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TIPSS, BRTO and portal hypertension

TIPSS, BRTO and portal hypertension - What it is

​Portal hypertension is a condition where there is an increase in the blood pressure of the portal vein. The portal vein carries blood from the bowel and spleen to the liver. The increase in portal vein pressure is caused by obstruction of blood flow due to scarring (liver cirrhosis) in patients with chronic liver disease. 

TIPSS, BRTO and portal hypertension - Symptoms

Increased pressure in the portal vein causes large veins (varices) to open up around the oesophagus and stomach in an effort to bypass the normal blood flow through liver. These varices are fragile and may bleed easily. The bleeding may be a gentle ooze or  can be major and result in serious and life threatening complications. A person may vomit blood or pass blood through their bowels. Other symptoms include :
  • Ascites – abdominal swelling caused by accumulation of fluid in the abdomen
  • Hepatic encephalopathy –  reduced ability of the liver to detoxify blood resulting in patients developing confusion as toxins accumulate and affect the brain and nervous system

The onset of these symptoms indicate transition from the stage of compensated liver disease to a decompensated state. Approximately 5 to 7% of patients with cirrhosis advance to this decompensated stage every year. This results in a reduction in survival from 12 years to just 2 years.

TIPSS, BRTO and portal hypertension - How to prevent?

  • Treatment with drugs ca n sometimes reduce the risk of bleeding. However, not everyone is suitable for this treatment and some may have side effects. 
  • There are two endoscopic methods to prevent bleeding: banding and injection sclerotherapy. 

TIPSS, BRTO and portal hypertension - Causes and Risk Factors

​Cirrhosis is the most common reason for developing portal hypertension. Cirrhosis develops when the liver is damaged from alcohol consumption, hepatitis B or C viruses as well as obesity. In cirrhosis, the scar tissue which forms inside the liver obstructs the flow of blood entering it through the portal vein and thereby increases the portal pressure.  

TIPSS, BRTO and portal hypertension - Diagnosis

Portal hypertension is diagnosed based on several factors:
  • A clinical evaluation by your doctor
  • Blood tests including liver function and blood clotting
  • Imaging tests, such as ultrasonography and a CT or MRI scan
  • Endoscopic examination 

TIPSS, BRTO and portal hypertension - Treatments

TIPSS – transjugular intrahepatic portosystemic shunt

TIPSS is most often performed for patients with variceal bleeding unresponsive to optimal medical/ endoscopic therapy and in patients with refractory ascites. It is a minimally invasive procedure performed by an Interventional Radiologist. As it is a minimally invasive procedure, the recovery time is shorter. With the help of x-ray guidance, an artificial tunnel is created through the liver, connecting the portal vein to a hepatic vein (a blood vessel that carries blood away from the liver). Once the tunnel is created, a small metal device called a stent is placed inside the tunnel to keep it open. The stent allows blood to flow across the liver resulting in a drop in the portal vein pressure. The procedure is performed under general anaesthesia and you should plan to stay in hospital for one or more days after the procedure. Studies have shown that this procedure can successfully reduce variceal bleeding in more than 90% of patients. However, as with all procedures, there are risks involved. These include liver injury resulting in life threatening bleeding requiring a blood transfusion, increased confusion (encephalopathy), contrast allergy, kidney and heart failure.
TIPSS
Figure illustrating angiographic image of gastro-oesophageal varices and portal vein.

  TIPSS
Figure illustrating creation of a tunnel within the liver by inflating an angioplasty balloon after placement of a TIPS stent. 

TIPSS
Figure illustrating angiographic image after placement of TIPS stent and coil embolization of the varices.

BRTO – balloon retrograde transvenous obliteration

This procedure involves blocking the dilated abnormal veins near the stomach (gastric varices) and is an alternative to TIPSS. Gastric varices bleed less commonly and have a lower pressure. However, when they do bleed, patients deteriorate much worse than with oesophageal varices. The gastric varices are also more difficult to treat with endoscopy. BRTO treats varices but does not reduce portal vein pressure. Although BRTO can inprove confusion from encephalopathy and liver function temporarily, it can also worsen oesophageal varices and ascites. The procedure is a miminally invasive x-ray guided procedure performed by an Interventional Radiologist. A needle is used to gain access into the internal jugular vein in the neck and a tube is guided into the large veins near the stomach using x-ray guidance. Once in position, a balloon is inflated and foam  (sodium tetradecyl sulphate 3%) in injected as as sclerosant agent. 

TIPSS, BRTO and portal hypertension - Preparing for surgery

To prepare for your TIPSS, a number of tests and procedures may need to be done. You may have them done ahead of time or the day you come to hospital. 
  • Blood tests
  • CT scan
  • Paracentesis – insertion of a tube/ drain into your abdomen to remove excess fluid 
  • Echocardiogram

Your procedure will be performed under general anaesthesia so you will be assessed by an Anaesthetist to see if you are able to have the procedure performed safely. Tell your doctor if there is any possibility you are pregnant and discuss any recent illness, medical conditions, allergies and medication you are taking. You will be advised to stop taking aspirin, non-steroidal anti inflammatory drugs (NSAIDs) and blood thinners several days before your procedure. You will be instructed not to eat or drink the night before.

TIPSS, BRTO and portal hypertension - Post-surgery care

As you will receive a general anaesthetic, you will be unconsious during the entire procedure. After the procedure, you will be monitored closely in the High Dependency Unit overnight. Devices to monitor your heart rate and blood pressure will be attached to your body. You will be able to be disharged home once your doctors are satisfied with your progress, usually one or two days after the procedure. Your Interventional Radiology team will come to see you every day while you are in hospital to assess your progress and will provide you with further advice and follow up appointments. 

References:
  • Punayima S J, Amarapurkar D N. Role of TIPS in improving survival of patients with decompensated liver disease. Int J Hepatol 2011
  • Boyer T D, Haskal Z J. The role of transjugular intrahepatic portosystemic shunt (TIPS) in the management of portal hypertension: Update 
2009. Hepatology; January 2009 

  • Rossle M, Gerbes A L. TIPS for the treatment of refractory ascites, hepatorenal syndrome and hepatic hydrothorax: A critical update. Gut 2010; 
59:988-1000
  • Fidelman N, Kwan S W, LaBerge J M, Gordon R L, Ring E J, Kerlan R 
K. The transjugular intrahepatic portosystemic shunt: An update. AJR 
2012; 199: 746-755
  • Gaba R C, Khiatani V L, Knuttinen M G et al. Comprehensive review of TIPS technical complications and how to avoid them. Am J Roentgen 2011;196 (3):675-685
  • Ripamonti R, Ferral H et al. Transjugular intrahepatic portosystemic shunt-related complications and practical solutions. Semin Intervent Radiol 2006;23(2):165-176


TIPSS, BRTO and portal hypertension - Other Information

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