The liver is the largest organ in the body. Weighing approximately 2.5 to 3 pounds, it is roughly the size of a flattened football. Nearly all of the blood that leaves the stomach and intestines must pass through the liver.

As the body’s largest chemical factory, the liver plays a vital role in many important body functions. These include the production of clotting factors, blood proteins, bile and enzymes; the metabolism of cholesterol; the maintenance of normal blood sugar concentration; hormone regulation; and the detoxification of drugs and poisons, including alcohol. Because of its critical role in maintaining health, a diseased liver can cause widespread disruption of body functions.

Millions of Americans suffer from both chronic and acute liver disease. Today, however, new procedures performed by interventional radiologists are successfully treating many conditions that were previously inoperable. These include portal hypertension, bile duct obstruction and liver cancer. 

Portal Hypertension Treatment—
Transjugular Intrahepatic Portosystemic Shunt (TIPS)

Most of the blood flowing to the liver comes from the portal vein. Blood leaving the liver flows through the hepatic vein which empties into the inferior vena cava—a large blood vessel leading to the heart. Portal hypertension results when a large pressure difference exists between the portal vein and the inferior vena cava.

Portal hypertension is most commonly caused by cirrhosis, a condition where normal liver cells are damaged and replaced by scar tissue. This decrease in normal liver tissue interferes with the flow of blood through the liver. The body responds by diverting this blood through blood vessels surrounding the upper portion of the stomach and the lower portion of the esophagus. The increased blood volume in these veins causes the formation of varices (swollen veins with weakened walls) which often rupture under increased pressure. Esophageal varices may be controlled by several different therapies, including the non-surgical formation of a transjugular intrahepatic portosystemic shunt (TIPS).

During the TIPS procedure, an OIA interventional radiologist will use x-ray guidance to make a tunnel through the liver with a needle to connect the portal vein (the vein that carries blood from the digestive organs to the liver) to one of the hepatic veins (the three veins that carry blood from the liver). A metal stent is placed in this tunnel to keep the track open. The rerouted blood flow in the liver helps reduce pressure in all abnormal veins—not only in the stomach and esophagus, but also in the bowel and the liver.

Transjugular Intrahepatic Portosystemic Shunt (TIPS) Insertion Guidelines

When Your Procedure Is Scheduled

• You will have had the following tests to determine the extent and severity of your portal hypertension:
  • Evaluation of your medical history
  • Ultrasound or angiogram
  • A physical examination
  • Endoscopy
  • Blood tests
  • Cardiac echo (2-D echo)
• Our scheduler will give you a date and time for your procedure at Overlake Hospital Medical Center. You will need to arrive at the hospital two hours before the procedure to allow the admitting and nursing staffs to get you ready.
• Please let the scheduler know if you take Coumadin, Plavix, Insulin or Metformin. You will need to receive specialized instructions.
  
• Please notify us if you’ve had a previous reaction to contrast dye.
  
• If you have any questions regarding your procedure, you may call us at 425-688-5507.
  
• The admitting department will attempt to call you the night before your procedure to confirm your arrival time.
  
• Please plan to leave any jewelry or valuables at home.

Preparation

• DO NOT eat anything after midnight the evening before the procedure.
• You may drink clear liquids on the day of the procedure.
  
• Ask your physician if you should take your daily medications before the procedure.
  Do not discontinue any medications without first consulting with your physician.
  
• You need to be at the hospital’s admitting area two hours before you procedure’s scheduled start time. This is located at the large desk at the hospital’s main entrance (across from Stanza’s Café).
  
• You will be taken down to your room where you will meet your nurse. You will be asked to change into a patient gown. An IV will be started and blood drawn for lab tests. The nurse will ask you for your medical history. If possible, bring a list of all the medications you take and when you take them.
  
• The nurse will also ask you about allergies. If you are allergic to radiologic/contrast dye please let them know.
  
• If there is a possibility that you’re pregnant, please let the nurse know. You will be asked to sign a form if you are a female of childbearing age (12-57).
  
• The nurse or tech will clean and shave, as necessary, an area around the catheter’s point of entry. For an angiogram, this includes both sides of the groin for access to the femoral artery. Depending on the type of venogram, the puncture site may be on the foot, arm, hand or groin.
  
• Before the procedure, the interventional nurse will meet with you and your family to review the procedure and answer any questions you might have.

What to Expect During the Procedure

• The procedure takes from 1-3 hours. You will meet the interventional radiologist who will go over the consent form and answer any questions you might still have.
  
• You will receive sedation medication during the procedure to help you relax.
  
• A catheter will be placed in the jugular vein on the right side of your neck. The catheter is threaded through the superior and inferior vena cava to the hepatic vein.
  
• The wall of the hepatic vein is punctured and the needle is directed across an approximate 2 inch gap to the portal vein. Successful passage into the portal vein is determined by the pattern of dye injected through the catheter.
  
• During this portion of the procedure you might feel warmth, tingling or flushing when you are given the contrast dye. This usually lasts about 10 seconds. 
  
• A guide wire is threaded through the needle to maintain the passage between the hepatic and portal veins. A balloon may be used (if needed) across the passage to widen the holes in the vessel walls and the passage through the liver tissue.
  
• Two hollow tubes called stents will then be positioned in the new passage extending into both veins. The stents are then opened to their maximum diameter by expanding a long balloon inside each one. Contrast dye is then injected and the blood flow from the portal vein across the stents to the hepatic vein and on to the vena cava is confirmed.
  
• During the procedure the nurse will be monitoring your heart, blood pressure and the oxygen level in your blood.
  
• Once the procedure is over you will be transferred back to your room.

Portal hypertension before the TIPS procedure—Portal hypertension causes blood flow to be forced backward, causing veins to enlarge and varicies to develop across the esophagus and stomach from the pressure in the portal vein. The pressure backup also causes the spleen to become enlarged.

After the TIPS procedure—The shunt allows the blood to flow normally through the liver to the hepatic vein. This reduces portal hypertension, and allows the veins to shrink to normal size, helping to stop variceal bleeding.

What to Expect After the Procedure

• You should expect to stay in the hospital 1 to 3 days after the procedure. Please bring a robe and any other items you would like to make your stay more comfortable.
  
• Your blood pressure, pulse and puncture site will be checked frequently for several hours after the procedure. You will also be monitored for any signs of bleeding.
  
• The head of your bed will be kept at 30 degrees or more for a few hours after you return to your room.
  
• You will not be able to have anything to eat or drink for a few hours after the procedure. Then, to help flush the contrast dye from your system, you will be encouraged to drink fluids (unless your physician has limited your fluid intake).
  
• The catheter will remain in the jugular vein in the right side of your neck and IV fluid will be run through the catheter. This line will probably remain in place for a day or more after the TIPS.
  
• An abdominal ultrasound will usually be done the day after your procedure to check the effectiveness of the TIPS procedure.
  
• You will be given written instructions and a phone number to call if you have any questions or concerns.
  
• One of the interventional nurses will do a follow-up call the next day after your discharge. Write down any questions you might have for them.
  
• To speak to an interventional nurse, please call 425-688-5005. It is best to call between 8AM and 4PM Monday thru Friday. You can leave a message on the voicemail, and a nurse will return your call as soon as possible.
  
• If you are on Coumadin and have been told not to take it before your procedure, you need to check with your physician, and/or the Anti-Coagulation Clinic for instructions.
  
• If you an insulin-dependent diabetic, your regular dose will be restarted when you return to your room. Check your sugar regularly and if you have a concern, contact your diabetic doctor.
  
• Prior to discharge or a few days after the procedure, you will have an ultrasound to determine the effectiveness of the shunt.
  
• Six weeks after the TIPS procedure (and again at 3 months, 6 months and 12 months after the procedure), you will have an ultrasound so your physician can check that the shunt is functioning properly. You will have an angiogram only if the ultrasound indicates that there is a problem. Lab work will also be done at these times.
  
• If the shunt is working well, every 6 months after the first year of follow-up appointments you will have an ultrasound, get lab work done and meet with your physician.
  
• More frequent follow-up visits may be necessary, depending on your condition.

Additional Information

Potential complications of the TIPS procedure, include:

• Shunt narrowing or blockage. Follow-up ultrasounds may be performed frequently after the TIPS procedure to detect these complications. These complications can be treated by an OIA interventional radiologist who can re-expand the shunt(s) with a balloon or repeat the insertion procedure to place a new stent.
  
• Mental changes caused by encephalopathy (abnormal functioning of the brain) that occur with severe liver disease. Encephalopathy can worsen when blood flow to the liver is reduced by TIPS which may result in toxic substances reaching the brain without being metabolized first by the liver. This condition can be treated with medications, diet or by revising the shunt.

Bile Duct Obstruction Treatment—
Percutaneous Transhepatic Cholangiogram & Percutaneous Biliary Drainage (PTC/PBD)

Another abnormality of the liver that is treated by OIA’s interventional radiologists is occlusion of the common bile duct. The procedure to alleviate this problem is often called a PTC/PBD, short for Percutaneous Transhepatic Cholangiogram and Percutaneous Biliary Drainage. It is an x-ray procedure in which a small tube is passed through the bile ducts in the liver and into the bowel. It is used to relieve blockages in the bile ducts of the liver that lead to the bowel. 

Inside the Interventional Radiology Procedure Room, your OIA interventional radiologist will inject x-ray dye through your right side and into your liver and bile ducts. After x-ray pictures are taken, the radiologist will place a small tube into one of the larger bile ducts so that blocked bile can drain out of the body.

Percutaneous Transhepatic Cholangiogram & Percutaneous Biliary Drainage (PTC/PBD) Guidelines

When Your Procedure Is Scheduled

• Our scheduler will give you a date and time for your procedure at Overlake Hospital Medical Center. You will need to arrive at the hospital two hours before the procedure to allow the admitting and nursing staffs to get you ready.
  
• Please let the scheduler know if you take Coumadin, Plavix, Insulin or Metformin. You will need to receive specialized instructions.
  
• Please notify us if you’ve had a previous reaction to contrast dye.
  
• If you have any questions regarding your procedure, you may call us at 425-688-5507.
  
• The admitting department will attempt to call you the night before your procedure to confirm your arrival time.
  
• Please plan to leave any jewelry or valuables at home.
  
• Make sure to arrange for someone to drive you home after the procedure.

Preparation

• You must not eat or drink anything after midnight the night before the procedure except for your normal medications.
  
• Your clinician or nurse will tell you if you should stop taking any of your medications prior to the procedure.
  
• If you are an inpatient, you will be brought down from your room to the Interventional Radiology Lab 1 hour prior to your procedure’s scheduled start time. If you are an outpatient, you need to be at the hospital’s admitting area two hours before you procedure’s scheduled start time. This is located at the large desk at the hospital’s main entrance (across from Stanza’s Café).
  
• You will be taken down to your room where you will meet your nurse. You will be asked to change into a patient gown. An IV will be started and blood drawn for lab tests.
  
• The nurse will ask you for your medical history. If possible, bring a list of all the medications you take and when you take them.
  
• The nurse will also ask you about allergies. If you are allergic to radiologic/contrast dye please let them know.
  
• If there is a possibility that you’re pregnant, please let the nurse know. You will be asked to sign a form if you are a female of childbearing age (12-57).
  
• Before the procedure, the interventional nurse will meet with you and your family to review the procedure and answer any questions you might have.
  
• The nurse or tech will clean and shave, as necessary, an area around the catheter’s point of entry. You will be covered with sterile drapes from your shoulders to your feet.

What to Expect During the Procedure

• The procedure normally takes 1 hour. You will meet the interventional radiologist who will go over the consent form and answer any questions you might still have.
  
• You will lie on a table with x-ray equipment and procedure materials all around you.
  
• A blood pressure cuff will be placed on your arm and a pulse oximeter sensor clip on your finger to monitor your blood pressure, heart rate and oxygen level. Electrocardiogram patches and wires on your legs and arms will check your heart rate and rhythm.
  
• The nurse will give you pain medication and a sedative which will help you relax before the procedure. The nurse will give you more medication if needed. You will feel relaxed, but you will be awake so that you can follow instructions.
  
• The OIA interventional radiologist will numb the work area with a local anesthetic and stick a long thin needle through your skin between the ribs, through the liver and into a bile duct.
• As the needle is withdrawn, a small amount of dye will be injected and x-rays will be taken.
• If the PTC results show a problem, such as a blockage in the bile duct, the interventional radiologist will replace the thin needle with a small drainage tube (catheter) that will be threaded into the small intestine (see illustration below).
• The radiologist may need to push hard on your right side when the catheter is inserted. Make sure you let the nurse know if you are feeling any pain.
  
• A small bag will be attached to the end of the tube to allow the bile to drain.
  
• If your referring clinician advises it, this bag may be taken off the next day. A small cap will be placed on the tube.

What to Expect After the Procedure

• You will be taken on a gurney to your room.
  
• You may feel some pain at the tube entry site for the next one or two days. The nurse will give you medication to ease the pain.
  
• Your blood pressure, pulse and puncture site will be monitored very frequently by the nurse.
  
• You will be encouraged to drink a lot of fluids to help wash the contrast out of your system. You will need to continue to drink fluids for the first 24 hours after your procedure, unless your physician has limited your fluid intake.
  
• The bile in the collection pouch will be checked for color, quantity and the presence of blood. You will receive several doses of antibiotic medication through your IV to prevent infection.
  
• If you are to be discharged with a drain tube in place, your nurse will teach you how to care for it at home. You will be taught how to change the bandage around the drain tube,
  how to do daily irrigations through the tube, and how to shower or bathe.
  
• You will be given written instructions and a phone number to call if you have any questions or concerns.
  
• One of the interventional nurses will do a follow-up call the day after your discharge. Write down any questions you might have for them.
  
• To speak to an interventional nurse, please call 425-688-5005. It is best to call between 8AM and 4PM Monday thru Friday. You can leave a message on the voicemail, and a nurse will return your call as soon as possible.
  
• If you are on Coumadin and have been told not to take it before your procedure, you need to check with your physician, and/or the Anti-Coagulation Clinic for instructions.
  
• You may resume taking all of your normal medications once you are home.

Liver Cancer Treatment—
Chemoemolization of Liver Tumors

Chemoembolization is an innovative method used to treat certain types of liver cancer. It involves injecting chemotherapy directly into the blood vessels that feed the liver tumor—whether the tumor began in the liver (liver cancer) or spread to it from another organ (metastasized to the liver).

Using x-ray guidance, a small catheter will be inserted through a needle into the femoral artery in the groin. The OIA interventional radiologist will then thread the catheter up through your aorta into the artery in your liver that feeds the tumor.

Chemotherapy mixed with a microsphere is injected directly through the catheter into this artery and into the tumor. When blood flow in the artery stops due to the blockage from the microsphere, the catheter is removed. This procedure provides a high concentration of chemotherapy into the tumor and provides a temporary cut off of the arterial blood supply to the tumor.

Chemoembolization of Liver Tumors Guidelines