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THE NORMAL LIVER OFFERS ALMOST NO RESISTANCE TO FLOW
The normal liver can withstand significant increases in flow, without resulting in increases in portal pressure. The normal portal venous system is a low-pressure system and vessels draining the intraabdominal organs, such as the coronary vein, drain into it.
ARCHITECTURAL LIVER DISRUPTION IS THE MAIN MECHANISM THAT LEADS TO AN INCREASED INTRAHEPATIC RESISTANCE
The deposition of fibrous tissue and the formation of nodules, disrupts the architecture of the liver, leading to an increased resistance to flow and to portal hypertension. Vessels that normally drain into the portal system, such as the coronary vein, reverse their flow and become porto-systemic collaterals. Additionally, with portal hypertension, the spleen increases in size and sequesters platelets and other formed blood cells leading to hypersplenism.
THE TRANSJUGULAR INTRAHEPATIC PORTOSYSTEMIC SHUNT
Portal hypertension can be corrected by creating a communication between the hypertensive portal system and low-pressure systemic veins, bypassing the liver, i.e., the site of increased resistance. This communication can be created surgically or by the transjugular placement of an intrahepatic stent that connects a branch of the portal vein with a branch of an hepatic vein, a procedure designated transjugular intrahepatic porto-systemic shunt (TIPS). TIPS is performed by advancing a catheter introduced through the jugular vein into a hepatic vein and into a main branch of the portal vein. An expandable stent is then introduced connecting hepatic and portal systems, and blood from the hypertensive portal vein and sinusoidal bed is shunted to the hepatic vein. The procedure is highly effective in correcting portal hypertension but can be associated with complications related to diversion of blood flow away from the liver, namely portal-systemic encephalopathy and liver failure.
Este hecho ha sido claramente constatado en la mayoría de las series de la literatura (mortalidad &gt;30 % de media). Por tanto, parece imprescindible determinar las variables predictivas de supervivencia en estos pacientes
Mortality was significantly higher in the TIPS group despite the use of TIPS as a rescue therapy in 7 pts, (4 of them or the 57% died), Sttudy of Monescillo 6w mortality (control 38% vs 15% TIPS); One year (control 65% vs 31% TIPS),
Hématémèse 0.0007 66% vs 34%
CHC 32% vs 10%p=0.0002 et 0.01
Infection 35% vs 11% 0.0005
Choc hypovol 22% vs 11% 0.05
EH 36% vs 7 % 0.000003
Ascite 6% vs 52% 0.000003
Act bl 41% vs 60% 0.05
MELD23.1 11.5 vs 12.7 6.6 0.0000001 et 0.006
Na+ 133 (130-136) vs 139 (138-139) 0.000006 et 0.005
+ facteurs pronostiques