TIPS. D Patch Royal Free Hospital London UK
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1 TIPS D Patch Royal Free Hospital London UK
2
3 TIPS Technique Ascites Budd Chiari Variceal Bleeding
4 Historical Experimental Development 1967 Piccone Shunt between recanalized umbilical vein and saphenous or jugular vein 1968 Rosch Transjugular portography 1979 Gutierrez TIPS 15mm PTA Balloon 1985 Palmaz TIPS Palmaz stents 1987 Rosch TIPS Z stents
5 Historical Clinical Development Radiological Portocaval Shunt 1982 Colapinto TIPS 9mm PTA balloon 1988 Richter TIPS Palmaz stent 1993 Royal Free Dr R Dick
6 TIPS Royal Free n=? Dr N Davies Radiologist Dr D Yu Radiologist Dr D Patch Hepatologist 24 hour service 7 days a week operating 1:3 on call Supported by on-call radiology registrar and x-ray staff (currently cases a year)
7 Technique: Image Guidance Pre proceedure USS, CT, MRA, During procedure CO2 wedged portography, USS, (Ideal) is for General anaesthesia and intubation TIPS
8 TIPS technique Covered stents for all 8mm for ascites, 10mm for Budd Chiari and bleeding Dilate to 6mm for ascites, 8 for bleeding, 10 for Budd Chiari?Target pressure-no-assess patient, and embolise varices-beware of low pressure varices Post TIPS follow up in era of covered stents-yes, with U/S (same time as screening for tumours) every six months
9
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12 TIPS Post stent venogram If visible varices despite 12mm dilatation proceed to coil or alcohol embolization 23.2% RFH
13 TIPS technique
14 TIPS technique
15 TIPS technique
16 Stomal varices
17 Colonic Varices
18 Keep stent short although can transplant and cut the stent!
19 Biliary Fistula Covered Stent
20 TIPS Occlusion 1998 Lost to follow up Occluded TIPS Aug 2001-covered stent
21 Occluded Right TIPS-Left sided Non transplant TIPS re-bleed Aug 2001
22 TIPS for ascites Currently, our commonest indication With the least evidence Be prepared to say no! GENERALLY, avoid if Jaundiced non-alcoholic/nash Abnormal EEG
23 TIPS for ascites N Ascites recurrence Death Av number enceph TIPS % LVP % Salerno et al Gastro 2007;133:825-34
24 TIPS for Budd Chiari V unpredicatable porto-atrial shunt Leaves surgical field clean Lots of case reports 3 initial series with long term follow up Rossle (40) Perello (13) RFH (16)
25 TIPS for Budd Chiari 124 consecutive patients yr survival 88% 5 year survival 78% Prognostic index: 0.08age+0.16bili+0.63INR 7\8 with score>7 died or OLT 4/4 with ALF and score>7 died (RFH experience) Garcia Pagan et al Gadstro 2008,135;808-15
26 Budd Chiari
27 TIPS for Budd chiari
28
29 Thrombosed Portal Vein Recanalisation n=3/26 (11.5%)? Convert to transplant candidate Decompress portal hypertension Mechanical or chemical thrombolysis USS guidance very helpful RFH series 18, failed in 4 Liatsos et al 2001 Liver Transplantation 7:5:
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33 TIPS for Variceal Bleeding
34 Mortality from variceal bleeding in a single centre (Carbonell 2004) Child Pugh A/B Child Pugh C
35 Clinical Trials for Variceal bleeding And the winner is.. The Patient (T Boyer 2007) (ps-he should live in France, or Italy, or Spain *)
36 Early shunting in management of variceal bleeding Prospective Randomised Trial of Emergency Portocaval Shunt and Emergency Medical Therapy in Unselected Cirrhotic Patients with Bleeding Varices Orloff et al Hepatology 1994;20:
37 Portal Pressure and Variceal Bleeding (Moitinho 1999) failure to control bleeding early rebleeding P<0.0004
38 Early shunting in management of variceal bleeding Monescillo et al Hepatology 2004;40: /116 HVPG>20mmHg within 24hours of variceal bleed. Randomised into urgent TIPS and standard management Early TIPS reduced failure (p=0.003) blood transfusion and use of ITU, and in-hospital and one year mortality (p<0.05) (Only one patient with Pughs A died.)
39 Early shunting in management of Variceal bleeding-mortality HR TIPS HR non-tips Low risk CP score 3/11/12 4/10/12 15/30/17 In hospital 3/26 (11%) P= /26 (38%) 3/64 5% 6 weeks 5/26 10/26% 3 I year (19%) 8/26 P=0.01 (38%) 17/26 5% 11/64 31% 65% 17%
40 HVPG PREDICTION of 5 DAY FAILURE in ACUTE VARICEAL BLEEDING (Albraldes 2008) 117 patients HVPG measured 48 h ( 4 centres) 18 (15%) failure at 5 days (vasoactive drugs,endoscopic therapy, antibiotics) HVPG 20 mmhg OR 5.4 ( ) Systolic BP 100mmHg OR 4.9 ( ) Non-alcoholic cirrhosis OR 4.9 ( ) c statistic 0.79 HVPG 20 mmhg strongly related to CP (p=0.0002) Child A 33% Child B 57% Child C 84% Replacing HVPG with Childs-Pugh Score: c statistic 0.8
41 Eraly TIPS in management of variceal bleeding N TIPS 32 Standard management 31 Death 4 16 Garcia Pagan J Hepatol 2008 ;48 (suppl 2) A992
42 Incompetence in the UK! 135 admissions with variceal bleeding 49 index bleeds 32 known to have cirrhosis 20 referred to gastro 17 attending 11 endoscoped 8 varices, 6 on beta blockers Mcleman L et al BASL 2006
43 TIPS for FHF (!) Transjugular route for portal vein hepatocyte transfusion in FHF Experience of 1(!)
44 1.50/L 0.48/L
Contraindications. Indications. Complications. Currently TIPS is considered second or third line therapy for:
Contraindications Absolute Relative Primary prevention variceal bleeding HCC if centrally located Active congestive heart failure Obstruction all hepatic veins Thomas D. Boyer, M.D. University of Arizona
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