ANESTHETIC CONSIDERATIONS FOR PROCEDURES INVOLVING THE LIVER AND BILIARY SYSTEM

Transjugular Intrahepatic Portal-Systemic Shunt Procedure

TIPS is a percutaneously created intrahepatic connection of the portal and systemic circulations. This procedure is typically used in patients with end-stage liver disease to decrease portal pressure and attenuate the complications related to portal hypertension, such as variceal bleeding or refractory ascites. Diversion of PBF into the hepatic vein is achieved by placement of an expandable intraparenchymal tract ( Fig. 55-7 ).

Although most patients can undergo TIPS placement with sedation, some clinicians prefer to use general anesthesia in selected patients because of the prolonged nature of the procedure, the potential respiratory-depressant effects of sedatives in cirrhotic patients with underlying pulmonary dysfunction as a result of ascites and hypoxemia from the hepatopulmonary syndrome, and concern regarding possible aspiration. Regardless of the anesthesia chosen, appropriate resuscitation with fluid and blood products is necessary before the procedure in patients who have had variceal bleeding. In addition, patients with cirrhosis undergoing a TIPS procedure frequently have a severe coagulopathy that requires preprocedural therapy.

Several complications can occur during placement of TIPS that may require intervention by the anesthesiologist. Pneumothorax or neck vessel injury can occur during vessel puncture, and these complications may be reduced by ultrasonographic guidance during jugular vein puncture. Cardiac dysrhythmias can be mechanically induced during intracardiac catheter passage. Finally, the anesthesiologist should be prepared to manage acute, life-threatening hemorrhage caused by hepatic artery puncture in conjunction with a hepatic capsular

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