1. Transjugular Intrahepatic Portosystemic Shunt (TIPS) Presented by R2 吳佳展 2002/10/01

2. Brief History  70 y/o male, liver cirrhosis with varices bleeding and chronic left hydrothorax, ascites, mild confusion  Uremia with hemodialysis  Previous TIPS, but occlusion  Incapable to lie still for prolonged procedure  No dyspnea with continuous O2 usage

3. Evaluation  High aspiration risk: ascites, EV bleeding  The possibility of desaturation under anesthesia or sedation without ventilatory support: ascites, pleural effusion  Limited access to the patient’s airway  Poor liver and renal function

4. Anesthesia  Rapid sequence induction and intubation  Fluctuating hemodynamics during the procedure  Delayed extubation at POR when the patient was fully awake and breathing with ordinary power ( still dependent on O2)

5. Indications  Rescue therapy to acute variceal bleeding refractory to medical and endoscopic treatment  Prophylaxis of rebleeding: lower rebleeding rate compared with endoscopic method but higher encephalopathy occurrence, same survival

6. Indications  Refractory ascites: large volume peritoneocentesis, peritoneovenous shunts, portosystemic shunts, liver transplantation  Refractory hepatic hydrothorax  TIPS improves hepatorenal syndrome, as a bridge to liver transplantation ?

7. Other indications for non- cirrhotic diseases

8. Procedure  Patients are positioned as for central venous catheter insertion  The guide wire is threaded into hepatic vein  Puncture into intrahepatic portal system  Stent positioning

9. Localization of portal system  Wedged hepatic vein angiography  sonography

10. Procedural Complications  Perforation: heart, vena cava, portal vein, liver capsule, pneumothorax  Fistula creation: arterioportal, arteriobiliary (hemobilia), biliary-stent (bilhemia)  Hemolysis  Stent displacement  Acute stent and portal vein thrombosis  Infection

11. Shunt-related Complications  Deterioration of liver function  Worsening of hepatic encephalopathy (age, Child class, degree of reduction of pressure gradient)  Exacerbation of the hyperdynamic circulation

12. Late complications  Follow up with duplex sonography and shunt angiography  Early shunt occlusion <30 days: thrombosis (local thrombolytic treatment, redilation, restenting)  Late: intimal thickening within the stent or hepatic vein ( dilation or another stent)