Transjugulärer intrahepatischer portosystemischer Shunt (TIPS) – Update 2016

Kernaussagen

TIPS bei Varizenblutungen

• Ein Hochrisikopatient ist definiert als ein Patient in Child-Pugh-Gruppe C (bis 13 Punkte) oder ein Patient in Child-Pugh-Gruppe B mit aktiver Blutung während der Endoskopie.

• TIPS bei Hochrisikopatienten führt zu einer signifikanten Senkung der Rezidivblutungsrate und zu einer signifikanten Verbesserung der Überlebensrate.

• Eine angiomorphologische Klassifikation der portosystemischen Kollateralen vor und nach TIPS-Anlage ist hilfreich, um das Blutungsrisiko einzuschätzen.

• Bei der Kombination von großen Ösophagus- und Magenvarizen und schlechter Leberfunktion (Child-Pugh > 8) steigt die Rezidivblutungsrate signifikant.

• Die Varizenembolisation stellt weiterhin eine wichtige additive Methode dar, um die Rezidivblutungsgefahr dauerhaft zu reduzieren.

• Es besteht eine eindeutige Indikation zur Varizenembolisation, wenn der portosystemische Gradient nach TIPS nicht ausreichend gesenkt wurde und/oder die hepatofugal perfundierten Varizen einen Konkurrenzfluss zum TIPS-Shunt darstellen.

TIPS bei anderen Indikationen

• Die Mehrzahl der Studien zeigt, dass nach TIPS Aszites und aszitesassoziierte Komplikationen oft sistieren oder besser medikamentös therapierbar sind.

• Die Therapie des Budd-Chiari-Syndroms sollte stufenweise erfolgen: Eine Verschlechterung der Leberfunktion muss ohne Zeitverzögerung zum Therapiewechsel führen.

• Bei der symptomatischen Pfortaderthrombose sollte immer über eine TIPS-Anlage als Therapieoption nachgedacht werden.

Komplikationen

• Die Komplikation mit der höchsten Morbidität und Letalität sind Blutungen. Um sie zu vermeiden, ist die prätherapeutische Abklärung der Leberdurchblutung essenziell.

• Zur Therapie der Enzephalopathie steht die medikamentöse Beeinflussung der Darmflora durch nicht resorbierbare Disaccharide und ein darmselektives Breitbandantibiotikum im Vordergrund.

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