Transjugularni intrahepatični portosistemski šant - TIPS. Sagić Dragan IKVB Dedinje Medicinski fakultet Beograd
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1 Transjugularni intrahepatični portosistemski šant - TIPS Sagić Dragan IKVB Dedinje Medicinski fakultet Beograd
2 Liver Cirrhosis Diffuse fibrosis or scarring of the liver. Common causes: Alcohol abuse Chronic viral hepatitis (B & C) Biliary cirrhosis (primary & secondary) Metabolic: Hemochromatosis Wilson dis, alfa-1- antitrypsin Autoimmune diseases (autoimmune hepatitis) Drugs and toxins Portal hypertension and hepatic failure
3 Mechanism of Portal HTN Cirrhosis Resistance portal flow Mechanical Nodules Dynamic Nitric oxide
4
5 Portal Hypertension Hepatic fibrosis resists the inflow from the portal veins. Increases the portal venous pressure. Results in: Varices (gastric & esophageal) Ascites Splenomegaly Hepatic encephalopathy from portal-systemic shunting Hepatorenal Sy
6 Portal Hypertension - Therapy Drugs Therapy: Beta-blockers or long-acting nitrates Vasopressin, NTG, Octreotide & Somatostatin Variceal Band Ligation. Sclerotherapy TIPS DSRS Liver transplant
7 Portal Hypertension - Therapy Intervencije sa redukcijom povišenog portnog pritiska TIPS Rekanalizacija hepatic venous outflow Rekanalizacija okludirane VP i grana Embolizacija art-portnih fistula Parcijalna splenična embol. Revizija hirur-radiol. šantova Palijativne procedure Perkutana transhepatična embolizacija variksa BRTO balon retrogradna obliteracija gastričnih variksa
8 Boyer T, Haskal Z. Hepatology 2005;41:1-15
9 TIPS - indikacije Akutna krvarenja i učestala, ponavljana variksna krvarenja (med. th ili endoskopska skleroterapija bez kliničkog poboljšanja) (gr. I) Refraktorni ascites (gr. II-2) Refraktorni hepatični hidrotoraks (gr. II-3) Splenomegalia sa hipersplenizmom (gr. II-3) Budd-Chiari sindrom (gr. II-3) Hepatorenalni sindrom (gr. II-3) Priprema za transplantaciju jetre (gr. III) Boyer T, Haskal Z. Hepatology 2005;41:1-15
10 TIPS Kontraindikacije CHF srčana slabost Art. plućna hipertenzija Insuficijencija desnog srca, TR gr III-IV Značajna insuficijencija i policistična bolest jetre Relativne kontraindikacije Intrahepatične/sistemske infekcije Med.th. nekontrolisana hepatična encefalopatija Hipervaskularni hepatični tumori Tromboza portne vene Trombocitopenija < cm3 Izražena koagulopatija (INR >5) Boyer T, Haskal Z. Hepatology 2005;41:1-15
11 Pre-TIPS: Doppler UZ, Angio (msct), MR Anatomija i prohodnost Hepatične vene, sliv portne vene (VL, VMS, VMI) Protok krvi u portnom slivu Hepatopetal: prema jetri (normal) Hepatofugal: preko portosistemskih kolaterala, od jetre. Rekanalizacija umbilikalne vene Varices, Ascites
12
13 Variksi Intrahepatički blok Ciroza jetre variksi CV VP Esophagus Gastric Colo-rectal Portal hypertensive gastropathy VL
14 Prehepatički blok Tromboza portne vene Cavernoma
15
16 Ascit Značajna komplikacija ciroze jetre: 50% za 10g. 50% mortalitet za 2g. Potreba planiranja transplantacije jetre
17 V.umbilicalis VP
18
19 TIPS - tehnika HV Punkcija desne unutrašnje jugularne vene Uvodnik, vodič Dijagnostički kateter desna hepatična vena Punkcija desne hapatične vene Colapinto ili Rosch punkcioni sistem igla usmerena anteromedijalno i kaudalno, prema desnoj grani VP. Optimalno punkcija 10 mm od bifurkacije portne vene Portografija, merenje gradijenta VP/RA, > 12mmHg VP
20 TIPS - tehnika Intrahepatični parenhimski put PTA balon-kateterom 8-10mm Samošireći metalni stent, dodatno PTA stenta Prominiranje stenta: HV, VP Struktura, dimenzije Merenje gradijenta P Portosist. gradijent <8mmHg Venografija Embolizacija VP A
21 PTFE covered stent Viatorr, Gore
22 TIPS
23 TIPS embolizacija variksa Ninoi T. TIPS Versus Transcatheter Sclerotherapy for Gastric Varices. AJR 2004;183:
24
25
26 VH
27 VP dex
28 VP sin V. umbilicalis VMI
29 VP VL VMI VU
30
31 TIPS - praćenje Tehnički uspeh TIPS-a je preko 95% Proceduralni mortalitet je < 1% Povećana smrtnost Pacijenti sa sistemskim bolestima Izraženo aktivno krvarenje tokom TIPS-a Dnevni mortalitet: 3% do 30% Child klasifikacija Stepen urgentnosti procedure Punamiya SJ. Indian Radiol J Imaging 2008;18: Boyer T, Haskal Z. Hepatology 2005;41:1-15
32 TIPS - praćenje TIPS jednogodišnje preživljavanje Krvareći variksi: 48%-90% Ascites: 48%-76% Okluzija/stenoza šanta ±50% do 6 meseci ±70% do 1 godine ±80% do 2 godine Ferral H. J Vasc Interv Radiol 2002;13: Boyer T, Haskal Z. Hepatology 2005;41:1-15
33 TIPS proceduralne komplikacije Perforacija: srce, VCI, VP, kapsula jetre, pneumothorax, lezije VJI Fistula creation: arterioportal, arteriobiliary (hemobilia), biliary-stent (bilhemia) Krvarenje Rascep kapsule Lezija hepatične arterije Punkcija ekstrahepatičnog dela VP Malpozicija stenta Akutna troboza: stent, VP Infekcija
34 TIPS proceduralne komplikacije Pogoršanje funkcije jetre Pogoršanje hep.encefalopatije (HE) Pre TIPS - HE Child C class ciroza Po TIPS - veći dijametar stenta Pogoršanje hiperdinamske cirkulacije
35 TIPS proceduralne komplikacije Boyer T, Haskal Z. Hepatology 2005;41:1-15
36 TIPS redukcioni stent Memotherm reduction stent (Angiomed) Bil. ductus OptiMed reduction stent Prevencija hep. encefalopatije Maleux G. AJR 2007;188:
37 TIPS proceduralne komplikacije Bil. ductus Boyer T, Haskal Z. Hepatology 2005;41:1-15
38 TIPS proceduralne komplikacije Bil. ductus Angulacija gr P 13mmHg Fraktura stenta po PTA Revizija - pokriven stent Cura M. AJR 2008; 191:
39 TIPS restenoza
40 TIPS restenoza Bil. ductus Cura M. AJR 2008; 191:
41 TIPS restenoza Wall stent Bil. ductus covered stent Instent restenoza Re PTA balonom Cura M. AJR 2008; 191:
42 TIPS restenoza Wall stent Bil. ductus Instent okluzija Re PTA balonom Cura M. AJR 2008; 191:
43 TS TIPS Comparison of transjugular intrahepatic portosystemic shunt (TIPS, dotted lines) and transcatheter sclerotherapy (TS, solid lines) groups for cumulative survival using Kaplan-Meier method and log rank test. Table beneath figure shows number of patients at risk in each group Ninoi T.AJR 2004;183:
44 TIPS TS Comparison of transjugular intrahepatic portosystemic shunt (TIPS, dotted lines) and transcatheter sclerotherapy (TS, solid lines) groups for cumulative bleeding using Kaplan-Meier method and log-rank test. Ninoi T.AJR 2004;183:
45 TIPS - praćenje Boyer T, Haskal Z. Hepatology 2005;41:1-15
46 Portal Hypertension - Therapy Intervencije sa redukcijom povišenog portnog pritiska TIPS Rekanalizacija hepatic venous outflow Rekanalizacija okludirane VP i grana Embolizacija art-portnih fistula Parcijalna splenična embol. Revizija hirur-radiol. šantova Palijativne procedure Perkutana transhepatična embolizacija variksa BRTO balon retrogradna obliteracija gastričnih variksa
47 Variksna krvarenja: šant operacije - GIB Stenoza hirurškog spleno-renalnog šanta Wall stent 8x40 (Boston Scientific) Sagic D. Arch Gastroenterohep. 2003;22:12-17
48 Variksna krvarenja: šant operacije - GIB C Portni kavernom CV v. coronaria ventr. V variksi jednjaka Perišić VN, Grujičić S, Sagić D. Balloon dilatation of a compromised splenorenal shunt. J Pediatr Gastroenterol Nutr 1997;25:
49 Variksna krvarenja: šant operacije - GIB VC vena cava inferior R leva renalna vena L lijenalna vena P vena Portae V variksi jednjaka kolateralne vene Perišić VN, Grujičić S, Sagić D. Balloon dilatation of a compromised splenorenal shunt. J Pediatr Gastroenterol Nutr 1997;25:
50 Variksna krvarenja: šant operacije - GIB VC vena cava inferior R leva renalna vena L lijenalna vena Perišić VN, Grujičić S, Sagić D. Balloon dilatation of a compromised splenorenal shunt. J Pediatr Gastroenterol Nutr 1997;25:
51 Variksna krvarenja: šant operacije - GIB v.lienalis v.renalis Okluzija hirurškog splenorenalnog šanta PTA šanta IKVB Dedinje, Beograd
52 Portal Hypertension - Therapy Intervencije sa redukcijom povišenog portnog pritiska TIPS Rekanalizacija hepatic venous outflow Rekanalizacija okludirane VP i grana Embolizacija art-portnih fistula Parcijalna splenična embol. Revizija hirur-radiol. šantova Palijativne procedure Perkutana transhepatična embolizacija variksa BRTO balon retrogradna obliteracija gastričnih variksa
53 Perkutana transhepatična embolizacija variksa Esophagus Gastric Colo-rectal Portal hypertensive gastropathy
54 Variksna krvarenja BRTO - balloon-occluded retrograde transvenous obliteration Balon - okluzivni venogram Gastro-renal šant Komunikacija sa perikardiofreničnom venom i druge manje kolaterale. Kiyosue H. RadioGraphics 2003;23:
55 Zaključak TIPS je invazivna metoda pomoću koje se značajno redukuje povišen pritisak u portnom venskom sistemu, sa prihvatljivim proceduralnim komplikacijama.
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