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Transjugular Intrahepatic Portosystemic Shunt in Candidates for Liver Transplantation - Single Center Experience M. Toma ¹, M.C. Grasu¹, R. Dumitru¹, Andreea Scheau¹, Ioana Gabriela Lupescu¹, I. Popescu² ¹ Radiology, Medical Imaging and Interventional Radiology Department ² Department of Surgery, Division of Liver Transplant, FUNDENI Clinical Institute, Bucharest GORE ® VIATORR ® TIPS Endoprosthes

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Page 1: M. Toma ¹, M.C. Grasu¹, R. Dumitru¹, Andreea Scheau¹, Ioana Gabriela Lupescu¹, I. Popescu² ¹ Radiology, Medical Imaging and Interventional Radiology Department

Transjugular Intrahepatic Portosystemic Shunt in Candidates for Liver Transplantation - Single Center Experience

M. Toma ¹, M.C. Grasu¹, R. Dumitru¹, Andreea Scheau¹, Ioana Gabriela Lupescu¹, I. Popescu²¹ Radiology, Medical Imaging and Interventional Radiology Department ² Department of Surgery, Division of Liver Transplant, FUNDENI Clinical Institute, Bucharest

GORE® VIATORR® TIPS Endoprosthesis

Page 2: M. Toma ¹, M.C. Grasu¹, R. Dumitru¹, Andreea Scheau¹, Ioana Gabriela Lupescu¹, I. Popescu² ¹ Radiology, Medical Imaging and Interventional Radiology Department

None of the authors have identified a conflict of interest.

Page 3: M. Toma ¹, M.C. Grasu¹, R. Dumitru¹, Andreea Scheau¹, Ioana Gabriela Lupescu¹, I. Popescu² ¹ Radiology, Medical Imaging and Interventional Radiology Department

TIPS- a brief history• Transjugular intrahepatic porto-systemic shunt (TIPS): conceived

by the interventional radiologist Josef Rosch in 1969

• Richter and colleagues reported their initial experience of TIPS using Palmaz stents in 1989

• Unfortunately, uncovered stents proved prone to stenosis and occlusion, and consequently, required close surveillance and high rates of re-intervention.

• Covered stents (or ‘‘stent-grafts’’) developed in the late 1990s to specifically address these problems now have proven superior patency compared with uncovered stents and have heralded a promising new era for TIPS.

Page 4: M. Toma ¹, M.C. Grasu¹, R. Dumitru¹, Andreea Scheau¹, Ioana Gabriela Lupescu¹, I. Popescu² ¹ Radiology, Medical Imaging and Interventional Radiology Department

Experimental TIPS in canines performed by a University of California LosAngeles team in 1969. From left to right: Josef Rösch, Nancy Ross, William Hanafee,Harold Snow Radiology 1969; 92: 1112-1114

Page 6: M. Toma ¹, M.C. Grasu¹, R. Dumitru¹, Andreea Scheau¹, Ioana Gabriela Lupescu¹, I. Popescu² ¹ Radiology, Medical Imaging and Interventional Radiology Department

Definitions• Portal hypertension- syndrome caused by increased resistance in the

portohepatic circulation and an increase in the splanchnic vein blood supply.

• Portal hypertension- defined as a gradient between pressures in the portal vein and the free hepatic veins or right atrium larger than 6 mm Hg. Clinical complications occur only when the pressure gradient exceeds 10–12 mm Hg.

• Transjugular intrahepatic portosystemic shunt (TIPS)= the percutaneous method of creating a porto-systemic shunt to decrease or treat portal hypertension.

• Technical success- decrease of the PSG to 12 mm Hg or less, or a reduction of at least 20 %.

• Clinical success- cessation of variceal bleeding, decrease of ascites and conversion into diuretic sensitive ascites, as well as improvement of liver function in patients referred for massive thrombosis of hepatic veins.

Page 7: M. Toma ¹, M.C. Grasu¹, R. Dumitru¹, Andreea Scheau¹, Ioana Gabriela Lupescu¹, I. Popescu² ¹ Radiology, Medical Imaging and Interventional Radiology Department

TIPS Indications

Page 8: M. Toma ¹, M.C. Grasu¹, R. Dumitru¹, Andreea Scheau¹, Ioana Gabriela Lupescu¹, I. Popescu² ¹ Radiology, Medical Imaging and Interventional Radiology Department

TIPS Indications (2)• Scoring of patients by the model of end-stage liver disease (MELD)

predicts early mortality after TIPS. Patients with MELD scores of>15–18 or a bilirubin level of> 3.5 mg/dl should be informed of their poor prognosis.

• Refractory ascites- the most frequent indication for TIPS.

• Variceal Bleeding- the causes of gastrointestinal hemorrhage in a patient with portal hypertension may be variceal rupture, portal hypertension gastropathy, postsclerotherapy ulcers, peptic ulcer disease, hemorrhagic gastritis, and Mallory-Weiss tear.

• TIPS- generally accepted as a second-line therapy after failure of endoscopic and medical therapy of bleeding from gastroesophageal varices.

• Budd-Chiari sd. (AASLD-2009)- TIPS is indicated when medical therapy fails. The rationale of the use of TIPS is to decompress the liver from venous congestion using the portal vein and TIPS as an outflow tract.

Page 9: M. Toma ¹, M.C. Grasu¹, R. Dumitru¹, Andreea Scheau¹, Ioana Gabriela Lupescu¹, I. Popescu² ¹ Radiology, Medical Imaging and Interventional Radiology Department

TIPS in the transplant candidate (1)• Insufficient number of organs available for transplantation in

contrast to the number of patients on waiting list substantially elongates waiting time.

• Patients awaiting liver transplantation frequently bleed from

varices or have refractory cirrhotic ascites and therefore are candidates for a TIPS.

• TIPS has long been referred to as a procedure performed as “a bridge to transplantation” since it decompresses the portal circulation and stabilizes patients.

• TIPS can be used both before and after liver transplantation.

Page 10: M. Toma ¹, M.C. Grasu¹, R. Dumitru¹, Andreea Scheau¹, Ioana Gabriela Lupescu¹, I. Popescu² ¹ Radiology, Medical Imaging and Interventional Radiology Department

TIPS in the transplant candidate(2)• The best candidates for preoperative TIPS are cirrhotic

patients with well-preserved or moderately impaired liver function (Pugh class A or B) and a significant amount of venous collaterals in the operative area.

• The decompression of portal hypertension before abdominal surgery in cirrhotic patients could decrease the perioperative bleeding and post-operative complications.

• TIPS does not induce abdominal adhesions and scars, neither complicates hepatectomy technically.

• TIPS patients were found to require less blood, plasma and platelets transfusions during transplantation.

Page 11: M. Toma ¹, M.C. Grasu¹, R. Dumitru¹, Andreea Scheau¹, Ioana Gabriela Lupescu¹, I. Popescu² ¹ Radiology, Medical Imaging and Interventional Radiology Department

TIPS in the transplant candidate (3)• Ascites resistant to diuretics is a major problem in patients

with liver cirrhosis awaitnig liver transplant.

• Repeated paracentesis resulted in significant protein loss from transudate. They are also at increased risk of ascites infection, which is a serious complication in the perspective of liver transplantation and subsequent immunosuppression.

• Hepatorenal syndrome has been noted to resolve after TIPS.

• In 75% of patients after TIPS ascites regresses completely, in another 18% partially and only in few patients with chronic renal injury TIPS turns out to be ineffective. Considering these facts, preparation of the patient for transplantation is easier and his/her quality of life much higher while on the waiting list.

Page 12: M. Toma ¹, M.C. Grasu¹, R. Dumitru¹, Andreea Scheau¹, Ioana Gabriela Lupescu¹, I. Popescu² ¹ Radiology, Medical Imaging and Interventional Radiology Department

TIPS in the transplant candidate (4)• In the setting of liver transplantation, the most important

problem of TIPS is stent extension into the inferior caval or portal vein, wich may make the transplant procedure more difficult. Correct placement of TIPS within the liver is advisable to facilitate a future liver transplantation.

• Early detection of thrombosis in Doppler ultrasound or computed tomography followed by TIPS can secure patency of the portal vein and open the gate to transplantation.

• TIPS can be done in acute thrombosis (<5–7 days from its beginning). When there’s residual thrombosis, a catheter in the portal vein is left for administration of fibrinolytic agents (urokinase/tissue plasminogen activator (rt-PA).

Page 13: M. Toma ¹, M.C. Grasu¹, R. Dumitru¹, Andreea Scheau¹, Ioana Gabriela Lupescu¹, I. Popescu² ¹ Radiology, Medical Imaging and Interventional Radiology Department

TIPS in the transplant candidate (5)• Systematic Doppler assessment of the portal flow is very

important in patients on the waiting list. Finding reduced flow (velocity below 10 cm/s) calls for shift towards the beginning of waiting list and such a patient should be a candidate for fast transplantation.

• To make sure that portal vein remains patent- TIPS should be considered.

• Hepatopulmonary Syndrome (the triad of liver disease, arterial hypoxemia and intrapulmonary vascular dilatation)- numerous reports show that this condition is reversible with orthotopic liver transplantation (OLT).

• However, patients with HPS often present with PaO2 levels that are quite low. OLT with a preoperative PaO2 less than 50 mm Hg is associated with unacceptably high mortality and morbidity. In this cases a TIPS is successfully used to improve oxygenation, thus allowing a successful elective OLT.

Page 14: M. Toma ¹, M.C. Grasu¹, R. Dumitru¹, Andreea Scheau¹, Ioana Gabriela Lupescu¹, I. Popescu² ¹ Radiology, Medical Imaging and Interventional Radiology Department

TIPS in liver transplant recipients- bridge to re-transplantation?

• TIPS- mainly a bridge to liver transplantation- its role in LT recipients who develop recurrent portal hypertension is undefined

• Recurrent liver disease post-LT is increasing:

-Chronic hepatitis C virus -Venous outflow obstruction

• TIPS implantation could be technically demanding in LT recipients, due to Cavo-Caval anastomosis

• TIPS may be beneficial as a bridge to redo-LT especially in patients with HCV allograft recurrence

•  

P.P. GOFFETTE ; O. Ciccarelli; E. Bonaccorsi; J.P. Lerut-St-Luc University Hospital-Transjugular Intrahepatic Portosystemic Stent Shunt(TIPSS) after liver transplantation- CIRSE 011, Munich, Germany

Page 15: M. Toma ¹, M.C. Grasu¹, R. Dumitru¹, Andreea Scheau¹, Ioana Gabriela Lupescu¹, I. Popescu² ¹ Radiology, Medical Imaging and Interventional Radiology Department

TIPS Contraindications (1)

Absolute Relative

Primary prevention of variceal bleeding

Hepatoma(central)

Congestive heart failure Obstruction of all hepatic veins

Multiple hepatic cysts Portal vein thrombosis

Uncontrolled systemic infection or sepsis

Severe coagulopathy(INR>5)

Unrelieved biliary obstruction Thrombocytopenia (<20,000/cm3)

Severe pulmonary hypertension

Severe liver failure

Page 16: M. Toma ¹, M.C. Grasu¹, R. Dumitru¹, Andreea Scheau¹, Ioana Gabriela Lupescu¹, I. Popescu² ¹ Radiology, Medical Imaging and Interventional Radiology Department

TIPS Contraindications (2)

• TIPS is absolutely contraindicated in cases of unproved portal hypertension (either clinically or anatomically).

• TIPS should be carefully considered in the following circumstances:

• -APACHE II score>20, especially in Child C patients, and irreversible phase of hemorrhagic shock;

• -Child-Pugh score>12 & MELD score>18; • -right-sided heart failure with elevation of the central

venous pressure (mean right atrium pressure >15 mm Hg);• -hepatic encephalopathy poorly controlled by lactulose; • -chronic occlusion of the portal vein with periportal collaterals,

hypervascular hepatic tumors, polycystic liver disease; • -active infection.

Page 17: M. Toma ¹, M.C. Grasu¹, R. Dumitru¹, Andreea Scheau¹, Ioana Gabriela Lupescu¹, I. Popescu² ¹ Radiology, Medical Imaging and Interventional Radiology Department

Pretreatment Imaging & endoscopy

Evaluation of endoscopic studies. In case of bleeding: confirm presence and localizationOf varices (esophageal vs. Gastric varices or hypertensive gastropathy)

Page 18: M. Toma ¹, M.C. Grasu¹, R. Dumitru¹, Andreea Scheau¹, Ioana Gabriela Lupescu¹, I. Popescu² ¹ Radiology, Medical Imaging and Interventional Radiology Department

Complications Frequency (%)   TIPS dysfunction  Thrombosis 10–15Occlusion/stenosis 18–78Transcapsular puncture 33Intraperitoneal bleed 1–2Hepatic infarction 1Fistulae RareHemobilia 5Sepsis 2–10Infection of TIPS RareHemolysis 10–15Encephalopathy  New/worse 10–44Chronic 5–20

Stent migration or placement into IVC or too far  into portal vein 10–20

Data from Boyer and Vargus and Ro¨ssle et al.-HEPATOLOGY, Vol. 51, No. 1, 2010

Complications

Page 19: M. Toma ¹, M.C. Grasu¹, R. Dumitru¹, Andreea Scheau¹, Ioana Gabriela Lupescu¹, I. Popescu² ¹ Radiology, Medical Imaging and Interventional Radiology Department

Biliary tree injury(13.06.2013)

Page 20: M. Toma ¹, M.C. Grasu¹, R. Dumitru¹, Andreea Scheau¹, Ioana Gabriela Lupescu¹, I. Popescu² ¹ Radiology, Medical Imaging and Interventional Radiology Department

Clinical Case• S.M., 54 y.o., listed for liver transplant; diagnosed with alcoholic

cirrhosis class Child B with signs of portal hypertension.

The pre-procedural CT scan confirms the large amount of perihepatic, perigastric and pelvic ascites seen at the US scan and allows the planing of a endohepatic stent placement. It is decided the shunting between the middle hepatic vein and the right portal vein.

Page 21: M. Toma ¹, M.C. Grasu¹, R. Dumitru¹, Andreea Scheau¹, Ioana Gabriela Lupescu¹, I. Popescu² ¹ Radiology, Medical Imaging and Interventional Radiology Department

• General preparations: informed consent, correction of coagulopathy, standard monitoring: ECG, O2 saturation and blood pressure, intravenous antibiotic prophylaxis (1h before)- cephalosporins, Vancomycin

• 1)Percutaneous femoral access under local anesthesia is performed.

• 2)Catheterisation of the caeliac trunk and superior mesenteric artery with arterial portography.

• 3)The procedure is performed under general anesthesia with endotracheal intubation.

• 4)Right internal jugular vein access and middle hepatic vein cannulation.

• 5)Liver puncture with Colapinto needle and right portal vein access with the establishment of a communication between the middle hepatic vein and the right portal vein.

Page 22: M. Toma ¹, M.C. Grasu¹, R. Dumitru¹, Andreea Scheau¹, Ioana Gabriela Lupescu¹, I. Popescu² ¹ Radiology, Medical Imaging and Interventional Radiology Department

• 6) Pre-TIPS pressure mesurement is performed: portal vein- 30 mmHg, right atrium -10mm Hg

7)The tract is dilated with a 9mm/40mm/75 cm high pressure balloon

8) Calculation of the tract length with a Cordis® Pig-tail catheter

Page 23: M. Toma ¹, M.C. Grasu¹, R. Dumitru¹, Andreea Scheau¹, Ioana Gabriela Lupescu¹, I. Popescu² ¹ Radiology, Medical Imaging and Interventional Radiology Department

9) The Boston Scientific WALLSTENT-UNI™ 10mm/94 mm/75 cm Endoprosthesis is deployed

Page 24: M. Toma ¹, M.C. Grasu¹, R. Dumitru¹, Andreea Scheau¹, Ioana Gabriela Lupescu¹, I. Popescu² ¹ Radiology, Medical Imaging and Interventional Radiology Department

• 11) Post-TIPS pressure mesurement is performed : Portal vein- 22 mmHg, right atrium-14 mmHg.

• 12) Right femoral access closure with Angio-seal™. Manual jugular hemostasis.

10)Post-Stent dilatation with a 9mm/40mm/75 cm high pressure balloon

Page 25: M. Toma ¹, M.C. Grasu¹, R. Dumitru¹, Andreea Scheau¹, Ioana Gabriela Lupescu¹, I. Popescu² ¹ Radiology, Medical Imaging and Interventional Radiology Department

• Post-procedural clinical status improvement at 24 hours, with no signs of post-TIPS hepatic encephalopathy, increased diuresis and rapid decrease of ascites.

• For 5 months- routine post-procedural follow-up exams (doppler US, CT scans and upper GI endoscopy).

• 6 months after TIPS- left lobe LDLT

Page 26: M. Toma ¹, M.C. Grasu¹, R. Dumitru¹, Andreea Scheau¹, Ioana Gabriela Lupescu¹, I. Popescu² ¹ Radiology, Medical Imaging and Interventional Radiology Department

2 months after liver transplant: portal vein anastomotic stricture with pseudoaneurismal dilatation of the post-stenotic segment of the intrahepatic portal vein

Page 27: M. Toma ¹, M.C. Grasu¹, R. Dumitru¹, Andreea Scheau¹, Ioana Gabriela Lupescu¹, I. Popescu² ¹ Radiology, Medical Imaging and Interventional Radiology Department

• Recent CT exam shows increase in size of the pseudoaneurismal dilatation of the post-anastomotic portal vein (01.07.2014)

Page 28: M. Toma ¹, M.C. Grasu¹, R. Dumitru¹, Andreea Scheau¹, Ioana Gabriela Lupescu¹, I. Popescu² ¹ Radiology, Medical Imaging and Interventional Radiology Department

• The patient’s clinical status is being monitored, in case of worsening a stenting of the portal vein anastomotic stenosis being considered

Page 29: M. Toma ¹, M.C. Grasu¹, R. Dumitru¹, Andreea Scheau¹, Ioana Gabriela Lupescu¹, I. Popescu² ¹ Radiology, Medical Imaging and Interventional Radiology Department

Outcomes• In the case presented above, TIPS placement was followed by

spectacular clinical status improvement at 24 hours, with increased diuresis and rapid decrease of ascites.

• Stenosis and occlusion are the most frequent complications related to shunt placement, followed by hepatic encefalopathy- unpredictable shunt patency remains the greatest problem.

• TIPS is effective in controlling acute bleeding from varices refractory to medicamentous therapy- should be used in preference to surgical shunts.

Page 30: M. Toma ¹, M.C. Grasu¹, R. Dumitru¹, Andreea Scheau¹, Ioana Gabriela Lupescu¹, I. Popescu² ¹ Radiology, Medical Imaging and Interventional Radiology Department

Take home message• Careful patient evaluation before procedure is critical.

• Ideally, the decision to proceed with a TIPS should be a multidisciplinary decision, involving a gastroenterologist, a transplant surgeon and an interventional radiologist

• TIPS as a minimally invasive method of portal hypertension decompression is a chance for patients awaiting liver transplantation, providing them with safe and hemorrhage-free waiting time.

• Secured against bleeding from gastro-oesophageal varices, candidates can wait for transplantation safely.

• Considering these facts, TIPS can be called a bridge to liver transplantation

Page 31: M. Toma ¹, M.C. Grasu¹, R. Dumitru¹, Andreea Scheau¹, Ioana Gabriela Lupescu¹, I. Popescu² ¹ Radiology, Medical Imaging and Interventional Radiology Department

References• 1) Pomier-Layrargues G. TIPS and hepatic encephalopathy.Semin Liver Dis 1996; 16:315–320• 2) The transjugular intrahepatic portosystemic shunt (TIPS); A.R. Owen,*, A.J. Stanleyb, A.

Vijayananthanc, J.G. Mossd; Clinical Radiology (2009) 64, 664-674• 3) Quality Improvement Guidelines for Transjugular Intrahepatic Portosystemic Shunt (TIPS); Antonin

Krajina, Petr Hulek, Tomas Fejfar, Vlastimil Valek; Cardiovasc Intervent Radiol (2012) 35:1295–1300;• 4) Transjugular Intrahepatic Portosystemic Shunt: Current Indications, Patient Selection and Results;

Yaacov Goykhman, Menahem Ben-Haim, Galia Rosen, Michal Carmiel-Haggai, Ran Oren, Richard Nakache, Oded Szold, Joseph Klausner and Isaac Kori; IMAJ,VOL 12,nov ember 2010

• 5) TIPS-related Hepatic Encephalopathy: Management Options with Novel Endovascular Techniques; David C. Madoff, Michael J. Wallace, Kamran Ahrar,Richard R. Saxon; RadioGraphics 2004; 24:21–37

• 6) Budd-Chiari syndrome management: Lights and shadows; Andrea Mancuso; World J Hepatol 2011 October 27; 3(10): 262-264

• 7) VIATORR stent grafts do not self-expand to their nominal diameters in cirrhotic livers: good news from a computed tomography-based Italian multicentric study-VIATORR stent grafts do not self-expand to their nominal diameters in cirrhotic livers: good news from a computed tomography-based Italian multicentric study- F. Schepis1, F. Vizzutti2, G. Marzocchi1, P. Quaretti3, A. Rampoldi4, R. Agazzi5, R. Golfieri6, A. Luca7, F. Fanelli8, C. Caporali1, S. Colopi1, M. De Santis1, L. Rega2, U. Arena2, I. Fiorina3, L.P. Moramarco3, A. Airoldi4, R. Nani5, M. Renzulli6, C. Mosconi6, R. Bruno3, S. Fagiuoli5, A. Cannavale8, T. Di Maira1, E. Villa1; 1Modena/IT, 2Florence/IT, 3Pavia/IT, 4Milan/IT, 5Bergamo/IT, 6Bologna/IT, 7Palermo/IT, 8Rome/IT- CIRSE 2014, Glasgow

• 8) Electromagnetically navigated TIPS procedure: phantom and in vivo evaluation- P. Isfort1, H.-S. Na1, T. Penzkofer2, C. Wilkmann1, S. Osterhues1, A. Besting3, T. Schmitz-Rode1, C. Kuhl1, P. Bruners1; 1Aachen/DE, 2Boston, MA/US, 3Herzogenrath/DE- CIRSE 2014, Glasgow

• 9) Tadeusz Wróblewski, Olgierd Rowiński, Jerzy Żurakowski, Bogna Ziarkiewicz-Wróblewska, Krzysztof Zieniewicz, Paweł Nyckowski, Marek Krawczyk- Transjugular Intrahepatic Porto-Caval Shunt (TIPS) in treatment of portal hypertension in liver transplant recipiens-Annals of Transplantation, 2008; 13(2): 42-45

• 10) Lerut JP, Goffette P, Molle G, et al. Transjugular intrahepatic portosystemic shunt after adult liver transplantation: experience in eight patients. Transplantation 1999; 68:379–384

Page 32: M. Toma ¹, M.C. Grasu¹, R. Dumitru¹, Andreea Scheau¹, Ioana Gabriela Lupescu¹, I. Popescu² ¹ Radiology, Medical Imaging and Interventional Radiology Department

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