small

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