Implantation of a Transjugular Intrahepatic Portosystemic Stent Shunt TIPSS

Checklist:

Implantation of a TIPSS

• Is the arterial perfusion of the liver sufficient?

• Is blood clotting sufficient despite the liver disease?

TIPSS needs experienced hands.

• Procedure: After the patient has been positioned on the interventional table and draped with sterile blankets, Segner carefully punctures the right internal jugular vein under ultrasound control. With a dedicated set he advances a needle into the right hepatic vein. He measures the pressure: 6 mmHg. Under ultrasound guidance ("Gregory, I need to see that needle tip!") he drives a large, gently angled Colapinto needle from the intrahepatic right hepatic vein through the liver tissue in the direction of the portal venous system. He is lucky: his first pass already hits a right portal vein branch of sufficient diameter. He injects a little contrast via the needle and checks its distribution in the vascular territory: Yes, it is a portal vein alright. He measures the pressure once again, this time in the portal vein. It is 31 mmHg. "Normally the gradient between the venous and the portal venous system may not exceed 12mmHg. Here it is 25mmHg already!" explains Segner. He pushes a stiff guide-wire with a floppy tip into the main portal vein. "It's right there where it belongs, mate," he drawls and gives Joey a wide grin. "You've got to be care-

I Implantation of a TIPSS

Portal Vein Coverd Stent

31 mmHg

21 mmHg

Fig. 7.12a After the right hepatic vein has been entered, a needle tract between the hepatic vein and the portal vein system is generated and the needle is advanced. After injecting contrast into the portal system, it can be visualized back to the level of the splenic vein and the superior mesenteric vein.

Projected over the spine you see tissue glue in inferior esophageal varices—traces of a previous intervention. b After dilation of the needle tract and insertion of a covered wall stent, a large-bore communication has been created between the portal vein and the vena cava—the portovenous shunt.

ful to hit the portal vein within the hepatic parenchyma and not in the hepatic hilum—that would cause a potentially lethal hemorrhage. Now the parenchymal channel between the liver vein and the portal system is dilated with a balloon and a beautiful coated stent is implanted." The stent procedure goes swiftly and without any difficulties. The stent runs in a smooth curve from the liver vein to the portal vein branch (Fig. 7.12b). Segner repeats the pressure measurements in the vena cava and the portal vein main trunk. The pressure is now 14 mmHg (vena cava) and 21 mmHg (portal vein). "Look how the gradient has decreased—from 25 to 7 mmHg. That is a splendid result. Of course the gradient must not be made too small because it drives the blood flow through the stent, and if it gets too low there is a higher risk of TIPSS thrombosis." He turns to the patient: "The danger of recurring hemorrhages should be close to nil now, Mrs. Woodworth." "Since we now have a great access route to the portal system we could go ahead and embolize directly any varices that might be still bleeding," Segner explains to Joey. The access set is withdrawn from the jugular vein and the puncture site is compressed carefully by hand. After a little while Joey may take over the compression. Forty minutes later, Mrs. Woodworth is back on the ward again. Should she develop a hepatic encephalopathy despite a protein-reduced diet, an oral lactulose regimen, and fluid substitution, the stent lumen could be reduced in a second intervention.

The hepatic encephalopathy can be treated conservatively and by intervention. Regular Doppler ultrasound controls are necessary to detect and treat stenoses early.

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