TIPS

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TIPS (also: TIPSS) is the abbreviation for a transjugular intrahepatic portosystemic (stent) shunt and describes an angiographically created connection between the portal vein and the hepatic vein through the liver ( portosystemic shunt ). The aim of the TIPS is to ensure that a certain part of the blood flow from the portal vein does not flow into the liver, but directly into the large bloodstream . A TIPS is used in the treatment of portal hypertension .

description

Portal hypertension (portal hypertension) describes the pressure increase in the flow area of ​​the portal vein . This can lead to varicose bypass circuit running ( esophageal varices , fundus varices , hypertensive gastropathy , caput Medusa lead with bleeding risk), as well as for splenomegaly and ascites . The portal hypertension is usually the result of cirrhosis of the liver . The TIPS, which is a short-circuit connection ( shunt ) located in the liver (“intrahepatic”) between the portal vein and the hepatic vein, transfers a certain part of the blood flow past the liver through the hepatic vein into the inferior vena cava and thus directly into the great bloodstream derived. The amount of blood flow that is to be directed past the liver can be varied by the diameter of the TIPS. As a result, the liver is less able to fulfill its detoxification function, since the blood partly drains off without passing through the liver. The TIPS, which essentially consists of metal (it is also partially coated with plastic), is approximately 4–5 cm long and has a diameter of approximately 6–10 mm.

Indications

  • Moderate to severe ascites : If ascites cannot be adequately treated conservatively ( i.e. using forced diuresis or ascites punctures ), a TIPS has been shown to be useful.
  • Acute variceal bleeding (emergency TIPS): If endoscopic and medicinal measures (e.g. terlipressin , somatostatin ) cannot stop the bleeding . However, if a TIPS is applied in an emergency when the bleeding cannot be controlled, the mortality rate is high .
  • Secondary prophylaxis of variceal bleeding (after first bleeding): In addition to drug and endoscopic therapy, TIPS implantation is an effective treatment for varices if they have already led to increased variceal bleeding . If you have had variceal bleeding before, there is a high chance that it will bleed again.
  • Hypertensive gastropathy : For recurrent bleeding that requires blood transfusions .
  • Budd-Chiari syndrome : a rare indication in which a blockage of the liver veins threatens liver failure. The TIPS system in this rare disease usually leads to good results with restoration of liver perfusion and function.
  • Excessive splenomegaly : This is a rare indication that may be considered in cases where a splenectomy is not possible or desirable.
  • (Primary) prophylaxis of first bleeding from varices : Varices are first treated with medication (e.g. with propranolol ). If this is not enough, endoscopic measures ( sclerotherapy or rubber band ligation ) are performed. Whether a TIPS should be used prophylactically if all of these options fail (i.e. if bleeding has never occurred before) has not yet been conclusively clarified. However, this can be considered on a case-by-case basis; it is then a matter of weighing up the risks that arise from a TIPS implantation with the risks that arise from the risk of variceal bleeding.

Contraindications

history

Portocaval, mesocaval and peritoneovenous shunts have been surgically created for the treatment of portal hypertension since the 1960s. In the years that followed, various experimental attempts were made to establish a transjugular portosystemic shunt in a non-surgical way, but without reaching the level of clinical applicability. Colapinto succeeded in doing this for the first time in 1982, but his method did not have any long-term success, because the shunt tracts he created between the hepatic vein and portal vein by balloon dilatation soon collapsed without being supported by stents (metal prostheses) and led to the tract becoming blocked. The final breakthrough came only after Julio Palmaz introduced the first splinting of the parenchymal tract in dogs with the stents (flexible metal grids) he had developed in 1985 in experimental basic work. After a further development of these stents, M. Rössle, GM Richter, G. Nöldge and J. Palmaz performed the first successful TIPSS system on a patient with liver cirrhosis and portal hypertension in the radiology department of the UKL Freiburg in January 1988. Due to the low stress on the patient, the TIPS is becoming increasingly important as an alternative to the surgical procedure. Compared to a surgically applied portocaval shunt (with a portocaval anastomosis ), the TIPS has the advantage that a later liver transplantation is neither made difficult nor prevented.

technology

The jugular vein is usually punctured in the neck and an angiography catheter is pushed over the superior vena cava through the atrium into the inferior vena cava. This is done under fluoroscopic control in an angiography . A hepatic vein (usually the right hepatic vein) is probed using a specially shaped probing catheter and, after the introduction of stable guide catheters / sheaths, a very stable, controllable hollow needle is inserted into the hepatic vein. The puncture of this TIPS needle (usually controlled by the use of an ultrasound device) is used to pierce the intrahepatic portal vein through the lower surface of the probed liver vein through the liver parenchyma. After successful puncture of the portal vein, an intrahepatic connection ( shunt ) is created between the hepatic vein and a branch of the portal vein by means of balloon dilation . This tract is then kept open with the help of a metal endoprosthesis ( stent ). In addition to balloon-expandable stents (very good erecting force, limited flexibility), self-expanding stents (good erecting force, very good flexibility) specially developed for the TIPS with a plastic layer lined (good erecting force, very good flexibility, lower frequency of occlusions) are used. Since the puncture of the portal vein wall and the dilatations are painful, the TIPS is usually applied under analgesic sedation (depending on the patient's clinical situation, also under general anesthesia ).

The TIPS system is a technically complex intervention that is therefore usually only carried out in large hospitals or university clinics.

Complications

A distinction must be made here between early, mostly angiography-associated complications and late effects from the TIPS system. The most common complication with TIPS is the risk of bleeding. The greatest danger during the TIPS application is a puncture of the (extrahepatic) portal vein that is not covered by liver tissue, which means an acute risk of death for the patient if this complication is not recognized.

By redistributing the blood flow (part of the portal vein flow now no longer flows virtually unfiltered into the liver parenchyma, but through the TIPS tract past the liver parenchyma into the atrium), a TIPS system favors the development of hepatic encephalopathy . The encephalopathy rate after TIPS application is 15–40%. When using balloon-expandable stents, however, it is possible to gradually expand their diameter by means of a corresponding balloon dilatation catheter and thus gradually adapt the portosystemic pressure gradient (i.e. the pressure difference between the portal vein and the atrium) to each patient. The treatment of therapy-refractory ascites requires a lower target pressure than a TIPS because of a previous bleeding of the esophageal varices.

By using foreign material (metal stent), the TIPS leads to a reaction of the vessel wall (so-called neointima formation) with the subsequent formation of a neo vessel wall on the metal struts. Depending on the formation of this layer within the lumen of the TIPS tract, a shunt stenosis or dysfunction occurs in up to 50% of cases. Therefore, patients with a TIPS must be followed up closely. Here, in addition to the use of duplex ultrasound (advantage: no invasiveness / disadvantage: suboptimal results after inserting a plastic-coated stent graft), a new angiography is also used. Different time intervals are used for the controls in the individual centers, however, a need for reintervention (e.g. renewed balloon dilatation or lengthening of the TIPS tract with an additional stent) of around 50–75% in the first postinterventional year can be assumed.

Individual evidence

  1. ^ GK Nazarian, H. Bjarnason, CA Dietz, CA Bernadas, MC Foshager, H. Ferral, DW Hunter: Refractory ascites: midterm results of treatment with a transjugular intrahepatic portosystemic shunt. In: Radiology. Volume 205, Number 1, October 1997, pp. 173-180, ISSN  0033-8419 . PMID 9314981 .
  2. ↑ M. Rössle, K. Haag, A. Ochs, M. Sellinger, G. Nöldge, JM Perarnau, E. Berger, U. Blum, A. Gabelmann, K. Hauenstein: The transjugular intrahepatic portosystemic stent-shunt procedure for variceal bleeding. In: The New England journal of medicine . Volume 330, Number 3, January 1994, pp. 165-171, ISSN  0028-4793 . doi : 10.1056 / NEJM199401203300303 . PMID 8264738 .
  3. ↑ a b Peter Layer: Practical Gastroenterology; 3. Edition; ISBN 3-437-23370-X
  4. ↑ JC Garcia-Pagán, M. Heydtmann, S. Raffa, A. Plessier, S. Murad, F. Fabris, G. Vizzini, JG Abraldes, S. Olliff, A. Nicolini, A. Luca, M. Primignani, HL Janssen, D. Valla, E. Elias, J. Bosch: TIPS for Budd-Chiari syndrome: long-term results and prognostics factors in 124 patients. In: Gastroenterology . Volume 135, Number 3, September 2008, pp. 808-815, ISSN  1528-0012 . doi : 10.1053 / j.gastro.2008.05.051 . PMID 18621047 .
  5. ↑ M. Rössle, GM Richter, G. Nöldge, JC Palmaz, Werner Wenz , W. Gerok: New non-operative treatment for variceal haemorrhage. In: The Lancet . Volume 2, Number 8655, July 1989, p. 153, ISSN  0140-6736 . PMID 2567908 .
  6. ↑ G. Maleux, J. Pirenne, J. Vaninbroukx, R. Aerts, F. Nevens: Are TIPS stent-grafts a contraindication for future liver transplantation? In: Cardiovascular and interventional radiology. Volume 27, Number 2, 2004 Mar-Apr, pp. 140-142, ISSN  0174-1551 . PMID 15259808 .
  7. ↑ M. Cejna, M. Peck-Radosavljevic, S. Thurnher, M. Schoder, T. Rand, B. Angermayr, J. Lammer: ePTFE-covered stent-grafts for revision of obstructed transjugular intrahepatic portosystemic shunt. In: Cardiovascular and interventional radiology. Volume 25, Number 5, 2002 Sep-Oct, pp. 365-372, ISSN  0174-1551 . doi : 10.1007 / s00270-001-0121-8 . PMID 11981612 .
  8. ^ GW Kauffmann, GM Richter: Transjugular intrahepatic portosystemic stent-shunt (TIPSS): technique and indications. In: European radiology. Volume 9, Number 4, 1999, pp. 685-692, ISSN  0938-7994 . PMID 10354885 . (Review).
  9. ↑ P. Sauer, L. Theilmann, W. Stremmel, C. Benz, GM Richter, A. Stiehl: Transjugular intrahepatic portosystemic stent shunt versus sclerotherapy plus propranolol for variceal rebleeding. In: Gastroenterology. Volume 113, Number 5, November 1997, pp. 1623-1631, ISSN  0016-5085 . PMID 9352865 .
  10. ↑ medical practice; 1999, edition: 93, page 10.
  11. ↑ GM Richter, G. Nöldge, M. Brado, J. Sharp, C. Simon, J. Hansmann, B. Radeleff, GW Kauffmann: TIPS: 10 years of clinical experience. In: RöFo: Advances in the field of X-rays and nuclear medicine. Volume 168, Number 4, April 1998, pp. 307-315, ISSN  1438-9029 . doi : 10.1055 / s-2007-1015135 . PMID 9589091 . (Review).