Transjugulärer intrahepatischer portosystemischer Stentshunt (TIPS): Pathophysiologische Grundlagen, gegenwärtige Indikationen und Ergebnisse mit Review der Literatur

Zusammenfassung

Hintergrund Der transjuguläre intrahepatische portosystemische Shunt (TIPS) ist eine nicht operative Intervention zur Druckentlastung des Pfortadersystems. Technische Entwicklungen der letzten Jahre und erweiterte zugrundeliegende pathophysiologische Kenntnisse haben die Indikationen zur TIPS-Platzierung geändert. Im vorliegenden Review soll daher auf den gegenwertigen Kenntnisstand eingegangen werden.

Methode Dazu werden anhand der Literatur gegenwärtige Indikationen im Hinblick auf pathophysiologische Grundlagen, Indikationen und Ergebnisse aufgezeigt und diskutiert.

Ergebnisse Etablierte Indikationen für einen TIPS waren und sind die akute, endoskopisch nicht kontrollierbare Varizenblutung und die Re-Blutung innerhalb von 5 Tagen. Neu in die europäischen Empfehlungen aufgenommen wurde der Einsatz des TIPS in der Behandlung der akuten Ösophagus- und gastroösophagealen Varizenblutung als sogenannter „early TIPS“. Zur sekundären Blutungsprävention wird ein TIPS erst nach Versagen der Erstlinientherapie angegeben. Neuere Studien zeigen jedoch, dass durch die TIPS-Implantation eine Verlängerung des blutungsfreien Intervalls sowie Reduzierung der Mortalität möglich ist. Bei therapie-refraktärem Aszites wird ein TIPS nur bei den Patienten empfohlen, die nicht auf die Behandlung mit NSBB ansprechen, obwohl Studien gezeigt haben, dass durch den TIPS, verglichen mit der Paracentese, die glomeruläre Filtrationsrate steigt, der Aszites besser kontrolliert und das Überleben verbessert werden kann. Weitere mögliche Indikationen sind der Einsatz des TIPS beim Budd-Chiari-Syndrom, bei der akuten Pfortaderthrombose, beim Hydrothorax, dem hepatopulmonalen und hepatorenalen Syndrom (Typ 2), bei Patienten mit einer transfusionspflichtigen portalen hypertensiven Gastropathie sowie zur Prophylaxe von Komplikationen vor geplanten abdominellen operativen Eingriffen, selten bei Blutungen durch ektope Varizen oder bei Chylothorax bzw. chylösen Aszites.

Schlussfolgerung Der TIPS ist ein mittlerweile etabliertes Verfahren mit einer neuen Indikation als „early-TIPS“. Obwohl der bisherigen Therapie durch Ligation und Betablockern klar überlegen, steht er in den europäischen Empfehlungen bei der sekundären Prävention einer Blutung nur an zweiter Stelle, ebenso wie beim therapie-refraktären Aszites.

Kernaussagen 

• Neben bereits anerkannten Indikationen ist der Einsatz als „early-TIPS“ bei der akuten Ösophagus- und gastroösophagealen Varizenblutung neu in den europäischen Empfehlungen.

Zitierweise

• Strunk H, Marinova M, . Transjugular Intrahepatic Portosystemic Shunt (TIPS): Pathophysiologic Basics, Actual Indications and Results with Review of the Literature. Fortschr Röntgenstr 2018; 190: 701 – 711

Key words

TIPS - porto-systemic shunt - stent-grafts - esophageal varices - transhepatic - ascites

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