Transjugular intrahepatic portocaval shunt placed through the strut of an inferior vena cava stent in a patient with Budd-Chiari syndrome: a technical modification

Technical and Medium-Term Clinical Outcomes of Transjugular Intrahepatic Portosystemic Shunt with Fluoroscopy and Additional Trans-abdominal Ultrasound Guidance

Background and Objective The aim of the study is to evaluate the technical and clinical outcomes of transjugular intrahepatic portosystemic shunt (TIPS) performed with additional transabdominal ultrasound guidance.

Material and Methods Patients who underwent TIPS between January 2004 to January 2020 in our center were studied. Technical, hemodynamic, angiographic, and clinical outcome were recorded up to 1 year of follow-up.

Results TIPS was attempted in 162 patients (median [range] age 37[3–69] years; 105 were males and 57 were females; Etiology: Budd-Chiari syndrome [BCS] 91, cirrhosis 65, symptomatic acute portal venous thrombosis [PVT] 3, veno-occlusive disease [VOD] 2, congenital portosystemic shunt [CPSS] 1) during the study period. Indication for TIPS was refractory ascites in 135 patients (BCS 86, cirrhosis 49) and variceal bleed in 21 patients (BCS 5, cirrhosis 16). Technical success was seen in 161 of the 162 (99.4%) patients. The tract was created from hepatic vein in 55 patients and inferior vena cava (IVC) in 106 patients. Complications within 1 week post TIPS were seen in 29 of the 162 (18%) patients, of whom one developed unexplained arrhythmia and hypotension and died. Of the patients with available follow-up, clinical success was noted in 120 (81%), while 14 (9%) patients had partial nonresponse and six (4%) had complete nonresponse. Eight (5%) patients died during the follow-up period.

Conclusion The technical success of TIPS creation with additional transabdominal ultrasound guidance is very high with low peri-procedural complication rate. It has enabled the inclusion of a wider spectrum of cases like acute PVT and obliterated hepatic veins which were otherwise considered contraindications.

Transjugular Intrahepatic Portosystemic Shunt Through the Strut of a Previously Placed Stent: Technical Feasibility and Long-Term Follow-Up Results

AIMS AND OBJECTIVES

To evaluate technical feasibility, long-term primary patency and clinical outcome of the transjugular intrahepatic portosystemic shunt (TIPS) through the struts of the previously placed stents.

MATERIALS AND METHODS

Retrospective evaluation of seven consecutive patients (three male and four female, age range 13-65 years, median 28) out of a total 95 patients, who underwent TIPS through the strut of the previously placed stents of hepatic vein (HV), inferior vena cava (IVC) or TIPS in a single tertiary care hospital. Six of the patients were diagnosed with Budd-Chiari syndrome (BCS) and one with alcohol-induced chronic liver disease (CLD). Kaplan-Meier test was used to calculate 18- and 60-month primary patency rate of TIPS stent.

RESULTS

TIPS through the strut of a previously placed stent was technically successful in all the patients (100%). The TIPS was direct intrahepatic portosystemic shunt (DIPS) in 5/7 cases, due to occluded HV. Mean portosystemic pressure gradient (PPG) reduced from 24 mmHg ± 5.9 (range, pre-TIPS 15-31 mmHg) to 8.57 mmHg ± 4.4 (range, post-TIPS, 3-14 mmHg). One patient required three sessions of TIPS revisions. Another patient needed TIPS revision after 5 years of TIPS creation. All the patients showed improvement in clinical symptoms and in mean Child-Turcotte-Pugh (CTP) score and modified end-stage liver disease (MELD) score during mean follow-up period 40.57 month ± 34.9 (range 3-100 month). Primary patency rates of TIPS stent measured with Kaplan-Meier estimate at 18- and 60-month follow-up were 80% (95% CI, 37-97%) and 40% (95% CI, 10-97%), respectively.

CONCLUSION

TIPS through the strut of a previously placed stent is technically feasible with good long-term primary patency and clinical outcome.

Mesoatrial Shunt for Budd-Chiari Syndrome

BACKGROUND

The long-term efficacy of mesoatrial shunt (MAS) for Budd-Chiari syndrome (BCS) is not well studied. The purpose of our study was to investigate the long-term outcome and efficacy of MAS for BCS.

METHODS

We retrospectively evaluated 11 patients who underwent MAS for BCS from April 1986 to November 1995. Records of patients' clinical presentations, laboratorial investigation, Doppler duplex ultrasonography, radiologic image, and treatment outcomes were all retrieved and analyzed.

RESULTS

Follow-up intervals ranged from 1 year and 2 months to 30 years and 2 months (mean, 17 years and 8 months). Portal pressure decreased significantly from 35.72 ± 3.52 cm H₂O to 27.86 ± 5.83 cm H₂O post-MAS (P = 0.001). The 5-year, 10-year, and 20-year patency were 72.7%, 54.5%, 36.4%, respectively; 63.3% of patients had survived for more than 10 years and 45.5% for more than 20 years. A male has been alive with patent shunt for 28 years and 1 month.

CONCLUSIONS

The MAS with enforced rings is an effective therapeutic modality for BCS with cautious perioperative management.

Transjugular intrahepatic portosystemic shunt for Budd-Chiari syndrome: techniques, indications and results on 51 Chinese patients from a single centre

BACKGROUND & AIMS

In Western countries, transjugular intrahepatic portosytemic shunt (TIPS) is widely applied for the treatment of Budd-Chiari syndrome (BCS). However, the outcome of Chinese BCS patients treated with TIPS is extremely limited. Furthermore, the timing of conversion from percutaneous recanalization to TIPS remains uncertain.

METHODS

All consecutive BCS patients treated with TIPS between December 2004 and June 2012 were included. Patients were classified as the early and converted TIPS groups. Indications, TIPS-related complications, post-TIPS hepatic encephalopathy, shunt dysfunction and death were reported.

RESULTS

Of 51 patients included, 39 underwent percutaneous recanalization for 1024 days (0-4574) before TIPS. Early TIPS group (n = 19) has a shorter history of BCS and a lower proportion of prior percutaneous recanalization than converted TIPS group (n = 32). Main indications were diffuse obstruction of three HVs (n = 12), liver failure (n = 2), liver function deterioration (n = 8), refractory ascites (n = 10) and variceal bleeding (n = 19). Procedure-related intraperitoneal bleeding was reversible in three patients. The cumulative 1-year rate of being free of first episode of post-TIPS hepatic encephalopathy and shunt dysfunction was 78.38 and 61.69% respectively. The cumulative 1-, 2-, and 3-year survival rates were 83.82, 81.20 and 76.93% respectively. BCS-TIPS score, but not Child-Pugh, MELD, Clichy or Rotterdam score, could predict the survival. Age, total bilirubin and inferior vena cava thrombosis were also significantly associated with overall survival. Survival was similar between early and converted TIPS groups.

CONCLUSIONS

TIPS can achieve an excellent survival in Chinese patients in whom percutaneous recanalization is ineffective or inappropriate. BCS-TIPS score could effectively predict these patients' survival.

Efficacy of transjugular intrahepatic portosystemic shunt with adjunctive embolotherapy with cyanoacrylate for esophageal variceal bleeding

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.

Transjugular intrahepatic portosystemic shunt in the treatment of Budd-Chiari syndrome: a critical review of literatures

An increasing number of patients with Budd-Chiari syndrome (BCS) have undergone transjugular intrahepatic portosystemic shunt (TIPS). However, the critical role of TIPS in the treatment of BCS has not been systematically reviewed. The authors identified all relevant literatures via the PubMed, EMBASE and Cochrane library databases. Overall, 160 papers from 29 countries reported the application of TIPS for BCS. The number of publications was increased over time, but the level of evidence in this field was low. Common indications for TIPS in BCS patients included refractory ascites, recurrent variceal bleeding, diffuse hepatic vein thrombosis and progressive liver failure. Successful TIPS insertion could improve the hemodynamic and clinical parameters. TIPS procedure-related complications were not infrequent (range: 0-56%), but procedure-related death was rare. Shunt dysfunction rate appeared to be higher (range: 18-100%). Compared with bare stents, covered stents could significantly decrease the rate of shunt dysfunction. Hepatic encephalopathy rate after TIPS was relatively low (range: 0-25%). Short- and long-term prognosis of BCS-TIPS patients was excellent with 1-year cumulative survival rate of 80-100% and 5-year cumulative survival rate of 74-78%. In conclusions, existing literatures supported the feasibility, safety and efficacy of TIPS in the treatment of BCS. Prospective cohort studies or randomized controlled trials were difficult due to the rarity of BCS, but might be very necessary to precisely identify the timing of transition from medical therapy and/or percutaneous recanalization to TIPS insertion and the real candidates in whom early TIPS should be promptly employed with no need of any prior therapy.