INTERVENTIONS IN PORTAL HYPERTENSION

WHAT IS PORTAL HYPERTENSION.

Portal hypertension refers to high blood pressure in the liver. One of the major possible complications of portal hypertension is gastric variceal bleeding. Varices are dilated vessels which may rupture, causing variceal bleeding. Gastric variceal bleeding describes the bleeding that occurs when dilated vessels in the stomach rupture, and is associated with high morbidity and mortality rates.

RETROGRADE TRANSVENOUS OBLITERATION

BALLOON RETROGRADE TRANSVENOUS OBLITERATION (BRTO) / PLUG ASSISTED RETROGRADE TRANSVENOUS OBLITERATION (PARTO)

What is BRTO/PARTO?

BRTO/PARTO is a minimally invasive technique that is used to treat gastric variceal bleeding. The procedure involves blocking the dilated vessels, reducing the risk of rupture. It can be used in addition to or as an alternative to Trans jugular Intrahepatic Portosystemic shunt (TIPS), which is the primary treatment for gastric varices. TIPS aims to relieve the pressure on the dilated vessels by creating new connections between blood vessels in the liver using a shunt.

HOW DOES THE PROCEDURE WORK?

We insert a balloon catheter (a thin, flexible tube with a tiny balloon at one end) through a vein in your thigh and guide the catheter to the gastrorenal or gastrocaval shunt and the balloon is expanded to block the shunt (BRTO). A Vascular Plug can be used as an alternative to the balloon catheter(PARTO).

We will then perform a venography, which is a type of imaging technique in which X-rays are used to see the vessels clearly. This will allow us to confirm exactly which vessels need to be treated and if there are any other abnormal or dilated vessels which have not previously been identified. A medication will then be injected into the dilated abnormal venous channels through the catheter, until they are completely filled. Finally, the balloon will be deflated and we withdraw the catheter in cases of BRTO and in cases of PARTO Vascular Plug is permanently deployed in the shunt.

WHY PERFORM IT?

You may be advised to undergo this procedure if you are at risk of or already have gastric variceal bleeding and hepatic encephalopathy as well as a gastrorenal shunt. Hepatic encephalopathy refers to the worsening of brain function that is caused by a damaged liver.

Recent reports have stated that BRTO/PARTO is a less invasive and more effective way to manage gastric varices than shunt surgery or TIPS. BRTO/PARTO can in most cases completely obliterate these abnormal bleeding venous channels. One of the greatest advantages of BRTO is its preservation of liver function. Moreover, the increase of blood flow in BRTO can also improve liver function in cases where the patient has cirrhosis (scarring of the liver).

WHAT ARE THE RISKS?

Procedure-related complications are minor and include bleeding and infection occurs uncommonly. Serious rare complications include pulmonary embolism (blockage in a lung’s main artery), fluid in or around the lungs and hypersensitivity.

Typically, the follow up is done with upper GI endoscopy and Triple Phase CT scan of the abdomen to check obliterated gastric varices is performed after 4-6 weeks.

BALLOON RETROGRADE TRANSVENOUS OBLITERATION (BRTO)

TRANSJUGULAR INTRAHEPATIC PORTOSYSTEMIC SHUNT (TIPS)

WHAT IS TIPS?

A shunt is an artificial passage which allows fluid to move from one part of your body to another .In a normal functioning liver the supplying vessel called portal vein brings blood from gastrointestinal tract and intra-abdominal organs to liver. This blood gets filtered and passed to the right side of the heart. In cases of liver cirrhosis these pathway gets resistance via liver because of the damaged liver tissue and thereby resulting in to increased pressure in the supplying portal vein resulting in condition called as Portal Hypertension. TIPS procedure is minimally invasive non surgical procedure which reduces recovery time and time spent in hospital. TIPS procedure routes the portion of excess blood flow to the liver reducing the portal hypertension.

HOW DOES THE PROCEDURE WORK?

The procedure is performed under general anesthesia.

We will puncture the jugular vein on the right side of the neck with a needle and will then insert a vascular sheath over a wire into the inferior vena cava. They will explore the hepatic vein with a catheter designed for this purpose.

We then puncture the portal vein through the liver with a special needle and position a wire between the two veins under Xray guidance. After the area has been dilated, a stent or stent graft will be placed between the portal and hepatic vein to create a lasting connection.

WHY PERFORM IT?

The TIPS procedure is usually performed in patients with liver cirrhosis. If In this condition, normal blood flow through the liver is blocked by scar tissue within the liver, which increases the pressure in your portal vein.

The increased pressure in your portal vein makes thin veins in your esophagus or stomach become abnormally enlarged and so at risk of bleeding. Another symptom of liver cirrhosis is an abnormal collection of fluid (ascites) in the abdominal cavity.

You may be advised to undergo TIPS if you have varices which bleed acutely or recurrently and have not responded to other treatments.

Once we have placed the shunt, the pressure in the portal vein decreases, rotecting the area from bleeding and reducing the ascites.

WHAT ARE THE RISKS?

Because a liver suffering from cirrhosis is shrunken and the liver tissue can be very hard, it is possible to puncture the outside of the liver. This can cause bleeding which requires further treatment.

Another risk is that after the TIPS procedure ammonia from the intestine might bypass the liver and be delivered to the brain, which may result in a condition called hepatic encephalopathy, the symptoms of which range from mild (alterations in thinking) to severe (confusion and coma).

Due to the shunt, there is an increased amount of blood flowing directly to the heart, which can cause heart failure. But precautions are taken before the procedure to avoid any such complications.