SURGICAL TREATMENT OF INTRAHEPATIC PORTOSYSTEMIC SHUNT … · • Surgical treatment in dogs...
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small SURGICAL TREATMENT OF INTRAHEPATIC PORTOSYSTEMIC SHUNT IN DOGS. ALTERNATIVES TO EMBOLIZATION A portosystemic shunt (PSS) is an abnormal connecEon between the portal vascular system and systemic circulaEon. IHPSS are usually single o double large vessels shunEng sizeable volumes of portal blood inside the liver parenchyma. Medical therapy is not curaEve. The objecEve of this therapy is to reduce blood ammonia levels in order to decrease clinical signs associated to hepaEc encephalopathy. Surgery treatment is the only curaEve opEon. Its objecEve is to restore normal portal blood flow and resolve clinical signs via total, progressive occlusion of anomalous vessel. There are two types of surgical treatment: • Minimally-invasive techniques: intervenEonal radiology. • Invasive techniques. PSS IntrahepEc IHPSS ExtrahepaEc EHPSS LeV, right or central division Large breed Small breed 1. To establish and compare different treatments of intrahepaEc congenital portosystemic shunts in dogs through a systemaEc review of the perEnent literature. 2. To introduce the concept of minimally- invasive technique, establishing and comparing the most used embolic agents. TREATMENT INTRODUCTION EMBOLIC AGENTS Rocío Ávila Amela (27 January) PSS CONCLUSIONS • Surgical treatment in dogs resulted in significantly improved survival rate and lower frequency of ongoing clinical signs which means a be]er quality of life, compared with medical management . • Complete vascular occlusion cannot be achieved in all dogs because of the development of sever portal hypertension. Only a minority of dogs (0-15,4%) can tolerate it, therefore, a second intervenEon is required compared with the rest of techniques. • Invasive surgical techniques are related to a poorer prognosHc in intrahepaEc portosystemic shunts, rather than extrahepaEc, parEally due to the difficulty of surgical approach. PerioperaEve complicaEons as hemorrhages are frequent. • Intravascular occlusion with intervenEonal radiology has been recommended to reduce complicaHons and mortality associated with tradiEonal surgical techniques. • Veterinary publicaEons about intervenEonal radiology for the treatment of intrahepaEc shunt are limited due to the high cost of the surgical technique and the high specializaEon of the surgery. • AVP represents an alternaEve to coils , because of its potenEal future opEon to treat and correct IHPSS in a cost-efficient an effecHve way. OBJECTIVES Amplatzer Vascular Plug Author Type of shunt Nº paHents/ Nº surgeries Treatment Medium survival Hme/ Follow up Time (months) Major complicaHons (*) Outcome (*) Mortality due to shunt or surgery (*) Intra- OP Post-OP (1w) Intra-OP Post-OP (1w) Post-OP (>1w) PerioperaEve period E F P PerioperaEve period Greenhalgh et al. 2014 110 EHPSS 14 IHPSS 124/97 Medical (27) 27/120 3/10 (30%) - 5/8 (62%) 3/8 (37%) - 24/27 (89%) Surgical (97): AC (29), CB (5), L/PL(63) 70/120 7/12 (58%) 11/46 (23%) 30/46 (65%) 5/46 (10%) 4/97 (4%) 17/97 (18%) Tivers et al. 2018 IHPSS 55/88 Surgical: L (10)/ PL (45) -/29 5/88 33/88 15/22 (68%) 5/22 (22%) 2/22 (1%) 1/88 6/88 9/48 (19%) 43,6% 8% Kyles et al. 2001 IHPSS 10/10 Surgical: AC -/33 0 6/10 6/8 (75%) 2/8 (25%) 0 0 1/10 0 60% 10% Case et al. 2018 IHPSS 58/61 Surgical 31 CB 60 (75%)/72 0 5/31 17/23 (73%) 0 6/23 (26%) 8/31 0 16% 25% 27 PTCE 60 (80%)/72 1 /27 2/27 23/25 (92%) 0 2/25 (1%) 2/27 0 12% 8% Weisse et al. 2014 IHPSS 95/111 Surgical: PTC(coils)E 71/32 3/111 14/111 57/86 (81%) 13/86 (15%) 16/86 (15%) 1/111 4/111 14/111 (13%) 20% 5% Hogan et al. 2010 EHPSS 7/7 Surgical: AVP -/24 1/6 1/6 5/7 (71%) 0 2/7 (28%) 0 0 0 34% 0% Table 1: Comparison between invasive techniques and minimally-invasive techniques for the treatment of IHPSS. * Number of animals/ Total number of animals. AbbreviaEons: PTE, Percutaneous Transvenous EmbolizaEon; AC, Ameroid Constrictor; CB, Cellophane Banding; L, LigaEon; PL, ParEal ligaEon; AVP, Amplatzer Vascular Plug; E, Excellent; F, Fair; P, Poor; w, week. TECHNIQUE COMPARISON Coils PSS Caudal vena cava The use of a big number of coils and a stent (to prevent coil migraEon). The use of an unique device with a minimal risk of migraEon, which can be retracted and reposiEoned as needed. h]ps://www.medicalexpo.com/prod/cook- medical/product-78422-480168.html h]ps://www.researchgate.net/ figure/e-Family-of-Amplatzer- vascular-plugs-leV-panel- shows-the-configuraEon-of- Type-I-to-type_fig1_281485487
Transcript of SURGICAL TREATMENT OF INTRAHEPATIC PORTOSYSTEMIC SHUNT … · • Surgical treatment in dogs...
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SURGICALTREATMENTOFINTRAHEPATICPORTOSYSTEMICSHUNTINDOGS.ALTERNATIVESTOEMBOLIZATION
Aportosystemicshunt(PSS)isanabnormalconnecEonbetweentheportalvascularsystemandsystemiccirculaEon.IHPSSareusually singleodouble largevessels shunEngsizeablevolumesofportalbloodinsidetheliverparenchyma.
Medicaltherapy isnotcuraEve.TheobjecEveofthistherapy isto reduce blood ammonia levels in order to decrease clinicalsignsassociatedtohepaEcencephalopathy.Surgerytreatment istheonlycuraEveopEon.ItsobjecEveistorestore normal portal blood flow and resolve clinical signs viatotal,progressiveocclusionofanomalousvessel.Thereare twotypesofsurgicaltreatment:• Minimally-invasivetechniques:intervenEonalradiology.• Invasivetechniques.
PSS
IntrahepEcIHPSS
ExtrahepaEcEHPSS
LeV,rightorcentraldivision
Largebreed
Smallbreed
1. To establish and compare differenttreatments of intrahepaEc congenitalportosystemic shunts in dogs througha systemaEc review of the perEnentliterature.
2. Tointroducetheconceptofminimally-invasive technique, establishing andcomparing the most used embolicagents.
TREATMENT
INTRODUCTION
EMBOLICAGENTS
RocíoÁvilaAmela(27January)
PSS
CVC
CONCLUSIONS
• Surgicaltreatmentindogsresultedinsignificantlyimprovedsurvivalrateandlowerfrequencyofongoingclinicalsignswhichmeansabe]erqualityoflife,comparedwithmedicalmanagement.
• Complete vascular occlusion cannot be achieved in all dogs because of thedevelopmentofseverportalhypertension.Onlyaminorityofdogs (0-15,4%)cantolerate it,therefore,asecondintervenEonisrequiredcomparedwiththerestoftechniques.
• Invasive surgical techniques are related to a poorer prognosHc in intrahepaEcportosystemic shunts, rather than extrahepaEc, parEally due to the difficulty ofsurgicalapproach.PerioperaEvecomplicaEonsashemorrhagesarefrequent.
• Intravascular occlusion with intervenEonal radiology has been recommended toreducecomplicaHonsandmortalityassociatedwithtradiEonalsurgicaltechniques.
• Veterinary publicaEons about intervenEonal radiology for the treatment ofintrahepaEcshuntarelimitedduetothehighcostofthesurgicaltechniqueandthehighspecializaEonofthesurgery.
• AVPrepresentsanalternaEvetocoils,becauseofitspotenEalfutureopEontotreatandcorrectIHPSSinacost-efficientaneffecHveway.
OBJECTIVES
AmplatzerVascularPlug
Author Typeofshunt
NºpaHents/
Nºsurgeries
Treatment
MediumsurvivalHme/
FollowupTime
(months)
MajorcomplicaHons(*)
Outcome(*)
Mortalityduetoshuntorsurgery(*)
Intra-OP
Post-OP(1w) Intra-OP Post-OP
(1w) Post-OP(>1w)PerioperaEve
period E F P PerioperaEveperiod
Greenhalghetal.2014
110EHPSS14IHPSS 124/97
Medical(27) 27/120
3/10(30%)-
5/8(62%)
3/8(37%) - 24/27
(89%)
Surgical(97):AC(29),CB(5),
L/PL(63)70/120 7/12(58%) 11/46
(23%)30/46(65%)
5/46(10%) 4/97(4%) 17/97
(18%)
Tiversetal.2018 IHPSS 55/88 Surgical:
L(10)/PL(45) -/295/88 33/88 15/22
(68%)5/22(22%)
2/22(1%)
1/88 6/88 9/48(19%)43,6% 8%
Kylesetal.2001 IHPSS 10/10 Surgical:AC -/33
0 6/10 6/8(75%)
2/8(25%) 0
0 1/100
60% 10%
Caseetal.2018 IHPSS 58/61 Surgical
31CB 60(75%)/720 5/31 17/23
(73%) 0 6/23(26%)
8/310
16% 25%
27PTCE 60(80%)/72
1/27 2/27 23/25(92%) 0 2/25
(1%)2/27
012% 8%
Weisseetal.2014 IHPSS 95/111 Surgical:
PTC(coils)E 71/323/111
14/111 57/86
(81%)13/86(15%)
16/86(15%)
1/111
4/111 14/111
(13%)20% 5%
Hoganetal.2010 EHPSS 7/7 Surgical:AVP -/24
1/6
1/6 5/7
(71%) 0 2/7(28%)
0 00
34% 0%
Table1:Comparisonbetweeninvasivetechniquesandminimally-invasivetechniquesforthetreatmentofIHPSS.*Numberofanimals/Totalnumberofanimals.AbbreviaEons:PTE,PercutaneousTransvenousEmbolizaEon;AC,AmeroidConstrictor;CB,
CellophaneBanding;L,LigaEon;PL,ParEalligaEon;AVP,AmplatzerVascularPlug;E,Excellent;F,Fair;P,Poor;w,week.
TECHNIQUECOMPARISON
Coils
PSS
Caudalvenacava
Theuseofabignumberofcoilsandastent(topreventcoilmigraEon).
TheuseofanuniquedevicewithaminimalriskofmigraEon,
whichcanberetractedandreposiEonedas
needed.
h]ps://www.medicalexpo.com/prod/cook-medical/product-78422-480168.html
h]ps://www.researchgate.net/figure/e-Family-of-Amplatzer-vascular-plugs-leV-panel-shows-the-configuraEon-of-Type-I-to-type_fig1_281485487
