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Torkian P, Wallace S, Lim N, Flanagan S, Golzarian J, Young SJ. Pre-existing Hepatic Encephalopathy: Really a Contraindication to Elective TIPS? Cardiovasc Intervent Radiol 2024; 47:69-77. [PMID: 37798432 DOI: 10.1007/s00270-023-03566-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/01/2023] [Accepted: 09/07/2023] [Indexed: 10/07/2023]
Abstract
PURPOSE To evaluate the impact of pre-transjugular intrahepatic portosystemic shunt (TIPS) hepatic encephalopathy (HE) on developing post-TIPS HE. MATERIALS AND METHODS In this retrospective, single center observational study, all patients who underwent successful TIPS placement between January 2005 and May 2020 with data pertaining to HE in their chart were included. Patient demographics and procedural details were recorded. Clinical outcomes post-TIPS, were collected and compared across patients with and without pre-TIPS HE. RESULTS Of 326 included patients, 159 (159/326, 48.8%) had a history of pre-TIPS HE. In total those without a history of HE were more likely to develop HE during follow up (136 (136/167, 81.4%) vs 107 (107/159, 67.3%), p = 0.001). When evaluating for predictors of developing HE within 3 months of TIPS placement, no significant variables were found on logistic regression, including prior history of HE (HR 1.16 (95% CI 0.73-1.84), p = 0.529). Univariate and multivariate regression analysis, however, showed that a history of HE was predictive of developing HE at any point in the follow-up period (p = 0.002 and p = 0.008, respectively). However, on Kaplan-Meier analysis no significant difference in the development of HE (p = 0.574) or hospital admission for HE (p = 0.554) post-TIPS was seen between patients with and without pre-TIPS HE. Additionally, there was no difference in 3-month survival (p = 0.412) or overall survival post-TIPS survival (p = 0.798). CONCLUSION Pre-TIPS HE did not predict the development of HE within 3 months of TIPS. Outcomes such as hospital admission and survivability were not different between patients with and without prior HE.
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Affiliation(s)
- Pooya Torkian
- Vascular and Interventional Radiology, Department of Radiology, University of Minnesota, B-228 Mayo Memorial Building, MMC 292420 Delaware Street S.E., Minneapolis, MN, 55455, USA.
| | - Stephanie Wallace
- Vascular and Interventional Radiology, Department of Radiology, University of Minnesota, B-228 Mayo Memorial Building, MMC 292420 Delaware Street S.E., Minneapolis, MN, 55455, USA
| | - Nicholas Lim
- Division of Gastroenterology, Hepatology and Nutrition, University of Minnesota, Minneapolis, MN, USA
| | - Siobhan Flanagan
- Vascular and Interventional Radiology, Department of Radiology, University of Minnesota, B-228 Mayo Memorial Building, MMC 292420 Delaware Street S.E., Minneapolis, MN, 55455, USA
| | - Jafar Golzarian
- Vascular and Interventional Radiology, Department of Radiology, University of Minnesota, B-228 Mayo Memorial Building, MMC 292420 Delaware Street S.E., Minneapolis, MN, 55455, USA
| | - Shamar J Young
- Department of Medical Imaging, University of Arizona, 1501 North Campbell Avenue, Tucson, AZ, USA
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2
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Li Y, Liu Z, Liu C. Efficacy and safety of laparoscopic splenectomy for hypersplenism secondary to portal hypertension after transjugular intrahepatic portosystemic shunt. BMC Gastroenterol 2021; 21:61. [PMID: 33573590 PMCID: PMC7879518 DOI: 10.1186/s12876-021-01647-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/14/2020] [Accepted: 01/18/2021] [Indexed: 02/07/2023] Open
Abstract
Background Laparoscopic splenectomy (LS) being used after Transjugular intrahepatic portosystemic shunt (TIPS) has not been reported. This report aims to explore the feasibility, safety, and potential efficacy of LS after TIPS hypersplenism secondary to portal hypertension (PHT). Methods We retrospectively reviewed a series of six patients who underwent LS after TIPS for hypersplenism secondary to PHT between 2014 and 2020. The perioperative data and patients’ clinical outcomes were recorded. Results LS was successfully performed in all patients. Hypersplenism was corrected after LS in all six patients. Postoperative prothrombin time, prothrombin activity, international normalized ratio, and total bilirubin showed a trend toward improvement. The preoperative and 1-month postoperative albumin and activated partial thromboplastin levels showed no significant difference. Plasma ammonia level and thromboelastography indicators were ameliorated in two limited recorded patients. No postoperative complications such as subphrenic abscess, portal vein thrombosis, variceal bleeding, hepatic encephalopathy, and liver failure occurred during the 1-month follow-up period. Conclusion LS following TIPS is feasible, safe, and beneficial for patients with hypersplenism secondary to PHT. The following LS not only corrects the hypersplenism, but also has the potential to improve liver function.
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Affiliation(s)
- Yingying Li
- Second Clinical College, Department of Surgery, Chongqing Medical University, 1 Medical College Road, Yuzhong District, Chongqing, China
| | - Zuojin Liu
- Department of Hepatobiliary Surgery, Chongqing Medical University Affiliated Second Hospital, 74 Linjiang Road, Yuzhong District, Chongqing, China.
| | - Chang'an Liu
- Department of Hepatobiliary Surgery, Chongqing Medical University Affiliated Second Hospital, 74 Linjiang Road, Yuzhong District, Chongqing, China
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3
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Madoff DC, Cornman-Homonoff J, Fortune BE, Gaba RC, Lipnik AJ, Yarmohammadi H, Ray CE. Management of Refractory Ascites Due to Portal Hypertension: Current Status. Radiology 2021; 298:493-504. [PMID: 33497318 DOI: 10.1148/radiol.2021201960] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Refractory ascites is a costly and debilitating condition that occurs most frequently in the setting of substantial cirrhotic portal hypertension, where it portends a poor prognosis. Many treatment options are available, among them medical management, serial large volume paracenteses, transjugular intrahepatic portosystemic shunts, and implanted drainage devices. Although the availability of multiple therapies ensures that most patients will achieve satisfactory results, it can be challenging for the provider to select the appropriate treatment for each specific patient. This article reviews the available therapeutic options for refractory ascites and incorporates available data and clinical experience to suggest a linear stepwise management approach to enhance patient outcomes.
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Affiliation(s)
- David C Madoff
- From the Department of Radiology and Biomedical Imaging, Section of Interventional Radiology, Yale School of Medicine, 330 Cedar St, TE-2, New Haven, CT 06520-8055 (D.C.M., J.C.); Department of Medicine, Division of Hepatology, New York-Presbyterian Hospital/Weill Cornell Medical Center, New York, NY (B.E.F.); Department of Radiology, Division of Interventional Radiology, University of Illinois at Chicago, Chicago, Ill (R.C.G., A.J.L., C.E.R.); and Department of Radiology, Interventional Radiology Service, Memorial Sloan-Kettering Cancer Center, New York, NY (H.Y.)
| | - Joshua Cornman-Homonoff
- From the Department of Radiology and Biomedical Imaging, Section of Interventional Radiology, Yale School of Medicine, 330 Cedar St, TE-2, New Haven, CT 06520-8055 (D.C.M., J.C.); Department of Medicine, Division of Hepatology, New York-Presbyterian Hospital/Weill Cornell Medical Center, New York, NY (B.E.F.); Department of Radiology, Division of Interventional Radiology, University of Illinois at Chicago, Chicago, Ill (R.C.G., A.J.L., C.E.R.); and Department of Radiology, Interventional Radiology Service, Memorial Sloan-Kettering Cancer Center, New York, NY (H.Y.)
| | - Brett E Fortune
- From the Department of Radiology and Biomedical Imaging, Section of Interventional Radiology, Yale School of Medicine, 330 Cedar St, TE-2, New Haven, CT 06520-8055 (D.C.M., J.C.); Department of Medicine, Division of Hepatology, New York-Presbyterian Hospital/Weill Cornell Medical Center, New York, NY (B.E.F.); Department of Radiology, Division of Interventional Radiology, University of Illinois at Chicago, Chicago, Ill (R.C.G., A.J.L., C.E.R.); and Department of Radiology, Interventional Radiology Service, Memorial Sloan-Kettering Cancer Center, New York, NY (H.Y.)
| | - Ron C Gaba
- From the Department of Radiology and Biomedical Imaging, Section of Interventional Radiology, Yale School of Medicine, 330 Cedar St, TE-2, New Haven, CT 06520-8055 (D.C.M., J.C.); Department of Medicine, Division of Hepatology, New York-Presbyterian Hospital/Weill Cornell Medical Center, New York, NY (B.E.F.); Department of Radiology, Division of Interventional Radiology, University of Illinois at Chicago, Chicago, Ill (R.C.G., A.J.L., C.E.R.); and Department of Radiology, Interventional Radiology Service, Memorial Sloan-Kettering Cancer Center, New York, NY (H.Y.)
| | - Andrew J Lipnik
- From the Department of Radiology and Biomedical Imaging, Section of Interventional Radiology, Yale School of Medicine, 330 Cedar St, TE-2, New Haven, CT 06520-8055 (D.C.M., J.C.); Department of Medicine, Division of Hepatology, New York-Presbyterian Hospital/Weill Cornell Medical Center, New York, NY (B.E.F.); Department of Radiology, Division of Interventional Radiology, University of Illinois at Chicago, Chicago, Ill (R.C.G., A.J.L., C.E.R.); and Department of Radiology, Interventional Radiology Service, Memorial Sloan-Kettering Cancer Center, New York, NY (H.Y.)
| | - Hooman Yarmohammadi
- From the Department of Radiology and Biomedical Imaging, Section of Interventional Radiology, Yale School of Medicine, 330 Cedar St, TE-2, New Haven, CT 06520-8055 (D.C.M., J.C.); Department of Medicine, Division of Hepatology, New York-Presbyterian Hospital/Weill Cornell Medical Center, New York, NY (B.E.F.); Department of Radiology, Division of Interventional Radiology, University of Illinois at Chicago, Chicago, Ill (R.C.G., A.J.L., C.E.R.); and Department of Radiology, Interventional Radiology Service, Memorial Sloan-Kettering Cancer Center, New York, NY (H.Y.)
| | - Charles E Ray
- From the Department of Radiology and Biomedical Imaging, Section of Interventional Radiology, Yale School of Medicine, 330 Cedar St, TE-2, New Haven, CT 06520-8055 (D.C.M., J.C.); Department of Medicine, Division of Hepatology, New York-Presbyterian Hospital/Weill Cornell Medical Center, New York, NY (B.E.F.); Department of Radiology, Division of Interventional Radiology, University of Illinois at Chicago, Chicago, Ill (R.C.G., A.J.L., C.E.R.); and Department of Radiology, Interventional Radiology Service, Memorial Sloan-Kettering Cancer Center, New York, NY (H.Y.)
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4
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Kohi MP, Lai JC. Impact of Muscle Gain after Transjugular Intrahepatic Portosystemic Shunt Creation on Patients Awaiting Liver Transplantation. J Vasc Interv Radiol 2019; 30:874-875. [PMID: 31126599 DOI: 10.1016/j.jvir.2019.02.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2019] [Accepted: 02/04/2019] [Indexed: 10/26/2022] Open
Affiliation(s)
- Maureen P Kohi
- Department of Radiology and Biomedical Imaging, 505 Parnassus Avenue, M-361, University of California-San Francisco, CA 94143.
| | - Jennifer C Lai
- Division of Gastroenterology/Hepatology, 505 Parnassus Avenue, M-361, University of California-San Francisco, CA 94143
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5
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TIPS for refractory ascites: a 6-year single-center experience with expanded polytetrafluoroethylene-covered stent-grafts. AJR Am J Roentgenol 2015; 204:654-61. [PMID: 25714299 DOI: 10.2214/ajr.14.12885] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
OBJECTIVE. This single-center study evaluated the use of expanded polytetrafluoroethylene (ePTFE)-covered stent-grafts for transjugular intrahepatic portosystemic shunt (TIPS) placement to manage portal hypertension-related refractory ascites. MATERIALS AND METHODS. One hundred patients at a single tertiary care center in a major metropolitan hospital underwent TIPS placement with an ePTFE-covered stent-graft (Viatorr TIPS Endoprosthesis). Patients with portal hypertension-related ascites and preexisting hepatocellular carcinoma or liver transplant were excluded from the analysis. Records were reviewed for demographic characteristics, technical success of the TIPS procedures, and stent follow-up findings. Clinical results were assessed at 90- and 180-day intervals. RESULTS. Immediate technical success of the TIPS procedure was 100%. Of the 61 patients with documented follow-up, 55 (90.2%) had a partial or complete ascites response to TIPS creation. Of these 55 patients, nine experienced severe encephalopathy. Six of 61 patients (9.8%) did not experience a significant ascites response. Overall survival was 78.7% at 365-day follow-up. The 365-day survival was 84.2% for patients with a model for end-stage liver disease (MELD) score of less than 15, 67.0% for those with a score of 15-18, and 53.8% for those with a score of greater than 18 (p = 0.01). For patients with a MELD score of less than 18, the 365-day survival was 88.0% for those with an albumin value of 3 mg/dL or greater and 72.8% for those with an albumin value of less than 3 mg/dL (p = 0.04). CONCLUSION. TIPS placement using an ePTFE-covered stent-graft is an efficacious therapy for refractory ascites. Patients with preserved liver function-characterized by a MELD score of less than 15 or a MELD score of less than 18 and an albumin value of 3 mg/dL or greater-experience the greatest survival benefit.
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6
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Dasarathy J, Alkhouri N, Dasarathy S. Changes in body composition after transjugular intrahepatic portosystemic stent in cirrhosis: a critical review of literature. Liver Int 2011; 31:1250-8. [PMID: 21745273 DOI: 10.1111/j.1478-3231.2011.02498.x] [Citation(s) in RCA: 55] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Change in body composition with reduced muscle mass with or without loss of fat mass occurs in 60-90% of patients with cirrhosis. This has an adverse impact on the outcome of these patients and is an understudied area. Transjugular intrahepatic portosystemic stent (TIPS) is now a standard therapy for portal hypertension but its beneficial impact on nutritional indices is not well recognized. We included all publications on TIPS that had any nutritional index as an outcome measure or end point. Given the heterogeneity of the patient population, differences in study design and outcome measures, a meta-analysis was not feasible. Data were summarized and interpreted. A total of eight studies have been published on the changes in body composition after TIPS in cirrhosis in a total of 152 patients followed for 3-12 months. Improvement in fat-free mass and fluid-free or ascites-free body weight was reported in all studies. Plasma leptin, IGF1, insulin sensitivity, rate of glucose disposal and growth hormone did not change after TIPS. One study measured muscle strength that improved. Direct measurement of skeletal muscle mass was not performed in any study. TIPS resulted in an improvement in body composition. Given the clinical significance of skeletal muscle and fat mass in cirrhosis, nutritional indices should be considered to be an important outcome measure in patients with TIPS. The mechanism of these is unclear, but its clinical implication is that this may contribute to the improved survival after TIPS.
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Affiliation(s)
- Jaividhya Dasarathy
- Department of Family Medicine, Metrohealth Medical Center, Cleveland, OH 44195, USA.
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7
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Abstract
Some patients with ascites due to liver cirrhosis become no longer responsive to diuretics. Once other causes of ascites such as portal vein thrombosis, malignancy or infection and non-compliance with medications and low sodium diet have been excluded, the diagnosis of refractory ascites can be made based on strict criteria. Patients with refractory ascites have very poor prognosis and therefore referral for consideration for liver transplantation should be initiated. Search for reversible components of the underlying liver pathology should be undertaken and targeted therapy, when available, should be considered. Currently, serial large volume paracentesis (LVP) and transjugular intrahepatic portasystemic stent-shunt (TIPS) are the two mainstay treatment options for refractory ascites. Other treatment options are available but not widely used either because they carry high morbidity and mortality (most surgical options) rates, or are new interventions that have shown promise but still need further evaluation. In this comprehensive review, we describe the evaluation and management of patients with refractory ascites from the prospective of the practicing physician.
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8
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Affiliation(s)
- Jean-Marie Péron
- Service d'Hépato-Gastroentérologie, Fédération Digestive, Hôpital Purpan, Toulouse.
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9
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Campbell MS, Brensinger CM, Sanyal AJ, Gennings C, Wong F, Kowdley KV, McCashland T, Reddy KR. Quality of life in refractory ascites: transjugular intrahepatic portal-systemic shunting versus medical therapy. Hepatology 2005; 42:635-40. [PMID: 16108073 DOI: 10.1002/hep.20840] [Citation(s) in RCA: 51] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Uncontrolled studies suggest that transjugular intrahepatic portal-systemic shunting (TIPS) may improve quality of life in patients with refractory ascites. We hypothesized that any improvement of quality of life in patients with TIPS would be matched in controls due to the competing effects of improved ascites and worsened hepatic encephalopathy. Thus, an analysis of quality of life was performed using original data from the North American Study for the Treatment of Refractory Ascites, a multicenter trial of 109 patients randomized to TIPS or repeated large volume paracentesis (LVP) for refractory ascites. Short form 36 (SF-36) surveys were completed at baseline and at 6- and 12-month follow-up. Variables analyzed were: randomization group, number of LVP performed, cumulative volume from LVP, shortness of breath, abdominal distention, abdominal pain, diuretic usage, confusion, hospitalizations, and emergency room visits. Outcomes were changes in physical component scale (PCS) and mental component scale (MCS) of SF-36 results. We constructed multivariable, mixed effects models, including randomization group and baseline MCS and PCS. Changes in PCS and MCS from baseline were similar between the two randomization groups. In multivariate analysis, PCS improvement was associated with lack of confusion, improved ascites, and lack of hospitalizations, but not directly with randomization group. Improvement in MCS was associated with randomization to TIPS and lack of confusion. In conclusion, patients with refractory ascites randomized to TIPS or repeated LVP had similar changes in quality of life. Competing effects of hepatic encephalopathy, requirement for repeated LVP, and need for hospitalizations explain similar changes in quality of life between the two groups.
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Affiliation(s)
- Mical S Campbell
- Division of Gastroenterology, University of Pennsylvania Health Services, Philadelphia, PA 19104, USA
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10
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Kee ST, Ganguly A, Daniel BL, Wen Z, Butts K, Shimikawa A, Pelc NJ, Fahrig R, Dake MD. MR-guided transjugular intrahepatic portosystemic shunt creation with use of a hybrid radiography/MR system. J Vasc Interv Radiol 2005; 16:227-34. [PMID: 15713923 DOI: 10.1097/01.rvi.0000143766.08029.6e] [Citation(s) in RCA: 61] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
PURPOSE To evaluate the performance of a combined hybrid radiography/magnetic resonance (MR) unit to guide portal vein (PV) puncture during human transjugular intrahepatic portosystemic shunt (TIPS) creation. MATERIALS AND METHODS Fourteen patients undergoing TIPS creation were studied during standard clinical applications. Patients were anesthetized and then positioned in an open MR unit containing a flat-panel radiographic fluoroscopic unit. With use of a combination of fluoroscopy and MR imaging, the PV was accessed and the TIPS procedure was performed. A noncovered nitinol stent or a covered stent-graft was placed in the TIPS tract. Number of punctures required, total procedure time, fluoroscopy time, procedural success rate, complications, and ultrasonographic and clinical follow-up were recorded. RESULTS Clinical success was obtained in 13 of 14 patients. In one patient, extrahepatic puncture of the PV occurred, resulting in hemorrhage and requiring placement of a covered stent to control the bleeding. The mean number of punctures required to access the PV was 2.6 +/- 1.7, and the total procedure time was 2.5 hours +/- 0.6. Mean fluoroscopy time was 22.3 minutes +/- 5.5. Results of clinical and ultrasonographic follow-up compare favorably to previously published reports. CONCLUSION TIPS creation with a combination hybrid radiography/MR unit is feasible and may reduce the number of needle passes required and radiation exposure, with similar overall outcomes compared with studies reported in the literature.
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Affiliation(s)
- Stephen T Kee
- Department of Radiology, Stanford University, California 94305, USA.
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11
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Ferral H, Patel NH. Selection Criteria for Patients Undergoing Transjugular Intrahepatic Portosystemic Shunt Procedures: Current Status. J Vasc Interv Radiol 2005; 16:449-55. [PMID: 15802443 DOI: 10.1097/01.rvi.0000149508.64029.02] [Citation(s) in RCA: 48] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
The transjugular intrahepatic portosystemic shunt (TIPS) procedure has a well-established role in the management of patients with complications of portal hypertension such as variceal bleeding or refractory ascites. Several clinical variables have been described to be associated with a poor prognosis after a TIPS procedure, including the presence of uncontrollable ascites, the number of sclerotherapy sessions to control a bleeding episode, the use of drugs for hemodynamic support, the use of balloon tamponade to control bleeding, the need for an emergency TIPS procedure, the need for mechanical ventilation, prothrombin time, increased serum creatinine, increased serum bilirubin, encephalopathy, and sepsis. In addition, several scoring systems have been developed and applied to patients undergoing TIPS procedures in an attempt to improve patient selection criteria for this invasive procedure. This article reviews the most important scoring systems that have been developed and applied to patients undergoing emergency or elective TIPS procedures, with particular emphasis on the prognostic index designed for patients undergoing emergency TIPS procedures and the Model for End-stage Liver Disease score designed for patients undergoing elective TIPS procedures. The most practical application of these scoring systems is probably that, with the information provided, the operator is able to discuss with referring physicians, patients, and family members the expected outcomes of this challenging procedure.
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Affiliation(s)
- Hector Ferral
- Department of Radiology, Rush University Medical Center, 1725 West Harrison Street, Suite 456, Chicago, Illinois 60612-3833, USA.
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12
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Gerbes AL, Gülberg V. Benefit of TIPS for patients with refractory or recidivant ascites: serum bilirubin may make the difference. Hepatology 2005; 41:217. [PMID: 15619245 DOI: 10.1002/hep.20509] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
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13
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Abstract
BACKGROUND Secondary prophylaxis for esophageal variceal hemorrhage (VH) is recommended, but there has never been a cost-utility analysis of its implementation. OBJECTIVE The objective was to compare the cost utility of various strategies for the secondary prophylaxis of VH including (a) observation alone, (b) medical therapy (MED), (c) endoscopic band ligation (EBL), (d) endoscopic band ligation plus medical therapy (EBL + M), and (e) transjugular intrahepatic portosystemic shunt (TIPS), and to examine the effect of adherence on these strategies. METHODS A Markov model was developed for all five strategies, and included surveillance, risk of hepatic encephalopathy, complications, and nonadherence. DATA SOURCES Published literature and the Health Care Financing Administration. TARGET POPULATION People with cirrhosis and a history of controlled VH. TIME HORIZON Three years. PERSPECTIVE Third-party payer. OUTCOME MEASURES Incremental cost-effectiveness ratios for quality-adjusted life-years (QALYs) gained. RESULTS OF BASE-CASE ANALYSIS Combination EBL + M was the optimal strategy, dominating all other strategies including observation, meaning that it was more effective and less expensive than the others. In addition, EBL alone dominated observation and TIPS in terms of QALYs, and MED alone dominated the strategy of observation in terms of QALYs. RESULTS OF SENSITIVITY ANALYSIS Important variables affecting the optimal strategy were the odds ratio (OR) of VH with EBL compared to MED, the OR of VH with EBL + M compared to EBL, and patients' preferences regarding taking the medication as reflected in the associated toll exacted on the health state utility. Variations in these parameters within the range of clinical plausibility allowed EBL or MED to become the optimal strategy. TIPS was the optimal strategy only if adherence rates for all strategies were less than 12%. RESULTS OF MONTE CARLO ANALYSIS: Neither observation nor TIPS was ever the optimal strategy, and EBL + M was optimal in 62% of cases. If the variables identified in the sensitivity analysis were controlled, then EBL + M was optimal in 95% of cases. CONCLUSIONS TIPS should be reserved only for patients with very poor adherence. Otherwise, patients are best served by medications, EBL, or a combination of both, depending on the comparative rates of rebleeding with each and patients' preferences regarding medical therapy. The redundancy of combination band ligation plus medical therapy can improve outcomes, particularly in the setting of poor patient adherence.
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Affiliation(s)
- Joel H Rubenstein
- Division of Gastroenterology, University of Michigan Health System, Ann Arbor, Michigan 48109-0362, USA
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14
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Haskal ZJ, Rees CR, Ring EJ, Saxon R, Sacks D. Reporting Standards for Transjugular Intrahepatic Portosystemic Shunts. J Vasc Interv Radiol 2003; 14:S419-26. [PMID: 14514857 DOI: 10.1097/01.rvi.0000094615.61428.2e] [Citation(s) in RCA: 47] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Affiliation(s)
- Ziv J Haskal
- Society of Interventional Radiology, 10201 Lee Highway, Suite 500, Fairfax, VA 22030, USA
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15
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Moore KP, Wong F, Gines P, Bernardi M, Ochs A, Salerno F, Angeli P, Porayko M, Moreau R, Garcia-Tsao G, Jimenez W, Planas R, Arroyo V. The management of ascites in cirrhosis: report on the consensus conference of the International Ascites Club. Hepatology 2003; 38:258-66. [PMID: 12830009 DOI: 10.1053/jhep.2003.50315] [Citation(s) in RCA: 553] [Impact Index Per Article: 26.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Ascites is a common complication of cirrhosis, and heralds a new phase of hepatic decompensation in the progression of the cirrhotic process. The development of ascites carries a significant worsening of the prognosis. It is important to diagnose noncirrhotic causes of ascites such as malignancy, tuberculosis, and pancreatic ascites since these occur with increased frequency in patients with liver disease. The International Ascites Club, representing the spectrum of clinical practice from North America to Europe, have developed guidelines by consensus in the management of cirrhotic ascites from the early ascitic stage to the stage of refractory ascites. Mild to moderate ascites should be managed by modest salt restriction and diuretic therapy with spironolactone or an equivalent in the first instance. Diuretics should be added in a stepwise fashion while maintaining sodium restriction. Gross ascites should be treated with therapeutic paracentesis followed by colloid volume expansion, and diuretic therapy. Refractory ascites is managed by repeated large volume paracentesis or insertion of a transjugular intrahepatic portosystemic stent shunt (TIPS). Successful placement of TIPS results in improved renal function, sodium excretion, and general well-being of the patient but without proven survival benefits. Clinicians caring for these patients should be aware of the potential complications of each treatment modality and be prepared to discontinue diuretics or not proceed with TIPS placement should complications or contraindications develop. Liver transplantation should be considered for all ascitic patients, and this should preferably be performed prior to the development of renal dysfunction to prevent further compromise of their prognosis.
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Affiliation(s)
- Kevin P Moore
- Centre for Hepatology, Royal Free and University College Medical School, UCL, London, United Kingdom.
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16
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Zhuang ZW, Teng GJ, Jeffery RF, Gemery JM, Janne d'Othee B, Bettmann MA. Long-term results and quality of life in patients treated with transjugular intrahepatic portosystemic shunts. AJR Am J Roentgenol 2002; 179:1597-603. [PMID: 12438061 DOI: 10.2214/ajr.179.6.1791597] [Citation(s) in RCA: 40] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
OBJECTIVE The purpose of our study was to determine long-term survival, shunt patency, and quality of life in patients after creation of a transjugular intrahepatic portosystemic shunt (TIPS). MATERIALS AND METHODS We followed up 103 patients who underwent TIPS for a mean of 20.10 +/- 25.58 months (range, 1 day-92 months). Various statistical methods were used to analyze long-term survival, shunt patency, and correlation with Child-Pugh classification and indications for TIPS. The Rand 36-Item Health Survey 1.0 was used to assess quality of life over time. RESULTS The cumulative survival rate was 68%, 60%, 50%, 41%, and 41% at years 1-5, respectively. The cumulative survival rate was significantly higher for patients classified as Child-Pugh class A or B versus those classified as class C (p < 0.01), as well as for patients with the original indication of variceal bleeding versus refractory ascites or hydrothorax (p < 0.01). No significant difference in survival rates was found between patients with Child-Pugh A and those with Child-Pugh B. The cumulative primary patency rate was 50%, 34%, 21%, 13%, and 13% at years 1-5, respectively, with assisted patency rate of 80%, 61%, 46%, 42%, and 36%. Cumulative secondary patency rate was 85%, 64%, 55%, 55%, and 55% at years 1-5. Mean follow-up time in 33 patients who completed quality-of-life questionnaires with one follow-up was 17.46 months. Scores after TIPS in all nine of the health categories were higher than those preprocedure with statistically significant improvement in four categories. The second follow-up was completed by 21 patients at a mean of 30.58 months after TIPS creation. Both scores after TIPS were higher than those before TIPS, and scores in five categories were further improved at the second surveillance (p < 0.0, only for health change), whereas in four categories, the scores were slightly worse. CONCLUSION TIPS has positive efficacy both for controlling bleeding or ascites and for improving the quality of life. The precise impact of TIPS on long-term survival, however, requires further clarification.
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Affiliation(s)
- Zhen W Zhuang
- Department of Radiology, Dartmouth-Hitchcock Medical Center, One Medical Center Dr., Lebanon, NH 03756, USA
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Ferral H, Vasan R, Speeg KV, Serna S, Young C, Postoak DW, Wholey MH, McMahan CA. Evaluation of a model to predict poor survival in patients undergoing elective TIPS procedures. J Vasc Interv Radiol 2002; 13:1103-8. [PMID: 12427809 DOI: 10.1016/s1051-0443(07)61951-4] [Citation(s) in RCA: 33] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
PURPOSE To validate a previously published model to predict the probability of patient death within 3 months after an elective transjugular intrahepatic portosystemic shunt (TIPS) procedure. The model is implemented with use of a nomogram or a formula. MATERIALS AND METHODS Patients who underwent an elective TIPS procedure between May 1, 1999, and May 1, 2001, were selected. Patients who underwent emergency TIPS creation and patients with serum creatinine levels greater than 3.0 mg/dL were excluded. A total of 72 patients met the inclusion criteria. The patients were divided into two groups: group A (ethanol-induced cirrhosis; n = 23) and group B (non-ethanol-induced cirrhosis; n = 49). The model was applied and the predicted probability of death was compared to actual patient survival. A high risk score (R > or = 1.8) is associated with a high risk of death within 3 months after TIPS creation. Survival curves were estimated with use of Kaplan-Meier product limit estimates and were compared with use of the log-rank test. The model's accuracy was evaluated with use of the c-statistic. P values lower than.05 indicated statistical significance. RESULTS The technical success rate was 98.7%. The 3-month survival rate for the whole group was 79.7%. The predicted mortality rate was higher than the observed mortality rate. The c-statistic was 0.65 for the formula and 0.66 for the nomogram. Patients with a risk score of at least 1.8 had a 3-month survival rate of 54.6% and patients with a risk score lower than 1.8 had a 3-month survival rate of 84.9% (P =.037). CONCLUSION These results confirm that, after an elective TIPS procedure, patients with risk scores of at least 1.8 have a significantly lower 3-month survival rate than patients with risk scores lower than 1.8.
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Affiliation(s)
- Hector Ferral
- Division of Cardiovascular and Special Interventions, Department of Radiology, University of Texas Health Science Center at San Antonio, 7703 Floyd Curl Drive, San Antonio, Texas 78229, USA.
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Fahrig R, Butts K, Wen Z, Saunders R, Kee ST, Sze DY, Daniel BL, Laerum F, Pelc NJ. Truly hybrid interventional MR/X-ray system: investigation of in vivo applications. Acad Radiol 2001; 8:1200-7. [PMID: 11770916 DOI: 10.1016/s1076-6332(03)80702-x] [Citation(s) in RCA: 39] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
RATIONALE AND OBJECTIVES The purpose of this study was to provide in vivo demonstrations of the functionality of a truly hybrid interventional x-ray/magnetic resonance (MR) system. MATERIALS AND METHODS A digital flat-panel x-ray system (1,024(2) array of 200 microm pixels, 30 frames per second) was integrated into an interventional 0.5-T magnet. The hybrid system is capable of MR and x-ray imaging of the same field of view without patient movement. Two intravascular procedures were performed in a 22-kg porcine model: placement of a transjugular intrahepatic portosystemic shunt (TIPS) (x-ray-guided catheterization of the hepatic vein, MR fluoroscopy-guided portal puncture, and x-ray-guided stent placement) and mock chemoembolization (x-ray-guided subselective catheterization of a renal artery branch and MR evaluation of perfused volume). RESULTS The resolution and frame rate of the x-ray fluoroscopy images were sufficient to visualize and place devices, including nitinol guidewires (0.016-0.035-inch diameter) and stents and a 2.3-F catheter. Fifth-order branches of the renal artery could be seen. The quality of both real-time (3.5 frames per second) and standard MR images was not affected by the x-ray system. During MR-guided TIPS placement, the trocar and the portal vein could be easily visualized, allowing successful puncture from hepatic to portal vein. CONCLUSION Switching back and forth between x-ray and MR imaging modalities without requiring movement of the patient was demonstrated. The integrated nature of the system could be especially beneficial when x-ray and MR image guidance are used iteratively.
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Affiliation(s)
- R Fahrig
- Department of Radiology, Stanford University, Calif 94305, USA
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19
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Abstract
Endoscopic sclerotherapy or ligation and/or drugs are the standard treatments for the prevention of variceal rebleeding. Failure of this treatment indicates the need for rescue transjugular intrahepatic portosystemic shunt (TIPS) implantation. The current practice to use endoscopic treatment as first-line and TIPS as second-line treatment is, however, not based on evidence since, in unselected patients, both treatments have a comparable survival. In addition, the timing for a change from endoscopic treatment to TIPS is not exactly defined. According to the randomized studies available a change may be recommended when uncontrolled rebleeding or more than two rebleedings within a time interval of 6-12 months indicate failure of the endoscopic treatment. This regimen may be reconsidered when future developments improve outcome of one or the other treatment. In this regard the TIPS treatment has a potential of improvement if further reduction of the rate of rebleeding can be achieved with less stenosis, and/or reduced encephalopathy.
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Affiliation(s)
- M Rössle
- Medizinische Universitätsklinik, Hugstetter Strasse 55, D-79106 Freiburg, Germany.
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Walser EM, DeLa Pena R, Villanueva-Meyer J, Ozkan O, Soloway R. Hepatic perfusion before and after the transjugular intrahepatic portosystemic shunt procedure: impact on survival. J Vasc Interv Radiol 2000; 11:913-8. [PMID: 10928532 DOI: 10.1016/s1051-0443(07)61811-9] [Citation(s) in RCA: 32] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022] Open
Abstract
PURPOSE This study correlates transjugular intrahepatic portosystemic shunt (TIPS) mortality with flow patterns in the cirrhotic liver. MATERIALS AND METHODS Twenty-seven TIPS patients and 10 control subjects were used for this study. The authors evaluated hepatic perfusion with venous injections of Tc-99m pertechnetate before and after TIPS. Hepatic time-activity curves were analyzed for type and amount of liver perfusion. These parameters were correlated with survival for a mean follow-up of 18 months. RESULTS The mean arterial contribution to liver blood flow was 25.4% in the normal control patients, 39.9% in patients prior to TIPS, and increased to 48.3% after TIPS. Although the proportion of arterial supply to the cirrhotic liver varied widely, TIPS mortality did not correlate with the preprocedure hepatic artery/portal venous perfusion ratio. However, patients with both an "arterialized" flow pattern and low total hepatic perfusion had higher mortality, with a mean survival of 2 months compared to patients with a more favorable perfusion profile (mean survival, 28.4 months). CONCLUSIONS The proportion of arterial perfusion to the liver before TIPS did not affect survival. However, patients with a combination of reduced total hepatic perfusion and an arterial flow pattern had poorer survival, suggesting that both the quantity and quality of hepatic perfusion predicts TIPS outcome.
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Affiliation(s)
- E M Walser
- Department of Radiology, University of Texas Medical Branch, Galveston 77555-0709, USA.
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21
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Abstract
Since the introduction of transjugular intrahepatic portosystemic shunt (TIPS) 10 years ago, it has been used increasingly in the management of portal hypertension and its complications. TIPS is now considered the procedure of choice for management of refractory variceal bleeding. Its role in the management of refractory ascites, hepatic hydrothorax, hepatorenal syndrome, and hepatopulmonary syndrome still awaits further prospective studies. The two main complications of TIPS are hepatic encephalopathy and shunt malfunction. Generally, TIPS stenosis or occlusion is a major drawback requiring routine surveillance of TIPS with doppler ultrasound. Venography with balloon dilation of the stent or placement of serial or parallel stents may be required in some cases. Promising modalities of preventing TIPS malfunction (e.g., brachy-therapy, covered stents, or anti-platelet derived growth factor) are currently being investigated.
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Affiliation(s)
- J P Ong
- Department of Gastroenterology, Cleveland Clinic Foundation, Ohio 44195, USA
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Kee ST, Rhee JS, Butts K, Daniel B, Pauly J, Kerr A, O'Sullivan GJ, Sze DY, Razavi MK, Semba CP, Herfkens RJ, Dake MD. 1999 Gary J. Becker Young Investigator Award. MR-guided transjugular portosystemic shunt placement in a swine model. J Vasc Interv Radiol 1999; 10:529-35. [PMID: 10357476 DOI: 10.1016/s1051-0443(99)70078-3] [Citation(s) in RCA: 58] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
PURPOSE To evaluate the performance of portal venous puncture with use of magnetic resonance (MR) guidance, and to place a transjugular intrahepatic portosystemic shunt (TIPS) in a swine model. MATERIALS AND METHODS A study of 12 swine was performed to evaluate the ability of interventional MR imaging to guide portal vein puncture and TIPS placement. Six swine had catheters placed in the right hepatic vein under C-arm fluoroscopy. A nitinol guide wire was left in the vein and the animals were then moved into an open configuration MR imaging unit. A TIPS needle set was used to puncture the portal vein using MR fluoroscopy. The animals were transferred to the C-arm, and venography confirmed portal vein puncture. A follow-up study was performed in six additional swine to place a TIPS using only MR imaging guidance. MR tracking was used to advance a catheter from the right atrium into the inferior vena cava. Puncture of the portal vein was performed and a nitinol stent was placed, bridging the hepatic parenchyma. MR venogram confirmed placement. RESULTS Successful portal vein puncture was achieved in all animals. The number of punctures required decreased from 12 in the first animal to a single puncture in the last eight swine. A stent was successfully placed across the hepatic tract in all six swine. CONCLUSIONS Real-time MR imaging proved to be a feasible method to guide portal vein puncture and TIPS placement in pigs.
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Affiliation(s)
- S T Kee
- Department of Radiology, Stanford University School of Medicine, California, USA
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Rössle M, Siegerstetter V, Huber M, Ochs A. The first decade of the transjugular intrahepatic portosystemic shunt (TIPS): state of the art. LIVER 1998; 18:73-89. [PMID: 9588766 DOI: 10.1111/j.1600-0676.1998.tb00132.x] [Citation(s) in RCA: 165] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
The transjugular intrahepatic portosystemic shunt (TIPS) is an interventional treatment resulting in decompression of the portal system by creation of a side-to-side portosystemic anastomosis. Since its introduction 10 years ago, more than 500 publications have appeared demonstrating rapid acceptance and increasing clinical use. This review summarizes the present knowledge of technical aspects and complications, follow-up of patients, and indications. With respect to the technique, the TIPS procedure is probably one of the most difficult interventions and, therefore, technical success and complications clearly depend on the skills of the operator. Thus, the number and kind of complications reported in this review do not necessarily relate to the procedural complications of an experienced center. The follow-up of the TIPS patient has to assess shunt patency, liver function and hepatic encephalopathy. Shunt patency can best be monitored by duplex-sonography. Routine radiological revision seems not to be helpful and does not improve results, i.e., rebleeding and survival. Short term patency may be improved by anticoagulation, while such a treatment does not influence long-term patency. With respect to the indications of TIPS, much is known about treatment of variceal bleeding. The nine randomized studies that are available to date show that survival is comparable between patients receiving TIPS or endoscopic treatment. The second group of patients is the group with refractory ascites and related complications, such as hepatorenal syndrome and hepatic hydrothorax. It has been demonstrated that TIPS improves these complications, but randomized studies are still lacking. In addition, TIPS has been applied successfully to patients with Budd-Chiari syndrome, portal vein thrombosis, before liver transplantation, and for the treatment of ectopic portal hypertensive bleeding.
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Affiliation(s)
- M Rössle
- School of Medicine, Department of Gastroenterology and Hepatology, Freiburg, Germany
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Kamath PS, McKusick MA. Transjugular intrahepatic portosystemic shunts (TIPS). BAILLIERE'S CLINICAL GASTROENTEROLOGY 1997; 11:327-49. [PMID: 9395751 DOI: 10.1016/s0950-3528(97)90043-9] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
Transjugular intrahepatic portosystemic shunt (TIPS) is a procedure recently introduced for the management of complications of portal hypertension. TIPS can be placed in the liver with relative ease by a skilled radiologist with a low risk of mortality. The major complications following the procedure are infection, especially in patients undergoing emergency TIPS, intra-abdominal haemorrhage from capsular punctures, and long-term problems related to encephalopathy and stenosis of the shunt. Encephalopathy is more of a problem in older patients with wide diameter shunts. Stenosis of the shunt is related to pseudo-intimal hyperplasia, probably related to transection of bile ductules during placement of the shunt. In view of the high rate of encephalopathy and stenosis following the shunt, a careful follow-up of all patients, including ultrasonographic and angiographic examination of the shunt, is mandatory. TIPS is used predominantly for the control of acute variceal haemorrhage, prevention of recurrent variceal bleeding, and refractory ascites when conventional treatment has failed. However, the role of TIPS in the management of complications of portal hypertension still awaits the outcome of clinical trials.
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Affiliation(s)
- P S Kamath
- Department of Gastroenterology and Internal Medicine, Mayo Clinic, Rochester, MN 55905, USA
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Haskal ZJ, Rees CR, Ring EJ, Saxon R, Sacks D. Reporting standards for transjugular intrahepatic portosystemic shunts. Technology Assessment Committee of the SCVIR. J Vasc Interv Radiol 1997; 8:289-97. [PMID: 9084000 DOI: 10.1016/s1051-0443(97)70558-x] [Citation(s) in RCA: 33] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023] Open
Affiliation(s)
- Z J Haskal
- Department of Radiology, Hospital of the University of Pennsylvania, Philadelphia 19104, USA
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