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home - Liver - Treatments - TIPPS Written by Dr Sebastian Zeki
Knowledge


Knows the indications for liver transplantation appropriate timing of
referral for assessment and outcomes after transplantation

Understands the long-term management of liver transplant recipients
including complications of immunosuppression and management of
recurrent disease

Skills
Can identify potential candidates for liver transplantation as well as
demonstrating an understanding of why patients with end-stage liver
disease are not appropriate candidates for liver transplantation

Has detailed understanding of the transplant process will
be required while training in specialist units and their satellites

Behaviours
Displays confidence that they can identify all potential candidates for
liver transplantation refer at the appropriate time and contribute to
life-long follow-up of liver recipients

TIPPS

TIPSS techniqueThe technical complications associated with insertion of TIPS can occur at various stages of the procedure.A needle catheter (Colapinto catheter) is passed via a transjugular route and wedged into the hepatic vein.The needle is then extruded and advanced through the liver parenchyma to the intrahepatic portion of the hepatic vein. Complications related to access to the hepatic vein:Carotid artery or tracheal puncture.Cardiac arrhythmias esp if catheter buckles in right atrium or prolapses into the right ventricle. Complications of portal vein ma-nipulation and stent placement:Extrahepatic puncture of portal vein with exsanguinating hemorrhage after portal vein dilatation and puncture.Extensive thrombosis of the TIPS, portal vein, or splenic vein -3 to 12 % - usually ocurs in the 1st month. Due to shunting of blood from the portal to systemic circulation Incidence of 40%, 2-3 weeks after TIPS insertionProphylaxis with lactulose/ rifaximin not usefuRisk FactorsIncreasing ageAdvanced liver failureHistory of encephalopathy The diameter of the shunt (lower resistance with wider diameter)-PSE increases if shunt diameters >10 mm.Treatment: As per hepatic encephalopathyIf no response- Try reducing the stent diameter- Liver transplant Fistulae between both large and microscopic bile ducts and the TIPS lumen assoc with shunt thrombosis and early stent occlusion. TraversalOccurs in 33%Haemoperitoneum is rareRIsk factors: Small liver / displaced (ascites etc) or portal vein thrombosis therefore should have paracentesis and portal vein dopplers before-handCan embolize if significant bleeding Intended path Another important complication during this part of the procedure is the creation of a tract between the shunt or the portal vein and the hepatic artery or bile ducts. Pseudointima (incomplete layer of lining endothelial cells with underlying collagenous matrix and mesenchymal cells interspersed between the collagen fibrils) from surrounding liver through the stent’s wire mesh- Incidence of stent stenosis is 75 % at 6 to 12 months.Greatly decreased with covered stentTypes1: Diffuse stenosis along the length of the stent (type 1 stenosis)2: Isolated focal narrowing at the hepatic venous end of the TIPS (type 2 stenosis).Treatment:Both patterns respond well to dilation and placement of additional stents in series with the preexisting stents to shore up the dilated stents.Portal hypertension can occur but risk reduces after 3 yearsMonitoring TIPS patencyDoppler sonography most commonly used but sensitivity of 35 % and a specificity of 83 %.Usually done 6m post insertion and then 6 monthly intervals for 2 yearsAngiography gold standard but not always availableHelical CT angiography also has shown promise. 30-day mortality- 30%Severe hyperbilirubinemia-5.4 % Risk factors of nonalcoholic liver disease and a baseline PT >17s. Hemolytic anemiaOccurs in 10%.Presents within 1-2 weeks of stentDue to injury to red cells from shear stress or direct mechanical trauma in shuntResolves within 8-2 weeks in mostRelated to endothelialisation of the metal wiresVegetative infectionsRare but can occur, especially with enteric infections. Absolute contraindications for TIPS:Primary prevention of variceal bleeding.Congestive heart failure.Multiple Hepatic Cysts.Uncontrolled systemic infection/ sepsis.Unrelieved biliary obstruction.Severe pulmonary hypertension. TIPS Indications:Secondary prevention of variceal bleeding.Refractory cirrhotic ascites.Refractory acutely bleeding varices.Portal hypertensive gastropathy.Bleeding gastric varices.Gastric antral vascular ectasiaRefractory hepatic hydrothorax.Hepatorenal syndrome (type 1/2).Budd-Chiari.Veno-occlusive disease.Hepatopulmonary syndrome. Role of TIPS variceal bleeding Prevention of Recurrent Variceal Haemorrhage.It is unlikely to recur as long as the TIPS remains patent.It is more effective than endoscopy to prevent recurrent bleed but may increase mortality.It is preferred to shunt surgery in patients with poor liver function. Complications Related to Portosystemic Shunting Portosystemic encephalopa-thy (PSE) Transjugular intrahepatic portosystemic Shunts Relative contraindications for TIPS:Hepatoma (esp central).Obstruction of all hepatic veins.Portal vein thrombosis.Severe coagulopathy (INR>5).Thrombocytopoenia (<20).Moderate pulmonary hypertension. Can be reduced by using an introducer (stiff sheath) Covered stents avoid need for anticoagulation not neededTreatment: Thrombolysis, anticoagulation, or suction thrombectomy or liver transplant Avoid by only using main branches for stent Complications related to creation of the intrahepatic tract TIPS stenosis Other systemic Problems Written by Dr Sebastian Zeki

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