Difference between revisions of "Transjugular intrahepatic portosystemic shunts"

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{{Infobox surgical case reference
{{Infobox surgical case reference
| anesthesia_type = General
| anesthesia_type = General or MAC sedation
| airway = ETT
| airway = ETT
| lines_access = Two large PIV, consider central line
| lines_access = Two large PIV, consider central line
| monitors = Standard Monitors, Arterial Line
| monitors = Standard Monitors, Arterial Line, possible Central Line
| considerations_preoperative =  
| considerations_preoperative = Coagulopathies from liver dysfunction
| considerations_intraoperative =  
| considerations_intraoperative = Possible large blood loss
| considerations_postoperative =  
| considerations_postoperative =  
}}
}}


Insertion of low-resistance percutaneous shunt between the portal and systemic circulations.
Insertion of low-resistance percutaneous shunt between the portal and systemic venous circulations.


== Preoperative management ==
TIPS is a procedure for patients with portal hypertension (typically from cirrhosis) and associated large gastric/esophageal varices or ascites. A percutaneous shunt between the portal and systemic circulations is created. An esophageal variceal bleed has a high mortality (30-80%).<ref>{{Cite journal|last=Wipassakornwarawuth|first=Suchart|last2=Opasoh|first2=Manus|last3=Ammaranun|first3=Kasiri|last4=Janthawanit|first4=Pathomporn|date=2002-06|title=Rate and associated risk factors of rebleeding after endoscopic variceal band ligation|url=https://pubmed.ncbi.nlm.nih.gov/12322843|journal=Journal of the Medical Association of Thailand = Chotmaihet Thangphaet|volume=85|issue=6|pages=698–702|issn=0125-2208|pmid=12322843}}</ref>


=== Patient evaluation<!-- Describe the unique and important aspects of preoperative evaluation. Add or remove rows from the systems table as needed. --> ===
As the name suggests, the right IJ is accessed and a guidewire/catheter is inserted in the right hepatic vein.  Carbon dioxide is wedged in the hepatic veins, through the sinusoids, and into the portal vein, creating a map.  A stiff wire then guides the metallic introducer (needle) through the hepatic vein into the portal vein.  This tract is then dilated with an angioplasty balloon and a self-expanding stent is deployed, creating a shunt from the high pressure portal system into the low pressured central venous system<ref>{{Cite book|url=https://www.worldcat.org/oclc/1117874404|title=Anesthesiologist's manual of surgical procedures|date=2020|others=Richard A. Jaffe, Clifford A. Schmiesing, Brenda Golianu|isbn=978-1-4698-2916-6|edition=Sixth edition|location=Philadelphia|oclc=1117874404}}</ref>.  This decrease in portal pressure decreases the risk of esophageal variceal bleeding and decreases ascites. <ref>{{Cite journal|last=Chana|first=A.|last2=James|first2=M.|last3=Veale|first3=P.|date=2016-12-01|title=Anaesthesia for transjugular intrahepatic portosystemic shunt insertion|url=https://www.bjaed.org/article/S2058-5349(17)30002-1/abstract|journal=BJA Education|language=English|volume=16|issue=12|pages=405–409|doi=10.1093/bjaed/mkw022|issn=2058-5349}}</ref> TIPS provides a survival benefit in patients with large volume, diuretic resistant ascites<ref>{{Cite journal|last=Narahara|first=Yoshiyuki|last2=Kanazawa|first2=Hidenori|last3=Fukuda|first3=Takeshi|last4=Matsushita|first4=Yoko|last5=Harimoto|first5=Hirotomo|last6=Kidokoro|first6=Hideko|last7=Katakura|first7=Tamaki|last8=Atsukawa|first8=Masanori|last9=Taki|first9=Yasuhiko|last10=Kimura|first10=Yuu|last11=Nakatsuka|first11=Katsuhisa|date=2011-01|title=Transjugular intrahepatic portosystemic shunt versus paracentesis plus albumin in patients with refractory ascites who have good hepatic and renal function: a prospective randomized trial|url=https://pubmed.ncbi.nlm.nih.gov/20632194|journal=Journal of Gastroenterology|volume=46|issue=1|pages=78–85|doi=10.1007/s00535-010-0282-9|issn=1435-5922|pmid=20632194}}</ref> as well as when used to control variceal bleeding. <ref>{{Cite journal|last=García-Pagán|first=Juan Carlos|last2=Caca|first2=Karel|last3=Bureau|first3=Christophe|last4=Laleman|first4=Wim|last5=Appenrodt|first5=Beate|last6=Luca|first6=Angelo|last7=Abraldes|first7=Juan G.|last8=Nevens|first8=Frederik|last9=Vinel|first9=Jean Pierre|last10=Mössner|first10=Joachim|last11=Bosch|first11=Jaime|date=2010-06-24|title=Early use of TIPS in patients with cirrhosis and variceal bleeding|url=https://pubmed.ncbi.nlm.nih.gov/20573925|journal=The New England Journal of Medicine|volume=362|issue=25|pages=2370–2379|doi=10.1056/NEJMoa0910102|issn=1533-4406|pmid=20573925}}</ref>
 
==Preoperative management==
 
===Patient evaluation<!-- Describe the unique and important aspects of preoperative evaluation. Add or remove rows from the systems table as needed. -->===
{| class="wikitable"
{| class="wikitable"
|+
|+
Line 20: Line 24:
|-
|-
|Neurologic
|Neurologic
|
|Hepatic Encephalopathy may be present and these patients are very sensitive to hypnotics and narcotics.
|-
|-
|Cardiovascular
|Cardiovascular
|
|Often hyperdynamic low PVR.  Cardiomyopathy and CAD common in this population.
|-
|-
|Pulmonary
|Pulmonary
|
|Large volume ascites may lead to low FRC, atelectasis, pulmonary shunting and hypoxemia.  Hepatopulmonary syndrome may be present.  Pleural effusions common.  Hepatic encephalopathy may cause hyperventilation, hypocapnia, and respiratory alkalosis with metabolic compensation.
|-
|-
|Gastrointestinal
|Gastrointestinal
|
|Possible full stomach.
|-
|-
|Hematologic
|Hematologic
|
|May need to correct coagulopathies due to liver dysfunction.  May require PRBC/FFP/CRYO/PLTs intraoperatively. Ideally plt>50, INR<1.5
|-
|-
|Renal
|Renal
|
|Possible hepatorenal syndrome
|-
|Endocrine
|
|-
|-
|Other
|Other
|
|If ascites drained, must be replaced with 25% albumin (8g per 2.5L drained)
|}
|}


=== Labs and studies<!-- Describe any important labs or studies. Include reasoning to justify the study and/or interpretation of results in the context of this procedure. If none, this section may be removed. --> ===
===Labs and studies<!-- Describe any important labs or studies. Include reasoning to justify the study and/or interpretation of results in the context of this procedure. If none, this section may be removed. -->===
 
*T&S
*T&C 2 units PRBC
*CBC, complete blood count
*CMP, comprehensive metabolic panel
*Coagulation panel (PT/INR, PTT, Fibrinogen)
*Thromboelastogram (TEG, ROTEM) if indicated
*Pre-op Echocardiography preferred
*Further cardiopulmonary studies as indicated
 
===Operating room setup<!-- Describe any unique aspects of operating room preparation. Avoid excessively granular information. Use drug classes instead of specific drugs when appropriate. If none, this section may be removed. -->===
 
*Fluid/blood warmer, LR/NS/PL/Albumin, possible rapid infuser (e.g. Belmont or Level 1)
*Arterial line, CVP as indicated
 
===Patient preparation and premedication<!-- Describe any unique considerations for patient preparation and premedication. If none, this section may be removed. -->===
 
*Consider reversing any coagulopathies
*Use caution with benzodiazepines and narcotics
 
==Intraoperative management==
 
===Monitoring and access<!-- List and/or describe monitors and access typically needed for this case. Please describe rationale for any special monitors or access. -->===
 
*Large bore PIV x2
*Arterial Line
*CVP if indicated
 
===Induction and airway management<!-- Describe the important considerations and general approach to the induction of anesthesia and how the airway is typically managed for this case. -->===


=== Operating room setup<!-- Describe any unique aspects of operating room preparation. Avoid excessively granular information. Use drug classes instead of specific drugs when appropriate. If none, this section may be removed. --> ===
*Typically GETA, but may be done as a MAC sedation.
*RSI indicated in gastroparesis, encephalopathy, variceal bleed, severe ascites


=== Patient preparation and premedication<!-- Describe any unique considerations for patient preparation and premedication. If none, this section may be removed. --> ===
===Positioning===


=== Regional and neuraxial techniques<!-- Describe any potential regional and/or neuraxial techniques which may be used for this case. If none, this section may be removed. --> ===
*Supine, head tilted to the left. Typical access is the right internal jugular.


== Intraoperative management ==
===Maintenance and surgical considerations===


=== Monitoring and access<!-- List and/or describe monitors and access typically needed for this case. Please describe rationale for any special monitors or access. --> ===
*Potential ''intraprocedural'' complications 1) Portal vein rupture; intra-abdominal hemorrhage may be massive and require emergency surgery 2) Liver capsule perforation 3) Complete heart block, especially in patients with LBBB.
*Patient may have markedly reduced drug metabolism, anticipate prolonged medication effects. Low albumin levels may alter pharmacokinetics of heavily protein-bound medications.


=== Induction and airway management<!-- Describe the important considerations and general approach to the induction of anesthesia and how the airway is typically managed for this case. --> ===
===Emergence<!-- List and/or describe any important considerations related to the emergence from anesthesia for this case. -->===


=== Positioning<!-- Describe any unique positioning considerations, including potential intraoperative position changes. If none, this section may be removed. --> ===
*Possibility of delayed emergence
*Extubate when fully awake and protecting airways


=== Maintenance and surgical considerations<!-- Describe the important considerations and general approach to the maintenance of anesthesia, including potential complications. Be sure to include any steps to the surgical procedure that have anesthetic implications. --> ===
==Postoperative management==


=== Emergence<!-- List and/or describe any important considerations related to the emergence from anesthesia for this case. --> ===
===Disposition<!-- List and/or describe the postoperative disposition and any special considerations for transport of patients for this case. -->===


== Postoperative management ==
*PACU, ICU or step down ICU as indicated


=== Disposition<!-- List and/or describe the postoperative disposition and any special considerations for transport of patients for this case. --> ===
===Pain management<!-- Describe the expected level of postoperative pain and approaches to pain management for this case. -->===


=== Pain management<!-- Describe the expected level of postoperative pain and approaches to pain management for this case. --> ===
*Multimodal analgesia, avoid lidocaine gtt
*IV narcotics, avoid morphine


=== Potential complications<!-- List and/or describe any potential postoperative complications for this case. --> ===
===Potential complications<!-- List and/or describe any potential postoperative complications for this case. -->===
Potential ''PACU'' complications include PV thrombosis (may mimic MI or PE), intraperitoneal bleed, hepatic infarction, new or worsening encephalopathy (20% of patients), hepatic infarction, stent migration, sepsis, fluid/electrolyte disturbance.


== Procedure variants<!-- This section should only be used for cases with multiple approaches (e.g. Laparoscopic vs. open appendectomy). Otherwise, remove this section. Use this table to very briefly compare and contrast various aspects between approaches. Add or remove rows as needed to maximize relevance. Consider using symbols rather than words when possible (e.g. +, –, additional symbols such as ↑ and ↓ are available using the "Ω" tool in the editor). --> ==
==Procedure variants<!-- This section should only be used for cases with multiple approaches (e.g. Laparoscopic vs. open appendectomy). Otherwise, remove this section. Use this table to very briefly compare and contrast various aspects between approaches. Add or remove rows as needed to maximize relevance. Consider using symbols rather than words when possible (e.g. +, –, additional symbols such as ↑ and ↓ are available using the "Ω" tool in the editor). -->==


{| class="wikitable"
{| class="wikitable"
|+
|+
!
!
!Variant 1
!TIPS
!Variant 2
!DIPS
|-
|-
|Unique considerations
|Unique considerations
|
|Transjugular Intrahepatic Portosystemic Shunt
|
|Direct IVC to Portal Shunt
|-
|-
|Position
|Surgical access
|
|Right internal jugular vein
|
 
*Fluoroscopic guidance using CO2 contrast from hepatic vein, through liver into the PV
|Internal jugular and femoral vein
 
*IV ultrasound guides needle puncture from IVC, through caudate lobe, into PV
|-
|-
|Surgical time
|Surgical time
Line 93: Line 132:
|-
|-
|EBL
|EBL
|
|0-3000 mL
|
|0-3000 mL
|-
|-
|Postoperative disposition
|Postoperative disposition
|
|PACU to stepdown or ICU
|
|PACU to stepdown or ICU
|-
|-
|Pain management
|Pain management
Line 109: Line 148:
|}
|}


== References ==
==References==


[[Category:Surgical procedures]]
[[Category:Surgical procedures]]
<references />

Revision as of 12:06, 4 August 2022

Transjugular intrahepatic portosystemic shunts
Anesthesia type

General or MAC sedation

Airway

ETT

Lines and access

Two large PIV, consider central line

Monitors

Standard Monitors, Arterial Line, possible Central Line

Primary anesthetic considerations
Preoperative

Coagulopathies from liver dysfunction

Intraoperative

Possible large blood loss

Postoperative
Article quality
Editor rating
Comprehensive
User likes
1

Insertion of low-resistance percutaneous shunt between the portal and systemic venous circulations.

TIPS is a procedure for patients with portal hypertension (typically from cirrhosis) and associated large gastric/esophageal varices or ascites. A percutaneous shunt between the portal and systemic circulations is created. An esophageal variceal bleed has a high mortality (30-80%).[1]

As the name suggests, the right IJ is accessed and a guidewire/catheter is inserted in the right hepatic vein. Carbon dioxide is wedged in the hepatic veins, through the sinusoids, and into the portal vein, creating a map. A stiff wire then guides the metallic introducer (needle) through the hepatic vein into the portal vein. This tract is then dilated with an angioplasty balloon and a self-expanding stent is deployed, creating a shunt from the high pressure portal system into the low pressured central venous system[2]. This decrease in portal pressure decreases the risk of esophageal variceal bleeding and decreases ascites. [3] TIPS provides a survival benefit in patients with large volume, diuretic resistant ascites[4] as well as when used to control variceal bleeding. [5]

Preoperative management

Patient evaluation

System Considerations
Neurologic Hepatic Encephalopathy may be present and these patients are very sensitive to hypnotics and narcotics.
Cardiovascular Often hyperdynamic low PVR. Cardiomyopathy and CAD common in this population.
Pulmonary Large volume ascites may lead to low FRC, atelectasis, pulmonary shunting and hypoxemia. Hepatopulmonary syndrome may be present. Pleural effusions common. Hepatic encephalopathy may cause hyperventilation, hypocapnia, and respiratory alkalosis with metabolic compensation.
Gastrointestinal Possible full stomach.
Hematologic May need to correct coagulopathies due to liver dysfunction. May require PRBC/FFP/CRYO/PLTs intraoperatively. Ideally plt>50, INR<1.5
Renal Possible hepatorenal syndrome
Other If ascites drained, must be replaced with 25% albumin (8g per 2.5L drained)

Labs and studies

  • T&S
  • T&C 2 units PRBC
  • CBC, complete blood count
  • CMP, comprehensive metabolic panel
  • Coagulation panel (PT/INR, PTT, Fibrinogen)
  • Thromboelastogram (TEG, ROTEM) if indicated
  • Pre-op Echocardiography preferred
  • Further cardiopulmonary studies as indicated

Operating room setup

  • Fluid/blood warmer, LR/NS/PL/Albumin, possible rapid infuser (e.g. Belmont or Level 1)
  • Arterial line, CVP as indicated

Patient preparation and premedication

  • Consider reversing any coagulopathies
  • Use caution with benzodiazepines and narcotics

Intraoperative management

Monitoring and access

  • Large bore PIV x2
  • Arterial Line
  • CVP if indicated

Induction and airway management

  • Typically GETA, but may be done as a MAC sedation.
  • RSI indicated in gastroparesis, encephalopathy, variceal bleed, severe ascites

Positioning

  • Supine, head tilted to the left. Typical access is the right internal jugular.

Maintenance and surgical considerations

  • Potential intraprocedural complications 1) Portal vein rupture; intra-abdominal hemorrhage may be massive and require emergency surgery 2) Liver capsule perforation 3) Complete heart block, especially in patients with LBBB.
  • Patient may have markedly reduced drug metabolism, anticipate prolonged medication effects. Low albumin levels may alter pharmacokinetics of heavily protein-bound medications.

Emergence

  • Possibility of delayed emergence
  • Extubate when fully awake and protecting airways

Postoperative management

Disposition

  • PACU, ICU or step down ICU as indicated

Pain management

  • Multimodal analgesia, avoid lidocaine gtt
  • IV narcotics, avoid morphine

Potential complications

Potential PACU complications include PV thrombosis (may mimic MI or PE), intraperitoneal bleed, hepatic infarction, new or worsening encephalopathy (20% of patients), hepatic infarction, stent migration, sepsis, fluid/electrolyte disturbance.

Procedure variants

TIPS DIPS
Unique considerations Transjugular Intrahepatic Portosystemic Shunt Direct IVC to Portal Shunt
Surgical access Right internal jugular vein
  • Fluoroscopic guidance using CO2 contrast from hepatic vein, through liver into the PV
 Internal jugular and femoral vein
  • IV ultrasound guides needle puncture from IVC, through caudate lobe, into PV
Surgical time
EBL 0-3000 mL 0-3000 mL
Postoperative disposition PACU to stepdown or ICU PACU to stepdown or ICU
Pain management
Potential complications

References

  1. ↑ Wipassakornwarawuth, Suchart; Opasoh, Manus; Ammaranun, Kasiri; Janthawanit, Pathomporn (2002-06). "Rate and associated risk factors of rebleeding after endoscopic variceal band ligation". Journal of the Medical Association of Thailand = Chotmaihet Thangphaet. 85 (6): 698–702. ISSN 0125-2208. PMID 12322843. Check date values in: |date= (help)
  2. ↑ Anesthesiologist's manual of surgical procedures. Richard A. Jaffe, Clifford A. Schmiesing, Brenda Golianu (Sixth edition ed.). Philadelphia. 2020. ISBN 978-1-4698-2916-6. OCLC 1117874404. |edition= has extra text (help)CS1 maint: others (link)
  3. ↑ Chana, A.; James, M.; Veale, P. (2016-12-01). "Anaesthesia for transjugular intrahepatic portosystemic shunt insertion". BJA Education. 16 (12): 405–409. doi:10.1093/bjaed/mkw022. ISSN 2058-5349.
  4. ↑ Narahara, Yoshiyuki; Kanazawa, Hidenori; Fukuda, Takeshi; Matsushita, Yoko; Harimoto, Hirotomo; Kidokoro, Hideko; Katakura, Tamaki; Atsukawa, Masanori; Taki, Yasuhiko; Kimura, Yuu; Nakatsuka, Katsuhisa (2011-01). "Transjugular intrahepatic portosystemic shunt versus paracentesis plus albumin in patients with refractory ascites who have good hepatic and renal function: a prospective randomized trial". Journal of Gastroenterology. 46 (1): 78–85. doi:10.1007/s00535-010-0282-9. ISSN 1435-5922. PMID 20632194. Check date values in: |date= (help)
  5. ↑ García-Pagán, Juan Carlos; Caca, Karel; Bureau, Christophe; Laleman, Wim; Appenrodt, Beate; Luca, Angelo; Abraldes, Juan G.; Nevens, Frederik; Vinel, Jean Pierre; Mössner, Joachim; Bosch, Jaime (2010-06-24). "Early use of TIPS in patients with cirrhosis and variceal bleeding". The New England Journal of Medicine. 362 (25): 2370–2379. doi:10.1056/NEJMoa0910102. ISSN 1533-4406. PMID 20573925.

Top contributors: Alexander Doyal, Tony Wang, David Sender, Jashvin Patel and Chris Rishel

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