Abdomen, Catheter venography, Angioplasty, Arterial access, Stents, Cirrhosis, Embolism / Thrombosis
A. Israr, R. R. Yadav, S. Singh, K. B. K. Rangan, R. V. Mall
Findings and procedure details
The objective of the treatment is to relieve hepatic venous outflow obstruction and improving liver perfusion. The treatment is governed by prognostic factors, potential for parenchymal recovery, surgical risk, and availability of live donor as well as the stage of disease at which the patient presents.
- Anticoagulation therapy: Early initiation of anticoagulation therapy is recommended in all patients 2
- Catheter Directed Thrombolysis: Catheter-assisted thrombolysis decreases systemic exposure to the drug. Better success rates are achieved when it is combined with angioplasty and/or stenting, especially in acute thrombus. The preferred thrombolytic agent is tissue plasminogen activator. The side hole catheter enables direct injection into the clot, thus augmenting the drug concentration and better results.
- Hepatic vein recanalization: The rationale being that continued hepatic congestion causes hypoxia and hepatocyte necrosis. Most physiological is restoration of flow within one of the hepatic veins and / or the occluded IVC. Re-opening of even one hepatic vein is enough to relieve the congestion. A transfemoral approach is preferred in case of the IVC whereas hepatic venous obstruction is accessed via the trans jugular route, or in rare cases, the percutaneous transhepatic approach.
- Endovascular shunt creation—TIPSS/DIPSS: When physiological re-opening of HV is not feasible, shunt procedures are recommended to de-congest the liver and ameliorate symptoms due to portal hypertension. Various endovascular options with appropriate patient selection and respective technical aspects are demonstrated in Figure 5
A list of complications that may occur in various procedures in summarised in Figure 12
The contraindications to the procedure are mentioned in Figure 13
- Surgical shunt: Failure of endovascular procedures is now an indication for surgical shunting.
- Liver transplant: Progressive liver failure after all these procedures or repeated occlusion is an indication for Liver transplantation.
- Numerous prognostic systems such as Child-Pugh score, Model for end stage liver disease (MELD), Rotterdam index, BCS-TIPSS index, and AIIMS HVOTO, CLICHY Index indices have been described to predict mortality. These have been summarized [11-16] in Figure 14
- After baseline evaluation, all patients are started on appropriate medical therapy eg. anticoagulation and diuretics.
- Planning of suitable endovascular interventional procedure is done.
- Upper GI endoscopy to document varices is performed in all patients. Grade III and IV varices are prophylactically ligated.
- Endovascular intervention is considered technically successful if:
- There is presence of good flow across the vessel (anyone HV/IVC) or shunt post procedure and;
- Normalization of post procedural hepatic venous pressure gradients (HVPG) and/or;
- Disappearance of intrahepatic veno-venous and cavo-caval collateral immediately post procedure (when HVPG not obtained).
Post procedural care and follow up protocols are summarized in Figure 15