Outline the mechanism of action and list the indications, contraindications and complications of the TIPSS procedure (Transjugular intrahepatic portosystemic shunt).

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College answer

Mechanism of action:

Percutaneous formation of a tract between hepatic vein and intrahepatic segment of portal vein. Blood is shunted away from portal circulation to systemic circulation, thereby reducing portal pressure.

Indications:              (20% Marks)

  • Uncontrolled variceal bleeding
  • Refractory ascites
  • Hepatic pleural effusion
  • Also consider in: bridge to transplant
  • Budd Chiari (may need a DIPS- shunt from IVC to portal vein)
  • HRS
  • Hepatic veno occlusive disease
  • Hepatic hydrothorax

Contraindications      (1 mark/point to max 4 points)            (30% marks)

  • Severe progressive liver failure with imminent death
  • Severe encephalopathy
  • Severe Right or congestive heart failure ( increases preload)
  • Polycystic liver disease
  • Caution in: portal vein thrombosis
  • Pulmonary hypertension/tricuspid regurg
  • Hepatopulmonary syndrome
  • Active infection
  • Tumor in shunt pathway

Complications:         (50% marks)

Peri-insertion:

  • Technical failure
  • Trauma to heart/liver
  • Bleeding haemoperitoneum
  • Bile leak
  • Stent Migration

Post insertion:

  • Encephalopathy
  • Stenosis/obstruction of shunt (uncommon with modern stents)
  • Portal or hepatic vein thrombosis
  • Acute liver ischamia
  • Infection: peritonitis, endotipsitis
  • Heart failure
  • Deterioration in hepatic function

Examiners Comments:

Candidates responses lacked specific details.

Discussion

In short, the rationale for a TIPS can be summarised as follows:

  • Portal hypertension causes the majority of the morbidity from chronic liver disease
  • This is due to raised portal pressure
  • TIPS decompresses the portal circulation by allowing it to empty into the comparatively lower central venous circulation
  • Ergo, TIPs should relieve the majority of the morbidity from chronic liver disease

Indications for TIPS include:

Contraindications (from Boyer and Haskal, 2009) include

  • Absolute contraindications:
    • Moderate to severe pulmonary hypertension
    • Congestive heart failure
    • Multiple hepatic cysts
    • Uncontrolled sepsis
    • Uncontrolled biliary obstruction
    • Total portal vein thrombosis (in the absence of any patent intrahepatic branches)
  • Relative contraindications:
    • A MELD score above 18
    • Central hepatocellular carcinoma
    • Portal vein thrombosis (in the absence of an experienced operator)
    • Hepatic vein thrombosis
    • Severe coagulopathy or thrombocytopenia

Technical complications of TIPS procedure:

  • Vascular access complications
  • Hepatic damage (through-and-through puncture): risk of intraperitoneal haemorrhage is 1-2%
  • Haemobilia (damage to the biliary tree)
  • Shunt stenosis or thrombosis (it happens in up to 70%)
  • Shunt migration
  • Hepatic vein stenosis (this can sabotage a future transplant)

Complications from portal venous shunt:

  • Worsening hepatic encephalopathy
  • Shunt thrombosis or portal vein thrombosis (7-10%). If there is already a portal vein thrombosis, this risk appears to increase somewhat (Perarnau et al, 2010) - which probably reflects the overall prothrombotic diathesis.
  • Bilirubin rise: the diseased liver doesn't even get a chance to metabolise it
  • Ischaemic hepatitis: the liver gets much of its oxygen from the portal vein, and even in spite of the hepatic arterial buffer response there is a risk of ischaemic hepatitis.
  • Haemolysis (due to the direct shearing effect of being in contact with the shunt)
  • "Unmasked" cardiomyopathy: the TIPS returns splanchnic blood to the heart and acts as a volume challenge, and if there was pre-existing cardiomyopathy, it may be dramatically revealed in this manner.
  • Tricuspid endocarditis (organisms may now travel directly from the leaky gut into the systemic circulation)
  • Shunt infection may occur, where the shunt may become the source of infection. The term "edotipsitis" is supposed to reflect the fact that persistent bacteraemia resembles bacterial endocarditis. 

References

References

Ochs, Andreas, et al.New England Journal of Medicine 332.18 (1995): 1192-1197."The transjugular intrahepatic portosystemic stent–shunt procedure for refractory ascites." 

Guevara, Mónica, et al. "Transjugular intrahepatic portosystemic shunt in hepatorenal syndrome: effects on renal function and vasoactive systems."Hepatology 28.2 (1998): 416-422.

Papatheodoridis, George V., et al. "Transjugular intrahepatic portosystemic shunt compared with endoscopic treatment for prevention of variceal rebleeding: A meta‐analysis." Hepatology 30.3 (1999): 612-622.

Azoulay, D., et al. "Transjugular intrahepatic portosystemic shunt (TIPS) for severe veno-occlusive disease of the liver following bone marrow transplantation." Bone marrow transplantation 25.9 (2000).

Ganger, Daniel R., et al. "Transjugular intrahepatic portosystemic shunt (TIPS) for Budd-Chiari syndrome or portal vein thrombosis." The American journal of gastroenterology 94.3 (1999): 603-608.

Freedman, A. M., et al. "Complications of transjugular intrahepatic portosystemic shunt: a comprehensive review." Radiographics 13.6 (1993): 1185-1210.

Rösch, J., et al. "Transjugular intrahepatic portacaval shunt an experimental work." The American Journal of Surgery 121.5 (1971): 588-592.

Rössle, Martin. "TIPS: 25years later." Journal of hepatology 59.5 (2013): 1081-1093.

Colapinto, R. F., et al. "Creation of an intrahepatic portosystemic shunt with a Grüntzig balloon catheter." Canadian Medical Association Journal 126.3 (1982): 267.

Conn, Harold O. "Transjugular Intrahepatic Portal‐systemic Shunts: The State of the Art." Hepatology 17.1 (1993): 148-158.

Gülberg, Veit, et al. "Hepatic arterial buffer response in patients with advanced cirrhosis." Hepatology 35.3 (2002): 630-634.

Boyer, Thomas D., and Ziv J. Haskal. "The role of transjugular intrahepatic portosystemic shunt (TIPS) in the management of portal hypertension: update 2009." Hepatology 51.1 (2010): 306-306.

Perarnau, Jean-Marc, et al. "Feasibility and long-term evolution of TIPS in cirrhotic patients with portal thrombosis." European journal of gastroenterology & hepatology 22.9 (2010): 1093-1098.

Orloff, Marshall J. "Emergency treatment of bleeding esophageal varices in cirrhosis." Current problems in surgery3.7 (1966): 13-28.

Unger, Lukas W., et al. "The role of TIPS in the management of liver transplant candidates." United European gastroenterology journal 5.8 (2017): 1100-1107.

DeSimone, J. A., et al. "Sustained bacteremia associated with transjugular intrahepatic portosystemic shunt (TIPS)." Clinical infectious diseases 30.2 (2000): 384-386.

Bouza, Emilio, et al. "Endotipsitis: an emerging prosthetic-related infection in patients with portal hypertension." Diagnostic microbiology and infectious disease 49.2 (2004): 77-82.

Sanyal, Arun J., and K. Rajender Reddy. "Vegetative infection of transjugular intrahepatic portosystemic shunts." Gastroenterology 115.1 (1998): 110-115.