Transjugular Intrahepatic Portosystemic Shunt (TIPS) Korean 환자교육방사선 / 영상서비스 경경정맥간내문맥정맥단락술 (TIPS) 귀하의시술소개 이자료용지는경경정맥간내문맥정맥단락술이무엇이며또한이시술을받음으로써기대할수있는것이무엇

Transjugular Intrahepatic Portosystemic Shunt (TIPS) Korean 환자교육방사선 / 영상서비스 경경정맥간내문맥정맥단락술 (TIPS) 귀하의시술소개 이자료용지는경경정맥간내문맥정맥단락술이무엇이며또한이시술을받음으로써기대할수있는것이무엇인지를설명합니다. TIPS 는무엇을의미하는가? TIPS 는경경정맥간내문맥정맥단락술을의미합니다 : 경경정맥 목의경정맥을거침 간내 간의내부 문맥정맥 문맥정맥에서간정맥까지 ( 문맥정맥은간으로혈액을운반합니다. 간정맥은간으로부터혈액을배출합니다.) 단락술 한혈액계로부터다른혈액계로흐름을허용하는천으로덮인금속관 왜나는 TIPS 시술을필요로하는가? 정상적으로혈액은창자와비장으로부터문맥정맥을통해간으로들어갑니다. 건강한간에서는혈구와내장에서흡수된영양소를처리합니다 (2페이지의왼쪽에있는사진참조 ). 다음에혈액은간조직을통해여과되어간정맥그리고심장으로배출됩니다. 귀하는문맥고혈압을초래시킨간의문제가있습니다. 이상태는위와식도, 비장및대장으로부터혈액을배출하는정맥네트워크에서압력의증가를초래합니다. 이러한문제의가장흔한원인은간경변이며, 이는간에넓게퍼지는흉터형성을말합니다.

2 페이지방사선 / 영상서비스경경정맥간내문맥정맥단락술 (TIPS) 식도 하대정맥 간정맥 식도 하대정맥 간정맥 단락술 간 위 위 비장 비장 문맥정맥 관상동맥 비장정맥 간 문맥정맥 관상동맥 비장정맥 건강한간은왼쪽에나와있습니다. 단락이있는간은오른쪽에나와있습니다. 문맥고혈압은 2 가지중대한문제를야기합니다 : 정맥류출혈 간에있는정맥에서의높은압력은간정맥의혈액흐름을후퇴시킬수있습니다. 그렇게되면혈액은정맥류라부르는새로운경로를통해배출되어야합니다. 정맥에너무많은양의혈액이차게되면, 정맥이약해집니다. 이것은많은출혈을초래할수있습니다. 복수 복수란복부에액체가축적되는것입니다. 이것은여러가지다양한이유로발생할수있습니다. TIPS 는이러한문제를치유할수있는가? TIPS 시술은이러한문제들의통제만을도와줍니다. 이시술은간기능을현재보다더낫게하지는못합니다. 단락술은문맥정맥과간정맥사이에새로운경로를만들어서간에혈액이축적되는것을방지합니다 ( 위의오른쪽에있는사진참조 ). 이시술은다른문제들을개선시킬수있습니다. 이치료가어떻게도움이될수있는지에대해의사가설명할것입니다. 문맥고혈압의유일한장기치유는간이식을받는것입니다. 만약의사로부터간이식이자신에게도움이될수있다고들으셨다면, TIPS를받은다음에라도이식을나중에할수있습니다.

3 페이지방사선 / 영상서비스경경정맥간내문맥정맥단락술 (TIPS) TIPS 는어떻게이루어지는가? TIPS는엑스레이나다른영상에의해인도되는시술의전문의인중재적방사선과의가수행합니다. 전체시술에는대개약 2에서 3시간이걸리지만 5에서 6시간까지걸릴수도있습니다. 전신마취를받게되며, 이것은완전히잠이들게됨을의미합니다. 호흡을도와주는호흡관이사용됩니다. 의사는목에있는커다란경정맥을통해정맥에접근합니다. 의사는그곳으로부터와이어및카테터 ( 얇은플라스틱관 ) 을사용하여간정맥으로진입합니다. 다음에, 간의조직을거쳐문맥정맥까지통로가만들어집니다. 스텐트 - 그라프트 ( 아래의사진참조 ) 를배치하여이통로가열려있도록합니다. 혈액은문맥계로부터대정맥 ( 상체와하체로부터의혈액을모아서심장의오른쪽심방 ( 방 ) 으로보내는커다란정맥 ) 으로직접흐르게됩니다. 이렇게함으로써문맥고혈압이완화됩니다. 스텐트 - 그라프트 시술후, 저희는귀하를깨워드립니다. 시술후목에약 ½ 인치길이의상처가남게됩니다. 시술당일에는계속졸리지만, 다음날부터는정상으로됩니다. 그렇게되면정상활동으로돌아갈수있습니다. TIPS 시술을받은다음기대할수있는것은? 단락은환자의 90 퍼센트에서가능합니다 (100 명가운데 90 명 ). 일부의경우 (10 퍼센트, 또는 100 명가운에 10 명 ), 단락을만드는것이가능하지않습니다.

4 페이지방사선 / 영상서비스경경정맥간내문맥정맥단락술 (TIPS) 만약의사가단락을만들수있었으며, 귀하에게 : 정맥류출혈이있었다면, 정맥류로부터더이상출혈이없게될확률은 80 에서 90 퍼센트입니다. 복수가있었다면, 귀하의배에있는액체가없어지거나약 1달이내에감소될확률은약 65퍼센트입니다. 시간이지남에따라단락주위에상처조직이형성될수있습니다. 이것은부분적 ( 또는드물게는완전한 ) 차단을초래할수있습니다. 이문제로인하여, 귀하는때때로초음파검사를통해단락이제대로작동하는지확인해야합니다. 만약단락의올바른작동이중단되는경우, 1회이상의시술을통해수리해야할수있습니다. 이러한시술은원래의 TIPS 시술보다는덜복잡하고위험합니다. 또한이는전신마취가아니라경미한진정으로됩니다. 이에따른위험이있는가? 대부분의 TIPS 시술을받은후문제가없습니다. 단락술을받은사람가운데약 3분의일 (100명가운데 33명 ) 은뇌병증 ( 경미한혼돈, 집중곤란또는수면-각성주기의변화 ) 이새로생기거나악화됩니다. 이러한증상들은대부분약으로관리할수있습니다. 그러나 TIPS를만드는일은심각한의학적시술입니다. 약 5에서 10퍼센트의사람들 (100명가운데 5에서 10명 ) 에서심각한합병증이발생합니다. 다음이포함될수있습니다 : 생명에위협이될수있는복부의출혈 심각한감염 간질환이훨씬악화됨처음며칠동안에는, 이시술자체에의한사망률은약 1퍼센트입니다 (100명가운데 1명이 TIPS에의해사망합니다 ). 그리고시술후처음몇달동안의사망률은훨씬더높을수있습니다. 이시술을받기전에의사가귀하의위험에관해알려줄것입니다. 모든질문과염려에대하여설명을듣도록하십시오. 시술전 TIPS 시술전에병원이나진료소에서마취전상담을받아야합니다. 이방문은저희가약속을잡아드릴것입니다. 외래환자인경우에는, 간호사조정관이시술전날오후에전화를드릴것입니다. 시술이월요일에있다면, 간호사는전주의금요일에전화할것입니다. 간호사는중요한지시사항을제공하며귀하의질문에답해드립니다.

5 페이지방사선 / 영상서비스경경정맥간내문맥정맥단락술 (TIPS) 귀하께서영어에미숙하여이러한지시사항이나시술의내용을이해하지못한다면, 가능한빨리저희에게알리십시오. 저희가병원통역사를연결하여도와드립니다. 귀하의가족이나친구는통역할수없습니다. 과거에조영제 ( 엑스레이염료 ) 에대하여알러지나부작용이있었다면, 간호사조정관에게전화하십시오 ( 마지막페이지에있는번호참고 ). 알러지가있다면시술전에투약이필요할수있습니다. 귀하의신장기능이정상이아닌상태에서엑스레이염료를혈관에투입해야한다면, 신장의보호를도와주며시술전후에복용하는약을처방해드릴수있습니다. 만약귀하께서혈액을희석시키는약 ( 쿠마딘, 로베녹스, 프라그민, 또는플라빅스 ) 을복용하고있다면, 시술전 3 에서 9 일동안그약의복용을중단해야할수있습니다. 이에대한지시를받게됩니다. 만약당뇨병으로인슐린이나메트포민 ( 글루코파지 ) 를복용하는경우에는, 포트를배치하는당일에그용량을중단하거나조절하는지시를받게됩니다. 시술전날시술전에다음지시를철저히따라야합니다 : 시술전날에는평상시와마찬가지로식사할수있습니다. 액체를충분히드십시오. 시술전 6 시간부터는, 맑은액체 ( 물, 스프라이트, 크랜베리주스, 약한차와같이투명한액체 ) 만을드실수있습니다. 시술전 2 시간부터는 : - 아무것도드시지마십시오. - 약을복용해야한다면, 약간의물로만삼키십시오. - 비타민이나다른보조식품을들지마십시오. 빈속이아플수있습니다. 시술당일 시술당일에는다른보통약들을복용하십시오. 의사나간호사의지시가없는한약을거르지마십시오. 복용하는약의목록을지참하십시오.

6 페이지방사선 / 영상서비스경경정맥간내문맥정맥단락술 (TIPS) 시술이지연되는경우에는, 대개예기치못하거나응급문제가있는다른분들을치료해야하기때문입니다. 이러한경우기다려주시면고맙겠습니다. 다른지시가없는한다음과같이하십시오 : - 귀하가 University of Washington Medical Center(UWMC) 의환자인경우, 병원 3 층 ( 메인 ) 에있는입원창구에서체크인하십시오. 입원창구는로비에있는안내데스크의뒤쪽오른편에있습니다. - 귀하가 Harborview Medical Center(HMC) 의환자라면, Maleng 빌딩의 8 층에있는통원시술과 (APA) 에서체크인하십시오. 보조원이착용할병원가운과소지품을넣을백을줄것입니다. 화장실은언제나사용할수있습니다. 정맥투여 (IV) 라인이시작됩니다. 정맥투여를통해수액과약이투여됩니다. 중재적방사선의가시술에관해설명한다음, 이에동의서에서명하지않았다면서명을요청할것입니다. 이때질문을할수있습니다. 다음에는마취전문의가귀하를잠들게합니다. 이의사는시술전체동안그리고마취로부터깨어나는동안귀하를관찰할것입니다. 시술후 깨어난후에는, 곧액체와단단한음식을드실수있습니다. 병원에서하루밤을지내게됩니다. 저희는귀하에게출혈이나감염의징후가있는지면밀히관찰합니다. 대부분은다음날에집으로돌아갑니다. 별도의회복은필요하지않습니다. 집에돌아간후 약의복용을정상적으로다시계속할수있습니다. 의사가처방하거나승인한약만복용하십시오. 시술후약 1 주일이되는때에복부의초음파검사를받도록예정될것입니다. 이약속을반드시지키십시오.

7 페이지방사선 / 영상서비스경경정맥간내문맥정맥단락술 (TIPS) 질문이있는경우? 귀하의질문은중요합니다. 질문이나걱정되는부분이있다면담당의나의료제공자에게문의하십시오. UWMC 클리닉직원도도와드릴수있습니다. 방사선 / 영상서비스 : 206-598-6200 전화연락시간다음의경우즉시저희에게전화하십시오 : 101 F (38.3 C) 가넘는열이나오한 새로운복통 악화되는혼돈이나졸리움 어지러움 눈이나피부가노랗게변색 악화되는숨참 전화할곳 University of Washington Medical Center (UWMC) 환자 중재적방사선과간호사조정관... 206-598-6897 시술예약... 206-598-6209 업무시간이후 ( 오후 5 시부터오전 7 시까지 ) 그리고주말과휴일당직중재적방사선과휄로우...206-598-6190 Harborview Medical Center (HMC) 환자 환자관리조정관...206-744-0112 또는 206-744-0113 업무시간이후 ( 오후 5 시부터오전 7 시까지 ) 그리고주말과휴일당직중재적방사선과휄로우... 206-744-0147 응급상황의경우 가장가까운응급실로직접가거나 9-1-1 에연락하십시오. 저희의료진과연락을위하여기다리지마십시오. Box 357115 1959 N.E. Pacific St. Seattle, WA 98195 206-598-6200 University of Washington Medical Center Transjugular Intrahepatic Portosystemic Shunt (TIPS) Korean Published/Clinician Review: 02/2012 Reprints on Health Online: http://healthonline.washington.edu

Patient Education Transjugular Intrahepatic Portosystemic Shunt (TIPS) About your procedure This handout explains what a transjugular intrahepatic portosystemic shunt is and what to expect when you have this procedure. What does TIPS mean? TIPS stands for transjugular intrahepatic portosystemic shunt: Transjugular through the jugular vein in your neck Intrahepatic within your liver Portosystemic from the portal vein to the hepatic vein (The portal vein carries blood into the liver. The hepatic vein drains blood from the liver.) Shunt a metal tube covered with fabric that allows flow from one blood system to another Why do I need a TIPS procedure? Normally, blood flows from your intestines and spleen through the portal vein into your liver. A healthy liver processes the blood cells and absorbed nutrients from the gut (see picture on left on page 2). The blood then filters through the liver tissue and drains into the hepatic veins and then into the heart. You have a problem with your liver that has caused portal hypertension. This condition causes increased pressure in the network of veins that drain your stomach, esophagus, spleen, and bowel. The most common reason for this problem is cirrhosis of the liver, which is widespread scarring in your liver.

Page 2 Transjugular Intrahepatic Portosystemic Shunt (TIPS) A healthy liver is shown on the left. A liver with a shunt in place is shown on the right. Portal hypertension causes 2 major problems: Variceal Bleeding High pressure in the veins in the liver can cause the blood flow in the portal veins to back up. The blood must then drain through new pathways called varices. When too much blood fills the veins, they weaken. This can cause a lot of bleeding. Ascites Ascites is a buildup of fluid in the abdomen. This may occur for many different reasons. Can TIPS cure these problems? The TIPS procedure only helps control these problems. It does not make your liver function any better than it already does. The shunt creates a new path between the portal vein and hepatic veins to keep blood from building up in the liver (see picture on the right, above). Other problems can also be improved with this procedure. Your doctor will talk with you about how this treatment may help you. The only long-term cure for portal hypertension is to have a liver transplant. If your doctor has told you that a liver transplant could help you, you can have TIPS done and still get a transplant later.

Page 3 Transjugular Intrahepatic Portosystemic Shunt (TIPS) How is TIPS done? TIPS is done by an interventional radiologist, a doctor who specializes in procedures that are guided by X-rays or other imaging. The entire procedure usually takes about 2 to 3 hours, but it can last as long as 5 to 6 hours. You will have general anesthesia, which means that you will be completely asleep. You will have a breathing tube to help you breathe. Your doctor will access your veins through the large jugular vein in your neck. From there, your doctor will use wires and catheters (thin plastic tubes) to enter your hepatic veins. Then, a passageway is created across the liver tissue to your portal vein. A stent-graft (see the picture below) will be placed to keep this passageway open. The blood will flow directly from your portal system into your vena cava (a large vein that drains blood from the upper body and the lower body, and empties into the right atrium (chamber) of the heart). This will relieve the portal hypertension. A stent-graft After the procedure, we will wake you up. You will have a scar about ½ inch long on your neck. You will feel sleepy for the rest of the day, but you should feel normal by the next day. After that, you should be able to return to your normal activities. What should I expect after my TIPS procedure? A shunt can be created in about 90% of patients (90 out of 100). For some people (10%, or 10 out of 100), it is not possible to create the shunt.

Page 4 Transjugular Intrahepatic Portosystemic Shunt (TIPS) If your doctor was able to create your shunt and you had: Variceal bleeding, there is an 80 to 90% chance that you will not have any more bleeding from the varices. Ascites, there is about a 65% chance that your belly fluid will go away or be reduced within about 1 month. Over time, your body may form scar tissue around the shunt. This can cause partial (or rarely, complete) blockage. Because of this problem, you will need ultrasound tests from time to time to make sure the shunt is working well. If the shunt stops working well, you may need 1 or more procedures to repair it. These procedures are less complicated and risky than the original TIPS procedure. They are done with mild sedation only, not general anesthesia. Are there risks involved? Most people do well after the TIPS procedure. About ⅓ of people (33 out of 100) who get a shunt develop new or worsened encephalopathy (mild confusion, trouble concentrating, or changes in your sleep-wake cycle). Most times, these symptoms can be managed with medicines. But, creating TIPS is a serious medical procedure. About 5 to 10% of people (5 to 10 out of 100) have a serious complication. These can include: Bleeding in the abdomen that may be life-threatening Serious infection Liver disease gets much worse In the first several days, the death rate from the procedure itself is about 1% (1 out of 100 people die from a TIPS procedure). And, the death rate in the first few months after the procedure can be much higher. Your doctor will talk with you about your risks before you have the procedure. Please be certain that all of your questions and concerns are addressed. Before Your Procedure You will need a pre-anesthesia consult, either in the hospital or in a clinic, before you have the TIPS procedure. We will schedule this visit for you. If you are an outpatient, a nurse coordinator will call you the afternoon before your procedure. If your procedure is on a Monday, the nurse will call you the Friday before. The nurse will give you important instructions and answer any questions you have.

Page 5 Transjugular Intrahepatic Portosystemic Shunt (TIPS) If you do not understand English well enough to understand these instructions or the details of the procedure, tell us as soon as possible. We will arrange for a hospital interpreter to assist you. A family member or friend may not interpret for you. If you have had an allergy or bad reaction to contrast (X-ray dye) in the past, please call our nurse coordinators (see numbers on the last page). You may need medicine for this allergy before the procedure. If your kidney function is not normal and we need to give X-ray dye into your blood vessels, we may prescribe a medicine for you to take before and after your procedure to help protect your kidneys. If you take any blood-thinning medicines (such as Coumadin, Lovenox, Fragmin, or Plavix), you may need to stop taking the medicine for 3 to 9 days before the procedure. You will receive instructions about this. If you have diabetes and take insulin or metformin (Glucophage), you will receive instructions about holding or adjusting your dose for the day your port is placed. Day Before Your Procedure You must closely follow these instructions before your procedure: The day before the procedure, you may eat as usual. Drink lots of fluids. Starting 6 hours before the procedure, you may only have clear liquids (liquid you can see through, such as water, Sprite, cranberry juice, weak tea). Starting 2 hours before your procedure: - Take nothing at all by mouth. - If you must take medicines, take them with only a sip of water. - Do not take vitamins or other supplements. They can upset an empty stomach. On the Day of Your Procedure Take all of your other usual medicines on the day of the procedure. Do not skip them unless your doctor or nurse tells you to. Bring a list of all the medicines you take with you.

Page 6 Transjugular Intrahepatic Portosystemic Shunt (TIPS) If there is a delay in getting your procedure started, it is usually because we need to treat other people with unexpected and urgent problems. Thank you for your patience if this occurs. Unless you are told otherwise: - If you are a patient at University of Washington Medical Center (UWMC), check in at Admitting on the 3rd (main) floor of the hospital. Admitting is to the right and behind the Information Desk in the lobby. - If you are a patient at Harborview Medical Center (HMC), check in at the Ambulatory Procedure Area (APA) on the 8th floor of the Maleng Building. A medical assistant will give you a hospital gown to put on and a bag for your belongings. You may use the restroom at that time. An intravenous (IV) line will be started. You will be given fluids and medicines through the IV. An interventional radiology doctor will talk with you about the procedure and ask you to sign a consent form if that has not already been done. You will be able to ask questions at that time. You will then be put to sleep by an anesthesiologist. This person will monitor you throughout the entire procedure and while you recover from anesthesia. After Your Procedure Soon after you are awake, you will be able to have liquids and then solid food. You will stay in the hospital overnight. We will watch you closely for any signs of bleeding or infection. Most people go home the next day. There is no other recovery needed. When You Get Home You may resume taking your normal medicines. Take only the medicines that your doctors prescribed or approved. You will be scheduled for an ultrasound of your abdomen about 1 week after your procedure. Be sure to keep this appointment.

Page 7 Transjugular Intrahepatic Portosystemic Shunt (TIPS) Questions? Your questions are important. Call your doctor or health care provider if you have questions or concerns. UWMC clinic staff are also available to help. Radiology/Imaging Services: 206-598-6200 When to Call Call us right away if you have: Fever higher than 101 F (38.3 C) or chills New abdominal pain Confusion or sleepiness that gets worse Dizziness Yellowing of your eyes or skin Shortness of breath that gets worse Who to Call University of Washington Medical Center (UWMC) Patients Interventional Radiology nurse coordinator... 206-598-6897 Procedure Scheduling... 206-598-6209 After hours (between 5 p.m. and 7 a.m.), and on weekends and holidays Ask for the Interventional Radiology Fellow on call... 206-598-6190 Harborview Medical Center (HMC) Patients Patient Care Coordinators... 206-744-0112 or 206-744-0113 After hours (between 5 p.m. and 7 a.m.), and on weekends and holidays Ask for the Interventional Radiology Fellow on call... 206-744-0147 If You Have an Emergency Go directly to the nearest Emergency Room or call 9-1-1. Do not wait to contact one of our staff. Box 357115 1959 N.E. Pacific St. Seattle, WA 98195 206-598-6200 University of Washington Medical Center Published/Clinician Review: 02/2012 Reprints on Health Online: http://healthonline.washington.edu