Long-term patency and clinical outcome of the transjugular intrahepatic portosystemic shunt using the expanded polytetrafluoroethylene stent-graft

Which patients benefit the most? An update on transjugular intrahepatic portosystemic shunt

This is a narrative review in which the advances in technical aspects, the main indications, limitations and clinical results of the transjugular intrahepatic portosystemic shunt (TIPS) in portal hypertension (PH) are addressed. With the emergence of the coated prosthesis, a better shunt patency, a lower incidence of hepatic encephalopathy (HE) and better survival when compared to TIPS with the conventional prosthesis are demonstrated. The main indications for TIPS are refractory ascites, acute variceal bleeding unresponsive to pharmacological/endoscopic therapy and, lastly, patients considered at high risk for rebleeding preemptive TIPS (pTIPS). Absolute contraindications to the use of TIPS are severe uncontrolled HE, systemic infection or sepsis, congestive heart failure, severe pulmonary arterial hypertension, and biliary obstruction. The control of hemorrhage due to variceal rupture can reach up to 90%-100% of cases, and 55% in refractory ascites. Despite evidences regarding pTIPS in patients at high risk for rebleeding, less than 20% of eligible patients are treated. TIPS may also decrease the incidence of future decompensation in cirrhosis and increase survival in selected patients. In conclusion, TIPS is an essential treatment for patients with PH, but is often neglected. It is important for the hepatologist to form a multidisciplinary team, in which the role of the radiologist with experience in interventional procedures is prominent.

Portal vein velocity and its dynamics: a potentially useful tool for detecting clinically silent transjugular intrahepatic porto-systemic shunt dysfunction using Doppler ultrasonography

Background   Ultrasound (US) surveillance for transjugular intrahepatic portosystemic shunt (TIPS) dysfunction has yet to be standardized, as clear-cut criteria have not been conventionally defined. This study evaluated the role of US-based parameters in detecting hemodynamic TIPS dysfunction (HD). Methods   We included consecutive patients treated with TIPS. All patients were scheduled within the first six weeks after the procedure for TIPS revision, comprised of a Doppler US exam and invasive hemodynamic reassessment. Clinical TIPS dysfunction (CD) was defined as symptom recurrence, while HD was defined by a portal pressure gradient (PPG)≥12 mmHg. The predictive capabilities of Doppler US for predicting TIPS dysfunction were tested against the hemodynamic gold standard. Results   86 patients were included. Secondary prophylaxis of variceal bleeding was the main indication for TIPS in 72 patients (83.7%), while 27 (31.4%) had refractory ascites. HD occurred in 37 cases (43%), of which 25 patients (67.5%) had no CD. Patients with HD had a significantly lower portal vein velocity (PVV): 35 (20-45) cm/s vs. 40.5 (35-50) cm/s, p=0.02. Compared to the immediate post-TIPS assessment, the patients without HD had a ΔPVV of 6.08±19.8 cm/s vs. a decrease of - 8.2±20.2 cm/s in HD (p=0.04). Using a cut-off value of 40.5 cm/s, PVV had an AUROC of 0.705 for predicting HD, while the addition of ΔPVV (cut-off 9.5 cm/s) improved the AUROC to 0.78. Conclusion   Despite adequate symptom control, a considerable percentage of patients have a post-TIPS PPG≥12 mmHg. The dynamic assessment of PVV and its temporal dynamics can reliably predict TIPS dysfunction.

Optimization stages of transjugular intrahepatic portosystemic shunt technique as a treatment method for portal hypertension complications

Aim. To describe the milestones to optimize of the technique of transjugular intrahepatic portosystemic shunt.

Materials and methods. The PubMed and Embase databases, the Web of Science platform, the Google Scholar retrieval system, the Cochrane Database of Systematic Reviews, the eLIBRARY.RU scientific electronic library, and the reference lists were used to search for articles. Articles corresponding to the aim of the review were selected for 1969-2023. The inclusion criteria were limited to technical solutions related to optimize of the technique of transjugular intrahepatic portosystemic shunt.

Results. Innovative ideas, subsequent experimental studies and preliminary experience in liver cirrhosis patients contributed to the introduction of transjugular intrahepatic portosystemic shunt into clinical practice. At the moment, the main achievement to optimize of the technique of transjugular intrahepatic portosystemic shunt is progress in the qualitative characteristics of stents. The transition from bare metal stents to expandable polytetrafluoroethylene-covered stent graft made it possible to largely prevent shunt dysfunction. However, the issue of its optimal diameter, contributing to an effective reduction of portal pressure without the risk of developing hepatic encephalopathy, which is one of the most common complications of transjugular intrahepatic portosystemic shunt, remains relevant.

Conclusion. Further to optimize of the technique of transjugular intrahepatic portosystemic shunt, as well as careful selection of patients based on cognitive indicators, nutritional status and assessment of liver function will reduce the incidence of hepatic encephalopathy and improve treatment results.

Milestones to optimize of transjugular intrahepatic portosystemic shunt technique as a method for the treatment of portal hypertension complications

This editorial describes the milestones to optimize of transjugular intrahepatic portosystemic shunt (TIPS) technique, which have made it one of the main methods for the treatment of portal hypertension complications worldwide. Innovative ideas, subsequent experimental studies and preliminary experience of use in cirrhotic patients contributed to the introduction of TIPS into clinical practice. At the moment, the main achievement in optimize of TIPS technique is progress in the qualitative characteristics of stents. The transition from bare metal stents to extended polytetrafluoroethylene-covered stent grafts made it possible to significantly prevent shunt dysfunction. However, the question of its preferred diameter, which contributes to an optimal reduction of portal pressure without the risk of developing post-TIPS hepatic encephalopathy, remains relevant. Currently, hepatic encephalopathy is one of the most common complications of TIPS, significantly affecting its effectiveness and prognosis. Careful selection of patients based on cognitive indicators, nutritional status, assessment of liver function, etc., will reduce the incidence of post-TIPS hepatic encephalopathy and improve treatment results. Optimize of TIPS technique has significantly expanded the indications for its use and made it one of the main methods for the treatment of portal hypertension complications. At the same time, there are a number of limitations and unresolved issues that require further randomized controlled trials involving a large cohort of patients.

Prediction of mortality and overt hepatic encephalopathy undergoing transjugular intrahepatic portosystemic shunt: a retrospective cohort study

PURPOSE

Data on medium- and long-term efficacy and safety of Transjugular intrahepatic portosystemic shunt (TIPS) using Viatorr stents in Chinese patients are limited. This study aimed to evaluate the 5-year mortality and the incidence of overt hepatic encephalopathy (OHE) after Viatorr stent insertion, and construct a model to predict post-TIPS OHE preoperatively.

METHODS

One hundred thirty-two patients undergoing Viatorr stent insertion in our institution between August 2016 and December 2019 were included, and randomly divided into training and validation cohort at a 70/30 ratio. Patients were followed up until death or the end date of follow-up (December 31st, 2021). The primary end point was all-cause mortality, and the secondary end points were OHE, variceal rebleeding, recurrent ascites and shunt dysfunction.

RESULTS

The 1-, 2-, 3-, 4- and 5-year cumulative survival rates were 92.4%, 87.9%, 85.3%, 80.2% and 80.2%, respectively. Post-TIPS OHE and Child-Pugh grade were independent prognostic factors. The rates of variceal rebleeding, recurrent ascites, shunt dysfunction and post-TIPS OHE were 9.1%, 14.3%, 5.3% and 28.0%, respectively. The variables of nomogram predicting post-TIPS OHE included age, diabetes and ascites grade. The area under time-dependent receiver operation characteristic (ROC) curve (AUC) in training and validation cohort were 0.806 and 0.751, respectively. The decision curve analysis (DCA) showed good net benefit both in training and validation cohort.

CONCLUSION

Post-TIPS OHE and Child-Pugh grade are independent prognostic factors for early mortality in cirrhosis patients, thus we construct a simple and convenient prediction model for post-TIPS OHE to identify high-risk patients preoperatively.

Shunt dysfunction patterns after transjugular intrahepatic portosystemic shunt creation using a combination of a generic stent-graft and bare-stents

PURPOSE

Even though transjugular intrahepatic portosystemic shunt (TIPS) using Fluency Stent-grafts provides good shunt patency rates, shunt dysfunction is a great concern after TIPS creation, occurring in up to 20% of cases within one year. The objective of this study was to describe shunt dysfunction patterns after TIPS creation using a combination of generic stent-grafts/bare-stents.

MATERIALS AND METHODS

Single-center retrospective study of all TIPS revisions between January 2005 and December 2020. TIPS revision angiograms were analyzed for stents' positions, stenoses' diameters, and stenoses' locations.

RESULTS

Out of 99 TIPS, a total of 33 TIPS revisions were included. The median time to TIPS revision was 10.4 months. Angiograms showed four patterns of TIPS dysfunction-associated features (DAF), defined as follows: Type 1 was defined as stenosis located after the stent end in the hepatic vein (HV), type 2 as intra-stent stenosis located in the hepatic vein, type 3 as intra-stent stenosis or a kink in the parenchymal tract or the portal vein end of the TIPS, and type 4 as a complete TIPS occlusion. Types 1, 2, 3, and 4 were seen in 23 (69.7%), 5 (15.2%), 2 (6.1%), and 3 (9.1%) TIPS respectively. TIPS revision was successful in 30 (90.1%) patients with median pre- and post-TIPS revision PSG of 18.5 mmHg and 8 mmHg respectively (p < .001).

CONCLUSION

Our results illustrate the four angiographic patterns of TIPS DAF after TIPS creation using a combination of generic stent-grafts/bare-stents and emphasize the need for appropriate stent length extending to the HV/inferior vena cava junction.

Small-Diameter Transjugular Intrahepatic Portosystemic Shunt versus Endoscopic Variceal Ligation Plus Propranolol for Variceal Rebleeding in Advanced Cirrhosis

Background Some studies have shown that transjugular intrahepatic portosystemic shunt (TIPS) placement within 72 hours of admission improves survival in patients at high risk who present with acute variceal bleeding. However, the role of small-diameter covered TIPS in the secondary prophylaxis of variceal bleeding is still debatable. Purpose To compare the efficacy of 8-mm TIPS and endoscopic variceal ligation (EVL) plus propranolol in the prevention of variceal rebleeding among participants with advanced cirrhosis. Materials and Methods Between June 2015 and December 2018, participants admitted to the hospital for variceal bleeding were considered for enrollment in this randomized controlled trial (ClinicalTrials.gov). Participants with Child-Pugh class B or C cirrhosis were randomly assigned to receive an 8-mm covered TIPS or EVL and propranolol. The primary end point was recurrent variceal bleeding assessed using Kaplan-Meier curve analysis. Secondary end points included survival and overt hepatic encephalopathy (HE) assessed using Kaplan-Meier curve analysis. Results A total of 100 participants were enrolled, with 50 randomly assigned to the EVL plus propranolol group (median age, 54 years; IQR, 45-60 years; 29 male, 21 female) and 50 randomly assigned to the TIPS group (median age, 49 years; IQR, 43-56 years; 32 male, 18 female). The median follow-up period was 43.4 months. In the TIPS group, variceal rebleeding risk was reduced compared with variceal rebleeding risk in the EVL plus propranolol group (hazard ratio [HR], 0.31; 95% CI: 0.14, 0.69; P = .008), but the incidence of overt HE was higher in the TIPS group (30.0% vs 16.0%, P = .03). No differences in survival were observed between the two groups (1-year survival: TIPS, 98.0%; EVL plus propranolol, 92.0%; 3-year survival: TIPS, 94.0%; EVL plus propranolol, 85.7%; HR, 0.52; 95% CI: 0.19, 1.42; P = .22). Conclusion When compared with EVL plus propranolol, 8-mm TIPS led to reduced variceal rebleeding but did not impact overall survival in participants with Child-Pugh class B or C cirrhosis. Clinical trial registration no. NCT02477384 © RSNA, 2023 Supplemental material is available for this article. See also the editorial by Barth in this issue.

Computational hemodynamic analysis for optimal stent position in the transjugular intrahepatic portosystemic shunt procedure

Transjugular intrahepatic portosystemic shunt (TIPS) is an effective treatment for portal hypertension (PH). The current study aimed to investigate the effect of stent position on post-TIPS hemodynamic performance using computational fluid dynamics. Patient-specific pre- and post-TIPS models were reconstructed from CT images of two patients, then virtual TIPS models were created by shifting the portal vein (PV) entry site of the stent. Although there were marginal differences the effects of left-sided and right-sided TIPS on post-TIPS portal pressure and shunting flow, right-sided TIPS resulted in a greater proportion of superior mesenteric vein (SMV) flow diverting to stents compared to that for left-sided TIPS. The results also demonstrated that the nearer the entry site of stent to the portal venous bifurcation, the greater and more stable the shunting blood flow. These results suggest that the entry site of the stent should be as close to the portal vein bifurcation as possible during TIPS. TIPS on the right branch of the portal vein may be more likely to result in post-TIPS hepatic encephalopathy than that on the left branch.

Use of doppler ultrasound to predict need for transjugular intrahepatic portosystemic shunt revision

BACKGROUND

Transjugular intrahepatic portosystemic shunt (TIPS) is used to treat complications of portal hypertension, such as ascites and variceal bleeding (VB). While liver doppler ultrasound (DUS) is used to assess TIPS patency, trans-shunt venography (TSV) is the gold standard.

AIM

To determine the accuracy of DUS to assess TIPS dysfunction and for need for revision.

METHODS

Retrospective review of patients referred for TIPS revision from 2008-2021. Demographics, DUS parameters at baseline and at the DUS preceding TIPS revision, TSV data were collected. Receiver operating characteristics curves, sensitivity, specificity, performance for doppler to predict need for revision were performed. Univariate and multivariate analyses were used to predict clinical factors associated with need for TIPS revision.

RESULTS

The cohort consisted of 89 patients with cirrhosis (64% men, 76% white, 31% alcohol as etiology); median age 59 years. Indication for initial TIPS were VB (41%), refractory ascites (51%), and other (8%). TIPS was revised in 44%. On univariate analysis, factors associated with need for TIPS revision were male (P = 0.03), initial indication for TIPS (P = 0.05) and indication for revision (P = 0.01). Revision of TIPS was associated with lower mortality (26% vs 46%) and significantly lower rates of transplant (13% vs 24%; P = 0.1). In predicting need for TIPS revision, DUS has a 40% sensitivity, 45% specificity, PPV 78%, and NPV 14%. The most accurate location for shunt velocity measure was distal velocity (Area under the curve: 0.79; P = 0.0007).

CONCLUSION

DUS has poor overall sensitivity and specificity in predicting need for TIPS revision. Non-invasive methods of predicting TIPS dysfunction are needed since those needing TIPS revision had better survival.

Prediction of Patient Hepatic Encephalopathy Risk with Freiburg Index of Post-TIPS Survival Score Following Transjugular Intrahepatic Portosystemic Shunts: A Retrospective Study

Background

Hepatic encephalopathy is a complication of portal hypertension. The Freiburg index of transjugular portosystemic shunt (TIPS) and patient outcomes have recently been described. This retrospective study was conducted at a single center in China and included 241 patients with portal hypertension who underwent TIPS implantation to evaluate the Freiburg index of post-TIPS survival score (FIPS) to predict hepatic encephalopathy.

Methods

A single-center retrospective study including 241 patients who underwent TIPS operation between April 2015 and July 2019 was conducted. Clinical demographics and relevant clinical parameters within 24h after admission were collected. The prediction performances of FIPS, Child–Pugh and the model for end-stage liver disease (MELD) scores were compared by decision curve analysis and receiver operating characteristic (ROC) curve analysis. In addition, multivariate analyses were performed to identify independent predictors.

Results

Eighty-three out of 241 patients (34.4%) finally developed post-TIPS hepatic encephalopathy. The area under the ROC curve of FIPS was 0.744 (95% confidence interval: 0.684–0.798). FIPS was identified as an independent risk factor for post-TIPS hepatic encephalopathy (hazard ratio: 2.23, 95% confidence interval: 1.71–2.90, p<0.001). Moreover, we further grouped the FIPS scores into two categories (FIPS ≤-0.97, low-risk; FIPS >-0.97, high risk) to improve its applicability. Patients with high FIPS scores had a significantly higher incidence of hepatic encephalopathy than patients with low FIPS scores (P<0.05).

Conclusion

This study showed that FIPS could be used to evaluate the risk of hepatic encephalopathy in this patient group with improved predictive performance when compared with the Child–Pugh and MELD scores.

A meta-analysis of combined generic-covered stent-graft with or without bare-metal stent for refractory variceal bleeding

Objectives:

The meta-analysis was conducted to systematically assess the efficacy and safety of generic stent-graft/bare-stent combination compared with Fluency stent alone in transjugular intrahepatic portosystemic shunt procedure for refractory variceal bleeding.

Methods:

PubMed, EMBASE, Scopus, Web of Science and the Cochrane Database were searched for relevant studies from January 1990 to September 2020; outcome measures studied were primary patency, hepatic encephalopathy, survival, re-bleeding and portal venous pressure.

Results:

Four studies (1 randomised controlled trial and 3 retrospective studies) with 449 subjects (157 patients in the combined stent group and 292 patients in the covered stent group) were included. No significant difference was observed in the incidence of mortality (hazard ratio [HR] = 1.069, 95% confidence interval [CI] [0.524, 2.178]), hepatic encephalopathy (odds ratio [OR] = 0.860, 95% CI [0.341, 2.169], P = 0.750) and re-bleeding (OR = 1.049, 95% CI [0.226, 4.881], P = 0.951). Compared with Fluency stent alone, combination therapy was associated with moderate decrease in outcomes on the post-operative portal venous pressure (standard mean difference [SMD] −0.210, 95% CI [−0.418, −0.001], P = 0.049) and was not associated with significant decrease in outcomes on the pre-operative portal venous pressure (SMD − 0.129, 95% CI [−0.336, 0.078], P = 0.223). The primary patency was significantly lower in the Fluency/bare-stent combination group (HR = 0.473, 95% CI [0.288, 0.776]).

Conclusions:

Generic stent-graft/bare-stent combination therapy was associated with significantly lower primary patency compared to Fluency stent alone.

A new choice of stent for transjugular intrahepatic portosystemic shunt creation: Viabahn ePTFE covered stent/bare metal stent combination

Objectives

To compare the clinical outcomes in terms of structure and function between the insertion of a transjugular intrahepatic portosystemic shunt (TIPS) created with the Viabahn ePTFE covered stent/bare metal stent (BMS) combination and the Fluency ePTFE covered stent/BMS combination.

Methods

A total of 101 consecutive patients who received a TIPS from February 2016 to August 2018 in our center were retrospectively analyzed. Sixty-four subjects were enrolled in the Viabahn group and 37 were enrolled in the Fluency group. The geometry characteristics of the TIPS were calculated, and the associated occurrence of shunt dysfunction, survival, overt hepatic encephalopathy, and variceal rebleeding were evaluated.

Results

The technical success rate was 100%. After the insertion of the TIPS, the rate of shunt dysfunction during the first 3 months was significantly different between the Viabahn and Fluency groups (1.6% and 13.5%, respectively; p ​= ​0.024). Multivariate analysis indicated that the angle of portal venous inflow (α) was the only independent risk factor for shunt dysfunction (hazard ratio ​= ​1.060, 95% confidence interval ​= ​1.009–1.112, p ​= ​0.020). In addition, 3 months after the TIPS insertion, the α angle distinctly increased from 20.9° ​± ​14.3°–26.9° ​± ​20.1° (p ​= ​0.005) in the Fluency group but did not change significantly in the Viabahn group (from 21.9° ​± ​15.1°–22.9° ​± ​17.6°, p ​= ​0.798).

Conclusions

Shunt dysfunction was related to the α angle owing to the slight effect on the α angle after the implantation of the TIPS. The Viabahn ePTFE covered stent/BMS combination was more stable in structure and promised higher short-term stent patency compared with the Fluency ePTFE covered stent/BMS combination.

Comparison of Transjugular Intrahepatic Portosystemic Shunt in the Treatment of Cirrhosis With or Without Portal Vein Thrombosis: A Retrospective Study

Aim: The purpose of our study was to conduct a retrospective analysis to compare the effectiveness of transjugular intrahepatic portosystemic shunts (TIPS) in the treatment of patients with cirrhosis with or without portal vein thrombosis (PVT).

Methods: We included a total of 203 cirrhosis patients successfully treated with TIPS between January 2015 and January 2018, including 72 cirrhosis patients with PVT (35.5%) and 131 without PVT (64.5%). Our subjects were followed for at least 1 year after treatment with TIPS. Data were collected to estimate the mortality, shunt dysfunction, and complication rates after TIPS creation.

Results: During the mean follow-up time of 19.5 ± 12.8 months, 21 (10.3%) patients died, 15 (7.4%) developed shunt dysfunction, and 44 (21.6%) experienced overt hepatic encephalopathy (OHE). No significant differences in mortality (P = 0.134), shunt dysfunction (P = 0.214), or OHE (P = 0.632) were noted between the groups. Age, model for end-stage liver disease (MELD) score, and refractory ascites requiring TIPS were risk factors for mortality. A history of diabetes, percutaneous transhepatic variceal embolization (PTVE), 8-mm diameter stent, and platelet (PLT) increased the risk of shunt dysfunction. The prevalence of variceal bleeding and recurrent ascites was comparable between the two groups (16.7 vs. 16.7% P = 0.998 and 2.7 vs. 3.8% P = 0.678, respectively).

Conclusions: Transjugular intrahepatic portosystemic shunts are feasible in the management of cirrhosis with PVT. No significant differences in survival or shunt dysfunction were noted between the PVT and no-PVT groups. The risk of recurrent variceal bleeding, recurrent ascites, and OHE in the PVT group was generally similar to that in the no-PVT group. TIPS represents a potentially feasible treatment option in cirrhosis patients with PVT.

Complications of transjugular intrahepatic portosystemic shunt (TIPS) in the era of the stent graft - What the interventionists need to know?

Transjugular intrahepatic portosystemic shunt (TIPS) is created between a hepatic vein (HV) and the portal vein (PV) to alleviate the symptoms of portal hypertension. Despite high procedural success rates, a myriad of complications may occur at every step of TIPS creation. These complications may be attributable to the procedure itself or the shunt. Portal vein puncture is the most challenging and rate-limiting step, with extrahepatic portal vein puncture being the most devastating tabletop complication. Hepatic encephalopathy is the most common shunt-related complication after TIPS. Unlike bare metallic stents, covered stents have a longer patency rate and lower incidence of TIPS dysfunction. Most of the TIPS dysfunction that occurs with stent-grafts is due to technical errors and mechanical factors. TIPS revision often requires a combination of angioplasty, mechanical thrombectomy, and thrombolytics with a need for additional stenting in some cases. This review article focuses on procedure and shunt-related complications, as well as preventive and management strategies.

Efficacy of albumin-bilirubin score to predict hepatic encephalopathy in patients underwent transjugular intrahepatic portosystemic shunt

BACKGROUND AND AIMS

The occurrence of hepatic encephalopathy is one of the main factors limiting the development and application of transjugular intrahepatic portosystemic shunt (TIPS). Our study aimed to verify the efficacy of the albumin-bilirubin score, an objective and simple scoring system, to predict post-TIPS hepatic encephalopathy.

METHODS

From February 2014 to July 2019, a total of 224 patients who underwent TIPS procedure were entered into the study. All patients were followed up after TIPS placement. Relevant clinical data within 24 h after admission were collected to compare the differences between patients with and without hepatic encephalopathy after TIPS placement.

RESULTS

A total of 82 (36.6%) patients developed post-TIPS hepatic encephalopathy. Age and albumin-bilirubin score was found to be independent risk factors for post-TIPS hepatic encephalopathy. The albumin-bilirubin score shows a good ability to predict the occurrence of hepatic encephalopathy within 1 year after TIPS. The area under the receiver operating characteristic curve is 0.74 (95% confidence interval: 0.673-0.806). In addition, in order to improve its feasibility, we regrouped the albumin-bilirubin score into three levels (albumin-bilirubin≤ -1.95, low risk; 1.95 <albumin-bilirubin ≤1.45, intermediate risk; albumin-bilirubin > -1.45, high risk).

CONCLUSION

The albumin-bilirubin score has a good predictive value for the possibility of post-TIPS hepatic encephalopathy, which is better than the model for end-stage liver disease and Child-Pugh score.

Combined Y-configured stents for revising occluded transjugular intrahepatic portosystemic shunt

PURPOSE

We aimed to determine the technical feasibility, safety and prognosis of the transjugular intrahepatic portosystemic shunt (TIPS) revision by combined Y-configured stents placement.

METHODS

We retrospectively evaluated 12 patients who received TIPS revision using Y-stenting technique between June 2015 and January 2019. The rates of technical success, complication, shunt patency, hepatic encephalopathy and mortality were described and analyzed.

RESULTS

The combined Y-configured stents were successfully placed in 11 of 12 patients (92%) without major complications. The median portosystemic pressure gradient (PPG) decreased from 23 mmHg (interquartile range, IQR, 18.5-27.5 mmHg) to 10 mmHg (IQR, 9-14 mmHg). The left internal jugular vein approach was used in 5 patients. Four patients required a shunt extension with an extra stent to resolve the stenosis at the portal venous terminus. Two patients developed hepatic encephalopathy, which was medically controlled within 3 months after the procedure. The TIPS patency and survival rates were both 100% during a median follow-up period of 10 months (IQR, 5.5-14 months).

CONCLUSION

TIPS revision by combined Y-configured stents placement was technically feasible and safe with favorable clinical outcomes.

The Importance of Sonographic Imaging With Alcoholic Liver Disease: A Case Study

Alcoholic liver disease (ALD), a precursor to alcohol-induced cirrhosis, is a disease caused by excessive ingestion of alcoholic substances that directly affects liver functions. Abnormal liver function can cause the liver to damage other organs within the abdomen. This case study examines the physiological nature of alcohol-induced cirrhosis and its pathogenesis, external and internal clinical presentations, and treatment options. Treatments for alcohol-induced cirrhosis include liver transplant for permanent correction as well as varied options to manage symptoms. This case study analyzes alcoholic liver disease within one male patient whose condition highlights the importance of sonography in routinely monitoring patients with ALD.

Parallel transjugular intrahepatic portosystemic shunt (TIPS) for TIPS dysfunction: technical and patency outcome

Background

Several methods have been used in treating TIPS dysfunction, including balloon angioplasty with/without telescoping stent. However, there are some cases refractory to recanalization and parallel shunt (PS) should be tried. The aim is to evaluate the technical and patency outcomes of the PS. We retrospectively reviewed the medical records of patients (n = 37) with refractory TIPS dysfunction who were managed by PS. All clinical, laboratory, and technical data as well as radiological data over 1 year were collected. Technical success was the primary outcome while complications and shunt patency were the secondary outcomes.

Results

Thirty-three out of the 37 patients (89.2%) of the study were Budd-Chiari syndrome cases. Caval puncture was done in 34/37 (91.9%) of cases while the hepatic vein puncture was done in 3/37 cases (8.1%). Portal entry through the left branch was done in 22 patients (59.5%), from neck of PV in 13 patients (35.1%) to right PV in 2 patients (5.4%). Technical success was achieved in 100% of cases. Porto-systemic pressure gradient (PSG) before PS insertion was 32.5 ± 8.1 mmHg and it became 8.9 ± 2.3 mmHg after the PS insertion (P < 0.01). The median primary patency duration was 11 months. The estimated 12 and 18 months primary patency rates were 32/37 (86.5%) and (78.4%) respectively. Intra-procedure complications occurred in 8 patients (21.6%) and were successfully treated medically. Acute PS thromboses occurred in 4 patients (10.8%) and required early successful interventions.

Conclusion

It is proven from this study that patients with refractory TIPS occlusion have another chance for a second PS to treat portal hypertension symptoms. Moreover, the PS is a durable, safe, and effective treatment on mid-term basis.

Long-term effects and complications of the transjugular intrahepatic portosystemic shunt: a single-centre experience

Background and aims: Accurate estimates of the long-term risks of adverse outcomes after transjugular intrahepatic portosystemic shunt (TIPS) treatment are needed. The aim of this cohort study was to estimate the risks of stent dysfunction, variceal bleeding, refractory ascites, hepatic encephalopathy (HE), and death after TIPS treatment. Methods: We extracted data from electronic medical records of 104 consecutive TIPS patients. Gore® Viatorr® TIPS endoprostheses were used in all patients. We conducted competing risks analysis of the risk of stent dysfunction and variceal bleeding, and Kaplan-Meier estimation of overall survival. Results: The overall 1-year survival after TIPS insertion was 82% (95% confidence interval [CI]: 73-88%), and the 1-year risk of stent dysfunction was 15% (95% CI: 9-22%). In patients who had a TIPS for variceal bleeding, the 1-year risk of rebleeding was 23% (95% CI: 13-35%). In patients who had a TIPS for refractory ascites, the risk of having an unsuccessful ascites outcome 1 year after TIPS for refractory ascites was 35% (95% CI: 21-52%). Overall, the 1-year risk of overt HE was 38% (95% CI: 32-43%). The risk of experiencing any of the defined complications during the first year was 56% (95% CI: 45-66%). Conclusion: TIPS is an effective treatment for variceal bleeding and refractory ascites in most cases, but more than half of the patients experience either death, stent dysfunction, recurrence of symptoms, or overt HE within the first year after the procedure.