TIPSS, BRTO and portal hypertension

TIPSS is most often performed for patients with variceal bleeding unresponsive to optimal medical/ endoscopic therapy and in patients with refractory ascites. It is a minimally invasive procedure performed by an Interventional Radiologist. As it is a minimally invasive procedure, the recovery time is shorter. With the help of x-ray guidance, an artificial tunnel is created through the liver, connecting the portal vein to a hepatic vein (a blood vessel that carries blood away from the liver). Once the tunnel is created, a small metal device called a stent is placed inside the tunnel to keep it open. The stent allows blood to flow across the liver resulting in a drop in the portal vein pressure. The procedure is performed under general anaesthesia and you should plan to stay in hospital for one or more days after the procedure. Studies have shown that this procedure can successfully reduce variceal bleeding in more than 90% of patients. However, as with all procedures, there are risks involved. These include liver injury resulting in life threatening bleeding requiring a blood transfusion, increased confusion (encephalopathy), contrast allergy, kidney and heart failure.

Figure illustrating angiographic image of gastro-oesophageal varices and portal vein.

  

Figure illustrating creation of a tunnel within the liver by inflating an angioplasty balloon after placement of a TIPS stent. 

Figure illustrating angiographic image after placement of TIPS stent and coil embolization of the varices.

This procedure involves blocking the dilated abnormal veins near the stomach (gastric varices) and is an alternative to TIPSS. Gastric varices bleed less commonly and have a lower pressure. However, when they do bleed, patients deteriorate much worse than with oesophageal varices. The gastric varices are also more difficult to treat with endoscopy. BRTO treats varices but does not reduce portal vein pressure. Although BRTO can inprove confusion from encephalopathy and liver function temporarily, it can also worsen oesophageal varices and ascites. The procedure is a miminally invasive x-ray guided procedure performed by an Interventional Radiologist. A needle is used to gain access into the internal jugular vein in the neck and a tube is guided into the large veins near the stomach using x-ray guidance. Once in position, a balloon is inflated and foam  (sodium tetradecyl sulphate 3%) in injected as as sclerosant agent.