Use of transjugular intrahepatic portosystemic shunt in liver disease

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1 Vol. XVIII No. 3 JOURNAL OF VASCULAR NURSING PAGE 83 Use of transjugular intrahepatic portosystemic shunt in liver disease Patricia Ann Radovich, RN, MSN, CCRN, FCCM Persons with cirrhosis have many complications. Two of these complications are refractory ascites and recurrent gastrointestinal hemorrhage. When medical management has proved ineffective in the management of these two complications, a transjugular intrahepatic portosystemic shunt can be a treatment option. This outpatient procedure can reduce ascites, minimize the need for diuretics, and reduce the potential for gastrointestinal hemorrhage. The procedure is associated with the development of hepatic encephalopathy, which requires vigilant nursing observation. Education of the patient and family regarding the potential development of encephalopathy and the need for follow-up by the physician is important. The collaboration of physicians and nurses in the ongoing monitoring and follow-up of these patients can contribute to an improved quality of life and reduced hospitalizations. Nurses play an important role in alerting physicians to changes in patient condition that might indicate a narrowing of the transjugular intrahepatic portosystemic shunt, which requires intervention. (J Vasc Nurs 2000;18:83-7) Persons with a diagnosis of cirrhosis can be asymptomatic for many years. They eventually become symptomatic and complications may develop. These complications include the development of ascites, portal hypertension with esophageal varices, jaundice, and encephalopathy. The esophageal varices and refractory ascites are the focus of this article. MEDICAL MANAGEMENT OF ESOPHAGEAL VARICIES Esophageal varices are diagnosed during an esophagogastroduodenoscopy or when upper gastrointestinal bleeding develops in the patient resulting in hospitalization and transfusion. Esophageal varices develop when the pressure in the portal system increases and causes dilatation of the esophageal veins. This complication of cirrhosis is associated with significant morbidity and mortality. The usual medical management to reduce or eliminate esophageal varices involves frequent endoscopies with either Patricia Ann Radovich, RN, MSN, CCRN, FCCM, is a clinical nurse specialist hepatology, Loma Linda University Medical Center, Loma Linda, California. Address reprint requests to Patricia Ann Radovich, RN, MSN, CCRN, FCCM, Loma Linda University Medical Center, Anderson St, Room 1405, Loma Linda, CA Copyright 2000 by the Society for Vascular Nursing, Inc /2000/$ /1/ doi: /mvn CASE 1 Mr C is a 49-year-old Hispanic man who had a TIPS placed for variceal hemorrhage in Since that time, he has had multiple revisions of his TIPS because of decreased velocity on Doppler ultrasonography. In January 1999, the ultrasonography revealed that flow in the caval end of the TIPS was 50 cm per second (normal flow = >50 cm per second). The pressure gradient at the end of the stent at that time was 15 mm Hg. A balloon dilatation was performed with the pressure gradient measurement reduced to 9-11 mm Hg. In September 1999, an upper gastroduodenoscopy was performed, which revealed grade 3 esophageal varices. The patient was symptomatic with an increase in ascitic fluid and increased lethargy. Throughout the course of his treatment, the patient had been on lactulose for chronic encephalopathy. Although TIPS was thought to be the treatment of choice for the reduction of portal hypertension, the development of hepatic encephalopathy and the need for frequent stent revisions have many physicians choosing surgical portosystemic shunts in patients who are Child s class A and who are not candidates for liver transplantation. In candidates for liver transplantation, TIPS is preferred. esophageal ligation (banding) or injection sclerotherapy as well as pharmacologic management with the use of β-blockers for reduction of portal pressure. In severe instances, balloon tamponade may be necessary. In spite of aggressive medical management, some patients with portal hypertension are refractory to treatment of their esophageal varices. In patients with recurrent variceal hemorrhage in spite of adequate medical and endoscopic treatment, a transjugular intrahepatic portosystemic shunt (TIPS) has been used to reduce the portal hypertension seen in cirrhosis (Case 1). MANAGEMENT OF ASCITES Ascites is the development of serous fluid in the intraabdominal cavity. It is a complication of liver disease. Persons in whom ascites develops are treated with a low-sodium diet (2 g sodium) and diuretic therapy. The diuretics used are spironolactone and furosemide, which are adjusted to a maximum of 400 mg of spironolactone and 180 mg of furosemide. 1 Diuretic adjustments are made on the basis of a person s weight gain or loss, renal function, dietary compliance, and frequency of abdominal paracentesis. When a patient has

2 PAGE 84 JOURNAL OF VASCULAR NURSING SEPTEMBER 2000 CASE 2 Figure 1. Interventional radiology film: Transjugular intrahepatic stent. Mr Y is a 51-year-old white man with cirrhosis secondary to alcoholic liver disease. Ascites developed and had become refractory during the last 4 months. His renal function was becoming impaired with a rising serum creatinine of 2.3. He was requiring large volume paracentesis (8-10 L) every 2 weeks. He was on spironolactone 100 mg (this had been reduced from 300 mg every morning because of his renal insufficiency) and furosemide 40 mg (which had been reduced from 120 mg every morning because of the renal insufficiency). He was following a 2-gm sodium diet with good compliance. His Child/Pugh score is 8 with a Child s class B. His laboratory values were sodium (Na) 136 mmol/l; potassium (K) 4.3 mmol/l; serum urea nitrogen (BUN) 36 mg/dl; creatinine (C) 2.3 mg/dl; albumin 2.8; total bilirubin (T bili) 0.4 mg/dl; alkaline phosphatase (ALK-P) 87 U/L; aspartate aminotransferase (AST) 27 U/L; alanine aminotransferase (ALT) 18 U/L; prothrombin time (PT) 16.4 sec; international normalized ratio (INR) TIPS PROCEDURE TIPS is an interventional radiologic procedure performed in many medical centers in the United States and internationally. A TIPS is a shunt created via a right transjugular approach and uses the normal liver vascular anatomy for an intrahepatic (parenchymal) tract between the intrahepatic portion of the portal vein and the hepatic veins. The right hepatic vein is usually used because of its large size. Before stent placement, pressure measurements are obtained from the portal vein and inferior vena cava to document the baseline portacaval gradient. A portacaval gradient of less than 12 mm Hg is considered acceptable. The tract is then reinforced with a metallic stent. The diameter of the stent is 8 mm to 10 mm depending on the reduction in portal pressures. The stent placement within this shunt will decompress the portal system (Figures 1 and 2). 2-4 Figure 2. Interventional radiology film: TIPS with a gradient of 15 mm Hg. reached the maximum dose of diuretics or when renal insufficiency develops requiring a reduction in diuretics and is requiring frequent large volume paracentesis (at least monthly but usually every 2 weeks), he or she is considered to have refractory ascites. 1 At this point, a TIPS is considered to relieve the debilitating condition (Case 2). CONTRAINDICATIONS Contraindications for placement of TIPS are divided into absolute contraindications, which include right-sided heart failure with elevated central venous pressure, polycystic liver, and severe hepatic failure. TIPS is also contraindicated in patients with known severe anaphylactoid reactions to contrast media. Placement of a TIPS in the setting of right-sided heart failure exacerbates the portal hypertension and increases the risk of variceal hemorrhage. In addition, TIPS has sometimes exacerbated right-sided heart failure. The use of TIPS in patients with polycystic liver disease has the risk of puncturing a hepatic cyst, resulting in hemorrhage. In severe hepatic failure, the use of TIPS could result in further compromise of hepatic function. Once the absolute contraindications have been eliminated, the physician will review the relative contraindications to placement of a TIPS. These contraindications include active intrahepatic or systemic infection, severe hepatic encephalopathy, and portal vein thrombosis. 3,5 ADVERSE EFFECTS Adverse effects of TIPS placement include procedural complications associated with any vascular procedure requiring con-

3 Vol. XVIII No. 3 JOURNAL OF VASCULAR NURSING PAGE 85 TABLE I. ADVERSE EFFECTS OF TIPS PLACEMENT Procedural complications Local puncture site hematoma Pain Puncture of other abdominal organs Dysrhythmias Hypotension Migration of stent Hemolytic anemia Fever Reaction to contrast agents Spontaneous thrombosis of TIPS Life-threatening complications Hemoperitoneum Hemobilia Acute hepatic ischemia Cardiac puncture Pulmonary edema Septicemia Chronic complications Portal or splenic vein thrombosis 1%-15% 2 Chronic hemolysis 1%-3% 2 Worsening of hepatic function 1%-5% 2 Shunt stenosis 33%-66% 2 Hepatic encephalopathy 15%-30% 2 trast media. Many of these events appear to be related to the experience of the person performing the procedure and range from site hematoma and nephrotoxicity from contrast media to more significant reactions including anaphylaxis secondary to contrast dye allergy. Severe life-threatening complications such as acute hepatic ischemia and pulmonary edema occur in 1% to 2% of the patients. Chronic complications, which appear to be the most frequently seen, include hepatic encephalopathy and TIPS dysfunction (Table I). 3,4 TIPS DYSFUNCTION Recent studies have found that the portacaval pressure gradient is significantly decreased after the TIPS procedure. The pressures have been decreased from 17.7 mm Hg to 8.6 mm Hg. If the pressure gradient increases to a mean pressure of 18 mm Hg, rebleeding occurs. This value is usually a pressure that was close to the mean portal pressure gradient before stent placement. In a study 1 year after TIPS placement, 77% of the patients underwent balloon angioplasty or restenting. In this same population, 80% again were found to have a portacaval pressure gradient of Figure 3. Interventional radiology film: TIPS after dilatation with a gradient of 9-11 mm Hg. greater than 12 mm Hg 1 year after reintervention. 6 TIPS dysfunction consists of a progressive stenosis rather than complete occlusion. Neointimal proliferation and development of fibrosis within the parenchymal tract occur, which gradually narrows the stent. The time of highest risk for occlusion is 6 to 12 months after placement. TIPS monitoring for patency is done by ultrasonography, initially within 1 month of placement, then every 3 months, progressing to every 6 months after the first year (Case 1). 7 HEPATIC ENCEPHALOPATHY After portal decompression with TIPS placement, an associated increased risk of the development of hepatic encephalopathy has occurred. 6 Rates of hepatic encephalopathy range from 25% to 30% after TIPS placement. In some patients, this is a new onset; whereas in a small number of patients, it is exacerbation of a current problem. Hepatic encephalopathy usually occurs within the first 3 months after stent placement. Although hepatic encephalopathy can be treated with medications, in a significant number of patients studied, the encephalopathy interfered with activities of daily living. In some severe cases (as high as 10%), the client was not responsive to treatment and required hospitalization. 3,8,9 Studies have identified predictive factors such as prior history of hepatic encephalopathy, nonalcoholic liver disease, age greater than 60 years, and portal systemic gradient of less than 12 mm Hg. A portal systemic gradient of less than 12 mm Hg is at decreased risk for rebleeding but has been associated with an increased risk of hepatic encephalopathy. SURGICAL SHUNTS It has been suggested that patients with good liver function should be candidates for surgical shunts in light of the long-term

4 PAGE 86 JOURNAL OF VASCULAR NURSING SEPTEMBER 2000 TABLE II. HEPATIC ENCEPHALOPATHY Subclinical encephalopathy Normal level of consciousness Normal intellect and personality Abnormal psychometric analysis Grade I encephalopathy Inverted sleep pattern, restlessness Forgetfulness, mild confusion, agitation, irritability Tremor, apraxia, incoordination, impaired handwriting Grade II encephalopathy Lethargy, slow responses Disorientation, amnesia, decreased inhibitions, inappropriate behavior Asterixis, dysarthria, ataxia, hypoactive reflexes Grade III encephalopathy Somnolence but arousability, confusion Disorientation, aggressive behavior Asterixis, hyperactive reflexes, Babinski s signs, muscle rigidity Grade IV encephalopathy Coma Decerebration patency, decreased rate of rebleeding, and decreased development of hepatic encephalopathy. The 7-year patency rate is 95% and the percentage of rebleeding is 8%. Many recent studies comparing complications, cost, and survival now indicate that use of a TIPS in patients with Child s class A cirrhosis is not warranted. 10,11 In fact, surgical shunts in these patients have been determined to be more cost effective than placement of a TIPS. Instead, TIPS should be used in patients with Child s class B cirrhosis who are candidates for liver transplantation. LIVER TRANSPLANTATION In patients who may undergo liver transplantation at a future date, it is important that the TIPS not compromise the surgical procedure. The stent should not extend into the suprahepatic cava because the recipient liver is transected at the level of the suprahepatic cava. It should not extend into the main portal vein because thrombosis can occur. 4 In patients who have undergone a portacaval H-graft shunt rather than a TIPS, there are associated intraoperative complications such as increased blood loss and coagulopathy. It has also been shown that the postoperative complication rate was higher for patients with primary nonfunction, re-exploration of intraperitoneal bleeding, and hematomas. 5 TABLE III. PATIENT AND CAREGIVER EDUCATION Procedure/presedation Risk for hepatic encephalopathy Signs and symptoms of hepatic encephalopathy Need for ultrasonography follow-up Need for revisions Signs and symptoms of stent stenosis Emergency procedures for variceal bleeding NURSING IMPLICATIONS The placement of a TIPS is usually an outpatient procedure unless the patient has been hospitalized for gastrointestinal hemorrhage. The care of the patient after the procedure involves ensuring recovery from the conscious sedation and monitoring of the patient s vital signs and airway. The immediate postprocedure concern is monitoring the insertion site for signs and symptoms of infection, hematoma formation, pain, or fever. If the patient is hospitalized, the nurse should monitor the patient for signs and symptoms of hepatic encephalopathy, elevation in liver tests, and postprocedure complications. Patients with cirrhosis who are going to undergo a TIPS and their caregivers should be aware of the potential for stenosis of the stent and development of hepatic encephalopathy (Table III). Nursing staff should review the signs and symptoms of hepatic encephalopathy (Table II) with both the patient and his or her caregiver. If hepatic encephalopathy develops in the patient after the procedure, medications for control of encephalopathy should be reviewed. Protein restriction is avoided unless medical management of the hepatic encephalopathy fails. The current method for identifying subclinical and clinical encephalopathy is by use of a number connection test called a Trail Test. 12 Ammonia levels have been found to poorly correlate with the grade of hepatic encephalopathy, and this measurement is of little value in the diagnosis of hepatic encephalopathy. 13 Nurses should be trained in the use of these number connection tests so that they may more accurately gage their patient s level of encephalopathy. Patients should also be instructed regarding the need for frequent ultrasonography and the importance of keeping these appointments so that the condition of the stent can be continuously monitored. In this way, a change in the blood flow through the stent can be observed before the development of rebleeding. Emergency instructions should be reviewed with the patient and caregiver in case rebleeding does occur. CONCLUSION The use of TIPS in the patient with cirrhosis with refractory gastrointestinal hemorrhage or ascites continues to be studied. It

5 Vol. XVIII No. 3 JOURNAL OF VASCULAR NURSING PAGE 87 has proven effective in reducing the life-threatening hemorrhages in patients with cirrhosis and in improving the quality of life for patients with refractory ascites. It is only with ongoing attentive observation and thorough patient education by nursing staff that clinical changes are detected early. However, the need for vigilant monitoring by nurses and physicians to detect the development of hepatic encephalopathy and the frequency of stent stenosis means that we must continue to look for more sustained, cost-effective therapy in this population. REFERENCES 1. Somberg KA, Lake JR, Tomlanovich SJ, et al. Transjugular intrahepatic portosystemic shunts for refractory ascites: assessment of clinical and hormonal response and renal function. Hepatology 1995;21: Sanyal AJ, Freedman AM, Luketic VA, et al. The natural history of portal hypertension after transjugular intrahepatic portosystemic shunts. Gastroenterology 1997;112: Shiffman ML, Jeffers L, Hoofnagle JH, et al. The role of transjugular intrahepatic portosystemic shunt for treatment of portal hypertension and its complications: a conference sponsored by the National Digestive Disease Advisory Board. Hepatology 1995;22: Kamath PS, McKusick MA. Transvenous intrahepatic portosystemic shunts. Gastroenterology 1996;111: Busitill RW, Klintmalm G. Transplantation of the liver. Philadelphia: WB Saunders; p Casado M, Bosch J, Carcia-Pagan JC, et al. Clinical events after transjugular intrahepatic portosystemic shunt: correlation with hemodynamic findings. Gastroenterology 1998; 114: Saxon RR, Ross PL, Mendel-Hartvig J, et al. Transjugular intrahepatic portosystemic shunt patency and the importance of stenosis location in the development of recurrent symptoms. Radiology 1998;207: Rössle M, Haag K, Ochs A, et al. The transjugular intrahepatic portosystemic stent-shunt procedure for variceal bleeding. N Engl J Med 1994;330: Coldwell DM, Ring EJ, Rees CR, et al. Multicenter investigation of the portal hypertension. Radiology 1969;20: Rosemurgy AS, Goode SE, Zwiebel BR, et al. A prospective trial of transjugular intrahepatic portasystemic stent shunts versus small diameter prosthetic h-graft portacaval shunts in the treatment of bleeding varices. Ann Surg 1996;224: Collins JC, Ong MJ, Rypins EB, et al. Partial portacaval shunt for variceal hemorrhage: longitudinal analysis of effectiveness. Arch Surg 1998;133: Stauch S, Kircheis G, Adler G, et al. Oral L-ornithine-Lasparate therapy of chronic hepatic encephalopathy: results of a placebo-controlled double-blind study. J Hepatol 1998;28: Riordan SM, Williams R. Treatment of hepatic encephalopathy. N Engl J Med 1997;337: RECOMMENDED READING Hausegger KA, Sternthal HM, Glein GE, et al. Transjugular intrahepatic portosystemic shunt: angiographic follow-up and secondary interventions. Radiology 1994;191: Darling RC III, Shah DM, Change BB, et al. Long term follow up of poor risk patients under going small diameter portacaval shunts. Am J Surg 1992;164: Capussotti L, Vergara V, Polastri R, et al. A critical appraisal of the small diameter portacaval H-graft. Am J Surg 1995;170: Shaked A, Busuttil R. Liver transplantation in patients with portal vein thrombosis and central portacaval shunts. Ann Surg 1991;214: Zakim D, Boyer TD. Hepatology: a textbook of liver disease. Vol 1. Philadelphia: WB Saunders; p. 735.