Optimal Management of Optimal Management of Ascites: TIPS Ascites: TIPS Michael A. Heller, MD Michael A. Heller, MD University of Colorado Health Sciences Center University of Colorado Health Sciences Center Department of Surgery Grand Rounds Department of Surgery Grand Rounds January 22, 2007 January 22, 2007
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Optimal Management of Ascites: TIPS - Denver, … Management of Ascites: TIPS ... The accumulation of free fluid within the abdominal The ... Decreases the need for serial paracentesisDecreases
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Optimal Management of Optimal Management of Ascites: TIPSAscites: TIPS
Michael A. Heller, MDMichael A. Heller, MDUniversity of Colorado Health Sciences CenterUniversity of Colorado Health Sciences Center
Department of Surgery Grand RoundsDepartment of Surgery Grand RoundsJanuary 22, 2007January 22, 2007
What is Ascites?What is Ascites?
The accumulation of free fluid within the abdominal The accumulation of free fluid within the abdominal cavity.cavity.
Normally < 150ml in abdomenNormally < 150ml in abdomen
PE findings:PE findings:Shifting dullness to percussion, fluid Shifting dullness to percussion, fluid wave, bulging flank.wave, bulging flank.Respiratory compromise lateRespiratory compromise late
Serous Albumin Serous Albumin ––Ascites Albumin = SAAGAscites Albumin = SAAG
What is Ascites? What is Ascites? -- PathophysiologyPathophysiology
Sequestration of fluid in the abdomen leads to further Sequestration of fluid in the abdomen leads to further sodium and water retention by the kidneys.sodium and water retention by the kidneys.
Ascites unresponsive to medical management x Ascites unresponsive to medical management x 2 weeks termed 2 weeks termed Refractory AscitesRefractory Ascites
10% develop spontaneous bacterial peritonitis10% develop spontaneous bacterial peritonitisCan be lethalCan be lethal
Hepatorenal syndromeHepatorenal syndromeDiscomfortDiscomfort50% survival rate at 2 years50% survival rate at 2 years
Treatment of Refractory AscitesTreatment of Refractory Ascites
Serial large volume paracentesisSerial large volume paracentesisTIPS (TIPS (transjugulartransjugular intrahepatic portosystemic intrahepatic portosystemic shunt)shunt)Surgical Surgical peritoneovenousperitoneovenous shuntsshuntsLiver transplantLiver transplant
Treatment Treatment –– Serial ParacentesisSerial Paracentesis
ProsProsImmediate reliefImmediate reliefRelatively low riskRelatively low riskCan be done as an outpatientCan be done as an outpatient
ConsConsDoes not resolve the ascitesDoes not resolve the ascitesRequires frequent follow upRequires frequent follow upDepletes protein storesDepletes protein storesIncreases risks of SBPIncreases risks of SBPDevelopment of renal failureDevelopment of renal failure
ProsProsRelatively simple procedureRelatively simple procedureCan be done under local anesthesiaCan be done under local anesthesiaImprove renal functionImprove renal functionDecreases the need for serial paracentesisDecreases the need for serial paracentesisDecreased chance of SBPDecreased chance of SBP
ConsConsShunt stenosis and obstructionShunt stenosis and obstructionDisseminated intravascular coagulation (DIC)Disseminated intravascular coagulation (DIC)
Effective at reducing ascites, but this comes at a Effective at reducing ascites, but this comes at a high risk.high risk.
Postoperative encephalopathyPostoperative encephalopathyNo improvement of shortNo improvement of short--term or longterm or long--term term survivalsurvivalHeart failureHeart failure
Franco et al., Arch Surg 1988
TIPSTIPS
Transjugular intrahepatic Transjugular intrahepatic portovenousportovenous shuntshuntPerformed by interventional radiologyPerformed by interventional radiologyCreates fistula between a hepatic vein and a Creates fistula between a hepatic vein and a portal vein.portal vein.
Initially created to treat recurrent variceal Initially created to treat recurrent variceal hemorrhagehemorrhage
TIPSTIPS
A sideA side--toto--side side portocavalportocaval shuntshunt
TIPS TIPS –– What Does it Do?What Does it Do?
Decreases the intrahepatic portal pressure, Decreases the intrahepatic portal pressure, thereby decreasing splanchnic vein pressure and thereby decreasing splanchnic vein pressure and decreasing ascites.decreasing ascites.
Initially became popular in the early 1990s, and Initially became popular in the early 1990s, and has since been tailored for specific patient has since been tailored for specific patient populations.populations.
TIPS ContraindicationsTIPS Contraindications
Initially high complication rates led more discrimination Initially high complication rates led more discrimination for those undergoing TIPS.for those undergoing TIPS.
AbsoluteAbsolute RelativeRelativePrimary prevention of variceal bleedingPrimary prevention of variceal bleeding HepatomaHepatoma
CHFCHF Obstruction of all hepatic veinsObstruction of all hepatic veins
Severe pulmonary HTNSevere pulmonary HTN Moderate pulmonary HTNModerate pulmonary HTN
Uncontrolled systemic infection or sepsisUncontrolled systemic infection or sepsis INR > 5INR > 5
Boyer & Haskal, Hepatology 2005
TIPS TIPS –– How ItHow It’’s Dones Done
TIPS vs. ParacentesisTIPS vs. Paracentesis
5 large scale randomized control trials 5 large scale randomized control trials completed to compare TIPS to paracentesiscompleted to compare TIPS to paracentesisRecent META analyses x2Recent META analyses x2
TIPS vs. ParacentesisTIPS vs. Paracentesis
Albillos et al., Journal of Hepatology 2005
TIPS vs. ParacentesisTIPS vs. Paracentesis
50% of TIPS patients 50% of TIPS patients were free of ascites at were free of ascites at one year, versus 12% of one year, versus 12% of patients who underwent patients who underwent paracentesisparacentesis
Deltenre et al, 2005
TIPS vs. ParacentesisTIPS vs. Paracentesis
Mortality overall is unchanged by TIPS.Mortality overall is unchanged by TIPS.Salerno, 2004, included the largest population of Child C Salerno, 2004, included the largest population of Child C cirrhoticscirrhotics
No increase in liver No increase in liver related mortalityrelated mortality
TIPS vs. ParacentesisTIPS vs. Paracentesis
Criticisms of current literatureCriticisms of current literatureNo double blinded studyNo double blinded studyHeterogeneous study populationHeterogeneous study populationMay be mortality difference based upon ChildMay be mortality difference based upon Child’’s s classificationclassificationQuality of life and cost has not yet been fully Quality of life and cost has not yet been fully evaluated.evaluated.
TIPS vs. ParacentesisTIPS vs. Paracentesis
Overall cost of TIPS may be higherOverall cost of TIPS may be higher
Gine et al, 2002
TIPS TIPS vsvs Surgical ShuntSurgical Shunt
Surgical (Surgical (LaVeenLaVeen or Denver Shunt) considered or Denver Shunt) considered 33rdrd line treatmentline treatment
Direct comparison of TIPS Direct comparison of TIPS vsvs Surgical shunt shows Surgical shunt shows superiority of TIPSsuperiority of TIPS
Better control of ascitesBetter control of ascitesBetter longBetter long--term term patencypatencyFewer shuntFewer shunt--associated infectionsassociated infectionsNo difference in mortalityNo difference in mortality
Rosemurgery et al, Annals of Surgery, 2004
TIPS TIPS vsvs Surgical ShuntSurgical Shunt
Surgical shunting provides more immediate relief from Surgical shunting provides more immediate relief from ascites, while TIPS provides better longascites, while TIPS provides better long--term control.term control.
0
20
40
60
80
100
1 mo 3 mo 6 mo 12 mo 36 mo 60 mo
TIPS
Denver Shunt
p = 0.006 @ 60 months
Percent of Patients with Controlled Ascites
Rosemurgery et al, Annals of Surgery, 2004
TIPS TIPS –– Future DirectionsFuture Directions
New PTFENew PTFE--coated stent.coated stent.
Bureau et al, 2004
Current Current stentsstents have a have a 50% dysfunction rate 50% dysfunction rate at 1 year.at 1 year.New PTFENew PTFE--coated coated stent thought to stent thought to greatly reduce the rate greatly reduce the rate of dysfunctionof dysfunction
TIPS TIPS –– Future DirectionsFuture DirectionsProbability of Remaining Free of Shunt Dysfunction
TIPS TIPS –– Future DirectionsFuture Directions
Bureau et al, 2004
Probability of Shunt Dysfunction Probability of Developing Encephalopathy
Historical PerspectiveHistorical Perspective
GoretexGoretex use as a vascular graft done first here at use as a vascular graft done first here at the University of Colorado in animalsthe University of Colorado in animals
TIPS is a relatively safe treatment for refractory TIPS is a relatively safe treatment for refractory ascites, though it does not affect overall survival ascites, though it does not affect overall survival and increases the risk of encephalopathy.and increases the risk of encephalopathy.The next generation of PTFE The next generation of PTFE stentsstents may may broaden the appeal of TIPS since it decreases broaden the appeal of TIPS since it decreases the risk of stent dysfunction.the risk of stent dysfunction.