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Jiang L, Han H, Yang J, Fang R, Xin Y, Chen Q, Yao J, Li Z. Do the stent blind insertion into the main portal vein (MPV) and stent diameter influence the surgical outcome of the transjugular intrahepatic portosystemic shunt (TIPS)? Comput Biol Med 2023; 164:107306. [PMID: 37542920 DOI: 10.1016/j.compbiomed.2023.107306] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2023] [Revised: 06/24/2023] [Accepted: 07/28/2023] [Indexed: 08/07/2023]
Abstract
Transjugular intrahepatic portosystemic shunt (TIPS) surgery is a clinical intervention to treat portal hypertension (PH) by deploying a covered stent to establish a shunt path for the portal vein (PV) system, and proper surgical strategy is of great importance to balance the shunt effect and the risk of complications. To understand the clinical strategies of the stent blind insertion and stent selection in clinic, this study investigated the effects of varying stent insertion positions and diameters on the PV hemodynamics and the shunt effect by computational fluid dynamics (CFD) analysis of five post-TIPS subjects. The results showed that the successful TIPS surgeries of the five PH subjects were confirmed by quantifying their pressure drops. The stent insertion positions at the main portal vein (MPV) slightly affected the clinically concerned hemodynamic indexes (i.e., MPV pressure, stent-outlet velocity) and the shunt index (SI). This indicated that the position of the stent going into the MPV may not need to be deliberately selected. Moreover, the covered stents with 6 mm and 8 mm diameters slightly influenced the hemodynamics as well, but the large-diameter stent better improved the shunt effect compared to the small-diameter one. Despite this, the 6 mm stent was suggested thanks to the higher risk of the hepatic encephalopathy (HE) observed in clinic, which indicated the excessive shunt of the 8 mm stent. The current work revealed the effects of different TIPS strategies on the surgical outcome, and could be useful for potential clinical practices.
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Affiliation(s)
- Lingyu Jiang
- Biomechanics Laboratory, School of Biological Science & Medical Engineering, Southeast University, Nanjing, 210096, China
| | - Hao Han
- Department of Ultrasound Medicine, Affiliated Drum Tower Hospital of Nanjing University Medical School, Nanjing, 210008, Jiangsu, People's Republic of China; Medical Imaging Center, Affiliated Drum Tower Hospital of Nanjing University Medical School, Nanjing, 210008, Jiangsu, People's Republic of China
| | - Jian Yang
- Department of Ultrasound Medicine, Affiliated Drum Tower Hospital of Nanjing University Medical School, Nanjing, 210008, Jiangsu, People's Republic of China; Medical Imaging Center, Affiliated Drum Tower Hospital of Nanjing University Medical School, Nanjing, 210008, Jiangsu, People's Republic of China
| | - Runxin Fang
- Biomechanics Laboratory, School of Biological Science & Medical Engineering, Southeast University, Nanjing, 210096, China
| | - Ying Xin
- Department of Ultrasound Medicine, Affiliated Drum Tower Hospital of Nanjing University Medical School, Nanjing, 210008, Jiangsu, People's Republic of China; Medical Imaging Center, Affiliated Drum Tower Hospital of Nanjing University Medical School, Nanjing, 210008, Jiangsu, People's Republic of China
| | - Qiang Chen
- Biomechanics Laboratory, School of Biological Science & Medical Engineering, Southeast University, Nanjing, 210096, China.
| | - Jing Yao
- Department of Ultrasound Medicine, Affiliated Drum Tower Hospital of Nanjing University Medical School, Nanjing, 210008, Jiangsu, People's Republic of China; Medical Imaging Center, Affiliated Drum Tower Hospital of Nanjing University Medical School, Nanjing, 210008, Jiangsu, People's Republic of China.
| | - Zhiyong Li
- Biomechanics Laboratory, School of Biological Science & Medical Engineering, Southeast University, Nanjing, 210096, China; School of Mechanical, Medical and Process Engineering, Queensland University of Technology (QUT), Brisbane, QLD4001, Australia; Faculty of Sports Science, Ningbo University, Ningbo, 315211, China
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Single Puncture TIPS—A 3D Fusion Image-Guided Transjugular Intrahepatic Portosystemic Shunt (TIPS): An Experimental Study. APPLIED SCIENCES-BASEL 2022. [DOI: 10.3390/app12105267] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
Abstract
Background: The use of a transjugular intrahepatic portosystemic shunt (TIPS) has been established as an effective treatment for portal hypertension. Despite the rapid development of this use, serious peri-procedural complications have been reported in over 10% of cases. This has largely been attributed to the access to the portal vein, also referred to as a “blind puncture”, which often requires multiple attempts. The aim of this study was to demonstrate the safety, reproducibility and accuracy of the use of real-time 3D fusion image-guided (3DFIG) single puncture TIPS to minimize the complications that are related to the “blind puncture” of TIPS procedures. Methods: A 3DFIG TIPS approach was utilized on 22 pigs by combining pre-procedural cross-sectional imaging (CT, MR or CBCT) with intra-procedural cone beam CT or angiogram imaging, which allowed for the improved 3D visual spatial orientation of the portal vein and real-time tracking of the needle in 3D. Results: Thirty-five portosystemic shunts were successfully deployed in all 22 subjects without any peri-procedural complications. Overall, 91% (32/35) of the procedures were carried out using a single puncture. In addition, the mean fluoroscopy time in our study was more than 12 times lower than the proposed reference level that has previously been proposed for TIPS procedures. Conclusion: Multi-modality real-time 3DFIG TIPS can be performed safely using a single puncture, without complications, and can potentially be used in both emergency and non-emergency clinical situations.
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Shrestha R, Thapa J, Yadav B, Thapa B, Paudel MS. Endoscopic Detection and Management of Esophagogastric Varices. Cureus 2021; 13:e16825. [PMID: 34522482 PMCID: PMC8425082 DOI: 10.7759/cureus.16825] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/02/2021] [Indexed: 11/17/2022] Open
Abstract
Introduction Gastrointestinal (GI) varices are abnormally dilated submucosal veins in the digestive tract caused due to portal hypertension. Esophagus and stomach are common locations of varices induced by portal hypertension. Their presence correlates with the severity of the liver disease. Endoscopic variceal band ligation is one of the preferred methods for bleeding and nonbleeding large varices to decrease bleeding risk. Tissue adhesives such as N-butyl-2-cyanoacrylate have been used for gastric variceal obturation. Methods This descriptive study was conducted in the Department of Gastroenterology, National Academy of Medical Sciences, Kathmandu, Nepal, from March 2014 to January 2020. The endoscopic detection of esophageal and gastric varices was observed. Endoscopic variceal ligation (EVL) was done for esophageal varices and injection of N-butyl 2-cyanoacrylate for gastric varices. Results Esopahageal varices were detected in 1266 patients (8%) and gastric varices were in 36 patients (0.2%) among 15,657 patients undergoing upper gastrointestinal (UGI) endoscopy. Nine hundred seven (71.6%) were male. Large esophageal varices were endoscopically detected in 54.8% patients, small varices in 31.4% and both (large and small varices) in 13.4%. EVL was done in 30.7% and EVL with cyanoacrylate glue injection in 35 patients (2.7%). Conclusion Esophageal and gastric varices are seen commonly in patients with chronic liver disease. This study was conducted to describe the different types of GI varices in patients undergoing UGI endoscopy. Variceal band ligation for esophageal varices and glue injection for gastric varices are viable options of management.
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Affiliation(s)
- Ramila Shrestha
- Gastroenterology, National Academy of Medical Sciences, Kathmandu, NPL
| | - Jiwan Thapa
- Gastroenterology, National Academy of Medical Sciences, Kathmandu, NPL
| | - Bhuwneshwer Yadav
- Gastroenterology, National Academy of Medical Sciences, Kathmandu, NPL
| | - Bhawesh Thapa
- Gastroenterology, National Academy of Medical Sciences, Kathmandu, NPL
| | - Mukesh S Paudel
- Gastroenterology, National Academy of Medical Sciences, Kathmandu, NPL
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Henry Z, Patel K, Patton H, Saad W. AGA Clinical Practice Update on Management of Bleeding Gastric Varices: Expert Review. Clin Gastroenterol Hepatol 2021; 19:1098-1107.e1. [PMID: 33493693 DOI: 10.1016/j.cgh.2021.01.027] [Citation(s) in RCA: 47] [Impact Index Per Article: 15.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/26/2020] [Revised: 01/13/2021] [Accepted: 01/18/2021] [Indexed: 02/07/2023]
Abstract
Management of bleeding gastric varices (GV) presents a unique challenge for patients with portal hypertension. Despite over thirty years of diagnostic and treatment advances standardized practices for bleeding GV are lacking and unsupported by adequate evidence. There are no definitive natural history studies to help with risk assessment or prospective clinical trials to guide clinical decision making. Available literature on the natural history and management of gastric varices consists of case series, restricted cohort studies, and a few small randomized trials, all of which have significant selection biases. This review summarizes the available data and recommendations based on expert opinion on how best to diagnose and manage bleeding from gastric varices. Table 1 summarizes our recommendations.
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Affiliation(s)
- Zachary Henry
- Division of Gastroenterology and Hepatology, Department of Medicine, University of Virginia, Charlottesville, Virginia.
| | - Kalpesh Patel
- Division of Gastroenterology and Hepatology, Department of Medicine, Baylor College of Medicine, Houston, Texas
| | - Heather Patton
- Gastroenterology Section, VA San Diego Healthcare System, San Diego, California
| | - Wael Saad
- Interventional Radiology, Radiology and Imaging Sciences, National Institutes of Health, Washington, DC
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Simonetti RG, Perricone G, Robbins HL, Battula NR, Weickert MO, Sutton R, Khan S. Portosystemic shunts versus endoscopic intervention with or without medical treatment for prevention of rebleeding in people with cirrhosis. Cochrane Database Syst Rev 2020; 10:CD000553. [PMID: 33089892 PMCID: PMC8095029 DOI: 10.1002/14651858.cd000553.pub3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
BACKGROUND People with liver cirrhosis who have had one episode of variceal bleeding are at risk for repeated episodes of bleeding. Endoscopic intervention and portosystemic shunts are used to prevent further bleeding, but there is no consensus as to which approach is preferable. OBJECTIVES To compare the benefits and harms of shunts (surgical shunts (total shunt (TS), distal splenorenal shunt (DSRS), or transjugular intrahepatic portosystemic shunt (TIPS)) versus endoscopic intervention (endoscopic sclerotherapy or banding, or both) with or without medical treatment (non-selective beta blockers or nitrates, or both) for prevention of variceal rebleeding in people with liver cirrhosis. SEARCH METHODS We searched the CHBG Controlled Trials Register; CENTRAL, in the Cochrane Library; MEDLINE Ovid; Embase Ovid; LILACS (Bireme); Science Citation Index - Expanded (Web of Science); and Conference Proceedings Citation Index - Science (Web of Science); as well as conference proceedings and the references of trials identified until 22 June 2020. We contacted study investigators and industry researchers. SELECTION CRITERIA Randomised clinical trials comparing shunts versus endoscopic interventions with or without medical treatment in people with cirrhosis who had recovered from a variceal haemorrhage. DATA COLLECTION AND ANALYSIS We used standard methodological procedures expected by Cochrane. When possible, we collected data to allow intention-to-treat analysis. For each outcome, we estimated a meta-analysed estimate of treatment effect across trials (risk ratio for binary outcomes). We used random-effects model meta-analysis as our main analysis and as a means of presenting results. We reported differences in means for continuous outcomes without a meta-analytic estimate due to high variability in their assessment among all trials. We assessed the certainty of evidence using GRADE. MAIN RESULTS We identified 27 randomised trials with 1828 participants. Three trials assessed TSs, five assessed DSRSs, and 19 trials assessed TIPSs. The endoscopic intervention was sclerotherapy in 16 trials, band ligation in eight trials, and a combination of band ligation and either sclerotherapy or glue injection in three trials. In eight trials, endoscopy was combined with beta blockers (in one trial plus isosorbide mononitrate). We judged all trials to be at high risk of bias. We assessed the certainty of evidence for all the outcome review results as very low (i.e. the true effects of the results are likely to be substantially different from the results of estimated effects). The very low evidence grading is due to the overall high risk of bias for all trials, and to imprecision and publication bias for some outcomes. Therefore, we are very uncertain whether portosystemic shunts versus endoscopy interventions with or without medical treatment have effects on all-cause mortality (RR 0.99, 95% CI 0.86 to 1.13; 1828 participants; 27 trials), on rebleeding (RR 0.40, 95% CI 0.33 to 0.50; 1769 participants; 26 trials), on mortality due to rebleeding (RR 0.51, 95% CI 0.34 to 0.76; 1779 participants; 26 trials), and on occurrence of hepatic encephalopathy, both acute (RR 1.60, 95% CI 1.33 to 1.92; 1649 participants; 24 trials) and chronic (RR 2.51, 95% CI 1.38 to 4.55; 956 participants; 13 trials). No data were available regarding health-related quality of life. Analysing each modality of portosystemic shunts individually (i.e. TS, DSRS, and TIPS) versus endoscopic interventions with or without medical treatment, we are very uncertain if each type of shunt has effect on all-cause mortality: TS, RR 0.46, 95% CI 0.19 to 1.13; 164 participants; 3 trials; DSRS, RR 0.93, 95% CI 0.65 to 1.33; 352 participants; 4 trials; and TIPS, RR 1.10, 95% CI 0.92 to 1.31; 1312 participants; 19 trial; on rebleeding: TS, RR 0.28, 95% CI 0.14 to 0.56; 127 participants; 2 trials; DSRS, RR 0.26, 95% CI 0.11 to 0.65; 330 participants; 5 trials; and TIPS, RR 0.44, 95% CI 0.36 to 0.55; 1312 participants; 19 trials; on mortality due to rebleeding: TS, RR 0.25, 95% CI 0.06 to 0.96; 164 participants; 3 trials; DSRS, RR 0.31, 95% CI 0.13 to 0.74; 352 participants; 5 trials; and TIPS, RR 0.65, 95% CI 0.40 to 1.04; 1263 participants; 18 trials; on acute hepatic encephalopathy: TS, RR 1.66, 95% CI 0.70 to 3.92; 115 participants; 2 trials; DSRS, RR 1.70, 95% CI 0.94 to 3.08; 287 participants; 4 trials, TIPS, RR 1.61, 95% CI 1.29 to 1.99; 1247 participants; 18 trials; and chronic hepatic encephalopathy: TS, Fisher's exact test P = 0.11; 69 participants; 1 trial; DSRS, RR 4.87, 95% CI 1.46 to 16.23; 170 participants; 2 trials; and TIPS, RR 1.88, 95% CI 0.93 to 3.80; 717 participants; 10 trials. The proportion of participants with shunt occlusion or dysfunction was overall 37% (95% CI 33% to 40%). It was 3% (95% CI 0.8% to 10%) following TS, 7% (95% CI 3% to 13%) following DSRS, and 47.1% (95% CI 43% to 51%) following TIPS. Shunt dysfunction in trials utilising polytetrafluoroethylene-covered stents was 17% (95% CI 11% to 24%). Length of inpatient hospital stay and cost were not comparable across trials. Funding was unclear in 16 trials; 11 trials were funded by government, local hospitals, or universities. AUTHORS' CONCLUSIONS Evidence on whether portosystemic shunts versus endoscopy interventions with or without medical treatment in people with cirrhosis and previous hypertensive portal bleeding have little or no effect on all-cause mortality is very uncertain. Evidence on whether portosystemic shunts may reduce bleeding and mortality due to bleeding while increasing hepatic encephalopathy is also very uncertain. We need properly conducted trials to assess effects of these interventions not only on assessed outcomes, but also on quality of life, costs, and length of hospital stay.
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Affiliation(s)
- Rosa G Simonetti
- Cochrane Hepato-Biliary Group, Copenhagen Trial Unit, Centre for Clinical Intervention Research, Department 7812, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Giovanni Perricone
- S.C. Epatologia e Gastroenterologia, Azienda Socio-Sanitaria Territoriale Grande Ospedale Metropolitano Niguarda, Milan, Italy
| | - Helen L Robbins
- Department of Surgery, University Hospital Coventry and Warwickshire, Coventry, UK
- University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Narendra R Battula
- Division of Hepatobiliary and Abdominal Transplant surgery, University of Florida, Gainesville, Florida, USA
| | - Martin O Weickert
- The ARDEN NET Centre, ENETS Centre of Excellence, University Hospitals Coventry and Warwickshire NHS Trust, Coventry, UK
| | - Robert Sutton
- Institute of Translational Medicine, University of Liverpool, Liverpool, UK
| | - Saboor Khan
- Surgery, University Hosptial Coventry and Warwickshire, Coventry, UK
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Misplacement of transjugular intrahepatic portosystemic shunts: A surgical challenge for liver transplantation? Surgery 2020; 169:447-454. [PMID: 32868109 DOI: 10.1016/j.surg.2020.07.028] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2020] [Revised: 07/19/2020] [Accepted: 07/21/2020] [Indexed: 01/11/2023]
Abstract
BACKGROUND The impact of transjugular intrahepatic portosystemic shunt misplacement on outcomes of liver transplantation remains controversial. We systematically reviewed the literature on the outcomes of liver transplantation with transjugular intrahepatic portosystemic shunt misplacement. METHODS This systematic review was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. The Cochrane library, PubMed, and Embase were searched (January 1990-April 2020) for studies reporting patients undergoing liver transplantation with transjugular intrahepatic portosystemic shunt misplacement. RESULTS Thirty-six studies reporting 181 patients who underwent liver transplantation with transjugular intrahepatic portosystemic shunt misplacement were identified. Transjugular intrahepatic portosystemic shunt was misplaced with a variable degree of extension toward the inferior vena cava/right heart in 63 patients (34%), the spleno/portal/superior mesenteric venous confluence in 105 patients (58%), and both in 15 patients (8%). Transjugular intrahepatic portosystemic shunt thrombosis was also present in 21 cases (12%). The median interval between transjugular intrahepatic portosystemic shunt placement and liver transplantation ranged from 1 day to 6 years. Complete transjugular intrahepatic portosystemic shunt removal was successfully performed in all but 12 (7%) patients in whom part of the transjugular intrahepatic portosystemic shunt was left in situ. Cardiac surgery under cardiopulmonary bypass was necessary to remove transjugular intrahepatic portosystemic shunt from the right heart in 4 patients (2%), and a venous graft interposition was necessary for a portal anastomosis in 5 patients (3%). Postoperative mortality (90 days) was 1.1% (2 patients), and portal vein thrombosis developed postoperatively in 4 patients (2%). CONCLUSION Misplaced transjugular intrahepatic portosystemic shunt removal is possible in most cases during liver transplantation with extremely low mortality and good postoperative outcomes. Preoperative surgical strategy and intraoperative tailored surgical technique reduces the potential consequences of transjugular intrahepatic portosystemic shunt misplacement.
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Farsad K, Narasimhan E, Russell L, Kaufman JA. Transjugular Intrahepatic Portosystemic Shunt Creation Using a Radiofrequency Wire: Prospective Clinical Safety and Feasibility Trial in Cirrhosis. J Vasc Interv Radiol 2020; 31:1401-1407. [PMID: 32792278 DOI: 10.1016/j.jvir.2020.05.025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2020] [Revised: 05/22/2020] [Accepted: 05/28/2020] [Indexed: 10/23/2022] Open
Abstract
PURPOSE To assess the safety and feasibility of using a radiofrequency (RF) wire for portosystemic shunt creation. MATERIALS AND METHODS Ten patients undergoing elective creation of a transjugular intrahepatic portosystemic shunt (TIPS) or a direct intrahepatic portosystemic shunt (DIPS) were prospectively enrolled. Primary outcomes were the safety and feasibility of RF wire used for the creation of TIPS and DIPS. Median age was 66.5 ± 6.1 years. Causes of liver disease included alcohol (n = 5), nonalcoholic steatohepatitis (n = 2), hepatitis C virus (n = 1), primary biliary cirrhosis (n = 1), autoimmune hepatitis (n = 1). The median score for model for end-stage liver disease was 11 ± 4.3. The Rosch-Uchida TIPS set was used with intravascular ultrasonography guidance in all cases. A 0.035-inch RF wire was used in lieu of the trocar needle through the 5-F TIPS set catheter to create a track between the hepatic vein and the portal vein. All shunts were created using stent grafts. RESULTS Technical success rate was 100%. In 7 of 10 patients, portal vein access was achieved with a single pass. A DIPS was created in 2 patients based on anatomic favorability. Median fluoroscopy time was 13.3 ± 3.8 min, and median total procedure time was 102 ± 19 min. The wire passed through parenchyma without subjective deflection. There was 1 case of extracapsular puncture with no clinical consequence. The RF wire was too stiff to curve into the main portal vein, requiring wire exchange in all but 1 case. Mean portosystemic gradient decreased from 13.9 ± 3.3 to 5.9 ± 2.1 mm Hg. No immediate complications were encountered. Shunt patency was 100% at 30 days. CONCLUSIONS Creation of TIPS and DIPS using an RF wire was safe and feasible, enabling creation of an intrahepatic track without subjective deflection in cirrhotic patients.
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Affiliation(s)
- Khashayar Farsad
- Department of Interventional Radiology, Dotter Interventional Institute, Oregon Health and Science University, 3181 SW Sam Jackson Park Road, Portland, OR 97239.
| | - Evan Narasimhan
- Department of Interventional Radiology, Dotter Interventional Institute, Oregon Health and Science University, 3181 SW Sam Jackson Park Road, Portland, OR 97239
| | - Lori Russell
- Department of Interventional Radiology, Dotter Interventional Institute, Oregon Health and Science University, 3181 SW Sam Jackson Park Road, Portland, OR 97239
| | - John A Kaufman
- Department of Interventional Radiology, Dotter Interventional Institute, Oregon Health and Science University, 3181 SW Sam Jackson Park Road, Portland, OR 97239
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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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Pandhi MB, Kuei AJ, Lipnik AJ, Gaba RC. Emergent Transjugular Intrahepatic Portosystemic Shunt Creation in Acute Variceal Bleeding. Semin Intervent Radiol 2020; 37:3-13. [PMID: 32139965 DOI: 10.1055/s-0039-3402015] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Emergent transjugular intrahepatic portosystemic shunt (TIPS) creation is most commonly employed in the setting of acute variceal hemorrhage. Given a propensity for decompensation, these patients often require a multidisciplinary, multimodal approach involving prompt diagnosis, pharmacologic therapy, and endoscopic intervention. While successful in the majority of cases, failure to medically control initial bleeding can prompt interventional radiology consultation for emergent portal decompression via TIPS creation. This article discusses TIPS creation in emergent, acute variceal hemorrhage, reviewing the natural history of gastroesophageal varices, presentation and diagnosis of acute variceal hemorrhage, pharmacologic therapy, endoscopic approaches, patient selection and risk stratification for TIPS, technical considerations for TIPS creation, adjunctive embolotherapy, and the role of salvage TIPS versus early TIPS in acute variceal hemorrhage.
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Affiliation(s)
- Mithil B Pandhi
- Department of Radiology, University of Illinois at Chicago, Chicago, Illinois
| | - Andrew J Kuei
- Department of Radiology, University of Illinois at Chicago, Chicago, Illinois
| | - Andrew J Lipnik
- Department of Radiology, University of Illinois at Chicago, Chicago, Illinois
| | - Ron C Gaba
- Department of Radiology, University of Illinois at Chicago, Chicago, Illinois.,Division of Interventional Radiology, University of Illinois at Chicago, Chicago, Illinois
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Vozzo CF, Singh T, Bullen J, Sarvepalli S, McCullough A, Kapoor B. Hospital readmission following transjugular intrahepatic portosystemic shunt: a 14-year single-center experience. Gastroenterol Rep (Oxf) 2019; 8:98-103. [PMID: 32280469 PMCID: PMC7136714 DOI: 10.1093/gastro/goz062] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/24/2019] [Revised: 07/01/2019] [Accepted: 07/24/2019] [Indexed: 12/17/2022] Open
Abstract
Background Placement of a transjugular intrahepatic portosystemic shunt (TIPS) is a relatively common procedure used to treat complications of portal hypertension. However, only limited data exist regarding the hospital-readmission rate after TIPS placement and no studies have addressed the causes of hospital readmission. We therefore sought to identify the 30-day hospital-readmission rate after TIPS placement at our institution and to determine potential causes and predictors of readmission. Methods We reviewed our electronic medical-records system at our institution between 2004 and 2017 to identify patients who had undergone primary TIPS placement with polytetrafluoroethylene-covered stents and to determine the 30-day readmission rate among these patients. A series of univariable logistic-regression models were fit to assess potential predictors of 30-day readmission. Results A total of 566 patients were included in the analysis. The 30-day readmission rate after TIPS placement was 36%. The most common causes for readmission were confusion (48%), infection (15%), bleeding (11%), and fluid overload (7%). A higher Model for End-Stage Liver Disease (MELD) score corresponded with a higher rate of readmission (odds ratio associated with each 1-unit increase in MELD score: 1.06; 95% confidence interval: 1.02–1.09; P = 0.001). Other potential predictors, including indication for TIPS placement, were not significantly associated with a higher readmission rate. Conclusions The 30-day readmission rate after TIPS placement with covered stents is high, with nearly half of these readmissions due to hepatic encephalopathy—a known complication of TIPS placement. Novel interventions to help reduce the TIPS readmission rate should be prioritized in future research.
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Affiliation(s)
- Catherine F Vozzo
- Department of Internal Medicine, Cleveland Clinic, Cleveland, OH, USA
| | - Tavankit Singh
- Department of Gastroenterology and Hepatology, Cleveland Clinic, Cleveland, OH, USA
| | - Jennifer Bullen
- Department of Quantitative Health Sciences, Cleveland Clinic, Cleveland, OH, USA
| | | | - Arthur McCullough
- Department of Gastroenterology and Hepatology, Cleveland Clinic, Cleveland, OH, USA.,Department of Inflammation and Immunity, Cleveland Clinic, Cleveland, OH, USA
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Intravascular Ultrasound in the Creation of Transjugular Intrahepatic Portosystemic Shunts: Review of the Literature and Future Directions. CURRENT RADIOLOGY REPORTS 2019. [DOI: 10.1007/s40134-019-0314-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
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12
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The Effect of Puncture Sites of Portal Vein in TIPS with ePTFE-Covered Stents on Postoperative Long-Term Clinical Efficacy. Gastroenterol Res Pract 2019; 2019:2935498. [PMID: 30728835 PMCID: PMC6343182 DOI: 10.1155/2019/2935498] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/12/2018] [Revised: 08/26/2018] [Accepted: 10/18/2018] [Indexed: 12/15/2022] Open
Abstract
Purpose To evaluate the effect of puncture sites of the portal vein in transjugular intrahepatic portosystemic shunt (TIPS) on long-term clinical efficacy. Methods A retrospective review was performed, including consecutive 171 patients who underwent TIPS with ePTFE-covered stents. All patients were divided into 3 groups according to the puncture site of the portal vein: intrahepatic bifurcation of the portal vein (group A, n = 88), right branch of the portal vein (group B, n = 48), and left branch of the portal vein (group C, n = 35). The Kaplan-Meier analysis was performed to assess the effect of different puncture sites on primary patency, the incidence of hepatic encephalopathy (HE), and survival. Results The primary restenosis rate was 29.8% (51/171). The total HE rate was 31.6% (54/171). The cumulative death rate was 19.3% (33/171). The Kaplan-Meier analysis showed that group C versus group A, group C versus group B, and group A versus group B were significantly different on the primary restenosis rate, respectively (χ 2 = 11.49, P = 0.001; χ 2 = 4.54, P = 0.033; and χ 2 = 4.12, P = 0.046), and group C is better than the other two groups. What is more, group C versus group A and group C versus group B were significantly different on the incidence of HE, respectively (χ 2 = 8.07, P = 0.004; χ 2 = 9.44, P = 0.002), and group C is better than the other two groups. There was no significant difference on survival. Conclusion Choosing the left branch of the portal vein as the puncture site to create the shunt in TIPS with ePTFE-covered stents may decrease the incident of primary restenosis and HE significantly.
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Transjugular intrahepatic portosystemic shunt as a bridge to liver transplant: Current state and future directions. Transplant Rev (Orlando) 2018; 33:64-71. [PMID: 30477811 DOI: 10.1016/j.trre.2018.10.004] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2018] [Revised: 10/27/2018] [Accepted: 10/29/2018] [Indexed: 02/07/2023]
Abstract
Liver transplantation is one of the mainstays of treatment for liver failure due to severe chronic liver disease. Bridging therapies, such as placement of a transjugular intrahepatic portosystemic shunt (TIPS), are frequently employed to control complications of portal hypertension such as ascites, hydrothorax, and variceal bleeding, and thereby reduce morbidity in patients awaiting transplant. There is no significant difference seen in either graft survival or patient survival between those receiving TIPS pre-transplant and those who do not, although those receiving TIPS placement on average have a longer waiting time on the transplant waitlist. Locoregional therapies, such as thermal ablation or chemoembolization, can be efficacious in patients with HCC and pre-existing TIPS; however there is a risk for increased adverse events in patients receiving these therapies who have TIPS compared to those who do not. In summary, TIPS is a safe, effective treatment that can be used to ameliorate the complications that are sequelae of portal hypertension. While it does not appear to improve survival post-transplant, TIPS placement pre-transplant may increase survival time to transplant, thus improving overall survival as well as quality of life.
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Brand M, Prodehl L, Ede CJ. Surgical portosystemic shunts versus transjugular intrahepatic portosystemic shunt for variceal haemorrhage in people with cirrhosis. Cochrane Database Syst Rev 2018; 10:CD001023. [PMID: 30378107 PMCID: PMC6516991 DOI: 10.1002/14651858.cd001023.pub3] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
BACKGROUND Variceal haemorrhage that is refractory or recurs after pharmacologic and endoscopic therapy requires a portal decompression shunt (either surgical shunts or radiologic shunt, transjugular intrahepatic portosystemic shunt (TIPS)). TIPS has become the shunt of choice; however, is it the preferred option? This review assesses evidence for the comparisons of surgical portosystemic shunts versus TIPS for variceal haemorrhage in people with cirrhotic portal hypertension. OBJECTIVES To assess the benefits and harms of surgical portosystemic shunts versus transjugular intrahepatic portosystemic shunt (TIPS) for treatment of refractory or recurrent variceal haemorrhage in people with cirrhotic portal hypertension. SEARCH METHODS We searched the Cochrane Hepato-Biliary Group Controlled Trials Register, CENTRAL, MEDLINE, Embase, LILACS, Science Citation Index Expanded, and Conference Proceedings Citation Index - Science. We also searched on-line trial registries, reference lists of relevant articles, and proceedings of relevant associations for trials that met the inclusion criteria for this review (date of search 8 March 2018). SELECTION CRITERIA Randomised clinical trials comparing surgical portosystemic shunts versus TIPS for the treatment of refractory or recurrent variceal haemorrhage in people with cirrhotic portal hypertension. DATA COLLECTION AND ANALYSIS Two review authors independently assessed trials and extracted data using methodological standards expected by Cochrane. We assessed risk of bias according to domains and risk of random errors with Trial Sequential Analysis (TSA). We assessed the certainty of the evidence using the GRADE approach. MAIN RESULTS We found four randomised clinical trials including 496 adult participants diagnosed with variceal haemorrhage due to cirrhotic portal hypertension. The overall risk of bias in all the trials was judged at high risk. All the trials were conducted in the United States of America (USA). Two of the trials randomised participants to selective surgical shunts versus TIPS. The other two trials randomised participants to non-selective surgical shunts versus TIPS. The diagnosis of liver cirrhosis was by clinical and laboratory findings. We are uncertain whether there is a difference in all-cause mortality at 30 days between surgical portosystemic shunts compared with TIPS (risk ratio (RR) 0.94, 95% confidence interval (CI) 0.44 to 1.99; participants = 496; studies = 4). We are uncertain whether there is a difference in encephalopathy between surgical shunts compared with TIPS (RR 0.56, 95% CI 0.27 to 1.16; participants = 496; studies = 4). We found evidence suggesting an increase in the occurrence of the following harms in the TIPS group compared with surgical shunts: all-cause mortality at five years (RR 0.61, 95% CI 0.42 to 0.90; participants = 496; studies = 4); variceal rebleeding (RR 0.18, 95% CI 0.07 to 0.49; participants = 496; studies = 4); reinterventions (RR 0.13, 95% CI 0.06 to 0.28; participants = 496; studies = 4); and shunt occlusion (RR 0.14, 95% CI 0.04 to 0.51; participants = 496; studies = 4). We could not perform an analysis of health-related quality of life but available evidence appear to suggest improved health-related quality of life in people who received surgical shunt compared with TIPS. We downgraded the certainty of the evidence for all-cause mortality at 30 days and five years, irreversible shunt occlusion, and encephalopathy to very low because of high risk of bias (due to lack of blinding); inconsistency (due to heterogeneity); imprecision (due to small sample sizes of the individual trials and few events); and publication bias (few trials reporting outcomes). We downgraded the certainty of the evidence for variceal rebleeding and reintervention to very low because of high risk of bias (due to lack of blinding); imprecision (due to small sample sizes of the individual trials and few events); and publication bias (few trials reporting outcomes). The small sample sizes and few events did not allow us to produce meaningful trial sequential monitoring boundaries, suggesting plausible random errors in our estimates. AUTHORS' CONCLUSIONS We found evidence suggesting that surgical portosystemic shunts may have benefit over TIPS for treatment of refractory or recurrent variceal haemorrhage in people with cirrhotic portal hypertension. Given the very low-certainty of the available evidence and risks of random errors in our analyses, we have very little confidence in our review findings.
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Affiliation(s)
- Martin Brand
- University of PretoriaDepartment of SurgeryPretoriaSouth Africa0001
| | - Leanne Prodehl
- University of the WitwatersrandDepartment of Surgery1 Jubilee RoadJohannesburgGautengSouth Africa2192
| | - Chikwendu J Ede
- University of the WitwatersrandDepartment of Surgery1 Jubilee RoadJohannesburgGautengSouth Africa2192
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15
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Long-term clinical outcomes in patients with viral hepatitis related liver cirrhosis after transjugular intrahepatic portosystemic shunt treatment. Virol J 2018; 15:151. [PMID: 30285813 PMCID: PMC6167830 DOI: 10.1186/s12985-018-1067-7] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2018] [Accepted: 09/25/2018] [Indexed: 12/14/2022] Open
Abstract
Background Transjugular intrahepatic portosystemic shunt (TIPS) procedure has played a vital role in management of portal hypertension. Thus, we aimed to investigate the natural history, long-term clinical outcome, predictors of survival in viral hepatitis related cirrhotic patients post-TIPS. Method A total of 704 patients with complete followed-up data were enrolled, and clinical characteristics of patients were collected and analyzed. Kaplan-Meier method was used to calculate survival, and comparisons were made by log rank test. A multivariate analysis of factors influencing survival was carried out using the Cox proportional hazards regression model. Results TIPS implatantion significantly decreased portal vein pressure with 9.77 cmH2O reduction, without influencing long-term liver functions. The total incidence rate of major complication post-TIPS, including HE and re-bleeding/bleeding, was 37.9% and 15.5%, respectively. Patients in Child-Pugh C stage revealed higher overt hepatic encephalopathy (HE) occurrence (65.6%), while patients receiving covered, 6 mm in diameter stents indicated notably lower incidence of HE in comparison with other groups (6.4%). The median survival was > 60 months, 27.0 months, and 11.5 months in cirrhotic patients with variceal bleeding, refractory ascites, and both complications, respectively. The cumulative 5-year survival was significantly higher in patients with variceal bleeding (75.6%) in comparison with either that in patients with refractory ascites (12.5%) or that in patients with both complications (1.96%) (P < 0.0001). Covered stents usage, baseline model for end-stage liver disease (MELD) score, and baseline Child-Pugh classification were predictive of survival (P < 0.001). Other variables including age, male gender, and pre-TIPS PVP were not emerged as significant predictors (P > 0.05). Conclusion TIPS was an effective and safe therapeutic method for decompression of portal hypertension and for treatment of its complications. Careful selection of patients with minimal liver dysfunction for TIPS implantation was essential for better long-term outcomes.
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Hüsing-Kabar A, Meister T, Köhler M, Domschke W, Kabar I, Wilms C, Hild B, Schmidt HH, Heinzow HS. Is de novo hepatocellular carcinoma after transjugular intrahepatic portosystemic shunt increased? United European Gastroenterol J 2018; 6:413-421. [PMID: 29774155 PMCID: PMC5949971 DOI: 10.1177/2050640617732886] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/21/2017] [Accepted: 08/30/2017] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND Portal hypertension is a major complication of liver cirrhosis. Transjugular intrahepatic portosystemic shunt is effective in treatment of portal hypertension. However, decreased parenchymal portal venous flow after transjugular intrahepatic portosystemic shunt insertion favours ischaemic liver injury which has been discussed to induce hepatocarcinogenesis causing hepatocellular cancer. AIM This study aimed to explore the association between transjugular intrahepatic portosystemic shunt placement and the development of hepatocellular cancer. METHODS A total of 1338 consecutive liver cirrhosis patients were included in this retrospective study between January 2004-December 2015. Data were analysed with regard to development of hepatocellular cancer during follow-up. Binary logistic regression and Kaplan-Meier analyses were conducted for the assessment of risk factors for hepatocellular cancer development. In a second step, to rule out confounders of group heterogeneity, case-control matching was performed based on gender, age, model of end-stage liver disease score and underlying cause of cirrhosis (non-alcoholic steatohepatitis, alcoholic liver disease and viral hepatitis). RESULTS Besides established risk factors such as older age, male gender and underlying viral hepatitis, statistical analysis revealed the absence of transjugular intrahepatic portosystemic shunt insertion as a risk factor for hepatocellular cancer development. Furthermore, matched-pair analysis of 432 patients showed a significant difference (p = 0.003) in the emergence of hepatocellular cancer regarding transjugular intrahepatic portosystemic shunt placement versus the non-transjugular intrahepatic portosystemic shunt cohort. CONCLUSION In patients with end-stage liver disease, transjugular intrahepatic portosystemic shunt insertion is significantly associated with reduced rates of hepatocellular cancer development.
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Affiliation(s)
- A Hüsing-Kabar
- Department of Transplant Medicine, University Hospital
Muenster, Muenster, Germany
| | - T Meister
- Department of Gastroenterology, HELIOS
Albert-Schweitzer-Hospital Northeim, Northeim, Germany
| | - M Köhler
- Department of Clinical Radiology, University Hospital
Muenster, Muenster, Germany
| | - W Domschke
- Department of Medicine B, University Hospital
Muenster, Muenster, Germany
| | - I Kabar
- Department of Transplant Medicine, University Hospital
Muenster, Muenster, Germany
| | - C Wilms
- Department of Transplant Medicine, University Hospital
Muenster, Muenster, Germany
| | - B Hild
- Department of Transplant Medicine, University Hospital
Muenster, Muenster, Germany
| | - HH Schmidt
- Department of Transplant Medicine, University Hospital
Muenster, Muenster, Germany
| | - HS Heinzow
- Department of Transplant Medicine, University Hospital
Muenster, Muenster, Germany
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Rabei R, Mathevosian S, Tasse J, Madassery S, Arslan B, Turba U, Ahmed O. Primary constrained TIPS for treating refractory ascites or variceal bleeding secondary to hepatic cirrhosis. Br J Radiol 2018; 91:20170409. [PMID: 29166137 DOI: 10.1259/bjr.20170409.pmid29166137;pmcid:pmc5965479] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/21/2023] Open
Abstract
OBJECTIVE To report an initial experience using a primary constrained transjugular intrahepatic portosystemic shunt (TIPS) technique for treating cirrhotic patients with refractory ascites or variceal bleeding. METHODS All patients undergoing primary constrained (n = 9) and conventional (n = 18) TIPS between July 2014 and June 2016 were retrospectively reviewed. Preprocedure demographics, Child-Pugh, model for end-stage liver disease and technical variables were recorded. Outcomes measured included technical and clinical success, complications, 30-day mortality, as well as necessity for TIPS revision. Average (SD) and median follow-up was 237 (190) and 226 days. RESULTS All constrained and conventional TIPS were technically successful (100%). Clinical success as defined as a reduction or improvement in presenting symptoms was 88.9% (8/9) and 100% (18/18) in the constrained and conventional groups, respectively (p = 1). The average reduction in portosystemic gradient was lower in the constrained group, 6.1 mmHg compared with 10.6 mmHg in the conventional group (p = 0.73). The rate of hepatic encephalopathy following TIPS placement was higher in the conventional group [16.7% (3/18)] compared with 0% in the constrained group (p = 0.52). The percentage of patients requiring TIPS revision was lower in the constrained group, although the results were not significant (11.1 vs 22.2%, p = 0.63). CONCLUSION Primary constrained TIPS is a feasible modification to conventional TIPS with similar technical and clinical success rates. A trend towards a smaller reduction in the portosystemic gradient and need for revision was observed in the constrained group. Advances in knowledge: Primary constrained TIPS allows for greater stepwise control over shunt diameter and may represent an improved technique for patients at risk for hepatic encephalopathy.
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Affiliation(s)
- R Rabei
- 1 Chicago Medical School , Rosalind Franklin University , North Chicago, IL , USA
| | - S Mathevosian
- 1 Chicago Medical School , Rosalind Franklin University , North Chicago, IL , USA
| | - J Tasse
- 2 Rush University Medical Center , Chicago, IL , USA
| | - S Madassery
- 2 Rush University Medical Center , Chicago, IL , USA
| | - B Arslan
- 2 Rush University Medical Center , Chicago, IL , USA
| | - U Turba
- 2 Rush University Medical Center , Chicago, IL , USA
| | - O Ahmed
- 2 Rush University Medical Center , Chicago, IL , USA
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18
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Buechter M, Manka P, Gerken G, Canbay A, Blomeyer S, Wetter A, Altenbernd J, Kahraman A, Theysohn JM. Transjugular Intrahepatic Portosystemic Shunt in Patients with Portal Hypertension: Patency Depends on Coverage and Interventionalist's Experience. Dig Dis 2018; 36:218-227. [PMID: 29316565 DOI: 10.1159/000486030] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/13/2017] [Accepted: 11/29/2017] [Indexed: 02/02/2023]
Abstract
BACKGROUND AND AIMS Transjugular intrahepatic portosystemic shunt (TIPS) is the treatment of choice in decompensated portal hypertension. TIPS revision due to thrombosis or stenosis increases morbidity and mortality. Our aim was to investigate patient- and procedure-associated risk factors for TIPS-revision. PATIENTS AND METHODS We retrospectively evaluated 189 patients who underwent the TIPS procedure. Only patients who required TIPS revision within 1 year (Group I, 34 patients) and patients who did not require re-intervention within the first year (Group II [control group], 54 patients) were included. RESULTS Out of 88 patients, the majority were male (69.3%) and mean age was 56 ± 11 years. Indications for TIPS were refractory ascites (68%), bleeding (24%), and Budd-Chiari syndrome (8%). The most frequent liver disease was alcohol-induced cirrhosis (60%). Forty-three patients (49%) received bare and 45 patients (51%) covered stents, thus resulting in reduction of hepatic venous pressure gradient (HVPG) from 19.0 to 9.0 mm Hg. When comparing patient- and procedure-related factors, the type of stent (p < 0.01) and interventionalist's experience (number of performed TIPS implantations per year; p < 0.05) were the only factors affecting the risk of re-intervention due to stent dysfunction, while age, gender, indication, Child-Pugh, and model of end-stage liver disease score, platelet count, pre- and post-HVPG, additional variceal embolization, stent diameter, and number of stents did not significantly differ. CONCLUSION Patients undergoing TIPS procedure should be surveilled closely for shunt dysfunction while covered stents and high-level experience are associated with increased -patency.
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Affiliation(s)
- Matthias Buechter
- Department of Gastroenterology and Hepatology, University Hospital Essen, Essen, Germany
| | - Paul Manka
- Department of Gastroenterology and Hepatology, University Hospital Essen, Essen, Germany.,Regeneration and Repair, Institute of Hepatology, Division of Transplantation Immunology and Mucosal Biology, Faculty of Life Sciences and Medicine, King's College London, London, United Kingdom
| | - Guido Gerken
- Department of Gastroenterology and Hepatology, University Hospital Essen, Essen, Germany
| | - Ali Canbay
- Department of Gastroenterology, Hepatology and Infectious Diseases, Otto-von-Guericke University, Magdeburg, Germany
| | - Sandra Blomeyer
- Department of Gastroenterology and Hepatology, University Hospital Essen, Essen, Germany
| | - Axel Wetter
- Department of Diagnostic and Interventional Radiology and Neuroradiology, University Hospital Essen, Essen, Germany
| | - Jens Altenbernd
- Department of Radiology and Neuroradiology, Klinikum Vest Knappschaftskrankenhaus Recklinghausen, Recklinghausen, Germany
| | - Alisan Kahraman
- Department of Gastroenterology and Hepatology, University Hospital Essen, Essen, Germany
| | - Jens M Theysohn
- Department of Diagnostic and Interventional Radiology and Neuroradiology, University Hospital Essen, Essen, Germany
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Stent Dysfunction After Transjugular Intrahepatic Portosystemic Shunt: A 14-Year Experience from a Single Tertiary Medical Center. IRANIAN JOURNAL OF RADIOLOGY 2017. [DOI: 10.5812/iranjradiol.15579] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
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Rabei R, Mathevosian S, Tasse J, Madassery S, Arslan B, Turba U, Ahmed O. Primary constrained TIPS for treating refractory ascites or variceal bleeding secondary to hepatic cirrhosis. Br J Radiol 2017; 91:20170409. [PMID: 29166137 DOI: 10.1259/bjr.20170409] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
OBJECTIVE To report an initial experience using a primary constrained transjugular intrahepatic portosystemic shunt (TIPS) technique for treating cirrhotic patients with refractory ascites or variceal bleeding. METHODS All patients undergoing primary constrained (n = 9) and conventional (n = 18) TIPS between July 2014 and June 2016 were retrospectively reviewed. Preprocedure demographics, Child-Pugh, model for end-stage liver disease and technical variables were recorded. Outcomes measured included technical and clinical success, complications, 30-day mortality, as well as necessity for TIPS revision. Average (SD) and median follow-up was 237 (190) and 226 days. RESULTS All constrained and conventional TIPS were technically successful (100%). Clinical success as defined as a reduction or improvement in presenting symptoms was 88.9% (8/9) and 100% (18/18) in the constrained and conventional groups, respectively (p = 1). The average reduction in portosystemic gradient was lower in the constrained group, 6.1 mmHg compared with 10.6 mmHg in the conventional group (p = 0.73). The rate of hepatic encephalopathy following TIPS placement was higher in the conventional group [16.7% (3/18)] compared with 0% in the constrained group (p = 0.52). The percentage of patients requiring TIPS revision was lower in the constrained group, although the results were not significant (11.1 vs 22.2%, p = 0.63). CONCLUSION Primary constrained TIPS is a feasible modification to conventional TIPS with similar technical and clinical success rates. A trend towards a smaller reduction in the portosystemic gradient and need for revision was observed in the constrained group. Advances in knowledge: Primary constrained TIPS allows for greater stepwise control over shunt diameter and may represent an improved technique for patients at risk for hepatic encephalopathy.
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Affiliation(s)
- R Rabei
- 1 Chicago Medical School , Rosalind Franklin University , North Chicago, IL , USA
| | - S Mathevosian
- 1 Chicago Medical School , Rosalind Franklin University , North Chicago, IL , USA
| | - J Tasse
- 2 Rush University Medical Center , Chicago, IL , USA
| | - S Madassery
- 2 Rush University Medical Center , Chicago, IL , USA
| | - B Arslan
- 2 Rush University Medical Center , Chicago, IL , USA
| | - U Turba
- 2 Rush University Medical Center , Chicago, IL , USA
| | - O Ahmed
- 2 Rush University Medical Center , Chicago, IL , USA
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Vasconcelos-Filho JOM, Pereira AH, Pitta GBB, Leitão-Batista L, Castro AA, Souza-Leão AR, Lacerda CM. Measurements between the hepatic veins and portal venous system, in human cirrhotic liver: a cast study. Surg Radiol Anat 2017; 40:395-400. [DOI: 10.1007/s00276-017-1909-9] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2016] [Accepted: 08/07/2017] [Indexed: 12/15/2022]
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Lin LL, Du SM, Fu Y, Gu HY, Wang L, Jian ZY, Shen XF, Luo J, Zhang C. Combination therapy versus pharmacotherapy, endoscopic variceal ligation, or the transjugular intrahepatic portosystemic shunt alone in the secondary prevention of esophageal variceal bleeding: a meta-analysis of randomized controlled trials. Oncotarget 2017; 8:57399-57408. [PMID: 28915680 PMCID: PMC5593651 DOI: 10.18632/oncotarget.18143] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2017] [Accepted: 04/25/2017] [Indexed: 12/27/2022] Open
Abstract
Patients with liver cirrhosis and variceal hemorrhage are at increased risk of rebleeding. We performed a meta-analysis toassess the clinical efficacy of combination therapy (pharmacotherapy and endoscopic variceal ligation (EVL)) compared with pharmacotherapy, EVL, or transjugular intrahepatic portosystemic shunt (TIPS) alone in the prevention of rebleeding and mortality. A literature search of MEDLINE, EMBASE, and the Cochrane Controlled Trials Register, up until November 2016, identified relevant randomized controlled trials. Data analysis was performed using Stata 12.0. Regarding overall mortality, combination therapy was as effective as EVL, pharmacotherapy, and TIPS (relative risk (RR) = 0.62, 95% confidence interval (CI): 0.36-1.08, RR=1.05, 95% CI: 0.68-1.63, and RR=1.39, 95% CI: 0.92-2.09, respectively). Combination therapy was as effective as EVL and pharmacotherapy alone in reducing blood-related mortality (RR=0.43, 95% CI: 0.15-1.25, and RR=0.42, 95% CI: 0.17-1.06), whereas TIPS was more effective than combination therapy (RR=5.66, 95% CI: 1.02-31.40). This was also the case for rebleeding; combination therapy was more effective than EVL and pharmacotherapy alone (RR=0.57, 95% CI: 0.41-0.79, and RR=0.65, 95% CI: 0.48-0.88), whereas TIPS was more effective than combination therapy (RR=9.42, 95% CI: 2.99-29.65). Finally, regarding rebleeding from esophageal varices, combination therapy was as effective as EVL alone (RR=0.59, 95% CI: 0.33-1.06) and was more effective than pharmacotherapy alone (RR=0.58, 95% CI: 0.40-0.85), although was less effective than TIPS (RR=2.20, 95% CI: 1.22-3.99). TIPS was recommended as the first choice of therapy in the secondary prevention of esophageal variceal bleeding.
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Affiliation(s)
- Lu-Lu Lin
- Center for Evidence-Based Medicine and Clinical Research, Taihe Hospital, Hubei University of Medicine, Shiyan 442000, China
| | - Shi-Ming Du
- Department of Pharmacy, Taihe Hospital, Hubei University of Medicine, Shiyan 442000, China
| | - Yan Fu
- Department of Hepatobiliary Surgery, Taihe Hospital, Hubei University of Medicine, Shiyan 442000, China
| | - Hui-Yun Gu
- Department of Gastroenterology, Taihe Hospital, Hubei University of Medicine, Shiyan 442000, China
| | - Lei Wang
- Administrative Offices, Taihe Hospital, Hubei University of Medicine, Shiyan 442000, China
| | - Zhi-Yuan Jian
- Hepatopancreatobiliary Surgery Treatment Center, Taihe Hospital, Hubei University of Medicine, Shiyan 442000, China
| | - Xian-Feng Shen
- Hepatopancreatobiliary Surgery Treatment Center, Taihe Hospital, Hubei University of Medicine, Shiyan 442000, China
| | - Jie Luo
- Center for Evidence-Based Medicine and Clinical Research, Taihe Hospital, Hubei University of Medicine, Shiyan 442000, China.,Administrative Offices, Taihe Hospital, Hubei University of Medicine, Shiyan 442000, China
| | - Chao Zhang
- Center for Evidence-Based Medicine and Clinical Research, Taihe Hospital, Hubei University of Medicine, Shiyan 442000, China
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Three-dimensional Image Fusion Guidance for Transjugular Intrahepatic Portosystemic Shunt Placement. Cardiovasc Intervent Radiol 2017; 40:1732-1739. [DOI: 10.1007/s00270-017-1699-9] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/26/2016] [Accepted: 05/09/2017] [Indexed: 12/14/2022]
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Veith FJ, Marin ML. Endovascular Surgery and its Effect on the Relationship between Vascular Surgery and Radiology. J Endovasc Ther 2016. [DOI: 10.1177/152660289500200101] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Frank J. Veith
- Division of Vascular Surgery and the Department of Surgery, Montefiore Medical Center/Albert Einstein College of Medicine, New York, New York
| | - Michael L. Marin
- Division of Vascular Surgery and the Department of Surgery, Montefiore Medical Center/Albert Einstein College of Medicine, New York, New York
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Portal Hypertension Over the Last 25 Years: Where Did It Go? J Am Coll Surg 2016; 222:1164-70. [PMID: 27234633 DOI: 10.1016/j.jamcollsurg.2016.02.017] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2015] [Revised: 01/04/2016] [Accepted: 02/16/2016] [Indexed: 11/22/2022]
Abstract
BACKGROUND Portal hypertension has seemingly vanished from surgery; this study was undertaken to determine where it has gone. STUDY DESIGN Data from the Agency for Health Care Administration for 33,166,201 hospital inpatients in Florida for the periods 1988 to 1992, 1998 to 2002, and 2008 to 2012 were analyzed. RESULTS Admissions with a diagnosis of portal hypertension dramatically increased: 5,473 patients from 1988 to 1992, 7,366 patients from 1998 to 2002, and 36,554 patients from 2008 to 2012. Endoscopic treatment of esophageal varices also dramatically increased. The number of decompressive shunts placed nominally increased, but application of endoscopic therapy increased significantly faster than the application of decompressive shunts (p < 0.0001). The percentage of patients who underwent shunting dramatically and significantly decreased (p < 0.0001), and surgeons undertook proportionally fewer shunts (42% in 1992 to 4% in 2012; p < 0.0001). For patients with a diagnosis of portal hypertension, in-hospital mortality progressively decreased, from 9% in 1988 to 1992 to 3% in 2008 to 2012 (p < 0.0001). CONCLUSIONS In the state of Florida, over 25 years, there has been a 7-fold increase in the number of patients admitted with a diagnosis of portal hypertension, with a 65% reduction of in-hospital mortality. Application of endoscopic treatment of varices has increased dramatically. Decompressive shunts are applied to an ever-decreasing percentage of patients, and when applied, are now routinely undertaken by nonsurgeons. Therefore, portal hypertension has disappeared from the purview of surgery and has migrated toward the world of medical and endoscopic therapy, probably never to return.
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Ferral H, Gomez-Reyes E, Fimmel CJ. Post-Transjugular Intrahepatic Portosystemic Shunt Follow-Up and Management in the VIATORR Era. Tech Vasc Interv Radiol 2016; 19:82-8. [PMID: 26997092 DOI: 10.1053/j.tvir.2016.01.009] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
The transjugular intrahepatic portosystemic shunt (TIPS) is a non-selective portosystemic shunt created using endovascular techniques. The first TIPS was performed in Germany in 1988. The VIATORR self-expandable PTFE covered stent-graft (WL Gore, Flagstaff AZ) was approved by the FDA for a TIPS application in December of 2004. This stent-graft offers excellent shunt patency rates and it is possible that it has a beneficial effect on patient survival. Patient surveillance and post-procedural management have changed after the introduction of this stent-graft. This article presents the current management strategies that are followed at our Institution for patients who have undergone a TIPS procedure with a VIATORR stent graft including imaging follow-up, management of encephalopathy, medical management and nutritional aspects.
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Affiliation(s)
- Hector Ferral
- The Department of Radiology, Section of Interventional Radiology, NorthShore University HealthSystem, Evanston, IL.
| | - Elisa Gomez-Reyes
- Departamento de Gastroenterologia, Instituto Nacional de la Nutricion Salvador Zubiran, Tlalpan, Mexico City, Mexico
| | - Claus J Fimmel
- University of Chicago Pritzker School of Medicine, Section Chief of Hepatology, Division of Gastroenterology, NorthShore University HealthSystem, Evanston, IL
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Ding PX, Zhang SJ, Li Z, Fu MT, Hua ZH, Zhang WG. Long-term safety and outcome of percutaneous transhepatic venous balloon angioplasty for Budd-Chiari syndrome. J Gastroenterol Hepatol 2016; 31:222-8. [PMID: 26102208 DOI: 10.1111/jgh.13025] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/24/2015] [Revised: 05/21/2015] [Accepted: 06/15/2015] [Indexed: 12/13/2022]
Abstract
BACKGROUND AND AIMS The restenosis following percutaneous transluminal balloon angioplasty (PTBA) is high for Budd-Chiari syndrome (BCS) patients with hepatic venous obstruction (HVO). We aim to evaluate the safety and long-term outcome of PTBA with a large balloon catheter in a large series of patients with HVO. METHODS Between January 2005 and December 2013, 93 consecutive BCS patients with HVO were referred for PTBA and subsequently underwent color Doppler ultrasonography or angiography follow-up. Data were retrospectively collected, and follow-up observations were performed at 1-, 2-, 2- to 5-, and 5- to 8-years postoperatively. RESULTS Percutaneous transluminal balloon angioplasty was technically successful in all patients. Ninety-one patients (97.85%) were treated with PTBA and two with PTBA and stent. Major procedure-related complications occurred in six of the 93 patients (6.45%). The cumulative 1-, 2-, 2- to 5-, and 5- to 8-year primary patency rates were 97.5%, 92.9%, 90%, and 86.5%, respectively. Cumulative 1-, 2-, 2- to 5-, and 5- to 8-year secondary patency rates were 100%, 100%, 98.6%, and 97.3%, respectively. Mean and median primary patency rates were 51.50 ± 3.01 months and 55.0 ± 3.63 months, respectively. Cumulative 1-, 2-, 2- to 5-, and 5- to 8-year survival rates were 98.75%, 98.6%, 100%, and 100%, respectively. Mean and median survival times were 53.10 ± 3.04 months and 55.0 ± 3.64 months, respectively. CONCLUSION Percutaneous transluminal balloon angioplasty with a large balloon is a safe and effective treatment that could provide excellent rates of long-term patency and survival for the majority of Chinese patients with BCS and HVO.
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Affiliation(s)
- Peng-Xu Ding
- Department of Vascular and Endovascular Surgery, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan, China
| | - Shui-Jun Zhang
- Department of Vascular and Endovascular Surgery, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan, China
| | - Zhen Li
- Department of Vascular and Endovascular Surgery, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan, China
| | - Ming-Ti Fu
- Department of Vascular and Endovascular Surgery, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan, China
| | - Zhao-Hui Hua
- Department of Vascular and Endovascular Surgery, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan, China
| | - Wen-Guang Zhang
- Department of Vascular and Endovascular Surgery, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan, China
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Quality Improvement Guidelines for Transjugular Intrahepatic Portosystemic Shunts. J Vasc Interv Radiol 2015; 27:1-7. [PMID: 26614596 DOI: 10.1016/j.jvir.2015.09.018] [Citation(s) in RCA: 108] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2015] [Revised: 09/25/2015] [Accepted: 09/25/2015] [Indexed: 12/12/2022] Open
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Portosystemic Shunts: Stable Utilization and Improved Outcomes, Two Decades After the Transjugular Intrahepatic Portosystemic Shunt. J Am Coll Radiol 2015; 12:1427-33. [PMID: 26410348 DOI: 10.1016/j.jacr.2015.06.037] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2015] [Revised: 06/24/2015] [Accepted: 06/25/2015] [Indexed: 02/07/2023]
Abstract
PURPOSE The aim of this study was to assess national trends in utilization, demographics, hospital characteristics, and outcomes of patients undergoing surgical or percutaneous portal decompression since the introduction of transjugular intrahepatic portosystemic shunts (TIPS). METHODS A retrospective analysis of patients undergoing surgical portal decompression and TIPS procedures was conducted using Medicare Physician/Supplier Procedure Summary Master Files from January 2003 through December 2013 and National (Nationwide) Inpatient Sample data from 1993, 2003, and 2012. Utilization rates normalized to the annual number of Medicare enrollees, estimated means, and 95% confidence intervals were calculated. RESULTS The Medicare total annual utilization rate per million for all portosystemic decompression procedures decreased by 6.5% during the study period, from 15.3 in 2003 to 14.3 in 2013. TIPS utilization increased by 19.4% (from 10.3 to 12.3 per million), whereas open surgical shunt utilization decreased by 60.0% (from 5.0 to 2.0 per million). TIPS procedures represented 86% of all procedures in 2013. From 1993 to 2012, mean age increased slightly (from 53.0 to 55.5 years, P < .05). The percentage of procedures performed at teaching hospitals increased, whereas in-hospital mortality and length of stay decreased by 42% (P < .05) and 20% (P < .05), respectively. Of factors evaluated, the performance of procedures on an elective basis was the most influential on in-hospital mortality (P < .01, all years studied) and length of stay (P < .0001, all years studied). CONCLUSIONS Approximately two decades after the introduction of TIPS, the utilization of all portal decompression procedures has remained relatively stable. The TIPS procedure represents the dominant portal decompression technique. In-hospital mortality and mean length of stay after decompression have decreased, partially because of the performance of procedures during elective admissions.
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Brand M, Prodehl L. Surgical portosystemic shunts versus transjugular intrahepatic portosystemic shunt for variceal haemorrhage. Hippokratia 2015. [DOI: 10.1002/14651858.cd001023.pub2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Affiliation(s)
- Martin Brand
- University of the Witwatersrand; Department of Surgery; Johannesburg South Africa 2109
| | - Leanne Prodehl
- University of the Witwatersrand; Department of Surgery; Johannesburg South Africa 2109
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Abstract
The evolution of modern interventional radiology began over half century ago with a simple question. Was it possible to use the same diagnostic imaging tools that had revolutionized the practice of medicine to guide the real-time treatment of disease? This disruptive concept led to rapid treatment advances in every organ system of the body. It became clear that by utilizing imaging some patients could undergo targeted procedures, eliminating the need for major surgery, while others could undergo procedures for previously unsolvable problems. The breadth of these changes now encompasses all of medicine and has forever changed the way we think about disease. In this brief review article, major advances in the field, as chronicled in the pages of Radiology, will be described.
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Affiliation(s)
- Richard A Baum
- From the Department of Interventional Radiology, Brigham and Women's Hospital, Boston, Mass (R.A.B.); and Department of Radiology, University of Pennsylvania, 3600 Market St, Suite 370, Philadelphia, PA 19104 (S.B.)
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Abstract
Transjugular intrahepatic portosystemic shunt (TIPS) is an established procedure for the complications of portal hypertension. The largest body of evidence for its use has been supported for recurrent or refractory variceal bleeding and refractory ascites. Its use has also been advocated for acute variceal bleed, hepatic hydrothorax, and hepatorenal syndrome. With the replacement of bare metal stents with polytetrafluoroethylene-covered stents, shunt patency has improved dramatically, thus, improving outcomes. Therefore, reassessment of its utility, management of its complications, and understanding of various TIPS techniques is important.
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Affiliation(s)
- Kavish R Patidar
- Department of Internal Medicine, Virginia Commonwealth University Hospital, 1200 East Broad Street, MCV Box 980342, Richmond, VA 23298-0342, USA
| | - Malcolm Sydnor
- Radiology, Virginia Commonwealth University Hospital, 1200 East Broad Street, MCV Box 980615, Richmond, VA 23298-0615, USA; Surgery, Virginia Commonwealth University Hospital, 1200 East Broad Street, Richmond, VA 23298, USA; Vascular Interventional Radiology, Virginia Commonwealth University Hospital, 1200 East Broad Street, Richmond, VA 23298, USA
| | - Arun J Sanyal
- Division of Gastroenterology, Department of Internal Medicine, Virginia Commonwealth University School of Medicine, 1200 East Broad Street, MCV Box 980342, Richmond, VA 23298-0342, USA.
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Saad WE. The history and future of transjugular intrahepatic portosystemic shunt: food for thought. Semin Intervent Radiol 2014; 31:258-61. [PMID: 25177087 DOI: 10.1055/s-0034-1382794] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
The origins of transjugular intrahepatic portosystemic shunt (TIPS) date back to the 1960s with inadvertent portal access during the early years of transjugular cholangiography. TIPS is now the most frequently performed portal hypertension decompressive procedure performed by interventional radiologists, and has become the primary portosystemic shunt (surgical or percutaneous) performed in the United States. One of the least discussed major advantages of TIPS in the transplant era is that it is intrahepatic and thus is removed in situ during a liver transplant, while extrahepatic shunts (surgical or percutaneous) have to be ligated or revised during the liver transplantation. However, since the widespread clinical utilization of TIPS in the 1990s, it has been plagued with two major problems, namely, patency and hepatic encephalopathy. With the advent of commercially available expanded polytetraflouroethylenne (e-PTFE) covered stents a decade ago, 12- to 24-month TIPS patency has improved significantly (by ∼20-30%). However, hepatic encephalopathy (although not proven to have increased due to e-PTFE covered stents grafts) remains a significant morbidity problem. The article discusses the history of TIPS, critiques the retrospective encephalopathy data in the literature, and discusses futuristic TIPS-design ideas about the management of post-TIPS hepatic encephalopathy.
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Affiliation(s)
- Wael E Saad
- Department of Radiology, University of Michigan Medical Center, Ann Arbor, Michigan
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Shi Y, Tian X, Hu J, Zhang J, Zhang C, Yang Y, Qin C. Efficacy of transjugular intrahepatic portosystemic shunt with adjunctive embolotherapy with cyanoacrylate for esophageal variceal bleeding. Dig Dis Sci 2014; 59:2325-32. [PMID: 24748182 DOI: 10.1007/s10620-014-3150-2] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/01/2014] [Accepted: 03/30/2014] [Indexed: 12/23/2022]
Abstract
BACKGROUND Transjugular intrahepatic portosystemic shunt (TIPS) with adjunctive embolotherapy has recently been reported to be effective in the prevention of variceal hemorrhage of cirrhotic patients. However, further investigation of its long-term efficacy is still needed. AIM To examine the rebleeding, survival, and hepatic encephalopathy (HE) after treatment with TIPS alone and TIPS with adjunctive embolotherapy using cyanoacrylate for esophageal variceal bleeding. METHODS Patients with refractory to endoscopic therapy for esophageal variceal bleeding were enrolled. TIPS was performed in 101 patients with adjunctive embolotherapy (n = 53) or alone (n = 48) between January 2006 and December 2011. Chart reviews were performed to determine rebleeding, survival rates, and the incidence of HE. RESULTS Recurrent hemorrhage occurred in 12 (11.9 %) patients during the mean follow-up periods of 35.8 months. Rebleeding was observed in 9/48 (18.8 %) patients in TIPS alone group and 3/53 (5.7 %) patients in TIPS with adjunctive embolotherapy group (p = 0.042). Death occurred in 30 patients during follow-up (TIPS alone: n = 16, TIPS with adjunctive embolotherapy: n = 14, p = 0.447). Twenty-six episodes of HE occurred in 18 patients in TIPS alone group and 16 episodes occurred in 10 patients in TIPS with embolotherapy group. The probability of HE was significantly higher in TIPS alone group than in TIPS with embolotherapy group (p = 0.019). CONCLUSIONS TIPS with adjunctive embolotherapy with cyanoacrylate is relatively safe and effective, with a lower rebleeding and HE incidence in comparison of TIPS alone.
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Affiliation(s)
- Yongjun Shi
- Department of Gastroenterology, Provincial Hospital Affiliated to Shandong University, 324 Jingwu Weiqi Road, Jinan, 250021, Shandong, People's Republic of China,
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Kruel CRP, Guimarães M, Chedid AD, Grezzana-Filho TMDJ, Leipnitz I, Araújo AD, Alvares-da-Silva MR, Kruel CDP. Bilhemia following transjugular intrahepatic portosystemic shunt placement (Tips): liver transplantation as a rescue procedure - case report. ABCD-ARQUIVOS BRASILEIROS DE CIRURGIA DIGESTIVA 2014; 26:238-40. [PMID: 24190385 DOI: 10.1590/s0102-67202013000300016] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
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Smith MT, Rase B, Woods A, Trotter J, Gipson M, Kondo K, Ray C, Durham J. Risk of hernia incarceration following transjugular intrahepatic portosystemic shunt placement. J Vasc Interv Radiol 2013; 25:58-62. [PMID: 24269791 DOI: 10.1016/j.jvir.2013.09.003] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2013] [Revised: 09/04/2013] [Accepted: 09/05/2013] [Indexed: 01/28/2023] Open
Abstract
PURPOSE Hernia complications after creation of a transjugular intrahepatic portosystemic shunt (TIPS) have been reported, although the incidence of this complication is unknown. This study was designed to determine the incidence, morbidity, and outcome of hernia complications in patients with preexisting abdominal or inguinal hernias after TIPS creation. MATERIALS AND METHODS The medical records of 244 consecutive patients undergoing TIPS creation between 1999 and 2007 at a single institution were reviewed. The study population was 57 patients (23%) with a preprocedural abdominal or inguinal hernia. The investigated outcome was small bowel obstruction or postprocedural incarceration of a preexisting hernia. Demographic and procedural variables were evaluated for an associated increased risk of hernia complications. RESULTS Hernia complications developed in 25% of patients (14 of 57) after TIPS creation at a mean presentation of 62 days (range, 2-588 d). Thirteen complications (93%) required emergent surgery, of which four (29%) required bowel resection for necrosis. There were no resulting deaths. Ninety-eight percent of patients with a hernia complication had the procedure to treat refractory ascites. The indication of refractory ascites was significantly associated with the risk of a hernia complication (P = .002). CONCLUSIONS A 25% incidence of hernia complications following TIPS creation in patients being treated for refractory ascites is higher than expected; emergent surgery is required in most cases. Further investigation to formulate a plan for elective management is warranted.
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Affiliation(s)
- Mitchell T Smith
- Department of Radiology, Division of Interventional Radiology, University of Colorado Denver, 12700 E. 19th Ave, Room P15-1205, Aurora, CO 80045.
| | - Benjamin Rase
- Department of Radiology, University of Colorado School of Medicine, Denver, Colorado
| | - Alyn Woods
- Department of Radiology, David Grant Medical Center, Travis AFB, California
| | - James Trotter
- Liver Transplantation Center, Baylor University Medical Center at Dallas, Dallas, Texas
| | - Matt Gipson
- Department of Radiology, Division of Interventional Radiology, University of Colorado Denver, 12700 E. 19th Ave, Room P15-1205, Aurora, CO 80045
| | - Kimi Kondo
- Department of Radiology, Division of Interventional Radiology, University of Colorado Denver, 12700 E. 19th Ave, Room P15-1205, Aurora, CO 80045
| | - Charles Ray
- Department of Radiology, Division of Interventional Radiology, University of Colorado Denver, 12700 E. 19th Ave, Room P15-1205, Aurora, CO 80045
| | - Janette Durham
- Department of Radiology, Division of Interventional Radiology, University of Colorado Denver, 12700 E. 19th Ave, Room P15-1205, Aurora, CO 80045
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Transjugular intrahepatic portosystemic shunt creation using intravascular ultrasound guidance. J Vasc Interv Radiol 2012; 23:1594-602. [PMID: 23099001 DOI: 10.1016/j.jvir.2012.08.023] [Citation(s) in RCA: 55] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2012] [Revised: 08/08/2012] [Accepted: 08/13/2012] [Indexed: 11/23/2022] Open
Abstract
PURPOSE To describe the use of intravascular ultrasound (US) guidance for creation of transjugular intrahepatic portosystemic shunts (TIPSs) in humans. MATERIALS AND METHODS The initial 25 cases of intravascular US-guided TIPS were retrospectively compared versus the last 75 conventional TIPS cases during the same time period at the same institution in terms of the number of needle passes required to establish portal vein (PV) access, fluoroscopy time, and needle pass-related complications. RESULTS Intravascular US-guided TIPS creation was successful in all cases, and there was no statistically significant difference in number of needle passes, fluoroscopy time, or needle pass-related complications between TIPS techniques. Intravascular US-guided TIPS creation was successful in cases in which conventional TIPS creation had failed as a result of PV thrombosis or distorted anatomy. Intravascular US guidance for TIPS creation was additionally useful in a patient with Budd-Chiari syndrome and in a patient with intrahepatic tumors. CONCLUSIONS Intravascular US is a safe and reproducible means of real-time image guidance for TIPS creation, equivalent in efficacy to conventional fluoroscopic guidance. Real-time sonographic guidance with intravascular US may prove advantageous for cases in which there is PV thrombus, distorted anatomy, Budd-Chiari syndrome, or hepatic tumors.
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Heinzow HS, Lenz P, Köhler M, Reinecke F, Ullerich H, Domschke W, Domagk D, Meister T. Clinical outcome and predictors of survival after TIPS insertion in patients with liver cirrhosis. World J Gastroenterol 2012; 18:5211-8. [PMID: 23066315 PMCID: PMC3468853 DOI: 10.3748/wjg.v18.i37.5211] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/31/2012] [Revised: 03/20/2012] [Accepted: 04/09/2012] [Indexed: 02/06/2023] Open
Abstract
AIM: To determine the clinical outcome and predictors of survival after transjugular intrahepatic portosystemic stent shunt (TIPS) implantation in cirrhotic patients.
METHODS: Eighty-one patients with liver cirrhosis and consequential portal hypertension had TIPS implantation (bare metal) for either refractory ascites (RA) (n = 27) or variceal bleeding (VB) (n = 54). Endpoints for the study were: technical success, stent occlusion and stent stenosis, rebleeding, RA and mortality. Clinical records of patients were collected and analysed. Baseline characteristics [e.g., age, sex, CHILD score and the model for end-stage liver disease score (MELD score), underlying disease] were retrieved. The Kaplan-Meier method was employed to calculate survival from the time of TIPS implantation and comparisons were made by log rank test. A multivariate analysis of factors influencing survival was carried out using the Cox proportional hazards regression model. Results were expressed as medians and ranges. Comparisons between groups were performed by using the Mann-Whitney U-test and the χ2 test as appropriate.
RESULTS: No difference could be seen in terms of age, sex, underlying disease or degree of portal pressure gradient (PPG) reduction between the ascites and the bleeding group. The PPG significantly decreased from 23.4 ± 5.3 mmHg (VB) vs 22.1 ± 5.5 mmHg (RA) before TIPS to 11.8 ± 4.0 vs 11.7 ± 4.2 after TIPS implantation (P = 0.001 within each group). There was a tendency towards more patients with stage CHILD A in the bleeding group compared to the ascites group (24 vs 6, P = 0.052). The median survival for the ascites group was 29 mo compared to > 60 mo for the bleeding group (P = 0.009). The number of radiological controls for stent patency was 6.3 for bleeders and 3.8 for ascites patients (P = 0.029). Kaplan-Meier calculation indicated that stent occlusion at first control (P = 0.027), ascites prior to TIPS implantation (P = 0.009), CHILD stage (P = 0.013), MELD score (P = 0.001) and those patients not having undergone liver transplantation (P = 0.024) were significant predictors of survival. In the Cox regression model, stent occlusion (P = 0.022), RA (P = 0.043), CHILD stage (P = 0.015) and MELD score (P = 0.004) turned out to be independent prognostic factors of survival. The anticoagulation management (P = 0.097), the porto-systemic pressure gradient (P = 0.460) and rebleeding episodes (P = 0.765) had no significant effect on the overall survival.
CONCLUSION: RA, stent occlusion, initial CHILD stage and MELD score are independent predictors of survival in patients with TIPS, speaking for a close follow-up in these circumstances.
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Saad WEA, Darcy MD. Transjugular Intrahepatic Portosystemic Shunt (TIPS) versus Balloon-occluded Retrograde Transvenous Obliteration (BRTO) for the Management of Gastric Varices. Semin Intervent Radiol 2012; 28:339-49. [PMID: 22942552 DOI: 10.1055/s-0031-1284461] [Citation(s) in RCA: 76] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Variceal bleeding is one of the major complications of portal hypertension. Gastric variceal bleeding is less common than esophageal variceal bleeding; however, it is associated with a high morbidity and mortality rate and its management is largely uncharted due to a relatively less-established literature. In the West (United States and Europe), the primary school of management is to decompress the portal circulation utilizing the transjugular intrahepatic portosystemic shunt (TIPS). In the East (Japan and South Korea), the primary school of management is to address the gastric varices (GVs) specifically by sclerosing them utilizing the balloon-occluded retrograde transvenous obliteration (BRTO) procedure. The concept (1970s), evolution, and development (1980s-1990s) of both procedures run parallel to one another; neither is newer than the other is. The difference is that one was adopted mostly by the East (BRTO), while the other has been adopted mostly by the West (TIPS). TIPS is effective in emergently controlling bleeding for GVs even though the commonly referenced studies about managing GVs with TIPS are studies with TIPS created by bare stents. However, the results have improved with the use of stent grafts for creating TIPS. Nevertheless, TIPS cannot be tolerated by patients with poor hepatic reserve. BRTO is equally effective in controlling bleeding GVs as well as significantly reducing the GV rebleed rate. But the resultant diversion of blood flow into the portal circulation, and in turn the liver, increases the risk of developing esophageal varices and ectopic varices with their potential to bleed. Unlike TIPS, the blood diversion that occurs after BRTO improves, if not preserves, hepatic function for 6-9 months post-BRTO. The authors discuss the detailed results and critique the literature, which has evaluated and remarked on both procedures. Future research prospects and speculation as to the ideal patients for each procedure are discussed.
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El Atrache M, Abouljoud M, Sharma S, Abbass AA, Yoshida A, Kim D, Kazimi M, Moonka D, Brown K. Transjugular intrahepatic portosystemic shunt following liver transplantation: can outcomes be predicted? Clin Transplant 2012; 26:657-61. [DOI: 10.1111/j.1399-0012.2011.01594.x] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Bhogal HK, Sanyal AJ. Using transjugular intrahepatic portosystemic shunts for complications of cirrhosis. Clin Gastroenterol Hepatol 2011; 9:936-46; quiz e123. [PMID: 21699820 PMCID: PMC3200495 DOI: 10.1016/j.cgh.2011.06.013] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/08/2011] [Revised: 06/01/2011] [Accepted: 06/05/2011] [Indexed: 02/07/2023]
Abstract
Transjugular intrahepatic portosystemic shunt (TIPS) decompresses the portal venous system. TIPS has been used to manage the complications of portal hypertension in cirrhosis, including variceal hemorrhage and refractory ascites. The uncoated TIPS stents are limited by stent stenosis; however, the introduction of coated stents has decreased this. With the introduction of coated stents, we must reevaluate the utility of TIPS in the management of complications of portal hypertension.
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Wallace MJ, Madoff DC. Transjugular intrahepatic portosystemic shunts in patients with hepatic malignancy. Semin Intervent Radiol 2011; 22:309-15. [PMID: 21326709 DOI: 10.1055/s-2005-925557] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Since its first clinical application in 1988, the transjugular intrahepatic portosystemic shunt (TIPS) has emerged as a safe and effective means of managing patients with morbid portal hypertension. Despite the considerable body of literature on TIPS, portal decompression in patients with malignancy has not been sufficiently examined. These patients typically experience sequelae of portal hypertension that requires palliation. The purpose of this article is to review the reported experience with TIPS in patients with malignancy.
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Affiliation(s)
- Michael J Wallace
- Department of Diagnostic Radiology, Section of Interventional Radiology, The University of Texas M.D. Anderson Cancer Center, Houston, Texas
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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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Comprehensive review of TIPS technical complications and how to avoid them. AJR Am J Roentgenol 2011; 196:675-85. [PMID: 21343513 DOI: 10.2214/ajr.10.4819] [Citation(s) in RCA: 80] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
OBJECTIVE The goal of this article is to describe potential technical complications related to transjugular intrahepatic portosystemic shunts (TIPS) placement and to discuss strategies to avoid and manage complications if they arise. CONCLUSION TIPS is an established interventional therapy for complications of portal hypertension. Although TIPS remains a relatively safe procedure, direct procedure-related morbidity rates are as high as 20%. The technical complexity of this intervention increases the risk for methodologic mishaps during all phases of TIPS placement, including venous access and imaging, transhepatic needle puncture, shunt insertion, and variceal embolization. Thus, interventional radiologists require a thorough stepwise understanding of TIPS insertion, possible adverse sequela, and technical tips and tricks to maximize the safety of this procedure.
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Schenker MP, Majdalany BS, Funaki BS, Yucel EK, Baum RA, Burke CT, Foley WD, Koss SA, Lorenz JM, Mansour MA, Millward SF, Nemcek AA, Ray CE. ACR Appropriateness Criteria® on Upper Gastrointestinal Bleeding. J Am Coll Radiol 2010; 7:845-53. [DOI: 10.1016/j.jacr.2010.05.029] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2010] [Accepted: 05/25/2010] [Indexed: 12/14/2022]
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Wu X, Han J, Cao J, Wu X, Li W, Sun J, Li J. Combined TIPS with portal-azygous disconnection improved the long term clinical outcome in portal hypertension patients. ACTA ACUST UNITED AC 2010; 16:858-64. [PMID: 19789834 DOI: 10.1007/s00534-009-0189-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2009] [Accepted: 09/10/2009] [Indexed: 01/15/2023]
Abstract
OBJECTIVE The results of TIPS and the combined TIPS and portal-azygous disconnection for portal hypertension and variceal bleeding were evaluated. METHODS 358 patients with portal hypertension were admitted to our clinical ward because of variceal bleeding. 263 patients underwent TIPS and 95 patients with combined TIPS and portal-azygous disconnection. Portal hemodynamics was evaluated by pressure measurements, venography and Doppler ultrasound before and 2 weeks after the procedure. The rates of shunt patency, rebleeding, encephalopathy and survival were observed during the follow-up period from 1 to 10 years. RESULTS The portal pressure and HVPG were decreased significantly after TIPS. TIPS procedure was successfully performed in 97.50% patients. During 1 month after treatment, acute shunt occlusion occurred in 3.42% patients with TIPS and there were no occluded shunts in patients with combined TIPS and portal-azygous disconnection. Encephalopathy was observed in 36.50% patients with TIPS and 18.95% with combined TIPS and portal-azygous disconnection. Recurrent variceal bleeding was documented in 6.46% patients with TIPS and none of patients with combined TIPS and azygous portal disconnection. Thirty-three patients with TIPS and two patients with combined TIPS and portal-azygous disconnection died. During follow-up periods, the patency of shunts in patients with TIPS and patients combined TIPS and azygous portal disconnection was 68.47, 43.84 and 87.06, 57.65% in 12 and 24 months after operation, respectively. The rates of rebleeding, and encephalopathy in patients with TIPS and patients with combined TIPS and azygous portal disconnection were 17.95, 31.79 and 7.04, 16.47%, respectively. The survival rate in 1, 5, 10 years in patients with TIPS and patients combined TIPS and azygous portal disconnection was 87.68, 51.23, 39.90 and 94.12, 81.18, 76.47%. CONCLUSION Combined TIPS and portal-azygous disconnection can improve the effect of TIPS for portal hypertension.
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Affiliation(s)
- Xingjiang Wu
- Research Institute of General Surgery, Jinling Hospital, Nanjing University School of Medicine, 305 East Zhongshan Road, 210002 Nanjing, Jiangsu, China.
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Björnsson E, Aabakken L, Olafsson S, Bendtsen F, Bendtsen F. Are specific guidelines necessary for treatment of esophageal varices in the Nordic countries? Scand J Gastroenterol 2010; 44:1037-47. [PMID: 19565407 DOI: 10.1080/00365520903075170] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Affiliation(s)
- Einar Björnsson
- Department of Internal Medicine, Sahlgrenska University Hospital, Gothenburg, Sweden.
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Mizrahi M, Adar T, Shouval D, Bloom AI, Shibolet O. Endotipsitis-persistent infection of transjugular intrahepatic portosystemic shunt: pathogenesis, clinical features and management. Liver Int 2010; 30:175-83. [PMID: 19929905 DOI: 10.1111/j.1478-3231.2009.02158.x] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/13/2023]
Abstract
Transjugular intrahepatic portosystemic shunt (TIPS) is in widespread use for the decompression of portal pressure. The entity of persistent TIPS infection, also known as 'endotipsitis' is a rare but serious complication of TIPS insertion. The exact definition of 'endotipsitis' is still debated, but involves persistent bacteremia and fever together with either shunt occlusion, or vegetation, or bacteremia in the presence of a patent shunt, when other sources of bacteremia have been ruled out. To date, approximately 40 cases of 'endotipsitis' have been described, with predominance for male and alcoholic hepatitis patients. The clinical course is variable, but fever and chills are a constant feature. Bacteremia, can either occur early (<120 days) or late (>120 days) after stent insertion, with some cases occurring many years after the procedure. Although no predominant bacterial species have been described in 'endotipsitis', staphylococci and other Gram-positive bacteria are more commonly seen in early infection. The diagnosis of 'endotipsitis' is difficult and requires a high index of suspicion. A rigorous imaging work-up to rule out other sources of endovascular infection is usually required including ultrasonography, computed tomography and echocardiography. Because removal of the infected stent is impractical, treatment is empirical and based on a prolonged course of antibiotics. If eligible, some patients may be referred for liver transplantation. The use of prophylactic antibiotics during the initial TIPS procedure is controversial, and despite the lack of evidence, prophylaxis is the common practice. The aim of this review was to describe the definition, clinical course, diagnosis, pathogenesis, microbiology, treatment and outcome of endotipsitis.
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Affiliation(s)
- Meir Mizrahi
- Liver Unit, Division of Medicine, Jerusalem, Israel
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Laparoscopic versus open splenectomy for hypersplenism secondary to liver cirrhosis. Surg Laparosc Endosc Percutan Tech 2009; 19:258-62. [PMID: 19542858 DOI: 10.1097/sle.0b013e3181a6ec7c] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
BACKGROUND Since the first laparoscopic splenectomy (LS) in 1991, LS has become the gold standard for the removal of normal-to-moderately enlarged spleens in benign conditions. Compared with open splenectomy (OS), fewer postsurgical complications and better postoperative recovery were observed, but it is contraindicated for hypersplenism secondary to liver cirrhosis owing to technical difficulties associated with splenomegaly, well-developed collateral circulation, and increased risk of bleeding. With the improvements of laparoscopic technique, the concept is changing. METHODS OS and LS performed for hypersplenism secondary to liver cirrhosis at our institution were analyzed. Relationships between postoperative increases in platelet counts, white blood cell counts, hemoglobin, and liver function were examined. Perioperative data of LSs were compared with those of OSs, including operative time, blood loss, excised spleen weight, complications, and hospital stays. RESULTS A total of 216 splenectomies (135 OS and 81 LS) were performed from April 1999 to March 2007. Five laparoscopic cases were converted to open surgery owing to operative bleeding or bleeding of splenic fossa. The other 76 patients were performed LSs successfully. No major operative complications occurred. There was no operative death. Excised spleen weight >400 g was present in 56% of cases in this series. At 7 days postoperatively, the platelet counts, white blood cell counts, and hemoglobin significantly increased after open and laparoscopic surgeries, and increase of alanine aminotransferase, aspartate aminotransferase, total bilirubin, and directed bilirubin of LS were significantly different with open cases. Operation times of LS and OS were 2.9+/-0.7 hours and 2.6+/-0.6 hours, respectively. Blood losses were 150.6+/-135.4 mL and 633.8+/-340.3 mL (P<0.01), excised spleen weights were 585.7+/-184.6 g and 591.1+/-153.4 g (P>0.05), and hospital stay were 8.2+/-2.0 days and 11.9+/-3.8 days (P<0.01). Operative associated complications were noted in both LS and OS. Less blood loss, shorter hospital stay, and less impairment of liver function were observed in LS than OS. CONCLUSIONS LS is feasible, effective, and safe procedures for hypersplenism secondary to liver cirrhosis and contributes to less impairment of liver function, less blood loss, and shorter hospital stay.
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Wong F. The 'Gerstmann's Syndrome' of transjugular intrahepatic portosystemic shunt: should it be the left or should it be the right. Liver Int 2009; 29:1129-31. [PMID: 19689612 DOI: 10.1111/j.1478-3231.2009.02094.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/13/2023]
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