Cardiac perforation and tamponade during Transjugular Intrahepatic Portosystemic Shunt (TIPS) placement.Objectives were to recognize the procedure-related complications and management of TIPS. A 50-year-old female with a history significant only for Hepatitis C and cirrhosis presented with hematemesis hematemesis /he·ma·tem·e·sis/ (he?mah-tem´e-sis) the vomiting of blood. he·ma·tem·e·sis n. The vomiting of blood. . Following a gastroenterologist's evaluation, the patient was considered for TIPS procedure. During the procedure she became hypotensive hypotensive /hy·po·ten·sive/ (-ten´siv) marked by low blood pressure or serving to reduce blood pressure. hy·po·ten·sive adj. 1. Of or characterized by low blood pressure. 2. , had acute cardiovascular compromise and was diagnosed with acute cardiac tamponade Cardiac Tamponade Definition Cardiac tamponade occurs when the heart is squeezed by fluid that collects inside the sac that surrounds it. Description The heart is surrounded by a sac called the pericardium. by clinical, EKG, chest x-ray and echocardiogram ech·o·car·di·o·gram n. A visual record produced by echocardiography. Echocardiogram A non-invasive ultrasound test that shows an image of the inside of the heart. . Emergency pericardiocentesis was performed with spontaneous improvement. A pericardial pericardial /peri·car·di·al/ (-kahr´de-al) 1. pertaining to the pericardium. 2. surrounding the heart. pericardial pertaining to the pericardium. tube was placed and removed after several days. TIPS is important addition to the therapeutic armamentarium against portal hypertension. It functions as a surgical side to side portacaval shunt. TIPS is not indicated for primary prophylaxis of variceal variceal /var·i·ce·al/ (var?i-se´al) varicose. var·i·ce·al adj. Of, relating to, or caused by a varix or varices. hemorrhage. It is expensive and invasive with significant morbidity, mortality, requiring close follow up. TIPS involves creation of a low resistance channel between hepatic vein and the intra-hepatic portion of portal vein using angiography. A needle catheter (Colapinto) is passed trans-jugular into the hepatic vein and wedged there. The needle is then extruded and advanced through the liver parenchyma Parenchyma A ground tissue of plants chiefly concerned with the manufacture and storage of food. The primary functions of plants, such as photosynthesis, assimilation, respiration, storage, secretion, and excretion—those associated with living to the intra-hepatic portion of the hepatic vein. Associated complications with TIPS are (1) technical complications, (2) complications related to creation of shunt, (3) unique to TIPS. Procedure related mortality ranges from 0-2%, 30 day mortality ranges from 7-45%. Complications during access to hepatic vein are: inadvertent carotid artery/tracheal puncture, cardiac arrhythmia, hemoperitoneum while creating intra-hepatic tract and, during manipulation of portal vein, puncture of portal vein with exsanguinating hemorrhage. There has been one reported case of cardiac perforation/tamponade and one reported case of aorto atrial fistula due to perforation of the right heart from guide wire/catheter manipulation. Cardiac tamponade should be considered in the differential diagnosis of patients developing hypotension during TIPS. It is essential for clinicians to be cognizant of the clinical spectrum of TIPS-related complications and their management. Tripura Mantha Bala, MD, Robert Magill, MD, M. Yates, MD, and Mukta Panda, MD. University of Tennessee, Chattanooga, TN. |
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