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[q unit=”Procedures” topic=”TIPSS”] Mechanism of action of TIPSS

[a] TIPSS involves accessign the internal jugular vein and IVC to place a stent between hepatic and portal veins using a needle.

– High pressure in portal system contributes to major complications of liver disease (varices, ascites)
– TIPSS creates a conduit between high-pressure portal system and low-pressure IVC system
– Allows blood to bypass dilated oesophageal veins and gastric veins
– used in end-stage liver failure

[q unit=”Procedures” topic=”TIPSS”] Indications for TIPSS

[a] Indications
– Variceal bleeding refractory to endoscopic banding or pharmacological measures
– Ascites refractory to medical treatment

[q unit=”Procedures” topic=”TIPSS”] Anaesthetic considerations of TIPSS

[a] Anaesthetic considerations
– Potential for massive haemorrhage / may already have a balloon tamponade in place. Resuscitate adequately
– Haemodynamically stable induction
– Invasive monitoring
– Inotropes and blood products at the ready

[q unit=”Procedures” topic=”TIPSS”] Contraindications of TIPSS

[a] Absolute Contraindications
– Anything which causes unnecessarily high central venous pressures (thus higher than portal pressures)
— Moderate / severe pulmonary hypertension
— congestive cardiac failure
– Anything which will unreasonably complicate accessing the correct site
— uncontrolled biliary obstruction (risk of bile-systemic shunt)
— multiple hepatic cysts
— Total portal vein thrombosis
– Unreasonable infection risk – uncontrolled sepsis

Relative Contraindications
– MELD >18
– Central hepatocellular carcinoma
– Portal vein thrombosis without an experienced operator
– Hepatic vein thrombosis
– severe coagulopathy / thrombocytopaenia

[q unit=”Procedures” topic=”TIPSS”] Complications of TIPSS

[a] Complications of TIPSS
– Worsened hepatic encephalopathy (high risk)
– Pneumothorax
– Arrhythmias
– Massive bleeding
– Infection (puncture site, blood, liver, shunt “endotipsitis”)
– Failure
– Capsular perforation
– Stent malposition, displacement, migration
– Stent thrombosis / obstruction
– RV failure / unmasked cardiomyopathy (due to increased venous return)
– TV endocarditis (gut organisms)
– Haemolysis (from shunt shearing)

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