1
|
Cheng S, Hu G, Jin Z, Wang Z, Xue H. Prediction of Hepatic Encephalopathy After Transjugular Intrahepatic Portosystemic Shunt Based on CT Radiomic Features of Visceral Adipose Tissue. Acad Radiol 2024; 31:1849-1861. [PMID: 38007366 DOI: 10.1016/j.acra.2023.10.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2023] [Revised: 09/22/2023] [Accepted: 10/05/2023] [Indexed: 11/27/2023]
Abstract
RATIONALE AND OBJECTIVES To evaluate the performance and clinical utility of CT radiomic features of visceral adipose tissue (VAT) in the prediction of hepatic encephalopathy (HE) after transjugular intrahepatic portosystemic shunt (TIPS). MATERIALS AND METHODS This multi-center study was retrospectively designed. Patients with cirrhosis who underwent TIPS were recruited from January 2015 to December 2020. Pre-TIPS contrast-enhanced CT images were collected for VAT segmentation and radiomic feature extraction. Least absolute shrinkage and selection operator regression with ten-fold cross-validation was performed to reduce dimension. Logistic regression with regularization, support vector machine, and random forest were used for model construction. RESULTS A total of 130 patients (90 men; mean age, 54 ± 11 years) were finally enrolled. The cohort was split into 85 patients for the training set (58 men; mean age, 53 ± 12 years) with 19 HE, 21 patients for the internal test set (17 men; mean age, 53 ± 11 years) with 5 HE, and 24 patients for the external test set (15 men; mean age, 55 ± 11 years). Ten radiomic features and C-reactive protein constituted radiomic-clinical models with the best performance. The average area under the receiver operating characteristic curve is 0.97 in the training set and 0.84 in the test sets. For a fixed sensitivity of 0.90, the specificity and negative predictive value of the model is 0.63 and 1.00, respectively; while for a fixed specificity of 0.90, the sensitivity and positive predictive value is 0.60 and 0.75, respectively. CONCLUSION Machine learning models based on CT radiomic features extracted from VAT can predict post-TIPS HE with satisfactory performance. CLINICAL RELEVANCE STATEMENT Our machine learning models based on CT radiomic features of visceral adipose tissue in patients with cirrhosis may assist in predicting hepatic encephalopathy after transjugular intrahepatic portosystemic shunt, indicating its potential in patient selection and clinical decision-making. KEY POINTS Radiomics of visceral adipose tissue provide great help in predicting hepatic encephalopathy after transjugular intrahepatic portosystemic shunt. The clinical-radiomic models showed satisfactory performance with an average area under the receiver operating characteristic curve of 0.84. The model can hypothetically provide 90% sensitivity and 100% negative predictive value for guiding patients who are considering transjugular intrahepatic portosystemic shunt.
Collapse
Affiliation(s)
- Sihang Cheng
- Department of Radiology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing 100730, China
| | - Ge Hu
- Medical research Center, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing 100730, China
| | - Zhengyu Jin
- Department of Radiology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing 100730, China
| | - Zhiwei Wang
- Department of Radiology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing 100730, China
| | - Huadan Xue
- Department of Radiology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing 100730, China.
| |
Collapse
|
2
|
Kang RD, Nezami N, Park P, DePalma AA, Loya MF, Mhaskar R, Engel C, Zwiebel B, Hoots G, Shaikh J. Safety and feasibility of a novel bi-directional portal vein access kit during transjugular intrahepatic portosystemic shunt creation. CVIR Endovasc 2023; 6:24. [PMID: 37074479 PMCID: PMC10115920 DOI: 10.1186/s42155-023-00366-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2022] [Accepted: 03/14/2023] [Indexed: 04/20/2023] Open
Abstract
BACKGROUND Transjugular intrahepatic portosystemic shunt (TIPS) creation remains as one of the more technically challenging endovascular procedures. Portal vein access from the hepatic vein often requires multiple needle passes, which increases procedure times, risk of complications, and radiation exposure. With its bi-directional maneuverability, the Scorpion X access kit may be a promising tool for easier portal vein access. However, the clinical safety and feasibility of this access kit has yet to be determined. MATERIALS AND METHODS In this retrospective study, 17 patients (12 male, average age 56.6 ± 9.01) underwent TIPS procedure using Scorpion X portal vein access kits. The primary endpoint was time taken to access the portal vein from the hepatic vein. The most common indications for TIPS were refractory ascites (47.1%) and esophageal varices (17.6%). Radiation exposure, total number of needle passes, and intraoperative complications were recorded. Average MELD Score was 12.6 ± 3.39 (range: 8-20). RESULTS Portal vein cannulation was successfully achieved in 100% of patients during intracardiac echocardiography-assisted TIPS creation. Total fluoroscopy time was 39.31 ± 17.97 min; average radiation dose was 1036.76 ± 644.15 mGy, while average contrast dose was 120.59 ± 56.87 mL. The average number of passes from the hepatic vein to the portal vein was 2 (range: 1-6). Average time to access the portal vein once the TIPS cannula was positioned in the hepatic vein was 30.65 ± 18.64 min. There were no intraoperative complications. CONCLUSIONS Clinical utilization of the Scorpion X bi-directional portal vein access kit is both safe and feasible. Utilizing this bi-directional access kit resulted in successful portal vein access with minimal intraoperative complications. LEVEL OF EVIDENCE Retrospective cohort.
Collapse
Affiliation(s)
- Richard D Kang
- University of South Florida, Morsani College of Medicine, Tampa, FL, USA
| | - Nariman Nezami
- Division of Vascular and Interventional Radiology, Department of Diagnostic Radiology and Nuclear Medicine, University of Maryland School of Medicine, Baltimore, MD, USA
- Experimental Therapeutics Program, University of Maryland Marlene and Stewart Greenebaum Comprehensive Cancer Center, Baltimore, MD, USA
| | - Peter Park
- Emory University, School of Medicine, Department of Radiology and Image Guided Medicine, Atlanta, GA, USA
| | - Anthony A DePalma
- Emory University, School of Medicine, Department of Radiology and Image Guided Medicine, Atlanta, GA, USA
| | - Mohammed F Loya
- Mid-Atlantic Permanente Medical Group, Kaiser Permanente, Rockville, MD, USA
| | - Rahul Mhaskar
- University of South Florida, Morsani College of Medicine, Tampa, FL, USA
| | - Chad Engel
- University of South Florida, Morsani College of Medicine, Tampa, FL, USA
- Department of Radiology, University of South Florida Health, Tampa General Hospital, Tampa, FL, USA
| | - Bruce Zwiebel
- University of South Florida, Morsani College of Medicine, Tampa, FL, USA
- Department of Radiology, University of South Florida Health, Tampa General Hospital, Tampa, FL, USA
| | - Glenn Hoots
- University of South Florida, Morsani College of Medicine, Tampa, FL, USA
- Department of Radiology, University of South Florida Health, Tampa General Hospital, Tampa, FL, USA
| | - Jamil Shaikh
- University of South Florida, Morsani College of Medicine, Tampa, FL, USA.
- Department of Radiology, University of South Florida Health, Tampa General Hospital, Tampa, FL, USA.
| |
Collapse
|
3
|
Li L, Mkangala A, Geng Z, Fan W, Ren Y, Wang Z, Zheng C, Xiao S. Morphine prophylaxis alleviates pain in transjugular intrahepatic portosystemic shunt procedure: A randomized clinical trial. Technol Health Care 2023:THC220572. [PMID: 36872805 DOI: 10.3233/thc-220572] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/06/2023]
Abstract
BACKGROUND Transjugular intrahepatic portosystemic shunt (TIPS) is an accepted minimal invasive procedure for the management of complications of portal hypertension. OBJECTIVE This study aims to investigate the value of the preemptive administration of morphine, when compared with on-demand morphine, during TIPS. METHODS The present study was a randomized control trial. A total of 49 patients were selected to receive 10 mg of morphine either before the TIPS procedure (group B, n= 26), or on demand when needed during the TIPS procedure (group A, n= 23). The patient's pain was scored using the visual analog scale (VAS) during the procedure. VAS, pain performance, HR, systolic pressure, diastolic pressure and SPO2 were recorded at four-time points: before the operation (T0), during the trans-hepatic puncture of the portal vein (T1), during the intrahepatic channel expansion (T2), and when the operation was finished (T3). The duration of the operation was also recorded. RESULTS In group A, the proportion of severe pain at T1 was 4.3% (one case), two cases were combined with vagus reflex, and the proportion of severe pain at T2 was 65.2% (15 cases). No severe pain occurred in group B. The VAS score significantly decreased at T1, T2 and T3 in group B, when compared to group A (P< 0.05). HR, systolic pressure and diastolic pressure significantly decreased at T2 and T3 in group B, when compared to group A (P< 0.05). There was no significant difference between the two groups in terms of SPO2 (P> 0.05). CONCLUSION Preemptive analgesia can effectively relieve severe pain during TIPS, improve patient comfort and compliance, ensure a routine procedure, and offer excellent safety, and is simple and effective.
Collapse
Affiliation(s)
- Ling Li
- Department of Radiology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, China.,Hubei Province Key Laboratory of Molecular Imaging, Wuhan, Hubei, China
| | - Abdala Mkangala
- Department of Radiology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, China.,Hubei Province Key Laboratory of Molecular Imaging, Wuhan, Hubei, China
| | - Zhiqi Geng
- Department of Radiology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, China.,Hubei Province Key Laboratory of Molecular Imaging, Wuhan, Hubei, China
| | - Wenliang Fan
- Department of Radiology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, China.,Hubei Province Key Laboratory of Molecular Imaging, Wuhan, Hubei, China
| | - Yanqiao Ren
- Department of Radiology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, China.,Hubei Province Key Laboratory of Molecular Imaging, Wuhan, Hubei, China
| | - Zhongmin Wang
- Department of Radiology, Rui Jin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Chuansheng Zheng
- Department of Radiology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, China.,Hubei Province Key Laboratory of Molecular Imaging, Wuhan, Hubei, China
| | - Shuping Xiao
- Department of Radiology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, China.,Hubei Province Key Laboratory of Molecular Imaging, Wuhan, Hubei, China
| |
Collapse
|
4
|
Madhusudhan KS, Sharma S, Srivastava DN. Percutaneous radiological interventions of the portal vein: a comprehensive review. Acta Radiol 2023; 64:441-455. [PMID: 35187977 DOI: 10.1177/02841851221080554] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
The portal vein is the largest vessel supplying the liver. A number of radiological interventions are performed through the portal vein, namely for primary pathologies of the portal vein, for inducing liver hypertrophy or to treat the sequelae of portal hypertension among others. The routes used include direct transhepatic, transjugular, and, uncommonly, trans-splenic and through subcutaneous varices. Portal vein embolization and transjugular intrahepatic portosystemic shunt are among the most common portal vein interventions that are performed to induce hypertrophy of the future liver remnant and to treat complications of portal hypertension, respectively. Other interventions include transhepatic obliteration of varices and shunts, portal vein thrombolysis, portal vein recanalization, pancreatic islet cell transplantation, and embolization of portal vein injuries. We present a detailed illustrative review of the various radiological portal vein interventions.
Collapse
Affiliation(s)
- Kumble Seetharama Madhusudhan
- Department of Radiodiagnosis and Interventional Radiology, 28730All India Institute of Medical Sciences, New Delhi, India
| | - Sanjay Sharma
- Department of Radiodiagnosis and Interventional Radiology, 28730All India Institute of Medical Sciences, New Delhi, India
| | - Deep Narayan Srivastava
- Department of Radiodiagnosis and Interventional Radiology, 28730All India Institute of Medical Sciences, New Delhi, India
| |
Collapse
|
5
|
Elective Transjugular Intrahepatic Portosystemic Shunt Using Viatorr Stent-Grafts: A Single-Center Experience from China. J Belg Soc Radiol 2022; 106:62. [PMID: 35854822 PMCID: PMC9248993 DOI: 10.5334/jbsr.2741] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/26/2021] [Accepted: 06/16/2022] [Indexed: 12/03/2022] Open
Abstract
Background and Aims: Transjugular intrahepatic portosystemic shunt (TIPS) is a well-established approach for the management of variceal bleeding, refractory ascites, hepatic hydrothorax, and preoperative treatment of portal hypertension prior to major abdominal surgery in patients with compensated cirrhosis, and so on. This study aimed to investigate the safety and long-term efficacy of TIPS implantation using Viatorr TIPS stent-grafts. Material and Methods: A cohort of 59 patients undergoing TIPS placement using Viatorr TIPS stent-grafts were included, and the periprocedural events, and long-term mortality, shunt dysfunction, variceal rebleeding and incidence of hepatic encephalopathy (HE) were analyzed. Results: The technical success rate was 100%. The median portosystemic pressure gradient was reduced from 21 mmHg (interquatile range: 19–25) to 13 mmHg (interquatile range: 10–16) before and after TIPS, leading to a hemodynamic success rate of 72.9%. The cumulative rate of overall mortality was 34.2% at five years, and direct bilirubin (hazard ratio [HR] = 1.336, 95% confidence interval [CI]: 1.050–1.700, P = 0.018) and post-TIPS right atrial pressure (HR = 1.238, 95% CI: 1.015–1.510, P = 0.035) were independent predictors for mortality. The cumulative rates of shunt dysfunction and variceal rebleeding were 11.0% and 28.3% at five years, respectively, and portal venous pressure gradient (HR = 2.572, 95% CI: 1.094–6.047, P = 0.030) was the only independent predictor for shunt dysfunction. The cumulative four-year HE-free rate was 48.6%. No severe adverse event was noted during TIPS procedures. Conclusion: Elective TIPS implantation using Viatorr TIPS stent-grafts is generally safe, and the long-term efficacy is favorable for the treatment of cirrhotic patients with recurrent variceal bleeding or refractory ascites.
Collapse
|
6
|
Artru F, Moschouri E, Denys A. Direct intrahepatic portocaval shunt (DIPS) or transjugular transcaval intrahepatic portosystemic shunt (TTIPS) to treat complications of portal hypertension: Indications, technique, and outcomes beyond Budd-Chiari syndrome. Clin Res Hepatol Gastroenterol 2022; 46:101858. [PMID: 34999250 DOI: 10.1016/j.clinre.2022.101858] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/21/2021] [Revised: 12/27/2021] [Accepted: 01/03/2022] [Indexed: 02/04/2023]
Abstract
Transjugular intrahepatic portosystemic shunt (TIPS) is nowadays the benchmark treatment of severe portal hypertension complications. However, besides usual contraindication to the procedure (namely recurrent hepatic encephalopathy, severe liver dysfunction, right heart failure and/or pulmonary hypertension), TIPS appears regularly unfeasible due to abnormal and/or distorted anatomy. In this situation, the only non-surgical approaches to treat severe portal hypertension consist in the creation of an intrahepatic portocaval shunt from percutaneous (direct intrahepatic portocaval shunt - DIPS) or transjugular route (transjugular transcaval intrahepatic portosystemic shunt - TTIPS). These procedures have been rapidly adopted in patients with Budd-Chiari syndrome but are only poorly reported in patients with cirrhosis and without BCS. Considering the broadening landscape of TIPS indication in patients with cirrhosis within the last ten years, we aimed to describe the techniques, safety and efficacy of DIPS and TTIPS procedures as an alternative to TIPS in case of unfavourable anatomy.
Collapse
Affiliation(s)
- Florent Artru
- Service de gastroentérologie et d'hépatologie du Centre Hospitalier Universitaire Vaudois (CHUV), Lausanne, Vaud, Switzerland; Institute of Liver Studies, King's College Hospital, London, United Kingdom
| | - Eleni Moschouri
- Service de gastroentérologie et d'hépatologie du Centre Hospitalier Universitaire Vaudois (CHUV), Lausanne, Vaud, Switzerland
| | - Alban Denys
- Service radiodiagnostic et de radiologie interventionnelle du Centre Hospitalier Universitaire Vaudois (CHUV), Lausanne, Vaud, Switzerland.
| |
Collapse
|
7
|
Manning C, Elzubeir A, Alam S. The role of pre-emptive Transjugular Intrahepatic Portosystemic Shunt in acute variceal bleeding: a literature review. Ther Adv Chronic Dis 2021; 12:2040622321995771. [PMID: 33747427 PMCID: PMC7940777 DOI: 10.1177/2040622321995771] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2020] [Accepted: 01/19/2021] [Indexed: 12/14/2022] Open
Abstract
The development of portal hypertension has serious implications in the natural history of liver cirrhosis, leading to complications such as ascites, hepatic encephalopathy and variceal bleeding. The management of acute variceal bleeding has improved in the last two decades, but despite the advances in endoscopic methods the overall prognosis remains poor, particularly within a subgroup of patients with more advanced disease. The role of Transjugular Intrahepatic Portosystemic Shunt (TIPSS) is a well-established method of achieving haemostasis by immediate portal decompression; however, its use in an emergency setting as a rescue strategy is still associated with high mortality. It has been shown that ‘early’ use of TIPSS as a pre-emptive strategy in a patient with acute variceal bleed in addition to the standard of care confers superior survival outcomes in a subgroup of patients at high risk of treatment failure and death. The purpose of this review is to appraise the literature around the indications, patient selection, utility, complications and economic considerations of pre-emptive TIPSS.
Collapse
Affiliation(s)
- Charelle Manning
- Department of Gastroenterology and Hepatology, Norfolk and Norwich University Hospital, Norwich, UK
| | - Amera Elzubeir
- Department of Gastroenterology and Hepatology, Norfolk and Norwich University Hospital, Norwich, UK
| | - Syed Alam
- Norfolk and Norwich University Hospital, Norwich, NR4 7UB, UK
| |
Collapse
|
8
|
Horhat A, Bureau C, Thabut D, Rudler M. Transjugular intrahepatic portosystemic shunt in patients with cirrhosis: Indications and posttransjugular intrahepatic portosystemic shunt complications in 2020. United European Gastroenterol J 2021; 9:203-208. [PMID: 32819214 PMCID: PMC8259430 DOI: 10.1177/2050640620952637] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/07/2019] [Accepted: 07/27/2020] [Indexed: 02/06/2023] Open
Abstract
Transjugular intrahepatic portosystemic shunt is a percutaneous radiologic-guided procedure that aims to reduce portal hypertension by creating a shunt between the portal venous system and the hepatic venous system. The most common cause of portal hypertension is liver cirrhosis in Western countries. Two main indications of transjugular intrahepatic portosystemic shunt are validated by randomised controlled studies in patients with cirrhosis and variceal bleeding (salvage transjugular intrahepatic portosystemic shunt, early transjugular intrahepatic portosystemic shunt or rebleeding despite an optimal secondary prophylaxis) or refractory ascites. Careful selection of the patients is crucial in order to prevent posttransjugular intrahepatic portosystemic shunt complications, including liver failure, posttransjugular intrahepatic portosystemic shunt encephalopathy occurrence and cardiac decompensation, for a better long-term outcome. In this review, we will discuss transjugular intrahepatic portosystemic shunt indications in 2020 in patients with cirrhosis and portal hypertension, with a special focus on variceal bleeding and refractory ascites. Then, we will describe transjugular intrahepatic portosystemic shunt-related complications, the contraindications and the current knowledge on patient's selection.
Collapse
Affiliation(s)
- Adelina Horhat
- Hepato-Gastroenterology Regional Institute, Cluj-Napoca, Romania
| | - Christophe Bureau
- Hepatology Department, Toulouse University Hospital, Toulouse, France
| | - Dominique Thabut
- Hepatology Intensive Care Unit, Pitie-Salpêtrière Hospital, Paris, France.,Hepatogastroenterology Intensive Care Unit, Hepatogastroenterology Department, APHP Sorbonne University, Paris, France
| | - Marika Rudler
- Hepatology Intensive Care Unit, Pitie-Salpêtrière Hospital, Paris, France
| |
Collapse
|
9
|
Bosch J. Small diameter shunts should lead to safe expansion of the use of TIPS. J Hepatol 2021; 74:230-234. [PMID: 32987029 DOI: 10.1016/j.jhep.2020.09.018] [Citation(s) in RCA: 29] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/02/2020] [Revised: 09/02/2020] [Accepted: 09/11/2020] [Indexed: 12/15/2022]
Abstract
Transjugular intrahepatic portosystemic shunt (TIPS) is increasingly used worldwide to treat the complications of portal hypertension in patients with advanced cirrhosis. However, its use is hampered by the risk of causing hepatic encephalopathy and of worsening liver function. The reported haemodynamic targets used to guide TIPS are too narrow to be achieved in most cases and are perhaps not entirely adequate nowadays as they were obtained in the pre-covered stent era. We propose that small diameter TIPS - alone or combined to pharmacological therapy or ancillary interventional radiology procedures - may overcome these limitations while maintaining the beneficial effects of the procedure.
Collapse
Affiliation(s)
- Jaume Bosch
- Department of Biomedical Research, Bern University; Hepatology, University Clinic for Visceral Medicine and Surgery, Inselspital, Bern (CH); University of Barcelona, IDIBAPS and CIBERehd, Barcelona (Spain).
| |
Collapse
|
10
|
Tejedor-Tejada J, Fuentes-Valenzuela E, García-Pajares F, Nájera-Muñoz R, Almohalla-Álvarez C, Sánchez-Martín F, Calero-Aguilar H, Villacastín-Ruiz E, Pintado-Garrido R, Sánchez-Antolín G. Long-term clinical outcome and survival predictors in patients with cirrhosis after 10-mm-covered transjugular intrahepatic portosystemic shunt. GASTROENTEROLOGIA Y HEPATOLOGIA 2020; 44:620-627. [PMID: 33249114 DOI: 10.1016/j.gastrohep.2020.10.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/29/2020] [Revised: 10/07/2020] [Accepted: 10/22/2020] [Indexed: 11/30/2022]
Abstract
BACKGROUND AND AIMS Transjugular intrahepatic portosystemic shunts (TIPS) are successfully used in the management of portal hypertension (PH)-related complications. Debate surrounds the diameter of the dilation. The aim was to analyse the outcomes of and complications deriving from TIPS in patients with cirrhosis and identify predictors of survival. METHODS This was a retrospective single-centre study, which included patients with cirrhosis who had a TIPS procedure for PH from 2009 to October 2018. Demographic, clinical and radiological data were collected. The Kaplan-Meier method was used to measure survival and predictors of survival were identified with the Cox regression model. RESULTS A total of 98 patients were included (78.6% male), mean age was 58.5 (SD±/-9.9) and the median MELD was 13.3 (IQR 9.5-16). The indications were refractory ascites (RA), variceal bleeding (VB) and hepatic hydrothorax (HH). Median survival was 72 months (RA 46.4, VB 68.5 and HH 64.7) and transplant-free survival was 26 months. Clinical and technical success rates were 70.5% and 92.9% respectively. Age (HR 1.05), clinical success (HR 0.33), sodium (HR 0.92), renal failure (HR 2.46) and albumin (HR 0.35) were predictors of survival. Hepatic encephalopathy occurred in 28.6% of patients and TIPS dysfunction occurred in 16.3%. CONCLUSIONS TIPS with 10-mm PTFE-covered stent is an effective and safe treatment for PH-related complications in patients with cirrhosis. Age, renal failure, sodium, albumin and clinical success are independent predictors of long-term survival.
Collapse
Affiliation(s)
- Javier Tejedor-Tejada
- Department of Gastroenterology, Hepatology and Liver Transplantation Unit, Hospital Universitario Rio Hortega, Valladolid, Spain.
| | - Esteban Fuentes-Valenzuela
- Department of Gastroenterology, Hepatology and Liver Transplantation Unit, Hospital Universitario Rio Hortega, Valladolid, Spain
| | - Félix García-Pajares
- Department of Gastroenterology, Hepatology and Liver Transplantation Unit, Hospital Universitario Rio Hortega, Valladolid, Spain
| | - Rodrigo Nájera-Muñoz
- Department of Gastroenterology, Hepatology and Liver Transplantation Unit, Hospital Universitario Rio Hortega, Valladolid, Spain
| | - Carolina Almohalla-Álvarez
- Department of Gastroenterology, Hepatology and Liver Transplantation Unit, Hospital Universitario Rio Hortega, Valladolid, Spain
| | - Fátima Sánchez-Martín
- Department of Gastroenterology, Hepatology and Liver Transplantation Unit, Hospital Universitario Rio Hortega, Valladolid, Spain
| | - Hermógenes Calero-Aguilar
- Department of Radiology, Division of Vascular and Interventional Radiology, Hospital Universitario Rio Hortega, Valladolid, Spain
| | - Elena Villacastín-Ruiz
- Department of Radiology, Division of Vascular and Interventional Radiology, Hospital Universitario Rio Hortega, Valladolid, Spain
| | - Rebeca Pintado-Garrido
- Department of Radiology, Division of Vascular and Interventional Radiology, Hospital Universitario Rio Hortega, Valladolid, Spain
| | - Gloria Sánchez-Antolín
- Department of Gastroenterology, Hepatology and Liver Transplantation Unit, Hospital Universitario Rio Hortega, Valladolid, Spain
| |
Collapse
|
11
|
Schultheiß M, Bettinger D, Thimme R, Rössle M. 30 Jahre transjugulärer intrahepatischer portosystemischer Shunt (TIPS) – Rückblick und Perspektive. ZEITSCHRIFT FUR GASTROENTEROLOGIE 2020; 58:877-889. [DOI: 10.1055/a-1217-7866] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
ZusammenfassungDer transjuguläre intrahepatische portosystemische Shunt (TIPS) wird seit 30 Jahren in der Therapie der portalen Hypertonie erfolgreich eingesetzt. In nationalen und internationalen Leitlinien ist die Indikation zur TIPS-Anlage bei Varizenblutung und refraktärem Aszites wissenschaftlich gut belegt und klar definiert. Bei seltenen Indikationen wie dem hepatorenalen Syndrom, der Pfortaderthrombose oder dem neoadjuvanten Einsatz fehlt derzeit noch eine eindeutige Studienlage. Eine wichtige Kontraindikation und klinisch bedeutendste Komplikation nach TIPS ist die hepatische Enzephalopathie (HE). Es wird versucht, die Post-TIPS HE mit technischen Weiterentwicklungen der Stents zu reduzieren.
Collapse
Affiliation(s)
- Michael Schultheiß
- Department Innere Medizin, Klinik für Innere Medizin II, Gastroenterologie, Hepatologie, Endokrinologie und Infektiologie, Universitätsklinikum Freiburg, Medizinische Fakultät, Albert-Ludwigs-Universität Freiburg
| | - Dominik Bettinger
- Department Innere Medizin, Klinik für Innere Medizin II, Gastroenterologie, Hepatologie, Endokrinologie und Infektiologie, Universitätsklinikum Freiburg, Medizinische Fakultät, Albert-Ludwigs-Universität Freiburg
| | - Robert Thimme
- Department Innere Medizin, Klinik für Innere Medizin II, Gastroenterologie, Hepatologie, Endokrinologie und Infektiologie, Universitätsklinikum Freiburg, Medizinische Fakultät, Albert-Ludwigs-Universität Freiburg
| | - Martin Rössle
- Department Innere Medizin, Klinik für Innere Medizin II, Gastroenterologie, Hepatologie, Endokrinologie und Infektiologie, Universitätsklinikum Freiburg, Medizinische Fakultät, Albert-Ludwigs-Universität Freiburg
| |
Collapse
|
12
|
Tripathi D, Stanley AJ, Hayes PC, Travis S, Armstrong MJ, Tsochatzis EA, Rowe IA, Roslund N, Ireland H, Lomax M, Leithead JA, Mehrzad H, Aspinall RJ, McDonagh J, Patch D. Transjugular intrahepatic portosystemic stent-shunt in the management of portal hypertension. Gut 2020; 69:1173-1192. [PMID: 32114503 PMCID: PMC7306985 DOI: 10.1136/gutjnl-2019-320221] [Citation(s) in RCA: 156] [Impact Index Per Article: 39.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/02/2019] [Revised: 01/20/2020] [Accepted: 01/22/2020] [Indexed: 12/15/2022]
Abstract
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.
Collapse
Affiliation(s)
- Dhiraj Tripathi
- Liver Unit, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK .,Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham, UK.,NIHR Birmingham Biomedical Research Centre, University Hospitals Birmingham NHS Foundation Trust and University of Birmingham, Birmingham, UK
| | - Adrian J Stanley
- Gastroenterology Department, Glasgow Royal Infirmary, Glasgow, UK
| | - Peter C Hayes
- Hepatology Department, Royal Infirmary of Edinburgh, Edinburgh, UK
| | - Simon Travis
- Department if Radiology, Queen's Medical Centre Nottingham University Hospital NHS Trust, Nottingham, UK
| | - Matthew J Armstrong
- Liver Unit, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK,Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham, UK,NIHR Birmingham Biomedical Research Centre, University Hospitals Birmingham NHS Foundation Trust and University of Birmingham, Birmingham, UK
| | - Emmanuel A Tsochatzis
- The Royal Free Sheila Sherlock Liver Centre, UCL Institute for Liver and Digestive Health, London, UK
| | | | | | - Hamish Ireland
- Department of Radiology, Royal Infirmary of Edinburgh, Edinburgh, UK
| | | | - Joanne A Leithead
- Liver Unit, Cambridge University Hospitals NHS Foundation Trust, Cambridge, Cambridgeshire, UK
| | - Homoyon Mehrzad
- Department of Radiology, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Richard J Aspinall
- Department of Hepatology, Portsmouth Hospitals NHS Trust, Portsmouth, UK
| | - Joanne McDonagh
- Liver Unit, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - David Patch
- The Royal Free Sheila Sherlock Liver Centre, UCL Institute for Liver and Digestive Health, London, UK
| |
Collapse
|
13
|
Vizzutti F, Schepis F, Arena U, Fanelli F, Gitto S, Aspite S, Turco L, Dragoni G, Laffi G, Marra F. Transjugular intrahepatic portosystemic shunt (TIPS): current indications and strategies to improve the outcomes. Intern Emerg Med 2020; 15:37-48. [PMID: 31919780 DOI: 10.1007/s11739-019-02252-8] [Citation(s) in RCA: 38] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/19/2019] [Accepted: 12/03/2019] [Indexed: 12/16/2022]
Abstract
Transjugular intrahepatic portosystemic shunt (TIPS) represents a very effective treatment of complications of portal hypertension. Established indications to TIPS in cirrhotic patients include portal hypertensive bleeding and refractory ascites. Over the years additional indications have been proposed, such as the treatment of vascular disease of the liver, hepatic hydrothorax, hepatorenal syndrome and bleeding from ectopic varices. Indications under evaluation include treatment of portal hypertension prior to major abdominal surgery and treatment of portal vein thrombosis. In spite of these advances, there are still uncertainties regarding the appropriate workup for patients to be scheduled for TIPS. Moreover, prevention and management of post-TIPS complications including hepatic encephalopathy and heart failure are still suboptimal. These issues are particularly relevant considering aging in TIPS candidates in Western countries. Correct selection of patients is mandatory to prevent complications which may eventually frustrate the good hemodynamic results and worsen the patient's quality of life or even life expectancy. The possible role of small diameter TIPS to prevent post-procedural complications is discussed.
Collapse
Affiliation(s)
- Francesco Vizzutti
- Department of Experimental and Clinical Medicine, University of Florence, Viale Morgagni 85, 50134, Florence, Italy
| | - Filippo Schepis
- Department of Internal Medicine, University of Modena and Reggio, Modena, Italy
| | - Umberto Arena
- Department of Experimental and Clinical Medicine, University of Florence, Viale Morgagni 85, 50134, Florence, Italy
| | - Fabrizio Fanelli
- Department of Radiology, Interventional Radiology, Azienda Ospedaliero Universitaria Careggi, Florence, Italy
| | - Stefano Gitto
- Department of Experimental and Clinical Medicine, University of Florence, Viale Morgagni 85, 50134, Florence, Italy
| | - Silvia Aspite
- Department of Experimental and Clinical Medicine, University of Florence, Viale Morgagni 85, 50134, Florence, Italy
| | - Laura Turco
- Department of Internal Medicine, University of Modena and Reggio, Modena, Italy
| | - Gabriele Dragoni
- Department of Experimental and Clinical Medicine, University of Florence, Viale Morgagni 85, 50134, Florence, Italy
| | - Giacomo Laffi
- Department of Experimental and Clinical Medicine, University of Florence, Viale Morgagni 85, 50134, Florence, Italy
| | - Fabio Marra
- Department of Experimental and Clinical Medicine, University of Florence, Viale Morgagni 85, 50134, Florence, Italy.
- Center for Research, High Education and Transfer DENOThe, University of Florence, Florence, Italy.
| |
Collapse
|
14
|
Lipnik AJ, Pandhi MB, Khabbaz RC, Gaba RC. Endovascular Treatment for Variceal Hemorrhage: TIPS, BRTO, and Combined Approaches. Semin Intervent Radiol 2018; 35:169-184. [PMID: 30087520 DOI: 10.1055/s-0038-1660795] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Variceal hemorrhage is a feared complication of portal hypertension, with high rates of morbidity and mortality. Optimal management requires a thoughtful, multidisciplinary approach. In cases of refractory or recurrent esophageal hemorrhage, endovascular approaches such as transjugular intrahepatic portosystemic shunt (TIPS) have a well-defined role. For hemorrhage related to gastric varices, the optimal treatment remains to be established; however, there is increasing adoption of balloon-occluded retrograde transvenous obliteration (BRTO). This article will review the concept, history, patient selection, basic technique, and outcomes for TIPS, BRTO, and combined TIPS + BRTO procedures for variceal hemorrhage.
Collapse
Affiliation(s)
- Andrew J Lipnik
- Department of Radiology, University of Illinois Hospital & Health Sciences System, Chicago, Illinois.,Division of Interventional Radiology, University of Illinois Hospital & Health Sciences System, Chicago, Illinois
| | - Mithil B Pandhi
- Department of Radiology, University of Illinois Hospital & Health Sciences System, Chicago, Illinois
| | - Ramzy C Khabbaz
- Department of Radiology, University of Illinois Hospital & Health Sciences System, Chicago, Illinois
| | - Ron C Gaba
- Department of Radiology, University of Illinois Hospital & Health Sciences System, Chicago, Illinois.,Division of Interventional Radiology, University of Illinois Hospital & Health Sciences System, Chicago, Illinois
| |
Collapse
|
15
|
Image-guided treatment of Budd-Chiari syndrome: a giant leap from the past, a small step towards the future. Abdom Radiol (NY) 2018; 43:1908-1919. [PMID: 28988356 DOI: 10.1007/s00261-017-1341-y] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Budd-Chiari syndrome (BCS) is a relatively rare vascular disease characterized by hepatic outflow tract obstruction, and image-guided endovascular treatment, namely percutaneous angioplasty, stenting, and transjugular intrahepatic portosystemic shunt (TIPS), has proven to be effective treatment modalities to alleviate symptoms and markedly improve the prognosis of the disease. Specifically, a step-wise approach is recommended, i.e., angioplasty and stenting are the prioritized choice for patients with membranous obstruction and short-length stenosis, whereas TIPS is the option for patients who fail this treatment. Currently, 5-year survival with the step-wise approach is about 75%, and the most promising way to further improve this value is to identify candidates who are at high risk of failing angioplasty, and perform pre-emptive TIPS in these patients.
Collapse
|
16
|
Hernández-Gea V, Bureau C. Practice makes better: TIPS procedures in referral centers. Hepatology 2018; 67:473-475. [PMID: 28873237 DOI: 10.1002/hep.29507] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/27/2017] [Accepted: 08/30/2017] [Indexed: 12/26/2022]
Affiliation(s)
- Virginia Hernández-Gea
- Barcelona Hepatic Hemodynamic Laboratory Liver Unit Hospital Clinic-Institut d'Investigacions Biomèdiques August Pi I i Sunyer, IMDIM, University of Barcelona, Barcelona, Spain.,Centro de Investigación Biomédica Red de Enfermedades Hepáticas y Digestivas, Spain
| | - Christophe Bureau
- Department of Hepato-Gastroenterology, Purpan Hospital, CHU Toulouse, France.,University of Paul Sabatier Toulouse, Toulouse, France.,Institut Cardiomet, Toulouse, France
| |
Collapse
|
17
|
Triantafyllou T, Aggarwal P, Gupta E, Svetanoff WJ, Bhirud DP, Singhal S. Polytetrafluoroethylene-Covered Stent Graft Versus Bare Stent in Transjugular Intrahepatic Portosystemic Shunt: Systematic Review and Meta-Analysis. J Laparoendosc Adv Surg Tech A 2018; 28:867-879. [PMID: 29356589 DOI: 10.1089/lap.2017.0560] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND & AIMS Transjugular Intrahepatic Portosystemic Shunt (TIPS) is used to control refractory variceal bleeding secondary to portal hypertension. This meta-analysis was conducted to systematically review polytetrafluoroethylene-covered stent grafts (CS) versus bare stents (BS) in TIPS procedure. METHODS Systematic search of literature databases was done from January-1990 till April-2017, using predecided keywords. Outcome measures studied were (1) primary-patency (PP) at 1 year (defined as absence of shunt insufficiency at 1 year), (2) rebleeding (RE) (3) new-onset hepatic encephalopathy ([HE] new-onset or worsening encephalopathy following the procedure), and (4) survival at 1 year (SU). Odds ratio (OR) was calculated for each outcome variable. Between-study heterogeneity was assessed by the I2 statistics and χ2 Q-test. RESULTS Fourteen studies (4 RCTs, 2 prospective nonrandomized, and 8 retrospective) were included with 2519 patients (1548 patients in BS group and 971 patients in CS group). Three-quarter outcome measures showed significantly better results with CS. PP was pooled from 13 studies and showed an OR = 4.75 (95% confidence interval [CI] = 3.32-6.79; P < .00001; I2 = 44%) in favor of CS. RE was pooled from six studies with odds ratio (OR) = 0.37(95% CI = 0.24-0.56; P < .00001; I2 = 0%) in favor of CS. SU was pooled from 11 studies with OR = 1.85 (95% CI = 1.44-2.38; P < .00001; I2 = 0%) in favor of CS. On subset analysis for RCTs, three outcome variables favored CS with minimal heterogeneity [PP: OR = 4.18 (95% CI = 2.66-6.55; P < .00001; I2 = 0%). RE: OR = 0.43 (95% CI = 0.25-0.72; P < .001; I2 = 0%). SU: OR = 1.85 (95% CI = 1.44-2.38, P < .00001; I2 = 0%)]. HE showed no difference between two stents on the overall and subset pooled analysis. Overall: OR = 0.86 (95% CI = 0.68-1.08; P = .19; I2 = 4%). Only RCTs: OR = 0.91 (95% CI = 0.63-1.32, P = .63; I2 = 0%). CONCLUSIONS CS is associated with better primary patency and survival and lesser rate of rebleeding than BS in patients undergoing TIPS procedure. There is no difference in new-onset hepatic encephalopathy.
Collapse
Affiliation(s)
| | - Piyush Aggarwal
- 2 All India Institute of Medical Sciences , New Delhi, India
| | - Ekansh Gupta
- 2 All India Institute of Medical Sciences , New Delhi, India
| | - Wendy Jo Svetanoff
- 3 Boston Children's Hospital , Harvard Medical School, Boston, Massachusetts
| | | | - Saurabh Singhal
- 5 St. Joseph's Hospital and Medical Centre , Phoenix, Arizona
| |
Collapse
|
18
|
Pateria P, Jeffrey GP, Garas G, Tibballs J, Ferguson J, Delriviere L, Huang Y, Adams LA, MacQuillan G. Transjugular intrahepatic portosystemic shunt: Indications, complications, survival and its use as a bridging therapy to liver transplant in Western Australia. J Med Imaging Radiat Oncol 2017; 61:441-447. [DOI: 10.1111/1754-9485.12563] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2016] [Accepted: 10/28/2016] [Indexed: 12/23/2022]
Affiliation(s)
- Puraskar Pateria
- Department of Gastroenterology and Hepatology; Sir Charles Gairdner Hospital; Nedlands Western Australia Australia
| | - Gary P Jeffrey
- Department of Gastroenterology and Hepatology; Sir Charles Gairdner Hospital; Nedlands Western Australia Australia
- School of Medicine and Pharmacology; University of Western Australia; Nedlands Western Australia Australia
| | - George Garas
- Department of Gastroenterology and Hepatology; Sir Charles Gairdner Hospital; Nedlands Western Australia Australia
- School of Medicine and Pharmacology; University of Western Australia; Nedlands Western Australia Australia
| | - Jonathan Tibballs
- Department of Radiology; Sir Charles Gairdner Hospital; Nedlands Western Australia Australia
| | - John Ferguson
- Department of Radiology; Sir Charles Gairdner Hospital; Nedlands Western Australia Australia
| | - Luc Delriviere
- School of Medicine and Pharmacology; University of Western Australia; Nedlands Western Australia Australia
- Department of Surgery; Sir Charles Gairdner Hospital; Nedlands Western Australia Australia
| | - Yi Huang
- School of Medicine and Pharmacology; University of Western Australia; Nedlands Western Australia Australia
| | - Leon A Adams
- Department of Gastroenterology and Hepatology; Sir Charles Gairdner Hospital; Nedlands Western Australia Australia
- School of Medicine and Pharmacology; University of Western Australia; Nedlands Western Australia Australia
| | - Gerry MacQuillan
- Department of Gastroenterology and Hepatology; Sir Charles Gairdner Hospital; Nedlands Western Australia Australia
- School of Medicine and Pharmacology; University of Western Australia; Nedlands Western Australia Australia
| |
Collapse
|
19
|
Hayek G, Ronot M, Plessier A, Sibert A, Abdel-Rehim M, Zappa M, Rautou PE, Valla D, Vilgrain V. Long-term Outcome and Analysis of Dysfunction of Transjugular Intrahepatic Portosystemic Shunt Placement in Chronic Primary Budd-Chiari Syndrome. Radiology 2016; 283:280-292. [PMID: 27797679 DOI: 10.1148/radiol.2016152641] [Citation(s) in RCA: 46] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Purpose To evaluate the long-term safety, technical success, and efficacy of transjugular intrahepatic portosystemic shunt (TIPS) in a series of patients with Budd-Chiari syndrome (BCS), and to determine the predictors of shunt dysfunction. Materials and Methods From 2004 to 2013, all patients with primary BCS referred for TIPS placement were included in the study. The primary and secondary technical success rates and the number and types of early (ie, before day 7) complications were noted. Factors associated with dysfunction were analyzed with uni- and multivariate analyses. Survival was analyzed with Kaplan-Meier curves. Results Fifty-four patients (34 women [63%]; mean age, 36 years ± 12 [standard deviation]) were included. Twenty-eight patients (52%) had myeloproliferative neoplasms. The mean Model for End-Stage Liver Disease score was 14.5 ± 4. The most frequent indication for TIPS was refractory ascites (50 of 54; 93%). Primary and secondary technical success rates were 93% and 98%, respectively. Early complications occurred in 17 patients (32%). After a mean follow-up of 56 months ± 41 (interquartile range, 22-92), 22 patients (42%) experienced at least one episode of TIPS dysfunction (median delay between administration of TIPS and first episode of dysfunction, 10.8 months). Cumulative 1-, 2-, 3-, 5-, and 10-year primary patency rates were 64%, 59%, 54%, 45%, and 45%, respectively. Dysfunction was associated with a myeloproliferative neoplasm (hazard ratio, 8.18; 95% confidence interval: 1.45, 46.18; P = .017), more than two initial stents (hazard ratio, 3.90; 95% confidence interval:1.16, 13.10; P = .027), and the occurrence of early complications (hazard ratio, 11.34; 95% confidence interval: 1.82, 70.69; P = .009). The 10-year survival rate was 76%. Conclusion TIPS placement in patients with chronic primary BCS was associated with a nonnegligible rate of early complications and required endovascular revision or revisions in 42% of patients. Nevertheless, secondary patency was close to 100%, and long-term survival was good. © RSNA, 2016 Online supplemental material is available for this article.
Collapse
Affiliation(s)
- Georges Hayek
- From the Departments of Radiology (G.H., M.R., A.S., M.A.R., M.Z., V.V.) and Hepatology (A.P., P.E.R., D.V.), APHP, University Hospitals Paris Nord Val de Seine, Beaujon Hospital, 100 Boulevard du Général Leclerc, 92118 Clichy, Hauts-de-Seine, France; University Paris Diderot, Sorbonne Paris Cité, Paris, France (M.R., P.E.R., D.V., V.V.); and INSERM U1149, Centre de Recherche Biomédicale Bichat-Beaujon, CRB3, Paris, France (M.R., V.V.)
| | - Maxime Ronot
- From the Departments of Radiology (G.H., M.R., A.S., M.A.R., M.Z., V.V.) and Hepatology (A.P., P.E.R., D.V.), APHP, University Hospitals Paris Nord Val de Seine, Beaujon Hospital, 100 Boulevard du Général Leclerc, 92118 Clichy, Hauts-de-Seine, France; University Paris Diderot, Sorbonne Paris Cité, Paris, France (M.R., P.E.R., D.V., V.V.); and INSERM U1149, Centre de Recherche Biomédicale Bichat-Beaujon, CRB3, Paris, France (M.R., V.V.)
| | - Aurélie Plessier
- From the Departments of Radiology (G.H., M.R., A.S., M.A.R., M.Z., V.V.) and Hepatology (A.P., P.E.R., D.V.), APHP, University Hospitals Paris Nord Val de Seine, Beaujon Hospital, 100 Boulevard du Général Leclerc, 92118 Clichy, Hauts-de-Seine, France; University Paris Diderot, Sorbonne Paris Cité, Paris, France (M.R., P.E.R., D.V., V.V.); and INSERM U1149, Centre de Recherche Biomédicale Bichat-Beaujon, CRB3, Paris, France (M.R., V.V.)
| | - Annie Sibert
- From the Departments of Radiology (G.H., M.R., A.S., M.A.R., M.Z., V.V.) and Hepatology (A.P., P.E.R., D.V.), APHP, University Hospitals Paris Nord Val de Seine, Beaujon Hospital, 100 Boulevard du Général Leclerc, 92118 Clichy, Hauts-de-Seine, France; University Paris Diderot, Sorbonne Paris Cité, Paris, France (M.R., P.E.R., D.V., V.V.); and INSERM U1149, Centre de Recherche Biomédicale Bichat-Beaujon, CRB3, Paris, France (M.R., V.V.)
| | - Mohamed Abdel-Rehim
- From the Departments of Radiology (G.H., M.R., A.S., M.A.R., M.Z., V.V.) and Hepatology (A.P., P.E.R., D.V.), APHP, University Hospitals Paris Nord Val de Seine, Beaujon Hospital, 100 Boulevard du Général Leclerc, 92118 Clichy, Hauts-de-Seine, France; University Paris Diderot, Sorbonne Paris Cité, Paris, France (M.R., P.E.R., D.V., V.V.); and INSERM U1149, Centre de Recherche Biomédicale Bichat-Beaujon, CRB3, Paris, France (M.R., V.V.)
| | - Magaly Zappa
- From the Departments of Radiology (G.H., M.R., A.S., M.A.R., M.Z., V.V.) and Hepatology (A.P., P.E.R., D.V.), APHP, University Hospitals Paris Nord Val de Seine, Beaujon Hospital, 100 Boulevard du Général Leclerc, 92118 Clichy, Hauts-de-Seine, France; University Paris Diderot, Sorbonne Paris Cité, Paris, France (M.R., P.E.R., D.V., V.V.); and INSERM U1149, Centre de Recherche Biomédicale Bichat-Beaujon, CRB3, Paris, France (M.R., V.V.)
| | - Pierre-Emmanuel Rautou
- From the Departments of Radiology (G.H., M.R., A.S., M.A.R., M.Z., V.V.) and Hepatology (A.P., P.E.R., D.V.), APHP, University Hospitals Paris Nord Val de Seine, Beaujon Hospital, 100 Boulevard du Général Leclerc, 92118 Clichy, Hauts-de-Seine, France; University Paris Diderot, Sorbonne Paris Cité, Paris, France (M.R., P.E.R., D.V., V.V.); and INSERM U1149, Centre de Recherche Biomédicale Bichat-Beaujon, CRB3, Paris, France (M.R., V.V.)
| | - Dominique Valla
- From the Departments of Radiology (G.H., M.R., A.S., M.A.R., M.Z., V.V.) and Hepatology (A.P., P.E.R., D.V.), APHP, University Hospitals Paris Nord Val de Seine, Beaujon Hospital, 100 Boulevard du Général Leclerc, 92118 Clichy, Hauts-de-Seine, France; University Paris Diderot, Sorbonne Paris Cité, Paris, France (M.R., P.E.R., D.V., V.V.); and INSERM U1149, Centre de Recherche Biomédicale Bichat-Beaujon, CRB3, Paris, France (M.R., V.V.)
| | - Valérie Vilgrain
- From the Departments of Radiology (G.H., M.R., A.S., M.A.R., M.Z., V.V.) and Hepatology (A.P., P.E.R., D.V.), APHP, University Hospitals Paris Nord Val de Seine, Beaujon Hospital, 100 Boulevard du Général Leclerc, 92118 Clichy, Hauts-de-Seine, France; University Paris Diderot, Sorbonne Paris Cité, Paris, France (M.R., P.E.R., D.V., V.V.); and INSERM U1149, Centre de Recherche Biomédicale Bichat-Beaujon, CRB3, Paris, France (M.R., V.V.)
| |
Collapse
|
20
|
Isfort P, Penzkofer T, Wilkmann C, Na HS, Kotzlowski C, Ito N, Pfeffer JG, Bisplinghoff S, Osterhues S, Besting A, Gooding J, Schmitz-Rode T, Kuhl C, Mahnken AH, Bruners P. Feasibility of electromagnetically guided transjugular intrahepatic portosystemic shunt procedure. MINIM INVASIV THER 2016; 26:15-22. [PMID: 27686414 DOI: 10.1080/13645706.2016.1214155] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
OBJECTIVES To develop an electromagnetic navigation technology for transjugular intrahepatic portosystemic shunt (TIPS) creation and translate it from phantom to an in-vivo large animal setting. MATERIAL AND METHODS A custom-designed device for TIPS creation consisting of a stylet within a 5 French catheter as well as a software prototype were developed that allow real-time tip tracking of both stylet and catheter using an electromagnetic tracking system. Feasibility of navigated TIPSS creation was tested in a phantom by two interventional radiologists (A/B) followed by in-vivo testing evaluation in eight domestic pigs. Procedure duration and number of attempts needed for puncture of the portal vein were recorded. RESULTS In the phantom setting, intervention time to gain access to the portal vein (PV) was 144 ± 67 s (A) and 122 ± 51 s (B), respectively. In the in-vivo trials, TIPS could be successfully completed in five out of eight animals. Mean time for the complete TIPS was 245 ± 205 minutes with a notable learning curve towards the last animal. CONCLUSIONS TIPS creation with the use of electromagnetic tracking technology proved to be feasible in-vitro as well as in-vivo. The system may be useful to facilitate challenging TIPSS procedures.
Collapse
Affiliation(s)
- Peter Isfort
- a Diagnostic and Interventional Radiology , RWTH Aachen University Hospital , Aachen , Germany
| | - Tobias Penzkofer
- a Diagnostic and Interventional Radiology , RWTH Aachen University Hospital , Aachen , Germany.,b Surgical Planning Laboratory , Brigham and Women's Hospital , Boston , MA , USA.,c Diagnostic and Interventional Radiology , Charité Universitätsmedizin Berlin , Berlin , Germany
| | - Christoph Wilkmann
- a Diagnostic and Interventional Radiology , RWTH Aachen University Hospital , Aachen , Germany
| | - Hong-Sik Na
- a Diagnostic and Interventional Radiology , RWTH Aachen University Hospital , Aachen , Germany
| | - Christian Kotzlowski
- a Diagnostic and Interventional Radiology , RWTH Aachen University Hospital , Aachen , Germany
| | - Nobutake Ito
- d Department of Radiology , Keio University , Tokyo , Japan.,e Applied Medical Engineering , RWTH Aachen University Hospital , Aachen , Germany
| | - Joachim Georg Pfeffer
- a Diagnostic and Interventional Radiology , RWTH Aachen University Hospital , Aachen , Germany
| | | | | | | | - Jorge Gooding
- e Applied Medical Engineering , RWTH Aachen University Hospital , Aachen , Germany
| | - Thomas Schmitz-Rode
- e Applied Medical Engineering , RWTH Aachen University Hospital , Aachen , Germany
| | - Christiane Kuhl
- a Diagnostic and Interventional Radiology , RWTH Aachen University Hospital , Aachen , Germany
| | - Andreas Horst Mahnken
- i Department of Diagnostic and Interventional Radiology , Philips University Hospital , Marburg , Germany
| | - Philipp Bruners
- a Diagnostic and Interventional Radiology , RWTH Aachen University Hospital , Aachen , Germany
| |
Collapse
|
21
|
Ertel AE, Chang AL, Kim Y, Shah SA. Management of gastrointestinal bleeding in patients with cirrhosis. Curr Probl Surg 2016; 53:366-95. [PMID: 27585818 DOI: 10.1067/j.cpsurg.2016.06.006] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2016] [Accepted: 06/21/2016] [Indexed: 12/14/2022]
Affiliation(s)
- Audrey E Ertel
- Department of Surgery, University of Cincinnati School of Medicine, Cincinnati, OH
| | - Alex L Chang
- Department of Surgery, University of Cincinnati School of Medicine, Cincinnati, OH
| | - Young Kim
- Department of Surgery, University of Cincinnati School of Medicine, Cincinnati, OH
| | - Shimul A Shah
- Department of Surgery, University of Cincinnati School of Medicine, Cincinnati, OH.
| |
Collapse
|
22
|
Bilbao Jaureguízar J. Twenty-five years after the first TIPS in Spain. RADIOLOGIA 2016. [DOI: 10.1016/j.rxeng.2016.05.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
|
23
|
Abstract
The rate of gastric variceal bleeding is significantly lower than that of esophageal variceal bleeding. Although gastric variceal bleeding occurs in only 10% of cirrhotic patients with hemorrhage, the bleeding is usually more severe, and is associated with higher mortality. To date, the majority of studies have focused on the treatment of esophageal variceal bleeding, but there were few studies on the treatment of gastric varices. As a result, there is still no standardized treatment for gastric varices. Endoscopic injection of cyanoacrylate is currently the optimum approach to control active bleeding from gastric varices. Transjugular intrahepatic portosystemic shunt (TIPS) can be used in acute gastric variceal bleeding and secondary prophylaxis. Balloon-occluded retrograde transvenous obliteration (BRTO) may be used in patients with gastric varices associated with a gastrorenal shunt. In recent years, endoscopic therapy and radiologic therapy have been developed for the treatment of patients with gastric variceal bleeding associated with portal hypertension. Here we describe the optimum treatment strategies for gastric variceal bleeding associated with portal hypertension as well as their therapeutic effects and complications.
Collapse
|
24
|
Gaba RC. Transjugular Intrahepatic Portosystemic Shunt Creation With Embolization or Obliteration for Variceal Bleeding. Tech Vasc Interv Radiol 2016; 19:21-35. [DOI: 10.1053/j.tvir.2016.01.003] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
|
25
|
Bilbao Jaureguízar JI. Twenty-five years after the first TIPS in Spain. RADIOLOGIA 2016; 58:178-88. [PMID: 26908250 DOI: 10.1016/j.rx.2016.01.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2015] [Revised: 01/04/2016] [Accepted: 01/07/2016] [Indexed: 02/07/2023]
Abstract
The incorporation, 25 years ago, of transjugular intrahepatic portosystemic shunting, better known by the acronym TIPS, represents an indisputable improvement in the treatment and management of patients with symptoms due to portal hypertension. This article discusses the origins of the technique and the technical innovations that have been progressively added through the years. The implantation of coated stents, which protect the stent from processes in the parenchymal track that can lead to stenosis, have helped ensure long-term patency, thus reducing the need for reintervention. Solid evidence from valuable publications has situated TIPS at the forefront of the treatment options in a wide variety of clinical situations associated with portal hypertension.
Collapse
|
26
|
Keller FS, Farsad K, Rösch J. The Transjugular Intrahepatic Portosystemic Shunt: Technique and Instruments. Tech Vasc Interv Radiol 2016; 19:2-9. [PMID: 26997084 DOI: 10.1053/j.tvir.2016.01.001] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Although transjugular intrahepatic portosystemic shunt (TIPS) was first described in 1971, it took 15 more years for technology, in the form of expandable metallic stents, to be developed to make TIPS a viable, widespread clinical procedure. Currently, expanded polytetrafluoroethylene-covered stent grafts that exhibit significantly greater long-term patency are used for TIPS creation by most interventionalists. TIPS creation requires specific interventional skills, tools, and devices for success. In the hands of skillful, experienced interventional radiologists, TIPS creation is performed safely and successfully in greater than 95% of cases.
Collapse
Affiliation(s)
- Frederick S Keller
- Dotter Interventional Institute, Oregon Health & Sciences University, Portland, OR.
| | - Khashayar Farsad
- Dotter Interventional Institute, Oregon Health & Sciences University, Portland, OR
| | - Josef Rösch
- Dotter Interventional Institute, Oregon Health & Sciences University, Portland, OR
| |
Collapse
|
27
|
Development of transjugular intrahepatic portosystemic shunt. J Vasc Interv Radiol 2015; 26:220-2. [PMID: 25645410 DOI: 10.1016/j.jvir.2014.11.011] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2014] [Accepted: 11/06/2014] [Indexed: 02/07/2023] Open
|
28
|
Andring B, Kalva SP, Sutphin P, Srinivasa R, Anene A, Burrell M, Xi Y, Pillai AK. Effect of technical parameters on transjugular intrahepatic portosystemic shunts utilizing stent grafts. World J Gastroenterol 2015; 21:8110-8117. [PMID: 26185383 PMCID: PMC4499354 DOI: 10.3748/wjg.v21.i26.8110] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/27/2015] [Revised: 03/25/2015] [Accepted: 05/04/2015] [Indexed: 02/06/2023] Open
Abstract
AIM: To assess the effect of technical parameters on outcomes of transjugular intrahepatic portosystemic shunt (TIPS) created using a stent graft.
METHODS: The medical records of 68 patients who underwent TIPS placement with a stent graft from 2008 to 2014 were reviewed by two radiologists blinded to the patient outcomes. Digital Subtraction Angiographic images with a measuring catheter in two orthogonal planes was used to determine the TIPS stent-to-inferior vena cava distance (SIVCD), hepatic vein to parenchymal tract angle (HVTA), portal vein to parenchymal tract angle (PVTA), and the accessed portal vein. The length and diameter of the TIPS stent and the use of concurrent variceal embolization were recorded by review of the patient’s procedure note. Data on re-intervention within 30 d of TIPS placement, recurrence of symptoms, and survival were collected through the patient’s chart. Cox proportional regression analysis was performed to assess the effect of these technical parameters on primary patency of TIPS, time to recurrence of symptoms, and all-cause mortality.
RESULTS: There was no significant association between the SIVCD and primary patency (P = 0.23), time to recurrence of symptoms (P = 0.83), or all-cause mortality (P = 0.18). The 3, 6, and 12-mo primary patency rates for a SIVCD ≥ 1.5 cm were 82.4%, 64.7%, and 50.3% compared to 89.3%, 83.8%, and 60.6% for a SIVCD of < 1.5 cm (P = 0.29). The median time to stenosis for a SIVCD of ≥ 1.5 cm was 19.1 mo vs 15.1 mo for a SIVCD of < 1.5 cm (P = 0.48). There was no significant association between the following factors and primary patency: HVTA (P = 0.99), PVTA (P = 0.65), accessed portal vein (P = 0.35), TIPS stent diameter (P = 0.93), TIPS stent length (P = 0.48), concurrent variceal embolization (P = 0.13) and reinterventions within 30 d (P = 0.24). Furthermore, there was no correlation between these technical parameters and time to recurrence of symptoms or all-cause mortality. Recurrence of symptoms was associated with stent graft stenosis (P = 0.03).
CONCLUSION: TIPS stent-to-caval distance and other parameters have no significant effect on primary patency, time to recurrence of symptoms, or all-cause mortality following TIPS with a stent-graft.
Collapse
MESH Headings
- Angiography, Digital Subtraction
- Blood Vessel Prosthesis
- Blood Vessel Prosthesis Implantation/adverse effects
- Blood Vessel Prosthesis Implantation/instrumentation
- Blood Vessel Prosthesis Implantation/mortality
- Female
- Graft Occlusion, Vascular/etiology
- Graft Occlusion, Vascular/physiopathology
- Graft Occlusion, Vascular/surgery
- Humans
- Hypertension, Portal/diagnosis
- Hypertension, Portal/mortality
- Hypertension, Portal/physiopathology
- Hypertension, Portal/surgery
- Kaplan-Meier Estimate
- Male
- Middle Aged
- Multivariate Analysis
- Phlebography/methods
- Portal Vein/diagnostic imaging
- Portal Vein/physiopathology
- Portal Vein/surgery
- Portasystemic Shunt, Transjugular Intrahepatic/adverse effects
- Portasystemic Shunt, Transjugular Intrahepatic/instrumentation
- Portasystemic Shunt, Transjugular Intrahepatic/mortality
- Proportional Hazards Models
- Prosthesis Design
- Recurrence
- Reoperation
- Retrospective Studies
- Risk Factors
- Stents
- Time Factors
- Treatment Outcome
- Vascular Patency
- Vena Cava, Inferior/diagnostic imaging
- Vena Cava, Inferior/physiopathology
- Vena Cava, Inferior/surgery
Collapse
|
29
|
Charalel RA, McGinty G, Brant-Zawadzki M, Goodwin SC, Khilnani NM, Matsumoto AH, Min RJ, Soares GM, Cook PS. Interventional Radiology Delivers High-Value Health Care and Is an Imaging 3.0 Vanguard. J Am Coll Radiol 2015; 12:501-6. [DOI: 10.1016/j.jacr.2014.10.024] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2014] [Accepted: 10/29/2014] [Indexed: 02/01/2023]
|
30
|
The risk of acute kidney injury with transjugular intrahepatic portosystemic shunts. J Nephrol 2015; 28:725-8. [DOI: 10.1007/s40620-015-0187-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2014] [Accepted: 02/25/2015] [Indexed: 11/25/2022]
|
31
|
Slovenian experience from diagnostic angiography to interventional radiology. Radiol Oncol 2014; 48:416-25. [PMID: 25435857 PMCID: PMC4230564 DOI: 10.2478/raon-2014-0023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2013] [Accepted: 11/25/2013] [Indexed: 11/24/2022] Open
Abstract
Background The purpose of writing this article is to document the important events and people in the first 50 years of diagnostic angiography and interventional radiology in Slovenia. During this period not only did the name of the institutions and departments change, but also its governance. Conclusions This depicted the important roles different people played at various times in the cardiovascular divisions inside and outside of the diagnostic and interventional radiology. Historical data show that Slovenian radiology has relatively immediately introduced the new methods of interventional radiology in clinical practice.
Collapse
|
32
|
Abstract
Transjugular intrahepatic portosystemic shunt (TIPS) is an established procedure for the complications of portal hypertension. The largest body of evidence for its use has been supported for recurrent or refractory variceal bleeding and refractory ascites. Its use has also been advocated for acute variceal bleed, hepatic hydrothorax, and hepatorenal syndrome. With the replacement of bare metal stents with polytetrafluoroethylene-covered stents, shunt patency has improved dramatically, thus, improving outcomes. Therefore, reassessment of its utility, management of its complications, and understanding of various TIPS techniques is important.
Collapse
Affiliation(s)
- Kavish R Patidar
- Department of Internal Medicine, Virginia Commonwealth University Hospital, 1200 East Broad Street, MCV Box 980342, Richmond, VA 23298-0342, USA
| | - Malcolm Sydnor
- Radiology, Virginia Commonwealth University Hospital, 1200 East Broad Street, MCV Box 980615, Richmond, VA 23298-0615, USA; Surgery, Virginia Commonwealth University Hospital, 1200 East Broad Street, Richmond, VA 23298, USA; Vascular Interventional Radiology, Virginia Commonwealth University Hospital, 1200 East Broad Street, Richmond, VA 23298, USA
| | - Arun J Sanyal
- Division of Gastroenterology, Department of Internal Medicine, Virginia Commonwealth University School of Medicine, 1200 East Broad Street, MCV Box 980342, Richmond, VA 23298-0342, USA.
| |
Collapse
|
33
|
Saad WE. The history and future of transjugular intrahepatic portosystemic shunt: food for thought. Semin Intervent Radiol 2014; 31:258-61. [PMID: 25177087 DOI: 10.1055/s-0034-1382794] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
The origins of transjugular intrahepatic portosystemic shunt (TIPS) date back to the 1960s with inadvertent portal access during the early years of transjugular cholangiography. TIPS is now the most frequently performed portal hypertension decompressive procedure performed by interventional radiologists, and has become the primary portosystemic shunt (surgical or percutaneous) performed in the United States. One of the least discussed major advantages of TIPS in the transplant era is that it is intrahepatic and thus is removed in situ during a liver transplant, while extrahepatic shunts (surgical or percutaneous) have to be ligated or revised during the liver transplantation. However, since the widespread clinical utilization of TIPS in the 1990s, it has been plagued with two major problems, namely, patency and hepatic encephalopathy. With the advent of commercially available expanded polytetraflouroethylenne (e-PTFE) covered stents a decade ago, 12- to 24-month TIPS patency has improved significantly (by ∼20-30%). However, hepatic encephalopathy (although not proven to have increased due to e-PTFE covered stents grafts) remains a significant morbidity problem. The article discusses the history of TIPS, critiques the retrospective encephalopathy data in the literature, and discusses futuristic TIPS-design ideas about the management of post-TIPS hepatic encephalopathy.
Collapse
Affiliation(s)
- Wael E Saad
- Department of Radiology, University of Michigan Medical Center, Ann Arbor, Michigan
| |
Collapse
|
34
|
The Evolution of Transjugular Intrahepatic Portosystemic Shunt: Tips. ISRN HEPATOLOGY 2014; 2014:762096. [PMID: 27335841 PMCID: PMC4890882 DOI: 10.1155/2014/762096] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 10/20/2013] [Accepted: 01/16/2014] [Indexed: 02/07/2023]
Abstract
Since Richter's description in the literature in 1989 of the first procedure on human patients, transjugular intrahepatic portosystemic shunt (TIPS) has been worldwide considered as a noninvasive technique to manage portal hypertension complications. TIPS succeeds in lowering the hepatic sinusoidal pressure and in increasing the circulatory flow, thus reducing sodium retention, ascites recurrence, and variceal bleeding. Required several revisions of the shunt TIPS can be performed in case of different conditions such as hepatorenal syndrome, hepatichydrothorax, portal vein thrombosis, and Budd-Chiari syndrome. Most of the previous studies on TIPS procedure were based on the use of bare stents and most patients chose TIPS 2-3 years after traditional treatment, thus making TIPS appear to be not superior to endoscopy in survival rates. Bare stents were associated with higher incidence of shunt failure and consequently patients required several revisions during the follow-up. With the introduction of a dedicated e-PTFE covered stent-graft, these problems were completely solved, No more reinterventions are required with a tremendous improvement of patient's quality of life. One of the main drawbacks of the use of e-PTFE covered stent-graft is higher incidence of hepatic encephalopathy. In those cases refractory to the conventional medical therapy, a shunt reduction must be performed.
Collapse
|
35
|
Abstract
In the 25 years since the first TIPS intervention has been performed, technical standards, indications, and contraindications have been set up. The previous considerable problem of shunt failure by thrombosis or intimal proliferation in the stent or in the draining hepatic vein has been reduced considerably by the availability of polytetrafluoroethylene (PTFE)-covered stents resulting in reduced rebleeding and improved survival. Unfortunately, most clinical studies have been performed prior to the release of the covered stent and, therefore, do not represent the present state of the art. In spite of this, TIPS has gained increasing acceptance in the treatment of the various complications of portal hypertension and vascular diseases of the liver.
Collapse
Affiliation(s)
- Martin Rössle
- Praxiszentrum and University Hospital, Freiburg, Germany.
| |
Collapse
|
36
|
Bhogal HK, Sanyal AJ. Using transjugular intrahepatic portosystemic shunts for complications of cirrhosis. Clin Gastroenterol Hepatol 2011; 9:936-46; quiz e123. [PMID: 21699820 PMCID: PMC3200495 DOI: 10.1016/j.cgh.2011.06.013] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/08/2011] [Revised: 06/01/2011] [Accepted: 06/05/2011] [Indexed: 02/07/2023]
Abstract
Transjugular intrahepatic portosystemic shunt (TIPS) decompresses the portal venous system. TIPS has been used to manage the complications of portal hypertension in cirrhosis, including variceal hemorrhage and refractory ascites. The uncoated TIPS stents are limited by stent stenosis; however, the introduction of coated stents has decreased this. With the introduction of coated stents, we must reevaluate the utility of TIPS in the management of complications of portal hypertension.
Collapse
|
37
|
Garcia-Pagán JC, Heydtmann M, Raffa S, Plessier A, Murad S, Fabris F, Vizzini G, Gonzales Abraldes J, Olliff S, Nicolini A, Luca A, Primignani M, Janssen HLA, Valla D, Elias E, Bosch J. TIPS for Budd-Chiari syndrome: long-term results and prognostics factors in 124 patients. Gastroenterology 2008; 135:808-15. [PMID: 18621047 DOI: 10.1053/j.gastro.2008.05.051] [Citation(s) in RCA: 221] [Impact Index Per Article: 13.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/17/2007] [Revised: 04/30/2008] [Accepted: 05/15/2008] [Indexed: 12/12/2022]
Abstract
BACKGROUND & AIMS Budd-Chiari syndrome (BCS) is a rare and life-threatening disorder secondary to hepatic venous outflow obstruction. Small series of BCS patients indicate that transjugular intrahepatic portosystemic shunt (TIPS) may be useful. However, the influence of TIPS on patient survival and factors that predict the outcome of TIPS in BCS patients remain unknown. METHODS One hundred twenty-four consecutive BCS patients treated with TIPS in 6 European centers between July 1993 and March 2006 were followed until death, orthotopic liver transplantation (OLT), or last clinical evaluation. RESULTS Prior to treatment with TIPS, BCS patients had a high Model of End Stage Liver Disease and high Rotterdam BCS prognostic index (98% of patients at intermediate or high risk) indicating severity of liver dysfunction. However, 1- and 5-year OLT-free survival were 88% and 78%, respectively. In the high-risk patients, 5-year OLT-free survival was much better than that estimated by the Rotterdam BCS index (71% vs 42%, respectively). In the whole population, bilirubin, age, and international normalized ratio for prothrombin time independently predicted 1-year OLT-free survival. A prognostic score with a good discriminative capacity (area under the curve, 0.86) was developed from these variables. Seven out of 8 patients with a score >7 died or underwent transplantation vs 5 out of 114 patients with a score <7. CONCLUSIONS Long-term outcome for patients with severe BCS treated with TIPS is excellent even in high-risk patients, suggesting that TIPS may improve survival. Furthermore, we identified a small subgroup of BCS patients with poor prognosis despite TIPS who might benefit from early OLT.
Collapse
Affiliation(s)
- Juan Carlos Garcia-Pagán
- Hepatic Hemodynamic Laboratory, Liver Unit Hospital Cliníc, IDIBAPS and Ciberehd, Barcelona, Spain.
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
38
|
Senzolo M, Burra P, Cholongitas E, Lodato F, Marelli L, Manousou P, Patch D, Sturniolo GC, Burroughs AK. The transjugular route: the key hole to the liver world. Dig Liver Dis 2007; 39:105-16. [PMID: 17196894 DOI: 10.1016/j.dld.2006.06.038] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/31/2006] [Revised: 06/20/2006] [Accepted: 06/27/2006] [Indexed: 02/07/2023]
Abstract
Portal hypertensive complications are major causes of morbidity and mortality in patients with liver cirrhosis. The advent of the transjugular route with its minimal access allows non-surgical management of portal hypertension, therapy of venous complications of liver transplantation, monitoring of therapy for portal hypertension, hepatic venous pressure gradient and is also the major route to treat hepatic venous obstruction syndromes. In addition, the transjugular route is a safe route to perform a liver biopsy (transjugular liver biopsy) and allows retrograde evaluation of the portal vein. All these procedures can be combined in the same session. These hepatic interventional radiological skills should be incorporated into the expertise of the liver team in specialised hepatological centres, particularly in liver transplant centres as they are especially useful in improving outcomes of cirrhotic patients on the liver transplantation waiting list. A limitation in achieving this goal, could be the number of experienced radiologists, but hepatologists can be trained, at least for the most simple procedures (transjugular liver biopsy and hepatic venous pressure gradient). This would allow wider applicability and use of these diagnostic and therapeutic techniques, all through a 2 mm hole in the neck--the key hole to the liver world.
Collapse
Affiliation(s)
- M Senzolo
- Liver Transplantation and Hepatobiliary Unit, Royal Free Hospital, London, Pond Street, London NW3 2QG, UK
| | | | | | | | | | | | | | | | | |
Collapse
|
39
|
Kisilevzky NH. TIPS para o controle das complicações da hipertensão portal: eficácia, fatores prognósticos associados e variações técnicas. Radiol Bras 2006. [DOI: 10.1590/s0100-39842006000600004] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
OBJETIVO: Avaliar a eficácia do TIPS (transjugular intrahepatic portosystemic shunt) para tratar as complicações clínicas em pacientes com hipertensão portal. MATERIAIS E MÉTODOS: Quarenta e quatro pacientes, sendo 30 do sexo masculino e 14 do feminino e com idade média de 52 anos foram analisados. A indicação para realização de TIPS foi hemorragia gastrintestinal em 28 e ascite refratária em 16. Houve 7 pacientes Child-Pugh A, 24 Child-Pugh B e 11 Child-Pugh C. RESULTADOS: O TIPS foi realizado com sucesso em todos os pacientes (100%), verificando-se queda do gradiente pressórico porto-sistêmico médio de 49,69% (de 18,98 mmHg para 9,55 mmHg). Comprovou-se melhora clínica em 35 pacientes (79,55%). A mortalidade pós-operatóriaia foi de 13,64%, sendo mais incidente nos pacientes Child-Pugh C (45,45%). Os fatores mais relevantes de mau prognóstico foram o aumento da bilirrubina e do nível de creatinina. A sobrevida média de pacientes Child-Pugh A foi de 11,5 meses, nos Child-Pugh B foi de 10,97 meses e nos Child-Pugh C foi de apenas 5,9 meses. Foram observadas complicações em nove casos (20,44%). CONCLUSÃO: O TIPS é eficiente para reduzir a pressão portal. As complicações e a morbi-mortalidade relacionadas com o procedimento podem ser consideradas aceitáveis. A mortalidade foi influenciada por alguns fatores clínicos, tais como classe Child-Pugh C e elevação dos níveis séricos de bilirrubina e creatinina.
Collapse
|
40
|
Tripathi D, Redhead D. Transjugular intrahepatic portosystemic stent-shunt: technical factors and new developments. Eur J Gastroenterol Hepatol 2006; 18:1127-33. [PMID: 17033430 DOI: 10.1097/01.meg.0000236871.78280.a7] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
The introduction of expandable metal stents in the mid 1980s led to the development of transjugular intrahepatic portosystemic stent-shunt (TIPSS) as we know it today. Short-lived detrimental effects on the hyperdynamic circulation in cirrhosis accompany the acute reduction in portal pressure following TIPSS creation. Caution is needed in patients with cardiac dysfunction or pulmonary hypertension. With increasing expertise and careful patient selection, fatal procedural complications are rare and TIPSS can even be safely used as a bridge to liver transplantation. Shunt insufficiency and hepatic encephalopathy are more common following TIPSS. Currently, however, novel approaches to tackling both these limitations exist. These include the combination of uncovered TIPSS with variceal band ligation, and the introduction of polytetrafluoroethylene covered stents. Despite the lack of controlled studies, covered stents are now widely used and have the potential to drastically reduce shunt insufficiency, the need for long-term shunt surveillance and even hepatic encephalopathy.
Collapse
Affiliation(s)
- Dhiraj Tripathi
- Department of Hepatology, Royal Infirmary of Edinburgh, Edinburgh, UK.
| | | |
Collapse
|
41
|
Bala TM, Panda M. Cardiac Perforation and Tamponade: A Potentially Fatal Complication During Transjugular Intrahepatic Portosystemic Shunt Placement. South Med J 2006; 99:1000-2. [PMID: 17004537 DOI: 10.1097/01.smj.0000233256.23569.b8] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Transjugular intrahepatic portosystemic shunt (TIPS) is a low-resistance channel between the hepatic vein and the intrahepatic portion of the portal vein. This is an important addition to the therapeutic armamentarium against portal hypertension. Complications are either technical or due to the creation of a shunt. Procedure-related mortality is about 0 to 2%. Cardiac perforation, one of the rarest complications during TIPS, can occur while traversing the catheter from the jugular vein past the right atrium to enter the hepatic vein. We are reporting the case of a 50-year-old woman who became acutely hypotensive with cardiovascular compromise during the TIPS procedure. A stat echocardiogram confirmed cardiac tamponade and emergency pericardiocentesis resulted in improvement of hemodynamic status with complete recovery.
Collapse
Affiliation(s)
- Tripura Mantha Bala
- Department of Medicine, University of Tennessee College of Medicine, Chattanooga Unit, 960 East Third Street, Suite 208, Chattanooga, TN 37403, USA.
| | | |
Collapse
|
42
|
Abstract
Rapid development of diagnostic radiological methods during recent decades has been followed by development of new interventional procedures involving portal circulation. The majority of these interventions were developed for treatment of patients with symptoms secondary to portal hypertension (PH). Interventions involving portal vein circulation have an established position in the treatment of PH and other diseases, and further development of these methods can be expected.
Collapse
Affiliation(s)
- W Cwikiel
- Department of Radiology, University of Michigan Hospital, Ann Arbor 48109, USA.
| |
Collapse
|
43
|
Boyer TD, Haskal ZJ. American Association for the Study of Liver Diseases Practice Guidelines: the role of transjugular intrahepatic portosystemic shunt creation in the management of portal hypertension. J Vasc Interv Radiol 2005; 16:615-29. [PMID: 15872315 DOI: 10.1097/01.rvi.0000157297.91510.21] [Citation(s) in RCA: 96] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Affiliation(s)
- Thomas D Boyer
- Liver Research Institute, University of Arizona School of Medicine, AHSC 245136, Tucson, 85750, USA.
| | | |
Collapse
|
44
|
Siewert E, Salzmann J, Purucker E, Schürmann K, Matern S. Recurrent thrombotic occlusion of a transjugular intrahepatic portosystemic stent-shunt due to activated protein C resistance. World J Gastroenterol 2005; 11:5064-7. [PMID: 16124068 PMCID: PMC4321932 DOI: 10.3748/wjg.v11.i32.5064] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
The transjugular intrahepatic portosystemic stent-shunt (TIPS) has successfully been used in the management of refractory variceal bleeding and ascites in patients with portal hypertension. Major drawbacks are the induction of hepatic encephalopathy and shunt dysfunction. We present a 59-year-old woman with alcoholic liver cirrhosis who received a TIPS because of recurrent bleeding from esophageal varices. Stent occlusion occurred 4 mo after placement of the TIPS. Laboratory testing revealed resistance to activated protein C (APC). Combination therapy with low-dose enoxaparin and clopidogrel could not prevent her recurrent stent occlusion. Finally, therapy with high-dose enoxaparin was sufficient to prevent further shunt complications up to now (follow-up period of 1 year). In conclusion, early occlusion of a TIPS warrants testing for thrombophilia. If risk factors are confirmed, anticoagulation should be intensified. There are currently no evidence-based recommendations regarding the best available anticoagulant therapy and surveillance protocol for patients with TIPS.
Collapse
Affiliation(s)
- Elmar Siewert
- Department of Internal Medicine III, Aachen University, Aachen, Germany.
| | | | | | | | | |
Collapse
|
45
|
Schmidt S, Suter PF. ANGIOGRAPHY OF THE HEPATIC AND PORTAL VENOUS SYSTEM IN THE DOG AND CAT: AN INVESTIGATIVE METHOD*. ACTA ACUST UNITED AC 2005. [DOI: 10.1111/j.1740-8261.1980.tb01353.x] [Citation(s) in RCA: 41] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
|
46
|
The role of transjugular intrahepatic portosystemic shunt in the management of portal hypertension. Hepatology 2005; 41:386-400. [PMID: 15660434 DOI: 10.1002/hep.20559] [Citation(s) in RCA: 286] [Impact Index Per Article: 15.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
|
47
|
Abstract
The transjugular intrahepatic portosystemic shunt (TIPS) is an interventional treatment resulting in decompression of the portal system by creation of a side-to-side portosystemic anastomosis. Since its introduction 16 years ago, more than 1,000 publications have appeared demonstrating broad acceptance and increasing clinical use. This review summarizes our present knowledge about technical aspects and complications, follow-up of patients and indications. A technical success rate near 100% and a low occurrence of complications clearly depend on the skills of the operator. The follow-up of the TIPS patient has to assess shunt patency, liver function, hepatic encephalopathy and the possible development of hepatocellular carcinoma. Shunt patency can best be monitored by duplex sonography and can avoid routine radiological revision. Short-term patency may be improved by anticoagulation, while such a treatment does not influence long-term patency. Stent grafts covered with expanded polytetrafluoroethylene show promising long-term patency comparable with that of surgical shunts. With respect to the indications of TIPS, much is known about treatment of variceal bleeding and refractory ascites. The thirteen randomized studies that are available to date show that survival is comparable in patients receiving TIPS or endoscopic treatment for acute or recurrent variceal bleeding. Another group comprises patients with refractory ascites and related complications, such as hepatorenal syndrome and hepatic hydrothorax. It has been demonstrated that TIPS improves these complications. Five randomized studies comparing TIPS with paracentesis and one study comparing TIPS with the peritoneo-venous shunt showed good response of ascites but controversial results on survival. In addition, TIPS has been successfully applied to patients with Budd-Chiari syndrome, portal vein thrombosis, before liver transplantation, and for the treatment of ectopic variceal bleeding.
Collapse
Affiliation(s)
- Andreas Ochs
- Department of Internal Medicine, Evangelisches Diakonie Krankenhaus, Teaching Hospital of the Medical Faculty, University of Freiburg, Freiburg, Germany.
| |
Collapse
|
48
|
HASHIMOTO T, KOIZUMI J, HOZAWA S, SAITO T, TOKIWA K, SHIBA T, MINE T, IMAI Y. Refractory gastric varices treated by multi-endovascular and endoscopic techniques. ACTA ACUST UNITED AC 2005. [DOI: 10.2957/kanzo.46.284] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Affiliation(s)
- Takeshi HASHIMOTO
- Department of Diagnostic Imaging, University of Tokai School of Medicine
| | - Jun KOIZUMI
- Department of Diagnostic Imaging, University of Tokai School of Medicine
| | - Shigenari HOZAWA
- Department of Internal Medicine, University of Tokai School of Medicine
| | - Takuro SAITO
- Department of Diagnostic Imaging, University of Tokai School of Medicine
| | - Kayoko TOKIWA
- Department of Internal Medicine, University of Tokai School of Medicine
| | - Tadahiko SHIBA
- Department of Internal Medicine, University of Tokai School of Medicine
| | - Tetsuya MINE
- Department of Internal Medicine, University of Tokai School of Medicine
| | - Yutaka IMAI
- Department of Diagnostic Imaging, University of Tokai School of Medicine
| |
Collapse
|
49
|
Rundback JH, Dorfman G, Safriel Y, Mauro M, Wright K, Bonn J, Farahani K, Murthy R. Development of a research agenda for interventional oncology: proceedings from an interdisciplinary consensus panel. J Vasc Interv Radiol 2004; 15:7-12. [PMID: 14709681 DOI: 10.1097/01.rvi.0000106389.63463.d3] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Affiliation(s)
- John H Rundback
- Department of Radiology, Columbia Presbyterian Medical Center, New York, New York 10032, USA.
| | | | | | | | | | | | | | | |
Collapse
|
50
|
Cadranel JF, Jouannaud V, Duron JJ. Prise en charge d’un hydrothorax hépatique. Rev Mal Respir 2004; 21:621-36. [PMID: 15292860 DOI: 10.1016/s0761-8425(04)71372-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Affiliation(s)
- J-F Cadranel
- Unité d'Hépatologie, Service d'Hépato-Gastroentérologie et de Diabétologie, Centre Hospitalier Laennec, BP 72, 60109 Creil
| | | | | |
Collapse
|