Cardiac perforation and tamponade: a potentially fatal complication during transjugular intrahepatic portosystemic shunt placement.

Abstract: Transjugular intrahepatic portosystemic shunt (TIPS) is a low-resistance channel between the hepatic vein and the intrahepatic portion of the portal vein. This is an important addition to the therapeutic armamentarium against portal hypertension. Complications are either technical or due to the creation of a shunt. Procedure-related mortality is about 0 to 2%. Cardiac perforation, one of the rarest complications during TIPS, can occur while traversing the catheter from the jugular vein past the right atrium to enter the hepatic vein. We are reporting the case of a 50-year-old woman who became acutely hypotensive with cardiovascular compromise during the TIPS procedure. A stat echocardiogram confirmed cardiac tamponade and emergency pericardiocentesis resulted in improvement of hemodynamic status with complete recovery.

Key Words: transjugular intrahepatic portosystemic shunt (TIPS), portal hypertension, cardiac tamponade

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In 1969, Rosch et al introduced the idea of creating an intrahepatic shunt leading to decompression of the splanchnic venous system in patients with portal hypertension. (1) Initial work with placement of a transjugular intrahepatic portosystemic shunt (TIPS) device in humans was first reported in 1982 by Colapinto. The use of an expandable metal stent by Richter in 1990 ensured long-term patency and led to the widespread use of TIPS for the management of portal hypertension complications, such as recurrent variceal bleeding and intractable ascites. The TIPS procedure does not alter the portal vein anatomy, which is an advantage if the patient subsequently undergoes liver transplantation. During the procedure, a catheter is inserted via the jugular vein past the right atrium and into the hepatic vein. The procedure can be associated with a number of complications, some of which may be fatal. (2) We are reporting a case of cardiac perforation during the TIPS procedure resulting in cardiac tamponade.

Case Report

A 50-year-old woman presented with hematemesis which began approximately 6 hours before presentation. She admitted to vomiting moderate amounts of bright red blood on two occasions. Her past medical history was consistent with cirrhosis of the liver secondary to hepatitis C, hypertension and esophageal varices with recurrent bleeds over 2 years and three banding procedures, the last one 3 months prior. She had a 15 pack-year tobacco history but denied alcohol or illicit drug use. Her medications included Prevacid, lisinopril and propranalol. On examination in the emergency room, she appeared anxious, was afebrile and tachycardic (90/min), and had a blood pressure of 108/70 mm Hg, with a normal respiratory rate and [O.sub.2] saturation. Heart and lung examinations were unremarkable. Abdominal examination did not reveal ascites or hepatosplenomegaly. Digital rectal examination was positive for occult blood with no hemorrhoids. Her hematocrit and platelet count were low (28.6% and 88,000/mL respectively). Her comprehensive metabolic panel and coagulation parameters were normal. Duplex ultrasound of the abdomen demonstrated a patent hepatic and portal venous system, mild splenomegaly and splanchnic vasodilatation, suggesting portal hypertension. In consultation with the gastroenterologist, the patient was recommended to undergo the TIPS procedure. After a detailed discussion of the procedure with risks and benefits, she consented for an elective TIPS by an interventional radiologist under general anesthesia. During the procedure she became acutely hemodynamically unstable (blood pressure 72/40 mm Hg), and had an elevated jugular venous pressure and decreased heart sounds. An urgent echocardiogram showed a large effusion surrounding the heart with early diastolic collapse of the right ventricular free wall, suggestive of cardiac tamponade. An emergent pericardiocentesis was performed resulting in improvement of her cardiovascular status. A repeat echocardiogram showed significant reduction in the effusion. A pericardial drain was placed and she was transferred to the intensive care unit. There was complete hemodynamic recovery. Follow up after one month revealed a normal echocardiogram.

Discussion

TIPS can be associated with complications, some of which may be fatal. The direct procedure-related mortality ranges from 0 to 2%, (2) while 30-day mortality ranges from 7 to 45%. The complications can be grouped under 3 broad categories:

1. Technical

2. Related to creation of a portosystemic shunt

3. Unique TIPS related

Technical complications include pneumothorax, arteriovenous fistula formation, stent dislocation, cardiac arrhythmias, and perforation of hepatic arteries, gallbladder or biliary ducts. These complications can occur either during access to the hepatic vein or during the creation of an intrahepatic tract or during manipulation of the portal vein and stent placement. Initially, when the needle is passed via the transjugular route, inadvertent carotid artery or tracheal puncture can occur. Cardiac arrhythmias can occur as the catheter is passed through the heart. Cardiac perforation due to the manipulation of a guide wire or catheter is an extremely rare but life-threatening complication of TIPS. (3,4,5) To our knowledge only four cases of cardiac perforation have been reported in the literature.

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Portosystemic encephalopathy (PSE) occurs due to shunting of blood from the portal to systemic circulation. The incidence of PSE is about 30%, which is similar to that reported after surgical portal diversion.

Unique TIPS-related complications include hemolytic anemia secondary to hemolysis associated with the procedure; hyperbilirubinemia associated with hemolysis and reduced hepatic reserve; vegetative infections, and TIPS stenosis.

This case report emphasizes a rare but potentially fatal complication of the TIPS procedure. Early recognition and prompt treatment saved the patient's life with complete recovery. Cardiac tamponade should be considered in the differential diagnosis of patients who develop hypotension during TIPS placement.

Acknowledgments

The authors would like to thank Dr. R. Magill and Dr. M. Yates for their assistance in the management of this patient.

References

1. Rosch J, Hanafee W, Snow H, et al. Transjugular intrahepatic portacaval shunt. An experimental work. Am J Surg 1971;121:588-592.

2. Freedman AM, Sanyal AJ, Tisnado J, et al. Complications of transjugular intrahepatic portosystemic shunt: a comprehensive review. Radiographics 1993;13:1185-1210.

3. McCowan TC, Hummel MM, Schmucker T. et al. Cardiac perforation and tamponade during transjugular intrahepatic portosystemic shunt placement. Cardivasc Intervent Radiol 2000;23:298-300.

4. Sehgal M. Brown DB, PicusD. Aortoatrial fistula complicating transjugular intrahepatic portosystemic shunt by protrusion of a stent into the right atrium: radiologic/pathologic correlation. J Vase Interv Radiol 2002; 13:409-412.

5. Prahlow JA, O'Bryant TJ, Barnard JJ, et al. Cardiac perforation due to Wallstent embolization: a fatal complication of the transjugular intrahepatic portosystemic shunt procedure. Radiology 1997;205:170-172.

All bad precedents began as justifiable measures.
--Julius Caesar

Tripura Mantha Bala, MD and Mukta Panda, MD.

From the Department of Medicine University of Tennessee College of Medicine, Chattanooga Unit, Chattanooga, TN.

Reprint requests to Tripura Mantha Bala MD, UTCOM-CU, Department of Medicine, 960 East Third Street, Suite 208, Chattanooga, TN 37403. Email: [e-mail]

This manuscript was prepared solely by the authors listed. The text and literature review was done by the primary author with input, modifications and critical review by the secondary author.

Accepted April 11, 2006.

RELATED ARTICLE: Key Points

* Transjugular intrahepatic portosystemic shunt (TIPS) is an intrahepatic shunt which causes decompression of splanchnic circulation in patients with portal hypertension.

* Portal hypertension, defined as a portal pressure gradient of 12 mm Hg or more, is often associated with varices and ascites.

* Cardiac tamponade is the compression of the heart caused by blood or fluid accumulation in the space between the myocardium and pericardium.

* Acute cardiac tamponade is characterized by Beck triad, which includes increased jugular venous pressure, hypotension and diminished heart sounds.