STROKOVNI SESTANEK ZDRUŽENJA HEMATOLOGOV SLOVENIJE IN ZDRUŽENJA ZA TRANSFUZIJSKO MEDICINO, Terme Zreče, 17.-18.4.2015 Barbara Rus Gadžijev Peter Popovič Klinični inštitut za radiologijo UKC Ljubljana
goals, indications and contraindications pre-tips imaging evaluation technique complications and how to provide solutions imaging follow up after TIPS
creation of minimally invasive portosystemic shunt treat or avoid portal hypertension complications hepatic venous pressure gradient (HVPG) < 12 mmhg
liver cirrhosis > 90 % increase in porto-systemic pressure gradient above 6 mmhg complications (> 10-12 mmhg) variceal bleeding ascites portal hypertensive gastropathy hepatorenal syndrome hepatic hydrothoraks Garcia-Tsao G et al. Hepatology 2007
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
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 1995 15 47/44 13/39 38/ 14 23/21 Cobrera 1996 15 31/32 23/51 33/13 19/15 Sanyal 1997 32 41/39 24/39 29/13 29/18 Cello 1997 19 24/25 12/48 50/44 33/32 Rosle 1997 14 61/65 15/45 29/14 13/12 Sauer 1997 18 42/41 25/57 29/13 28/27 Merli 1998 18 38/43 24/51 55/26 24/19 Garcia-Villareal 1999 20 22/24 9/50 23/25 15/33 Jalan 1997 16 31/27 10/52 16/11 42/37 Pomier-Layrorgus 2001 19 41/39 18/66 47/44 57/56 Narahara 2001 37 38/40 16/28 26/15 29/18 Guiberg 2002 24 28/26 25/65 7/4 14/15
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
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
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
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
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
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
Recommendations Right atrium Hepatic vein IVC
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
Recommendations Performing the intrahepatic tract portography and portal pressure meaurements Parenchimal tract dilatation (8 mm or 10 mm)
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
Procedural (major 3%) Intraabdominal bleeding Hemobilia Sepsis Long term PSE Shunt dysfunction Right heart failure
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
incidence 18% - 78% psevdointimal hyperplasia and neointimal hyperplasia dilatation or placement of an additional stent Primary patency 1 yr. 60-66% 2 yr. 32-50% Secondary patency 1 yr. 95% 2 yr. 90% Boyer TD,Haskal ZJ. Hepatology 2010 H.Ferral.Radiology 2004
5 mmhg PSG 13 mmhg 8 mmhg 18 mmhg 10 mm stent graft -7 cm Reintervention-PTA + stentgraft
clinical examination upper gastrointestinal endoscopy color duplex sonography venography
TIPS has an established role for the treatment of some complications of portal hypertension It is the most efficient method to lower portal pressure
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