Week 3 7/5/21

The third week of my stay at NYC coincided with the July 4th weekend. After seeing a great fireworks show on Sunday and taking a break on Monday, I resumed the clinical immersion on Tuesday. This week I have been following different clinicians in the IR departments and occasionally stepping off to other OR units. Overall the shadowing done this week was a good mix of surgeries and patient consultations.


An interesting case of consult I saw, while I was with Dr. Kesselman in the clinic, was a patient who came for a potential TIPS procedure. TIPS stands for transjugular intrahepatic portosystemic shunt and it is an artificial channel which directly connects a branch of the portal vein with the hepatic vein. The portal vein carries blood from the intestine to the liver. With the shunt in place, a portion of this inflow would bypass the liver, directly enter the hepatic vein and return to the heart. This procedure is typically done to relieve patients from complications of portal hypertension that usually results from liver cirrhosis. The fibrous tissue in the diseased liver creates higher resistance for blood flow and eventually, with so much resistance in place, the blood backflows into the portal vein or it diverges into the collateral veins connected to the esophagus. Portal hypertension can thus lead to esophageal varices (extremely dilated veins which are prone to bleeding), ascites (buildup of fluid in the abdomen), and other symptoms. If left untreated, patients may experience life-threatening internal bleeding or liver failure. TIPS can provide a method to prevent these fatal outcomes.


During a TIPS procedure, an IR surgeon will enter a wire into the patient’s jugular vein under image guidance and navigate the wire into the inferior vena cava, and then into the hepatic vein in the liver. The surgeon will then blindly create a connection from the hepatic vein to a branch of the portal vein using a needle, and confirm this entry via contrast imaging. Then, the surgeon will pass a balloon and inflate the just-created pathway, followed by placing a permanent wire meshed stent. After the TIPS procedure, the pressure of blood flow in the liver should decrease. However, TIPS is not without complications. Since liver usually performs the filtration of toxic chemicals ingested from food, bypassing a portion of the blood coming from the intestine may lead to hepatic encephalopathy (damaging the brain), which alters the patient’s level of consciousness. Other complications include increased load for the heart or even heart failure, as well as liver failure due to decreased blood supply from the portal vein.


Outside of clinical visits, this week I also had the chance to observe procedures in the IR department. Additionally, I joined a few of our classmates in the OR units and observed plastic surgeries and cervical orthopaedic surgeries, which was a very different experience from the minimal invasive procedures done at IR. After business hours, I also participated in a MRI scan study, and I would like to thank Dr. Alexey Dimov and Dr. Junghun Cho for their help. 




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