A case-control study of transjugular intrahepatic portosystemic stent shunts for patients admitted to intensive care following variceal bleeding

Risk factors for early rebleeding and mortality in acute variceal hemorrhage

AIM: To investigate the risk factors for 6-wk rebleeding and mortality in acute variceal hemorrhage (AVH) patients treated by percutaneous transhepatic variceal embolization (PTVE).

METHODS: A retrospective cohort study of AVH patients who had undergone PTVE treatment was conducted between January 2010 and December 2012. Demographic information, medical histories, physical examination findings, and laboratory test results were collected. The PTVE procedure was performed as a rescue therapy for patients who failed endoscopic and pharmacologic treatment. Survival analysis was estimated using the Kaplan-Meier method and compared using the log-rank test. The multivariate analysis was performed using the Cox regression test to identify independent risk factors for rebleeding and mortality.

RESULTS: One hundred and one patients were included; 71 were males and the average age was 51 years. Twenty-one patients rebled within 6 wk. Patients with high-risk stigmata, PTVE with trunk obliteration, and a hepatic vein pressure gradient (HVPG) ≥ 20 mmHg were at increased risk for rebleeding (OR = 5.279, 95%CI: 2.782-38.454, P = 0.003; OR = 4.309, 95%CI: = 2.144-11.793, P < 0.001; and OR = 1.534, 95%CI: 1.062-2.216, P = 0.022, respectively). Thirteen patients died within 6 wk. A model for end-stage liver disease (MELD) score ≥ 18 and an HVPG ≥ 20 mmHg were associated with 6-wk mortality (OR = 2.162, 95%CI: 1.145-4.084, P = 0.017 and OR = 1.423, 95%CI: 1.222-1.657, P < 0.001, respectively).

CONCLUSION: MELD score and HVPG in combination allow for early identification of patients with AVH who are at substantially increased risk of death over the short term.

Percutaneous transhepatic intrahepatic portosystemic shunt plus embolotherapy for treatment of gastroesophageal varices

AIM: To evaluate the efficacy of percutaneous transjugular intrahepatic portosystemic shunt (PTIPS) plus embolotherapy in the treatment of gastroesophageal varices.

METHODS: A total of 15 patients with gastroesophageal varices underwent PTIPS plus embolotherapy from May 2009 to May 2012 at the Affiliated Nanhua Hospital of Nanhua University.

RESULTS: The technical success rate of PTIPS plus embolotherapy was 100%. The portal vein pressures declined from 40.25 cmH₂O ± 4.86 cmH₂O (1 cmH₂O = 0.098 kPa) preoperatively to 24.79 cmH₂O ± 5.21 cmH₂O, t = 20.324, P < 0.01) postoperatively. Angiography showed that gastroesophageal varices disappeared in all patients. Both liver function and gastroesophageal varices were markedly improved. During the follow-up period of 6-12 mo, 3 cases developed hepatic encephalopathy, 1 case developed stent restenosis and 1 case developed intercostal artery bleeding. Most cases recorded after treatment. No rebleeding occurred during the follow-up period.

CONCLUSION: PTIPS plus embolotherapy can effectively lower portal vein pressure and cure gastroesophageal variceal bleeding. PTIPS plus embolotherapy is safe and effective in the treatment of portal hypertension with exceptionally challenging anatomy.

Role of transjugular intrahepatic portosystemic shunt in the management of portal hypertension

A transjugular intrahepatic portosystemic shunt (TIPS) is an expandable metal stent inserted via the jugular vein that creates a shunt from the portal vein to the systemic circulation via an artificial communication through the liver. It is used to treat complications of portal hypertension. In addition to rescue treatment in variceal bleeding, TIPS can play an important role in prevention of rebleeding. TIPS can improve symptoms if medical treatment of ascites or hepatic hydrothrorax has failed, but may not improve survival. Selected cases of Budd-Chiari syndrome improve with TIPS. This article discusses the indications, evidence, and complications of TIPS.