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Sayadi A, Duhaut L, Robert F, Savale L, Coilly A. [Hepatopulmonary syndrome]. Rev Med Interne 2024; 45:156-165. [PMID: 37005097 DOI: 10.1016/j.revmed.2023.03.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2022] [Revised: 03/07/2023] [Accepted: 03/17/2023] [Indexed: 04/03/2023]
Abstract
The hepatopulmonary syndrome (HPS) is one of the lung diseases associated with cirrhosis and portal hypertension. It should be discussed for any dyspnea in cirrhotic patients. HPS is a pulmonary vascular disease characterized by intrapulmonary vascular dilatations (IPVD). The pathogenesis is complex and seems to rely on communications between the portal and pulmonary circulations. The diagnosis is based on a triad of liver disease and portal hypertension, evidence of IPVDs, and impaired gas exchange (alveolar-arterial oxygen difference [A-aO2]≥15mmHg). HPS impairs prognosis (23% survival at 5years) and patients' quality of life. Liver transplantation (LT) allows regression of IPDVD in almost 100% of cases, normalization of gas exchange and improves survival with a 5-year post-LT survival between 76 and 87%. It is the only curative treatment, indicated in patients with severe HPS, defined by an arterial partial pressure of oxygen (PaO2) below 60mmHg. When LT is not indicated or feasible, long-term oxygen therapy may be proposed as a palliative treatment. A better understanding of the pathophysiological mechanisms is needed to improve the therapeutic possibilities in a near future.
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Affiliation(s)
- A Sayadi
- UMR-S 1193, hôpital Paul-Brousse, centre hépato-biliaire, université Paris-Saclay, AP-HP, 94800 Villejuif, France
| | - L Duhaut
- UMR-S 1193, hôpital Paul-Brousse, centre hépato-biliaire, université Paris-Saclay, AP-HP, 94800 Villejuif, France
| | - F Robert
- Inserm UMR_S 999, 94270 Le Kremlin-Bicêtre, France
| | - L Savale
- Inserm UMR_S 999, 94270 Le Kremlin-Bicêtre, France; Service de pneumologie, hôpital Bicêtre, université Paris-Saclay, AP-HP, 94270 Le Kremlin-Bicêtre, France
| | - A Coilly
- UMR-S 1193, hôpital Paul-Brousse, centre hépato-biliaire, université Paris-Saclay, AP-HP, 94800 Villejuif, France.
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Carroll A, Boike JR. TIPS: indications, Contraindications, and Evaluation. Curr Gastroenterol Rep 2023; 25:232-241. [PMID: 37603109 DOI: 10.1007/s11894-023-00884-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/09/2023] [Indexed: 08/22/2023]
Abstract
PURPOSE OF REVIEW This review summarizes the current and emerging indications, contraindications, and evaluation for TIPS. In the last three decades of use, there have been substantial changes and progress in this field, including the use of controlled-expansion, covered stents, which has broadened the clinical uses of TIPS. RECENT FINDINGS Recent findings have rapidly expanded the indications for TIPS, including emerging uses in hepatorenal syndrome, hepatopulmonary syndrome and before abdominal surgery. The widespread use of controlled-expansion, covered stents has decreased rates of post-TIPS hepatic encephalopathy, opening TIPS to a larger patient population. Overall, with newer stent technology and more research in this area, the clinical utility and potential of TIPS has rapidly expanded. Going forward, a renewed focus on randomized-control trials and long-term outcomes will be a crucial element to selecting appropriate TIPS recipients and recommending emerging indications for this procedure.
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Affiliation(s)
- Allison Carroll
- Department of Medicine, Division of Gastroenterology & Hepatology, Northwestern University Feinberg School of Medicine, 676 N. St. Clair, Suite 1900, Chicago, IL, 60611, USA
- Feinberg School of Medicine, Northwestern University, Chicago, USA
| | - Justin R Boike
- Department of Medicine, Division of Gastroenterology & Hepatology, Northwestern University Feinberg School of Medicine, 676 N. St. Clair, Suite 1900, Chicago, IL, 60611, USA.
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Prevalence and prognostic impact of hepatopulmonary syndrome in patients with unresectable hepatocellular carcinoma undergoing transarterial chemoembolization: a prospective cohort study. Chin Med J (Engl) 2022; 135:2043-2048. [PMID: 36255217 PMCID: PMC9746741 DOI: 10.1097/cm9.0000000000002034] [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] [Indexed: 02/04/2023] Open
Abstract
BACKGROUND To determine the prevalence and prognostic impact of hepatopulmonary syndrome (HPS) in patients with unresectable hepatocellular carcinoma (HCC) undergoing transarterial chemoembolization (TACE). METHODS Fifty-four patients with unresectable HCC undergoing TACE between December 2014 and December 2015 were prospectively screened for HPS and were followed up for a maximum of 2 years or until the end of this prospective study. RESULTS Nineteen of the 54 (35.2%) patients were considered to have HPS, including one (5.3%) with severe HPS, nine (47.4%) with moderate HPS, and nine (47.4%) with mild HPS. The median overall survival (OS) was 10.1 (95% confidence interval [CI], 3.9-16.3) months for patients with HPS and 15.1 (95% CI, 7.3-22.9) months for patients without HPS, which is not a significant difference ( P = 0.100). The median progression-free survival was also not significantly different between patients with and without HPS (5.2 [95% CI, 0-12.8] vs. 8.4 [95% CI, 3.6-13.1] months; P = 0.537). In the multivariable Cox regression analyses, carbon monoxide diffusing capacity (hazard ratio [HR] = 1.033 [95% CI, 1.003-1.064]; P = 0.028) and Child-Pugh class (HR = 1.815 [95% CI, 1.011-3.260]; P = 0.046) were identified to be the independent prognostic factors of OS. CONCLUSION Mild or moderate HPS is common in patients with unresectable HCC undergoing TACE, but it does not seem to have a significant prognostic impact.
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Vulasala SSR, Onteddu NKR, Kalva SP, Smolinski-Zhao S. Expanding Indications of TIPS in the Management of Portal Hypertension Complications. JOURNAL OF CLINICAL INTERVENTIONAL RADIOLOGY ISVIR 2022. [DOI: 10.1055/s-0042-1748818] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/10/2022] Open
Abstract
AbstractTransjugular intrahepatic portosystemic shunt (TIPS) is a nonsurgical intervention to reduce portal pressure by creating a low-resistance channel between the portal and systemic circulations. It is a well-accepted treatment for gastroesophageal varices and refractory ascites. This review aims to discuss the evidence-based applications of TIPS in other complications of portal hypertension beyond gastroesophageal varices and refractory ascites.
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Affiliation(s)
- Sai Swarupa Reddy Vulasala
- Department of Radiology, University of Florida College of Medicine, Jacksonville, Florida, United States
| | - Nirmal Kumar Reddy Onteddu
- Division of Hospital Medicine, Department of Internal Medicine, Flowers Hospital, Dothan, Alabama, United States
| | - Sanjeeva Prasad Kalva
- Division of Interventional Radiology, Department of Radiology, Massachusetts General Hospital, Boston, Massachusetts, United States
| | - Sara Smolinski-Zhao
- Division of Interventional Radiology, Department of Radiology, Massachusetts General Hospital, Boston, Massachusetts, United States
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Téllez L, Guerrero A. Management of Liver Decompensation in Advanced Liver Disease (Renal Impairment, Liver Failure, Adrenal Insufficiency, Cardiopulmonary Complications). Clin Drug Investig 2022; 42:15-23. [PMID: 35522396 PMCID: PMC9205830 DOI: 10.1007/s40261-022-01149-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/25/2022] [Indexed: 12/17/2022]
Abstract
Systemic complications often occur in patients with advanced liver disease. In particular, the development of renal complications (acute kidney injury, hepatorenal syndrome), acute-on-chronic liver failure, cardiopulmonary diseases, or relative adrenal insufficiency can be serious in patients with advanced liver disease and may determine the patient’s quality of life and prognosis. Therefore, the early diagnosis of possible complications is the key to the prompt initiation of specific treatments that can improve quality of life and survival. For this purpose, networking with reference centers where multidisciplinary units are available is essential so that every patient is evaluated in clinical discussions involving specialists from different fields.
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Affiliation(s)
- Luis Téllez
- Department of Gastroenterology and Hepatology, Hospital Universitario Ramón y Cajal, Insituto Ramón y Cajal de Investigación Sanitaria (IRYCIS), Centro de Investigación Biomédica en Red (CIBERehd), Universidad de Alcalá, Ctra. Colmenar Viejo, km 9,100, 28034, Madrid, Spain.
| | - Antonio Guerrero
- Department of Gastroenterology and Hepatology, Hospital Universitario Ramón y Cajal, Insituto Ramón y Cajal de Investigación Sanitaria (IRYCIS), Centro de Investigación Biomédica en Red (CIBERehd), Universidad de Alcalá, Ctra. Colmenar Viejo, km 9,100, 28034, Madrid, Spain
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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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Gandhi KD, Taweesedt PT, Sharma M, Surani S. Hepatopulmonary syndrome: An update. World J Hepatol 2021; 13:1699-1706. [PMID: 34904039 PMCID: PMC8637683 DOI: 10.4254/wjh.v13.i11.1699] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/16/2021] [Revised: 06/25/2021] [Accepted: 08/31/2021] [Indexed: 02/06/2023] Open
Abstract
Hepatopulmonary syndrome (HPS) is characterized by defects in oxygenation caused by intra-pulmonary vasodilation occurring because of chronic liver disease, portal hypertension, or congenital portosystemic shunts. Clinical implications of portal hypertension are very well-known, however, awareness of its effect on multiple organs such as the lungs are less known. The presence of HPS in chronic liver disease is associated with increased mortality. Medical therapies available for HPS have not been proven effective and definitive treatment for HPS is mainly liver transplantation (LT). LT improves mortality for patients with HPS drastically. This article provides a review on the definition, clinical presentation, diagnosis, and management of HPS.
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Affiliation(s)
- Kejal D Gandhi
- Department of Internal Medicine, Medstar Washington Hospital Center/Georgetown University, Washigton, DC 20010, United States
| | - Pahnwat Tonya Taweesedt
- Department of Medicine, Corpus Christi Medical Center, Corpus Christi, TX 78412, United States
| | - Munish Sharma
- Department of Medicine, Corpus Christi Medical Center, Corpus Christi, TX 78412, United States
| | - Salim Surani
- Department of Medicine, Texas A&M University, Bryan, TX 78413, United States
- Department of Anesthesiology, Mayo Clinic, Rochester, MN 55905, United States
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Yeoh SW, Kok HK. Transjugular intrahepatic portosystemic shunts in portal vein thrombosis: A review. J Dig Dis 2021; 22:506-519. [PMID: 34323378 DOI: 10.1111/1751-2980.13035] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/17/2021] [Revised: 07/16/2021] [Accepted: 07/26/2021] [Indexed: 12/11/2022]
Abstract
The presence of portal vein thrombosis (PVT) has previously been considered a contraindication to the insertion of transjugular intrahepatic portosystemic shunts (TIPSS). However, patients with PVT may have portal hypertension complications and may thus benefit from TIPSS to reduce portal venous pressure. There is an increasing body of literature that discusses the techniques and outcomes of TIPSS in PVT. This review summarizes the techniques, indications and outcomes of TIPSS in PVT in published case reports, case series and comparative trials, especially regarding the reduction in portal hypertensive complications such as variceal bleeding. A comprehensive literature search was conducted using MEDLINE and PubMed databases. Manuscripts published in English between 1 January 1990 and 1 March 2021 were used. Abstracts were screened and data from potentially relevant articles analyzed. TIPSS in PVT has been reported with high levels of technical success, short-term portal vein recanalization and long-term PV patency and TIPSS patency outcomes. Several comparative studies, including randomized controlled trials, have shown favorable outcomes of TIPSS compared with non-TIPSS treatment of PVT complications. Outcomes of TIPSS with PVT appear similar to those in TIPSS without PVT. However, TIPSS may be more technically difficult in the presence of PVT, and such procedures should be performed in expert high-volume centers to mitigate the risk of procedural complications. The presence of PVT should no longer be considered a contraindication to TIPSS. TIPSS for PVT has been acknowledged as a therapeutic strategy in recent international guidelines, although further studies are needed before recommendations can be strengthened. KEY POINTS: Portal vein thrombosis (PVT) is no longer a contraindication to the insertion of transjugular intrahepatic portosystemic shunts (TIPSS) TIPSS often leads to the spontaneous dissolution of PVT, but can be combined with mechanical or pharmacological thrombectomy TIPSS reduces portal hypertensive complications of PVT, such as variceal bleeding, and can also facilitate liver transplantation where PVT may otherwise interfere with vascular anastomoses Studies have shown favorable long-term outcomes of TIPSS compared with TIPSS without PVT; as well as compared with non-TIPSS treatment of PVT complications TIPSS in PVT should be performed in high-volume specialist centers due to technical difficulties.
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Affiliation(s)
- Sern Wei Yeoh
- Department of Gastroenterology, Northern Health, Melbourne, Victoria, Australia.,School of Medical Education, University of Melbourne, Melbourne, Victoria, Australia
| | - Hong Kuan Kok
- Department of Radiology, Northern Health, Melbourne, Victoria, Australia.,School of Medicine, Deakin University, Melbourne, Victoria, Australia
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Tsauo J, Tie J, Xue H, Zhao JB, Li JJ, Fang ZT, Guo WH, Li X. Transjugular Intrahepatic Portosystemic Shunt Creation for the Prevention of Gastric Variceal Rebleeding in Patients with Hepatocellular Carcinoma: A Multicenter Retrospective Study. J Vasc Interv Radiol 2021; 32:963-969. [PMID: 33864909 DOI: 10.1016/j.jvir.2021.04.005] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2021] [Revised: 03/28/2021] [Accepted: 04/03/2021] [Indexed: 02/07/2023] Open
Abstract
PURPOSE To evaluate the effectiveness and safety of transjugular intrahepatic portosystemic shunt (TIPS) creation for the prevention of gastric variceal rebleeding in patients with hepatocellular carcinoma (HCC). MATERIALS AND METHODS This multicenter retrospective study included 126 cirrhotic patients (mean age, 54.1 ± 10.2 years; 110 men) with HCC who underwent TIPS creation for the prevention of gastric variceal rebleeding. Of these, 110 (87.3%) patients had gastroesophageal varices and 16 (12.7%) patients had isolated gastric varices. Thirty-five (27.8%) patients had portal vein tumor thrombus. RESULTS TIPS creation was technically successful in 124 (98.4%) patients. Rebleeding occurred in 26 (20.6%) patients during the follow-up period. The 6-week and 1-year actuarial probabilities of patients remaining free of rebleeding were 98.3% ± 1.2% and 81.2% ± 3.9%, respectively. Forty-nine (38.8%) patients died during the follow-up period. The 6-week and 1-year actuarial probabilities of survival were 98.4 ± 1.1% and 65.6 ± 4.4%, respectively. Two (1.6%) patients had major procedure-related complications, including acute liver failure (n = 1) and intra-abdominal bleeding (n = 1). Thirty-three (26.2%) patients had at least 1 episode of overt hepatic encephalopathy during the follow-up period. Shunt dysfunction occurred in 15 (11.9%) patients after a median follow-up time of 11.4 months (range, 1.4-41.3 months). Lung metastasis occurred in 3 (2.4%) patients, 3.9-32.9 months after TIPS creation. CONCLUSIONS TIPS creation may be effective and safe for the prevention of gastric variceal rebleeding in patients with HCC.
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Affiliation(s)
- Jiaywei Tsauo
- Department of Interventional Therapy, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Jun Tie
- National Clinical Research Center for Digestive Diseases, State Key Laboratory of Cancer Biology and Xijing Hospital of Digestive Diseases, Xijing Hospital, Air Force Military Medical University, Xi'an, Shaanxi, China
| | - Hui Xue
- Department of Gastroenterology, First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, Shaanxi, China
| | - Jian-Bo Zhao
- Division of Vascular and Interventional Radiology, Department of General Surgery, Nanfang Hospital, Southern Medical University, Guangzhou, Guangdong, China
| | - Jian-Jun Li
- Hepatic Disease and Tumor Interventional Therapy Center, Beijing Youan Hospital, Capital Medical University, Beijing, China
| | - Zhu-Ting Fang
- Shengli Clinical Medical College of Fujian Medical University, Fuzhou, Fujian, China; Department of Interventional Radiology, Fujian Provincial Hospital, Fuzhou, Fujian, China
| | - Wu-Hua Guo
- Department of Interventional Radiology, Mengchao Hepatobiliary Hospital, Fujian Medical University, Fuzhou, Fujian, China
| | - Xiao Li
- Department of Interventional Therapy, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China.
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Weinfurtner K, Forde K. Hepatopulmonary Syndrome and Portopulmonary Hypertension: Current Status and Implications for Liver Transplantation. CURRENT HEPATOLOGY REPORTS 2020; 19:174-185. [PMID: 32905452 PMCID: PMC7473417 DOI: 10.1007/s11901-020-00532-y] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/11/2023]
Abstract
PURPOSE OF REVIEW Hepatopulmonary syndrome (HPS) and portopulmonary hypertension (PoPH) are both pulmonary vascular complications of advanced liver disease; however, these syndromes have distinct pathophysiology, clinical implications, and management. RECENT FINDINGS While both conditions are associated with portal hypertension, HPS results from diffuse pulmonary capillary vasodilation and PoPH results from vasoconstriction and vascular remodeling of pulmonary arteries. In HPS, no medical therapies clearly improve outcomes; however, patients have excellent post-LT outcomes with near uniform reversal of hypoxemia. In PoPH, several medical therapies used in idiopathic pulmonary hypertension have been shown improve pulmonary hemodynamics, symptoms, and potentially LT outcomes; however, further study is needed to determine best treatment regimens, long-term outcomes on medical therapy, and role of LT. SUMMARY While HPS results in severe hypoxemia that is usually reversible by LT, PoPH patients develop progressive pulmonary hypertension that may improve with medical therapy.
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Affiliation(s)
- Kelley Weinfurtner
- Division of Gastroenterology and Hepatology, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Kimberly Forde
- Division of Gastroenterology and Hepatology, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
- Center for Clinical Epidemiology and Biostatistics, Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
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Boike JR, Flamm SL. Transjugular Intrahepatic Portosystemic Shunts: Advances and New Uses in Patients with Chronic Liver Disease. Clin Liver Dis 2020; 24:373-388. [PMID: 32620278 DOI: 10.1016/j.cld.2020.04.007] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Transjugular intrahepatic portosystemic shunts is an established treatment for portal hypertensive complications. Advancements in technology and technique have led to novel indications, including treatment of chronic portal vein thrombosis and use before abdominal surgery to alleviate portal hypertensive complications. Use of TIPS can facilitate the embolization of large portal-systemic shunts to alleviate refractory hepatic encephalopathy owing to excessive portal shunting. Despite these advances, transjugular intrahepatic portosystemic shunts is an invasive procedure with risk for complications and should be performed at a center with expertise to ensure a successful patient outcome.
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Affiliation(s)
- Justin R Boike
- Department of Medicine, Northwestern Feinberg School of Medicine, 676 North St. Clair Street, Suite 1400, Chicago, IL 60611, USA.
| | - Steven L Flamm
- Hepatology Program, Department of Medicine, Northwestern Feinberg School of Medicine, Chicago, IL, USA
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