Podcast
Questions and Answers
What is the primary purpose of placing a stent during a TIPS procedure?
What is the primary purpose of placing a stent during a TIPS procedure?
Which of the following is a contraindication for TIPS placement?
Which of the following is a contraindication for TIPS placement?
During the TIPS procedure, what is used to visualize the intrahepatic portal vein branches?
During the TIPS procedure, what is used to visualize the intrahepatic portal vein branches?
What type of contrast media is used for the TIPS procedure?
What type of contrast media is used for the TIPS procedure?
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Which step is NOT performed during the TIPS procedure?
Which step is NOT performed during the TIPS procedure?
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What should be confirmed prior to attempting TIPS placement?
What should be confirmed prior to attempting TIPS placement?
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Which patient condition may require the use of CO2 during TIPS to avoid complication?
Which patient condition may require the use of CO2 during TIPS to avoid complication?
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What type of anesthesia is preferably used during the TIPS procedure?
What type of anesthesia is preferably used during the TIPS procedure?
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What is the primary purpose of thrombolysis?
What is the primary purpose of thrombolysis?
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Which method is preferred for arterial puncture during thrombolysis?
Which method is preferred for arterial puncture during thrombolysis?
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What is one of the main risks associated with using the brachial approach for arterial puncture?
What is one of the main risks associated with using the brachial approach for arterial puncture?
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Which equipment is commonly used during the thrombolysis procedure?
Which equipment is commonly used during the thrombolysis procedure?
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Why should multiple arterial punctures be avoided during thrombolysis?
Why should multiple arterial punctures be avoided during thrombolysis?
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What is generally not indicated for thrombolysis after a thrombotic event?
What is generally not indicated for thrombolysis after a thrombotic event?
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What type of catheter is commonly recommended for most thrombolysis cases?
What type of catheter is commonly recommended for most thrombolysis cases?
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Which characteristic should be considered when planning the arterial puncture location for thrombolysis?
Which characteristic should be considered when planning the arterial puncture location for thrombolysis?
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What is the primary purpose of the crossed catheter technique?
What is the primary purpose of the crossed catheter technique?
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What should be done if significant bleeding persists after stopping the infusion during thrombolysis?
What should be done if significant bleeding persists after stopping the infusion during thrombolysis?
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What complication is associated with prolonged and severe ischaemia after thrombectomy?
What complication is associated with prolonged and severe ischaemia after thrombectomy?
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When should a CT scan be performed during thrombolysis treatment?
When should a CT scan be performed during thrombolysis treatment?
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What is the typical action if a patient experiences acute clinical deterioration and increased pain during treatment?
What is the typical action if a patient experiences acute clinical deterioration and increased pain during treatment?
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Which of the following statements regarding microemboli is accurate?
Which of the following statements regarding microemboli is accurate?
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What is a consideration for the catheter used in mechanical thrombectomy?
What is a consideration for the catheter used in mechanical thrombectomy?
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What type of thrombus does mechanical thrombectomy work best with?
What type of thrombus does mechanical thrombectomy work best with?
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What is the purpose of stent placement during a TIPS procedure?
What is the purpose of stent placement during a TIPS procedure?
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Which of the following is NOT assessed during shunt surveillance?
Which of the following is NOT assessed during shunt surveillance?
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What is considered a complication that occurs in approximately 38% of TIPS procedures?
What is considered a complication that occurs in approximately 38% of TIPS procedures?
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What is the primary purpose of the AngioJet's powerpulse technique?
What is the primary purpose of the AngioJet's powerpulse technique?
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What is the Doppler criterion indicating compromised TIPS function?
What is the Doppler criterion indicating compromised TIPS function?
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Which type of injury is more likely to occur due to vascular trauma during TIPS procedures?
Which type of injury is more likely to occur due to vascular trauma during TIPS procedures?
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May-Thurner syndrome increases the risk of which condition?
May-Thurner syndrome increases the risk of which condition?
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What is collateral circulation?
What is collateral circulation?
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Which of the following statements regarding TIPS procedures is incorrect?
Which of the following statements regarding TIPS procedures is incorrect?
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What is the main indication for placing a Transjugular Intrahepatic Portosystemic Shunt (TIPS)?
What is the main indication for placing a Transjugular Intrahepatic Portosystemic Shunt (TIPS)?
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What diameter is typically used for stents in TIPS procedures?
What diameter is typically used for stents in TIPS procedures?
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How is shunt patency maintained during the TIPS procedure?
How is shunt patency maintained during the TIPS procedure?
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Which of the following describes a serious complication of TIPS reported in fewer than five percent of cases?
Which of the following describes a serious complication of TIPS reported in fewer than five percent of cases?
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What complication can TIPS help manage effectively?
What complication can TIPS help manage effectively?
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What is the main effect of May-Thurner syndrome on the left extremity?
What is the main effect of May-Thurner syndrome on the left extremity?
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Study Notes
Thrombolysis
- Thrombolysis is the use of drugs to break up blood clots by dissolving the fibrin that holds the clot together.
- Clinically indicated thrombolysis is typically not given more than 6 weeks after a thrombotic event.
- Equipment for thrombolysis varies with the strategy chosen.
- Minimally invasive techniques may be preferred, with ultrasound guidance to minimize arterial puncture sites.
- Basic angiography sets, specialized catheters, and specialized pumps may be needed.
- The most direct approach is generally the best, focusing on direct graft puncture if possible.
- Brachial artery access is avoided when possible due to risk of peri-catheter thrombus embolization causing CVA (cerebrovascular accident).
Equipment
- Mini access kits help maintain minimum puncture size.
- Basic angiography sets include straight catheters with side holes, suitable for most cases.
- Infusion pumps are also used.
- Co-axial systems or microcatheters may assist in specific cases.
- Specialized catheters and pumps are necessary for pulse spray techniques.
Approach
- The shortest and most direct approach is typically the best, as it offers the widest range of intervention options.
- Bypass graft puncture is often the preferred method when possible.
- Avoid the brachial artery approach if possible to reduce the risk of catheter thrombus embolization resulting in a CVA.
Arterial Puncture
- Thrombolysis typically leads to bleeding from any extra puncture site.
- Use ultrasound guidance for arterial puncture to assure safe access.
- Employ mini access kits to minimize undesirable extra holes.
- Common femoral artery (CFA) insertion is most common for infra-inguinal grafts.
- Shaped catheters (Cobra or RDC) facilitate guidewire placement towards the graft origin.
Direct Prosthetic Graft Puncture
- Ultrasound guidance for graft palpation is often preferred.
- The graft is fixed between the forefinger and thumb during puncture.
- The distinct give and fall in resistance is used as an indication that the needle is entering the graft lumen.
- Retrograde lysis is sometimes needed if the origin or outflow cannot be reached in the direct approach.
- Occasionally, a second puncture from the opposite end of the graft (crossed catheter technique) is needed.
Complications
- Thrombolysis complications are not rare and can be lifethreatening, increasing with the age of the patient, treatment duration, and lytic agent dose.
- Heparin and the lytic agent infusion should be stopped if a complication arises.
- Urgent CT scanning is necessary if there are signs of a cerebrovascular accident (CVA).
- Expert neurological intervention is important for thrombotic CVAs.
- Hemorrhage means cessation of thrombolytic procedures.
- Manual pressure over puncture sites can reduce hematoma formation.
- Consider exchanging for larger sheaths in case of sheath displacement.
- Significant bleeding after the infusion requires haematologist consultation and intervention.
- Surgical intervention may be necessary if blood and fresh frozen plasma (FFP) are inadequate for resuscitation.
Acute Clinical Deterioration with Increased Pain
- Often the cause of distal thromboembolism (in up to 5% of patients).
- Macroemboli may resolve spontaneously or require aspiration.
- Microemboli are more problematic compared to macroemboli.
- Reassess the situation and potentially aspirate the thrombus.
Reperfusion Syndrome
- Prolonged severe ischemia may cause reperfusion syndrome.
- Adult respiratory distress syndrome (ARDS) and renal failure commonly occur in severe cases.
- Patients with this syndrome often have a high mortality rate.
Mechanical Thrombectomy
- Specialized catheters are used to macerate the thrombus.
- The residue is often small enough to be removed or aspirated.
- A catheter requires appropriate vessel size; larger vessels require larger catheters.
- This method often works best with fresh thrombi and small acute emboli.
Catheter-Directed Intrathrombus Thrombolysis (CDT)
- Infusion of a fibrinolytic drug directly into the venous thrombus using imaging guidance is employed.
- A multi-side-hole catheter is embedded in the thrombus.
Medical Devices for Mechanical Thrombectomy
- AngioJet, Angiovac Cleaner XT, 15/EKOS, Penumbra Indigo System, and Trerotola are examples of medical devices used in mechanical thrombectomy.
- These devices often use a pulse-spray technique delivering the thrombolytic drug into the thrombus.
May-Thurner Syndrome
- The compression of the left iliac vein by the right iliac artery, increasing deep vein thrombosis (DVT) risk in the left extremity, is the defining characteristic of this syndrome.
- A DVT may partially or completely block venous blood flow.
Collateral Circulation
- A network of tiny blood vessels may be created to bypass the blocked vessel, protecting the heart tissue.
- The vessels are typically not open under normal conditions but can open in the event of blockage.
Stent/Shunt Placement
- A procedure such as a transjugular intrahepatic portosystemic shunt (TIPS) creates a connection between portal and systemic circulation.
- A stent is often used in the connection creating the TIPS.
Transjugular Intrahepatic Portosystemic Shunt (TIPS)
- A percutaneous connection is created between the portal and systemic circulations within the liver.
- TIPS is often used to reduce portal pressure in patients with complications from portal hypertension.
- A less invasive alternative to surgical procedures.
- A common indication for a TIPS procedure is portal hypertension.
Indications for TIPS
- Acute variceal bleeding not successfully controlled by medical treatment (e.g., sclerotherapy).
- Repeated or recalcitrant variceal bleeding.
- Refractory ascites.
- Portal decompression in patients with Budd-Chiari syndrome and/or hepatorenal syndrome.
- Acute variceal hemorrhage management.
- Initial or recurrent variceal hemorrhage prevention.
- Liver transplantation intraoperative morbidity reduction.
Absolute Contraindications for TIPS
- Right-sided heart failure with elevated central venous pressure.
- Polycystic liver disease.
- Severe hepatic failure.
Relative Contraindications for TIPS
- Active intrahepatic or systemic infection may colonize the stent and cause complications.
- Poorly controlled severe hepatic encephalopathy.
- Hypervascular hepatic tumors
- Portal vein (PV) thrombosis, though not an absolute contraindication.
Patient Preparation for TIPS Placement
- Prophylactic broad-spectrum antibiotics usage.
- Proper patient resuscitation, including fluid and blood products.
- Portal vein (PV) patency confirmation prior to TIPS placement using Doppler sonography, arterial portography, and/or MRI.
- Assess and address coagulopathy prior to procedure in cirrhosis patients.
Procedure
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Patient positioning on the supine position. General IV sedation is given.
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Contrast media injection for venography.
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Catheter insertion through the jugular vein into the vena cava and into the liver.
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Creating a pathway for connection of portal vein to hepatic vein.
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Stent placement. The stent keeps the passage open ensuring blood normal flow.
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High portal vein pressure and venous bleeding issues decrease due to normal blood flow through a stent.
Imaging Guidance for TIPS
- Needle advancement through hepatic vein into a major portal venous branch.
- Use of guidewire and balloon to create a tract through the hepatic parenchyma.
- Stent placement.
- Final result is a nonselective portosystemic shunt.
Contrast media Type and Amount
- Type: nonionic contrast media (Omnipaque).
- Amount: 40ml for adults.
Steps in a TIPS procedure
- Initial portal hypertension situation.
- Needle introduction via the jugular vein into the portal vein. The hepatic vein to portal vein is traced.
- Tract dilation with a balloon.
- Stent placement for normalizing portal pressure.
- The goal of TIPS is immediate reduction of portal hypertension and prevention of related complications.
Steps in a TIPS procedure (Close-up view)
- Needle creating a bypass. Needle tracing to reroute blood.
- Metal stent in the tunnel, new blood flow, and decreased varice pressures.
This technique (general anesthesia and puncture of hepatic vein) is commonly undertaken
- General anesthesia is usually needed for the procedure.
- Jugular vein puncture is most likely the route for catheter insertion.
- This route may require ultrasound guidance, most commonly the right jugular vein.
- A catheter is introduced into the hepatic vein and wedged within the liver parenchyma.
Retrograde Visualization
- Dye injection to allow retrograde visualization of portal vein branches.
- CO2 can aid in patients with renal difficulties to prevent dye toxicity.
- Modification of Ross needle is used for intrahepatic portal vein insertion.
- Guidewire is placed in the main portal vein.
Tract Dilation
- Dilate the tract between the portal vein and hepatic vein through an angioplasty balloon catheter (size about 8-10mm)
- The balloon followed by stent placement between these vessels to maintain communication.
Wedged Hepatic Venogram
- Digital subtraction imaging with CO2 gas to accurately demonstrate the location of the portal vein.
- A catheter is placed and wedged within the branches of the right hepatic vein.
TIPS Stent Placement
- Imaging to demonstrate a 8mm x 68 mm stent has been placed.
- Check stent flow, filling of the splenorenal shunt.
Shunt Surveillance
- Regular 3-to-6-month assessments for shunt related changes.
- Look for ascites.
- Portosystemic collateral development and spleen size.
- Stent diameter commonly 8-10mm.
- Look for narrowing, stent extension into portal and hepatic veins.
Hemodynamics
- Directional flow assessment in the extrahepatic and intrahepatic portal, and hepatic veins.
- Include SMV, splenic vein, coronary vein.
- Peak blood flow assessment in main portal vein and proximal, middle, and distal aspects of stent.
Doppler Criteria for Compromised TIPS Function
- Shunt velocity less than 50 cm/sec.
- Shunt velocity increase or reduction higher than 50 cm/sec compared to baseline values post-procedure.
- Hepatofugal flow in the main portal vein.
Complications
- Shunt obstruction in 38% of patients.
- Hepatic vein stenosis.
- Vascular injury, including hepatic artery pseudoaneurysm.
- Arterioportal fistulas.
- Intrahepatic or subcapsular hematomas.
- Liver capsule penetration leading to hemoperitoneum.
- Transient bile duct dilation (hemobilia).
- Bile collection.
- Stent dislodgement with embolization to the right atrium, pulmonary artery, or internal jugular vein.
- Severe stent occlusion leading to rapid symptom recurrence.
- Stent or stent lining infection.
- Severe abdominal bleeding requiring a transfusion.
- Hepatic artery laceration and severe liver injury requiring transfusion or urgent intervention.
- Heart arrhythmias or congestive heart failure.
- Death.
Follow-up
- Follow-up scans, including duplex ultrasound and shunt angiography, to monitor shunt function, and complications, particularly early shunt occlusion(<30days).
- Look for stent/hepatic vein intimal thickening, requiring dilation, restenting, or another stent.
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Description
Test your knowledge on the TIPS (Transjugular Intrahepatic Portosystemic Shunt) and thrombolysis procedures. This quiz covers key concepts, contraindications, techniques, and anesthesia requirements associated with these medical interventions. Perfect for medical students and healthcare professionals seeking to enhance their understanding.
