In Reply to: 597 10 -- Fine needle TIPS for Budd-Chiari Syndrome posted by Editor on May 15, 1997 at 16:57:19:
Reports of novel uses of existing equipment help us all.
These patients (Budd-Chiari) have proved to be among the hardest TIPS procedures I've done.
It becomes clear how crucial the leather-hard liver of cirrhosis is to creating TIPS. I'm
a big fan of the 16 g Colapinto TIPS set. Its needle is
very mobile, and can quickly home into a targetted portal vein. The soft, unscarred
liver of B-C patients means that there's no 'feel' to a needle; one can almost
rotate it freely within the liver--like coring an apple.
The liver is like a large swollen blood filled sac. In some cases all needle passes
may return blood because of the extensive hepatic vein collaterals. Carbon dioxide
injection within the parenchyma, as well as wedged, will sometimes only fill
hepatic vein networks, leading back to the IVC. I've approached these cases with
a fine needle system, sometimes using the inner 20 g fine needle like a PTC needle,
injecting into the parenchyma, hunting for the portal vein.
The initial absolute portal pressures are among the highest I've seen
45 to 50 mm Hg. A single shunt may not reduce pressure to typical levels, yet rapid diuresis
may still ensue and the gradient may subsequently drop. One 22 year woman
had her portosystemic gradient dropped from the 40's to 18 mm Hg with
a 12 mm shunt. Two days, and 20 lbs of spontaneous diuresis later, her gradient
was 8 mm Hg. Point is, the same 'magic endpoint' of 10-15 mm Hg may not be
necessary.
These are the most satisfying patients to treat with TIPS because we have the potential
to help reverse liver destruction (due to hepatocyte congestion and necrosis). Once
the underlying etiology is treated (anticoagulation, interferon etc.), the
TIPS may prove no longer necessary and can be allowed to occlude. All my B-C patients have
had transplantation entirely tabled. This is very unlike
the 'temporizing tightrope' we walk with TIPS in advanced cirrhotic patients--no bleeding
or ascites versus less nutrient portal flow, worsened liver function, and more encephalopathy.