1. Transjugular Intrahepatic Portosytemic Shunt Kevin A. Smith, MD Interventional Radiologist Roper Radiologists, PA

2. What is a TIPSS? Transjugular portosystemic shunt Creation of conduit from portal vein to hepatic vein to decrease portal pressure Stent is placed from portal vein to hepatic vein

3. 3 WWho gets a TIPSS? Majority of patients have advanced cirrhosis resulting in portal hypertension –Portosystemic gradient normal 3-6mmHg –Corrected Sinosoidal Pressure= free hepatic pressure minus wedged hepatic pressure (CSP), normally <5mmHg –Mild 5-10, moderate 10-20, severe >20 –Goal TIPS gradient to <12mmHg, <8mmHg ascites Budd-Chiari 3

4. The Problem

5. Indications TIPSS: 1. Acute uncontrollable esophageal or gastric varices 2. Recurrent variceal bleeding despite endoscopic Rx 3. Refractory ascites, hydrothorax 4. Budd-Chiari syndrome 4. Portal Gastropathy

6. Absolute Contraindications 1. Severe progressive liver failure 2. Severe or uncontrollable encephalopathy 3. Severe heart failure 4. Pulmonary hypertension 5. Biliary Sepsis 6. Splenic vein occlusion with isolated gastric varices

7. Preprocedure Work-up CBC Coags MELD score - T bili, creat, albumin ammonia MRI/CT –Anatomy –Portal vein patency –HCC

8. 8 Procedure Type and cross 4 units PRBCs General anesthesia versus conscious sedation Performed using fluoroscopic guidance Procedure time 1.5-2hrs Success rate ~ 96% 30 day mortality – 4-13%

13. 13 Complications Acute – hemoperitoneum – hemobilia – progressive liver failure – right heart failure – hepatic encephalopathy Delayed – stenosis – shunt thrombosis or occlusion – biliary-shunt fistula formation 13

14. 14 Post-procedure Patient tranferred to PACU or directly to ICU Signs of internal hemorrhage H&H q 4 hours overnight Fecal blood or hematemesis Abdominal distension Hepatic encephalopathy Hematoma @ access site Hospital Stay 2-5 days

15. 15 Thank You!