose reducer stent device (covered or bare) permanent stent occlusion G. Maleux.AJR 2007

20 incidence 18% - 78% psevdointimal hyperplasia and neointimal hyperplasia dilatation or placement of an additional stent Primary patency 1 yr % 2 yr % Secondary patency 1 yr. 95% 2 yr. 90% Boyer TD,Haskal ZJ. Hepatology 2010 H.Ferral.Radiology 2004

21 5 mmhg PSG 13 mmhg 8 mmhg 18 mmhg 10 mm stent graft -7 cm Reintervention-PTA + stentgraft

22 clinical examination upper gastrointestinal endoscopy color duplex sonography venography

23 TIPS has an established role for the treatment of some complications of portal hypertension It is the most efficient method to lower portal pressure

24 ZREŠKO JEZERO HVALA ZA POZORNOST

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