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Posa A, Tenore L, Barbieri P, Mazza G, Sala E, Iezzi R. The Role of the Transjugular Intrahepatic Porto-Systemic Shunt in an Emergency Setting. Life (Basel) 2023; 13:life13040868. [PMID: 37109397 PMCID: PMC10146175 DOI: 10.3390/life13040868] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2023] [Revised: 03/14/2023] [Accepted: 03/23/2023] [Indexed: 04/29/2023] Open
Abstract
Transjugular intrahepatic porto-systemic shunt (TIPSS) is an interventional radiology procedure whose aim is to create artificial communication between the portal and the hepatic blood flow in order to reduce the pressure gradient in portal hypertension. The indications to perform a TIPSS procedure can be framed in an elective or emergency setting: refractory ascites to diuretic therapy and secondary prophylaxis of variceal hemorrhage are the most frequent reasons for executing a TIPSS in an election context, while acute uncontrolled variceal bleeding is the principal indication that a TIPSS needs to be performed in an emergency setting. In recent years, the role of the TIPSS has been redefined for several conditions, such as ectopic varices, portal vein thrombosis, Budd-Chiari syndrome, hepatic veno-occlusive disease, and many others. This review aims to perform a deep analysis of when and why a TIPSS procedure should be carried out in an emergency, pointing out the related most common technical difficulties and complications.
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Affiliation(s)
- Alessandro Posa
- Department of Diagnostic Imaging, Oncologic Radiotherapy and Hematology, A. Gemelli University Hospital Foundation IRCCS, L.go A. Gemelli 8, 00168 Rome, Italy
| | - Lorenzo Tenore
- Department of Diagnostic Imaging, Oncologic Radiotherapy and Hematology, A. Gemelli University Hospital Foundation IRCCS, L.go A. Gemelli 8, 00168 Rome, Italy
| | - Pierluigi Barbieri
- Department of Diagnostic Imaging, Oncologic Radiotherapy and Hematology, A. Gemelli University Hospital Foundation IRCCS, L.go A. Gemelli 8, 00168 Rome, Italy
| | - Giulia Mazza
- Department of Diagnostic Imaging, Oncologic Radiotherapy and Hematology, A. Gemelli University Hospital Foundation IRCCS, L.go A. Gemelli 8, 00168 Rome, Italy
| | - Evis Sala
- Department of Diagnostic Imaging, Oncologic Radiotherapy and Hematology, A. Gemelli University Hospital Foundation IRCCS, L.go A. Gemelli 8, 00168 Rome, Italy
- Istituto di Radiodiagnostica, Catholic University of the Sacred Heart, L.go F. Vito 1, 00168 Rome, Italy
| | - Roberto Iezzi
- Department of Diagnostic Imaging, Oncologic Radiotherapy and Hematology, A. Gemelli University Hospital Foundation IRCCS, L.go A. Gemelli 8, 00168 Rome, Italy
- Istituto di Radiodiagnostica, Catholic University of the Sacred Heart, L.go F. Vito 1, 00168 Rome, Italy
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Bhavsar R, Yadav A, Nundy S. Portal cavernoma cholangiopathy: Update and recommendations on diagnosis and management. Ann Hepatobiliary Pancreat Surg 2022; 26:298-307. [PMID: 36168271 PMCID: PMC9721250 DOI: 10.14701/ahbps.22-029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/17/2022] [Accepted: 06/07/2022] [Indexed: 12/15/2022] Open
Abstract
Portal cavernoma cholangiopathy is defined as an obstruction of the biliary system due to distended veins surrounding bile ducts that mainly occur in patients with extrahepatic portal venous obstruction. The periductal venous plexuses encircling the ducts can cause morphological changes which may or may not become symptomatic. Currently, non-invasive techniques such as ultrasonography, computed tomography, magnetic resonance cholangiopancreatography, and dynamic contrast enhanced magnetic resonance images are being used to diagnose this disorder. Only a few patients who have symptoms of biliary obstruction require drainage which might be accomplished using endoscopic stenting, decompression of the portal venous system usually via a lienorenal shunt, a difficult direct hepaticojejunostomy, and rarely a liver transplant.
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Affiliation(s)
- Ruchir Bhavsar
- Department of Surgical Gastroenterology and Liver Transplantation, Sir Ganga Ram Hospital, New Delhi, India,Corresponding author: Ruchir Bhavsar, MS, Fellowship in Surgical Gastroenterology and Liver Transplantation Department of Surgical Gastroenterology and Liver Transplantation, Sir Ganga Ram Hospital, Rajinder Nagar, New Delhi 110060, India Tel: +91-9898269932, E-mail: ORCID: https://orcid.org/0000-0002-7026-5245
| | - Amitabh Yadav
- Department of Surgical Gastroenterology and Liver Transplantation, Sir Ganga Ram Hospital, New Delhi, India
| | - Samiran Nundy
- Department of Surgical Gastroenterology and Liver Transplantation, Sir Ganga Ram Hospital, New Delhi, India
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Will V, Rodrigues SG, Berzigotti A. Current treatment options of refractory ascites in liver cirrhosis - A systematic review and meta-analysis. Dig Liver Dis 2022; 54:1007-1014. [PMID: 35016859 DOI: 10.1016/j.dld.2021.12.007] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/27/2021] [Revised: 10/24/2021] [Accepted: 12/11/2021] [Indexed: 12/12/2022]
Abstract
BACKGROUND Refractory ascites is a severe complication of liver cirrhosis and treatment options consist in large volume paracentesis, transjugular intrahepatic portosystemic shunt, alfapump®, peritoneovenous shunt and permanent indwelling peritoneal catheter. AIM Our aim was to assess the efficacy, mortality and complications of each treatment. METHODS We performed a systematic review using Pubmed and Embase. Frequencies were summarized with Comprehensive Meta-Analysis Software. RESULTS Seventy-seven studies were included. In patients with transjugular intrahepatic portosystemic shunt, 1-year mortality was 33% (95% CI 0.29-0.39, I2=82.1; τ2 = 0.37; p<0.001) with lower mortality in newer studies (26% vs. 44%). At 6 months, mortality in patients with alfapump® was 24% (95% CI 0.16-0.33, I2=0.00; τ2 = 0.00; p = 0.83), 31% developed acute kidney injury (95% CI 0.18-0.48, I2=44.0; τ2 = 0.22; p = 0.15). Mortality at 12 months was 44% (95% CI 32%-58%, I2=76.7, τ2 = 0.44, p<0.001) in peritoneovenous shunts and 45% (95% CI 38%-53%, I2=61.4, τ2 = 0.18, p = 0.003) in large volume paracentesis, respectively. Overall mortality in patients with permanent indwelling catheters was 66% (95% CI 33%-89%, I2=82.5, τ2 = 1.57, p = 0.001). DISCUSSION Mortality in patients with transjugular intrahepatic portosystemic shunt was lower in newer studies, probably due to a better patient selection. Acute kidney injury was frequent in patients with alfapump®. Permanent indwelling catheters seemed to be a good option in a palliative setting.
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Affiliation(s)
- Valerie Will
- Department for Visceral Surgery and Medicine, Inselspital, University Hospital of Bern, University of Bern, BHH D115, Freiburgstrasse 10, CH-3008 Bern, Switzerland; Department of Biomedical Research, University of Bern, Bern, Switzerland
| | - Susana G Rodrigues
- Department for Visceral Surgery and Medicine, Inselspital, University Hospital of Bern, University of Bern, BHH D115, Freiburgstrasse 10, CH-3008 Bern, Switzerland; Department of Biomedical Research, University of Bern, Bern, Switzerland
| | - Annalisa Berzigotti
- Department for Visceral Surgery and Medicine, Inselspital, University Hospital of Bern, University of Bern, BHH D115, Freiburgstrasse 10, CH-3008 Bern, Switzerland; Department of Biomedical Research, University of Bern, Bern, Switzerland.
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Newcomer JB, Chishti EA, Raissi D. Combined transhepatic and transjugular approach for mechanical thrombectomy of massive TIPS thrombosis. Radiol Case Rep 2022; 17:1464-1469. [PMID: 35265241 PMCID: PMC8899117 DOI: 10.1016/j.radcr.2022.01.086] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2022] [Accepted: 01/31/2022] [Indexed: 11/19/2022] Open
Abstract
Transjugular intrahepatic portosystemic shunt (TIPS) is a well-validated decompressive therapy option to manage ascites and variceal bleeding secondary to portal hypertension. Complications following TIPS procedures include hepatic encephalopathy, liver failure, and TIPS dysfunction. TIPS dysfunction is due to occlusion or stenosis of the TIPS shunt and can be caused by acute or chronic thrombosis. TIPS thrombosis is often treated with mechanical thrombectomy or catheter-directed thrombolytic therapy. Most cases of in-stent occlusion can be treated via a transjugular approach with recanalization or placement of additional stents. We present a case of a 72-year-old female who presented with worsening ascites 17 months after initial TIPS procedure; she was found to have a large thrombus completely occluding the TIPS stent. In our case, a combined transhepatic and transjugular approach was required for TIPS revision given the extent of well-organized clot located near the hepatic venous end of the stent, resulting from prolonged stent occlusion. This was an extremely challenging scenario with two overlapping covered stents and a bare metal stent at the hepatic venous end in the setting of chronic thrombosis and a well-organized fibrous cap. The case highlights the need for optimal initial placement of the primary TIPS shunt to avoid the need for subsequent complex interventions to maintain TIPS shunt patency.
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Affiliation(s)
- Jack B. Newcomer
- Department of Radiology, University of Kentucky College of Medicine, Lexington, Kentucky, 40506, USA
- Corresponding author.
| | - Emad A. Chishti
- Department of Radiology, University of Kentucky College of Medicine, Lexington, Kentucky, 40506, USA
| | - Driss Raissi
- Division of Vascular and Interventional Radiology, Department of Radiology, University of Kentucky College of Medicine, Lexington, Kentucky, 40506, USA
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Evaluation of impact of elective invasive examinations in patients with transjugular intrahepatic portosystemic shunt in the long-term follow up. ZEITSCHRIFT FUR GASTROENTEROLOGIE 2021; 59:24-34. [PMID: 33429447 DOI: 10.1055/a-1330-9867] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
INTRODUCTION In the management of patients with decompensated liver cirrhosis, transjugular intrahepatic portosystemic shunt (TIPS) insertion is well-established but common recommendations in the follow up management are inconsistent. Doppler sonography is commonly used for detection for TIPS dysfunction whilst data on the impact of elective invasive examinations are scarce. AIM The aim of this retrospective analysis is to evaluate potential benefits of elective invasive examinations in the follow up management of patients after TIPS insertion METHODS: Data of all patients receiving TIPS at the university hospitals of Muenster and Bonn between 2013 and 2018 (n = 534) were collected. The impact of performance of elective invasive examinations at 12 months after TIPS insertion on the occurrence of liver related events (LREs) and frequency of TIPS revisions within 24 months after TIPS insertion was analyzed. RESULTS No significant differences were found concerning occurrence of liver related events after 24 months depending on whether an elective invasive examination was performed. Occurrence of hepatic encephalopathy, relapse of initial indication for TIPS, as well as death or liver transplantation all did not differ. These findings were verified by a subgroup analysis including only patients who did not experience a LRE or TIPS revision within the first 12 months after TIPS procedure. CONCLUSION The analyzed data suggest no evidence for a beneficial impact due to implementation of an elective invasive examination program after TIPS insertion. Invasive examinations should remain reserved to patients with suspected TIPS dysfunction.
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Zhou L, Zhong B, Du H, Wang W, Shen J, Zhang S, Li W, Tang H, Zhang P, Yang W, Zhu X. Comparison of embolic agents for varices during transjugular intrahepatic portosystemic shunt for variceal bleeding: Tissue gel or coil? J Interv Med 2020; 3:195-200. [PMID: 34805934 PMCID: PMC8562183 DOI: 10.1016/j.jimed.2020.08.008] [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: 04/29/2020] [Revised: 08/03/2020] [Accepted: 08/11/2020] [Indexed: 11/23/2022] Open
Abstract
Purpose We aimed to compare treatment efficacy, safety and material cost between tissue gel and coil regarding variceal embolization during transjugular intrahepatic portosystemic shunt (TIPS). Materials & Methods: This retrospective study including cirrhotic patients with variceal bleeding treated with TIPS combined with variceal embolization between January 2016 and August 2017. Patients were divided into three groups according to embolic agents used in variceal embolization: tissue gel group (Group A), combination group (Group B), and coil group (Group C). The primary endpoint was 1-year rebleeding rate after TIPS creation. The secondary endpoints included shunt dysfunction, overt hepatic encephalopathy, liver function, and embolic agents-related expense. Results A total of 60 patients (30, 10, and 20 in Group A, B, and C) were included. Variceal rebleeding occurred in 3 (10%), 0 (0%), and 4 (20%) patients within one year after TIPS creation in Group A, B, and C, respectively. Stent dysfunction occurred in 2 (3.3%) patients and 9 (15.0%) patients experienced overt hepatic encephalopathy. No significant differences were observed between three groups regarding primary and secondary endpoints except embolic agents-related expense, with a significantly lower cost in Group A when compared to the other two groups. Stent dysfunction occurred in two patients, with one patient in Group A developed acute occlusion caused by thrombus and another patient in Group C underwent stent stenosis during follow-up. Conclusions Compares to coil alone or combines with coil, tissue gel has similar treatment efficacy and safety, but with significantly lower cost for variceal bleeding during TIPS.
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Affiliation(s)
- Linfeng Zhou
- Department of Interventional Radiology, The First Affiliated Hospital of Soochow University, Suzhou, China
- Department of Interventional Radiology, Hubei Cancer Hospital, Hubei Cancer Research Institute, Affiliated Cancer Hospital of Tongji Medical College, Huazhong University of Science and Technology, HuBei, China
| | - Binyan Zhong
- Department of Interventional Radiology, The First Affiliated Hospital of Soochow University, Suzhou, China
| | - Hang Du
- Department of Interventional Radiology, The First Affiliated Hospital of Soochow University, Suzhou, China
| | - Wansheng Wang
- Department of Interventional Radiology, The First Affiliated Hospital of Soochow University, Suzhou, China
| | - Jian Shen
- Department of Interventional Radiology, The First Affiliated Hospital of Soochow University, Suzhou, China
| | - Shuai Zhang
- Department of Interventional Radiology, The First Affiliated Hospital of Soochow University, Suzhou, China
| | - Wanci Li
- Department of Interventional Radiology, The First Affiliated Hospital of Soochow University, Suzhou, China
| | - Haohuan Tang
- Department of Interventional Radiology, The First Affiliated Hospital of Soochow University, Suzhou, China
| | - Peng Zhang
- Department of Interventional Radiology, The First Affiliated Hospital of Soochow University, Suzhou, China
| | - Weihao Yang
- Department of Interventional Radiology, The First Affiliated Hospital of Soochow University, Suzhou, China
| | - Xiaoli Zhu
- Department of Interventional Radiology, The First Affiliated Hospital of Soochow University, Suzhou, China
- Corresponding author. Department of Interventional Radiology, The First Affiliated Hospital of Soochow University, No. 188, Shizi Street, Suzhou, 215006, China.
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Li S, Zhang C, Lin LL, Wang Q, Zuo HX, Zhan AL, Luo J, Niu YM, Zhong GQ. Early-TIPS Versus Current Standard Therapy for Acute Variceal Bleeding in Cirrhosis Patients: A Systemic Review With Meta-analysis. Front Pharmacol 2020; 11:603. [PMID: 32581776 PMCID: PMC7282546 DOI: 10.3389/fphar.2020.00603] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2019] [Accepted: 04/17/2020] [Indexed: 12/14/2022] Open
Abstract
Background The survival of early placement (within 72h after admission) of transjugular intrahepatic portosystemic shunts (early-TIPS) in patients with cirrhosis and acute variceal bleeding (AVB) is controversial. Objectives We performed a systemic review and meta-analysis to assess whether early-TIPS could improve survival in patients with cirrhosis and acute variceal bleeding. Methods A systematic search of the literature was conducted in PubMed, EMBASE, and Cochrane Library published before 25 June 2019 for eligible studies that compared early-TIPS with a combination of endoscopic variceal ligation (EVL) and pharmacotherapy in the therapeutic effect in AVB patients. Results A total of five studies with 1,754 participants were enrolled. The early-TIPS demonstrated a significant improvement in prevention of treatment failure (OR=0.11,95%CI=0.05-0.23), 6-weeks mortality (OR=0.24,95%CI=0.13-0.46), rebleeding within 6 weeks (OR=0.21,95%CI=0.12-0.36), rebleeding within 1 year (OR=0.16,95%CI=0.07-0.36), new or worsening ascites (OR=0.33,95%CI=0.21-0.53), except in encephalopathy (OR=1.29,95%CI=0.996-1.67). For 1-year mortality, a significant prior effect was also observed in early-TIPS (OR=0.64,95%CI=0.46-0.90), and the beneficial effect in Child-Pugh C patients (OR=0.35,95%CI=0.18-0.68) was equal to Child-Pugh B patients (OR=0.34,95%CI=0.25-0.58). No difference in liver transplantation and mortality caused by liver failure was observed. Conclusions Early covered-TIPS could be recommended for the management of AVB patients in cirrhosis demonstrating a significant improvement in treatment failure, both short- and long-term mortality, rebleeding risk, and new or worsening ascites compared to standard therapy, especially for high-risk AVB patients. It will also apply to patients with Child-Pugh A until solutions to prevent hepatic encephalopathy in future research are found.
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Affiliation(s)
- Shuang Li
- Center for Evidence-Based Medicine and Clinical Research, Taihe Hospital, Hubei University of Medicine, Shiyan, China
| | - Chao Zhang
- Center for Evidence-Based Medicine and Clinical Research, Taihe Hospital, Hubei University of Medicine, Shiyan, China
| | - Lu-Lu Lin
- Center for Evidence-Based Medicine and Clinical Research, Taihe Hospital, Hubei University of Medicine, Shiyan, China
| | - Qi Wang
- Center for Evidence-Based Medicine and Clinical Research, Taihe Hospital, Hubei University of Medicine, Shiyan, China
| | - Hong-Xia Zuo
- Center for Evidence-Based Medicine and Clinical Research, Taihe Hospital, Hubei University of Medicine, Shiyan, China
| | - Ai-Ling Zhan
- Department of Anesthesiology, Central Hospital of Shanghai Songjiang District, Shanghai, China
| | - Jie Luo
- Center for Evidence-Based Medicine and Clinical Research, Taihe Hospital, Hubei University of Medicine, Shiyan, China
| | - Yu-Ming Niu
- Center for Evidence-Based Medicine and Clinical Research, Taihe Hospital, Hubei University of Medicine, Shiyan, China
| | - Guo-Qing Zhong
- Department of Obstetrical, Jining No.1 People's Hospital, Jining, China
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Contrast-enhanced ultrasound at high mechanical index: a new method for transjugular intrahepatic portosystemic shunt follow-up. Clin Radiol 2020; 75:302-307. [DOI: 10.1016/j.crad.2019.10.011] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2019] [Accepted: 10/09/2019] [Indexed: 12/23/2022]
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Lee JH, Kim TH, Choi JW, Kim SY, Choi JY, Lee CK, Park BK, Chung JB. A case report of bleeding from duodenal varices treated with percutaneous transhepatic obliteration. INTERNATIONAL JOURNAL OF GASTROINTESTINAL INTERVENTION 2019. [DOI: 10.18528/ijgii190002] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
Affiliation(s)
- Ji Hyun Lee
- Department of Internal Medicine, National Health Insurance Service Ilsan Hospital, Goyang, Korea
- Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Korea
| | - Tae Hwan Kim
- Department of Vascular and Interventional Radiology, National Health Insurance Service Ilsan Hospital, Goyang, Korea
| | - Jong Won Choi
- Department of Internal Medicine, National Health Insurance Service Ilsan Hospital, Goyang, Korea
| | - Sun Young Kim
- Department of Internal Medicine, National Health Insurance Service Ilsan Hospital, Goyang, Korea
| | - Jin Young Choi
- Department of Internal Medicine, National Health Insurance Service Ilsan Hospital, Goyang, Korea
| | - Chun Kyon Lee
- Department of Internal Medicine, National Health Insurance Service Ilsan Hospital, Goyang, Korea
| | - Byung Kyu Park
- Department of Internal Medicine, National Health Insurance Service Ilsan Hospital, Goyang, Korea
| | - Jae Bok Chung
- Department of Internal Medicine, National Health Insurance Service Ilsan Hospital, Goyang, Korea
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Sturm L, Bettinger D, Giesler M, Boettler T, Schmidt A, Buettner N, Thimme R, Schultheiss M. Treatment with proton pump inhibitors increases the risk for development of hepatic encephalopathy after implantation of transjugular intrahepatic portosystemic shunt (TIPS). United European Gastroenterol J 2018; 6:1380-1390. [PMID: 30386611 DOI: 10.1177/2050640618795928] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/18/2018] [Accepted: 07/23/2018] [Indexed: 12/18/2022] Open
Abstract
Background and objective Treatment with proton pump inhibitors (PPIs) has been associated with development of hepatic encephalopathy (HE). As development of HE is a major complication after implantation of a transjugular intrahepatic portosystemic shunt (TIPS), we hypothesized that PPI treatment may be associated with a higher risk of post-TIPS HE. Methods We analyzed data of 397 patients with liver cirrhosis who received de novo TIPS implantation at the University Medical Center Freiburg, Germany. We assessed whether PPI medication and other patient characteristics are predictive factors for the development of post-TIPS HE. Results Patients with PPI treatment at the time of TIPS implantation showed significantly higher rates of post-TIPS HE than those without PPI medication (30.4% vs 11.7%, p < 0.001). The rate of post-TIPS HE increased in a dose-dependent manner. However, PPI medication did not directly affect transplant-free survival. Remarkably, in 59.1% of patients who received PPIs there was no clear indication. Conclusions PPI treatment may be an independent risk factor for the development of post-TIPS HE and the risk increases with PPI dose. Indication for PPI treatment should be assessed carefully prior to TIPS implantation in patients with liver cirrhosis.
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Affiliation(s)
- Lukas Sturm
- Department of Medicine II, Medical Center University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Dominik Bettinger
- Department of Medicine II, Medical Center University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany.,Berta-Ottenstein-Programme, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Max Giesler
- Department of Medicine II, Medical Center University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Tobias Boettler
- Department of Medicine II, Medical Center University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Arthur Schmidt
- Department of Medicine II, Medical Center University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Nico Buettner
- Department of Medicine II, Medical Center University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Robert Thimme
- Department of Medicine II, Medical Center University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Michael Schultheiss
- Department of Medicine II, Medical Center University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
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Jahangiri Y, Kerrigan T, Li L, Prosser D, Brar A, Righetti J, Schenning RC, Kaufman JA, Farsad K. Risk factors for stent graft thrombosis after transjugular intrahepatic portosystemic shunt creation. Cardiovasc Diagn Ther 2017; 7:S150-S158. [PMID: 29399518 DOI: 10.21037/cdt.2017.10.03] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Background To identify risk factors of stent graft thrombosis after transjugular intrahepatic portosystemic shunt (TIPS) creation. Methods Patients who underwent TIPS creation between June 2003 and January 2016 and with follow-up assessing stent graft patency were included (n=174). Baseline comorbidities, liver function, procedural details and follow-up liver function tests were analyzed in association with hazards of thrombosis on follow-up. Competing risk cox regression models were used considering liver transplant after TIPS creation as the competing risk variable. Results One-, 2- and 5-year primary patency rates were 94.1%, 91.7% and 78.2%, respectively. Patient age [sub-hazard ratio (sHR): 1.13; P=0.001], body mass index (BMI) <30 (sHR: 33.08; P=0.008) and a higher post-TIPS portosystemic pressure gradient (sHR: 1.14; P=0.023) were significantly associated with TIPS thrombosis in multivariate analysis. A higher rate of TIPS thrombosis was observed in those for whom the procedure was clinically unsuccessful (P=0.014). A significant increase in incidence of thrombosis was noted with increasing tertiles of post-TIPS portosystemic gradients (P value for trend=0.017). Conclusions Older age, lower BMI and higher post-TIPS portosystemic gradients were associated with higher hazards of shunt thrombosis after TIPS creation using stent grafts. Higher rates of shunt thrombosis were seen in patients for whom TIPS creation was clinically unsuccessful. The association between TIPS thrombosis and higher post-TIPS portosystemic gradients may indicate impaired flow through the shunt, a finding which may be technical or anatomic in nature and should be assessed before procedure completion.
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Affiliation(s)
- Younes Jahangiri
- Charles T. Dotter Department of Interventional Radiology, Oregon Health and Science University, Portland, OR, USA
| | - Timothy Kerrigan
- Charles T. Dotter Department of Interventional Radiology, Oregon Health and Science University, Portland, OR, USA
| | - Lei Li
- Charles T. Dotter Department of Interventional Radiology, Oregon Health and Science University, Portland, OR, USA
| | - Dominik Prosser
- Charles T. Dotter Department of Interventional Radiology, Oregon Health and Science University, Portland, OR, USA
| | - Anantnoor Brar
- Charles T. Dotter Department of Interventional Radiology, Oregon Health and Science University, Portland, OR, USA
| | - Johnathan Righetti
- Charles T. Dotter Department of Interventional Radiology, Oregon Health and Science University, Portland, OR, USA
| | - Ryan C Schenning
- Charles T. Dotter Department of Interventional Radiology, Oregon Health and Science University, Portland, OR, USA
| | - John A Kaufman
- Charles T. Dotter Department of Interventional Radiology, Oregon Health and Science University, Portland, OR, USA
| | - Khashayar Farsad
- Charles T. Dotter Department of Interventional Radiology, Oregon Health and Science University, Portland, OR, USA
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Parbhu SK, Adler DG. Endoscopic management of acute esophageal variceal bleeding. TECHNIQUES IN GASTROINTESTINAL ENDOSCOPY 2017. [DOI: 10.1016/j.tgie.2017.03.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
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Routhu M, Safka V, Routhu SK, Fejfar T, Jirkovsky V, Krajina A, Cermakova E, Hosak L, Hulek P. Observational cohort study of hepatic encephalopathy after transjugular intrahepatic portosystemic shunt (TIPS). Ann Hepatol 2017; 16:140-148. [PMID: 28051803 DOI: 10.5604/16652681.1226932] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
UNLABELLED Introduction and Aim: Hepatic encephalopathy (HE) is a common complication of transjugular intrahepatic portosystemic shunting (TIPS). It is associated with a reduced quality of life and poor prognosis. The aim of this study was to compare two groups of patients who did and did not develop overt HE after TIPS. We looked for differences between these groups before TIPS. MATERIALS AND METHODS A study of 895 patients was conducted based on a retrospective analysis of clinical data. Data was analyzed using Fisher's exact test, Chi-square, Mann Whitney test, unpaired t-test and logistic regression. After the initial analyses, we have looked at a regression models for the factors associated with development of HE after TIPS. RESULTS 257 (37.9%) patients developed HE after TIPS. Patients' age, pre-TIPS portal venous pressure, serum creatinine, aspartate transaminase, albumin, presence of diabetes mellitus and etiology of portal hypertension were statistically significantly associated with the occurrence of HE after TIPS (p < 0.01). However, only the age, pre-TIPS portal venous pressure, serum creatinine, presence of diabetes mellitus and etiology of portal hypertension contributed to the regression model. Patients age, serum creatinine, presence of diabetes mellitus and portal vein pressure formed the model describing development of HE after TIPS for a subgroup of patients with refractory ascites. CONCLUSION we have identified, using a substantial sample, several factors associated with the development of HE after TIPS. This could be helpful in further research.
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Affiliation(s)
- Michaela Routhu
- School of Psychiatry, Health Education Wessex, United Kingdom
| | - Vaclav Safka
- Department of Physiology, Faculty of Medicine in Hradec Kralove, Charles University in Prague, Czech Republic
| | | | - Tomas Fejfar
- Department of Internal Medicine, University Hospital in Hradec Kralove, Czech Republic
| | - Vaclav Jirkovsky
- Department of Internal Medicine, University Hospital in Hradec Kralove, Czech Republic
| | - Antonin Krajina
- Department of Radiology, University Hospital in Hradec Kralove, Czech Republic
| | - Eva Cermakova
- Computer Technology Center, Faculty of Medicine in Hradec Kralove, Charles University in Prague, Czech Republic
| | - Ladislav Hosak
- Department of Psychiatry, University Hospital in Hradec Kralove, Czech Republic
| | - Petr Hulek
- Department of Psychiatry, University Hospital in Hradec Kralove, Czech Republic.,Department of Psychiatry, Faculty of Medicine in Hradec Kralove, Charles University in Prague, Czech Republic
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Expanded polytetrafluoroethylene-covered stent-grafts for transjugular intrahepatic portosystemic shunts in cirrhotic patients: Long-term patency and clinical outcome results. Eur Radiol 2016; 27:1795-1803. [PMID: 27629421 DOI: 10.1007/s00330-016-4570-5] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2016] [Revised: 08/11/2016] [Accepted: 08/22/2016] [Indexed: 01/23/2023]
Abstract
PURPOSE To retrospectively analyse long-term patency and overall survival of cirrhotic patients treated with TIPSS using e-PTFE-covered stents. Additionally, prognostic factors for better patency and survival were analysed. MATERIALS AND METHODS Two hundred and eighty-five consecutive cirrhotic patients with severe portal hypertension-related symptoms were included. Follow-up, including clinical assessment and duplex ultrasound, was analysed up to end of study, patient's death, liver transplantation or TIPSS-reduction. Patency rates and overall survival were estimated by the Kaplan-Meier method; potential differences in outcome between subgroups were calculated using the Pepe and Mori test. RESULTS The 1-, 2- and 5-year primary patencies were 91.5 %, 89.2 % and 86.2 %, respectively, with no new shunt dysfunctions after 5 years' follow-up. TIPSS revision was performed more often in ascites patients (P = 0.02). The 1-, 4- and 10-year survival rates were 69.2 %, 52.1 % and 30.7 %, respectively. Survival was higher in Child-Pugh class A-B (P = 0.04), in the recurrent bleeding group (P = 0.008) and in patients with underlying alcoholic cirrhosis (P = 0.01). CONCLUSION Long term, primary patency of e-PTFE-covered TIPSS stents remains very high (>80 %); shunt revision was required more frequently in ascites patients. Overall survival was better in Child-Pugh A-B patients with recurrent variceal bleeding and alcoholic liver cirrhosis. KEYPOINTS • Long-term primary patency rate of e-PTFE-covered TIPSS stents remains very high. • No new shunt dysfunction was found after 5 years of follow-up. • Shunt revision was required more frequently in ascites patients. • Four and 10 years' overall survival was 50 and 30 %, respectively.
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Lu Y. Letter: cardiovascular complications in patients with transjugular intrahepatic portosystemic shunt - the necessity for regular cardiac surveillance. Aliment Pharmacol Ther 2016; 44:422-3. [PMID: 27412996 DOI: 10.1111/apt.13699] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Affiliation(s)
- Y Lu
- Department of Gastroenterology, West China Hospital, Sichuan University, Chengdu, China.
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Outcomes and Predictors of Rebleeding After 2-Octyl Cyanoacrylate Injection in Acute Gastric Variceal Hemorrhage. J Clin Gastroenterol 2016; 50:458-63. [PMID: 26890326 DOI: 10.1097/mcg.0000000000000487] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
BACKGROUND AND AIM Endoscopic injection of 2-octyl cyanoacrylate (2-OCA) is used on an off-label basis for gastric variceal hemorrhage (GVH) in the United States. We assessed the efficacy, safety, and predictors of rebleeding after gastric variceal obturation (GVO) with 2-OCA in patients with acute GVH. MATERIALS AND METHODS A retrospective analysis was performed of patients with GVH who underwent 2-OCA injection for GVO over a 15-year period. Rates of acute hemostasis, predictors of rebleeding, and cyanoacrylate-related adverse events were assessed. RESULTS A total of 95 patients (63 males, median age 59±14 y) were analyzed. Gastric varices were categorized as GOV-1 (3%), GOV-2 (61%), and isolated gastric varices type 1 (36%) per Sarin classification. Initial hemostasis was achieved in all patients. Successful GVO, defined as sustained hemostasis within a month after injection, was achieved in 87 (92%) patients. Failed GVO with in-hospital rebleeding was observed in 8 (8%) patients. On univariate analysis, only the model for end-stage liver disease score was associated with an increased risk of rebleeding (odds ratio 1.2; 95% confidence interval, 1.1-1.4; P<0.01). Glue-related adverse events consisted of pulmonary emboli in 2 patients (2.1%), resulting in death in 1 patient. All cause in-hospital mortality was 13% due to uncontrolled gastric variceal rebleeding (n=3), renal failure (n=6), metastatic hepatocellular carcinoma (n=1), hemorrhagic stroke (n=1), and pulmonary embolism (n=1). CONCLUSIONS Injection of 2-OCA was effective at achieving hemostasis in a high proportion of patients (92%) admitted for acute GVH. The risk of glue-related pulmonary embolism approximated 2% in our patient cohort, including 1 fatality.
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Spira D, Wiskirchen J, Lauer U, Ketelsen D, Nikolaou K, Wiesinger B. Implantability, Complications, and Follow-Up After Transjugular Intrahepatic Portosystemic Stent-Shunt Creation With the 6F Self-Expanding Sinus-SuperFlex-Visual Stent. IRANIAN JOURNAL OF RADIOLOGY 2016; 13:e28689. [PMID: 27853493 PMCID: PMC5106871 DOI: 10.5812/iranjradiol.28689] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/14/2015] [Revised: 05/14/2015] [Accepted: 06/08/2015] [Indexed: 12/31/2022]
Abstract
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.
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Affiliation(s)
- Daniel Spira
- Department of Diagnostic and Interventional Radiology, University Hospital Heidelberg, Heidelberg, Germany
- Corresponding author: Daniel Spira, Department of Diagnostic and Interventional Radiology, University Hospital Heidelberg, Heidelberg, Germany. Tel: +49-6221566410, Fax: +49-6221565730, E-mail:
| | - Jakub Wiskirchen
- Department of Radiology and Nuclear Medicine, Franziskus Hospital, Bielefeld, Germany
| | - Ulrich Lauer
- Department of Gastroenterology and Hepatology, Eberhard-Karls-University, Tubingen, Germany
| | - Dominik Ketelsen
- Department of Diagnostic and Interventional Radiology, Eberhard-Karls-University, Tubingen, Germany
| | - Konstantin Nikolaou
- Department of Diagnostic and Interventional Radiology, Eberhard-Karls-University, Tubingen, Germany
| | - Benjamin Wiesinger
- Department of Diagnostic and Interventional Radiology, Eberhard-Karls-University, Tubingen, Germany
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Suhocki PV, Lungren MP, Kapoor B, Kim CY. Transjugular intrahepatic portosystemic shunt complications: prevention and management. Semin Intervent Radiol 2015; 32:123-32. [PMID: 26038620 DOI: 10.1055/s-0035-1549376] [Citation(s) in RCA: 67] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
Transjugular intrahepatic portosystemic shunt (TIPS) insertion has been well established as an effective treatment in the management of sequelae of portal hypertension. There are a wide variety of complications that can be encountered, such as hemorrhage, encephalopathy, TIPS dysfunction, and liver failure. This review article summarizes various approaches to preventing and managing these complications.
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Affiliation(s)
- Paul V Suhocki
- Division of Vascular and Interventional Radiology, Duke University Medical Center, Durham, North Carolina
| | - Matthew P Lungren
- Department of Radiology, Stanford University Medical Center, Palo Alto, California
| | - Baljendra Kapoor
- Section of Interventional Radiology, Imaging Institute, Cleveland Clinic, Cleveland, Ohio
| | - Charles Y Kim
- Division of Vascular and Interventional Radiology, Duke University Medical Center, Durham, North Carolina
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Zhao JB, Feng C, Zhu QH, He XF, Li YH, Chen Y. Transjugular intrahepatic portosystemic shunt with covered stents for hepatocellular carcinoma with portal vein tumor thrombosis. World J Gastroenterol 2014; 20:1602-1607. [PMID: 24587637 PMCID: PMC3925870 DOI: 10.3748/wjg.v20.i6.1602] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/23/2013] [Revised: 11/13/2013] [Accepted: 12/13/2013] [Indexed: 02/06/2023] Open
Abstract
AIM: To evaluate transjugular intrahepatic portosystemic shunt (TIPS) with covered stents for hepatocellular carcinoma (HCC) with main portal vein tumor thrombus (PVTT).
METHODS: Eleven advanced HCC patients (all male, aged 37-78 years, mean: 54.3 ± 12.7 years) presented with acute massive upper gastrointestinal bleeding (n = 9) or refractory ascites (n = 2) due to tumor thrombus in the main portal vein. The diagnosis of PVTT was based on contrast-enhanced computed tomography and color Doppler sonography. The patients underwent TIPS with covered stents. Clinical characteristics and average survival time of 11 patients were analyzed. Portal vein pressure was assessed before and after TIPS. The follow-up period was 2-18 mo.
RESULTS: TIPS with covered stents was successfully completed in all 11 patients. The mean portal vein pressure was reduced from 32.0 to 11.8 mmHg (t = 10.756, P = 0.000). Gastrointestinal bleeding was stopped in nine patients. Refractory ascites completely disappeared in one patient and was alleviated in another. Hepatic encephalopathy was observed in six patients and was resolved with drug therapy. During the follow-up, ultrasound indicated the patency of the shunt and there was no recurrence of symptoms. Death occurred 2-14 mo (mean: 5.67 mo) after TIPS in nine cases, which were all due to multiple organ failure. In the remaining two cases, the patients were still alive at the 16- and 18-mo follow-up, respectively.
CONCLUSION: TIPS with covered stents for HCC patients with tumor thrombus in the main portal vein is technically feasible, and short-term efficacy is favorable.
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Jiang TP, Wang LZ, Li X, Song J, Wu XP, Zhou S. Transjugular intrahepatic portosystemic shunt creation with expanded polytetrafluoroethylene-covered stent. Shijie Huaren Xiaohua Zazhi 2013; 21:3265-3269. [DOI: 10.11569/wcjd.v21.i30.3265] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
AIM: To assess the feasibility of transjugular intrahepatic portosystemic shunt (TIPS) creation with expanded polytertrafluoroethylene-covered stent and its influence on patency rate.
METHODS: Clinical data for 114 cirrhotic patients treated by de novo TIPS placement between May 2005 and March 2011 were reviewed. All the patients (54 ± 14 years old) were admitted with variceal bleeding (n = 92), refractory ascites (n = 8), or both (n = 14). The stents used were composed of a 60 to 80 mm long nickel-titanium stent (diameter, 7 to 10 mm) and an expanded-polytertrafluoroethylene graft covering with the same length. Portal venous pressure and portosystemic pressure gradient were assessed before and after stent implantation. Patients underwent Doppler ultrasound on 7 d and at 1, 3, 6, and 12 mo after the procedure and underwent venography whenever necessary.
RESULTS: Fifteen patients underwent an additional bare stent implantation on the portal side of the covered-stent at the same time. Mean portal venous pressure dropped from 34 ± 8 cmH2O to 24 ± 4 cmH2O (P < 0.01). Mean portosystemic pressure gradient dropped from 27.3 ± 6.5 cmH2O to 12.1 ± 3.2 cmH2O (P < 0.01). During the follow-up, sixteen stenoses were observed, of whom 12 underwent implantation of the second stent, 2 underwent a second TIPS, and 2 with portal thrombosis died of treatment failure. The cumulative 1- and 2-year patency rates were 86.7% and 75.2%, respectively.
CONCLUSION: Our results clearly show the feasibility of TIPS placement with expanded polytertrafluoroethylene-covered stent, which can significantly improve patency compared to bear stents. The structural weaknesses of expanded polytertrafluoroethylene-covered stent can be compensated by implanting an additional bear stent on the portal side of the shunt.
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Chen S, Li X, Wei B, Tong H, Zhang MG, Huang ZY, Cao JW, Tang CW. Recurrent variceal bleeding and shunt patency: prospective randomized controlled trial of transjugular intrahepatic portosystemic shunt alone or combined with coronary vein embolization. Radiology 2013; 268:900-6. [PMID: 23657891 DOI: 10.1148/radiol.13120800] [Citation(s) in RCA: 55] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
PURPOSE To prospectively evaluate the efficacy of a transjugular intrahepatic portosystemic shunt (TIPS) alone and TIPS in association with embolotherapy (TIPS+E) in the variceal coronary vein to prevent recurrent variceal bleeding and stent dysfunction after TIPS creation. MATERIALS AND METHODS Institutional review board approval was obtained; all participants provided informed consent. A total of 106 patients (66 men, 40 women; age range, 18-70 years) with recurrent variceal bleeding due to hepatic cirrhosis were assigned randomly to the TIPS+E (n = 54) or TIPS (n = 52) group from May 2007 to July 2011. The TIPS was created by using covered stents. Patients in the TIPS+E group underwent embolotherapy via the jugular vein before TIPS implantation. Rates of recurrent variceal bleeding, stent patency, and survival were evaluated. Scores for liver function and life quality were calculated. RESULTS TIPS placement was successful in all patients. Recurrent variceal bleeding ranked second among causes of death after TIPS placement. Although the 3-year cumulative rates of shunt patency, recurrent variceal bleeding, and survival in the two groups were not significantly different (P > .05), the 6-month overall rate of shunt patency in the TIPS+E group was significantly higher than that in the TIPS group (96.2% vs 82.0%, P = .019), and the 6-month overall rate of recurrent variceal bleeding was also significantly lower than that in the TIPS group (5.7% vs 20.0%, P = .029). CONCLUSION The TIPS+E regimen may reduce the risk of recurrent variceal bleeding during the first 6 months after the TIPS procedure by preventing shunt dysfunction, which may improve liver function and quality of life. © RSNA, 2013.
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Affiliation(s)
- Shuang Chen
- Department of Gastroenterology, West China Hospital, Sichuan University, Chengdu 610041, P. R. China
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Wang J, Tian XG, Li Y, Zhang CQ, Liu FL, Cui Y, Liu JY. Comparison of modified percutaneous transhepatic variceal embolization and endoscopic cyanoacrylate injection for gastric variceal rebleeding. World J Gastroenterol 2013; 19:706-14. [PMID: 23430149 PMCID: PMC3574596 DOI: 10.3748/wjg.v19.i5.706] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/14/2012] [Revised: 11/19/2012] [Accepted: 11/24/2012] [Indexed: 02/06/2023] Open
Abstract
AIM: To compare the efficacy of modified percutaneous transhepatic variceal embolization (PTVE) with 2-octyl-cyanoacrylate (2-OCA) and endoscopic variceal obturation (EVO) with an injection of 2-OCA for prophylaxis of gastric variceal rebleeding.
METHODS: In this retrospective study, the medical records of liver cirrhosis patients with gastric variceal bleeding who underwent either endoscopic 2-OCA (EVO) or modified PTVE using 2-OCA at Shandong Provincial Hospital from January 2006 to December 2008 were reviewed. Patient demographics, rebleeding rate, survival rate, and complications were compared between the two groups (PTVE and EVO). All results were expressed as mean ± SD, or as a percentage. Quantitative variables were compared by two sample Student t tests, and qualitative variables were compared by the Fisher exact test or the χ2 test (with Yates correction) where appropriate. A P value less than 0.05 was considered significant. Statistical computation was performed using SPSS 13.0 software.
RESULTS: A total of 77 patients were included; 45 patients who underwent EVO and 32 patients who received PTVE. During the follow-up (19.78 ± 7.70 mo in the EVO group, vs 21.53 ± 8.56 mo in the PTVE group) rebleeding occurred in 17 patients in the EVO group and in 4 patients in the PTVE group (37.78% vs 12.5%, P = 0.028). The cumulative rebleeding-free rate was 75%, 59%, and 49% in 1, 2, and 3 years respectively for EVO, and 93%, 84%, and 84% for PTVE (P = 0.011). Cox analysis was used to identify independent factors that predicted rebleeding after treatment. Variables including age, gender, cause, Child-Pugh classification, size of gastric varices (GV), location of GV, and treatment methods were analyzed. It was revealed that Child-Pugh classification [risk ratio (RR) 2.10, 95%CI: 1.03-4.28, P = 0.040], choice of treatment (RR 0.25, 95%CI: 0.08-0.80, P = 0.019), and size of GV (RR 2.14, 95%CI: 1.07-4.28, P = 0.032) were the independent factors for predicting rebleeding. Follow-up computed tomography revealed that cyanoacrylate was retained in the varices and in the feeding veins of PTVE patients. During the follow-up, eight patients in the EVO group and four patients in the PTVE group died. The cumulative survival rates at 1, 2, and 3 years were 93%, 84%, and 67% respectively in the EVO group, and 97%, 88%, and 74% respectively in the PTVE group. The survival rates were not significantly different between the two groups (P = 0.432). Cox analysis showed that the Child-Pugh classification was the most significant prognostic factor of survival (RR 2.77, 95%CI: 1.12-6.80, P = 0.027). The incidence of complications was similar in both groups.
CONCLUSION: With extensive and permanent obliteration of gastric varices and its feeding veins, PTVE with 2-OCA is superior to endoscopic 2-OCA injection for preventing gastric variceal rebleeding.
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Toomey PG, Ross SB, Golkar FC, Hernandez JM, Clark WC, Luberice K, Alsina AE, Rosemurgy AS. Outcomes after transjugular intrahepatic portosystemic stent shunt: a "bridge" to nowhere. Am J Surg 2013; 205:441-6. [PMID: 23375760 DOI: 10.1016/j.amjsurg.2012.06.005] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2012] [Revised: 04/23/2012] [Accepted: 06/18/2012] [Indexed: 12/23/2022]
Abstract
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.
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Affiliation(s)
- Paul G Toomey
- University of South Florida, Department of Surgery, Tampa, FL, USA
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Wu Q, Jiang J, He Y, Jiang T, Zhou S. Transjugular intrahepatic portosystemic shunt using the FLUENCY expanded polytetrafluoroethylene-covered stent. Exp Ther Med 2012; 5:263-266. [PMID: 23251280 PMCID: PMC3523954 DOI: 10.3892/etm.2012.776] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2012] [Accepted: 10/15/2012] [Indexed: 12/13/2022] Open
Abstract
The aim of this study was to evaluate the feasibility of transjugular intrahepatic portosystemic shunts using FLUENCY expanded polytetraf luoroethylene (PTFE)-covered stents and the effect on the patency rate. A total of 114 cirrhotic patients who were treated by transjugular intrahepatic portosystemic stent shunt (TIPS) placement using a FLUENCY expanded, PTFE-covered stent were enrolled in the present study. Of the patients, 15 underwent an additional bare metal stent implantation on the portal side of the covered stent, simultaneously. Patients underwent Doppler sonography during the follow-up. Mean portal venous pressure dropped from 2.499±0.588 cmHg to 1.764±0.294 cmHg. The cumulative patency rates for one and two years were 86.7% and 75.2%, respectively. The results demonstrate the feasibility of TIPS placement with the FLUENCY expanded PTFE-covered stent. TIPS placement with the FLUENCY expanded PTFE-covered stent was able to improve patency when compared with the use of conventional bare-metal stents.
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Affiliation(s)
- Qinghua Wu
- Department of Radiology, The Third Affiliated Hospital of Nantong University
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TIPS for Treatment of Variceal Hemorrhage: Clinical Outcomes in 128 Patients at a Single Institution over a 12-Year Period. J Vasc Interv Radiol 2012; 23:227-35. [DOI: 10.1016/j.jvir.2011.10.015] [Citation(s) in RCA: 55] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2011] [Revised: 09/20/2011] [Accepted: 10/22/2011] [Indexed: 02/07/2023] Open
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Modified Percutaneous Transhepatic Variceal Embolization With 2-Octylcyanoacrylate for Bleeding Gastric Varices: Long-Term Follow-Up Outcomes. AJR Am J Roentgenol 2011; 197:502-9. [PMID: 21785101 DOI: 10.2214/ajr.10.6005] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
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Bai M, Qi X, Yang Z, Yin Z, Nie Y, Yuan S, Wu K, Han G, Fan D. Predictors of hepatic encephalopathy after transjugular intrahepatic portosystemic shunt in cirrhotic patients: a systematic review. J Gastroenterol Hepatol 2011; 26:943-51. [PMID: 21251067 DOI: 10.1111/j.1440-1746.2011.06663.x] [Citation(s) in RCA: 118] [Impact Index Per Article: 9.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND AND AIM Hepatic encephalopathy (HE) is a very common complication in patients after transjugular intrahepatic portosystemic shunt (TIPS). The purpose of this study is to determine the most robust predictors of post-TIPS HE by performing a systematic review of studies that identified the risk factors for patients with post-TIPS HE. METHODS A PUBMED search was performed using the predefined rule. Studies were selected for analysis based on certain inclusion and exclusion criteria. Data were extracted from each study on the basis of predefined items. Meta-analyses were executed to verify the relevant risk factors. RESULTS Thirty studies were included in this systematic review. In the 30 studies, the numbers of variables evaluated by univariate and multivariate analyses were 60 and 32, respectively. The numbers of variables found to be significant in univariate and multivariate analyses were 18 and 14, respectively. According to the accumulated number of studies that identified these variables as significant, the three most vigorous predictors of post-TIPS HE were age, prior HE and Child-Pugh class/score in both univariate analysis and multivariate analysis. Our meta-analysis showed that patients with HE before TIPS or higher Child-Pugh class/score had increased risk of post-TIPS HE. CONCLUSIONS Increased age, prior HE and higher Child-Pugh class/score were the most robust predictors for post-TIPS HE.
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Affiliation(s)
- Ming Bai
- Department of Digestive Interventional Radiology, Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an, China
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Mizrahi M, Roemi L, Shouval D, Adar T, Korem M, Moses A, Bloom A, Shibolet O. Bacteremia and "Endotipsitis" following transjugular intrahepatic portosystemic shunting. World J Hepatol 2011; 3:130-6. [PMID: 21731907 PMCID: PMC3124881 DOI: 10.4254/wjh.v3.i5.130] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/22/2010] [Revised: 03/27/2011] [Accepted: 04/03/2011] [Indexed: 02/06/2023] Open
Abstract
AIM To identify all cases of bacteremia and suspected endotipsitis after Transjugular intrahepatic portosystemic shunting (TIPS) at our institution and to determine risk factors for their occurrence. METHODS We retrospectively reviewed records of all patients who underwent TIPS in our institution between 1996 and 2009. Data included: indications for TIPS, underlying liver disease, demographics, positive blood cultures after TIPS, microbiological characteristics, treatment and outcome. RESULTS 49 men and 47 women were included with a mean age of 55.8 years (range 15-84). Indications for TIPS included variceal bleeding, refractory ascites, hydrothorax and hepatorenal syndrome. Positive blood cultures after TIPS were found in 39/96 (40%) patients at various time intervals following the procedure. Seven patients had persistent bacteremia fitting the definition of endotipsitis. Staphylococcus species grew in 66% of the positive cultures, Candida and enterococci species in 15% each of the isolates, and 3% cultures grew other species. Multi-variate regression analysis identified 4 variables: hypothyroidism, HCV, prophylactic use of antibiotics and the procedure duration as independent risk factors for positive blood cultures following TIPS (P < 0.0006, 0.005, 0.001, 0.0003, respectively). Prophylactic use of antibiotics before the procedure was associated with a decreased risk for bacteremia, preventing mainly early infections, occurring within 120 d of the procedure. CONCLUSION Bacteremia is common following TIPS. Risk factors associated with bacteremia include failure to use prophylactic antibiotics, hypothyroidism, HCV and a long procedure. Our results strongly support the use of prophylaxis as a means to decrease early post TIPS infections.
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Affiliation(s)
- Meir Mizrahi
- Liver Unit, Division of Medicine, Hadassah-Hebrew University Medical Center, Jerusalem 91120, Israel
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Dumortier J, Walter T, Guillaud O, Pietu F, Vallin M, Henry L, Pilleul F. Transcatheter local thrombolysis in patients with extensive TIPS thrombosis. ACTA ACUST UNITED AC 2010; 34:721-5. [PMID: 20934290 DOI: 10.1016/j.gcb.2010.07.011] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2010] [Revised: 07/09/2010] [Accepted: 07/13/2010] [Indexed: 01/27/2023]
Abstract
BACKGROUND Transcatheter local thrombolytic therapy in patients with portosplanchnic venous thrombosis has been used in few cases. CASE REPORTS Here, we present our single-center experience with transcatheter thrombolytic therapy in three patients with extensive refractory portal and transjugular intrahepatic portosystemic shunt (TIPS) thrombosis. Thrombolytic therapy was successful for all three patients. Two patients developed minor procedure-related bleeding. CONCLUSION Local thrombolysis could be proposed in case of TIPS thrombosis for patients in whom the venous flow cannot be restored by using conventional anticoagulant therapy and stent mechanical revision.
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Affiliation(s)
- J Dumortier
- Fédération des spécialités digestives, Hospices civils de Lyon, hôpital Édouard-Herriot, pavillon Hbis, 69437 Lyon cedex 03, France.
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Rebleeding rates following TIPS for variceal hemorrhage in the Viatorr era: TIPS alone versus TIPS with variceal embolization. Hepatol Int 2010; 4:749-56. [PMID: 21286346 DOI: 10.1007/s12072-010-9206-2] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/30/2009] [Accepted: 07/13/2010] [Indexed: 12/23/2022]
Abstract
PURPOSE To compare rebleeding rates following treatment of variceal hemorrhage with TIPS alone versus TIPS with variceal embolization in the covered stent-graft era. METHODS In this retrospective study, 52 patients (M:F 29:23, median age 52 years) with hepatic cirrhosis and variceal hemorrhage underwent TIPS insertion between 2003 and 2008. Median Child-Pugh and MELD scores were 8.5 and 13.5. Generally, 10-mm diameter TIPS were created using covered stent-grafts (Viatorr; W.L. Gore and Associates, Flagstaff, AZ). A total of 37 patients underwent TIPS alone, while 15 patients underwent TIPS with variceal embolization. The rates of rebleeding and survival were compared. RESULTS All TIPS were technically successful. Median portosystemic pressure gradient reductions were 13 versus 11 mmHg in the embolization and non-embolization groups. There were no statistically significant differences in Child-Pugh and MELD score, or portosystemic pressure gradients between each group. A trend toward increased rebleeding was present in the non-embolization group, where 8/37 (21.6%) patients rebled while 1/15 (6.7%) patients in the TIPS with embolization group rebled (P = 0.159) during median follow-up periods of 199 and 252 days (P = 0.374). Rebleeding approached statistical significance among patients with acute hemorrhage, where 8/32 (25%) versus 0/14 (0%) rebled in the non-embolization and embolization groups (P = 0.055). A trend toward increased bleeding-related mortality was seen in the non-embolization group (P = 0.120). CONCLUSIONS TIPS alone showed a high incidence of rebleeding in this series, whereas TIPS with variceal embolization resulted in reduced recurrent hemorrhage. The efficacy of embolization during TIPS performed for variceal hemorrhage versus TIPS alone should be further compared with larger prospective randomized trials.
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Procaccini NJ, Al-Osaimi AMS, Northup P, Argo C, Caldwell SH. Endoscopic cyanoacrylate versus transjugular intrahepatic portosystemic shunt for gastric variceal bleeding: a single-center U.S. analysis. Gastrointest Endosc 2009; 70:881-7. [PMID: 19559425 DOI: 10.1016/j.gie.2009.03.1169] [Citation(s) in RCA: 105] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/30/2008] [Accepted: 03/20/2009] [Indexed: 02/07/2023]
Abstract
BACKGROUND AND OBJECTIVES Gastric variceal hemorrhage treatment remains a difficult issue for clinicians. There is controversy regarding whether first-line treatment should be endoscopic therapy with cyanoacrylate glue or placement of a transjugular intrahepatic portosystemic shunt (TIPS). We compared these methods on the basis of rebleeding, survival, and complications. DESIGN, SETTING, PATIENTS, AND INTERVENTIONS: This was a retrospective cohort analysis of cirrhotic patients with gastric variceal hemorrhage treated with endoscopic cyanoacrylate therapy or TIPS placement at a single U.S. center from 1997 to 2007. The groups were compared for rebleeding at 72 hours, 3 months, and 1 year; survival rates at 3 months and 1 year; and acute and extended complications and morbidity. MAIN OUTCOME MEASUREMENTS AND RESULTS A total of 105 patients were included. There were no significant pretreatment differences between the 2 groups in age, sex, MELD (Model for End-Stage Liver Disease) score at the time of admission, or cause of liver disease. There were no significant differences in rebleeding at 72 hours, 3 months, and 1 year; survival at 3 months and 1 year; and aggregate long-term survival or acute complications. However, the TIPS group had a higher rate of long-term morbidity requiring hospitalization (41% with a TIPS and 1.6% in the cyanoacrylate arm, P < .0001). LIMITATIONS Retrospective and uncontrolled samples. CONCLUSION In patients with similar characteristics, cyanoacrylate therapy performed as well as a TIPS in controlling and preventing gastric variceal hemorrhage with no significant differences in survival. Patients receiving cyanoacrylate therapy experienced significantly less long-term morbidity related to therapy than patients who received a TIPS. Cyanoacrylate therapy appears to be safe and effective and compares favorably with TIPS therapy.
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Affiliation(s)
- Nicholas J Procaccini
- Division of Gastroenterology and Hepatology, Digestive Health Center of Excellence, University of Virginia Health System, Charlottesville, VA 22908-0708, USA
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Long-term patency of transjugular intrahepatic portosystemic shunt in a patient with portal vein web. J Clin Gastroenterol 2009; 43:791-2. [PMID: 19471165 DOI: 10.1097/mcg.0b013e31819d85d5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
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Liu F, Zhang CQ. Pathogenesis of hepatic encephalopathy and its prevention after transjugular intrahepatic portosystemic shunt. Shijie Huaren Xiaohua Zazhi 2009; 17:798-804. [DOI: 10.11569/wcjd.v17.i8.798] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
With the increasing use of transjugular intrahepatic portosystemic shunt (TIPS), we have obtained a breakout progress in the therapy of acute esophageal and gastric-fundus variceal bleeding and refractory ascites. whereas the patency of stent and hepatic encephalopathy (or namely portal-systemic encephalopathy, PSE) after TIPS become two great problems for TIPS. The patency of stent has been improved greatly after the use of covered stent such as Viator stents or covered vascular stents. But the problem of hepatic encephalopathy has not been well solved. In this review, we try to explore the pathogenesis of hepatic encephalopathy and its prevention after TIPS.
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Jung HS, Kalva SP, Greenfield AJ, Waltman AC, Walker TG, Athanasoulis CA, Wicky ST. TIPS: comparison of shunt patency and clinical outcomes between bare stents and expanded polytetrafluoroethylene stent-grafts. J Vasc Interv Radiol 2008; 20:180-5. [PMID: 19097918 DOI: 10.1016/j.jvir.2008.11.005] [Citation(s) in RCA: 41] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2007] [Revised: 10/27/2008] [Accepted: 11/09/2008] [Indexed: 02/06/2023] Open
Abstract
PURPOSE To compare shunt patency and clinical outcomes in two groups of patients who received a transjugular intrahepatic portosystemic shunt (TIPS): one group with bare stents and one with expanded polytetrafluoroethylene stent-grafts. MATERIALS AND METHODS TIPS were created with bare stents (n = 41) or stent-grafts (n = 40). Overall TIPS patency rates were compared between these two groups, as were clinical outcomes in patients with variceal bleeding and those with ascites. RESULTS In the bare stent group, primary shunt patency rates were 63%, 48%, and 24% at 3, 6, and 12 months, respectively. Secondary patency rates were 75% and 62% at 3 and 6 months, respectively. In the stent-graft group, primary patency rates were 94%, 67%, and 38% at 3, 6, and 12 months, respectively. Secondary patency rates were 100% and 92% at 3 and 6 months, respectively. All stent patency rates were higher in the stent-graft group, but only the difference in the 3-month primary patency rate (63% vs 94%) reached significance (P = .03). In patients with variceal bleeding as well as those with ascites, early and overall clinical success rates were higher in the stent-graft group, but only the 3-month and 12-month differences were statistically significant. CONCLUSIONS TIPS created with stent-grafts had better 3-month primary patency rates and better 3-month and 12-month clinical success rates compared with those created with bare stents.
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Affiliation(s)
- Hyun S Jung
- Department of Radiology, Massachusetts General Hospital and Harvard Medical School, GRB-290, 55 Fruit Street, Boston, MA 02114, USA
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Stadlbauer V, Tauss J, Portugaller HR, Stiegler P, Iberer F, Stauber RE. Hepatic encephalopathy following transjugular intrahepatic portosystemic shunt (TIPS): management with L-ornithine-L-aspartate and stent reduction. Metab Brain Dis 2007; 22:45-50. [PMID: 17165154 DOI: 10.1007/s11011-006-9032-3] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/30/2005] [Accepted: 06/23/2006] [Indexed: 12/23/2022]
Abstract
Hepatic encephalopathy (HE) is a common problem after insertion of a trans-jugular intrahepatic portosystemic shunt (TIPS), which may be difficult to manage. We present a case of severe post-TIPS HE unresponsive to high doses of L-ornithine-L-aspartate (LOLA) despite reduction of venous ammonia levels in a dose-dependent fashion. Ultimately, high-grade HE was successfully treated by a reduction stent and the patient subsequently underwent successful liver transplantation.
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Affiliation(s)
- Vanessa Stadlbauer
- Department of Internal Medicine, Division of Gastroenterology and Hepatology, Medical University of Graz, Graz, Austria.
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Garcia-Tsao G. The transjugular intrahepatic portosystemic shunt for the management of cirrhotic refractory ascites. ACTA ACUST UNITED AC 2006; 3:380-9. [PMID: 16819501 DOI: 10.1038/ncpgasthep0523] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2005] [Accepted: 04/12/2006] [Indexed: 12/26/2022]
Abstract
Cirrhotic ascites results from sinusoidal hypertension and sodium retention, which is secondary to a decreased effective arterial blood volume. Transjugular intrahepatic portosystemic shunt (TIPS) placement is currently indicated in cirrhotic patients with refractory ascites who require large-volume paracentesis (LVP) more than two or three times per month. TIPS placement is associated with normalization of sinusoidal pressure and a significant improvement in urinary sodium excretion that correlates with suppression of plasma renin activity, which is, itself, indicative of an improvement in effective arterial blood volume. Compared with serial LVP, placement of an uncovered TIPS stent is more effective at preventing ascites from recurring; however, increased incidence of hepatic encephalopathy and shunt dysfunction rates after TIPS placement are important issues that increase its cost. Although evidence suggests that TIPS placement might result in better patient survival, this needs to be confirmed, particularly in light of the development of polytetrafluoroethylene-covered stents. Favorable results apply to centers experienced in placing the TIPS, with the aim being to decrease the portosystemic gradient to <12 mmHg but >5 mmHg. This article reviews the pathophysiologic basis for the use of a TIPS in patients with refractory ascites, the results of controlled trials comparing TIPS placement (using uncovered stents) versus LVP, and a systematic review of predictors of death after TIPS placement for refractory ascites.
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Abstract
Improvements in surgical technique, advances in the field of immunosuppresion and the early diagnosis and treatment of complications related to liver transplantation have all led to prolonged survival after liver transplantation. In particular, advances in diagnostic and interventional radiology have allowed the Interventional Radiologist, as part of the transplant team, to intervene early in patients presenting with complications related to organ transplant with resultant increase in graft and patient survival. Such interventions are often achieved using minimally invasive percutaneous endovascular techniques. Herein we present an overview of some of these diagnostic and therapeutic approaches in the treatment and management of patients before and after liver transplantation.
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Affiliation(s)
- Nikhil B Amesur
- Department of Radiology, Division of Vascular and Interventional Radiology, University of Pittsburgh Medical Center, Pittsburgh, PA 15213, USA.
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Vignali C, Bargellini I, Grosso M, Passalacqua G, Maglione F, Pedrazzini F, Filauri P, Niola R, Cioni R, Petruzzi P. TIPS with expanded polytetrafluoroethylene-covered stent: results of an Italian multicenter study. AJR Am J Roentgenol 2005; 185:472-80. [PMID: 16037523 DOI: 10.2214/ajr.185.2.01850472] [Citation(s) in RCA: 89] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
OBJECTIVE Our objective is to describe the results of a multicenter prospective trial on the safety and efficacy of transjugular intrahepatic portosystemic shunts (TIPS) using the Viatorr stent-graft. SUBJECTS AND METHODS From 2001 to 2003, 114 patients (75 men and 39 women; mean age, 59.3 years) with portal hypertension underwent TIPS with the Viatorr stent-graft. Indications for treatment were variceal bleeding (n = 49, 43.0%), refractory ascites (n = 52, 45.6%), hypertensive gastropathy (n = 10, 8.8%), Budd-Chiari syndrome (n = 1, 0.9%), and hepatorenal syndrome (n = 2, 1.7%). Eight patients (7.0%) had Child-Pugh class A cirrhosis; 60 (52.6%), Child-Pugh class B; and 46 (40.4%), Child-Pugh class C. Patients were monitored by color Doppler sonography and phlebography. RESULTS The procedure was successful in 113 (99.1%) of 114 patients; in one patient, creation of the track was not feasible. The mean portosystemic pressure gradient decreased from 21.8 to 8.7 mm Hg. Three minor immediate complications (2.6%) occurred (two cases of self-limiting hemoperitoneum and one extrahepatic portal puncture requiring covered stenting). At a mean follow-up of 11.9 months, the overall mortality rate was 31.0% (35/113), with a 30-day mortality rate of 8.8% (10/113). Mortality was significantly higher in patients in Child-Pugh class C with refractory ascites and with post-procedural encephalopathy. Cumulative primary patency rates were 91.9%, 79.9%, and 75.9% at 6, 12, and 24 months' follow-up, respectively. Restenosis occurred in 15 patients (13.3%) within the stent (n = 8, 53.3%) or at the ends of the portal (n = 1, 6.7%) or hepatic (n = 6, 40%) veins and was solved by percutaneous transluminal angioplasty (n = 11), stenting (n = 3), or parallel TIPS (n = 1). The secondary patency rate was 98.2%. Post-procedural encephalopathy occurred in 27 patients (23.9%). CONCLUSION The Viatorr stent-graft is safe and effective in TIPS creation, with high primary patency rates. Covering the entire track up to the inferior vena cava can increase patency.
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Affiliation(s)
- Claudio Vignali
- Division of Diagnostic and Interventional Radiology, Department of Oncology, Transplants, and Advanced Technologies in Medicine, University of Pisa, Via Roma 67, Pisa 56127, Italy.
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Siewert E, Salzmann J, Purucker E, Schürmann K, Matern S. Recurrent thrombotic occlusion of a transjugular intrahepatic portosystemic stent-shunt due to activated protein C resistance. World J Gastroenterol 2005; 11:5064-7. [PMID: 16124068 PMCID: PMC4321932 DOI: 10.3748/wjg.v11.i32.5064] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
The transjugular intrahepatic portosystemic stent-shunt (TIPS) has successfully been used in the management of refractory variceal bleeding and ascites in patients with portal hypertension. Major drawbacks are the induction of hepatic encephalopathy and shunt dysfunction. We present a 59-year-old woman with alcoholic liver cirrhosis who received a TIPS because of recurrent bleeding from esophageal varices. Stent occlusion occurred 4 mo after placement of the TIPS. Laboratory testing revealed resistance to activated protein C (APC). Combination therapy with low-dose enoxaparin and clopidogrel could not prevent her recurrent stent occlusion. Finally, therapy with high-dose enoxaparin was sufficient to prevent further shunt complications up to now (follow-up period of 1 year). In conclusion, early occlusion of a TIPS warrants testing for thrombophilia. If risk factors are confirmed, anticoagulation should be intensified. There are currently no evidence-based recommendations regarding the best available anticoagulant therapy and surveillance protocol for patients with TIPS.
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Affiliation(s)
- Elmar Siewert
- Department of Internal Medicine III, Aachen University, Aachen, Germany.
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Deltenre P, Mathurin P, Dharancy S, Moreau R, Bulois P, Henrion J, Pruvot FR, Ernst O, Paris JC, Lebrec D. Transjugular intrahepatic portosystemic shunt in refractory ascites: a meta-analysis. Liver Int 2005; 25:349-56. [PMID: 15780061 DOI: 10.1111/j.1478-3231.2005.01095.x] [Citation(s) in RCA: 102] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
UNLABELLED Transjugular intrahepatic portosystemic shunt (TIPS) is a more effective treatment for refractory ascites than large volume paracentesis (LVP), but the magnitude of its effect in terms of control of ascites, encephalopathy and survival has not been established. AIM This meta-analysis compare TIPS to LVP in terms of control of ascites at 4 and 12 months, encephalopathy and survival at 1 and 2 years. RESULTS Five randomized controlled trials involving 330 patients were included. In the TIPS group, control of ascites was more frequently achieved at 4 months (66% vs 23.8%, mean difference: 41.4%, 95% confidence interval (CI): 29.5-53.2%, P < 0.001) and 12 months (54.8% vs 18.9%, mean difference: 35%, 95% CI: 24.9-45.1%, P < 0.001), whereas encephalopathy was higher (54.9% vs 38.1%, mean difference: 17%, 95% CI: 7.3-26.6%, P < 0.001). Survival at 1 year (61.7% vs 56.5%, mean difference: 3.2%, 95% CI: -14.7 to 21.9%) and 2 years (50% vs 42.8%, mean difference: 6.8%, 95% CI: -10 to 23.6%) were not significantly different. CONCLUSIONS TIPS is a more effective treatment for refractory ascites than LVP. However, TIPS increase encephalopathy and does not improve survival.
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Affiliation(s)
- P Deltenre
- Services d'Hépato-Gastroentérologie, Hôpital Huriez, CHRU Lille, France
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