TIPSS, BRTO and portal hypertension

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 :

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.

Portal hypertension is diagnosed based on several factors:

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.

Figure illustrating angiographic image of gastro-oesophageal varices and portal vein.

  

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

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

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. 

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. 

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.

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. 

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