Transjugular intrahepatic portosystemic stent-shunt insufficiency and the role of diabetes mellitus

Transjugular intrahepatic portosystemic stent-shunt: technical factors and new developments

The introduction of expandable metal stents in the mid 1980s led to the development of transjugular intrahepatic portosystemic stent-shunt (TIPSS) as we know it today. Short-lived detrimental effects on the hyperdynamic circulation in cirrhosis accompany the acute reduction in portal pressure following TIPSS creation. Caution is needed in patients with cardiac dysfunction or pulmonary hypertension. With increasing expertise and careful patient selection, fatal procedural complications are rare and TIPSS can even be safely used as a bridge to liver transplantation. Shunt insufficiency and hepatic encephalopathy are more common following TIPSS. Currently, however, novel approaches to tackling both these limitations exist. These include the combination of uncovered TIPSS with variceal band ligation, and the introduction of polytetrafluoroethylene covered stents. Despite the lack of controlled studies, covered stents are now widely used and have the potential to drastically reduce shunt insufficiency, the need for long-term shunt surveillance and even hepatic encephalopathy.

The natural history of parallel transjugular intrahepatic portosystemic stent shunts using uncovered stent: the role of host-related factors

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.

Transjugular Intrahepatic Portosystemic Shunts: Long-term Patency and Clinical Results in a Patient Cohort Observed for 3–9 Years

PURPOSE

To retrospectively assess the outcome of transjugular intrahepatic portosystemic shunt (TIPS) placement in a nonselected group of consecutive patients.

MATERIALS AND METHODS

TIPS placement was attempted in 82 patients. Patients were followed up for at least 3 years according to a standard protocol that included repeated shunt evaluations. Fifty-four patients underwent TIPS placement for variceal bleeding, 24 for refractory ascites, and four for other indications. Recurrent bleeding, effect on ascites, long-term patency, development of encephalopathy, and survival and complication rates were evaluated with Kaplan-Meier survival analysis and Cox multivariate analysis.

RESULTS

TIPS placement was successful in 75 patients (91%). Mean follow-up lasted 29.4 months. Primary patency was 22% and 12%, primary-assisted patency was 67% and 46%, and secondary patency was 91% and 91% at 1- and 5-year follow-up, respectively. Nonalcoholic liver disease (P =.007) and increasing platelet counts (P =.006) independently predicted development of shunt insufficiency. The 1- and 5-year rates of recurrent variceal bleeding were 21% and 27%, respectively. In the majority of patients with refractory ascites, a beneficial effect of TIPS placement was observed. The risk for encephalopathy was 25% at 1-month follow-up and 52% at 3-year follow-up. The risk for chronic or severe intermittent encephalopathy was 15% at 1-year follow-up and 20% at 3-year follow-up. Serum creatinine levels (P =.001) and age (P =.02) were independent risk factors. Overall survival rate was 61%, 49%, and 42% at 1-, 3-, and 5-year follow-up, respectively. Age (P =.03), serum albumin level (P =.02), and serum creatinine level (P <.001) were independently related to mortality.

CONCLUSION

The risk for definitive loss of shunt function was 17% at 5-year follow-up, indicating that surveillance with shunt revision-when indicated-results in excellent long-term TIPS patency. TIPS placement effectively protects against recurrent bleeding.