The transjugular intrahepatic portosystemic stent shunt is a minimal invasive method through which the increased pressure in portal vein of liver is reduced by placing a stent bridging the portal vein and hepatic vein. The TIPSS leads to decrease in life threatening complications caused by blood congestion in the liver.

What causes the increase in portal venous pressure?

The portal venous pressure describes the increase in pressure in regions of liver supplied by portal vein. In most cases the increase in portal venous pressure is due to liver cirrhosis. Due to cirrhotic changes of the liver parenchyma the vessels are narrowed. This leads to decrease in the volume of blood drained from the liver into the heart. This causes congestion of blood entering the portal vein with consecutive increase in pressure.

What are the complications of increased portal venous pressure?

This procedure can lead to varicosed collateral circulation like for e.g., oesophagus varicosis, varicosis in fundus of stomach, hypertensive gastropathy, caput medusae and also splenomegaly and ascites. Such collateral circulation can lead to sudden, massive and life threatening bleeding. The ascites is a result of increased pressure in the portal vein so that it cannot excrete the excess fluid in the body. This causes collection of the fluid in tissues, firstly in form of edema in the legs and finally in the abdominal cavity. This fluid collection in abdomen is very uncomfortable for the patient and in cases of infection of abdominal cavity can be life threatening.

Indications

• Average to severe ascites: when ascites cannot be sufficiently treated conservatively.
• Acute varicosis bleeding (emergency TIPSS).
• Secondary prophylaxis of varicosis bleeding (after first episode of bleeding).
• In case of residual bleeding which calls for repeated blood transfusion.
• Budd-Chiari-Syndrome.
• Massive splenomegaly.
• Primary prophylaxis of first episode of varicosis bleeding.

Contraindications

• Thrombosis of portal vein.
• Right heart insufficiency.
• Pulmonary hypertension.
• Spontaneous bacterial peritonitis.
• Polycystic liver disease.
• In cases of very low INR (> 2) or thrombocytopenia (<50.000/µl).
• Hepatic encephalopathy.

When is the TIPSS done?

The TIPSS is performed when the effects of increased portal venous pressure becomes life threatening for the patient. Transplantation of liver is the only life saving therapy at this stage of liver disease. But liver transplantation is a major operation and not always immediately possible. Through the placement of TIPSS one can bridge the time required till transplantation.

How is the TIPSS perforemed?

The patient first receives some pain medication and a sedative. A full narkosis or general anaesthesia is not possible because the patient has be awake to react to our commands during the intervention. Normally, a catheter is placed from the right side of the neck and pushed caudally till the right liver vein. This catheter serves as medium for placement of the required instruments for shunt placement. From the right liver vein an intrahepatic connection to portal vein is achieved using a stable maneuverable hollow needle mostly under the guidance of ultrasound. After this an intrahepatic connection between the liver vein and a branch of portal vein is created using balloon dilatation. This tract is kept patent with the placement of a stent-shunt.

What are the possible complication of TIPSS?

The most common complication of TIPSS is bleeding. It is possible that after the placement of TIPSS the draining liver vein in due course of time is narrowed and hence lead to compromised blood supply. Seldom, there can be accumulation of clots on the stent wall in which case a new TIPSS placement has to be undertaken. The diversion of blood flow through TIPSS can lead to early development of hepatic encephalopathy.

 

Document Date: unknown   Author: Ahmed Koujan

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