Transjugular intrahepatic portosystemic shunt in Vienna – A decade later

25 years of experience with transjugular intrahepatic portosystemic shunt (TIPS): changes in patient selection and procedural aspects

Background

TIPS is an established treatment for portal hypertension. The aim was to analyze how patient selection for TIPS implantation and procedural aspects have changed over 25 years. Routinely collected demographic, clinical, laboratory, and procedural data of 835 patients treated with TIPS in a single center were used. Time trends over the observational period from 1993 to 2018 were retrospectively analyzed. Descriptive statistical analysis was performed.

Results

The most common indication for TIPS implantation has changed significantly from secondary prevention of variceal hemorrhage in the early years to treatment of recurrent ascites. During the observation period, increasingly more severely ill patients became TIPS candidates. There was little change in MELD scores over this period (in total median 13.00; IQR 10.00–18.00). The proportion of patients with Child–Pugh C cirrhosis increased. The most frequent underlying diseases in total were alcohol-related liver disease (66.5%) and viral hepatitis (11.9%). However, shares of cryptogenic liver cirrhosis, autoimmune hepatitis, and NASH increased over time. The proportion of patients post liver transplant also increased. While bare metal stents were standard in the past, use of covered stents increased. The success rate of TIPS (defined by successful implantation and a decrease in the portosystemic pressure gradient ≤ 12 mmHg) increased significantly over time. The total success rate according to this definition was 84.9%.

Conclusion

The results of our analysis reflect technical developments in TIPS, especially in terms of stent material and gains in clinical experience, particularly regarding indications and patient selection for TIPS implantation.

ePTFE-TIPS vs repetitive LVP plus albumin for the treatment of refractory ascites in patients with cirrhosis

BACKGROUND & AIMS

Reduction in portal pressure by self-expandable polytetrafluoroethylene (ePTFE)-covered transjugular intrahepatic portosystemic shunts (TIPS) is a treatment option for refractory ascites. Data on clinical outcomes after ePTFE-TIPS vs repetitive large-volume paracentesis (LVP) plus albumin (A) administration for the treatment of patients with refractory ascites are limited.

METHODS

Retrospective comparison of ePTFE-TIPS vs LVP+A in terms of (i) control of ascites, (ii) occurrence of overt hepatic encephalopathy (HE) and (iii) transplant-free survival in cirrhotic patients with refractory ascites.

RESULTS

Among n = 221 patients with cirrhosis and refractory ascites, n = 140 received ePTFE-TIPS and were compared to n = 71 patients undergoing repetitive LVP+A. After ePTFE-TIPS, ascites was controlled without any further need for paracentesis in n = 76 (54%; n = 7 without and n = 69 with diuretics). The need for frequent large-volume paracentesis was significantly higher in the LVP+A group than with ePTFE-TIPS (median 0.67 (IQR: 0.23-2.63) months vs 49.5 (IQR: 5.07-102.60) months until paracentesis, log-rank P < .001). De-novo incidence of HE was similar in ePTFE-TIPS and LVP+A patients (log-rank P = .361). Implantation of ePTFE-TIPS was associated with improved 1-year survival as compared to LVP+A (65.6% vs 48.4%, log-rank P = .033). Age (odds ratio (OR):1.05; 95% confidence interval (95% CI):1.03-1.07; P < .001), serum albumin (OR: 0.95; 95% CI: 0.92-0.99; P = .013) and hepatocellular carcinoma (OR: 1.66; 95% CI: 1.06-2.58; P = .026) emerged as independent predictors of survival.

CONCLUSIONS

ePTFE-TIPS results in superior control of ascites without increasing the risk for overt HE as compared to LVP+A. Although ePTFE-TIPS improved 1-year survival in cirrhotic patients with refractory ascites, its use was not independently associated with transplant-free survival.

Nebivolol treatment increases splanchnic blood flow and portal pressure in cirrhotic rats via modulation of nitric oxide signalling

BACKGROUND

We evaluated the effects of nebivolol, a third generation beta-blocker capable of increasing NO-bioavailability on portal pressure, and on splachnic and systemic haemodynamics in a cirrhotic portal hypertensive rat model.

METHODS

Male Sprague-Dawley rats underwent sham operation (SO) or bile duct ligation (BDL). When cirrhosis was fully developed, the animals were orally treated with low-dose (5 mg/kg) or high-dose (10 mg/kg) nebivolol (NEBI) or vehicle (VEH) for 7 days. Heart rate (HR), mean arterial pressure (MAP), portal pressure (PP) and superior mesenteric artery blood flow (SMABF) were measured. Portosystemic collateral blood flow (PSCBF) was quantified using radioactive microspheres. Hepatic and splanchnic NOx levels and GSH/GSSG ratios (RedOx state) were determined using commercially available kits.

RESULTS

BDL-VEH rats showed increased HR, PP and PSCBF, whereas MAP was decreased compared to SO-VEH rats. Nebivolol significantly reduced HR both in SO (P < 0.001) and BDL (P < 0.001) rats. BDL-NEBI animals had significantly higher PP (15.5 vs. 12.6 mmHg; P = 0.006) and SMABF (5.3 vs. 3.7 ml/min/100g; P = 0.016) than BDL-VEH animals. The increase in PP and SMABF was noted both in low-dose and high-dose BDL-NEBI rats. While no beneficial effects on hepatic RedOx state were observed, splanchnic NOx levels were significantly increased by NEBI treatment in a dose-dependent manner. Nebivolol treatment did not affect PSCBF in SO and BDL animals.

CONCLUSION

Nebivolol increases portal pressure in cirrhotic animals by increasing splanchnic blood flow via modulation of NO signalling. Portosystemic collateral blood flow remained unchanged. These data do not support the use of nebivolol for treatment of cirrhotic patients with portal hypertension.

Aetiology of cirrhosis of the liver has an impact on survival predicted by the Model of End-stage Liver Disease score

BACKGROUND

Originally, aetiology of liver disease has been incorporated into the computation of the Model of End-stage Liver Disease (MELD) score. Clinical observations prompted us to hypothesize that patients with viral and alcoholic cirrhosis may differ in predicted survival rates. Until now, no large representative studies evaluated the impact of aetiology on long-term survival predicted by the Child-Pugh and MELD scores.

MATERIALS AND METHODS

Four hundred and ninety-three patients who underwent transjugular intrahepatic portosystemic shunt implantation in Vienna, Austria, and Palermo, Italy, were included in this retrospective study. The main analyses were a logistic regression model and a Cox proportional hazards regression model calculating the interaction of the aetiology with the scores.

RESULTS

Both groups had similar survival rates (median 1377 and 1721 days for viral and alcoholic cirrhosis, respectively; P = 0.58), but patients with viral cirrhosis had significantly lower MELD scores (P = 0.002). In the Cox analysis, aetiology had a significant impact on the prediction of overall survival by MELD score. For 3-month survival, MELD score was adequately predictive for both groups. For 1-year survival, aetiology had a significant impact on survival, indicating that patients with identical scores but different aetiologies differed in survival rates. When stratifying patients into high- and low-risk patients (MELD < 16 vs. MELD >or= 16), aetiology of cirrhosis had no impact on the predictive value for low-risk patients; high-risk-patients (MELD >or= 16) with viral cirrhosis had significantly lower survival rates than patients with alcoholic cirrhosis and identical scores. With regard to Child-Pugh Score, no significant differences between the two patient groups and in the prediction of 3-month and 1-year survival could be observed.

CONCLUSIONS

Our study suggests that aetiology of cirrhosis has an impact on 1-year survival predicted by the MELD score. This becomes more apparent in patients with advanced stage of liver disease (MELD >or= 16). Since MELD score is used for ranking patients for liver transplantation and waiting times are regularly longer than 3 months, our observations suggest that with increasing time on the waiting list and severity of disease, patients with viral cirrhosis may have a disadvantage in the current allocation policy.