TIPS: Indicazioni consolidate e controindicazioni assolute Stefano Fagiuoli

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1 TIPS: Indicazioni consolidate e controindicazioni assolute Stefano Fagiuoli Stefano Fagiuoli USC Gastroenterologia Epatologia e Trapiantologia Ospedale Papa Giovanni XXIII - Bergamo

2 TIPS - Technique

3 TIPS Diversion of Portal Flow Decreased Liver Perfusion Arterial Blood Flow (Arterial Buffer Response) Hypoxic damage Tissue Oxygenation Bilirubin (Albumin - INR non affected) Liver Hypoxic Damage RARE

4 TIPS Indication Contraindications Assessment Before TIPS implantation Exclude: Hepatic functional insufficiency Clinically overt hepatic encephalopathy Cardio-Pulmonary disease Portal and hepatic arterial abnormalities. (Road mapping by CT or MRI is not routinely necessary but may help facilitate the anatomical orientation)

5 TIPS Hepatic Encephalopathy Predictive Facrors HE inducing Factors TIPS Diameter Age Advanced Liver Failure History of HE Low Serum Na Worsened Liver Function Blood Flow Improved MAP Serum Na [C] Renal function Nutrition 6, 8, 10 mm? PSPG < 12mmHg >? POST TIPS HE

6 TIPS

7 TIPS 4 4 1A 4 2B 4? 4 1B + Embolization? 1A 4 2B

8 TIPS Levels of evidence: 1A = systematic review of randomized controlled trials 1B = individual randomized control trial 2B = individual cohort study 4 = case series. 1A 1A B 4? 4 1B + Embolization? 4 2B

9 TIPS Severe Tricuspid regurgitation (AJR 2013) Tipsitis???? (> 45mmHg) Hepatic Hencephalopathy (AJR 2013) (??) PLT number????

10 TIPS - Indications

11 TIPS - Indications Banding????

12 TIPS - Indications

13 TIPS - Indications

14 TIPS - Indications

15 TIPS - Indications BUT..

16 TIPS - Indications 2013 TIPS on portal vein thrombosis in cirrhosis: 87% improved (complete recanalization in 57%) 24-month survival 81%. Considering the positive results, several factors argue in favour of TIPS: Portal perfusion is already abolished or limited by thrombosis and TIPS may not exert its known negative effects. If complications of portal hypertension are present, TIPS implantation may be beneficial for their treatment. Later use of TIPS in case of its urgent indication may be more difficult due to aging of the thrombus or extension into intrahepatic branches. NB: Portal Vein Thrombosis DO NOT AFFECT SURVIVAL!!!!

17 Portal Hypertension ASCITES

18 TIPS - Indications However, given the uncertainty as to the effect of TIPS creation on survival and the increased risk of encephalopathy, TIPS should be used in those patients who are intolerant of repeated large volume paracentesis. Evidence-I

19 TIPS Prognosis (Age/Bilirubin/Na Related)

20 TIPS - Indications

21 TIPS - Indications Renal function improvement after TIPS 1 and 2-year survival rates. Type 1: 20% - Type 2: 70% and 45% Liver failure was one of the most frequent causes of death following TIPS. TIPS may also have a role in maintaining patients who initially respond to vasoconstrictor treatment and awaiting transplantation

22 TIPS - Indications Mild disease can be managed medically Severe disease or acute hepatic failure are best managed by liver transplantation. Evidence-II-3

23 TIPS - Indications NB: post Stem Cell Transplantation!!! Improvement of Ascites No Benefit in Survival

24 TIPS - Indications

25 TIPS - Indications

26 TIPS - Indications NB: Few Data!!!!! Improvement in oxygenation and some but not all showed a decrease in the intrapulmonary shunts. The mechanism by which TIPS may improve intrapulmonary shunting in patients with portal hypertension is unclear.

27 TIPS!?!

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30 TIPS

31 Grazie dell Attenzione Ladakh Passo Khardung La m.s.l.m.

32 TIPS - Complications Mortality 1%-2% (Centre Experience) Capsule Perforation/Laceration (during CO CO 2 Indirect 2 Portography) Hepatic Artery / Biliay Tree Tree Puncture Injury to to Portal Vein Vein Wall Wall Extrahepatic Portal Vein Vein Laceration Pulmonary Embolism (collateral circols) Stent Dislocation Early Shunt Thrombosis

33 TIPS - stenosis 20%-40% Stenosis due to to Intimal Hyperplasia Caudal Stenosi due to to non optimal position TIPSOGRAM angioplastic (80%) or or stent Parallel TIPS Left side TIPS

34 Covered STENTS ALL studies Show reduced incidence/severity of stenosis Gastroenterology 2004;126: covered vs vs non-covered F-up 300 days 5 (13%) vs vs (44%) stent dysfunction [p<0.001] Clinical recurrence 3 (8%) vs vs (29%)

35 TIPS - Ascites 12-month Efficacy Senzolo et al, Eur J Gastro & Hepatol 2006

36 TIPS - Ascites 12-month Mortality p= ns Senzolo et al, Eur J Gastro & Hepatol 2006

37 TIPS - Ascites Encephalopathy Senzolo et al, Eur J Gastro & Hepatol 2006

38 TIPS Ascites Current Literature Trials Complete Response Any Response HE Stenosis Mortality Retrospective % % % % % Prospective % % % % % RCTs (vs paracentesis) % % % % % RFH 73 % 100 % 47 % 35 % 29 %

39 TIPS vs Para Favour TIPS Favour Paracentesis

40 TIPS vs Para Favour TIPS Favour Paracentesis

41 TIPS vs Para Favour TIPS Favour Paracentesis

42 TIPS vs Para Favour TIPS Favour Paracentesis

43 TIPS vs Para Favour TIPS Favour Paracentesis

44 No Advantage for for TIPS?

45 TIPS vs Para p = 0,035

46 TIPS vs Para Probability of death According to MELD MELD MELD = MELD MELD = MELD MELD =

47 TIPS vs Para Encephalopathy p = ns

48 Encephalopathy Predictive Factors

49 Why this Difference? Metanalysis based on Individual Patients Time-Dependant Analysis

50 2007 Metanalysis : Individual Individual data / Time dependent analysis TIPS improves OLT-free Survival compared with with Paracentesis In In addition to to shunt, survival is is independently associated with: AGE AGE Bilirubin Serum Serum Na Na Risk Risk of of ascites recurrence is is markedly reduced Probability of of HE HE is is increased by by TIPS (? (? No No of of episodes/ptn) ptn) Higher risk risk for for HE HE in: in: Low Low MAP MAP High High MELD MELD LOW LOW PSPG PSPG

51 Suspicion for Refractory Ascites Are Are Dx Dx criteria criteria fullfilled? fullfilled? Exclude Exclude: NSAIDS NSAIDS Diet Diet non non compliance compliance Other Other causes causes (malignant (malignant ascites, ascites,, PV PV thrombosis, thrombosis, Infection, Infection, nephrogenic nephrogenic ascites) ascites) Search Search for for reversible reversible component component for for underlying underlying liver liver disease disease Keep Keep on on repeated repeated paracentesis paracentesis + albumin, albumin, low low Na Na diet, diet, fluid fluid restriction restriction if if Na Na <130 <130 Work Work on on prevention prevention of of other other complications complications of of cirrhosis cirrhosis (SBP, (SBP, HRS, HRS, Variceal Variceal Bleeding) Bleeding) Evaluate Evaluate for for OLT OLT Pt. Requires > 3 Taps/mo (while compliant to diet) or frequent paracentesis not possible (technical) Consider TIPS Candidate for TIPS: CPS< 12 MELD < 18 < < 70 yrs old No HE No cardiopulmonary disease Not Candidate Keep on previous measures till OLT Not Candidate For TIPS or OLT and frequent Taps not possible: Consider Peritoneovenous shunt

52 Thank You for Your Attention