Transjugular intrahepatic portosystemic shunt (TIPS). Thrombogenicity in stents and its effect on shunt patency

The effects and safety of anticoagulation or antiplatelet therapy following TIPS in cirrhotic patients with portal hypertension: A meta-analysis

Introduction: Transjugular intrahepatic portosystemic shunt (TIPS) is an effective way to improve portal hypertension, however, the role of anticoagulation or antiplatelet therapy following TIPS remains controversial. We conducted this study to evaluate the efficacy and safety of anticoagulation or antiplatelet therapy following TIPS. Methods: A literature search was conducted on anticoagulation or antiplatelet therapy after TIPS using Pubmed, Web of Science, EMBASE, and Cochrane. The retrieval period was from the earliest accessible date in the database to 31 October 2022. We collected information on the incidence of stent dysfunction, bleeding, hepatic encephalopathy, the new occurrence of portal vein thrombosis, and the survival rate. Stata was analyzed in RevMan. Results: 1. Four studies received anticoagulation or antiplatelet therapy after TIPS without control groups. According to the single-group rate meta-analysis, stent dysfunction occurred at 27% [95% CI (0.19, 0.38)], bleeding occurred at 21% [95% CI (0.14, 0.29)], new portal vein thrombosis occurred at 17% [(95%CI(0.04.0.71)], hepatic encephalopathy occurred at 47% [95%CI (0.34, 0.63)], and death occurred at 31% [95% CI (0.22, 0.42)]. 2. Eight studies, including 1025 patients, compared anticoagulation and antiplatelet therapy after TIPS to TIPS alone. In terms of stent dysfunction, bleeding, and hepatic encephalopathy, there were no significant differences between the two groups. The use of anticoagulation or antiplatelet therapy may result in a significant decrease in the incidence of new portal vein thrombosis and mortality over 1 year. Discussion: Anticoagulant or antiplatelet therapy may not improve the patency rate of TIPS, but may effectively prevent new portal vein thrombosis after TIPS. Following TIPS, the use of anticoagulants or antiplatelet drugs does not lead to an increase in bleeding or death.

Aspirin improves transplant-free survival after TIPS implantation in patients with refractory ascites: a retrospective multicentre cohort study

BACKGROUND AND AIMS

Transjugular intrahepatic portosystemic shunt (TIPS) implantation is an established procedure to treat portal hypertension. Impact of administration of aspirin on transplant-free survival after TIPS remains unknown.

METHODS

A multicenter retrospective analysis including patients with TIPS implantation between 2011 and 2018 at three tertiary German Liver Centers was performed. N = 583 patients were included. Survival analysis was performed in a matched cohort after propensity score matching. Patients were grouped according to whether aspirin was (PSM-aspirin-cohort) or was not (PSM-no-aspirin-cohort) administered after TIPS. Primary endpoint of the study was transplant-free survival at 12 months after TIPS.

RESULTS

Aspirin improved transplant-free survival 12 months after TIPS with 90.7% transplant-free survival compared to 80.0% (p = 0.001) after PSM. Separated by TIPS indication, aspirin did improve transplant-free survival in patients with refractory ascites significantly (89.6% vs. 70.6% transplant-free survival, p < 0.001), while no significant effect was observed in patients with refractory variceal bleeding (91.1% vs. 92.2% transplant-free survival, p = 0.797).

CONCLUSION

This retrospective multicenter study provides first data indicating a beneficial effect of aspirin on transplant-free survival after TIPS implantation in patients with refractory ascites.

TIPS-related hepatic encephalopathy: management options with novel endovascular techniques

Hepatic encephalopathy is a common complication that develops after creation of a transjugular intrahepatic portosystemic shunt (TIPS). Although most patients respond well to conservative medical therapy (ie, protein-restricted diet, nonabsorbable disaccharides, nonabsorbable antibiotics), a small percentage of patients (3%-7%) do not benefit from these methods and require more invasive therapeutic approaches. One option is emergent liver transplantation, but the majority of patients are not suitable candidates. Recently, various percutaneous techniques have been described that alter the hemodynamics through the shunt by occluding it with coils or balloons or by reducing its diameter by inserting constrained stents or stent-grafts. Other techniques have been used for patients with TIPS-related hepatic encephalopathy in whom spontaneous splenorenal shunts are present. In many patients with refractory hepatic encephalopathy, these percutaneous techniques have produced symptomatic improvement, with either a complete resolution or a substantial reduction in hepatic encephalopathy symptoms that can be controlled with medical therapy. Unfortunately, despite all attempts, some patients remain incapacitated and ultimately die. Further research is necessary to improve our understanding of TIPS-related hepatic encephalopathy so that newer, less invasive and safer procedures can be developed to treat this difficult clinical problem.

TIPS: an update

During the last 15 years the transjugular intrahepatic portosystemic shunt (TIPS) procedure has become a safe and effective treatment of portal hypertension. Its major obstacle, the high rate of shunt insufficiency, is going to be solved by the availability of covered stents showing a patency rate of up to 90%. The treatment of acute oesophageal and gastric variceal bleeding is an unsolved problem because variceal bleeding remains the major cause of death in patients with cirrhosis. TIPS has become the rescue treatment of choice because it combines high efficacy with low invasiveness. In this context, the timing of the rescue TIPS is of major importance for achieving definitive haemostasis before multi-organ failure develops. In the prevention of re-bleeding, TIPS is accepted as a second-line treatment, required in about 10-20% of patients. TIPS may be indicated when more than two significant re-bleedings occurred within a time frame of 12 months in spite of adequate first-line measures i.e. drugs or ligation. Refractory ascites is the third main indication for TIPS. Five randomized studies comparing TIPS with paracentesis show good response and comparable survival. Interpretations of authors and comments of reviewers are, however, controversial and do not permit a definitive recommendation.

Use of balloon-expandable stents in transjugular intrahepatic portosystemic shunts in cases of Wallstent endoprosthesis technical failure and revision of shunt stenosis

Thirteen patients underwent placement of a balloon-expandable stent either at initial transjugular intrahepatic portosystemic shunt (TIPS) creation (n = 3) because of immediate technical failure of the Wallstent or at shunt revision because of failure of the Wallstent to reduce the portosystemic gradient <or=12 mm Hg despite overdilation (n = 2), stenosis of the Wallstent (n = 1), or parenchymal tract shunt stenosis (n = 7). The mean duration of primary patency when balloon-expandable stents were used at initial shunt creation was 162.7 days +/- 110.1 (SD). The time from initial TIPS creation or shunt revision with a Wallstent to placement of a balloon-expandable stent was 88.6 days +/- 115.3. The time from balloon-expandable stent placement to shunt revision (n = 6), most recent follow-up (n = 2), death (n = 1), or liver transplantation (n = 1) was 171.9 days +/- 121.6. No significant difference in shunt patency was found between the Wallstent and balloon-expandable stent (P =.31). Because no added benefit in patency was seen between the balloon-expandable stent and Wallstent, it appears that balloon-expandable stent placement is valuable only when placement of a Wallstent technically fails as a result of its limited radial force or when precision in placement is needed to treat a hepatic vein stenosis near the confluence with the inferior vena cava.

Primary placement of Palmaz long medium stents in transjugular intrahepatic portosystemic shunts

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.

Portal hypertension, varices, and transjugular intrahepatic portosystemic shunts

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.

Clinical efficacy of portal vein stent placement in patients with hepatocellular carcinoma invading the main portal vein

BACKGROUND/AIMS

Hepatocellular carcinoma frequently invades the portal veins, and when it invades the main portal vein, the patient's prognosis is extremely poor. This study was undertaken to evaluate the clinical efficacy of stent placement into the portal vein in these patients.

METHODS

Twenty-one patients with hepatocellular carcinoma invading the main portal vein were studied. Stents were placed in the portal veins to compress tumor thrombi after percutaneous transhepatic portography.

RESULTS

Stents were successfully placed in the portal veins in all patients. Portal venous pressure significantly decreased from 25.3 +/- 7.4 mmHg to 22.4 +/- 6.6 mmHg (p < 0.0001) immediately after stent placement, leading to improvement in gastroesophageal varices, melena and ascites. Although a pseudoaneurysm of the hepatic artery related to portal vein puncture developed in one patient, there were no major complications in the other 20 patients. Blood flow through the stent was maintained during the survival period in 15 patients. The mean stent patency period was 12.4 months. Fifteen patients underwent transcatheter arterial chemoembolization without major complications after stent placement. The survival rate was 64.2% at 6 months and 29.2% at 1 and 2 years, respectively. The mean survival period was 13.7 months.

CONCLUSION

Stent placement into the portal vein is a relatively safe and feasible procedure. It improves portal hypertension, expands treatment options, and helps to prolong the survival period in patients with hepatocellular carcinoma invading the main portal vein.