PSS Flashcards
Joffe, Vet Surg, 2019:
Methods of securing cellophane bands for EHPSS
Cellophane bands with how many layers were more likely to fail and failed at lower pressures?
Difference in failure rates between bands applied to create 25% vs 50% attenuation?
What sized clips failed less often?
Difference in failure rates between polymer locking ligation clips vs titanium ligation clips?
offe, Vet Surg, 2019:
3-layer cellophane bands were 4 times more likely to fail than 4-layer cellophane bands and failed at lower pressures
No difference in failure rates between bands applied to create 25% vs 50% attenuation
Medium clips failed less often than medium-large clips
Failure rates did not differ between polymer locking ligation clips and titanium ligation clips
Weisse, JAVMA, 2018:
IHPSS
Major intra-op complication rate?
Minor intra-op complication rate?
Early post-op complication rate?
What % of dogs had post-op GI hemorrhage?
Outcomes?
MST?
Dogs with shunts in which division of the liver had better outcomes?
Weisse, JAVMA, 2018:
Major intra-op complication rate: 3%
Minor intra-op complication rate: 12%
Early post-op complication rate: 16%
21% had post-op GI hemorrhage
66% excellent outcomes, 15% fair outcomes, 19% poor outcomes
MST: >6 years
Dogs with central divisional shunts had better outcomes (80% excellent outcome)
Culp, Vet Surg, 2018:
Percutaneous transvenous coil embolization (PTCE) for IHPSS
Intra-op complication rate?
Short-term post-op complication rate?
Long-term post-op complication rate?
What % of dogs had a decrease in shunt fraction post-op?
What % of dogs had resolution of clinical signs at 3 months post-op?
Culp, Vet Surg, 2018:
Intra-op complication rate: 8%
Short-term post-op complication rate: 8%
Long-term post-op complication rate: 8%
70% of dogs had a decrease in shunt fraction post-op, but none of the dogs had shunt fractions within the normal range
92% of dogs had resolution of clinical signs at 3 months post-op
Case, Vet Surg, 2018:
Cellophane banding vs percutaneous transvenous coil embolization (PTCE) for IHPSS
Any differences in resolution of clinical signs and improvements in hepatic biochemical markers post-op for cellophane banding vs PTCE?
Which technique had fewer post-op complications?
Case, Vet Surg, 2018:
No difference in resolution of clinical signs and improvements in hepatic biochemical markers post-op for cellophane banding vs PTCE
PTCE had fewer post-op complications
Traverson, Vet Surg, 2018:
Ameroid ring constrictor (ARC) vs cellophane banding for EHPSS
What % of shunts were correctly localized by ultrasound?
What % of dogs had concurrent urinary calculi?
Post-op complication rate for ARC vs cellophane banding?
Most severe complication?
Post-op mortality rate for ARC vs cellophane banding?
Parameters of hepatic function returned to normal in what % of dogs following ARC vs cellophane banding?
Complete shunt occlusion was achieved at a median of 5 months post-op in what % of dogs following ARC vs cellophane banding?
What was a risk factor for post-op complications?
Traverson, Vet Surg, 2018:
Shunt location was consistent with ultrasonographic localization in 82% of the dogs
41% had concurrent urinary calculi
Post-op complication rate: 26% for ARC vs 23% for cellophane banding
Coagulopathy was the most severe complication
Post-op mortality rate: 4% for ARC vs 0% for cellophane banding
Parameters of hepatic function returned to normal in 18% of ARC dogs vs 12% of cellophane banding dogs
Complete shunt occlusion was achieved at a median of 5 months post-op in 100% of ARC dogs vs 53% of cellophane banding dogs
Lower body weight was a risk factor for post-op complications - for every 1kg increase in body weight, the odds of developing post-op complications decreased by 30%
Wallace, Vet Surg, 2018:
Self-retaining polyacrylic acid-silicone device for attenuation of an EHPSS
What % of shunts had complete attenuation by 4 weeks post-op and what % had complete attenuation by 8 weeks post-op?
Bile acids concentration normalized in what % of dogs?
Wallace, Vet Surg, 2018:
33% had complete attenuation by 4 weeks post-op and 33% had complete attenuation by 8 weeks post-op; the remaining 34% had continued mild residual flow at 8 weeks post-op
Bile acids concentrations normalized in 83% of the dogs
Strickland, Vet Surg, 2018:
Post-attenuation neurological signs (PANS)
What % of dogs developed PANS?
Risk factors for developing PANS?
What factor(s) were not associated with the development of PANS?
Effect(s) of prophylactic administration of levetiracetam?
Strickland, Vet Surg, 2018:
11% developed PANS
Risk factors for PANS:
-pre-op hepatic encephalopathy (increased odds of PANS by 2.7-fold)
-increasing age (each year increase in age increased the odds of PANS 1.5-fold)
-Pre-op ammonia levels & shunt location (extrahepatic vs intrahepatic) were not associated with development of PANS
Prophylactic administration of levetiracetam did not reduce the development of PANS or seizures
Mullins, Vet Surg, 2019:
Post-attenuation neurological signs (PANS)
Overall incidence of PANS?
Effect of prophylactic treatment with levetiracetam on incidence of PANS?
Mullins, Vet Surg, 2019:
Overall incidence of PANS: 8%
Prophylactic treatment with levetiracetam was not associated with a reduced incidence of PANS
Joffe
Securing cellophane bands
VetSurg 2019
Medium clips failed less than Medium-large clips at 50% attenuation
3 layer failed more than 4 layer
Mullins
Short term survival for post attenuation seizures
VetSurg 2020
32% survived 30 d
82% experienced generalized seizures
Short term survival is associated with
~hx of pre-op seizures
~development of focal seizures
Otomo
Long term with a thin-film band or Ameroid
VetSurg 2020
Post-op seizures 8%
Strickland
Cats with Congenital PSS
VetSurg 2021
Post attenuation neuro signs?
Associated with neuro signs?
Post attenuation signs 62%
Osmolality low at 24 h post-op in cats with neuro signs
No association with Keppra
Devriendt
Serum momoethylglycylxylidide (MEGX) concentration to assess shunt closure
JVIM 2021
MEGX higher in closed than at diagnosis, but not to those with persistent shunting
at T15
Tivers
Intrahepatic congenital PSS with suture attenuation
JSAP 2018
Overall Mortality?
Complete attenuation?
PO complication rate?
Outcomes of repeat surgery?
overall PO mortality 13%
First surgery
~18% tolerated complete attenuation
~82% tolerated partial attenuation
Postoperative complications 44%
11% died
Repeat surgery 85%
85% ultimately achieved complete shunt attenuation
3% died
Strickland Vet Surg 2018
Risk for neurological signs after attenuation of PSS
What % developed PO neuro signs?
What % developed seizures?
% of PO neuro signs did not survive?
What increased the odds of developing PNS and seizures?
Was Levetiracetam protective?
11% PO neuro signs
5% Seizures
PO neuro signs 18% did not survive
Neuro signs and seizures associated with
~Hepatic encephalopathy
~Increased age
No association with
~Location of shunt
~Levitracetam
Bristow et al JSAP 2017
What did the authors conclude about bile acids after complete extra hepatic shunt ligation?
Significant decrease after surgery, but pre- and post-prandial samples remain well above normal
Valiente et al JVIM 2020
What was the conclusion regarding PO bile acids in cats after thin film banding of PSS?
25/28 cats had normal bile acids after thin film banding
Anglin JAVMA 2022
Factors associated with MAPSS related death?
Was survival time affected by previous PSS attenuation?
Factors associated with MAPSS related death?
- BW (first recheck)
- Alb conc (first recheck)
at last recheck:
-Alb
-cholesterol
-TS
-Glucose conc
*Not receiving medical management or w/o signs at initial exam were less likely to die
Was survival time affected by previous PSS attenuation?
No
Escribano Carrera JAVMA 2022
What % had post-attenuation seizures?
What % had post-attenuation neurologic signs other than seizures?
Neurological signs fully resolved in what % of dogs by the time of discharge?
Signs resolved in what % of patients that had neurological signs at the time of discharge?
What % had post-attenuation seizures?
-60%
What % had post-attenuation neurologic signs other than seizures?
40%
Neurological signs fully resolved in what % of dogs by the time of discharge?
48%
Signs resolved in what % of patients that had neurological signs at the time of discharge?
67%
Wallace JAVMA 2022
Survival time in dogs >5y that had PSS attenuation vs medical management
Preoperative mortality rate
Survival time in dogs >5y that had PSS attenuation vs medical management
M: 3.4y
S: 10.9y
Preoperative mortality rate
7.3%
Serrano JVIM 2022
In Comparison of diet, lactulose, and metronidazole combinations in the control of pre-surgical clinical signs in dogs with congenital extrahepatic portosystemic shunts, which combination of treatment was most effective at controlling fasting ammonia levels?
Diet and lactulose
adding Metronidazole did not improve FA
Mullins Vet Surg 2021
Risk factors for PANS
Prognostic factors positively associated with short-term survival
Risk factors include
-preoperative hepatic encephalopathy
-increasing age
-possibly certain breeds
-possibly extrahepatic shunt morphology
Prognostic factors positively associated with short-term survival
-history of preoperative seizures -development of focal seizures only
Sunlight Vet Surg 2022
At what time point was PC activity increased?
Mean pot op values that were elevated in patients with excellent outcomes?
What was associated with completely occluded shunts?
At what time point was PC activity increased?
Post op
Mean pot op values that were elevated in patients with excellent outcomes?
-PC
-HCT
-MCV
-Alb
-BUN
What was associated with completely occluded shunts?
-Elevated PC
Tributaries of portal vein
Mesenteric vessels
-small intestines
Cranial mesenteric v
Caudal mesenteric v
-colon & rectum
splenic v
-spleen
-left gastric v
left gastric v
gastroduodenal v
-pancreas
-duodenum
-stomach
