Transjugular intrahepatic portosystemic shunts

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, possible full stomach,
Intraoperative	Possible large blood loss, altered drug effect, complete heart block
Postoperative	Hepatic encephalopathy, PV thrombosis, hepatic infarction, hemorrhage, fluid/electrolyte imbalance.
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Editor rating	Comprehensive
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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%).

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, thus creating a map. A stiff wire then guides the metallic introducer (needle) through the hepatic vein into the portal vein. This tract is dilated with an angioplasty balloon and a self-expanding stent is deployed. This creates a shunt from the high pressure portal system into the low pressure central venous system. This drop in portal pressure lowers the risk of esophageal variceal bleeding and decreases ascites. TIPS provides a survival benefit in patients with large volume, diuretic resistant ascites that necessitates paracentesis as well as when used to control variceal bleeding.

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, but will often be given from interventional team.

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

Volume Management

• Post-paracentesis albumin is not necessary for removal of <5L.
• For ≥5L removed, albumin replacement can be given.
• The AASLD Class IIA recommendation is 6-8 grams of albumin for every liter removed (~1 bottle of 50cc of 25% OR ~1 bottle of 250cc of 5% IV albumin per 2 liters of ascites).

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), stent migration, sepsis, fluid/electrolyte disturbance, biliary tree injury.

Hepatic encephalopathy: failure of liver to filter toxic metabolites such as ammonia, which leads to CNS toxicity. Most sedative-hypnotics and IV induction agents serve to decrease blood flow to the liver and may result in acute accumulation of toxic metabolites which can precipitate hepatic encephalopathy. Of note, propofol has minimal effect on hepatic blood flow and predictable pharmacokinetic profile even in the setting of severe hepatic dysfunction.

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	Multimodal analgesics	Multimodal analgesics
Potential complications