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1、Transjugular Intrahepatic Portosystemic Shunt for Acute Variceal Bleeding AbstractnGastrointestinal bleeding due to ruptured esophageal or gastric varices is the most severe complication of portal hypertension syndrome. Despite therapeutic advances, its mortality rate is approximately 30% (l), and i
2、s higher in patients with severe liver failure (2.3)n If primary hemostasis cannot be obtained or uncontrollable early rebleeding occurs, transjugular intrahepatic portosystemic shunt (TIPS) is recommended as rescue treatment.Garcia-Pagln JC, Calvet X, TerCs J. et al 1998Pugh RNH. Murray-Lyon MDIM .
3、 Br J Surg 1973:60:646-64Burroughs AK. McCormick PA. Baillieres Clin Gastroenterol 1992nAcute variceal hemorrhage that poorly controlled with endoscopic therapy is generally well controlled with TIPS, which has a 90% to 100% success rate. However, TIPS is associated with a mortality of 30% to 50% in
4、 such a setting. Emergency TIPS should be considered early in patients with refractory variceal bleeding once medical treatment and endoscopic sclerotherapy fail, before the clinical condition worsens.IntroductionnAcute variceal bleeding is a common clinical emergency and is caused most often by cir
5、rhosis-related portal hypertension. Less common causes include splenic vein thrombosis, hepatic veno-occlusive disease, and primary biliary cirrhosis. nIt is defined as visible bleeding from an esophageal or gastric varix at the time of endoscopy, the presence of large esophageal varices with recent
6、 stigmata of bleeding or fresh blood visible in the stomach with no other source of bleeding identified. Incidence and prognosis nThe frequency of gastroesophageal varices in cirrhosis varies from 30% to 70% with bleeding occurring in approximately one-third of patients. nTwenty percent of cirrhotic
7、s with acute variceal hemorrhage die within 6 weeks. The rebleeding rates range from 30% to 40% in 6 weeks and the mortality from rebleeding reaches 30% . Gastro-esophageal varices account for approximately 80% of all cases of variceal bleeding.Causes of Gastro-esophageal varices bleeding nThe preci
8、pitating cause for bleeding, presumably an acute rise in portal pressure and subsequent variceal rupture, remains uncertain but several factors have been implicated including raised intra-abdominal pressure, presence of bacterial infection, continued excess alcohol consumption and postprandial incre
9、ase in splanchnic blood flow. nPredictive factors for variceal bleeding include a hepatic venous pressure gradient (HVPG) of 20 mmHg , the presence of large varices with red signs and underlying severe liver disease (Child-Pugh grade C) .Managements of variceal bleedingnOptimal management of varicea
10、l bleeding requires a multidisciplinary approach, involving a team of gastroenterologists, hepatologists, critical care physicians, surgeons, and interventional radiologists.nThe principal components of therapy airway maintenance hemodynamic stabilization control of the variceal bleeding alteration
11、of the hemodynamic effects of portal hypertensionTreatment options for the management of acute variceal bleedingn 1 endoscopic therapy, n 2 use of vasoactive drugs, n 3 balloon tamponade n （ alone or in combination, are effective in controlling acute variceal bleeding in 80%90% of patients ）n 4(TIPS
12、) and surgical portosystemic shunts with or without splenectomy. Patients who do not respond to these measures are referred for rescue therapies, which include transjugular intrahepatic portosystemic shunt (TIPS) and surgical portosystemic shunts with or without splenectomy. Because of the higher mo
13、rtality of surgery in the acute setting, TIPS is the favored rescue procedure for uncontrolled variceal bleeding.Levels of evidence of indication for TIPSIndication Best available level of evidenceSecondary prevention of variceal bleeding 1ARefractory of ascites 1ARefractory of variceal bleeding 1BP
14、ortal hypertensive gastropathy 2BHepatorenal syndromes 2BBudd-Chiarri syndromes 4Hepatic hydrothorax4Hepatic veno-occlusive disease4Hepatopulmonary syndrome4Material and methods n27 patients(23 men,4 women) who underwent urgent TIPS in our study, due to refractory vacireal bleeding, between December
15、 2010 to October 2016 in The First Affiliated Hospital of Guangxi University were included in the study. The clinical characteristics of the patients were summarized in the table .nThe TIPS was performed for recurrent or uncontrolled acute variceal bleeding despite endoscopic intervention and vasoac
16、tive therapy. The procedure was performed on an emergency basis for active bleeding in 10 patients and elective in17.nPatients were excluded if they had the following: portal vein thrombosis; hepatic encephalopathy; advanced hepatocellular carcinoma and/or with hepatic vein/ portal vein tumor thromb
17、osis; severe hepatic dysfunction.General Characteristics of Patients at EntryGeneral Characteristics of Patients at EntryPatient characteristicsNo.%(meanSD)(N=30)Age (yr)5311.2（38-78）Sex distribution (M/F)23/4Child Pugh classA6B16C5Etiology of liver diseaseAlcohol3Hepatitis B24Location of varicesEso
18、phageal17Contiguous gastric10Procedural steps of TIPS creationStep1Venous accessStep2Hepatic venography, Portal venographyStep3Wedged hepatic venography and measurement of portosystemic gradientStep4Accessing the portal vein, portography, measurement of portal venous pressure Step5Portal and/or Hepa
19、tic iflow venography (iflow angiography)Step6Dilatation of the parenchymal tractStep7Deployment of a stent across the parenchymal tractStep8Portography and measurement of portosystemic gradientStep9Ancillary procedures as embolization of varicesFollow-upnDoppler ultrasonography and endoscopy were ca
20、rried out during 1 to 4 weeks after TIPS, every 6 months, thereafter and whenever stent dysfunction was suspected clinically. nDoppler ultrasonographic measurements of peak flow velocity (Vmax) within stent of 50 cm/sec or less and reversal of intra hepatic portal venous flow direction from hepatofu
21、gal to hepatopetal are indicators of the stent dysfunction in this study. nAngiography was performed in the surviving patients if rebleeding occurred, or if ultrasonography or endoscopy suggested stent dysfunction.Clinical OutcomeOutcomes of TIPSnTIPS were succefully carried out in 26/27 patients (9
22、6.2%). One failure occurred when procedure. TIPS achieved hemostasis in 25 patients. Portal venous pressure decreased from initial 46.628.19 to 28.585.72cmH2O after TIPS (P0.001). Post-TIPS portal venous pressure remained above 27 cmH2O in 12 patients. The degree of varices significant improved afte
23、r TIPS.nThe sized of gastric varices disappeared in 6 patients, decreased in 16 patients,and remained the same as pre-TIPS in 5patients.Deaths and RebleedingnDeaths One patient died when proceduring TIPS. 6 patients had died after TIPS between December 2010 and October 2016. Overall mortality was 23
24、.1%. The causes of death were uncontrolled bleeding, hepatic failure and recurrent variceal bleeding. Uncontrolled rebleeding led to death in two cases. Two cases died due to rebleeding. Three cases died of progressive liver failure.nRebleeding Hemostasis was achieved in 25 patients received TIPS su
25、ccessfully. Both balloon tamponade and vasopressin were discontinued in all cases within 24 hours after TIPS. In this study, only two episodes of rebleeding occurred in the first 3 weeks after TIPS placement. one related to stent dysfunction, the other related to portal vein thrombosis. 4 patient re
26、bled during follow-up, one for peptic ulcer, the other 3 for variceal.Causes of Rebleeding and DeathCauses of death after TIPSCauses of rebleeding(n=6)(n=6)Uncontrolled bleeding(n=1)Stent dysfunction（n=1）Progressive liver failure (n=3)Variceal (n=3)rebleeding(n=2)Peptic ulcer (n=1)Portal vein thromb
27、osis(n=1)Typical cases sharingCase 1nA 59-year-old woman with hematemesis for two hours was recruited in April 31, 2016nPast history: Chronic hepatitis B and liver cirrhosis for 25+ years without any anti-virus treatment,variceal bleeding. Splenectomy in 1990 at Nanninng hospital of traditional medi
28、cine nEndoscopy: the presence of large varices with red signs nPhysical examination: HR83 beats/min, BP120-146/70-85mmHgHepatic vein and portal vein angiography, and the iflow picHepatic vein pressure 42cmH2OTime of hepatopetal 3.47s，the time blood flow to proximal oesophageal vein 2.40s， distal end
29、 5.33s，Post-TIPS hepatic vein pressure 32cmH2O。Pre and post balloon dilatation The blood flow to proximal venae coronaria ventriculi 3.47secs (Pre-TIPS 2.4secs) and the oesophageal vein disappearedCase 2nA 59-year-old man with repeated melena after administration of anti-inflammatory agentsnPast his
30、tory: diagnosed hepatitis B for 10+ yrsnEndoscopy: the presence of large varices with red signs nPhysical examination: HR 110 beats/sec,BP:90/63mmHg.nBRT: Decrease of hemoglobinPre-TIPS hepatic vein pressure 60cmH2OPortal vein iflow angiography: The time of blood flow from splenic hilum vein to vena
31、e coronaria ventriculi was 2.67secs,the same as main portal vein. Portal decompression from pre-TIPS 60cmH2O to post-TIPS 30cmH2O after stent implantationIflow angiography before and after ballon delitation Portal vein iflow angiography of post-TIPS:The time of blood flow from splenic hilum vein to
32、venae coronaria ventriculi post-TIPS was 4.0secs(Pre 2.67secs),the time to main portal vein2.13s(Pre 2.67secs)Case 3nA 44-year-old man with hematemesis and melena when hospitalization and failed to endoscopic therapy and pharmacotherapynPast history: Underwent endoscopic variceal ligation for the ag
33、gravation of esophageal varices 6 months ago.nPhysical examination: HR 120 beats/sec,BP:95/58mmHg.nBRT: Decrease of hemoglobin 75g/L pre-TIPSTIPS procedureTIPS procedurenA. Accessing the portal vein, portography; B intestinal varices,C balloon dilatation of the parenchymal after embolization with co
34、ils of venae coronaria ventriculi. D stent implantation of portosystemic tract but the stent migrated to portal vein for the restlessness of the patient.ABCDnendoscopic variceal ligation for the esophageal varices with recent stigmata of bleeding for melenaAngiography was performed a week after TIPS
35、 for rebleeding occurrednA.Transjugular portography showed that the completely occlusion of venae coronaria ventriculi and superior extremity of the stent capped, B intestinal varices the same as before, C-D embolization of intestinal varices, E Another naked stent placement of the portosystemic tra
36、ct.ABCDEDiscussionn1.whether TIPS should be considered first-line treatment of all patients presenting with acute variceal hemorrhage?n2. should all patients undergo TIPS when they fail EST (as defined above) or when EST is not possible?n3.the timing of TIPS (the definitive intervention)?Conclusionn
37、1. The role of TIPS in the management of acute variceal bleeding that is refractory to endoscopic therapy is well established.n2. TIPS was technically successful in almost all cases, and the complication rates were well within the range of published values.n3. The use of ifow soft angiography may be better for judgment of portal vein pressure and supervising the procedure of TIPS.n4. Although highly efficiency in controlling the bleeding, the mortality with urgent TIPS is high. Early selective intervention is key to achieving better results. Thanks for your attention!
醫(yī)學交流課件：TransjugularIntrahepaticPortosystemicShuntforAcuteVaricealBleeding
