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Deltenre P, Zanetto A, Saltini D, Moreno C, Schepis F. The role of transjugular intrahepatic portosystemic shunt in patients with cirrhosis and ascites: Recent evolution and open questions. Hepatology 2023; 77:640-658. [PMID: 35665949 DOI: 10.1002/hep.32596] [Citation(s) in RCA: 17] [Impact Index Per Article: 17.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/15/2022] [Revised: 05/14/2022] [Accepted: 05/16/2022] [Indexed: 01/28/2023]
Abstract
In selected patients with cirrhosis and ascites, transjugular intrahepatic portosystemic shunt (TIPS) placement improves control of ascites and may reduce mortality. In this review, we summarize the current knowledge concerning the use of TIPS for the treatment of ascites in patients with cirrhosis, from pathophysiology of ascites formation to hemodynamic consequences, patient selection, and technical issues of TIPS insertion. The combination of these factors is important to guide clinical decision-making and identify the best strategy for each individual patient. There is still a need to identify the best timing for TIPS placement in the natural history of ascites (recurrent vs. refractory) as well as which type and level of renal dysfunction is acceptable when TIPS is proposed for the treatment of ascites in cirrhosis. Future studies are needed to define the optimal stent diameter according to patient characteristics and individual risk of shunt-related side effects, particularly hepatic encephalopathy and insufficient cardiac response to hemodynamic consequences of TIPS insertion.
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Affiliation(s)
- Pierre Deltenre
- Department of Gastroenterology, Hepatopancreatology, and Digestive Oncology , CUB Hôpital Erasme, Université Libre de Bruxelles , Brussels , Belgium.,Department of Gastroenterology and Hepatology , CHU UCL Namur, Université Catholique de Louvain , Yvoir , Belgium.,Department of Gastroenterology and Hepatology , Clinique St Luc , Bouge , Belgium
| | - Alberto Zanetto
- Division of Gastroenterology, Hepatic Hemodynamic Laboratory , Azienda Ospedaliero-Universitaria di Modena, and University of Modena and Reggio Emilia , Modena , Italy.,Gastroenterology and Multivisceral Transplant Unit, Department of Surgery, Oncology, and Gastroenterology , Padova University Hospital , Padova , Italy
| | - Dario Saltini
- Division of Gastroenterology, Hepatic Hemodynamic Laboratory , Azienda Ospedaliero-Universitaria di Modena, and University of Modena and Reggio Emilia , Modena , Italy
| | - Christophe Moreno
- Department of Gastroenterology, Hepatopancreatology, and Digestive Oncology , CUB Hôpital Erasme, Université Libre de Bruxelles , Brussels , Belgium.,Laboratory of Experimental Gastroenterology , Université Libre de Bruxelles , Brussels , Belgium
| | - Filippo Schepis
- Division of Gastroenterology, Hepatic Hemodynamic Laboratory , Azienda Ospedaliero-Universitaria di Modena, and University of Modena and Reggio Emilia , Modena , Italy
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Tuifua TS, Partovi S, Remer EM, Ragheb J, Bullen JA, Kattan MW, Kapoor B. Assessment of Clinical Outcomes, Clinical Manifestations, and Risk Factors for Hepatic Infarction After Transjugular Intrahepatic Portosystemic Shunt Placement (TIPS): A Retrospective Comparative Study. Cardiovasc Intervent Radiol 2022; 45:1512-1523. [DOI: 10.1007/s00270-022-03219-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/23/2022] [Accepted: 06/28/2022] [Indexed: 11/28/2022]
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Transjugular intrahepatic portosystemic shunt: a meta-analysis of 8 mm versus 10 mm stents. Wideochir Inne Tech Maloinwazyjne 2021; 16:623-632. [PMID: 34950255 PMCID: PMC8669991 DOI: 10.5114/wiitm.2021.104198] [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: 12/22/2020] [Accepted: 01/15/2021] [Indexed: 11/17/2022] Open
Abstract
Introduction Transjugular intrahepatic portosystemic shunt (TIPS) is an approach that is used to alleviate portal hypertension-related symptoms. The optimal stent diameter for TIPS remains controversial. Aim To assess outcomes in patients who underwent TIPS using 8 mm and 10 mm stents. Material and methods The PubMed, Embase, and Cochrane Library databases were queried for all pertinent studies. The meta-analysis was conducted using RevMan v5.3. This meta-analysis was registered at the PROSPERO website (Number: CRD42020212392). Results Eighty-two potentially relevant articles were initially detected, with seven of these ultimately being included in this meta-analysis. Patients in the 10 mm stent group exhibited a significantly higher Δportosystemic pressure gradient (ΔPPG) relative to the 8 mm group (p = 0.04), whereas no differences between groups were observed with respect to postoperative hepatic encephalopathy (HE, p = 0.25), re-bleeding (p = 0.82), liver transplantation (p = 0.45), or mortality (p = 0.43) rates. The TIPS dysfunction rate was significant lower in the 10 mm group (p = 0.01). In Asian studies, the postoperative HE rate was found to be significantly lower in the 8 mm group relative to the 10 mm group (p = 0.02), whereas all other endpoints were comparable between these groups. In Western studies, ΔPPG values were significantly greater in the 10 mm group (p < 0.0001), whereas all other endpoint data were comparable between these groups. Conclusions TIPS with 10 mm stents provides a lower TIPS dysfunction rate. However, 8 mm stents may be recommended for Asian patients, as they can decrease the risk of postoperative HE.
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Matsumoto N, Ogawa M, Kanda T, Matsuoka S, Moriyama M, Matsusaki K. Large-volume cell-free and concentrated ascites reinfusion therapy improves venous flow in patients with liver cirrhosis. J Med Ultrason (2001) 2021; 48:315-322. [PMID: 33835337 DOI: 10.1007/s10396-021-01094-2] [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: 10/29/2020] [Accepted: 04/01/2021] [Indexed: 10/21/2022]
Abstract
PURPOSE Hemodynamic change after total paracentesis was investigated because it might lead to various complications. Although cell-free and concentrated ascites reinfusion therapy (CART) is safer and more effective than total paracentesis in theory, hemodynamic change after CART has been never reported. And previous studies did not mention hemodynamics of the venous system. METHODS We investigated the hemodynamic change, including that of the venous system, before and after CART using color Doppler ultrasonography and fast Fourier transform analysis. Twenty-eight patients with tensive cirrhotic ascites underwent ultrasonography the day before and after total volume CART. The diameter and velocity of the main, right, and left portal vein; inferior vena cava (IVC); and right renal vein were measured using ultrasonography. RESULTS A total of 11.8 ± 4.4 L of ascites (range 3.6-20.9 L) was filtered and concentrated to 0.85 ± 0.40 L (range 0.36-1.50 L). The diameter of the IVC increased from median 13.5 ± 5.4 mm (range 4-25 mm) to 18.5 ± 4.1 mm (range 7-29 mm) (p = 0.007). The diameter of the right segmental renal vein significantly increased after KM-CART [from 5.0 ± 1.0 (4-8) mm to 7.0 ± 2.0 (3-10) mm] (p = 0.011). Hemodynamic change of the portal venous system was not significant. The time to the next CART in patients with an IVC diameter ≥ 20 mm and < 20 mm was 86 days and 20.5 days (p = 0.035), respectively. CONCLUSION Tensive ascites results in venous congestion in patients with cirrhotic ascites. CART improved venous flow, but it did not change the hemodynamics of the portal venous system.
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Affiliation(s)
- Naoki Matsumoto
- Division of Gastroenterology and Hepatology, Department of Medicine, Nihon University School of Medicine, 30-1 Oyaguchi Kamimachi, Itabashi-ku, Tokyo, 173-8610, Japan.
| | - Masahiro Ogawa
- Division of Gastroenterology and Hepatology, Department of Medicine, Nihon University School of Medicine, 30-1 Oyaguchi Kamimachi, Itabashi-ku, Tokyo, 173-8610, Japan
| | - Tatsuo Kanda
- Division of Gastroenterology and Hepatology, Department of Medicine, Nihon University School of Medicine, 30-1 Oyaguchi Kamimachi, Itabashi-ku, Tokyo, 173-8610, Japan
| | - Shunichi Matsuoka
- Division of Gastroenterology and Hepatology, Department of Medicine, Nihon University School of Medicine, 30-1 Oyaguchi Kamimachi, Itabashi-ku, Tokyo, 173-8610, Japan
| | - Mitsuhiko Moriyama
- Division of Gastroenterology and Hepatology, Department of Medicine, Nihon University School of Medicine, 30-1 Oyaguchi Kamimachi, Itabashi-ku, Tokyo, 173-8610, Japan
| | - Keisuke Matsusaki
- Ascites Treatment Center, Kanamecho Hospital, 1-11-13 Kanamecho, Toshima-ku, Tokyo, 171-0043, Japan
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Nicolas C, Le Gouge A, d’Alteroche L, Ayoub J, Georgescu M, Vidal V, Castaing D, Cercueil JP, Chevallier P, Roumy J, Trillaud H, Boyer L, Le Pennec V, Perret C, Giraudeau B, Perarnau JM, STIC-TIPS group. Evaluation of Doppler-ultrasonography in the diagnosis of transjugular intrahepatic portosystemic shunt dysfunction: A prospective study. World J Hepatol 2017; 9:1125-1132. [PMID: 29026464 PMCID: PMC5620422 DOI: 10.4254/wjh.v9.i27.1125] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/28/2017] [Revised: 08/24/2017] [Accepted: 09/05/2017] [Indexed: 02/06/2023] Open
Abstract
AIM To prospectively evaluate the performance of Doppler-ultrasonography (US) for the detection of transjugular intrahepatic portosystemic shunt (TIPS) dysfunction within a multicenter cohort of cirrhotic patients.
METHODS This study was conducted in 10 french teaching hospitals. After TIPS insertion, angiography and liver Doppler-US were carried out every six months to detect dysfunction (defined by a portosystemic gradient ≥ 12 mmHg and/or a stent stenosis ≥ 50%). The association between ultrasonographic signs and dysfunction was studied by logistic random-effects models, and the diagnostic performance of each Doppler criterion was estimated by the bootstrap method. This study was approved by the ethics committee of Tours.
RESULTS Two hundred and eighteen pairs of examinations performed on 87 cirrhotic patients were analyzed. Variables significantly associated with dysfunction were: The speed of flow in the portal vein (P = 0.008), the reversal of flow in the right (P = 0.038) and left (P = 0.049) portal branch, the loss of modulation of portal flow by the right atrium (P = 0.0005), ascites (P = 0.001) and the overall impression of the operator (P = 0.0001). The diagnostic performances of these variables were low; sensitivity was < 58% and negative predictive value was < 73%. Therefore, dysfunction cannot be ruled out from Doppler-US.
CONCLUSION The performance of Doppler-US for the detection of TIPS dysfunction is poor compared to angiography. New tools are needed to improve diagnosis of TIPS dysfunction.
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Affiliation(s)
- Charlotte Nicolas
- Service d’Hépato-Gastroentérologie, Hôpital Trousseau, CHRU Tours, 37044 Tours, France
| | - Amélie Le Gouge
- CIC, CHRU de Tours, 37044 Tours, France
- INSERM, CIC 202, 37044 Tours, France
| | - Louis d’Alteroche
- Service d’Hépato-Gastroentérologie, Hôpital Trousseau, CHRU Tours, 37044 Tours, France
| | - Jean Ayoub
- Unité d’échographie-doppler, Hôpital Trousseau, CHRU Tours, 37044 Tours, France
| | - Monica Georgescu
- Unité d’échographie-doppler, Hôpital Trousseau, CHRU Tours, 37044 Tours, France
| | - Vincent Vidal
- Service de Radiologie, Hôpital de la Timone, 13385 Marseille, France
| | - Denis Castaing
- Centre Hépato-Biliaire, Hôpital Paul Brousse, 94800 Villejuif, France
| | | | - Patrick Chevallier
- Service d’Imagerie Médicale Diagnostique et interventionnelle Hôpital de l’Archet II Nice, 06200 Nice, France
| | - Jérôme Roumy
- Service de Radiologie et Echographie, CHRU Poitiers, 86021 Poitiers, France
| | - Hervé Trillaud
- Service d’Imagerie Médicale Hôpital Saint André, CHRU Bordeaux, 33000 Bordeaux, France
| | - Louis Boyer
- Service d’Imagerie viscérale et vasculaire, CHRU Clermont Ferrand, 63003 Clermont Ferrand, France
| | | | | | - Bruno Giraudeau
- CIC, CHRU de Tours, 37044 Tours, France
- INSERM, CIC 202, 37044 Tours, France
| | - Jean-Marc Perarnau
- Service d’Hépato-Gastroentérologie, Hôpital Trousseau, CHRU Tours, 37044 Tours, France
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Riggio O, Nardelli S, Pasquale C, Pentassuglio I, Gioia S, Onori E, Frieri C, Salvatori FM, Merli M. No effect of albumin infusion on the prevention of hepatic encephalopathy after transjugular intrahepatic portosystemic shunt. Metab Brain Dis 2016; 31:1275-1281. [PMID: 26290375 DOI: 10.1007/s11011-015-9713-x] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/16/2015] [Accepted: 07/16/2015] [Indexed: 12/14/2022]
Abstract
Hepatic encephalopathy (HE) is a major problem in patients submitted to TIPS. Previous studies identified low albumin as a factor associated to post-TIPS HE. In cirrhotics with diuretic-induced HE and hypovolemia, albumin infusion reduced plasma ammonia and improved HE. Our aim was to evaluate if the incidence of overt HE (grade II or more according to WH) and the modifications of venous blood ammonia and psychometric tests during the first month after TIPS can be prevented by albumin infusion. Twenty-three patients consecutively submitted to TIPS were enrolled and treated with 1 g/Kg BW of albumin for the first 2 days after TIPS followed by 0,5 g/Kg BW at day 4th and 7th and then once a week for 3 weeks. Forty-five patients included in a previous RCT (Riggio et al. 2010) followed with the same protocol and submitted to no pharmacological treatment for the prevention of HE, were used as historical controls. No differences in the incidence of overt HE were observed between the group of patients treated with albumin and historical controls during the first month (34 vs 31 %) or during the follow-up (39 vs 48 %). Two patients in the albumin group and three in historical controls needed the reduction of the stent diameter for persistent HE. Venous blood ammonia levels and psychometric tests were also similarly modified in the two groups. Survival was also similar. Albumin infusion has not a role in the prevention of post-TIPS HE.
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Affiliation(s)
- Oliviero Riggio
- Department of Clinical Medicine, Center for the Diagnosis and Treatment of Portal Hypertension "Sapienza" University of Rome, Rome, Italy.
- Centro di Riferimento per l'Ipertensione Portale, II Gastroenterologia, Dipartimento di Medicina Clinica, "Sapienza" Università di Roma, Viale dell'Università 37, 00185, Roma, Italy.
| | - Silvia Nardelli
- Department of Clinical Medicine, Center for the Diagnosis and Treatment of Portal Hypertension "Sapienza" University of Rome, Rome, Italy
| | - Chiara Pasquale
- Department of Clinical Medicine, Center for the Diagnosis and Treatment of Portal Hypertension "Sapienza" University of Rome, Rome, Italy
| | - Ilaria Pentassuglio
- Department of Clinical Medicine, Center for the Diagnosis and Treatment of Portal Hypertension "Sapienza" University of Rome, Rome, Italy
| | - Stefania Gioia
- Department of Clinical Medicine, Center for the Diagnosis and Treatment of Portal Hypertension "Sapienza" University of Rome, Rome, Italy
| | - Eugenia Onori
- Department of Clinical Medicine, Center for the Diagnosis and Treatment of Portal Hypertension "Sapienza" University of Rome, Rome, Italy
| | - Camilla Frieri
- Department of Clinical Medicine, Center for the Diagnosis and Treatment of Portal Hypertension "Sapienza" University of Rome, Rome, Italy
| | - Filippo Maria Salvatori
- Department of Clinical Medicine, Center for the Diagnosis and Treatment of Portal Hypertension "Sapienza" University of Rome, Rome, Italy
| | - Manuela Merli
- Department of Clinical Medicine, Center for the Diagnosis and Treatment of Portal Hypertension "Sapienza" University of Rome, Rome, Italy
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Pereira K, Baker R, Salsamendi J, Doshi M, Kably I, Bhatia S. An Approach to Endovascular and Percutaneous Management of Transjugular Intrahepatic Portosystemic Shunt (TIPS) Dysfunction: A Pictorial Essay and Clinical Practice Algorithm. Cardiovasc Intervent Radiol 2015; 39:639-651. [DOI: 10.1007/s00270-015-1247-4] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/25/2015] [Accepted: 11/07/2015] [Indexed: 12/22/2022]
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Pinter SZ, Rubin JM, Kripfgans OD, Novelli PM, Vargas-Vila M, Hall AL, Fowlkes JB. Volumetric blood flow in transjugular intrahepatic portosystemic shunt revision using 3-dimensional Doppler sonography. JOURNAL OF ULTRASOUND IN MEDICINE : OFFICIAL JOURNAL OF THE AMERICAN INSTITUTE OF ULTRASOUND IN MEDICINE 2015; 34:257-66. [PMID: 25614399 PMCID: PMC6314288 DOI: 10.7863/ultra.34.2.257] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/06/2023]
Abstract
OBJECTIVES Three-dimensional (3D)/4-dimensional (4D) sonographic measurement of blood volume flow in transjugular intrahepatic porto systemic shunt revision with the intention of objective assessment of shunt patency. METHODS A total of 17 patients were recruited (12 male and 5 female; mean age, 55 years; range, 30-69 years). An ultrasound system equipped with a 2.0-5.0-MHz probe was used to acquire multivolume 3D/4D color Doppler data sets to assess prerevision and postrevision shunt volume flow. Volume flow was computed offline based on the principle of surface integration of Doppler-measured velocity vectors in a lateral-elevational c-surface positioned at the color flow focal depth (range, 8.0-11.5 cm). Volume flow was compared to routine measurements of the prerevision and postrevision portosystemic pressure gradient. Prerevision volume flow was compared with the outcome to determine whether a flow threshold for revision could be defined. RESULTS Linear regression of data from revised transjugular intrahepatic portosystemic shunt cases showed an inverse correlation between the mean-normalized change in prerevision and postrevision shunt volume flow and the mean-normalized change in the prerevision and postrevision portosystemic pressure gradient (r(2) = 0.51; P = .020). Increased shunt blood flow corresponded to a decreased pressure gradient. Comparison of prerevision flows showed preliminary threshold development at 1534 mL/min, below which a shunt revision may be recommended (P = .21; area under the receiver operating characteristic curve = 0.78). CONCLUSIONS Shunt volume flow measurement with 3D/4D Doppler sonography provides a potential alternative to standard pulsed wave Doppler metrics as an indicator of shunt function and predictor of revision.
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Affiliation(s)
- Stephen Z Pinter
- Department of Radiology, University of Michigan, Ann Arbor, Michigan USA (S.Z.P., J.M.R., O.D.K., P.M.N., M.V.-V., J.B.F.); and GE Healthcare, Milwaukee, Wisconsin USA (A.L.H.)
| | - Jonathan M Rubin
- Department of Radiology, University of Michigan, Ann Arbor, Michigan USA (S.Z.P., J.M.R., O.D.K., P.M.N., M.V.-V., J.B.F.); and GE Healthcare, Milwaukee, Wisconsin USA (A.L.H.)
| | - Oliver D Kripfgans
- Department of Radiology, University of Michigan, Ann Arbor, Michigan USA (S.Z.P., J.M.R., O.D.K., P.M.N., M.V.-V., J.B.F.); and GE Healthcare, Milwaukee, Wisconsin USA (A.L.H.).
| | - Paula M Novelli
- Department of Radiology, University of Michigan, Ann Arbor, Michigan USA (S.Z.P., J.M.R., O.D.K., P.M.N., M.V.-V., J.B.F.); and GE Healthcare, Milwaukee, Wisconsin USA (A.L.H.)
| | - Mario Vargas-Vila
- Department of Radiology, University of Michigan, Ann Arbor, Michigan USA (S.Z.P., J.M.R., O.D.K., P.M.N., M.V.-V., J.B.F.); and GE Healthcare, Milwaukee, Wisconsin USA (A.L.H.)
| | - Anne L Hall
- Department of Radiology, University of Michigan, Ann Arbor, Michigan USA (S.Z.P., J.M.R., O.D.K., P.M.N., M.V.-V., J.B.F.); and GE Healthcare, Milwaukee, Wisconsin USA (A.L.H.)
| | - J Brian Fowlkes
- Department of Radiology, University of Michigan, Ann Arbor, Michigan USA (S.Z.P., J.M.R., O.D.K., P.M.N., M.V.-V., J.B.F.); and GE Healthcare, Milwaukee, Wisconsin USA (A.L.H.)
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Perarnau JM, Le Gouge A, Nicolas C, d'Alteroche L, Borentain P, Saliba F, Minello A, Anty R, Chagneau-Derrode C, Bernard PH, Abergel A, Ollivier-Hourmand I, Gournay J, Ayoub J, Gaborit C, Rusch E, Giraudeau B. Covered vs. uncovered stents for transjugular intrahepatic portosystemic shunt: a randomized controlled trial. J Hepatol 2014; 60:962-8. [PMID: 24480619 DOI: 10.1016/j.jhep.2014.01.015] [Citation(s) in RCA: 128] [Impact Index Per Article: 12.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/17/2013] [Revised: 01/14/2014] [Accepted: 01/14/2014] [Indexed: 12/16/2022]
Abstract
BACKGROUND & AIMS The first studies comparing covered stents (CS) and bare stents (BS) to achieve Transjugular Intrahepatic Portosystemic Shunt (TIPS) were in favor of CS, but only one randomized study has been performed. Our aim was to compare the primary patency of TIPS performed with CS and BS. METHODS The study was planned as a multicenter, pragmatic (with centers different in size and experience), randomized, single-blinded (with blinding of patients only), parallel group trial. The primary endpoint was TIPS dysfunction defined as either a portocaval gradient ⩾12mmHg, or a stent lumen stenosis ⩾50%. A transjugular angiography with portosystemic pressure gradient measurement was scheduled every 6months after TIPS insertion. RESULTS 137 patients were randomized: 66 to receive CS, and 71 BS. Patients who were found to have a hepato-cellular carcinoma, or whose procedure was cancelled were excluded, giving a sample of 129 patients (62 vs. 67). Median follow-up for CS and BS were 23.6 and 21.8months, respectively. Compared to BS, the risk of TIPS dysfunction with CS was 0.60 95% CI [0.38-0.96], (p=0.032). The 2-year rate of shunt dysfunction was 44.0% for CS vs. 63.6% for BS. Early post TIPS complications (22.4% vs. 34.9%), risk of hepatic encephalopathy (0.89 [0.53-1.49]) and 2-year survival (70% vs. 67.5%) did not differ in the two groups. The 2-year cost/patient was 20k€ [15.9-27.5] for CS vs. 23.4k€ [18-37] for BS (p=0.52). CONCLUSIONS CS provided a significant 39% reduction in dysfunction compared to BS. We did not observe any significant difference with regard to hepatic encephalopathy or death.
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Affiliation(s)
- Jean Marc Perarnau
- Service d'Hépato-Gastroentérologie, Hôpital Trousseau, CHRU Tours, France.
| | - Amélie Le Gouge
- INSERM, CIC 202, Tours, France; CHRU de Tours, Tours, France
| | - Charlotte Nicolas
- Service d'Hépato-Gastroentérologie, Hôpital Trousseau, CHRU Tours, France; Université François-Rabelais de Tours, PRES Centre-Val de Loire Université, Tours, France
| | - Louis d'Alteroche
- Service d'Hépato-Gastroentérologie, Hôpital Trousseau, CHRU Tours, France
| | - Patrick Borentain
- Service d'Hépato-Gastroentérologie, Hôpital de la Conception, Marseille, France
| | - Faouzi Saliba
- Service d'Hépato-Gastroentérologie, Hôpital Paul Brousse, Paris, France
| | - Anne Minello
- Service d'Hépato-Gastroentérologie, CHRU Dijon, France
| | - Rodolphe Anty
- Institut National de la Santé et de la Recherche Médicale (INSERM), U1065, Team 8, "Hepatic Complications in Obesity", Nice F-06204, Cedex 3, France; Centre Hospitalier Universitaire of Nice, Digestive Center, Nice F-06202, Cedex 3, France; University of Nice-Sophia-Antipolis, Faculty of Medecine, Nice F-06107, Cedex 2, France
| | | | | | - Armand Abergel
- Service d'Hépato-Gastroentérologie, CHRU Clermont-Ferrand, France
| | | | | | - Jean Ayoub
- Service d'Echographie Hôpital Trousseau, CHRU Tours, France
| | - Christophe Gaborit
- Service d'information médicale, épidémiologie et économie de la santé, CHRU Bretonneau, Tours, France
| | - Emmanuel Rusch
- Service d'information médicale, épidémiologie et économie de la santé, CHRU Bretonneau, Tours, France
| | - Bruno Giraudeau
- INSERM, CIC 202, Tours, France; CHRU de Tours, Tours, France; Université François-Rabelais de Tours, PRES Centre-Val de Loire Université, Tours, France
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MacNicholas R, Olliff S, Elias E, Tripathi D. An update on the diagnosis and management of Budd-Chiari syndrome. Expert Rev Gastroenterol Hepatol 2012; 6:731-44. [PMID: 23237258 DOI: 10.1586/egh.12.56] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Budd-Chiari syndrome is a rare disorder caused by hepatic venous outflow obstruction and resulting hepatic dysfunction. Despite a lack of prospective randomized trials, much progress has been made in its management over the last 20 years. The main goals of treatment are to ameliorate hepatic congestion and prevent further thrombosis. The selective use of anticoagulation, vascular stents, transjugular intrahepatic portosystemic stent-shunt and liver transplant has resulted in a significant increase in survival. The diagnosis, initial management and long-term follow-up of patients with Budd-Chiari syndrome is reviewed. The concept of individualization of treatment and a stepwise approach to invasive procedures is also discussed.
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Wu Q, Jiang J, He Y, Jiang T, Zhou S. Transjugular intrahepatic portosystemic shunt using the FLUENCY expanded polytetrafluoroethylene-covered stent. Exp Ther Med 2012; 5:263-266. [PMID: 23251280 PMCID: PMC3523954 DOI: 10.3892/etm.2012.776] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2012] [Accepted: 10/15/2012] [Indexed: 12/13/2022] Open
Abstract
The aim of this study was to evaluate the feasibility of transjugular intrahepatic portosystemic shunts using FLUENCY expanded polytetraf luoroethylene (PTFE)-covered stents and the effect on the patency rate. A total of 114 cirrhotic patients who were treated by transjugular intrahepatic portosystemic stent shunt (TIPS) placement using a FLUENCY expanded, PTFE-covered stent were enrolled in the present study. Of the patients, 15 underwent an additional bare metal stent implantation on the portal side of the covered stent, simultaneously. Patients underwent Doppler sonography during the follow-up. Mean portal venous pressure dropped from 2.499±0.588 cmHg to 1.764±0.294 cmHg. The cumulative patency rates for one and two years were 86.7% and 75.2%, respectively. The results demonstrate the feasibility of TIPS placement with the FLUENCY expanded PTFE-covered stent. TIPS placement with the FLUENCY expanded PTFE-covered stent was able to improve patency when compared with the use of conventional bare-metal stents.
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Affiliation(s)
- Qinghua Wu
- Department of Radiology, The Third Affiliated Hospital of Nantong University
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Perumalswami PV, Schiano TD. The management of hospitalized patients with cirrhosis: the Mount Sinai experience and a guide for hospitalists. Dig Dis Sci 2011; 56:1266-81. [PMID: 21416246 DOI: 10.1007/s10620-011-1619-9] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/15/2010] [Accepted: 02/05/2011] [Indexed: 12/15/2022]
Abstract
BACKGROUND Cirrhosis and chronic liver disease carry appreciable morbidity and mortality. Cirrhotic patients frequently require hospitalization and their care is both extremely complex and labor-intensive. AIM We seek to provide a review for gastroenterologists, hepatologists, internists, and hospitalists on the approach to care in patients hospitalized for complications related to end-stage liver disease. METHODS The Mount Sinai Medical Center's inpatient liver service has developed an integrated team approach for cirrhotic patients and throughout the years has educated fellows-in-training and medical house staff on both the treatment principles and "pearls" in managing the hospitalized cirrhotic patient. We reviewed the literature and provide recommendations on the management of complications of end-stage liver disease. Additionally, we provide a review of the protocols used at our institution in the care for cirrhotic patients. RESULTS Major complications of advanced liver disease include infection, ascites, spontaneous bacterial peritonitis, hepatic encephalopathy, portal hypertension, variceal hemorrhage, hepatorenal syndrome, and hepatocellular carcinoma. Management of these complications involves selecting the appropriate diagnostic studies and prompt administration of therapy. CONCLUSIONS There are many complications of cirrhosis. Management of these complications can be complex and are targeted at stabilizing the patient's clinical condition. Liver transplantation remains the only definitive treatment.
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Affiliation(s)
- Ponni V Perumalswami
- Division of Liver Diseases, The Mount Sinai Medical Center, Mount Sinai School of Medicine, One Gustave Levy Place, Box 1104, New York, NY 10029, USA
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Riggio O, Ridola L, Angeloni S, Cerini F, Pasquale C, Attili AF, Fanelli F, Merli M, Salvatori FM. Clinical efficacy of transjugular intrahepatic portosystemic shunt created with covered stents with different diameters: results of a randomized controlled trial. J Hepatol 2010; 53:267-72. [PMID: 20537753 DOI: 10.1016/j.jhep.2010.02.033] [Citation(s) in RCA: 100] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/01/2009] [Revised: 02/25/2010] [Accepted: 02/25/2010] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS The incidence of post-TIPS hepatic encephalopathy (HE) could be reduced by using stents with a small diameter. The aim of this study was to compare the incidence of HE and the clinical efficacy of TIPS created with 8- or 10-mm PTFE-covered stents. METHODS Consecutive cirrhotics submitted to TIPS for variceal bleeding or refractory ascites were randomized to receive a 8- or 10-mm covered stent. As recommended by our Ethical Committee, the trial was stopped after the inclusion of 45 patients. RESULTS The two groups were comparable for age, sex, etiology, and psychometric performance. After TIPS, the portosystemic pressure gradient was significantly higher in the 8-mm stent group (8.9+/-2.7 versus 6.5+/-2.7 mmHg; p=0.007). Consequently, the probability of remaining free of complications due to portal hypertension was significantly higher in the 10-mm than in the 8-mm stent group: 82.9% versus 41.9% at one year; log-rank test, p=0.002. In particular, the persistence of ascites with the need for repeated paracentesis was significantly more frequent in the patients treated with 8-mm stent diameter for refractory ascites (log-rank test, p=0.008). The probability of remaining free of HE was similar in both groups. Cumulative survival rate was similar in both groups. CONCLUSIONS The use of 8-mm diameter stents for TIPS leads to a significantly less efficient control of complications of portal hypertension. HE remains an unsolved major problem after TIPS.
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Affiliation(s)
- Oliviero Riggio
- II Gastroenterologia, Dipartimento di Medicina Clinica, La Sapienza Università di Roma, Italy.
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Dabos KJ, Stanley AJ, Redhead DN, Jalan R, Hayes RC. Efficacy of balloon angioplasty, restenting, and parallel shunt insertion for shunt insufficiency after transjugular intrahepatic portosystemic stent-shunt (TIPSS). MINIM INVASIV THER 2009. [DOI: 10.3109/13645709809152867] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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MRI of TIPS with covered stent-grafts: In vitro analysis using a flow phantom and initial clinical experience. AJR Am J Roentgenol 2009; 192:W317-20. [PMID: 19457796 DOI: 10.2214/ajr.07.2731] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
OBJECTIVE The use of the Viatorr stent-graft for transjugular intrahepatic portosystemic shunt (TIPS) creation is thought to improve patency rates. This study was designed to show the feasibility and pitfalls of imaging Viatorr TIPS using MRI. CONCLUSION MRI of the Viatorr stent-graft is feasible for the initial assessment of the TIPS. Familiarity with the imaging patterns will allow proper interpretation of the MRI findings. MRI also allows the depiction of detailed anatomic information concerning stent positioning.
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Riggio O, Angeloni S, Salvatori FM, De Santis A, Cerini F, Farcomeni A, Attili AF, Merli M. Incidence, natural history, and risk factors of hepatic encephalopathy after transjugular intrahepatic portosystemic shunt with polytetrafluoroethylene-covered stent grafts. Am J Gastroenterol 2008; 103:2738-46. [PMID: 18775022 DOI: 10.1111/j.1572-0241.2008.02102.x] [Citation(s) in RCA: 184] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
BACKGROUND AND AIMS The aim of this study was to assess the incidence, natural history, and risk factors of hepatic encephalopathy (HE) after transjugular intrahepatic portosystemic shunt (TIPS) with the new polytetrafluoroethylene (PTFE)-covered stent grafts in cirrhotic patients. PATIENTS AND METHODS Seventy-eight cirrhotic patients treated by TIPS with PTFE-covered stent grafts and followed by the same medical team--according to a prospective protocol for diagnostic workup and surveillance strategy--were reviewed. The follow-up was 19.9 +/- 20.6 months. RESULTS At least one episode of HE occurred in 35 of 78 (44.8%) patients. The probability of remaining free of HE was 53.8% (95% confidence interval [CI] 41.4-66.2] at 1 yr and 50.9% at 2 yr (95% CI 38.2-63.8%). The total number of HE episodes was 89. Fifty-five percent of the episodes were grades III-IV. The occurrence of HE tended to be constant during the follow-up, probably because of the very low incidence of shunt dysfunction (13.6% at 2 yr). Moreover, in six patients, a refractory HE required the reduction of the shunt diameter. One patient died due to variceal bleeding after this procedure. At a multivariate analysis, an older age, high creatinine levels, and low serum sodium and low albumin values were shown to be independent factors for the occurrence of HE. Serum creatinine level was the only variable related to the development of refractory HE at the logistic multivariate analysis. CONCLUSIONS HE after TIPS with PTFE-covered stent grafts is frequent; its incidence is not confined to the first post-TIPS period, but it has the tendency to be frequent over time. Refractory HE occurred in 8% of patients and may be successfully managed by reducing the stent diameter. The selection of patients undergoing TIPS placement should be very accurate, especially for those subjects with abnormal creatinine level.
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Affiliation(s)
- Oliviero Riggio
- II Gastroenterologia, Dipartimento di Medicina Clinica, Sapienza Università di Roma, Rome, Italy
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Is sonographic surveillance of polytetrafluoroethylene-covered transjugular intrahepatic portosystemic shunts (TIPS) necessary? A single centre experience comparing both types of stents. Clin Radiol 2008; 63:1142-8. [PMID: 18774362 DOI: 10.1016/j.crad.2008.04.016] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2007] [Revised: 03/27/2008] [Accepted: 04/01/2008] [Indexed: 02/06/2023]
Abstract
AIM To investigate whether sonographic (US) surveillance of polytetrafluoroethylene covered transjugular intrahepatic portosystemic shunts (TIPS) is necessary. MATERIALS AND METHODS We identified 128 patients who underwent TIPS for complications of portal hypertension between January 2001 and December 2005 at a large tertiary centre. Procedural data were retrospectively analysed. US surveillance of the TIPS was performed at baseline with scheduled follow-up or whenever shunt dysfunction was suspected. Clinical and radiology reports were compared to assess US surveillance of the TIPS. RESULTS Four hundred and twenty-six US studies were performed, with a median of three per patient (range 1-5). The median follow-up period was 378 days (range 1-1749 days). Twenty-three patients (18%) had baseline US studies performed only whereas 105 (82%) also had follow-up studies. Forty-one (32%) of 128 patients [32 (78%) Wallstent, nine (22%) Viatorr] had Doppler ultrasound abnormalities noted. Venography was performed in all 41 patients. Abnormal venography and elevated hepatic venous pressure gradient (HVPG) was seen in 34 (82.9%) of the 41 patients [29 (85.3%) Wallstent, five (14.7%) Viatorr]. Among the 34 patients, 17 (50%) [13 (76.5%) Wallstent, four (23.5%) Viatorr] had venographic abnormalities noted at the hepatic venous end accompanied by increased HVPG. All four of the Viatorr patients had minor narrowing at the hepatic venous end and HVPG measurements that ranged 3-4 mm Hg above 12 mm Hg. CONCLUSION Considering the improved patency of covered stents in TIPS, US surveillance may be superfluous after the baseline study.
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Hiraki T, Pavcnik D, Uchida BT, Timmermans HA, Wu RH, Niyyati M, Keller FS, Rösch J. Small intestinal submucosa sandwich Zilver stent-grafts for TIPS: experimental pilot study in swine. MINIM INVASIV THER 2007; 14:32-8. [PMID: 16754151 DOI: 10.1080/13645700510010818] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
The aim of this study was the evaluation of preliminary suitability of the piglet small intestinal submucosa (SIS) sandwich Zilver endograft for experimental transjugular intrahepatic portosystemic shunt (TIPS) creation. TIPS was created in six swine. The five surviving animals underwent the follow-up portogram and were sacrificed at four weeks after TIPS creation. Gross and histologic examination was performed in all animals. TIPS creation was successful in all animals. One animal died four days after TIPS creation. In the five surviving animals, one shunt was occluded and four shunts were stenosed on the follow-up portogram. The mean percentage narrowing of the most advanced stenoses was 72% (range, 60%-100%). The most advanced stenosis was located in the parenchymal tract in three shunts and in the hepatic vein portion in one shunt. Gross and histologic examination showed abundant neointimal formation composed mainly of fibroblasts leading to the significant shunt stenoses. The piglet SIS sandwich Zilver stent-graft was found to offer only limited TIPS patency and should not be used for the definitive long-term TIPS study.
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Affiliation(s)
- T Hiraki
- Dotter Interventional Institute, Oregon Health and Science University, Portland, Oregon 97239, USA
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Carr CE, Tuite CM, Soulen MC, Shlansky-Goldberg RD, Clark TWI, Mondschein JI, Kwak A, Patel AA, Coleman BG, Trerotola SO. Role of ultrasound surveillance of transjugular intrahepatic portosystemic shunts in the covered stent era. J Vasc Interv Radiol 2006; 17:1297-305. [PMID: 16923976 DOI: 10.1097/01.rvi.0000231951.47931.82] [Citation(s) in RCA: 35] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
PURPOSE To assess ultrasound (US) surveillance of expanded polytetrafluoroethylene (ePTFE)-covered stents in transjugular intrahepatic portosystemic shunts (TIPS). MATERIALS AND METHODS Procedural data, including stent size and portosystemic gradients (PSG) before and after creation of TIPS, were obtained retrospectively in 55 patients (33 men, 22 women). Chart review provided clinical information, including etiology of liver disease, indication for TIPS creation, and Child-Pugh class. Radiology reports provided US venography data and pathology reports confirmed shunt status in transplant recipients. Patients had baseline US examinations 3-7 days after TIPS creation with scheduled follow-up at 1, 3, 6, and 12 months after the procedure. Clinical and radiology reports were compared to evaluate US surveillance of Viatorr stents. RESULTS One hundred fifty-nine US examinations were performed on 52 patients, for an average 3.1 studies per patient (range, 1-7) over a mean follow-up duration of 173 days (range, 0-1,013 d). Sixty-four US studies (40%) were baseline studies, 88 studies (55%) were routine follow-up studies, and seven (4%) were interval studies. US predicted TIPS abnormalities in 30 of 159 studies (19%); venography followed 15 of 30 abnormal US findings (50%) and clinical examinations complemented 10 of 15 venograms (67%). Venography and US were concordant in eight of 15 paired studies (53%); clinical examinations, when conducted, accurately predicted shunt status in all but one case. US findings changed management in six of 159 studies (4%): five of six (83%) were baseline evaluations and the other one (17%) was a routine follow-up examination. A total of five baseline US examinations (8%) and one surveillance examination (1%) altered patient management. CONCLUSIONS A single US examination after a TIPS procedure to confirm immediate function may be valuable, but routine US is not effective for long-term surveillance of ePTFE-covered stents.
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Affiliation(s)
- Caitlin E Carr
- Department of Radiology, Division of Interventional Radiology, University of Pennsylvania Medical Center, 1 Silverstein, 3400 Spruce Street, Philadelphia, 19104, USA
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Helmy A, Redhead DN, Stanley AJ, Hayes PC. The natural history of parallel transjugular intrahepatic portosystemic stent shunts using uncovered stent: the role of host-related factors. Liver Int 2006; 26:572-8. [PMID: 16762002 DOI: 10.1111/j.1478-3231.2006.01264.x] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
OBJECTIVES Parallel shunts (PS) are used in the management of transjugular intrahepatic portosystemic stent-shunt (TIPS) insufficiency, a major limitation of the technique. This study describes the natural history of PS, and uses them as a model to assess the role of host factors in the development of primary shunt insufficiency. METHODS Out of 338 patients with TIPS, 40 (11.8%) patients required insertion of a PS. Baseline and follow-up data of these patients were collected. Regular shunt surveillance involved biannual clinic visits and transjugular portography. RESULTS The non-PS group (group 1; n = 298) and the PS group (group 2; n = 40) had similar baseline demographic and disease characteristics. Index shunts of both groups and the PS produced a significant portal pressure gradient drop (P < 0.001), which was less in the index shunts of Group 2 (P < 0.02 for both). PS had similar cumulative shunt patency rates to those of the index shunts of Group 1, and both were greater than those of index shunts in Group 2 (P < 0.001 for both). The intervention rate (number of interventions/number of check portograms x 100) was similar for PS and the index shunts of Group 1 (38.7% and 43% respectively), but was significantly higher in the index shunts of Group 2 (85.6%; P < 0.01 for both). In Group 1 and Group 2, 144 patients (48.3%) and 21 patients (52.5%) died during follow-up after a median period of 23.4 and 8.9 months respectively. CONCLUSIONS These findings do not support the hypothesis that shunt insufficiency is related to host factors.
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Affiliation(s)
- Ahmed Helmy
- Department of Liver Transplantation, Hepatobiliary and Pancreatic Surgery, King Faisal Specialist Hospital & Research Center, Riyadh, Saudi Arabia.
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Hidajat N, Wust P, Kreuschner M, Felix R, Schröder RJ. Radiation risks for the radiologist performing transjugular intrahepatic portosystemic shunt (TIPS). Br J Radiol 2006; 79:483-6. [PMID: 16714750 DOI: 10.1259/bjr/67632946] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
The aim of this study is to evaluate the radiation dose to the interventional radiologist in transjugular intrahepatic portosystemic shunt (TIPS) concerning the risk of cancer and deterministic radiation effects and the relation to recommended dose limits. In 18 TIPS interventions radiation doses were measured with thermoluminescence dosemeters (TLD) fixed at the eyebrow, thyroid and hand of the radiologist without special lead shielding of these body parts and at the chest, abdomen and testes under the lead apron. The doses of the eye lens, thyroid gland and hand were assumed to be equal to the corresponding surface doses. The dose at the abdomen under the lead apron was used as an estimation of the ovarian dose. Effective dose equivalent was estimated by Webster's method. The estimated effective dose equivalent was 0.087 mSv and the effective dose 0.110 mSv. The risk of fatal cancer was of 10(-6) and the risk of severe genetic defect of 10(-7) for one single intervention. The maximum permissible number of TIPS interventions was 181, otherwise the dose limit for effective dose would be exceeded. When the radiologist performed more than 372 TIPS procedures per year for many years, the dose to the lens of the eye could exceed the threshold for cataract. If the interventionist performs a large number of TIPS procedures in a year, the risk of fatal cancer and developing cataracts becomes relatively high.
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Affiliation(s)
- N Hidajat
- Department of Radiology, Charité Campus Virchow-Klinikum, University Medicine Berlin, Augustenburger Platz 1, 13353 Berlin, Germany
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Abstract
Many advances have occurred in the management of varices over the years. Guidelines based on sound evidence have been developed to manage the esophageal variceal hemorrhage. Less is known about how best to manage some of the more difficult cases of bleeding related to portal hypertension. This article reviews evidence in the hypertensive gastropathy, ectopic varices, and management of patients who are intolerant of or have not responded to beta-blocker therapy. The goal of this article is to review the sparse available evidence and to suggest reasonable management options.
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Affiliation(s)
- Atif Zaman
- Division of Gastroenterology and Hepatology, Oregon Health & Science University, 3181 Southwest Sam Jackson Park Road, Mailcode PV310, Portland, OR 97210, USA.
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Hidajat N, Stupavsky A, Gellermann J, Kreuschner M, Stahl H, Wust P, Felix R, Schroeder RJ. Intraluminal brachytherapy of de novo TIPS: a prospective randomized double-blind study. AJR Am J Roentgenol 2006; 186:1133-7. [PMID: 16554592 DOI: 10.2214/ajr.04.1857] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
OBJECTIVE The aim of this prospective double-blind and randomized study was to assess whether intraluminal brachytherapy of de novo transjugular intrahepatic portosystemic shunts (TIPS) can prevent significant shunt stenosis. SUBJECTS AND METHODS Forty patients with portal hypertension due to liver cirrhosis were enrolled. In the irradiation group of 20 patients, the gamma radiation source, iridium-192, was introduced into the shunt within a special balloon catheter that allows the radionuclide to be centered within the shunt. A dose of 14 Gy in the shunt wall at a depth of 2 mm should be achieved. In the control group of 20 patients, a dummy source was used. Doppler sonography was performed immediately, 1 day, 1 week, 4 weeks, and 3 months after TIPS placement and then at an interval of 3 months during the first year. The primary end point of the study was the percentage of patients who developed significant shunt stenosis, defined as a reduction of maximum flow velocity below 50 cm/sec in the proximal part of the shunt 1 cm from the entry of the stent into the punctured portal vein branch. Fisher's exact test was used. RESULTS The TIPS procedure was technically successful in all patients. Seventeen patients in the irradiation group and 15 patients in the control group were followed up. Five patients (29.4%) in the irradiation group and 10 (66.7%) in the control group developed significant shunt stenosis during the first year after TIPS placement (p = 0.0392). The time until such stenosis occurred did not differ significantly between the two groups. CONCLUSION Our results suggest that brachytherapy can be useful in reducing the incidence of TIPS stenosis. A larger study with histopathologic analysis may be needed to confirm these findings.
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Affiliation(s)
- Nico Hidajat
- Department of Radiology, Charité Hospital, Berlin, Germany
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Vassiliadis T, Garipidou V, Perifanis V, Tziomalos K, Giouleme O, Patsiaoura K, Avramidis M, Nikolaidis N, Vakalopoulou S, Tsitouridis I, Antoniadis A, Semertzidis P, Kioumi A, Premetis E, Eugenidis N. A case of successful management with splenectomy of intractable ascites due to congenital dyserythropoietic anemia type II-induced cirrhosis. World J Gastroenterol 2006; 12:818-21. [PMID: 16521204 PMCID: PMC4066141 DOI: 10.3748/wjg.v12.i5.818] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [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 congenital dyserythropoietic anemias comprise a group of rare hereditary disorders of erythropoiesis, characterized by ineffective erythropoiesis as the predominant mechanism of anemia and by characteristic morphological aberrations of the majority of erythroblasts in the bone marrow. Congenital dyserythropoietic anemia type II is the most frequent type. All types of congenital dyserythropoietic anemias distinctly share a high incidence of iron loading. Iron accumulation occurs even in untransfused patients and can result in heart failure and liver cirrhosis. We have reported about a patient who presented with liver cirrhosis and intractable ascites caused by congenital dyserythropoietic anemia type II. Her clinical course was further complicated by the development of autoimmune hemolytic anemia. Splenectomy was eventually performed which achieved complete resolution of ascites, increase of hemoglobin concentration and abrogation of transfusion requirements.
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Affiliation(s)
- Themistoklis Vassiliadis
- 2nd Propedeutic Department of Internal Medicine, Aristotle University of Thessaloniki, Hippokration General Hospital, Thessaloniki, Greece
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Saravanan R, Nayar M, Gilmore IT, Smart H, McWilliams RG, Rowlands PC, Evans J, Murphy M, Gould D, Taylor S, Sutton R, Lombard MG. Transjugular intrahepatic portosystemic stent shunt: 11 years' experience at a regional referral centre. Eur J Gastroenterol Hepatol 2005; 17:1165-71. [PMID: 16215427 DOI: 10.1097/00042737-200511000-00003] [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: 12/21/2022]
Abstract
OBJECTIVES Transjugular intrahepatic portosystemic stent shunt (TIPSS) is now widely used in the treatment of uncontrolled and recurrent variceal haemorrhage. This study reports the outcome and long-term follow-up of 125 patients who were referred to a single centre for TIPSS. METHODS One hundred and twenty-five patients were referred to undergo TIPSS. All but 10 had variceal haemorrhage. The 10 patients referred with refractory ascites were excluded from the analysis. Our follow-up protocol was to assess shunt patency only if bleeding recurred or there was a clinical indication. The mean age was 51.5 years (range 18-87 years) and 64 patients (56%) were male. The commonest aetiology for chronic liver disease was alcohol (80%). At referral, 19 patients (16%) were Child-Pugh class A, 26 patients (23%) were Child-Pugh class B and 70 patients (61%) were Child-Pugh class C. The mean follow-up period was 20.4 months (range 0-95 months). RESULTS TIPSS was successfully placed in 108 of 115 patients (94%). The thirty-day mortality was 30%. One-year and 2-year overall cumulative survival was 52% (survival ratio, 0.525; 95% confidence interval, 0.432-0.619) and 43% (survival ratio, 0.436; 95% confidence interval, 0.340-0.532), respectively. CONCLUSION TIPSS is effective in the treatment of uncontrolled or recurrent variceal bleeding. In comparison with previously published studies, our study suggests no value in regular or routine shunt surveillance to reduce rebleeding episodes or mortality, but this needs to be further assessed in prospective randomized studies.
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Affiliation(s)
- Ramasamy Saravanan
- Department of Gastroenterology, Royal Liverpool & Broadgreen University Hospitals, UK
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Charon JPM, Alaeddin FH, Pimpalwar SA, Fay DM, Olliff SP, Jackson RW, Edwards RD, Robertson IR, Rose JD, Moss JG. Results of a Retrospective Multicenter Trial of the Viatorr Expanded Polytetrafluoroethylene– covered Stent-Graft for Transjugular Intrahepatic Portosystemic Shunt Creation. J Vasc Interv Radiol 2004; 15:1219-30. [PMID: 15525740 DOI: 10.1097/01.rvi.0000137434.19522.e5] [Citation(s) in RCA: 99] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
PURPOSE To report the results of a multicenter experience with the Viatorr expanded polytetrafluoroethylene-covered stent-graft for transjugular intrahepatic portosystemic shunt (TIPS) creation in which patency and clinical outcome were evaluated. MATERIALS AND METHODS One hundred consecutive patients with portal hypertension, with a mean age of 52 years (range, 22-86 years), underwent implantation of the Viatorr TIPS stent-graft at one of three hospital centers. The indications for TIPS creation were variceal bleeding (n = 81) and refractory ascites (n = 19). Twenty patients had Child-Pugh class A disease, 46 had class B disease, and 34 had class C disease. Eighty-seven patients underwent de novo TIPS placements, with 13 treated for recurrent TIPS stenosis. Sixty-two patients were available for follow-up portal venography and portosystemic pressure gradient (PSG) measurement commencing 6 months after Viatorr stent-graft placement. RESULTS The technical success rate was 100%. TIPS creation resulted in an immediate decrease in mean PSG (+/-SD) from 21 mm Hg +/- 6 to 7 mm Hg +/- 3. Acute repeat intervention (within 30 days) was required for portal vein thrombosis (n = 1), continued bleeding (n = 3), and encephalopathy (n = 1). The all-cause 30-day mortality rate was 12%. Two patients developed acute severe refractory encephalopathy, which led to death in one case. New or worsening encephalopathy was identified in 14% of patients. The incidence of recurrent bleeding was 8%. The cumulative survival rate at 1 year was 65%. Sixty-two patients available for venographic follow-up had a mean PSG of 9 mm Hg +/- 5 at a mean interval of 343 days (range, 56-967 days). There were four stent-graft occlusions (6%) and seven hemodynamically significant stenoses (11%), four within the stent-graft and three in the non-stent-implanted hepatic vein. The primary patency rate at 1 year by Kaplan-Meier analysis was 84%. CONCLUSIONS This retrospective multicenter experience with the Viatorr stent-graft confirms the preliminary findings of other investigators of good technical results and improved patency compared with bare stents. Early mortality and symptomatic recurrence rates are low by historical standards. The theoretical increase in TIPS-related encephalopathy was not demonstrated. Longer-term follow-up will be required to determine whether the additional cost of the Viatorr stent-graft will be offset by reduced surveillance and repeat intervention.
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Affiliation(s)
- Jean-Pierre M Charon
- Department of Clinical Radiology, Gartnavel General Hospital, 1053 Great Western Road, Glasgow, G12 0YN, United Kingdom
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Hernández-Guerra M, Turnes J, Rubinstein P, Olliff S, Elias E, Bosch J, García-Pagán JC. PTFE-covered stents improve TIPS patency in Budd-Chiari syndrome. Hepatology 2004; 40:1197-202. [PMID: 15486923 DOI: 10.1002/hep.20436] [Citation(s) in RCA: 118] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Transjugular intrahepatic portosystemic shunt (TIPS) have been shown to be an efficient portal-systemic derivative treatment for Budd-Chiari syndrome (BCS) patients uncontrolled by medical therapy. However, the main drawback of TIPS for this condition is a very high rate of shunt dysfunction. Recently, polytetrafluoroethylene (PTFE)-covered stents have been shown to reduce the incidence of TIPS dysfunction in patients with cirrhosis. The aim of the study was to assess the incidence of TIPS dysfunction in 2 cohorts of BCS patients treated with bare or PTFE-covered stents. The study included 25 TIPS procedures (16 bare stents and 9 covered stents) with a median follow-up period of 20.4 months (range, 3.9-124.8). Fourteen of 16 patients (87%) receiving bare stents had TIPS dysfunction compared to 3 of the 9 patients (33%) receiving PTFE-covered stents (P = .005). The actuarial rates of primary patency in the bare-stent group were 19% at 1 year compared with 67% in the PTFE-covered stent group (P = .02; log-rank test). The number of additional interventional procedures to maintain TIPS patency was significantly greater in the bare-stent than in the PTFE-covered stent group (1.9 +/- 1.2 vs. 0.6 +/- 0.9; P = .007). The number of patients with clinical relapses was greater in the bare-stent group compared to the PTFE-covered stent group (13 vs. 5 episodes in 9 and 3 patients, respectively). In conclusion, PTFE-covered stents have a considerable advantage over bare stents for the TIPS treatment of BCS patients, with a lower dysfunction rate, a lower number of reinterventions, and fewer prosthesis requirements. PTFE-covered stents are preferable in patients with Budd-Chiari Syndrome.
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Affiliation(s)
- Manuel Hernández-Guerra
- Hepatic Hemodynamic Laboratory, Liver Unit, Institut de Malalties Digestives, Hospital Clinic, Institut d'Investigaciones Biomédiques August Pi i Sunyer, Barcelona, Spain
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Abstract
BACKGROUND Secondary prophylaxis for esophageal variceal hemorrhage (VH) is recommended, but there has never been a cost-utility analysis of its implementation. OBJECTIVE The objective was to compare the cost utility of various strategies for the secondary prophylaxis of VH including (a) observation alone, (b) medical therapy (MED), (c) endoscopic band ligation (EBL), (d) endoscopic band ligation plus medical therapy (EBL + M), and (e) transjugular intrahepatic portosystemic shunt (TIPS), and to examine the effect of adherence on these strategies. METHODS A Markov model was developed for all five strategies, and included surveillance, risk of hepatic encephalopathy, complications, and nonadherence. DATA SOURCES Published literature and the Health Care Financing Administration. TARGET POPULATION People with cirrhosis and a history of controlled VH. TIME HORIZON Three years. PERSPECTIVE Third-party payer. OUTCOME MEASURES Incremental cost-effectiveness ratios for quality-adjusted life-years (QALYs) gained. RESULTS OF BASE-CASE ANALYSIS Combination EBL + M was the optimal strategy, dominating all other strategies including observation, meaning that it was more effective and less expensive than the others. In addition, EBL alone dominated observation and TIPS in terms of QALYs, and MED alone dominated the strategy of observation in terms of QALYs. RESULTS OF SENSITIVITY ANALYSIS Important variables affecting the optimal strategy were the odds ratio (OR) of VH with EBL compared to MED, the OR of VH with EBL + M compared to EBL, and patients' preferences regarding taking the medication as reflected in the associated toll exacted on the health state utility. Variations in these parameters within the range of clinical plausibility allowed EBL or MED to become the optimal strategy. TIPS was the optimal strategy only if adherence rates for all strategies were less than 12%. RESULTS OF MONTE CARLO ANALYSIS: Neither observation nor TIPS was ever the optimal strategy, and EBL + M was optimal in 62% of cases. If the variables identified in the sensitivity analysis were controlled, then EBL + M was optimal in 95% of cases. CONCLUSIONS TIPS should be reserved only for patients with very poor adherence. Otherwise, patients are best served by medications, EBL, or a combination of both, depending on the comparative rates of rebleeding with each and patients' preferences regarding medical therapy. The redundancy of combination band ligation plus medical therapy can improve outcomes, particularly in the setting of poor patient adherence.
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Affiliation(s)
- Joel H Rubenstein
- Division of Gastroenterology, University of Michigan Health System, Ann Arbor, Michigan 48109-0362, USA
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Lévy S. [Gastrointestinal hemorrhage. What can be done if drug and endoscopic treatments fail?]. GASTROENTEROLOGIE CLINIQUE ET BIOLOGIQUE 2004; 28 Spec No 2:B104-17. [PMID: 15150502 DOI: 10.1016/s0399-8320(04)95245-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 04/29/2023]
Affiliation(s)
- Stéphane Lévy
- Soins de suite spécialisés en Hépato-Gastroentérologie, Hôpital Goüin, 92110 Clichy
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Angeloni S, Merli M, Salvatori FM, De Santis A, Fanelli F, Pepino D, Attili AF, Rossi P, Riggio O. Polytetrafluoroethylene-covered stent grafts for TIPS procedure: 1-year patency and clinical results. Am J Gastroenterol 2004; 99:280-5. [PMID: 15046218 DOI: 10.1111/j.1572-0241.2004.04056.x] [Citation(s) in RCA: 59] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
OBJECTIVES Polytetrafluoroethylene (PTFE)-covered stent grafts appear to have the potential to improve TIPS patency, but data available are few and controversial. The aim of this prospective nonrandomized trial was to assess TIPS safety and 1-yr patency with a new commercially available PTFE-covered stent graft in comparison with a group of historical controls treated with conventional stents. METHODS Between July 1992 and December 1999, 87 consecutive cirrhotics underwent TIPS with conventional stents, while from January 2000 to November 2001, 32 consecutive cirrhotics were treated with PTFE-covered stent grafts. All patients were followed by the same medical team according to a prospective protocol for a diagnostic work-up and a surveillance strategy. RESULTS The two groups were comparable for age, sex, etiology, and severity of cirrhosis. The 1-yr probability of remaining free of shunt dysfunction tended to be higher in the covered stent group: 76.3% (95% CI = 58.7-93.9%) versus 57.5% (95% CI = 46.6-68.4%); log rank test: p = 0.055. However, stenoses inside the stent were significantly higher in patients with bare stents (88% vs 17%), while stenoses at the hepatic or portal vein were more frequent in PTFE-covered stent-graft group (50% vs 9% and 33% vs 3%, respectively), (chi2 = 15.42; df = 2.0; p = 0.0004). Stenoses inside the covered portion of the stent did not occur. One-year cumulative rebleeding, encephalopathy, and survival were similar. CONCLUSIONS PTFE-covered stents are able to solve pseudointimal hyperplasia within the stent tract, but have a high incidence of hepatic or portal vein stenosis. Improvements in stent design and insertion techniques are necessary to fully achieve the potential benefit of this new device.
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Affiliation(s)
- Stefania Angeloni
- II Gastroenterologia, Dipartimento di Medicina Clinica, Università di Roma "La Sapienza", Italy
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Affiliation(s)
- Jaime Bosch
- Hepatic Hemodynamic Laboratory, Liver Unit, IMD, Hospital Clinic, IDIBAPS, University of Barcelona, Villarroel 170, 08036, Barcelona, Spain.
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Haskal ZJ, Rees CR, Ring EJ, Saxon R, Sacks D. Reporting Standards for Transjugular Intrahepatic Portosystemic Shunts. J Vasc Interv Radiol 2003; 14:S419-26. [PMID: 14514857 DOI: 10.1097/01.rvi.0000094615.61428.2e] [Citation(s) in RCA: 47] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Affiliation(s)
- Ziv J Haskal
- Society of Interventional Radiology, 10201 Lee Highway, Suite 500, Fairfax, VA 22030, USA
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Middleton WD, Teefey SA, Darcy MD. Doppler evaluation of transjugular intrahepatic portosystemic shunts. Ultrasound Q 2003; 19:56-70; quiz 108 - 10. [PMID: 12973091 DOI: 10.1097/00013644-200306000-00002] [Citation(s) in RCA: 38] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Transjugular intrahepatic portosystemic shunts are becoming an increasingly popular technique for the treatment of portal hypertension and its complications. However, to maintain patency, revisions are periodically required to treat stenosis and thrombosis. At many centers, Doppler sonography is used for routine follow-up. A variety of hemodynamic parameters, including main portal vein velocity, maximum stent velocity, minimum stent velocity, velocity gradient in the stent, temporal changes in stent velocity, flow direction in the intrahepatic portal and hepatic veins, and pulsatility of flow in the stent can be used. Many studies have confirmed that Doppler sonography is a valuable, noninvasive means of detecting stent malfunction, although the criteria vary somewhat at different institutions.
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Affiliation(s)
- William D Middleton
- Mallinckrodt Institute of Radiology, Washington University School of Medicine, St Louis 63110, Missouri, USA
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Abstract
AIM: To determine the feasibility of creating direct intrahepatic portacaval shunt (DIPS) in swine with puncture under sonographic guidance.
METHODS: DIPS was created in 10 domestic swine under sonographic guidance. Liver function, blood ammonia level and portosystemic gradient (PSG) were compared before and after the procedure. Patency of shunt was followed by portography every 7 d after DIPS.
RESULTS: DIPS was successfully established in all 10 swine without any complications. One day after procedure the alanine aminotransferase (ALT), aspartate aminotransferase (AST), and blood ammonia level (BAL) of swine rose from 5.40 ± 0.69, 16.00 ± 0.79 and 35.66 ± 4.10 to 34.20 ± 3.46, 59.70 ± 2.22 and 66.94 ± 3.44 respectively (P < 0.05). The PSG decreased from 0.59 ± 0.20 kPa to 0.24 ± 0.11 kPa after DIPS (P < 0.05). The shunt of 10 swine was kept patent from 7-28 d (median patency time was 14 d).
CONCLUSION: This initial experience demonstrated that creating intrahepatic portacaval shunt from retrohepatic segment of IVC to portal vein with puncture under sonographic guidance in swine is safe and feasible. Further studies are necessary to perform DIPS in cirrhosis patients.
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Affiliation(s)
- Jian-Jun Luo
- Deatrtment of Radiology, Affiliated Zhongshan Hospital, Medical Center of Fundan University, 180 Fenglin Road, Shanghai 200032, China.
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Escorsell A, Bañares R, García-Pagán JC, Gilabert R, Moitinho E, Piqueras B, Bru C, Echenagusia A, Granados A, Bosch J. TIPS versus drug therapy in preventing variceal rebleeding in advanced cirrhosis: a randomized controlled trial. Hepatology 2002; 35:385-92. [PMID: 11826413 DOI: 10.1053/jhep.2002.30418] [Citation(s) in RCA: 136] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
Prevention of variceal rebleeding is mandatory in cirrhotic patients. We compared the efficacy, safety, and cost of transjugular intrahepatic portosystemic shunt (TIPS) versus pharmacologic therapy in preventing variceal rebleeding in patients with advanced cirrhosis. A total of 91 Child-Pugh class B/C cirrhotic patients surviving their first episode of variceal bleeding were randomized to receive TIPS (n = 47) or drug therapy (propranolol + isosorbide-5-mononitrate) (n = 44) to prevent variceal rebleeding. Mean follow-up was 15 months. Rebleeding occurred in 6 (13%) TIPS-treated patients versus 17 (39%) drug-treated patients (P =.007). The 2-year rebleeding probability was 13% versus 49% (P =.01). A similar number of reinterventions were required in the 2 groups; these were mainly angioplasty +/- restenting in the TIPS group (90 of 98) and endoscopic therapy for rebleeding in the medical group (45 of 62) (not significant). Encephalopathy was more frequent in TIPS than in drug-treated patients (38% vs. 14%, P =.007). Child-Pugh class improved more frequently in drug-treated than in TIPS-treated patients (72% vs. 45%; P =.04). The 2-year survival probability was identical (72%). The identified cost of therapy was double for TIPS-treated patients. In summary, medical therapy was less effective than TIPS in preventing rebleeding. However, it caused less encephalopathy, identical survival, and more frequent improvement in Child-Pugh class with lower costs than TIPS in high-risk cirrhotic patients. This suggests that TIPS should not be used as a first-line treatment, but as a rescue for failures of medical/endoscopic treatments (first-option therapies).
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Affiliation(s)
- Angels Escorsell
- Hepatic Hemodynamic Laboratory, Liver Unit, Hospital Clínic, IDIBAPS, Barcelona, Spain
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Petersen B, Uchida BT, Timmermans H, Keller FS, Rosch J. Intravascular US-guided direct intrahepatic portacaval shunt with a PTFE-covered stent-graft: feasibility study in swine and initial clinical results. J Vasc Interv Radiol 2001; 12:475-86. [PMID: 11287535 DOI: 10.1016/s1051-0443(07)61887-9] [Citation(s) in RCA: 52] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023] Open
Abstract
PURPOSE To determine the feasibility of the creation of a direct intrahepatic inferior vena cava (IVC)-to-portal-vein shunt with puncture guided by a transfemorally placed intravascular ultrasound (IVUS) probe and use of a polytetrafluoroethylene (PTFE)-covered stent-graft. MATERIALS AND METHODS In five swine, transjugular access was used to perform a direct puncture from the IVC to the portal vein with use of a modified Rosch-Uchida Portal Access set directed with real-time IVUS (9 MHz) introduced from a transfemoral venous approach. The direct intrahepatic portocaval shunt (DIPS) was then created with single or overlapping PTFE-covered Palmaz stents placed through a 10-F sheath and dilated to a diameter of 8 mm. Follow-up was performed with transhepatic portography at 2, 4, and 8 weeks. Animals were killed when shunts occluded or at the termination of the study at 8 weeks. Gross and microscopic histologic study was performed on sacrificed animals. A similar technique was used to create DIPS in five patients with intractable ascites, with follow-up by US and venography. RESULTS All experimental DIPS created in swine were created without complications. Portal vein punctures were achieved in four of five swine on the first or second pass of the needle. Follow-up transhepatic portography at 2 weeks demonstrated occlusion of two shunts, both explained by technical reasons at sacrifice. At 4 and 8 weeks, the remaining three shunts were patent on portography. Histology showed a thin neointimal lining with no significant tissue ingrowth or hyperplasia. Clinically, in five patients, successful puncture of the portal vein from the IVC was achieved in one to three passes. Creation of DIPS led to a reduction of mean portosystemic gradient from 18-29 mm Hg (mean, 24 mm Hg) to 9-10 mm Hg (mean, 9 mm Hg). One patient died of liver failure 2 days after creation of DIPS. The other four patients were doing well 2-15 months (mean, 8 months) after the procedure, with patency confirmed by US and venography. CONCLUSION Creation of DIPS is technically feasible, and the direct IVC-to-portal-vein puncture can be done accurately with real-time IVUS guidance. Further studies and longer follow-up are necessary to determine if the short length of the PTFE-covered stent-graft and avoidance of the hepatic vein will increase the long-term patency compared to standard transjugular intrahepatic portosystemic shunt creation.
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Affiliation(s)
- B Petersen
- Dotter Interventional Institute, Oregon Health Sciences University L342, 3181 SW Sam Jackson Park Rd., Portland, OR 97201, USA.
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37
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Shah SH, Lui HF, Lui HF, Helmy A, Redhead DN, Penny K, Hayes PC. Transjugular intrahepatic portosystemic stent-shunt insufficiency and the role of diabetes mellitus. Eur J Gastroenterol Hepatol 2001; 13:257-61. [PMID: 11293445 DOI: 10.1097/00042737-200103000-00007] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
Abstract
BACKGROUND/AIMS Maintenance of long-term patency of transjugular intrahepatic portosystemic stent-shunts (TIPSS) has proved problematic. Various prognostic variables have been assessed as predictors, but the role of diabetes mellitus, which induces vascular endothelial cell dysfunction, has not been assessed. METHODS We analysed the records of 248 patients who underwent TIPSS between July 1991 and July 1997, followed-up through to August 1998. Patients with at least one shunt assessment by portography and available blood glucose levels were eligible (177 patients; median follow-up, 15.0 months). Fourteen patients had a pre-procedural diagnosis of diabetes (one insulin dependent, seven oral hypoglycaemic treated and six diet controlled). In another 14 patients, diabetes was diagnosed at TIPSS insertion, giving a 28/177 (15.8%) prevalence of diabetes in our patients. Fifty-nine patients were excluded from the final analysis (including five diabetics), as they either died or had early shunt insufficiency (within 1 month of stent placement), leaving 118 patients (including 23 diabetics) to be included in the final analysis. RESULTS Mean age, sex distribution, median follow-up (months) and pre-shunt portal pressure gradient were comparable in the two groups (diabetics versus non-diabetics). Child-Pugh classes A and B were more common in the diabetic group (P < 0.01), and the mean inserted stent diameter was larger in the diabetic group (P < 0.05). The presence of diabetes was associated with a higher incidence of delayed shunt insufficiency (P = 0.02), but there was no evidence of an association between presence of diabetes and variceal haemorrhage post TIPSS. Kaplan-Meier analyses revealed earlier insufficiency in diabetic patients compared with those without diabetes (P = 0.04). Age, gender and presence of diabetes are included in the final logistic regression model. Individuals who have diabetes are more likely to experience shunt insufficiency independent of age and gender. CONCLUSIONS Diabetes mellitus is common in patients undergoing TIPSS and is associated independently with increased incidence of primary delayed shunt insufficiency.
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Affiliation(s)
- S H Shah
- Department of Medicine, Royal Infirmary of Edinburgh, UK
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38
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Carreiro G, da Luz Moreira A, Murad FF, Azevedo F, Coelho HS. [TIPS - Transjugular intrahepatic portosystemic shunt. A review]. ARQUIVOS DE GASTROENTEROLOGIA 2001; 38:69-80. [PMID: 11586999 DOI: 10.1590/s0004-28032001000100013] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
At the present time several therapeutic options are used for the treatment of bleeding esophageal varices in patients with portal hypertension. We will review the main medical publications on transjugular intrahepatic portosystemic shunt (TIPS), a procedure seldom used among us. TIPS works as a portocaval side-to-side shunt and decreases the risk of esophageal bleeding through lowering of the portal system pressure and a decrease of the portal hepatic pressure gradient. TIPS consists in the percutaneous insertion, through the internal jugular vein, of a metallic stent under fluoroscopic control in the hepatic parenchyma creating a true porta caval communication. There are several studies demonstrating the efficacy of TIPS, although only a few of them are randomized and control-matched to allow us to conclude that this procedure is safe, efficient and with a good cost benefit ratio. In this review, we search for the analysis of the TIPS utilization, its techniques, its major indications and complications. TIPS has been used in cases of gastroesophageal bleeding that has failed with pharmacologic or endoscopic treatment in patients Child-Pugh B and C. It can be used also as a bridge for liver transplantation. Others indications for TIPS are uncontrolled ascites, hepatic renal syndrome, and hepatic hydrothorax. The main early complications of TIPS using are related to the insertion site and hepatic encephalopathy and the stent occlusion is the chief late complication.
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Affiliation(s)
- G Carreiro
- Serviço de Gastroenterologia e Serviço de Radiologia do Departamento de Clínica Médica, Universidade Federal do Rio de Janeiro-UFRJ-Hospital Clementino Fraga Filho, Rio de Janeiro, RJ
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Seong CK, Kim YJ, Shin TB, Park HY, Kim TH, Kang DS. Transcaval TIPS in patients with failed revision of occluded previous TIPS. Korean J Radiol 2001; 2:204-9. [PMID: 11754327 PMCID: PMC2718122 DOI: 10.3348/kjr.2001.2.4.204] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
OBJECTIVE To determine the feasibility of transcaval transjugular intrahepatic portosystemic shunt (TIPS) in patients with occluded previous TIPS. MATERIALS AND METHODS Between February 1996 and December 2000 we performed five transcaval TIPS procedures in four patients with recurrent gastric cardiac variceal bleeding. All four had occluded TIPS, which was between the hepatic and portal vein. The interval between initial TIPS placement and revisional procedures with transcaval TIPS varied between three and 31 months; one patient underwent transcaval TIPS twice, with a 31-month interval. After revision of the occluded shunt failed, direct cavoportal puncture at the retrohepatic segment of the IVC was attempted. RESULTS Transcaval TIPS placement was technically successful in all cases. In three, tractography revealed slight leakage of contrast materials into hepatic subcapsular or subdiaphragmatic pericaval space. There was no evidence of propagation of extravasated contrast materials through the retroperitoneal space or spillage into the peritoneal space. After the tract was dilated by a bare stent, no patient experienced trans-stent bleeding and no serious procedure-related complications occurred. After successful shunt creation, variceal bleeding ceased in all patients. CONCLUSION Transcaval TIPS placement is an effective and safe alternative treatment in patients with occluded previous TIPS and no hepatic veins suitable for new TIPS.
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Affiliation(s)
- C K Seong
- Department of Radiology, Kyungpook National University School of Medicine, Daegu, Korea.
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Hillebrand DJ, Kojouri K, Cao S, Runyon BA, Ojogho O, Concepcion W. Small-diameter portacaval H-graft shunt: a paradigm shift back to surgical shunting in the management of variceal bleeding in patients with preserved liver function. Liver Transpl 2000; 6:459-65. [PMID: 10915169 DOI: 10.1053/jlts.2000.6141] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Small-diameter portacaval H-graft (SDPHG) shunts are partial portosystemic shunts that control variceal bleeding while preserving nutrient blood flow to the liver, minimizing postoperative encephalopathy and liver failure. Since July 1, 1997, we placed SDPHG shunts in 18 patients (age, 52.1 +/- 2.6 years; range, 35 to 72 years) with cirrhosis (Child's class A, B, and C in 6, 10, and 2 patients, respectively) and refractory variceal bleeding who were not candidates for transplantation. Ten procedures (55.6%) were urgent or emergent. SDPHG shunts effectively reduced the portacaval pressure gradient (18 +/- 3 v 5 +/- 2 mm Hg; P <.05). Surgical times (210 +/- 11 minutes), estimated blood losses (358.3 +/- 107.8 mL), transfusion requirements (0 transfusions in 10 patients; 55.6%; mean, 0.9 +/- 0.3 units), and postoperative hospitalization (7.7 +/- 1.0 days) were excellent. Surgical mortality (30 days) was 0%. During 14. 0 +/- 1.9 months (range, 1.1 to 29.1 months) of follow-up, 4 patients (22.2%) died, including both patients with Child's class C cirrhosis. The cumulative 1-year survival rate was 82.1% (Child's class A, B, and C, 83.3%, 90%, and 0%, respectively). Long-term survivors had significantly lower preoperative Child-Pugh scores compared with nonsurvivors (7.8 +/- 0.3 v 9.5 +/- 1.0; P <.05). Postoperative encephalopathy developed in 3 survivors (20%). Fifteen patients (83.3%) have not experienced rebleeding; shunt failure led to rebleeding in only 1 patient (5.6%). SDPHG shunt placement can be performed with low morbidity and surgical mortality. Nontransplantation candidates with Child's class A and B cirrhosis have excellent long-term survival with this safe, effective, and definitive treatment for refractory variceal bleeding.
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Affiliation(s)
- D J Hillebrand
- Department of Medicine, Division of Gastroenterology-Hepatology, Transplantation Institute, Loma Linda University Medical Center, Loma Linda, CA 92354, USA.
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Zizka J, Eliás P, Krajina A, Michl A, Lojík M, Ryska P, Masková J, Hůlek P, Safka V, Vanásek T, Bukac J. Value of Doppler sonography in revealing transjugular intrahepatic portosystemic shunt malfunction: a 5-year experience in 216 patients. AJR Am J Roentgenol 2000; 175:141-8. [PMID: 10882264 DOI: 10.2214/ajr.175.1.1750141] [Citation(s) in RCA: 56] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
OBJECTIVE The purpose of the study was to evaluate the long-term clinical efficacy of Doppler sonography in revealing failure of transjugular intrahepatic portosystemic shunts (TIPS). SUBJECTS AND METHODS During a 5-year period, 1192 Doppler examinations were performed in 216 patients with TIPS. No regular follow-up shunt venography was performed. Doppler examinations were retrospectively compared with the results of shunt revisions. Sonograms with negative findings were compared with the patients' clinical status so that the number of false-negative sonographic findings leading to an episode of shunt failure (recurrence of gastrointestinal bleeding or ascites) could be ascertained. Sonographic parameters assessed included diameter, velocity, flow volume, and congestion index of the portal vein; and shunt velocities. RESULTS Doppler sonography revealed shunt occlusion in 25 of 26 angiographically proven cases (sensitivity, 96%). The combination of velocity criteria (peak intrashunt velocity > or =250 cm/sec, maximum velocity in the portal third of the shunt < or =50 cm/sec, or maximum portal vein velocity less than or equal to two thirds of the baseline value) revealed shunt stenosis in 103 of 110 cases (sensitivity, 94%). Doppler sonography missed a significant shunt stenosis that led to an episode of gastrointestinal bleeding or ascites recurrence in only seven cases. The congestion index of the portal vein showed significant differences between patent and malfunctioning shunts (p < 0.001). CONCLUSION Doppler sonography is an effective primary imaging method for long-term follow-up of patients with TIPS.
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Affiliation(s)
- J Zizka
- Department of Diagnostic Radiology, Charles University Hospital, Hradec Králové, Czech Republic
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Luketic VA, Sanyal AJ. Esophageal varices. II. TIPS (transjugular intrahepatic portosystemic shunt) and surgical therapy. Gastroenterol Clin North Am 2000; 29:387-421, vi. [PMID: 10836187 DOI: 10.1016/s0889-8553(05)70120-5] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/16/2023]
Abstract
The role of surgery in the prevention and treatment of variceal hemorrhage is reviewed. Types of available surgery, their physiologic basis, and literature supporting their use are discussed in the context of the natural history of variceal hemorrhage. The evolution of transjugular intrahepatic portosystemic shunt (TIPS) as a treatment modality for variceal hemorrhage is reviewed. The effects of TIPS on portal and systemic hemodynamics and clinical usefulness in the management of variceal hemorrhage are discussed. A treatment algorithm for the integrated use of the various treatments is provided.
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Affiliation(s)
- V A Luketic
- Department of Medicine, Medical College of Virginia Commonwealth University, Richmond, USA.
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Müller-Hülsbeck S, Höpfner M, Hilbert C, Krämer-Hansen H, Heller M. Mechanical thrombectomy of acute thrombosis in transjugular intrahepatic portosystemic shunts. Invest Radiol 2000; 35:385-91. [PMID: 10853614 DOI: 10.1097/00004424-200006000-00008] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
RATIONALE AND OBJECTIVES To evaluate the feasibility of mechanical thrombectomy with the use of the Amplatz thrombectomy device (ATD) in restoring patency to acutely thrombosed stent-shunts after transjugular intrahepatic portosystemic shunt (TIPS) placement. METHODS Mechanical thrombectomy with the ATD was performed in 10 consecutive patients with angiographically documented complete thrombosis of the stent-shunt (mean +/- SD, 6.6 +/- 3.4 cm), which occurred an average of 2.8 months (range, 0-11 months) after the TIPS procedure. RESULTS In all patients, immediate restoration of patency of the stent-shunt was achieved after thrombectomy alone (n = 1), thrombectomy plus percutaneous transluminal angioplasty (PTA; n = 4), and thrombectomy, PTA, and stenting (n = 5). The mean activation time of the ATD was 253 +/- 43 seconds. The pressure gradient for portal decompression decreased from 23 +/- 6 mmHg before to 11 +/- 3 mmHg after the procedure. The primary patency rate was 80% at 3 months and 60% at 11 months. CONCLUSIONS Mechanical thrombectomy with the ATD in acutely thrombosed TIPS is technically feasible. Mechanical thrombectomy is a potential alternative to thrombolysis.
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Affiliation(s)
- S Müller-Hülsbeck
- Department of Radiology, Christian-Albrechts-University of Kiel, Germany.
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Affiliation(s)
- R Jalan
- Liver Unit Department of Medicine and Department of Radiology Royal Infirmary of Edinburgh 1 Lauriston Place Edinburgh EH3 9YW, UK
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Borsa JJ, Fontaine AB, Hoffer EK, Bloch RD, Tong E, Kowdley KV, Schmiedl UP. Primary placement of Palmaz long medium stents in transjugular intrahepatic portosystemic shunts. J Vasc Interv Radiol 2000; 11:189-94. [PMID: 10716388 DOI: 10.1016/s1051-0443(07)61463-8] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023] Open
Abstract
PURPOSE To describe our results with primary placement of the long-medium Palmaz stent for transjugular intrahepatic portosystemic shunts (TIPS). MATERIALS AND METHODS Between December 1997 and December 1998 primary placement of long-medium Palmaz stents was performed for TIPS procedures in 17 patients. Patency was determined with ultrasound, angiography, or pathologic examination in the event of transplant. RESULTS Primary patency was achieved in 13 of 17 patients (76.5%) (follow up, 1-399 days; mean, 99 days). Secondary patency was achieved in 17 of 17 patients (100%) (follow-up, 1-399 days; mean, 110 days). Among the four patients who required revision, the mean time to revision from initial shunt creation was 81 days (range, 13-125 days). Two of these four patients had symptoms of worsening ascites as well as abnormal ultrasound findings prior to their revision; the other two patients were asymptomatic and had abnormal ultrasound findings only. Revisions were performed for intimal hyperplasia within the stent in three of the patients and acute thrombus within the stent in the remaining patient. Kaplan-Meier survival analysis for primary patency yielded mean survival time of 265 days (standard error, 52 days). CONCLUSION The long-medium Palmaz stent is a viable stent for creation of TIPS shunts.
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Affiliation(s)
- J J Borsa
- Department of Radiology, University of Washington Medical Center, Seattle 98195, USA.
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Abstract
Transjugular intrahepatic protosystemic shunts (TIPS) is the newest and the least invasive method of eradicating varices. This article defines portal hypertension succinctly, describes how it gives rise to varices and their consequences, and briefly reviews the development, short experience with, and current status of TIPS.
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Affiliation(s)
- H O Conn
- Department of Medicine, Yale University School of Medicine, New Haven, Connecticut, USA
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Abstract
Since the introduction of transjugular intrahepatic portosystemic shunt (TIPS) 10 years ago, it has been used increasingly in the management of portal hypertension and its complications. TIPS is now considered the procedure of choice for management of refractory variceal bleeding. Its role in the management of refractory ascites, hepatic hydrothorax, hepatorenal syndrome, and hepatopulmonary syndrome still awaits further prospective studies. The two main complications of TIPS are hepatic encephalopathy and shunt malfunction. Generally, TIPS stenosis or occlusion is a major drawback requiring routine surveillance of TIPS with doppler ultrasound. Venography with balloon dilation of the stent or placement of serial or parallel stents may be required in some cases. Promising modalities of preventing TIPS malfunction (e.g., brachy-therapy, covered stents, or anti-platelet derived growth factor) are currently being investigated.
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Affiliation(s)
- J P Ong
- Department of Gastroenterology, Cleveland Clinic Foundation, Ohio 44195, USA
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Luca A, D'Amico G, La Galla R, Midiri M, Morabito A, Pagliaro L. TIPS for prevention of recurrent bleeding in patients with cirrhosis: meta-analysis of randomized clinical trials. Radiology 1999; 212:411-21. [PMID: 10429698 DOI: 10.1148/radiology.212.2.r99au46411] [Citation(s) in RCA: 159] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
PURPOSE To compare the effects of transjugular intrahepatic portosystemic shunt (TIPS) creation with those of endoscopic treatment with or without propranolol administration (i.e, conventional treatment) on recurrent bleeding, encephalopathy, and mortality by using meta-analysis of 11 published randomized clinical trials. MATERIALS AND METHODS Data from 11 relevant studies were retrieved by means of computerized and manual search. The combinability of the studies was assessed in terms of clinical and statistical criteria. Data were extracted on the basis of the intention-to-treat principle, and treatment effects were measured as risk differences between TIPS creation and conventional treatment. Pooled estimates were computed according to a random-effects model. RESULTS A total of 750 patients were included in 11 trials. No significant heterogeneity was found for any of the outcomes. Pooled risk differences were recurrent bleeding, -31% (95% CI, -39%, -23%); encephalopathy, +16% (95% CI, +10%, +22%); death due to all causes, +2% (95% CI, -4%, +9%); and death due to bleeding, -5% (95% CI, -11%, +6%). Clinically important complications occurred in 22% of patients and were associated with both treatments. TIPS dysfunction occurred in 55% of patients. CONCLUSION TIPS creation markedly reduces risk of rebleeding but increases risk of encephalopathy without affecting survival. Therefore, TIPS creation may not be the best first-choice therapy for prevention of recurrent variceal bleeding. Criteria for selection of candidates for TIPS creation should be assessed in future prospective studies.
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Affiliation(s)
- A Luca
- Department of Radiology, University of Palermo, Italy
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Meddi P, Merli M, Lionetti R, De Santis A, Valeriano V, Masini A, Rossi P, Salvatori F, Salerno F, de Franchis R, Capocaccia L, Riggio O. Cost analysis for the prevention of variceal rebleeding: a comparison between transjugular intrahepatic portosystemic shunt and endoscopic sclerotherapy in a selected group of Italian cirrhotic patients. Hepatology 1999; 29:1074-7. [PMID: 10094949 DOI: 10.1002/hep.510290411] [Citation(s) in RCA: 37] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/07/2022]
Abstract
The aim of the present study was to compare the cumulative cost of the first 18-month period in a selected group of Italian cirrhotic patients treated with transjugular intrahepatic portosystemic shunt (TIPS) versus endoscopic sclerotherapy (ES) to prevent variceal rebleeding. Thirty-eight patients enrolled in a controlled trial were considered (18 TIPS and 20 sclerotherapy). The number of days spent in the hospital for the initial treatment and during the follow-up period were defined as the costs of hospitalization. ES sessions, TIPS procedures, angioplasty or addition of a second stent to maintain the shunt patency, were defined as the costs of therapeutic procedures. The two groups were comparable for age, sex, and Child-Pugh score. During the observation period 4 patients died in the TIPS group, and 2 died and 1 was transplanted in the sclerotherapy group. The rebleeding rate was significantly higher in the sclerotherapy group. Despite this, the number of days spent in the hospital was similar in the two groups. This was because of a higher number of hospital admissions for the treatment of hepatic encephalopathy and shunt insufficiency in the TIPS group. The therapeutic procedures were more expensive for TIPS. Consequently, the cumulative cost was higher for patients treated with TIPS than for those treated with sclerotherapy. The extra cost was because of the initial higher cost of the procedure and the difference was still maintained at the end of the 18-month follow-up. When the cumulative costs were expressed per month free of rebleeding, the disadvantage of TIPS disappeared. In conclusion, a program of prevention of variceal rebleeding with TIPS, despite the longer interval free of rebleeding, is not a cost-saving strategy in comparison with sclerotherapy.
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Affiliation(s)
- P Meddi
- Department of Clinical Medicine, University of Rome "La Sapienzao," Rome, Italy
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