Covered TIPS versus endoscopic band ligation plus propranolol for the prevention of variceal rebleeding in cirrhotic patients with portal vein thrombosis: a randomised controlled trial

Transjugular intrahepatic portosystemic stent-shunt as minimally invasive method of portal hypertension correction in multi-disciplinary clinic

Aim. Optimization of the tactics of management of patients with liver cirrhosis who underwent Transjugular Intrahepatic Portosystemic Shunt – TIPS based on own experience and literature data. Materials and methods. From 2014 to 2019 years 51 Transjugular Intrahepatic Portosystemic Shunt procedures were performed. Results. The indications for Transjugular Intrahepatic Portosystemic Shunt procedure were detailed. The tactics of treatment in post-operative period was assessed. Shot-term and long-term results of the treatment were discussed. Especial attention was put to persons who included in patient list of liver transplantation. Conclusion. Transjugular Intrahepatic Portosystemic Shunt allows obtaining stable decompression in portal system that reduces frequency of bleeding relapse from gastric and esophageal veins. The mortality was decreased, and patients can wait till liver transplantation.

Portosystemic shunts versus endoscopic intervention with or without medical treatment for prevention of rebleeding in people with cirrhosis

BACKGROUND

People with liver cirrhosis who have had one episode of variceal bleeding are at risk for repeated episodes of bleeding. Endoscopic intervention and portosystemic shunts are used to prevent further bleeding, but there is no consensus as to which approach is preferable.

OBJECTIVES

To compare the benefits and harms of shunts (surgical shunts (total shunt (TS), distal splenorenal shunt (DSRS), or transjugular intrahepatic portosystemic shunt (TIPS)) versus endoscopic intervention (endoscopic sclerotherapy or banding, or both) with or without medical treatment (non-selective beta blockers or nitrates, or both) for prevention of variceal rebleeding in people with liver cirrhosis.

SEARCH METHODS

We searched the CHBG Controlled Trials Register; CENTRAL, in the Cochrane Library; MEDLINE Ovid; Embase Ovid; LILACS (Bireme); Science Citation Index - Expanded (Web of Science); and Conference Proceedings Citation Index - Science (Web of Science); as well as conference proceedings and the references of trials identified until 22 June 2020. We contacted study investigators and industry researchers.

SELECTION CRITERIA

Randomised clinical trials comparing shunts versus endoscopic interventions with or without medical treatment in people with cirrhosis who had recovered from a variceal haemorrhage.

DATA COLLECTION AND ANALYSIS

We used standard methodological procedures expected by Cochrane. When possible, we collected data to allow intention-to-treat analysis. For each outcome, we estimated a meta-analysed estimate of treatment effect across trials (risk ratio for binary outcomes). We used random-effects model meta-analysis as our main analysis and as a means of presenting results. We reported differences in means for continuous outcomes without a meta-analytic estimate due to high variability in their assessment among all trials. We assessed the certainty of evidence using GRADE.

MAIN RESULTS

We identified 27 randomised trials with 1828 participants. Three trials assessed TSs, five assessed DSRSs, and 19 trials assessed TIPSs. The endoscopic intervention was sclerotherapy in 16 trials, band ligation in eight trials, and a combination of band ligation and either sclerotherapy or glue injection in three trials. In eight trials, endoscopy was combined with beta blockers (in one trial plus isosorbide mononitrate). We judged all trials to be at high risk of bias. We assessed the certainty of evidence for all the outcome review results as very low (i.e. the true effects of the results are likely to be substantially different from the results of estimated effects). The very low evidence grading is due to the overall high risk of bias for all trials, and to imprecision and publication bias for some outcomes. Therefore, we are very uncertain whether portosystemic shunts versus endoscopy interventions with or without medical treatment have effects on all-cause mortality (RR 0.99, 95% CI 0.86 to 1.13; 1828 participants; 27 trials), on rebleeding (RR 0.40, 95% CI 0.33 to 0.50; 1769 participants; 26 trials), on mortality due to rebleeding (RR 0.51, 95% CI 0.34 to 0.76; 1779 participants; 26 trials), and on occurrence of hepatic encephalopathy, both acute (RR 1.60, 95% CI 1.33 to 1.92; 1649 participants; 24 trials) and chronic (RR 2.51, 95% CI 1.38 to 4.55; 956 participants; 13 trials). No data were available regarding health-related quality of life. Analysing each modality of portosystemic shunts individually (i.e. TS, DSRS, and TIPS) versus endoscopic interventions with or without medical treatment, we are very uncertain if each type of shunt has effect on all-cause mortality: TS, RR 0.46, 95% CI 0.19 to 1.13; 164 participants; 3 trials; DSRS, RR 0.93, 95% CI 0.65 to 1.33; 352 participants; 4 trials; and TIPS, RR 1.10, 95% CI 0.92 to 1.31; 1312 participants; 19 trial; on rebleeding: TS, RR 0.28, 95% CI 0.14 to 0.56; 127 participants; 2 trials; DSRS, RR 0.26, 95% CI 0.11 to 0.65; 330 participants; 5 trials; and TIPS, RR 0.44, 95% CI 0.36 to 0.55; 1312 participants; 19 trials; on mortality due to rebleeding: TS, RR 0.25, 95% CI 0.06 to 0.96; 164 participants; 3 trials; DSRS, RR 0.31, 95% CI 0.13 to 0.74; 352 participants; 5 trials; and TIPS, RR 0.65, 95% CI 0.40 to 1.04; 1263 participants; 18 trials; on acute hepatic encephalopathy: TS, RR 1.66, 95% CI 0.70 to 3.92; 115 participants; 2 trials; DSRS, RR 1.70, 95% CI 0.94 to 3.08; 287 participants; 4 trials, TIPS, RR 1.61, 95% CI 1.29 to 1.99; 1247 participants; 18 trials; and chronic hepatic encephalopathy: TS, Fisher's exact test P = 0.11; 69 participants; 1 trial; DSRS, RR 4.87, 95% CI 1.46 to 16.23; 170 participants; 2 trials; and TIPS, RR 1.88, 95% CI 0.93 to 3.80; 717 participants; 10 trials. The proportion of participants with shunt occlusion or dysfunction was overall 37% (95% CI 33% to 40%). It was 3% (95% CI 0.8% to 10%) following TS, 7% (95% CI 3% to 13%) following DSRS, and 47.1% (95% CI 43% to 51%) following TIPS. Shunt dysfunction in trials utilising polytetrafluoroethylene-covered stents was 17% (95% CI 11% to 24%). Length of inpatient hospital stay and cost were not comparable across trials. Funding was unclear in 16 trials; 11 trials were funded by government, local hospitals, or universities.

AUTHORS' CONCLUSIONS

Evidence on whether portosystemic shunts versus endoscopy interventions with or without medical treatment in people with cirrhosis and previous hypertensive portal bleeding have little or no effect on all-cause mortality is very uncertain. Evidence on whether portosystemic shunts may reduce bleeding and mortality due to bleeding while increasing hepatic encephalopathy is also very uncertain. We need properly conducted trials to assess effects of these interventions not only on assessed outcomes, but also on quality of life, costs, and length of hospital stay.

Placement of a transjugular intrahepatic portosystemic shunt in addition to recanalization of acute and chronic portomesenteric vein occlusions - a retrospective evaluation

Background

Portomesenteric vein thrombosis may be life-threatening due to bowel ischemia caused by venous stasis, or variceal bleeding caused by portal hypertension.

Purpose

To evaluate the effectiveness and safety of recanalization combined with transjugular intrahepatic portosystemic shunt in acute and chronic portomesenteric vein thrombosis in patients with and without liver cirrhosis.

Material and Methods

21 consecutive patients (5 women, 16 men; mean 48 years) with portomesenteric vein thrombosis (8 acute, 13 chronic) treated at the Interventional Radiology department between March 2014 and September 2018 were retrospectively reviewed. The main portal vein was completely obliterated and the portomesenteric vein thrombosis extended into the superior mesenteric vein in all patients. The portomesenteric vein thromboses were recanalized transhepatically, a transjugular intrahepatic portosystemic shunt was inserted, thrombectomy was performed in acute portomesenteric vein thrombosis, and angioplasty with or without additional stenting was performed in chronic portomesenteric vein thrombosis.

Results

Recanalization was successful in 8/8 patients (100%) with acute portomesenteric vein thrombosis, and in 11/13 patients (85%) with chronic portomesenteric vein thrombosis. In 12 patients, blood flow was restored in one session. Several sessions were more frequently needed in patients with acute portomesenteric vein thrombosis compared to those with chronic portomesenteric vein thrombosis (p = 0.003). Re-occlusion occurred and was recanalized in 10/19 patients and was more frequent in patients with chronic (n = 8/11) than on those with acute (n = 2/8) portomesenteric vein thrombosis (p = 0.04). Adverse events occurred in five patients. There was no 30-day mortality.

Conclusion

Recanalization and insertion of a transjugular intrahepatic portosystemic shunt is safe and effective in patients with acute and chronic portomesenteric vein thrombosis with or without cirrhosis. Recanalization was more likely to stay patent in acute compared with chronic portomesenteric vein thrombosis.

Transjugular intrahepatic portosystemic shunt in cirrhosis: An exhaustive critical update

More than five decades after it was originally conceptualized as rescue therapy for patients with intractable variceal bleeding, the transjugular intrahepatic portosystemic shunt (TIPS) procedure continues to remain a focus of intense clinical and biomedical research. By the impressive reduction in portal pressure achieved by this intervention, coupled with its minimally invasive nature, TIPS has gained increasing acceptance in the treatment of complications of portal hypertension. The early years of TIPS were plagued by poor long-term patency of the stents and increased incidence of hepatic encephalopathy. Moreover, the diversion of portal flow after placement of TIPS often resulted in derangement of hepatic functions, which was occasionally severe. While the incidence of shunt dysfunction has markedly reduced with the advent of covered stents, hepatic encephalopathy and instances of early liver failure continue to remain a significant issue after TIPS. It has emerged over the years that careful selection of patients and diligent post-procedural care is of paramount importance to optimize the outcome after TIPS. The past twenty years have seen multiple studies redefining the role of TIPS in the management of variceal bleeding and refractory ascites while exploring its application in other complications of cirrhosis like hepatic hydrothorax, portal hypertensive gastropathy, ectopic varices, hepatorenal and hepatopulmonary syndromes, non-tumoral portal vein thrombosis and chylous ascites. It has also been utilized to good effect before extrahepatic abdominal surgery to reduce perioperative morbidity and mortality. The current article aims to review the updated literature on the status of TIPS in the management of patients with liver cirrhosis.

The Prognosis Analysis of Liver Cirrhosis with Acute Variceal Bleeding and Validation of Current Prognostic Models: A Large Scale Retrospective Cohort Study

Background

Acute variceal bleeding is a major cause of death in liver cirrhosis. This large scale retrospective cohort study aims to analyze the prognosis of patients with cirrhosis and acute variceal bleeding and to validate the current prognostic models.

Methods

Patients with cirrhosis and acute variceal bleeding were enrolled from Jan 2019 to March 2020. The independent prognostic factors for in-hospital death were identified by logistic regression analyses. Area under curves (AUCs) was compared among Child-Pugh, cirrhosis acute gastrointestinal bleeding (CAGIB) score, and model for end-stage liver disease (MELD) and neutrophil-lymphocyte ratio (NLR) scores.

Results

Overall, 379 patients with liver cirrhosis and acute variceal bleeding were consecutively evaluated. The majority of the patients were males (59.1%) and the mean age of all patients were 53.7 ± 1.3 years (range 14-89). Hepatitis B virus (HBV) was the most common underlying cause of liver cirrhosis (54.1%). 72 (19%) patients had hepatocellular carcinoma. Multivariate logistic regression analyses showed that age, HCC, WBC, total serum bilirubin, serum creatinine, and ALT were independently associated with in-hospital death. And the odds ratios (ORs) for in-hospital death were 1.066 (95% CI 1.017-1.118, P = 0.008), 7.19 (95% CI 2.077-24.893, P = 0.001), 1.123 (95% CI 1.051-1.201, P = 0.001), 1.014 (95% CI 1.005-1.023, P = 0.003), 1.012 (95% CI 1.004-1.021, P = 0.006), and 1.005 (95% CI 1.000-1.009, P = 0.036), respectively. In the whole cohort with HCC patients, the AUCs of Child-Pugh, CAGIB, MELD and NLR scores were 0.842 (95% CI 0.801-0.878), 0.840 (95% CI 0.799-0.876), 0.798 (95% CI 0.754-0.838), and 0.688 (95% CI 0.639-0.735), respectively. The differences were statistically significant between Child-Pugh and NLR scores (P = 0.0118), and between CAGIB and NLR scores (P = 0.0354).

Conclusion

Child-Pugh and CAGIB scores showed better predictive performance for prognosis of patients with cirrhosis and acute variceal bleeding than NLR scores.

PTFE-covered TIPS is an effective treatment for secondary preventing variceal rebleeding in cirrhotic patients with high risks

AIM

To compare the effectiveness and safety of transjugular intrahepatic portosystemic shunt (TIPS) with endoscopic therapy plus non-selective β-blockers (NSBBs) for secondary prevention of gasroesophageal variceal bleeding (GEVB) in cirrhotic patients with high-risk factors of treatment failure.

METHODS AND MATERIAL

A total of 122 cirrhotic patients with history of gasroesophageal variceal bleeding and high factors including hepatic vein pressure gradient (HVPG) ≥ 20 mmHg, portal vein thrombosis (PVT), gastrorenal shunt (GRS), or extraluminal para-gastric veins (ep-GVs) detected by endoscopic ultrasound, were analyzed retrospectively. Seventy-seven patients underwent TIPS with PTFE-covered stent (group A) and 102 patients received endoscopic therapy combined with nonselective β-blockers (NSBBs) (group B). According to above high-risk factors, both groups were stratified into four paired subgroups (A1-A4 and B1-B4). Two-year rebleeding rate, overt hepatic encephalopathy, overall survival, and procedure-related adverse events were compared between the two groups and paired subgroups.

RESULTS

The 2-year cumulative probability of free of variceal rebleeding was higher in group A than group B (93 vs. 62%, P < 0.001). Similarly, the 2-year cumulative probability of free of variceal rebleeding was also higher in the subgroups A1-A4 than the subgroups B1-B4 (91 vs. 67%, P = 0.022, 90 vs. 67%, P = 0.021, 94 vs. 59%, P = 0.029, and 90 vs. 58%, P = 0.016, respectively). There was no significant difference between the two groups and corresponding subgroups in overt hepatic encephalopathy and survival.

CONCLUSION

Compared to secondary prophylaxis with endoscopic therapy plus NSBBs, polytetrafluoroethylene-covered TIPS could significantly reduce the variceal rebleeding rate in cirrhotic patients with HVPG ≥ 20 mmHg, PVT, GRS, or ep-GVs, without increasing the incidence of hepatic encephalopathy.

Misplacement of transjugular intrahepatic portosystemic shunts: A surgical challenge for liver transplantation?

BACKGROUND

The impact of transjugular intrahepatic portosystemic shunt misplacement on outcomes of liver transplantation remains controversial. We systematically reviewed the literature on the outcomes of liver transplantation with transjugular intrahepatic portosystemic shunt misplacement.

METHODS

This systematic review was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. The Cochrane library, PubMed, and Embase were searched (January 1990-April 2020) for studies reporting patients undergoing liver transplantation with transjugular intrahepatic portosystemic shunt misplacement.

RESULTS

Thirty-six studies reporting 181 patients who underwent liver transplantation with transjugular intrahepatic portosystemic shunt misplacement were identified. Transjugular intrahepatic portosystemic shunt was misplaced with a variable degree of extension toward the inferior vena cava/right heart in 63 patients (34%), the spleno/portal/superior mesenteric venous confluence in 105 patients (58%), and both in 15 patients (8%). Transjugular intrahepatic portosystemic shunt thrombosis was also present in 21 cases (12%). The median interval between transjugular intrahepatic portosystemic shunt placement and liver transplantation ranged from 1 day to 6 years. Complete transjugular intrahepatic portosystemic shunt removal was successfully performed in all but 12 (7%) patients in whom part of the transjugular intrahepatic portosystemic shunt was left in situ. Cardiac surgery under cardiopulmonary bypass was necessary to remove transjugular intrahepatic portosystemic shunt from the right heart in 4 patients (2%), and a venous graft interposition was necessary for a portal anastomosis in 5 patients (3%). Postoperative mortality (90 days) was 1.1% (2 patients), and portal vein thrombosis developed postoperatively in 4 patients (2%).

CONCLUSION

Misplaced transjugular intrahepatic portosystemic shunt removal is possible in most cases during liver transplantation with extremely low mortality and good postoperative outcomes. Preoperative surgical strategy and intraoperative tailored surgical technique reduces the potential consequences of transjugular intrahepatic portosystemic shunt misplacement.

Retrograde transvenous obliteration for the prevention of variceal rebleeding in patients with portal vein thrombosis: a multicenter study

OBJECTIVES

To evaluate the effectiveness of retrograde transvenous obliteration (RTO) for the prevention of variceal rebleeding in cirrhotic patients with portal vein thrombosis (PVT).

METHODS

Consecutive cirrhotic patients with PVT who underwent RTO for the prevention of variceal rebleeding between January 2002 and June 2019 were included in this multicenter retrospective study. The primary outcome measure was rebleeding. The secondary outcome measures were survival, other complications of portal hypertension, liver function, and PVT.

RESULTS

Forty-five patients (mean age, 66.0 ± 10.6 years; mean Model for End-Stage Liver Disease (MELD) score, 13.9 ± 5.5) were included. The 1-year actuarial probability of remaining free of rebleeding was 92.8 ± 4.0%. The 6-week, 1-year, and 3-year actuarial probabilities of survival were 79.8 ± 6.0%, 48.8 ± 7.7%, and 46.1 ± 7.9%, respectively. MELD score (hazard ratio (HR), 1.09 (95% confidence interval (CI), 1.01-1.17); p = .013) and ascites (HR, 2.84 (95% CI, 1.24-6.55); p = .014) were identified as significant predictors of survival. The 1-year actuarial probabilities of remaining free of new or worsening ascites and esophageal varices were 81.2 ± 8.7% and 89.2 ± 6.0%, respectively. No patients had overt hepatic encephalopathy during follow-up. MELD score significantly increased by a mean of 3.8 (95% CI, 1.7-6.0) at 3 months (p = .001). PVT had improved in 32.0%, worsened in 12.0%, and remained unchanged in 56.0% of patients at 3 months.

CONCLUSION

RTO may be effective for the prevention of variceal rebleeding in cirrhotic patients with PVT.

KEY POINTS

• Retrograde transvenous obliteration may prevent variceal rebleeding in cirrhotic patients with portal vein thrombosis. • The risks of other complications of portal hypertension may not be high after retrograde transvenous obliteration in cirrhotic patients with portal vein thrombosis. • Portal vein thrombosis may improve in approximately one-third of cirrhotic patients within 3 months after retrograde transvenous obliteration.

Where does TIPS fit in the management of patients with cirrhosis?

In this review, we summarise the current knowledge on the indications and contraindications of transjugular intrahepatic portosystemic shunt (TIPS) placement for the treatment of the complications of portal hypertension in cirrhosis, specifically variceal haemorrhage and ascites. Moreover, we discuss the role of TIPS for the treatment of portal vein thrombosis (PVT) and the prevention of complications after extrahepatic surgery ('preoperative TIPS') in patients with cirrhosis. The position of TIPS in the treatment hierarchy depends on the clinical setting and on patient characteristics. In acute variceal haemorrhage, preemptive TIPS is indicated in patients at a high risk of failing standard therapy, that is those with a Child-Pugh score of 10-13 points or Child-Pugh B with active bleeding at endoscopy, although the survival benefit in the latter group still remains to be established. Non-preemptive TIPS is a second-line therapy for the prevention of recurrent variceal haemorrhage and for the treatment of ascites. Of note, TIPS may also improve sarcopenia. Contraindications to TIPS placement, independent of clinical setting, include very advanced disease (Child-Pugh >13 points), episodes of recurrent overt hepatic encephalopathy without an identifiable precipitating factor, heart failure, and pulmonary hypertension. In patients with PVT, TIPS placement not only controls complications of portal hypertension, but also promotes portal vein recanalisation. Although the severity of portal hypertension correlates with poor outcomes after extrahepatic surgery, there is no evidence to recommend preoperative TIPS placement.

Evaluation and Management of Esophageal and Gastric Varices in Patients with Cirrhosis

Variceal bleeding is a complication of cirrhosis that defines decompensation. Important advances in the management of gastroesophageal varices have led to a significant decrease in the morbidity and mortality. Achieving these results in clinical practice is contingent on clinicians applying the best practice strategies and appropriate referral to a tertiary center. Several quality metrics were developed by the American Association for the Study of Liver Diseases. This article aims to update outpatient and inpatient strategies to include the latest recommendations on variceal screening and surveillance, primary and secondary prophylaxis of variceal bleeding, and therapy for patients with acute variceal bleeding.

High-mobility group protein B1: A predictive biomarker for hepatic encephalopathy after transjugular intrahepatic portosystemic shunt

BACKGROUND

The aim of the present study was to investigate whether portal level of high-mobility group protein B1 (HMGB1) is associated with hepatic encephalopathy (HE) after transjugular intrahepatic portosystemic shunt (TIPS).

METHODS

We enrolled 127 consecutive patients who underwent TIPS and collected portal and peripheral blood samples in our department from December 2017 to May 2019. HMGB1 levels were determined using enzyme-linked immunosorbent assay kits. HMGB1 and other HE related parameters were estimated by competing risk analysis, receiver operating characteristic (ROC) analysis and Kaplan-Meier analysis.

RESULTS

Patients with HE after TIPS were older (P = .019) and had higher portal HMGB1 level (P = .038) than those without. Univariate competing risk analysis: age (sHR 1.025, P = .026), hepatorenal syndrome (sHR 3.149, P = .010), model for end-of-stage liver disease (MELD) score (sHR 1.055, P = .024), prior HE (sHR 4.029, P = .0005), portal HMGB1 before TIPS (sHR 1.177, P = .001) reached statistical significance. Multivariate analysis: age (sHR 1.025, P = .037), MELD score (sHR 1.062, P = .011), prior HE (sHR 2.492, P = .030) and portal HMGB1 level before TIPS (sHR 1.217, P = .0002) were significantly different. ROC analyses and Kaplan-Meier curve showed portal HMGB1 level changes before and after TIPS (ΔHMGB1) had good predictive value in the cut-off 0.012 ng/mL (AUC = 0.748, P < .001, Sensitivity = 0.743, Specificity = 0.655).

CONCLUSIONS

Portal HMGB1 may be a therapeutic target for post-TIPS HE.

Comparison of Therapies for Secondary Prophylaxis of Esophageal Variceal Bleeding in Cirrhosis: A Network Meta-analysis of Randomized Controlled Trials

PURPOSE

The decision regarding the optimal secondary prophylactic treatment for esophageal variceal bleeding (EVB) in hepatic cirrhosis is controversial. A network meta-analysis was conducted to assess the benefits of various treatments for the secondary prophylaxis of EVB in patients with cirrhosis.

METHODS

A thorough examination of databases, including EMBASE, PubMed, and Cochrane Database of Controlled Trials, was conducted to identify relevant randomized controlled trials up to December 2019. Key primary outcomes included mortality and rebleeding. Within the identified databases, a network meta-analysis was performed. Results were expressed by using a 95% credible interval (CrI) and odds ratios (ORs). The quality of results was assessed by using the Grading of Recommendations, Assessment, Development and Evaluation approach.

FINDINGS

Forty-eight trials with 4415 participants with cirrhosis and portal hypertension who had a history of recent variceal bleeding were included. Carvedilol ranked first (surface under the cumulative ranking curve [SUCRA], 87.4%) in overall survival, and some advantage was suggested; however, the findings were not statistically significant, compared with endoscopic variceal ligation + nonselective beta-blockers (NSBB) (OR, 0.59; CrI, 0.28, 1.3), NSBB + isosorbide mononitrate (OR, 0.67; CrI, 0.33, 1.4), and transjugular intrahepatic portosystemic shunt (TIPS) (OR, 0.52; CrI, 0.24, 1.1). NSBB + isosorbide mononitrate (SUCRA, 63.9%) ranked higher than NSBB + endoscopic variceal ligation (SUCRA, 49.6%) in reducing mortality. TIPS (SUCRA, 98.8%) ranked higher than other treatments in reducing rebleeding but did not confer any survival benefit.

IMPLICATIONS

TIPS ranks first in preventing rebleeding of secondary prophylaxis of EVB and carvedilol shows outstanding efficacy in improving survival. International Prospective Register of Systematic Reviews: identifier CRD42019131814.

Transjugular intrahepatic portosystemic stent-shunt in the management of portal hypertension

These guidelines on transjugular intrahepatic portosystemic stent-shunt (TIPSS) in the management of portal hypertension have been commissioned by the Clinical Services and Standards Committee (CSSC) of the British Society of Gastroenterology (BSG) under the auspices of the Liver Section of the BSG. The guidelines are new and have been produced in collaboration with the British Society of Interventional Radiology (BSIR) and British Association of the Study of the Liver (BASL). The guidelines development group comprises elected members of the BSG Liver Section, representation from BASL, a nursing representative and two patient representatives. The quality of evidence and grading of recommendations was appraised using the GRADE system. These guidelines are aimed at healthcare professionals considering referring a patient for a TIPSS. They comprise the following subheadings: indications; patient selection; procedural details; complications; and research agenda. They are not designed to address: the management of the underlying liver disease; the role of TIPSS in children; or complex technical and procedural aspects of TIPSS.

Hepatic venous pressure gradient-guided laparoscopic splenectomy and pericardial devascularisation versus endoscopic therapy for secondary prophylaxis for variceal rebleeding in portal hypertension (CHESS1803): study protocol of a multicenter randomised controlled trial in China

INTRODUCTION

Gastro-oesophageal variceal bleeding is one of the most common and severe complications with high mortality in cirrhotic patients who developed portal hypertension. Hepatic venous pressure gradient (HVPG) is a globally recommended golden standard for the portal pressure assessment and an HVPG ≥16 mm Hg indicates a higher risk of death and rebleeding. This study aims to compare the effectiveness and safety of splenectomy and pericardial devascularisation (laparoscopic therapy) plus propranolol and endoscopic therapy plus propranolol for variceal rebleeding in cirrhotic patients with HVPG between 16 and 20 mm Hg.

METHODS AND ANALYSIS

This is a multicenter, randomised, controlled clinical trial. Participants will be 1:1 assigned randomly into either laparoscopic or endoscopic groups. Forty participants whose transjugular HVPG lies between 16 and 20 mm Hg with a history of gastro-oesophageal variceal bleeding will be recruited from three sites in China. Participants will receive either endoscopic therapy plus propranolol or laparoscopic therapy plus propranolol. The primary outcome measure will be the occurrence of gastro-oesophageal variceal rebleeding. Secondary outcome measures will include overall survival, occurrence of hepatocellular carcinoma, the occurrence of venous thrombosis, the occurrence of adverse events, quality of life and tolerability of treatment. Outcome measures will be evaluated at baseline, 12 weeks, 24 weeks, 36 weeks, 48 weeks and 60 weeks. Multivariate COX regression model will be introduced for analyses of occurrence data and Kaplan-Meier analysis with the log-rank test for intergroup comparison.

ETHICS AND DISSEMINATION

Ethical approval was obtained from all three participating sites. Primary and secondary outcome data will be submitted for publication in peer-reviewed journals and widely disseminated.

TRIAL REGISTRATION NUMBER

NCT03783065; Pre-results.

TRIAL STATUS

Recruitment for this study started in December 2018 while the first participant was randomised in January 2019. Recruitment is estimated to stop in October 2019.

Long-term results of variceal bleeding management in 302 patients with chronic extrahepatic portal vein obstruction

BACKGROUND AND AIM

Treatment modalities of variceal bleeding or rebleeding for extrahepatic portal vein obstruction (EHPVO) are limited, and their long-term results and prognostic factors are unclear. This study aimed at assessing the long-term results of EHPVO treated with current recommendations and investigating the influencing factors.

METHODS

Between 2009 and 2016, 302 consecutive patients with EHPVO were included. Watch-and-wait policy was applied for those with no (n = 59) or small varices (n = 55), nonselective beta-adrenergic blocker and nonselective beta-adrenergic blocker plus endotherapy were for primary (n = 115) and secondary prophylaxis (n = 87), transjugular intrahepatic portosystemic shunt (TIPS) or combination therapy was for those with recurrent bleeding (n = 92).

RESULTS

The median follow up was 58.8 months. The 1-, 3-, and 5-year cumulative rates were 3.6%, 19.2%, 32.3% for small varices development and 4.5%, 30.9%, 53.4% for large varices development. The 1-, 3-, and 5-year cumulative rates were 11.1%, 20.9%, and 34.9% for first variceal bleeding and 16.0%, 26.9%, and 33.6% for variceal rebleeding. For those with recurrent variceal bleeding, only TIPS (n = 37, technical success rate: 90.2%) was associated with a reduced risk of variceal rebleeding (1-, 3-, and 5-year: 5.6%, 11.7%, and 21.9%). The 1-, 3-, and 5-year survival rates were 96.9%, 95.8%, and 91.9%. Prothrombotic factors and anticoagulation did not influence the risk of variceal bleeding, rebleeding, and survival.

CONCLUSIONS

By applying the same variceal management as recommended for patients with liver cirrhosis, patients with non-cirrhotic EHPVO showed a similar development of varices and variceal bleeding. This is also true for the beneficial effect of TIPS to prevent rebleeding.

TIPS for management of portal-hypertension-related complications in patients with cirrhosis

Portal hypertension is primarily due to liver cirrhosis, and is responsible for complications that include variceal bleeding, ascites and hepatorenal syndrome. The transjugular intrahepatic portosystemic shunt (TIPS) is a low-resistance channel between the portal vein and the hepatic vein, created by interventional radiology, that aims to reduce portal pressure. TIPS is a potential treatment for severe portal-hypertension-related complications, including esophageal and gastric variceal bleeding. TIPS is currently indicated as salvage therapy in this setting when patients fail to respond to standard endoscopic and medical treatment. More recently, early TIPS has been shown to be effective in decreasing risk of rebleeding after variceal hemorrhage and mortality in Child-Pugh B patients with active hemorrhage at endoscopy, and in Child-Pugh C patients. TIPS is also an efficient treatment for refractory ascites and hepatic hydrothorax. In contrast, the role of TIPS in the hepatorenal syndrome has not been precisely defined. The aim of this review was to specifically describe the current role of TIPS in management of portal hypertension in patients with cirrhosis.

Clinical Features and Outcomes of Repeated Endoscopic Therapy for Esophagogastric Variceal Hemorrhage in Cirrhotic Patients: Ten-Year Real-World Analysis

Objective

This study is aimed at evaluating the survival of cirrhotic patients with different etiologies after endoscopic therapy for acute variceal bleeding and the effect of repeated endotherapy on patients' prognosis.

Methods

We retrospectively evaluated the clinical features and outcomes between cirrhotic patients with chronic HBV or HCV infections and other etiologies. The 3-year and 5-year survival rates and rehemorrhage rate in one year between the viral and nonviral cirrhosis patients were compared by Kaplan-Meier curves and log-rank test. Cox analysis was used to identify the impact factors that affect the long-term survival of patients with cirrhosis and variceal bleeding after endotherapy.

Results

Out of 2665 patients with liver cirrhosis and variceal hemorrhage selected from our medical center between September 2008 and December 2017, a total of 1342 patients were included for analysis. The median follow-up duration was 32.9 months (range 0.16-111.4 months), the 3- and 5-year cumulative survival rates were 75.3% and 52.8%, respectively. The median survival time was significantly longer in viral cirrhosis patients (47.1 months [95% CI: 24.9-69.1]) compared with nonviral cirrhosis patients (37.0 months [95% CI: 25.0-56.0], p = 0.001). The 3-year and 5-year survival rates of the viral group were higher than the nonviral group. The rehemorrhage rate at one year was higher in nonviral patients than in viral patients (p < 0.001).

Conclusion

Repeated endotherapy combined with effective antiviral therapy is helpful for long-term survival of cirrhotic population with variceal hemorrhage and HBV or HCV infection.

Exploration of interventional therapy strategy for portal vein occlusion: a case series study

OBJECTIVES

To explore the candidates, efficacy and safety of interventional therapies in the treatment of portal vein occlusion (PVO).

METHODS

In our study, 13 patients diagnosed with PVO were included. Of all 13 patients, two received percutaneous portal vein recanalization (PVR), 10 received PVR and transjugular intrahepatic portosystemic shunt (PVR-TIPS), and one underwent intrahepatic portal branch-large collateral vessel shunt.

RESULTS

Interventional approaches were completed in all patients, and the technical success rate was 100%. The portal pressure gradient of patients treated with PVR-TIPS fell from 31 ± 4 to 12 ± 3 mmHg. During the procedures, no life-threatening complications occurred. All the clinical symptoms were effectively controlled after the interventional therapies and all the patients survived during the follow-up, with no rebleeding or overt hepatic encephalopathy. But stent thrombosis occurred in one patient, the cumulative rate of stent patency was 92%.

CONCLUSION

Interventional therapy was proved to be a well tolerated and effective strategy for PVO. For PVO patients without high intrahepatic resistance, if the patient is equipped with available portal inflow tract (superior mesenteric vein or splenic vein) and outflow tract (intrahepatic portal branches), PVR is the first choice; if the outflow tract is completely blocked with only available inflow tract, PVR-TIPS can be considered. For PVO patients with high intrahepatic resistance, as long as there is an available portal inflow tract, PVR-TIPS can be adopted.

Computed tomography-based score model/nomogram for predicting technical and midterm outcomes in transjugular intrahepatic portosystemic shunt treatment for symptomatic portal cavernoma

BACKGROUND

Transjugular intrahepatic portosystemic shunt (TIPS) may be technically difficult in patients with cavernous transformation of the portal vein (CTPV). Computed tomography (CT) is widely used for assessing the situation of the portal vein and its tributaries before TIPS, and an ultrasound-based Yerdel grading system has been developed, which is deemed useful for liver transplantation. Therefore, we hypothesized that a CT-based CTPV scoring system could be useful for predicting technical and midterm outcomes in TIPS treatment for symptomatic portal cavernoma.

AIM

To investigate the clinical significance of a CT-based score model/nomogram for predicting technical success and midterm outcome in TIPS treatment for symptomatic CTPV.

METHODS

Patients with symptomatic CTPV who had undergone TIPS from January 2010 to June 2017 were retrospectively analysed. The CTPV was graded with a score of 1-4 based on contrast-CT imaging findings of the diseased vessel. Outcome measures were technical success rate, stent patency rate, and midterm survival. Cohen's kappa statistic, the Kaplan-Meier and log-rank tests, and uni- and multivariable analyses were performed. A nomogram was constructed and verified by calibration and decision curve analysis.

RESULTS

A total of 76 patients (45 men and 31 women; mean age, 52.3 ± 14.7 years) were enrolled in the study. The inter-reader agreement (κ) of the CTPV score was 0.81. TIPS was successfully placed in 78% of patients (59/76). The independent predictor of technical success was CTPV score (odds ratio [OR] = 5.56, 95% confidence interval [CI]: 3.55-9.67, P = 0.002). The independent predictors of primary TIPS patency were CTPV score and splenectomy (OR = 9.22, 95%CI: 4.78-13.45, P = 0.009; OR = 4.67, 95%CI: 2.59-7.44, P = 0.017). The survival rates differed significantly between the TIPS success and failure groups. The clinical nomogram was made up of patient age, model for end-stage liver disease score, and CTPV score. The calibration curves and decision curve analysis verified the usefulness of the CTPV score-based nomogram for clinical practice.

CONCLUSION

TIPS should be considered a safe and feasible therapy for patients with symptomatic CTPV. Furthermore, the CT-based score model/nomogram might aid interventional radiologists in therapeutic decision-making.

Using transjugular intrahepatic portosystemic shunt as the first-line therapy in secondary prophylaxis of variceal hemorrhage

BACKGROUND AND AIM

This study aims to evaluate and compare the survival and other portal hypertension-related complications of patients with portal pressure gradient (PPG) ≥ 25 mmHg using transjugular intrahepatic portosystemic shunt (TIPS) as the first-line and second-line therapies in secondary prophylaxis of variceal hemorrhage.

METHODS

Fifty patients diagnosed with liver cirrhosis were enrolled in this retrospective study, with 35 of whom received TIPS as the first-line therapy in secondary prophylaxis of variceal hemorrhage and 15 of whom as second-line treatment. We observed and analyzed the survival, occurrence of variceal rebleeding and hepatic encephalopathy (HE) of patients in the two groups during the follow up.

RESULTS

The technical success rate was 100%. In a median follow-up time of 12 (1-37) and 15 (2-27) months, respectively, significant statistical difference was observed between the first-line group and the second-line group concerning cumulative survival rate (94.3% vs 66.7%, log-rank P = 0.01). But that was not the case when it comes to the cumulative rate of variceal rebleeding (8.6% vs 26.7%, log-rank P = 0.164) and HE (22.9% vs 20.0%, log-rank P = 0.793). And multivariate analysis indicated that group assignment (hazard ratio = 8.250, 95% confidence interval = 1.383-49.213, P = 0.021) was the only predictor of survival. Interestingly, we found that spleen diameter (hazard ratio = 0.578, 95% confidence interval = 0.393-0.849, P = 0.005) could be regarded as independent predictor of the occurrence of HE.

CONCLUSIONS

For patients with PPG ≥ 25 mmHg who have recovered from an episode of acute esophageal variceal hemorrhage, utilizing TIPS as the first-line therapy to prevent rebleeding is demonstrated effective in improving the survival and therefore should be recommended to a wider range of clinical practice.

Diabetes mellitus increases the risk of hepatic encephalopathy after a transjugular intrahepatic portosystemic shunt in cirrhotic patients

OBJECTIVE

The aim of this study was to examine the effect of diabetes mellitus (DM) on the rate of hepatic encephalopathy (HE) in patients with decompensated liver cirrhosis after the creation of a transjugular intrahepatic portosystemic shunt (TIPS).

PATIENTS AND METHODS

This study retrospectively reviewed 436 consecutive patients with cirrhosis receiving TIPS in our department from 2008 to 2016. By comparing two groups of patients, with or without DM, the incidence of developing overt HE after TIPS, as well as the correlation between diabetes and HE, was analyzed. Data were analyzed using the χ-tests, unpaired t-tests, logistic regression, and Kaplan-Meier curves. After the initial data processing, we used a regression model to analyze whether or not DM is associated with the development of HE after TIPS.

RESULTS

Of the 436 patients who underwent TIPS, 85 (19.5%) had diabetes at admission and 126 (28.9%) had HE after TIPS. Patients with DM more frequently had HE compared with those without DM (44.7 vs. 25.1%; P = 0.000). The logistic regression analysis showed that DM (P = 0.015) and age (P = 0.002) were independent risk factors for HE after TIPS. Finally, using the Kaplan-Meier curves, we found that diabetes significantly increases the incidence of overt HE (log-rank P = 0.026).

CONCLUSION

Similar to old age, DM may increase the risk of HE in cirrhotic patients after the creation of TIPS.

Transjugular Intrahepatic Portosystemic Shunt Placement in Patients with Schistosomiasis-Induced Liver Fibrosis

Purpose

Evaluate the efficacy and safety of transjugular intrahepatic portosystemic shunt (TIPS) insertion on patients with schistosomiasis-induced liver fibrosis, and compare with that of patients with HBV-induced cirrhosis.

Materials and Methods

This was a retrospective study from November 2015 to December 2018 including 82 patients diagnosed with portal hypertension, one group of which is induced by schistosomiasis (n = 20), the other by hepatitis B virus (HBV) (n = 62). Both groups of subjects underwent TIPS placement for the management of portal hypertension complications.

Results

TIPS was inserted successfully in all patients (technical success 100%). After a median follow-up of 14 months following TIPS insertion, portal pressure gradient (PPG) value in both schistosomiasis-induced group and HBV-induced group underwent a significant decrease with no major difference between the two groups. There exists no significant difference demonstrated by Kaplan–Meier curves between two groups concerning cumulative rate of hepatic encephalopathy (HE) (log-rank p = 0.681), variceal rebleeding (log-rank p = 0.837) and survival (log-rank p = 0.429), and no statistically difference was found in terms of alleviation of portal vein thrombosis (PVT). In addition, splenectomy (HR 19, 95% CI 4–90, p < 0.001) was identified as independent predictor of PVT.

Conclusions

TIPS placement is well-founded to be considered as a safe and effective treatment in patients with schistosomiasis-induced portal hypertension and relevant severe complications. We also found the risk of PVT is 19 times higher in patients who underwent splenectomy than in untreated patients.

Level of Evidence

Historically controlled studies, level 4.

Management of acute variceal hemorrhage

Gastrointestinal bleeding is one of the major causes of death in patients with cirrhosis, and gastroesophageal varices represent the main source of hemorrhage. Even though in the last decades survival has been improved because of the widespread adoption of effective treatments and optimization of general medical care, mortality is still significantly high, and decompensated patients pose a complex challenge requiring a multidisciplinary approach that is crucial to improve survival. The aims of this commentary are to review the most recent advances in the management of esophageal variceal bleeding and to highlight useful information to aid hepatologists in clinical practice.

Early TIPS with covered stents versus standard treatment for acute variceal bleeding in patients with advanced cirrhosis: a randomised controlled trial

BACKGROUND

The survival benefit of early placement of transjugular intrahepatic portosystemic shunts (TIPS) in patients with cirrhosis and acute variceal bleeding is controversial. We aimed to assess whether early TIPS improves survival in patients with advanced cirrhosis and acute variceal bleeding.

METHODS

We did an investigator-initiated, open-label, randomised controlled trial at an academic hospital in China. Consecutive patients with advanced cirrhosis (Child-Pugh class B or C) and acute variceal bleeding who had been treated with vasoactive drugs plus endoscopic therapy were randomly assigned (2:1) to receive either early TIPS (done within 72 h after initial endoscopy [early TIPS group]) or standard treatment (vasoactive drugs continued to day 5, followed by propranolol plus endoscopic band ligation for the prevention of rebleeding, with TIPS as rescue therapy when needed [control group]). Randomisation was done by web-based randomisation system using a Pocock and Simon's minimisation method with Child-Pugh class (B vs C) and presence or absence of active bleeding as adjustment factors. The primary outcome was transplantation-free survival, analysed in the intention-to-treat population, excluding individuals subsequently found to be ineligible for enrolment. This study is registered with ClinicalTrials.gov, number NCT01370161, and is completed.

FINDINGS

From June 26, 2011, to Sept 30, 2017, 373 patients were screened and 132 patients were randomly assigned to the early TIPS group (n=86) or to the control group (n=46). After exclusion of three individuals subsequently found to be ineligible for enrolment (two patients in the early TIPS group with non-cirrhotic portal hypertension or hepatocellular carcinoma, and one patient in the control group due to non-cirrhotic portal hypertension), 84 patients in the early TIPS group and 45 patients in the control group were included in the intention-to-treat population. 15 (18%) patients in the early TIPS group and 15 (33%) in the control group died; two (2%) patients in the early TIPS group and one (2%) in the control group underwent liver transplantation. Transplantation-free survival was higher in the early TIPS group than in the control group (hazard ratio 0·50, 95% CI 0·25-0·98; p=0·04). Transplantation-free survival at 6 weeks was 99% (95% CI 97-100) in the early TIPS group compared with 84% (75-96; absolute risk difference 15% [95% CI 5-48]; p=0·02) and at 1 year was 86% (79-94) in the early TIPS group versus 73% (62-88) in the control group (absolute risk difference 13% [95% CI 2-28]; p=0·046). There were no significant differences between the two groups in the incidence of hepatic hydrothorax (two [2%] of 84 patients in the early TIPS group vs one [2%] of 45 in the control group; p=0·96), spontaneous bacterial peritonitis (one [1%] vs three [7%]; p=0·12), hepatic encephalopathy (29 [35%] vs 16 [36%]; p=1·00), hepatorenal syndrome (four [5%] vs six [13%]; p=0·10), and hepatocellular carcinoma (four [5%] vs one [2%]; p=0·68). There was no significant difference in the number of patients who experienced other serious adverse events (ten [12%] vs 11 [24%]; p=0·07) or non-serious adverse events (21 [25%] vs 19 [42%]; p=0·05) between groups.

INTERPRETATION

Early TIPS with covered stents improved transplantation-free survival in selected patients with advanced cirrhosis and acute variceal bleeding and should therefore be preferred to the current standard of care.

FUNDING

National Natural Science Foundation of China, National Key Technology R&D Program, Optimized Overall Project of Shaanxi Province, Boost Program of Xijing Hospital.

TIPSS for variceal bleeding in patients with idiopathic non-cirrhotic portal hypertension: comparison with patients who have cirrhosis

BACKGROUND

In patients with idiopathic non-cirrhotic portal hypertension (INCPH), the usual recommended strategy for management of variceal bleeding is the same as that in cirrhosis. However, this policy has been challenged by the different natural history between INCPH and cirrhosis.

AIM

To compare outcomes after transjugular intrahepatic portosystemic shunt (TIPSS) between INCPH and cirrhotic patients admitted for variceal bleeding.

METHODS

Between March 2001 and September 2015, 76 consecutive patients with biopsy-proven INCPH undergoing TIPSS for variceal bleeding in a tertiary-care centre were included. 76 patients with cirrhotic portal hypertension receiving TIPSS for variceal bleeding, and matched for age, sex, Child-Pugh class, stent type and index year of TIPSS creation served as controls.

RESULTS

Patients with INCPH, compared to those with cirrhosis, had significantly lower mortality (11% vs 36% at 5 years, adjusted HR, 0.37; 95% CI 0.15-0.87, P = 0.022), overt hepatic encephalopathy (16% vs 33% at 5 years, adjusted HR, 0.35; 95% CI 0.16-0.75, P = 0.007) and hepatic impairment, despite similar rates of further bleeding (33% vs 32% at 5 years, adjusted HR, 0.72; 95% CI 0.36-1.44, P = 0.358), and shunt dysfunction (35% vs 36% at 5 years, adjusted HR, 0.84; 95% CI 0.41-1.72, P = 0.627). These findings were consistent across different relevant subgroups.

CONCLUSIONS

Patients with INCPH treated with TIPSS for variceal bleeding had similar progression of portal hypertension (further bleeding and shunt dysfunction) but fewer complications of liver disease (overt hepatic encephalopathy and hepatic insufficiency) and lower mortality rate compared with cirrhotic patients with comparable liver function.

High-density lipoprotein cholesterol for the prediction of mortality in cirrhosis with portal vein thrombosis: a retrospective study

BACKGROUND

Lipid profiles disorders frequently occur in patients with chronic liver diseases, and the mortality of cirrhosis complicated with portal vein thrombosis (PVT) remains high. Research identifying simple and objective prognosis indicators for cirrhotic PVT has been limited. The aim of the present study was to investigate the association between lipid profiles and liver function, which may help predict the 1-year mortality in non-malignant cirrhosis with PVT.

METHODS

A retrospective cohort of 117 subjects with non-malignant cirrhotic PVT was conducted. The primary indicators of lipid profiles included triglyceride, cholesterol, high-density lipoprotein cholesterol (HDL-C) and low-density lipoprotein cholesterol. Correlations of lipid profiles with liver function tests, the Child-Turcotte-Pugh (CTP) score and the model for end-stage liver disease (MELD) score were investigated. The relationship between lipid profiles and 1-year mortality was assessed using the area under the receiver operating characteristic curves (AUROC). Logistic regression models were established to confirm the association between HDL-C and mortality.

RESULTS

The level of HDL-C was significantly decreased in non-survivors (p < 0.01) and patients with more severe liver damage stages (CTP p < 0.001; MELD p < 0.001). There was no significant difference in the HDL-C level among patients with different severities of PVT (p = 0.498). The level of HDL-C was positively correlated with albumin (p < 0.001, R = 0.438) and platelet (p = 0.022, R = 0.212) levels. The level of HDL-C was negatively correlated with bilirubin (p < 0.001, R = - 0.319), C-reactive protein (p < 0.001, R = - 0.342), the aspartate aminotransferase to alanine aminotransferase ratio (p < 0.0.1, R = - 0.237), the CTP score (p < 0.001, R = - 0.397) and the MELD score (p < 0.001, R = - 0.406). The 1-year mortality rate was 12.8%. The AUROC of HDL-C for the prediction of 1-year mortality in this population was 0.744 (p < 0.01, 95%CI 0.609-0.879). The level of HDL-C was independently associated with mortality by multivariate logistic regression models.

CONCLUSIONS

The HDL-C level significantly decreases with the deterioration of liver function, which may serve as a potential indicator for the prognosis of non-malignant cirrhotic patients with PVT.

Diastolic dysfunction on echocardiography does not predict survival after transjugular intrahepatic portosystemic stent-shunt in patients with cirrhosis

BACKGROUND

Cardiac dysfunction is frequently observed in patients with cirrhosis. There remains a paucity of data from routine clinical practice regarding the role of echocardiography in the pre-assessment of transjugular intrahepatic portosystemic stent-shunt.

AIM

Our study aimed to investigate if echocardiography parameters predict outcomes after transjugular intrahepatic portosystemic stent-shunt insertion in cirrhosis.

METHODS

Patients who underwent echocardiography and transjugular intrahepatic portosystemic stent-shunt insertion at the liver unit (Birmingham, UK) between 1999 and 2016 were included. All echocardiography measures (including left ventricle ejection fraction; early maximal ventricular filling/late filling velocity ratio, diastolic dysfunction as per British Society of Echocardiography guidelines) were independently reviewed by a cardiologist. Predictors of 30-day and overall transplant free-survival were assessed.

RESULTS

One Hundred and Seventeen patients with cirrhosis (median age 56 years; 54% alcohol; Child-Pugh B/C 71/14.5%; Model For End-Stage Liver Disease 12) underwent transjugular intrahepatic portosystemic stent-shunt for ascites (n = 78) and variceal haemorrhage (n = 39). Thirty-day and overall transplant-free survival was 90% (n = 105) and 31% (n = 36), respectively, over a median 663 (IQR 385-2368) days follow-up. Model for End-Stage Liver Disease (P < 0.001) and Child-Pugh Score (P = 0.002) significantly predicted 30-day and overall transplant-free survival. Model for End-Stage Liver Disease ≥15 implied three-fold risk of death. Six per cent (n = 7) of patients pre-transjugular intrahepatic portosystemic stent-shunt had a history of ischaemic heart disease and 34% (n = 40) had 1 or more cardiovascular disease risk factors. Fifty per cent (n = 59) had an abnormal echocardiogram and 33% (n = 39) had grade 1-3 diastolic dysfunction. On univariate analysis none of the echocardiography measures pre-intervention were related to 30-day or overall transplant-free survival post-transjugular intrahepatic portosystemic stent-shunt.

CONCLUSIONS

Ventricular, in particular diastolic dysfunction in patients with cirrhosis does not predict survival after transjugular intrahepatic portosystemic stent-shunt insertion. Model for End-Stage Liver Disease and Child-Pugh scores remain the best predictors of survival. Further prospective study is required to clarify the role of routine echocardiography prior to transjugular intrahepatic portosystemic stent-shunt insertion.

Transjugular intrahepatic portosystemic shunt prevents rebleeding in cirrhotic patients having cavernous transformation of the portal vein without improving their survival

OBJECTIVE

To compare the efficacy of transjugular intrahepatic portosystemic shunts (TIPS) and endoscopic variceal ligations (EVL) plus propranolol in decreasing rebleeding and improving survival rates in cirrhotic patients with cavernous transformation of the portal vein (CTPV).

METHODS

Cirrhotic patients with CTPV and a history of variceal bleeding who were treated for recurrent variceal bleeding between June 2010 and July 2016 were identified and classified based on the treatment they received (TIPS or EVL plus propranolol). Their characteristics and clinical data were recorded. The rebleeding and long-term survival rates between the two groups were analyzed.

RESULTS

A total of 51 patients were included, of whom 25 were treated with TIPS and 26 with EVL plus propranolol. The mean duration of follow up was 21 months (range 1-47 months) in the former group and 27 months (range 6-73 months) in the latter group. The recurrent variceal bleeding-free rate increased remarkably in the TIPS group compared with the EVL + propranolol group (P = 0.047). Three (14.3%) patients died in the TIPS group, and one (3.8%) in the EVL plus propranolol group (P = 0.305). Hepatic encephalopathy occurred in 14.3% (3/21) of the patients in the TIPS group and in 3.8% (1/26) in the EVL + propranolol group (P = 0.202).

CONCLUSION

TIPS appeared to be more effective in preventing rebleeding in cirrhotic patients with CTPV compared with EVL plus propranolol, without improving survival.

Anticoagulation and Transjugular Intrahepatic Portosystemic Shunting for Treatment of Portal Vein Thrombosis in Cirrhosis: A Systematic Review and Meta-Analysis

Portal vein thromboses (PVTs) are associated with hepatic decompensation, worse survival, and worse liver transplant outcomes. We evaluated the impact of anticoagulation (AC) and transjugular intrahepatic portosystemic shunting (TIPS) on recanalization and mortality in patients with cirrhosis and PVT. Systematic search of electronic databases was performed. Clinical trials and observational studies that evaluated primary outcomes of recanalization and survival in patients with cirrhosis having PVT treated with AC or TIPS were included. Risk of bias was assessed. Summary odds ratios (ORs) for pooled data from the included studies were generated using a random effects model. A total of 505 studies were screened for inclusion. After review, 7 studies were ultimately included. Data from 327 patients in total were evaluated. Overall, treatment with either AC or TIPS resulted in partial or complete recanalization (OR: 4.56 [95% confidence interval, CI: 2.46-8.47]) but did not significantly impact mortality (OR: 0.57 [95% CI: 0.21-1.57]). The summary OR of AC for recanalization was 6.00 (95% CI: 2.38-15.07). The summary OR of TIPS for recanalization was 3.80 (95% CI: 1.47-9.83). The summary OR of mortality in patients treated with AC for PVT was 0.28 (95% CI: 0.08-0.95). The mortality summary OR was 1.10 (95% CI 0.23-5.16) in patients who underwent TIPS. There was insufficient data to assess complications such as hepatic encephalopathy or bleeding. Both AC and TIPS have a significant effect on recanalization. Anticoagulation appears to have a protective effect on mortality that is not seen with TIPS. More studies with control groups are need.

A prediction model for successful anticoagulation in cirrhotic portal vein thrombosis

BACKGROUND AND OBJECTIVE

Portal vein thrombosis (PVT) is a common complication in cirrhosis, and when complete, it increases morbidity and mortality in liver transplant candidates. The aim of the study was to assess the hemostatic status, as well as clinical characteristics of thrombus and patients, as predictors of therapeutic efficacy of anticoagulation for the treatment of PVT in cirrhotics.

PATIENTS AND METHODS

Patients with cirrhosis consecutively treated for PVT with enoxaparin were enrolled. All patients underwent evaluation of coagulation status and thrombophilia screening. Thrombus characteristics and extension were evaluated at baseline and during follow-up. Anticoagulation was continued until recanalization or up to 12 months. Variables correlated with the response to anticoagulation were used to create a predictive score that was validated in an external multicenter cohort.

RESULTS

A total of 65 patients were included and had partial PVT in most cases (72%). Treatment with enoxaparin resulted in an overall response rate of 66% (43/65) after a median time of 4.4 months and 76% (33/43) within the first 6 months. At multivariate analysis, efficacy of anticoagulation correlated with the severity of liver disease, complete verus partial PVT, age of the thrombus, and time interval from treatment start (<6 months). The areas under the curve of the statistical model for predicting the response to anticoagulation were 0.84 and 0.76 for the training (n=65) and validation (n=60) cohorts, respectively.

CONCLUSION

Early diagnosis and early treatment are key factors for the successful management of PVT in cirrhosis, so that screening of PVT and prompt start of anticoagulant treatment should be mandatory.

Comparison of transjugular intrahepatic portosystemic shunt (TIPS) alone and combined with embolisation for the management of cardiofundal varices: a retrospective study

OBJECTIVES

To assess the efficacy of transjugular intrahepatic portosystemic shunt (TIPS) with and without adjunctive embolisation in managing cardiofundal varices bleeding.

METHODS

The retrospective study comprised 82 patients (54 men; mean age 53.9 years; mean Model of End-stage Liver Disease score 9.3) with cardiofundal varices bleeding who underwent TIPS creation from 2011 to 2015. Variceal rebleeding, the outflow tracts of varices, overt hepatic encephalopathy (HE) and post-procedure varices patency were assessed.

RESULTS

Gastrorenal shunt was present in 92.7% of patients (n = 76). Embolisation was performed in 67.1% of patients (n = 55). The 1- and 2-year variceal rebleeding rates in the TIPS combined with embolisation group were significantly lower than those in the TIPS alone group (3.8% and 13.4% vs 13.0% and 28.0%, respectively; p = 0.041). No significant differences between the two groups were found in the cardiofundal varices patency, overt HE or survival (p > 0.05).

CONCLUSIONS

The results suggest that TIPS combined with embolisation can reduce the risk of variceal rebleeding for patients with cardiofundal varices.

KEY POINTS

• TIPS combined with embolisation reduces the risk of rebleeding in treating cardiofundal varices. • TIPS combined with embolisation could not completely occlude cardiofundal varices. • TIPS combined with embolisation could not prevent the development of hepatic encephalopathy.

Role of band ligation for secondary prophylaxis of variceal bleeding

AIM

To summarize and critically examine the role of band ligation in secondary prophylaxis of variceal bleeding in patients with cirrhosis.

METHODS

A literature review was performed using the MEDLINE and PubMed databases. The search terms consisted of the words “endoscopic band ligation” OR “variceal band ligation” OR “ligation” AND “secondary prophylaxis” OR “secondary prevention” AND “variceal bleeding” OR “variceal hemorrhage” AND “liver cirrhosis”. The data collected from relevant meta-analyses and from the most recent randomized studies that were not included in these meta-analyses were used to evaluate the role of endoscopic band ligation in an effort to demonstrate the most recent advances in the treatment of esophageal varices.

RESULTS

This study included 11 meta-analyses published from 2002 to 2017 and 10 randomized trials published from 2010 to 2017 that evaluated the efficacy of band ligation in the secondary prophylaxis of variceal bleeding. Overall, the results proved that band ligation was superior to endoscopic sclerotherapy. Moreover, the use of β-blockers in combination with band ligation increased the treatment effectiveness, supporting the current recommendations for secondary prophylaxis of variceal bleeding. The use of transjugular intrahepatic portosystemic shunt was superior to combination therapy regarding rebleeding prophylaxis, with no difference in the survival rates; however, the results concerning the hepatic encephalopathy incidence were conflicting. Recent advances in the management of secondary prophylaxis of variceal bleeding have targeted a decrease in portal pressure based on the pathophysiological mechanisms of portal hypertension.

CONCLUSION

This review suggests that future research should be conducted to enhance current interventions and/or to develop innovative treatment options with improved clinical endpoints.