Uncovering the truth about covered stents: is there a difference between covered versus uncovered stents with transjugular intrahepatic portosystemic shunts?

A Nomogram to Predict the Risk of Stent Dysfunction After TIPS in Patients with Hepatitis B Cirrhosis

RATIONALE AND OBJECTIVES

To develop and validate a nomogram for the prediction of stent dysfunction after transjugular intrahepatic portosystemic shunt (TIPS) placement in patients with hepatitis B cirrhosis.

MATERIALS AND METHODS

From 2012 to 2020, 355 patients with hepatitis B cirrhosis who underwent TIPS placements were enrolled in this study. A multivariable logistic regression analysis was applied to determine independent risk factors for the nomogram construction. Discrimination, calibration, and clinical usefulness of the prediction model were assessed by using receiver operating characteristic curves, calibration scatter plots, and a decision curve analysis (DCA).

RESULTS

Independent factors for TIPS stent dysfunction included diabetes, previous splenectomy, the shunting branch of the portal vein, and stent position, which were used to construct the nomogram. The AUC values in the training and validation cohorts were 0.817 (95% CI: 0.731-0.903) and 0.804 (95% CI: 0.673-0.935), respectively, which suggested a good predictive ability. The calibration curves in both cohorts revealed good agreement between the predictions and actual observations. The DCA curve indicated that when the threshold probability ranged from 2% to 88%, the nomogram could provide clinical usefulness and a net benefit.

CONCLUSION

The nomogram that we developed could be conveniently used to predict TIPS stent dysfunction in patients with hepatitis B cirrhosis.

Surgical portosystemic shunts versus transjugular intrahepatic portosystemic shunt for variceal haemorrhage in people with cirrhosis

BACKGROUND

Variceal haemorrhage that is refractory or recurs after pharmacologic and endoscopic therapy requires a portal decompression shunt (either surgical shunts or radiologic shunt, transjugular intrahepatic portosystemic shunt (TIPS)). TIPS has become the shunt of choice; however, is it the preferred option? This review assesses evidence for the comparisons of surgical portosystemic shunts versus TIPS for variceal haemorrhage in people with cirrhotic portal hypertension.

OBJECTIVES

To assess the benefits and harms of surgical portosystemic shunts versus transjugular intrahepatic portosystemic shunt (TIPS) for treatment of refractory or recurrent variceal haemorrhage in people with cirrhotic portal hypertension.

SEARCH METHODS

We searched the Cochrane Hepato-Biliary Group Controlled Trials Register, CENTRAL, MEDLINE, Embase, LILACS, Science Citation Index Expanded, and Conference Proceedings Citation Index - Science. We also searched on-line trial registries, reference lists of relevant articles, and proceedings of relevant associations for trials that met the inclusion criteria for this review (date of search 8 March 2018).

SELECTION CRITERIA

Randomised clinical trials comparing surgical portosystemic shunts versus TIPS for the treatment of refractory or recurrent variceal haemorrhage in people with cirrhotic portal hypertension.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed trials and extracted data using methodological standards expected by Cochrane. We assessed risk of bias according to domains and risk of random errors with Trial Sequential Analysis (TSA). We assessed the certainty of the evidence using the GRADE approach.

MAIN RESULTS

We found four randomised clinical trials including 496 adult participants diagnosed with variceal haemorrhage due to cirrhotic portal hypertension. The overall risk of bias in all the trials was judged at high risk. All the trials were conducted in the United States of America (USA). Two of the trials randomised participants to selective surgical shunts versus TIPS. The other two trials randomised participants to non-selective surgical shunts versus TIPS. The diagnosis of liver cirrhosis was by clinical and laboratory findings. We are uncertain whether there is a difference in all-cause mortality at 30 days between surgical portosystemic shunts compared with TIPS (risk ratio (RR) 0.94, 95% confidence interval (CI) 0.44 to 1.99; participants = 496; studies = 4). We are uncertain whether there is a difference in encephalopathy between surgical shunts compared with TIPS (RR 0.56, 95% CI 0.27 to 1.16; participants = 496; studies = 4). We found evidence suggesting an increase in the occurrence of the following harms in the TIPS group compared with surgical shunts: all-cause mortality at five years (RR 0.61, 95% CI 0.42 to 0.90; participants = 496; studies = 4); variceal rebleeding (RR 0.18, 95% CI 0.07 to 0.49; participants = 496; studies = 4); reinterventions (RR 0.13, 95% CI 0.06 to 0.28; participants = 496; studies = 4); and shunt occlusion (RR 0.14, 95% CI 0.04 to 0.51; participants = 496; studies = 4). We could not perform an analysis of health-related quality of life but available evidence appear to suggest improved health-related quality of life in people who received surgical shunt compared with TIPS. We downgraded the certainty of the evidence for all-cause mortality at 30 days and five years, irreversible shunt occlusion, and encephalopathy to very low because of high risk of bias (due to lack of blinding); inconsistency (due to heterogeneity); imprecision (due to small sample sizes of the individual trials and few events); and publication bias (few trials reporting outcomes). We downgraded the certainty of the evidence for variceal rebleeding and reintervention to very low because of high risk of bias (due to lack of blinding); imprecision (due to small sample sizes of the individual trials and few events); and publication bias (few trials reporting outcomes). The small sample sizes and few events did not allow us to produce meaningful trial sequential monitoring boundaries, suggesting plausible random errors in our estimates.

AUTHORS' CONCLUSIONS

We found evidence suggesting that surgical portosystemic shunts may have benefit over TIPS for treatment of refractory or recurrent variceal haemorrhage in people with cirrhotic portal hypertension. Given the very low-certainty of the available evidence and risks of random errors in our analyses, we have very little confidence in our review findings.

Polytetrafluoroethylene-Covered Stent Graft Versus Bare Stent in Transjugular Intrahepatic Portosystemic Shunt: Systematic Review and Meta-Analysis

BACKGROUND & AIMS

Transjugular Intrahepatic Portosystemic Shunt (TIPS) is used to control refractory variceal bleeding secondary to portal hypertension. This meta-analysis was conducted to systematically review polytetrafluoroethylene-covered stent grafts (CS) versus bare stents (BS) in TIPS procedure.

METHODS

Systematic search of literature databases was done from January-1990 till April-2017, using predecided keywords. Outcome measures studied were (1) primary-patency (PP) at 1 year (defined as absence of shunt insufficiency at 1 year), (2) rebleeding (RE) (3) new-onset hepatic encephalopathy ([HE] new-onset or worsening encephalopathy following the procedure), and (4) survival at 1 year (SU). Odds ratio (OR) was calculated for each outcome variable. Between-study heterogeneity was assessed by the I² statistics and χ² Q-test.

RESULTS

Fourteen studies (4 RCTs, 2 prospective nonrandomized, and 8 retrospective) were included with 2519 patients (1548 patients in BS group and 971 patients in CS group). Three-quarter outcome measures showed significantly better results with CS. PP was pooled from 13 studies and showed an OR = 4.75 (95% confidence interval [CI] = 3.32-6.79; P < .00001; I² = 44%) in favor of CS. RE was pooled from six studies with odds ratio (OR) = 0.37(95% CI = 0.24-0.56; P < .00001; I² = 0%) in favor of CS. SU was pooled from 11 studies with OR = 1.85 (95% CI = 1.44-2.38; P < .00001; I² = 0%) in favor of CS. On subset analysis for RCTs, three outcome variables favored CS with minimal heterogeneity [PP: OR = 4.18 (95% CI = 2.66-6.55; P < .00001; I² = 0%). RE: OR = 0.43 (95% CI = 0.25-0.72; P < .001; I² = 0%). SU: OR = 1.85 (95% CI = 1.44-2.38, P < .00001; I² = 0%)]. HE showed no difference between two stents on the overall and subset pooled analysis. Overall: OR = 0.86 (95% CI = 0.68-1.08; P = .19; I² = 4%). Only RCTs: OR = 0.91 (95% CI = 0.63-1.32, P = .63; I² = 0%).

CONCLUSIONS

CS is associated with better primary patency and survival and lesser rate of rebleeding than BS in patients undergoing TIPS procedure. There is no difference in new-onset hepatic encephalopathy.

Transjugular Intrahepatic Portosystemic Shunt in Patients with Portal Hypertension: Patency Depends on Coverage and Interventionalist's Experience

BACKGROUND AND AIMS

Transjugular intrahepatic portosystemic shunt (TIPS) is the treatment of choice in decompensated portal hypertension. TIPS revision due to thrombosis or stenosis increases morbidity and mortality. Our aim was to investigate patient- and procedure-associated risk factors for TIPS-revision.

PATIENTS AND METHODS

We retrospectively evaluated 189 patients who underwent the TIPS procedure. Only patients who required TIPS revision within 1 year (Group I, 34 patients) and patients who did not require re-intervention within the first year (Group II [control group], 54 patients) were included.

RESULTS

Out of 88 patients, the majority were male (69.3%) and mean age was 56 ± 11 years. Indications for TIPS were refractory ascites (68%), bleeding (24%), and Budd-Chiari syndrome (8%). The most frequent liver disease was alcohol-induced cirrhosis (60%). Forty-three patients (49%) received bare and 45 patients (51%) covered stents, thus resulting in reduction of hepatic venous pressure gradient (HVPG) from 19.0 to 9.0 mm Hg. When comparing patient- and procedure-related factors, the type of stent (p < 0.01) and interventionalist's experience (number of performed TIPS implantations per year; p < 0.05) were the only factors affecting the risk of re-intervention due to stent dysfunction, while age, gender, indication, Child-Pugh, and model of end-stage liver disease score, platelet count, pre- and post-HVPG, additional variceal embolization, stent diameter, and number of stents did not significantly differ.

CONCLUSION

Patients undergoing TIPS procedure should be surveilled closely for shunt dysfunction while covered stents and high-level experience are associated with increased -patency.

Use of concomitant variceal embolization and prophylactic antiplatelet/anticoagulative in transjugular intrahepatic portosystemic shunting: A retrospective study of 182 cirrhotic portal hypertension patients

Transjugular intrahepatic portosystemic shunting (TIPS) is an effective treatment modality for refractory variceal bleeding and ascites in patients with cirrhotic portal hypertension (CPH). Variceal rebleeding and shunt dysfunction are major post-TIPS morbidities. This study aimed to retrospectively evaluate the effectiveness and safety of use of concomitant variceal embolization and prophylactic antiplatelet/anticoagulative in patients with CPH undergoing TIPS. Between October 2006 and October 2011, 182 patients with CPH were retrospectively and consecutively hospitalized for elective TIPS with Fluency stenting. Concomitant variceal embolization was given after establishing the shunt. Subcutaneous heparin was given after TIPS and replaced by oral clopidogrel, aspirin, or warfarin for at least 6 months. Main outcome measures included shunt patency rate, recurrence of CPH (rebleeding and/or refractory ascites), hepatic encephalopathy (HE) frequency, and post-TIPS survival. The cumulative primary patency rate was 96%, 94%, 90%, 88%, and 88% at 6, 12, 24, 36, and 48 months, respectively. Shunt stenosis occurred in 16 (9%) patients, gastrointestinal (GI) rebleeding in 32 (17.5%) patients, recurrence of refractory ascites 44 (48%) patients, HE in 42 (23%) patients, and death in 36 (20%) patients during the follow-up period. Use of concomitant variceal embolization and prophylactic antiplatelet/anticoagulative was associated with a favorable shunt patency and a low risk of GI rebleeding.

Added Value of Covered Stents in Transjugular Intrahepatic Portosystemic Shunt: A Large Single-Center Experience

PURPOSE

Transjugular intrahepatic portosystemic shunts (TIPS) were historically placed using uncovered bare-metal stents. Current practice has now shifted toward the use of polytetrafluoroethylene (PTFE)-covered stents, given the improved primary patency seen with these stents. The aim of this study was to determine whether there is any added value, such as overall survival or stent patency, when using covered stents versus uncovered stents in TIPS placement in a large cohort.

MATERIALS AND METHODS

From April 1995 to June 2012, a total of 744 consecutive adult patients underwent de novo TIPS placement (378 receiving uncovered stents, 366 receiving covered stents). Information was obtained on demographics, baseline clinical variables, and outcomes after TIPS placement. Data were collected, compared, and analyzed to assess outcomes including mortality, primary patency (determined via repeat intervention), and secondary patency (determined via ultrasound parameters).

RESULTS

Covered stents were associated with significantly improved primary patency (P < 0.001) and secondary patency (P < 0.001) when compared with uncovered stents in TIPS procedures. Additionally, covered stents were associated with higher estimated overall survival rates and higher survival rates when TIPS was performed emergently and in patients with higher Model for End-Stage Liver Disease (MELD) scores. For example, in patients with MELD scores between 11 and 18, there was a predicted survival of 59.2% with covered stents versus 42.8% with uncovered stents at 1 year.

CONCLUSION

This study demonstrated that covered stents offer the additional value of higher estimated overall survival and higher estimated survival in patients undergoing TIPS emergently and in those with higher MELD scores when compared to uncovered stents.

Portal Hypertension Over the Last 25 Years: Where Did It Go?

BACKGROUND

Portal hypertension has seemingly vanished from surgery; this study was undertaken to determine where it has gone.

STUDY DESIGN

Data from the Agency for Health Care Administration for 33,166,201 hospital inpatients in Florida for the periods 1988 to 1992, 1998 to 2002, and 2008 to 2012 were analyzed.

RESULTS

Admissions with a diagnosis of portal hypertension dramatically increased: 5,473 patients from 1988 to 1992, 7,366 patients from 1998 to 2002, and 36,554 patients from 2008 to 2012. Endoscopic treatment of esophageal varices also dramatically increased. The number of decompressive shunts placed nominally increased, but application of endoscopic therapy increased significantly faster than the application of decompressive shunts (p < 0.0001). The percentage of patients who underwent shunting dramatically and significantly decreased (p < 0.0001), and surgeons undertook proportionally fewer shunts (42% in 1992 to 4% in 2012; p < 0.0001). For patients with a diagnosis of portal hypertension, in-hospital mortality progressively decreased, from 9% in 1988 to 1992 to 3% in 2008 to 2012 (p < 0.0001).

CONCLUSIONS

In the state of Florida, over 25 years, there has been a 7-fold increase in the number of patients admitted with a diagnosis of portal hypertension, with a 65% reduction of in-hospital mortality. Application of endoscopic treatment of varices has increased dramatically. Decompressive shunts are applied to an ever-decreasing percentage of patients, and when applied, are now routinely undertaken by nonsurgeons. Therefore, portal hypertension has disappeared from the purview of surgery and has migrated toward the world of medical and endoscopic therapy, probably never to return.

Implantability, Complications, and Follow-Up After Transjugular Intrahepatic Portosystemic Stent-Shunt Creation With the 6F Self-Expanding Sinus-SuperFlex-Visual Stent

Background

The transjugular intrahepatic portosystemic stent-shunt (TIPSS) builds a shortcut between the portal vein and a liver vein, and represents a sophisticated alternative to open surgery in the management of portal hypertension or its complications.

Objectives

To describe clinical experiences with a low-profile nitinol stent system in TIPSS creation, and to assess primary and long-term success.

Patients and Methods

Twenty-six patients (5 females, 21 males; mean age 54.6 years) were treated using a low-profile 6F self-expanding sinus-SuperFlex-Visual stent system. The indication for TIPSS creation was refractory bleeding in 9 of the 26 patients, refractory ascites in 18 patients, and acute thrombosis of the portal vein confluence in one patient. Portosystemic pressure gradients before and after TIPSS, periprocedural and long-term complications, and the time to orthotopic liver transplantation (OLT) or death were recorded.

Results

The portosystemic pressure gradient was significantly reduced, from 20.9 ± 6.3 mmHg before to 8.2 ± 2.3 mmHg after TIPSS creation (P < 0.001). Procedure-related complications included acute tract occlusion (n = 2), liver hematoma (n = 1), hepatic encephalopathy (n = 1), and cardiac failure (n = 1). Three of the 26 patients had late-onset TIPSS occlusion (at 12, 12, and 39 months after TIPSS creation). Three patients died within one week after the procedure due to their poor general condition (multiorgan failure, acute respiratory distress syndrome, necrotizing pancreatitis, and aspiration pneumonia). Another four patients succumbed to their underlying advanced liver disease within one year after TIPSS insertion. Seven patients underwent OLT at a mean time of 9.4 months after TIPSS creation.

Conclusion

The sinus-SuperFlex-Visual stent system can be safely deployed as a TIPSS device. The pressure gradient reduction was clinically sufficient to treat the patients’ symptoms, and periprocedural complications were due to the TIPSS procedure per se rather than to the particular stent system employed in this study.

Efficacy of covered and bare stent in TIPS for cirrhotic portal hypertension: A single-center randomized trial. Sci Rep. 2016;6:21011. [PMID: 26876503 PMCID: PMC4753460 DOI: 10.1038/srep21011]

We conducted a single-center randomized trial to compare the efficacy of 8 mm Fluency covered stent and bare stent in transjugular intrahepatic portosystemic shunt (TIPS) for cirrhotic portal hypertension. From January 2006 to December 2010, the covered (experimental group) or bare stent (control group) was used in 131 and 127 patients, respectively. The recurrence rates of gastrointestinal bleeding (18.3% vs. 33.9%, P = 0.004) and refractory hydrothorax/ascites (6.9% vs. 16.5%, P = 0.019) in the experimental group were significantly lower than those in the control group. The cumulative restenosis rates in 1, 2, 3, 4, and 5-years in the experimental group (6.9%, 11.5%, 19.1%, 26.0%, and 35.9%, respectively) were significantly lower (P < 0.001) than those in the control group (27.6%, 37.0%, 49.6%, 59.8%, 74.8%, respectively). Importantly, the 4 and 5-year survival rates in the experimental group (83.2% and 76.3%, respectively) were significantly higher (P = 0.001 and 0.02) than those in the control group (71.7% and 62.2%, respectively). The rate of secondary interventional therapy in the experimental group was significantly lower than that in the control group (20.6% vs. 49.6%; P < 0.001). Therefore, Fluency covered stent has advantages over the bare stent in terms of reducing the restenosis, recurrence, and secondary interventional therapy, whereas improving the long-term survival for post-TIPS patients.

Transjugular intrahepatic portosystemic shunt versus surgical shunting in the management of portal hypertension

Background:

The purpose of this article was to clarify the optimal management concerning transjugular intrahepatic portosystemic shunts (TIPSs) and surgical shunting in treating portal hypertension.

Methods:

All databases, including CBM, CNKI, WFPD, Medline, EMBASE, PubMed and Cochrane up to February 2014, were searched for randomized controlled trials (RCTs) comparing TIPS with surgical shunting. Four RCTs, which were extracted by two independent investigators and were evaluated in postoperative complications, mortality, 2- and 5-year survival, hospital stay, operating time and hospitalization charges.

Results:

The morbidity in variceal rehemorrhage was significantly higher in TIPS than in surgical shunts (odds ratio [OR] = 7.45, 95% confidence interval[CI]: (3.93–14.15), P < 0.00001), the same outcomes were seen in shunt stenosis (OR = 20.01, 95% CI: (6.67–59.99), P < 0.000001) and in hepatic encephalopathy (OR = 2.50, 95% CI: (1.63–3.84), P < 0.0001). Significantly better 2-year survival (OR = 0.66; 95% CI: (0.44–0.98), P = 0.04) and 5-year survival (OR = 0.44; 95% CI: (0.30–0.66), P < 0.00001) were seen in patients undergoing surgical shunting compared with TIPS.

Conclusions:

Compared with TIPS, postoperative complications and survival after surgical shunting were superior for patients with portal hypertension. Application of surgical shunting was recommended for patients rather than TIPS.

Clinical Management of Chronic Portal/Mesenteric Vein Thrombosis: The Surgeon's Point of View

BACKGROUND

Bleeding from esophageal varices is a life-threatening complication of chronic portal hypertension (PH), occuring in 15% of patients with a mortality rate between 20 and 35%.

METHODS

Based on a literature review and personal experience in the therapy of PH, we recommend a therapy strategy for the secondary prophylaxis of variceal bleeding in PH.

RESULTS

The main causes for PH in western countries are alcoholic/viral liver cirrhosis and extrahepatic portal/mesenteric vein occlusion, mainly caused by myeloproliferative neoplasms or hypercoagulability syndromes. The primary therapy is medical; however, when recurrent bleeding occurs, a definitive therapy is required. In the case of parenchymal decompensation, liver transplantation is the causal therapy, but in case of good hepatic reserve or without underlying liver disease, a portal decompressive therapy is necessary. Transjugular intrahepatic portosystemic shunt has achieved a widespread acceptance, although evidence is comparable with or better for surgical shunting procedures in patients with good liver function. The type of surgical shunt should be chosen depending on the patent veins of the portovenous system and the personal expertise.

CONCLUSION

The therapy decision should be based on liver function, morphology of the portovenous system, and imminent liver transplantation and should be made by an interdisciplinary team of gastroenterologists, interventional radiologists, and visceral surgeons.

Randomized trials of endoscopic therapy and transjugular intrahepatic portosystemic shunt versus portacaval shunt for emergency and elective treatment of bleeding gastric varices in cirrhosis

IMPORTANCE

Bleeding esophageal varices has been studied extensively, but bleeding gastric varices (BGV) has received much less investigation. However, BGV has been reported in ≤ 30% of patients with acute variceal bleeding. In our studies of 1,836 bleeding cirrhotics, 12.7% were bleeding from gastric varices. BGV mortality rate of 45-55% has been reported. The BGV literature has mainly involved retrospective case reports, often with short-term follow-up.

OBJECTIVE

We sought to describe the results of a prospective, randomized, controlled trial (RCT) in unselected, consecutive patients with BGV comparing endoscopic therapy (ET) with portacaval shunt (PCS; n = 518), and later comparing emergency transjugular intrahepatic portosystemic shunt (TIPS) with emergency portacaval shunt (EPCS; n = 70).

DESIGN, SETTING, AND PARTICIPANTS

Initially, our RCT involved 518 patients with BGV comparing ET with direct PCS regarding control of bleeding, mortality rate, and disability. When entry of patients ended, the RCT was expanded to compare emergency TIPS with EPCS (n = 70). This RCT of BGV was separate from our other RCTs of bleeding esophageal varices.

INTERVENTIONS

Initially, ET was compared with PCS. In the second part of our RCT, emergency TIPS was compared with emergency PCS (EPCS).

MAIN OUTCOME MEASURES

Outcomes were survival, control of bleeding, portal-systemic encephalopathy (PSE), quality of life, and direct costs of care. In the RCT of ET versus PCS, 28 and 30%, respectively, were in Child class C. In the expanded RCT of TIPS versus EPCS, 40 and 41%, respectively, were in Child class C. Permanent control of BGV was achieved in 97-100% of patients treated by emergency or elective PCS, compared with 27-29% by ET. TIPS was even less effective, achieving long-term control of BGV in only 6%. Survival rates after PCS were greater at all time intervals and in all Child classes (P < .001). Repeated episodes of PSE occurred in 50% of TIPS patients, 16-17% treated by ET, and 8-11% treated by PCS. Shunt stenosis or occlusion occurred in 67% of TIPS patients, in contrast with 0-2% of PCS patients.

CONCLUSION

These results support the conclusion that PCS is uniformly effective, whereas ET and TIPS are not very effective.

TIPS for refractory ascites: a 6-year single-center experience with expanded polytetrafluoroethylene-covered stent-grafts. AJR Am J Roentgenol. 2015;204:654-661. [PMID: 25714299 DOI: 10.2214/ajr.14.12885]

OBJECTIVE. This single-center study evaluated the use of expanded polytetrafluoroethylene (ePTFE)-covered stent-grafts for transjugular intrahepatic portosystemic shunt (TIPS) placement to manage portal hypertension-related refractory ascites. MATERIALS AND METHODS. One hundred patients at a single tertiary care center in a major metropolitan hospital underwent TIPS placement with an ePTFE-covered stent-graft (Viatorr TIPS Endoprosthesis). Patients with portal hypertension-related ascites and preexisting hepatocellular carcinoma or liver transplant were excluded from the analysis. Records were reviewed for demographic characteristics, technical success of the TIPS procedures, and stent follow-up findings. Clinical results were assessed at 90- and 180-day intervals. RESULTS. Immediate technical success of the TIPS procedure was 100%. Of the 61 patients with documented follow-up, 55 (90.2%) had a partial or complete ascites response to TIPS creation. Of these 55 patients, nine experienced severe encephalopathy. Six of 61 patients (9.8%) did not experience a significant ascites response. Overall survival was 78.7% at 365-day follow-up. The 365-day survival was 84.2% for patients with a model for end-stage liver disease (MELD) score of less than 15, 67.0% for those with a score of 15-18, and 53.8% for those with a score of greater than 18 (p = 0.01). For patients with a MELD score of less than 18, the 365-day survival was 88.0% for those with an albumin value of 3 mg/dL or greater and 72.8% for those with an albumin value of less than 3 mg/dL (p = 0.04). CONCLUSION. TIPS placement using an ePTFE-covered stent-graft is an efficacious therapy for refractory ascites. Patients with preserved liver function-characterized by a MELD score of less than 15 or a MELD score of less than 18 and an albumin value of 3 mg/dL or greater-experience the greatest survival benefit.

Outcomes of transjugular intrahepatic portosystemic shunts for ascites

Refractory ascites represents a devastating complication of portal hypertension. Transjugular intrahepatic portosystemic shunt (TIPS) is an efficacious option for patients for whom transplant is not an immediate option. Techniques to optimize the hepatic venous pressure gradient and the use of covered stents have reduced rates of hepatic encephalopathy and stent occlusion, respectively. Patients with a Model for End-Stage Liver Disease score less than 15, serum creatinine less than 2 mg/dL, and serum bilirubin less than 2 mg/dL are particularly suited for TIPS placement. TIPS is also effective for hepatic hydrothorax and for massive ascites in the posttransplant setting, although future investigations are necessary to elucidate risk factors and establish the effect on transplant-free survival.

Selection of a TIPS stent for management of portal hypertension in liver cirrhosis: An evidence-based review

Nowadays, transjugular intrahepatic portosystemic shunt (TIPS) has become a mainstay treatment option for the management of portal hypertension-related complications in liver cirrhosis. Accumulated evidence has shown that its indications are being gradually expanded. Notwithstanding, less attention has been paid for the selection of an appropriate stent during a TIPS procedure. Herein, we attempt to review the current evidence regarding the diameter, type, brand, and position of TIPS stents. Several following recommendations may be considered in the clinical practice: (1) a 10-mm stent may be more effective than an 8-mm stent for the management of portal hypertension, and may be superior to a 12-mm stent for the improvement of survival and shunt patency; (2) covered stents are superior to bare stents for reducing the development of shunt dysfunction; (3) if available, Viatorr stent-grafts may be recommended due to a higher rate of shunt patency; and (4) the placement of a TIPS stent in the left portal vein branch may be more reasonable for decreasing the development of hepatic encephalopathy. However, given relatively low quality of evidence, prospective well-designed studies should be warranted to further confirm these recommendations.

Diagnostic radiology of transjugular intrahepatic portosystemic shunts

Transjugular intrahepatic portosystemic shunts (TIPS) are an effective method for treating the complications of portal hypertension. Specific indications for TIPS include secondary prevention of variceal bleeding and refractory ascites. The purpose of this review is to summarize the role of diagnostic radiology in the creation and assessment of TIPS, to highlight the complications that can occur post-TIPS, and to critically evaluate the literature regarding ultrasound evaluation of TIPS.

MRI-monitored intra-shunt local agent delivery of motexafin gadolinium: towards improving long-term patency of TIPS

Background

Transjugular intrahepatic portosystemic shunt (TIPS) has become an important and effective interventional procedure in treatment of the complications related to portal hypertension. Although the primary patency of TIPS has been greatly improved due to the clinical application of cover stent-grafts, the long-term patency is still suboptimal. This study was to investigate the feasibility of using magnetic resonance imaging (MRI)-monitored intra-shunt local agent delivery of motexafin gadolinium (MGd) into shunt-vein walls of TIPS. This new technique aimed to ultimately inhibit shuntstenosis of TIPS.

Methodology

Human umbilical vein smooth muscle cells (SMCs) were incubated with various concentrations of MGd, and then examed by confocal microscopy and T1-map MRI. In addition, the proliferation of MGd-treated cells was evaluated. For in vivo validation, seventeen pigs underwent TIPS. Before placement of the stent, an MGd/trypan-blue mixture was locally delivered, via a microporous balloon, into eleven shunt-hepatic vein walls under dynamic MRI monitoring, while trypan-blue only was locally delivered into six shunt-hepatic vein walls as serve as controls. T1-weighted MRI of the shunt-vein walls was achieved before- and at different time points after agent injections. Contrast-to-noise ratio (CNR) of the shunt-vein wall at each time-point was measured. Shunts were harvested for subsequent histology confirmation.

Principal Findings

In vitro studies confirmed the capability of SMCs in uptaking MGds in a concentration-dependent fashion, and demonstrated the suppression of cell proliferation by MGds as well. Dynamic MRI displayed MGd/blue penetration into the shunt-vein walls, showing significantly higher CNR of shunt-vein walls on post-delivery images than on pre-delivery images (49.5±9.4 vs 11.2±1.6, P<0.01), which was confirmed by histology.

Conclusion

Results of this study indicate that MRI-monitored intra-shunt local MGd delivery is feasible and MGd functions as a potential therapeutic agent to inhibit the proliferation of SMCs, which may open alternative avenues to improve the long-term patency of TIPS.

Transjugular intrahepatic portosystemic shunt dysfunction

Transjugular intrahepaticportosystemic shunt (TIPS) is an effective method for the management of complications of portal hypertension, and it should be considered the first-line treatment for acute hemorrhage due to ruptured esophageal varices caused by portal hypertension. Keeping the stent unobstructed is key to the success of TIPS. Stent thrombosis is one of the main reasons for TIPS dysfunction. There has been no mention of TIPS postoperative anticoagulation in both domestic and foreign anticoagulation guidelines, because the consensus has not been reached yet. This paper reviews recent advances in research of TIPS dysfunction.

Outcomes after transjugular intrahepatic portosystemic stent shunt: a "bridge" to nowhere

BACKGROUND

Transjugular intrahepatic portosystemic stent shunt (TIPS) has become the modality of choice for complicated portal decompression. This study was undertaken to determine outcomes after TIPS and the usefulness of TIPS as a "bridge" to transplantation.

METHODS

Patients undergoing TIPS from 2001 to 2010 at a teaching hospital with a transplant program were studied. The median data are presented.

RESULTS

TIPS was undertaken in 256 patients. TIPS decreased portal vein-inferior vena cava (IVC) gradients from 17 to 5 mm Hg (P < .001). Reinterventions were undertaken in 54 patients (21%). Survival after TIPS was 26 months; liver transplantation was undertaken in 35 (14%) patients.

CONCLUSIONS

TIPS effectively decompresses portal hypertension but leads to frequent reinterventions and short survival. After TIPS, liver transplantation is uncommonly undertaken. TIPS is a "bridge" to transplantation that is seldom "crossed," and TIPS continues to be plagued by frequent reinterventions. Outcomes after TIPS and the infrequency of transplantation after TIPS make it difficult to recommend on merit.

The role of Transjugular Intrahepatic Portosystemic Stent-Shunt (TIPSS) in the management of variceal hemorrhage

BACKGROUND

Variceal bleeding in cirrhosis represents a lethal complication of their disease. In the last 20 years, management of AVH has improved greatly with reduction in mortality from 43% in 1980 to 15% in 2000.

AIM

Advances in endoscopic therapy, pharmacologic agents including vasoconstrictor therapy and antibiotics have played a large part in improving outcomes, but the role of Transjugular Intrahepatic Portosystemic Stent-Shunt (TIPSS) remains controversial, which this review will cover.

METHODS

MEDLINE search for the following terms was performed to July 2011: variceal hemorrhage, portal hypertension, cirrhosis, transjugular intrahepatic portosystemic stent-shunt (TIPSS), PTFE, covered stents. Where possible randomized controlled studies were used for this review, although uncontrolled studies were also included if they made a significant contribution to the literature.

RESULTS

Literature used for the present study was selected from a total of 252 publications and abstracts from meetings.

RESULTS

TIPSS has been used as a salvage therapy after initial medical and endoscopic therapy for the bleed given its high success rate in arresting uncontrolled variceal bleeding. The recent trial by Garcia- Pagan et al. suggested beneficial effects of an earlier covered TIPSS in those at high risk of treatment failure (Childs C and those who are Childs B with active bleeding).

CONCLUSIONS

TIPSS can reduce failure to control bleeding and rebleeding as well as mortality with no increase in the risk of hepatic encephalopathy.This needs to be confirmed in further trials. However, it is clear that prevention of rebleeding is the key to improved outcomes following a variceal bleed.

Randomized controlled trial of emergency transjugular intrahepatic portosystemic shunt versus emergency portacaval shunt treatment of acute bleeding esophageal varices in cirrhosis

BACKGROUND

Emergency treatment of bleeding esophageal varices (BEV) in cirrhosis is of paramount importance because of the resultant high mortality rate. Emergency therapy today consists mainly of endoscopic and pharmacologic measures, with use of transjugular intrahepatic portosystemic shunt (TIPS) when bleeding is not controlled. Surgical portosystemic shunt has been relegated to last resort salvage when all other measures fail. Regrettably, no randomized controlled trials have been reported in which TIPS and surgical portosystemic shunt were compared in unselected patients with acute BEV, with long-term follow-up. This is a report of a long-term prospective randomized controlled trial (RCT) that compared TIPS with emergency portacaval shunt (EPCS) in patients with cirrhosis and acute BEV.

STUDY DESIGN

A total of 154 unselected, consecutive cirrhotic patients ("all comers") with acute BEV were randomized to TIPS (n = 78) or EPCS (n = 76), and the two treatments were compared with regard to effect on survival, control of bleeding, portal-systemic encephalopathy (PSE), and disability. Diagnostic workup was completed within 6 h and TIPS or EPCS was initiated within 24 h. Regular follow-up was accomplished in 100 % of patients and lasted for 5 to 10 years in 85 % and 3 to 4.5 years in the remainder. This report focuses on control of bleeding and survival.

RESULTS

The clinical characteristics of the two groups were similar, and the distribution of Child classes A, B, and C was almost identical. TIPS was successful in controlling BEV for 30 days in 80 % of patients but achieved long-term control of BEV in only 22 %. In contrast, EPCS controlled BEV immediately in all patients and permanently in 97 % (p < 0.001). TIPS patients required almost twice as many units of blood transfusion as EPCS patients. Survival rate at all time intervals and in all Child classes was significantly greater following EPCS than after TIPS (p < 0.001). Median survival was over 10 years following EPCS, compared to 1.99 years following TIPS. Stenosis or occlusion of TIPS was demonstrated in 84 % of patients who survived 21 days, 63 % of whom underwent TIPS revision, which failed in 80 %. In contrast, EPCS remained permanently patent in 97 % of patients. Recurrent PSE was threefold more frequent following TIPS than after EPCS (61 versus 21 %).

CONCLUSIONS

EPCS was uniformly effective in the treatment of BEV, while TIPS was disappointing. EPCS accomplished long-term survival while TIPS resulted in a survival rate that was less than one fifth that of EPCS. The results of this RCT in unselected, consecutive patients justify the use of EPCS as a first-line emergency treatment of BEV in cirrhosis (clinicaltrials.gov #NCT00734227).

Prosthetic H-graft portacaval shunts vs transjugular intrahepatic portasystemic stent shunts: 18-year follow-up of a randomized trial

BACKGROUND

Widespread application of transjugular intrahepatic portasystemic shunt (TIPS) continues despite the lack of trials documenting efficacy superior to surgical shunting. Here we present an 18-year follow-up of a prospective randomized trial comparing TIPS with small-diameter prosthetic H-graft portacaval shunt (HGPCS) for portal decompression.

STUDY DESIGN

Beginning in 1993, patients were prospectively randomized to undergo either TIPS or HGPCS as definitive therapy for portal hypertension due to cirrhosis. Complications of shunting and long-term outcomes were noted. Failure of shunting was prospectively defined as the inability to place shunt, irreversible shunt occlusion, major variceal rehemorrhage, unanticipated liver transplantation, or death. Survival and shunt failure were compared using Kaplan-Meier curve analysis. Median data are reported.

RESULTS

Patient presentation, circumstances of shunting, causes of cirrhosis, severity of hepatic dysfunction (eg, Child's class, Model for End-Stage Liver Disease score), and predicted survival after shunting did not differ between patients undergoing TIPS (n = 66) or HGPCS (n = 66). Survival was significantly longer after HGPCS for patients of Child's class A (91 vs 19 months; p = 0.009) or class B (63 vs 21 months; p = 0.02). Shunt failure occurred later after HGPCS than TIPS (45 vs 22 months; p = 0.04).

CONCLUSIONS

Compared with TIPS, survival after HGPCS was superior for patients with better liver function (eg, Child's class A or B). Shunt failure after HGPCS occurred later than after TIPS. Rather than TIPS, application of HGPCS is preferred for patients with complicated cirrhosis and better hepatic function.