Transjugular intrahepatic portosystemic stent shunt

Transjugular intrahepatic portosystemic shunts (TIPS) for the prevention of variceal re-bleeding - A two decades experience

BACKGROUND AND AIMS

Transjugular intrahepatic portosystemic shunts (TIPS) are used in patients with cirrhosis for the prevention of variceal rebleeding.

METHODS

We retrospectively evaluated re-bleeding rate, patency, mortality, and transplant-free survival (TFS) in cirrhotic patients receiving TIPS implantation for variceal bleeding between 1994-2014.

RESULTS

286 patients received TIPS (n = 119 bare metal stents, n = 167 polytetrafluorethylene (PTFE)-covered stents) for prevention of variceal re-bleeding. Mean age was 55.1 years, median MELD was 11.8, and the main etiology of cirrhosis was alcoholic liver disease (70%). Median follow-up was 821 days. 67 patients (23%) experienced at least one re-bleeding event. Patients with PTFE-TIPS were at significantly lower risk for variceal re-bleeding than patients with bare metal stents (14% vs. 37%, OR:0.259; p<0.001) and had less need for stent revision (21% vs. 37%; p = 0.024). Patients with PTFE stent grafts showed lower mortality than patients with bare stents after 1 year (19% vs. 31%, p = 0.020) and 2 years (29% vs. 40%; p = 0.041) after TIPS implantation. Occurrence of hepatic encephalopathy after TIPS was similar between groups (20% vs. 24%, p = 0.449).

CONCLUSIONS

PTFE-TIPS were more effective at preventing variceal re-bleeding than bare metal stents due to better patency. Since this tended to translate in improved survival, only covered stents should be implemented for bleeding prophylaxis when TIPS is indicated.

Cholestatic syndromes

PURPOSE OF REVIEW

This review highlights recent developments in the molecular pathogenesis of cholestasis as well new aspects of pathogenesis and management of clinical cholestatic disorders.

RECENT FINDINGS

Highlights include the role of nuclear receptors including FXR ligands as potential therapeutic agents, new genetic defects for pediatric cholestasis and sclerosing cholangitis, and novel infections and environmental agents as etiologies for primary biliary cirrhosis. Important clinical studies have been published in the area of pediatric cholestatic syndromes, intrahepatic cholestasis of pregnancy, primary biliary cirrhosis, primary and secondary sclerosing cholangitis, cholestasis of sepsis, viral cholestatic syndromes, and drug-induced cholestasis.

SUMMARY

These advances continue to improve understanding of the pathophysiology, diagnosis, and management of cholestatic liver disease.

Patency and reintervention rates during routine TIPSS surveillance

PURPOSE

To assess the medium-term outcome of transjugular intrahepatic portosystemic stent shunts (TIPSS) by measuring the incidence of shunt obstruction or failure during routine surveillance and the number of interventions performed.

METHODS

This is a retrospective study covering a 4-year period, from 1992 to 1996, during which 102 TIPSS procedures were performed. Indications for treatment were variceal bleeding (76%) and refractory ascites (24%). Follow-up protocol after TIPSS included transfemoral or transjugular portal venography and measurement of portosystemic pressure gradient (PPG) at 3 months, 12 months, and then at yearly intervals. The results of the first 155 venograms on 62 patients (mean follow-up 14 months) have been reviewed and Kaplan-Meier analysis performed.

RESULTS

One hundred and thirty-seven of 155 (88%) examinations showed patent shunts. Fifty-six of 137 (41%) of the patent TIPSS had elevated PPG with signs of stenosis. The majority (41/56) of shunt stenoses with elevated pressure gradients were related to neointimal hyperplasia in the hepatic venous aspect of the shunt. Interventions used to reduce the pressure gradient or to restore patency included: angioplasty (62/102 interventions), additional stents (21/102), a second TIPSS procedure (2/102), and thrombolysis or thrombectomy (4/102). The primary patency rate was 66% at 1 year (52% at 2 years). Primary assisted patency was 72% at 1 year (58% at 2 years). Secondary patency was 86% at 1 year (63% at 2 years).

CONCLUSION

The majority of TIPSS shunts will remain patent when regular portal venography, with appropriate intervention, is undertaken. Although there is a high reintervention rate this mainly takes the form of balloon angioplasty.

Scintigraphic evaluation of hepatic blood flow after intrahepatic portosystemic shunt (TIPS)

In patients with liver cirrhosis a transjugularly placed intrahepatic portocaval shunt (TIPS) is a non-surgical portosystemic device which aims to reduce portal venous pressure. In comparison with Doppler sonography, we evaluated in 28 patients the diagnostic impact of liver perfusion scintigraphy (with technetium-99m diethylene triamine penta-acetic acid) in the assessment of changes in the hepatic blood flow after TIPS shunting. The arterial and portal contributions to hepatic flow were calculated from the areas under the biphasic time-activity curve. In the course of TIPS shunting, patency is threatened by reocclusion. Angiography is the gold standard for TIPS shunt reassessment. However, there is a need for a less invasive diagnostic procedure, such as scintigraphy or Doppler sonography, for the early detection of shunt insufficiency. Scintigraphy demonstrated that prior to TIPS shunting the portal venous contribution to hepatic perfusion was reduced to 29.2%, this reduction being due to portal hypertension. After TIPS placement a significant increase in portal venous perfusion was observed (38.2%; P<0.02). TIPS shunt occlusion was identified in patients by a significant reduction in the scintigraphically measured portal venous contribution to hepatic blood flow. Hepatic perfusion scintigraphy appears to be a valuable method to determine the immediate effect of TIPS on hepatic blood flow. Post-TIPS follow-up studies of hepatic haemodynamics by liver perfusion scintigraphy appear able to contribute to the detection of TIPS shunt occlusion before the clinical consequences of this complication have become apparent.

Emergency oesophageal transection for uncontrolled variceal haemorrhage

Continued haemorrhage from oesophageal varices despite adequate injection sclerotherapy and tamponade has a high mortality rate. Such patients are usually referred for surgery. Over a 10-year period, 30 patients (21 men and nine women of median age 52 (range 21-70) years) with acute variceal haemorrhage uncontrolled by initial treatment underwent early emergency oesophageal transection. Portal hypertension was caused by alcoholic cirrhosis in 22 patients; other forms of cirrhosis were present in seven and portal vein thrombosis in one. Hepatic function immediately before operation was Pugh grade A in two patients, B in six and C in 22. Deterioration between admission and transection from grade A to B occurred in one patient and from B to C in five. Oesophageal transection stopped variceal haemorrhage in 29 of the 30 patients. Rebleeding from gastric varices within 35 days of surgery occurred in five patients. Postoperative haemorrhage also occurred from perioesophageal vessels (two patients), a gastrotomy (one) and oesophageal ulceration (two). Hepatic failure developed in seven patients, renal failure in five and both hepatic and renal failure in four. Mortality at 30 days occurred in neither of the two patients with liver function of grade A, in one of six of grade B and in 18 of 22 of grade C. The overall 30-day mortality rate was thus 63 per cent. Mortality was related to the preoperative Pugh grade (hazard ratio 3.95 per grade; P = 0.013) and preoperative blood transfusion (hazard ratio 1.37 per unit; P = 0.035). Four of six patients with grade B liver function died within 3 months and 21 of 22 with grade C disease within 1 year. Oesophageal transection is effective at stopping variceal bleeding but does not modify the underlying disease. Caution is urged for patients with grade C hepatocellular impairment proceeding to acute oesophageal transection after initial sclerotherapy. Such patients may benefit more from treatment with somatostatin or an intrahepatic porta-systemic stent shunt while awaiting definitive therapy.

Review article: the transjugular intrahepatic portosystemic shunt (TIPS) in the treatment of portal hypertension

The transjugular intrahepatic portosystemic shunt (TIPS) is a non-surgical intrahepatic shunt connecting the hepatic and portal veins. The shunt can be inserted successfully in more than 90% of patients and it effectively decompresses the portal venous circulation. Serious complications, such as intraperitoneal bleeding, occur but they are uncommon. The role of TIPS in the treatment of portal hypertension is currently being evaluated. There are few controlled data available to compare TIPS with established treatment such as drugs, injection sclerotherapy, endoscopic banding or shunt surgery. TIPS has also been used to treat ascites, the Budd-Chiari syndrome and cirrhotic hydrothorax. Concerns over the long-term patency and the true incidence of encephalopathy following TIPS raise doubts about its long-term efficacy. Controlled trials are required to demonstrate the cost-effectiveness of TIPS for individual indications before it is widely adopted. TIPS may find its most immediate application in the emergency treatment of active variceal haemorrhage refractory to standard medical and endoscopic therapy, as there is no satisfactory treatment currently available for this high-risk group. TIPS may also have a role in patients awaiting liver transplantation who bleed from varices. Long-term patency should not be an issue in this patient group and portal decompression may reduce blood transfusion requirements during transplant surgery.