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Linkedin Twitter Facebook. Click on the button at right to take the quiz. Liver cirrhosis may lead to the development of portal hypertension, which has a significant impact on patient outcomes and survival.
These patients are clinically challenging and costly to manage, often requiring treatment for consequences of liver failure such as ascites, variceal haemorrhage, sepsis, and renal failure.
Transjugular intrahepatic portosystemic shunt TIPS insertion offers a minimally invasive option for lowering raised portal pressure, which can provide symptomatic relief and confer a survival benefit in selected patients suffering the complications of portal hypertension.
The first TIPS procedures were carried out in the s, and success rates have increased as endovascular and radiological technologies have developed.
There are, however, considerable challenges to delivering an effective TIPS service, including the organization of multidisciplinary input with appropriate anaesthetic expertise and support.
The hepatic arteries carry oxygenated blood via the aorta and coeliac axis, while the portal vein carries nutrient-rich blood from the gastrointestinal tract to process within the hepatic parenchyma.
The portal vein is formed by union of the mesenteric veins and splenic vein posterior to the head of the pancreas, and divides into right and left branches which enter the respective liver lobes.
Venous drainage is via the hepatic veins to the inferior vena cava. In addition to the fixed obstruction resulting from structural disruption, there can be a dynamic component due to stellate cell contraction within the liver as a result of acute events such as sepsis or acute high alcohol intake.
The diagnosis of portal hypertension may be suspected clinically in patients with features of cirrhosis, suggestive haematology thrombocytopenia , or diagnostic radiological findings splenomegaly, recanalization of the umbilical vein, or reversal of flow in the portal vein.
Diagnosis can be confirmed by measurement of the hepatic venous pressure gradient HVPG , which is the gold standard for assessing portal hypertension and also has prognostic value.
HVPG is a surrogate for the portal pressure gradient and is measured at hepatic venous catheterization as the difference between the balloon-wedged hepatic venous pressure and free hepatic venous pressure.
The physiological effects which result from the consequences of advanced liver disease and portal hypertension have been described in detail elsewhere.
In addition, treating the underlying cause, such as achieving abstinence from alcohol or using antiviral regimes, frequently limits or reverses complications.
Ascites and hepatic hydrothorax may respond to a sodium restricted diet or diuretics e. Diuretic-resistant ascites may require repeated large-volume paracentesis with i.
In any patient with established cirrhosis, endoscopic surveillance for varices should be performed at diagnosis and repeated every 2—3 yr.
When medical or endoscopic therapy fails and portal pressure remains persistently high, shunt procedures such as TIPS may be beneficial. TIPS provides symptomatic benefit and improves survival in patients with diuretic-resistant ascites which requires frequent paracentesis.
Clinical outcomes, including mortality, after TIPS can be predicted using liver disease severity scores such as the model for end-stage liver disease or Child—Pugh scores.
Where possible, clinical assessment by a hepatologist, echocardiography, and triple-phase computed tomography CT should be performed in all patients.
Contraindications to TIPS insertion 6. TIPS insertion requires expertise in interventional radiology and is usually performed in the angiography suite.
Internal jugular vein cannulation allows passage of a catheter into the hepatic vein where wedge pressure is measured and HVPG calculated.
Hepatic venography using contrast or carbon dioxide , often ultrasound-assisted by a second operator, is used to delineate the vascular anatomy of the liver and a communication between a branch of the hepatic venous and portal venous circulation is created by the cutting tip of the catheter under fluoroscopic control.
After balloon dilatation of this communicating track, a polytetrafluoroethane-covered nitinol e. Internal jugular vein access can be complicated by carotid or tracheal puncture, pneumothorax or haemothorax, thoracic duct, or brachial plexus injury.
The passage of the catheter through the right atrium may cause irritation precipitating arrhythmias, and rarely damage to the myocardium. Technical difficulty can occur in puncture of the portal vein, which may result in liver capsule puncture and potentially fatal haemorrhage into the peritoneal cavity.
Portal venous rupture, inadvertent puncture of the hepatic arteries, biliary structures, and right kidney have also been reported.
Late complications such as stent occlusion, thrombosis, or dislodgement may also occur. Patients undergoing TIPS are medically complex as a result of chronic liver disease causing multisystem physiological disruption.
They should receive multidisciplinary input as part of comprehensive preoperative assessment and optimization before undergoing the procedure.
Patients who are potential or confirmed transplant candidates must be carefully considered as TIPS may rarely precipitate sudden decompensation to fulminant hepatic failure.
These cases should be discussed with a transplant centre and transferred if appropriate. A full evaluation of co-existing conditions should be undertaken in the usual manner before anaesthesia, although there are several particular areas to which attention must be directed in order to ensure optimal outcomes.
The urgency of the procedure will determine the extent of preoperative work-up that is feasible. Cardiovascular status must be assessed. Patients with cirrhosis often exhibit a hyperdynamic circulation with low-normal arterial pressure due to persistent splanchnic vasodilatation.
Cardiac output will increase after TIPS insertion as pooled venous blood returns to the systemic circulation; hence, any degree of heart failure must be assessed before shunt insertion as this is likely to deteriorate with the effective fluid challenge post-procedure.
Symptomatic heart failure and tricuspid regurgitation should be assessed using transthoracic echocardiography and treatment optimized before TIPS is considered.
All patients should undergo echocardiography to determine left ventricular function and to exclude severe pulmonary hypertension; this would contraindicate the procedure due to the expected increase in right heart and pulmonary pressures with increased preload after shunting.
Reduced functional residual capacity due to ascites and hepatic hydrothorax impairs respiratory function.
This is exacerbated by the supine position required for the procedure. Baseline ventilatory observations may reveal respiratory dysfunction, while a chest radiograph will indicate the presence and extent of hydrothorax.
Consideration should be given to drainage of any intraperitoneal or intrathoracic fluid collection in patients with severe respiratory compromise.
This is normally performed on the day before the TIPS procedure and should involve the use of albumin for volume replacement 8 g per 2.
Thrombocytopenia and coagulopathy are common in cirrhotic patients and these abnormalities should be corrected before shunt insertion. Cross-matched blood should be requested according to local policy, bearing in mind that patients have often had multiple transfusions in the past after repeated variceal haemorrhage and may therefore have atypical antibodies requiring extended cross-matching and import of blood products from regional centres.
Baseline renal impairment must be investigated further, as this may represent intrinsic renal damage or a degree of hepatorenal syndrome.
In either case, the receipt of a significant contrast load during TIPS insertion may adversely affect renal function.
This may be attenuated by correction of hyponatraemia, volume expansion with human albumin solution, and the use of acetylcysteine for 48 h, although there is a lack of trial evidence to support this.