TIPS with expanded polytetrafluoroethylene-covered stent: results of an Italian multicenter study

Transjugular Intrahepatic Portosystemic Shunt (TIPS) Check and Revision in a Freestanding Outpatient Facility: Safety and Efficacy

Aim This study aims to evaluate the safety and efficacy of transjugular intrahepatic portosystemic shunt (TIPS) check and revision procedures performed in a freestanding interventional radiology (IR) outpatient facility. Methodology A total of 40 patients (male 31:female 9, median age 60 years old) underwent a TIPS check and/or revision at a freestanding IR outpatient facility between 2009 and 2017. Procedures were performed using a mobile C-arm unit under intravenous (IV) moderate sedation, with the patient discharged home on the same day. The decision to perform a TIPS check was based on abnormal surveillance ultrasound findings or the recurrence of portal hypertension symptoms. TIPS were revised if the patient was found to have angiographic stenosis, elevated portosystemic gradients, or recurrent symptoms. TIPS were revised with balloon angioplasty and/or bare metal stent placement. Results Revision was attempted in 34 cases, and 6 were found to not require a revision. The average time to revision was 19 months (range 0.6-99 months). Of the 40 patients, 24 (60%) underwent a TIPS check and/or revision due to findings from surveillance ultrasound, while 16 (40%) underwent a check or revision due to a recurrence of symptoms. Of the 34 TIPS revisions, 28 (83%) involved angioplasty alone, 5 (15%) were stent-assisted, and 1 failed due to unsuccessful cannulation. The overall technical success rate for performing the revisions was 94% (32/34). The one-year patency rate was approximately 57%. The mean fluoroscopy time was 16.1 minutes (range: 3.7-52.5 minutes). Post-procedural recovery time was minimal, averaging one to two hours. No major complications were observed (0%, 0/40). One patient (2.5%, 1/40) experienced a minor complication (access site hematoma), and two patients were hospitalized within 30 days for reasons unrelated to the procedure. Conclusions TIPS revision can be performed successfully and safely in an outpatient facility.

Comparison of specialized stent versus generic stent and bare stent combination for transjugular intrahepatic portosystemic shunt creation

Transjugular intrahepatic portosystemic shunt (TIPS) creation using the Viatorr stent remains relatively uncommon in underdeveloped and high-burden disease regions in Asia-Pacific, and there is a lack of comparative studies regarding its prognostic effects compared with the generic stent-graft/bare stent combination. The purpose of this retrospective study is to compare the prognostic endpoints of these two treatments in patients who underwent TIPS creation. Clinical data from 145 patients were collected, including 82 in the combination group and 63 in the Viatorr group. Differences in prognostic endpoints (shunt dysfunction, death, overt hepatic encephalopathy [OHE], rebleeding) between the two groups were analyzed using Kaplan-Meier curves. The Cox proportional hazards model was used to identify independent risk factors for post-TIPS shunt dysfunction. The TIPS procedure was successful in all patients. After TIPS creation, both groups showed a significant decrease in porto-caval pressure gradient compared to that before TIPS creation. The stent patency rates at 6, 12, and 18 months were high in both the combination and Viatorr groups (93.7%, 88.5%, and 88.5% vs. 96.7%, 93.4%, and 93.4%, respectively). The stent patency rates was higher in the combination group than in the Viatorr group, although not statistically significant (HR = 2.105, 95% CI 0.640-6.922, Log-rank P = 0.259). There were no significant differences in other prognostic endpoints (death, OHE, rebleeding) between the two groups. The Cox model identified portal vein diameter (HR = 0.807, 95% CI 0.658-0.990, P = 0.040) and portal vein thrombosis (HR = 13.617, 95% CI 1.475-125.678, P = 0.021) as independent risk factors for post-TIPS shunt dysfunction. The shunt patency rates between the Viatorr stent and the generic stent-graft/bare stent combination showed no significant difference and the generic stent-graft/bare stent combination may be a viable alternative in areas where the Viatorr stent is not yet available.

Transjugular Intrahepatic Portosystemic Shunt: Devices Evolution, Technical Tips and Future Perspectives

Portal hypertension (PH) constitutes a pivotal factor in the progression of cirrhosis, giving rise to severe complications and a diminished survival rate. The transjugular intrahepatic portosystemic shunt (TIPS) procedure has undergone significant evolution, with advancements in stent technology assuming a central role in managing PH-related complications. This review aims to outline the progression of TIPS and emphasizes the significant influence of stent advancement on its effectiveness. Initially, the use of bare metal stents (BMSs) was limited due to frequent dysfunction. However, the advent of expanding polytetrafluoroethylene-covered stent grafts (ePTFE-SGs) heralded a transformative era, greatly enhancing patency rates. Further innovation culminated in the creation of ePTFE-SGs with controlled expansion, enabling precise adjustment of TIPS diameters. Comparative analyses demonstrated the superiority of ePTFE-SGs over BMSs, resulting in improved patency, fewer complications, and higher survival rates. Additional technical findings highlight the importance of central stent placement and adequate stent length, as well as the use of smaller calibers to reduce the risk of shunt-related complications. However, improving TIPS through technical means alone is inadequate for optimizing patient outcomes. An extensive understanding of hemodynamic, cardiac, and systemic factors is required to predict outcomes and tailor a personalized approach. Looking forward, the ongoing progress in SG technology, paired with the control of clinical factors that can impact outcomes, holds the promise of reshaping the management of PH-related complications in cirrhosis.

Expanded polytetrafluoroethylene (ePTFE)-covered stents versus bare stents for transjugular intrahepatic portosystemic shunt in people with liver cirrhosis

BACKGROUND

Transjugular intrahepatic portosystemic shunt (TIPS) is a widely used procedure for management of uncontrolled upper gastrointestinal bleeding and refractory ascites in people with liver cirrhosis. However, nearly half of the people experience shunt dysfunction and recurrent symptoms within one year of the procedure. Expanded polytetrafluoroethylene (ePTFE)-covered stents are assumed to decrease shunt dysfunction by approximately 20% to 30%.

OBJECTIVES

To evaluate the benefits and harms associated with the use of expanded polytetrafluoroethylene (ePTFE)-covered stents versus bare stents in transjugular intrahepatic portosystemic shunts (TIPSs) for managing people with liver cirrhosis.

SEARCH METHODS

We used standard, extensive Cochrane search methods. The latest search date was 28 February 2023.

SELECTION CRITERIA

Randomised clinical trials comparing ePTFE-covered stents versus bare stents in TIPS for treatment of people with liver cirrhosis.

DATA COLLECTION AND ANALYSIS

We used standard Cochrane methods. Our primary outcomes were 1. all-cause mortality, 2. procedure-related complications, and 3. health-related quality of life. Our secondary outcomes were 4. upper gastrointestinal bleeding, 5. recurrence of ascites, 6. hepatic encephalopathy, 7. kidney failure, 8. early thrombosis, 9. non-serious adverse events, and 10. shunt dysfunction. We used GRADE to assess certainty of evidence. We analysed outcome data at the maximum follow-up, except for the 'early thrombosis' outcome for which it was within 12 weeks after the TIPS procedure.

MAIN RESULTS

We included four trials with 565 randomised participants (age range: 18 to 75 years; male range: 63.6% to 75.0%). A total of 527 participants provided data for analyses because of losses to follow-up. Two trials were conducted in China; one in France; and one in France, Spain, and Canada. Participants were classified with cirrhosis Child-Pugh class A, B, or C, and for some, the class was not reported. We used intention-to-treat principle (four trials) and per-protocol analysis (one trial) to meta-analyse the data. One trial compared ePTFE-covered stents versus bare stents of the same diameter and three trials compared ePTFE-covered stents versus stents of different diameters. ePTFE-covered stents versus bare stents of the same diameter One trial with 258 participants compared 8 mm covered stent versus 8 mm bare stent. Mortality in the covered stent group is possibly lower than in the bare stent group (risk ratio (RR) 0.63, 95% confidence interval (CI) 0.43 to 0.92; low-certainty evidence). Upper gastrointestinal bleeding (RR 0.54, 95% CI 0.35 to 0.84), recurrence of ascites (RR 0.42, 95% CI 0.20 to 0.87), and shunt dysfunction (RR 0.42, 95% CI 0.28 to 0.61) occurred more often in the bare stent group than in the covered stent group (all low-certainty evidence). There was no difference in hepatic encephalopathy between groups (RR 1.10, 95% CI 0.76 to 1.61; very low-certainty evidence). The trial did not report data on procedure-related complications, health-related quality of life, early thrombosis, and segmental liver ischaemia (a non-serious adverse event). ePTFE-covered stents versus bare stents of different stent diameters Three trials compared ePTFE-covered stents versus bare stents of different diameters (10.5 (standard deviation (SD) 0.9) mm versus 11.7 (SD 0.8) mm; 8 mm versus 10 mm; and one trial used 10-mm stents that could be dilated from 8 mm to 10 mm). There was no evidence of a difference between the ePTFE-covered stents versus bare stents groups in mortality (RR 0.75, 95% CI 0.48 to 1.16; 3 trials, 269 participants), procedure-related complications (RR 0.53, 95% CI 0.05 to 5.57; 1 trial, 80 participants), upper gastrointestinal bleeding (RR 0.46, 95% CI 0.15 to 1.38; 3 trials, 269 participants), hepatic encephalopathy (RR 0.93, 95% CI 0.66 to 1.30; 3 trials, 269 participants), and kidney failure (RR 7.59, 95% CI 0.40 to 143.92; 1 trial, 121 participants) (all very low-certainty evidence). Recurrence of ascites (RR 0.30, 95% CI 0.11 to 0.85; 3 trials, 269 participants; low-certainty evidence), shunt dysfunction (RR 0.50, 95% CI 0.28 to 0.92; 3 trials, 269 participants; low-certainty evidence), and early thrombosis (RR 0.28, 95% CI 0.09 to 0.82; I2 = 0%; 3 trials, 261 participants; very low-certainty evidence) occurred more often in the bare stents group. There was no evidence of a difference in segmental liver ischaemia (RR 5.25, 95% CI 0.26 to 106.01; 1 trial, 80 participants; very low-certainty evidence). No trial presented data on health-related quality of life. Funding One trial did not clearly report funding sources. The remaining three trials declared that they had no funding with vested interests.

AUTHORS' CONCLUSIONS

Based on the small number of trials with insufficient sample size and events, and study limitations, we assessed the overall certainty of evidence in the predefined outcomes as low or very low. Therefore, we are uncertain which of the two interventions (ePTFE-covered stents or bare stents of the same diameter and ePTFE-covered stents versus bare stents of different stent diameters) is effective for the evaluated outcomes. None of the four trials reported data on health-related quality of life, and data on complications were either missing or rarely reported. We lack high-quality trials to evaluate the role of ePTFE-covered stents for TIPS for managing people with liver cirrhosis.

Transjugular Intrahepatic Portosystemic Shunt With or Without Gastroesophageal Variceal Embolization for the Prevention of Variceal Rebleeding: A Systematic Review and Meta-Analysis

Background

The role of variceal embolization (VE) during transjugular intrahepatic portosystemic shunt (TIPS) creation for preventing gastroesophageal variceal rebleeding remains controversial. Therefore, we performed a meta-analysis to compare the incidence of variceal rebleeding, shunt dysfunction, encephalopathy, and death between patients treated with TIPS alone and those treated with TIPS in combination with VE.

Methods

We performed a literature search using PubMed, EMBASE, Scopus, and Cochrane databases for all studies comparing the incidence of complications between TIPS alone and TIPS with VE. The primary outcome was variceal rebleeding. Secondary outcomes include shunt dysfunction, encephalopathy, and death. Subgroup analysis was performed based on the type of stent (covered vs. bare metal). The random-effects model was used to calculate the relative risk (RR) with the corresponding 95% confidence intervals (CIs) of outcome. A P value < 0.05 was considered statistically significant.

Results

Eleven studies with a total of 1,075 patients were included (597: TIPS alone and 478: TIPS plus VE). Compared to the TIPS alone, the TIPS with VE had a significantly lower incidence of variceal rebleeding (RR: 0.59, 95% CI: 0.43 - 0.81, P = 0.001). Subgroup analysis revealed similar results in covered stents (RR: 0.56, 95% CI: 0.36 - 0.86, P = 0.008) but there was no significant difference between the two groups in the subgroup analysis of bare stents and combined stents. There was no significant difference in the risk of encephalopathy (RR: 0.84, 95% CI: 0.66 - 1.06, P = 0.13), shunt dysfunction (RR: 0.88, 95% CI: 0.64 - 1.19, P = 0.40), and death (RR: 0.87, 95% CI: 0.65 - 1.17, P = 0.34). There were similarly no differences in these secondary outcomes between groups when stratified according to type of stent.

Conclusions

Adding VE to TIPS reduced the incidence of variceal rebleeding in patients with cirrhosis. However, the benefit was observed with covered stents only. Further large-scale randomized controlled trials are warranted to validate our findings.

Transjugular intrahepatic portosystemic shunt (TIPS) complications: what diagnostic radiologists should know

Transjugular intrahepatic portosystemic shunt (TIPS) is an effective therapy for portal hypertension complications and can successfully treat variceal bleeding and refractory ascites. Although TIPS is relatively safe, procedural- or shunt-related morbidity can reach 20%, and procedural complications have a fatality rate of 2%. Delayed recognition and treatment of TIPS complications can lead to life-threatening clinical scenarios. Complications can vary from stent migration or malpositioning to nontarget organ injury, TIPS dysfunction, encephalopathy, or liver failure. This review aims to outline the role of diagnostic radiology in assessing post-TIPS complications.

Prevention of post-tips hepatic encephalopathy: The search of the ideal candidate

Transjugular intrahepatic portosystemic shunt (TIPS) has been used since more than 25 years to treat some of the complications of portal hypertension, especially variceal bleeding and ascites refractory to conventional therapy. TIPS establishes a communication between the portal and hepatic veins, inducing the blood to shift from the splanchnic circulation into the systemic vascular bed with the aim of decompressing the portal venous system, and avoids the major complications of portal hypertension. However, the shunt of the portal blood into the systemic circulation is the cause of one of the major complications of the procedure: the post-TIPS hepatic encephalopathy (HE). To date, few pharmacological treatment has been proven effective to prevent this complication and thus, the identification of patients at high risk of post-TIPS hepatic encephalopathy and the patients' carefully selection is the only way to prevent this frequent complication.

Retrospective evaluation of early thrombosis in transjugular intrahepatic portosystemic polytetrafluoroethylene-coated shunts under 2-day postinterventional heparinization

The development of acute thrombosis within the TIPS tract may be prevented by prophylactic anticoagulation; however, there is no evidence of the correct anticoagulation regimen after TIPS placement. The purpose of this single-center retrospective study was to evaluate the short-term occlusion rate of transjugular intrahepatic portosystemic shunts (TIPSs) with polytetrafluorethylene (PTFE)-coated stents under consequent periprocedural full heparinization (target partial thromboplastin time [PTT]: 60–80 s). We analyzed TIPS placements that were followed up over a six-month period by Doppler ultrasound in 94 patients and compared the study group of 54 patients who received intravenous periprocedural full heparinization (target PTT: 60–80 s) without any other anticoagulation to patients with prolonged anticoagulation medication. The primary endpoint was TIPS patency after six months. The primary patency rate was 88.3% overall, and in the study group, 90.7%, with an early thrombosis rate of 3.2% (study group: 1.9%) and a primary assisted patency rate of 95.7% (study group: 96.3%). In the study group, one case of TIPS thrombosis occurred on the 23rd day after TIPS placement. Two patients underwent reintervention because of stenosis or buckling. Moreover, the target PTT was not attained in 8 of the 54 patent TIPSs. Four patients had an increased portosystemic pressure gradient, without stenosis, and the flow rate was corrected by increasing the TIPS diameter by dilation. Two-day heparinization seems sufficient to avoid early TIPS thrombosis over a six-month period.

Predicting death or recurrence of portal hypertension symptoms after TIPS procedures

BACKGROUND

Accurate prediction of portal hypertension recurrence after transjugular intrahepatic portosystemic shunt (TIPS) placement will improve clinical decision-making.

PURPOSE

To evaluate if perioperative variables could predict disease-free survival (DFS) in cirrhotic patients with portal hypertension (PHT) treated with TIPS.

MATERIALS AND METHODS

We recruited 206 cirrhotic patients with PHT treated with TIPS, randomly assigned to training (n = 138) and validation (n = 68) sets. We recorded 7 epidemiological, 4 clinical, and 9 radiological variables. TIPS-distal end positioning (TIPS-DEP) measured the distance between the distal end of the stent and the hepatocaval junction on contrast-enhanced CT scans. In the training set, the signature was defined as the random forest for survival algorithm achieving the lowest error rate for the prediction of DFS which was landmarked 4 weeks after the TIPS procedure. In the training set, a simple to use scoring system was derived from variables selected by the signature. The primary endpoint was to assess if TIPS-DEP was associated with DFS. The secondary endpoint was to validate the scoring system in the validation set.

RESULTS

Overall, patients with TIPS-DEP ≥ 6 mm (n = 49) had a median DFS of 24.5 months vs. 72.8 months otherwise (n = 157, p = 0.004). In the training set, the scoring system was calculated by adding age ≥ 60 years old, Child-Pugh B or C, and TIPS-DEP ≥ 6 mm (1 point each) since the signature showed high DFS probability at 6.5 months post-landmark in patients that did not meet these criteria: 86%, 80%, and 78%, respectively. The hazard ratio [95 CI] between patients determined to be low-risk (< 2 points) and high-risk (≥ 2 points) was 2.30 [1.35-3.93] (p = 0.002) in the training set and 2.01 [0.94-4.32] (p = 0.072) in the validation set.

CONCLUSION

TIPS-DEP is an actionable radiological biomarker which can be combined with age and Child-Pugh score to predict death or PHT symptom recurrence after TIPS procedure.

KEY POINTS

• TIPS-DEP measurement was the third most important but only actionable variable for predicting DFS. • TIPS-DEP < 6 mm was associated with a DFS probability of 78% at 6.5 months post-landmark. • A simple scoring system calculated using age, Child-Pugh score, and TIPS-DEP predicted DFS after TIPS.

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.

Transjugular intrahepatic portosystemic shunt for Budd-Chiari syndrome: A comprehensive review

Budd-Chiari syndrome (BCS) is a relatively rare clinical condition with a wide range of symptomatology, caused by the obstruction of the hepatic venous outflow. If left untreated, it has got an high mortality rate. Its management is based on a step-wise approach, depending on the clinical presentation, and includes different treatment from anticoagulation therapy up to Interventional Radiology techniques, such as transjugular intrahepatic portosystemic shunt (TIPS). TIPS is today considered a safe and highly effective treatment and should be recommended for BCS patients, including those awaiting orthotopic liver transplantation. In this review the pathophysiology, diagnosis and treatment options of BCS are presented, with a special focus on published data regarding the techniques and outcomes of TIPS for the treatment of BCS. Moreover, unresolved issues and future research will be discussed.

Comparison of embolic agents for varices during transjugular intrahepatic portosystemic shunt for variceal bleeding: Tissue gel or coil?

Purpose

We aimed to compare treatment efficacy, safety and material cost between tissue gel and coil regarding variceal embolization during transjugular intrahepatic portosystemic shunt (TIPS).

Materials & Methods: This retrospective study including cirrhotic patients with variceal bleeding treated with TIPS combined with variceal embolization between January 2016 and August 2017. Patients were divided into three groups according to embolic agents used in variceal embolization: tissue gel group (Group A), combination group (Group B), and coil group (Group C). The primary endpoint was 1-year rebleeding rate after TIPS creation. The secondary endpoints included shunt dysfunction, overt hepatic encephalopathy, liver function, and embolic agents-related expense.

Results

A total of 60 patients (30, 10, and 20 in Group A, B, and C) were included. Variceal rebleeding occurred in 3 (10%), 0 (0%), and 4 (20%) patients within one year after TIPS creation in Group A, B, and C, respectively. Stent dysfunction occurred in 2 (3.3%) patients and 9 (15.0%) patients experienced overt hepatic encephalopathy. No significant differences were observed between three groups regarding primary and secondary endpoints except embolic agents-related expense, with a significantly lower cost in Group A when compared to the other two groups. Stent dysfunction occurred in two patients, with one patient in Group A developed acute occlusion caused by thrombus and another patient in Group C underwent stent stenosis during follow-up.

Conclusions

Compares to coil alone or combines with coil, tissue gel has similar treatment efficacy and safety, but with significantly lower cost for variceal bleeding during TIPS.

The Pull-Through Technique for Recanalization of Transjugular Intrahepatic Portosystemic Shunt Dysfunction

Purpose

To evaluate the technical efficacy and safety of the pull-through technique in recanalization of transjugular intrahepatic portosystemic shunt (TIPS) when standard transjugular approach is inaccessible.

Materials and Methods

A retrospective review of patients underwent TIPS revision via the pull-through technique was performed. Transhepatic directly punctured stent was conducted if the portal vein could not be accessed via standard transjugular approach. Technical success was defined by recanalization of shunt. Clinical success was defined as bleeding interruption and ascites regression without pharmacological support. All patients were followed up by clinical evaluation and Doppler ultrasound.

Results

Between January 2010 and December 2016, a total of 63 patients underwent TIPS revision, and 14 of them could not be accessed via standard transjugular approaches owing to stenosis or occlusion of the hepatic vein. The pull-through technique was successful in 13 patients, and one patient underwent parallel TIPS. No procedure-related complication was observed. One patient died of liver failure one week after the procedure. During the follow-up, three patients developed hepatic encephalopathy, and one patient developed TIPS dysfunction again and experienced variceal bleeding. The primary patency rate after TIPS revision was 92% (11/12) at 12 months.

Conclusion

The pull-through technique was effective and safe for recanalization of TIPS inaccessible via standard transjugular approach.

Long-term follow-up of transjugular intrahepatic portosystemic shunt (TIPS) with stent-graft

PURPOSE

We aimed to retrospectively evaluate the long-term clinical and patency results after the placement of transjugular intrahepatic portosystemic shunts (TIPS) using stent-graft. Many studies show the clinical results and the patency follow-up of TIPS with stent-graft in the short and medium term. However, few studies show long-term results.

METHODS

Between 2002 and 2016, TIPS with stent-grafts were placed in 132 patients. The median age was 59.5 years. The median Model for End-stage Liver Disease (MELD) score was 13, and 71% were Child-Pugh B. Indications for TIPS were bleeding (83%) and ascites or hydrothorax (17%). The technical and clinical success rates were calculated, as were the rates of patency, survival and complications. The median follow-up period was 43 months.

RESULTS

The technical success rate was 98%, and the clinical success rates were 85% in patients with indication for bleeding and 95% in patients with indication for ascites or hydrothorax. Primary patency did not decrease from 66% after 6 years (95% confidence interval [CI], 56.2%-75.8%) primary assisted patency remained stable at 87% after 6 years (95% CI, 77.2%-96.8%) and secondary patency did not decrease from 98% after 4 years (95% CI, 95.1%-100%). The median overall survival was 42.8 months (95% CI, 33.8-51.8 months). A total of 54 patients suffered some type of complication, minor (28 patients) or major (26 patients), during the follow-up.

CONCLUSION

The clinical success rate was high. The choice of the maximum initial limit of portosystemic gradient and the diameter of the post-TIPS shunt, together with the number of shunt reductions, are important to be able to compare results between publications. In our study, the patency rates did not decrease after 6 years; hence, long-term follow-up of these patients may not be necessary.

Clinical effect of single covered stent and double covered stent on TIPS in the treatment of hemorrhage due to rupture of esophageal and gastric varices in cirrhosis and its influence on immune function

Clinical effect of single covered stent and double covered stent in transjugular intrahepatic portosystemic shunt (TIPS) in the treatment of hemorrhage due to rupture of esophageal and gastric varices in cirrhosis and its influence on the immune function of patients was investigated. Altogether 124 patients with liver cirrhosis and esophageal and gastric varices bleeding who were admitted to the First People's Hospital of Neijiang from February 2012 to April 2016 were selected as research objects and divided into group A and B. Group A (65 cases) was treated with simple covered stent, and group B (59 cases) was treated with double covered stent simulating Viatorr technique. The therapeutic effect of the two groups after operation was observed. The changes of portal vein pressure before and after treatment and the changes of esophageal and gastric varices after operation were observed. The levels of peripheral blood T lymphocyte subsets (CD3⁺, CD4⁺ and CD4⁺/CD8⁺) were detected by flow cytometry. The therapeutic effect of group B was higher than that of group A (P>0.05). The postoperative portal vein pressure in group B was significantly lower than that in group A (P<0.05). The disappearance rate and overall effective rate of varicose veins in group B were better than those in group A (P>0.05). After three days of treatment, the levels of CD3⁺, CD4⁺, CD4⁺/CD8⁺ in the peripheral blood of group B were higher than those of group A (P>0.05), while the decline rate of CD3⁺, CD4⁺, CD4⁺/CD8⁺ in the peripheral blood of group B was higher than that of group A after seven days of treatment. Double-stent simulated Viatorr has a higher effective rate, has a certain improvement on the immune function of patients, and the survival rate is also higher than that of single covered stent, which is worthy of clinical application and promotion.

An Update: Portal Hypertensive Gastropathy and Colopathy

Complications of portal hypertension include portal hypertensive gastropathy and colopathy. These disorders may cause chronic or acute gastrointestinal bleeding. The diagnosis is made endoscopically; therefore, there is great variability in their assessment. Portal hypertensive gastropathy can range from a mosaic-like pattern resembling snakeskin mucosa to frankly bleeding petechial lesions. Portal hypertensive colopathy has been less well-described and is variably characterized (erythema, vascular lesions, petechiae). Treatment is challenging and results are inconsistent. Currently, available evidence does not support the use of beta-blockers for primary prevention. Further investigation of the pathogenesis, natural history, and treatment of these disorders is needed.

Refractory ascites-the contemporary view on pathogenesis and therapy

Refractory ascites (RA) refers to ascites that cannot be mobilized or that has an early recurrence that cannot be prevented by medical therapy. Every year, 5-10% of patients with liver cirrhosis and with an accumulation of fluid in the peritoneal cavity develop RA while undergoing standard treatment (low sodium diet and diuretic dose up to 400 mg/day of spironolactone and 160 mg/day of furosemide). Liver cirrhosis accounts for marked alterations in the splanchnic and systemic hemodynamics, causing hypovolemia and arterial hypotension. The consequent activation of renin-angiotensin and sympathetic systems and increased renal sodium re-absorption occurs during the course of the disease. Cirrhotic patients with RA have poor prognoses and are at risk of developing serious complications. Different treatment options are available, but only liver transplantation may improve the survival of such patients.

[Redo surgery for portacaval shunt dysfunction after TIPS procedure]

AIM

To analyze various methods for treatment of TIPS dysfunction.

MATERIAL AND METHODS

There were 45 patients (29 men, 16 women, aged 52.2±2.03 years) with TIPS dysfunction. Dysfunction of bare-metal stent was noted in 29 cases, stent-graft - in 16 cases. TIPS thrombosis occurred in 24 patients, hyperplasia of hepatic vein intima - in 7, pseudointimal hyperplasia of the shunt - in 7, liver tissue prolapse - in 5, migration of stent - in 2 patients. Redo surgery included rheolytic thrombectomy, balloon angioplasty, stent-in-stent technique, u-shaped and parallel stenting.

RESULTS

Patients were hospitalized in 3, 6 and 12 months after surgery for evaluation of the results of redo interventions. Balloon angioplasty and rheolytic thrombectomy (5 patients) were followed by TIPS dysfunction after 1 week in 2 patients, after 12 months - in 2. Normal function of stent over 1 year was noted in 1 patient. Isolated balloon angioplasty (n=23) was followed by TIPS dysfunction within 1 week in 13 patients, within 3 months in 3 patients, up to 6 months in 1 patient, within 6-12 months in 1 patient. Normal function of TIPS over 1 year was observed in 4 patients. Stent-in-stent stenting (n=18) was followed by early thrombosis in 5 patients, normal function of TIPS up to 3 months was noted in 3 patients, within 3-6 months - in 2 patients, up to 1 year - in 1 patient. Normal function of TIPS over 1 year was observed in 7 patients. TIPS thrombosis occurred in 1 patient on the 2^nd day after U-shaped stenting. Normal function of TIPS over 1 year was observed in another patient after the same procedure. Early TIPS dysfunction occurred in 2 patients after parallel stenting, dysfunction within 3 months was revealed in 2 patients. Normal function of TIPS over 1 year was observed in 2 patients.

CONCLUSION

Rheolytic thrombectomy combined with balloon angioplasty is preferred for early TIPS dysfunction. Parallel stenting is advisable in long-term period. The use of stent grafts as a shunt can reduce the incidence of TIPS dysfunction.

Image-guided treatment of Budd-Chiari syndrome: a giant leap from the past, a small step towards the future

Budd-Chiari syndrome (BCS) is a relatively rare vascular disease characterized by hepatic outflow tract obstruction, and image-guided endovascular treatment, namely percutaneous angioplasty, stenting, and transjugular intrahepatic portosystemic shunt (TIPS), has proven to be effective treatment modalities to alleviate symptoms and markedly improve the prognosis of the disease. Specifically, a step-wise approach is recommended, i.e., angioplasty and stenting are the prioritized choice for patients with membranous obstruction and short-length stenosis, whereas TIPS is the option for patients who fail this treatment. Currently, 5-year survival with the step-wise approach is about 75%, and the most promising way to further improve this value is to identify candidates who are at high risk of failing angioplasty, and perform pre-emptive TIPS in these patients.

ePTFE-TIPS vs repetitive LVP plus albumin for the treatment of refractory ascites in patients with cirrhosis

BACKGROUND & AIMS

Reduction in portal pressure by self-expandable polytetrafluoroethylene (ePTFE)-covered transjugular intrahepatic portosystemic shunts (TIPS) is a treatment option for refractory ascites. Data on clinical outcomes after ePTFE-TIPS vs repetitive large-volume paracentesis (LVP) plus albumin (A) administration for the treatment of patients with refractory ascites are limited.

METHODS

Retrospective comparison of ePTFE-TIPS vs LVP+A in terms of (i) control of ascites, (ii) occurrence of overt hepatic encephalopathy (HE) and (iii) transplant-free survival in cirrhotic patients with refractory ascites.

RESULTS

Among n = 221 patients with cirrhosis and refractory ascites, n = 140 received ePTFE-TIPS and were compared to n = 71 patients undergoing repetitive LVP+A. After ePTFE-TIPS, ascites was controlled without any further need for paracentesis in n = 76 (54%; n = 7 without and n = 69 with diuretics). The need for frequent large-volume paracentesis was significantly higher in the LVP+A group than with ePTFE-TIPS (median 0.67 (IQR: 0.23-2.63) months vs 49.5 (IQR: 5.07-102.60) months until paracentesis, log-rank P < .001). De-novo incidence of HE was similar in ePTFE-TIPS and LVP+A patients (log-rank P = .361). Implantation of ePTFE-TIPS was associated with improved 1-year survival as compared to LVP+A (65.6% vs 48.4%, log-rank P = .033). Age (odds ratio (OR):1.05; 95% confidence interval (95% CI):1.03-1.07; P < .001), serum albumin (OR: 0.95; 95% CI: 0.92-0.99; P = .013) and hepatocellular carcinoma (OR: 1.66; 95% CI: 1.06-2.58; P = .026) emerged as independent predictors of survival.

CONCLUSIONS

ePTFE-TIPS results in superior control of ascites without increasing the risk for overt HE as compared to LVP+A. Although ePTFE-TIPS improved 1-year survival in cirrhotic patients with refractory ascites, its use was not independently associated with transplant-free survival.

Transjugular intrahepatic portosystemic shunt treatment of variceal bleeding in an unselected patient population

OBJECTIVE

To evaluate transjugular intrahepatic portosystemic shunt (TIPS) in variceal bleeding in a clinical setting.

MATERIALS AND METHODS

Retrospective review of 131 patients (116 with liver cirrhosis) treated with TIPS with covered stent grafts in a single centre from 2002 to 2016.

RESULTS

Survival at 1 and 2 years was 70% and 57% in patents with, and 100% at 2 years in patients without liver cirrhosis, respectively. A high Child-Pugh score and severe hepatic encephalopathy (HE) within 12 months post-TIPS were related to increased mortality. Re-bleeding occurred in 8% within 12 months and was related to TIPS dysfunction and a post-TIPS portosystemic gradient (PSG) of ≥5 mmHg. The main cause of TIPS dysfunction was that the stent did not fully reach the inferior vena cava. There was no correlation between the PSG and the occurrence of HE.

CONCLUSIONS

TIPS was safe and prevented re-bleeding in patients with variceal bleeding, with or without liver cirrhosis, regardless of Child-Pugh class and of how soon after bleeding onset, the TIPS procedure was performed. A post-TIPS PSG of ≥5 mmHg was associated with an increased risk for re-bleeding and there was no correlation between the post-TIPS PSG and the occurrence of HE.

Construction of Transjugular Intrahepatic Portosystemic Shunt: Bare Metal Stent/Stent-graft Combination versus Single Stent-graft, a Prospective Randomized Controlled Study with Long-term Patency and Clinical Analysis

BACKGROUND

Balanced adjustment of the portal vein shunt volume during a transjugular intrahepatic portosystemic shunt (TIPS) is critical for maintaining liver perfusion and decreasing the incidence of liver insufficiency. A stent-graft is proved to be superior to a bare metal stent (BMS) for the construction of a TIPS. However, the clinical results of the combination application of stents and stent-grafts have not been determined. This study aimed to compare the technique of using a combination of stents and stent-grafts with using a single stent-graft to construct a TIPS.

METHODS

From April 2011 to November 2014, a total of fifty patients were randomly assigned to a stents-combination group (Group I, n = 28) or a stent-graft group (Group II, n = 22). Primary patency rates were calculated. Clinical data, including the technical success rate, bleeding control results, incidence of encephalopathy, liver function preservation, and survival rate, were assessed.

RESULTS

Technically, the success rate was 100% for both groups. The primary patency rates at 1, 2, and 3 years for Group I were 96%, 84%, and 77%, respectively; for Group II, they were 90%, 90%, and 78%, respectively. The survival rates at 1, 2, and 3 years for Group I were 79%, 74%, and 68%, respectively; for Group II, they were 82%, 82%, and 74%, respectively. The incidence of hepatic encephalopathy was 14.3% for Group I and 13.6% for Group II. The Child-Pugh score in Group I was stable at the end of the follow-up but had significantly increased in Group II (t = -2.474, P = 0.022).

CONCLUSIONS

The construction of a TIPS with either the single stent-graft or BMS/stent-graft combination is effective for controlling variceal bleeding. The BMS/stent-graft combination technique is superior to the stent-graft technique in terms of hepatic function preservation indicated by the Child-Pugh score. However, considering the clinical results of the TIPS, the two techniques are comparable in their primary shunt patency, incidence of encephalopathy and patient survival during the long-term follow-up.

An Algorithm for Management After Transjugular Intrahepatic Portosystemic Shunt Placement According to Clinical Manifestations

We propose an algorithm for management after transjugular intrahepatic portosystemic shunt (TIPS) placement according to clinical manifestations. For patients with an initial good clinical response, surveillance Doppler ultrasound is recommended to detect stenosis or occlusion. A TIPS revision can be performed using basic or advanced techniques to treat stenosis or occlusion. In patients with an initial poor clinical response, a TIPS venogram with pressure measurements should be performed to assess shunt patency. The creation of a parallel TIPS may also be required if the patient is symptomatic and the portal pressure remains high after TIPS revision. Additional procedures may also be necessary, such as peritoneovenous shunt (Denver shunt) placement for refractory ascites, tunneled pleural catheter for hepatic hydrothorax, and balloon-occluded retrograde transvenous obliteration procedure for gastric variceal bleeding. A TIPS reduction procedure can also be performed in patients with uncontrolled hepatic encephalopathy or hepatic failure.

Expanded polytetrafluoroethylene-covered stent-grafts for transjugular intrahepatic portosystemic shunts in cirrhotic patients: Long-term patency and clinical outcome results

PURPOSE

To retrospectively analyse long-term patency and overall survival of cirrhotic patients treated with TIPSS using e-PTFE-covered stents. Additionally, prognostic factors for better patency and survival were analysed.

MATERIALS AND METHODS

Two hundred and eighty-five consecutive cirrhotic patients with severe portal hypertension-related symptoms were included. Follow-up, including clinical assessment and duplex ultrasound, was analysed up to end of study, patient's death, liver transplantation or TIPSS-reduction. Patency rates and overall survival were estimated by the Kaplan-Meier method; potential differences in outcome between subgroups were calculated using the Pepe and Mori test.

RESULTS

The 1-, 2- and 5-year primary patencies were 91.5 %, 89.2 % and 86.2 %, respectively, with no new shunt dysfunctions after 5 years' follow-up. TIPSS revision was performed more often in ascites patients (P = 0.02). The 1-, 4- and 10-year survival rates were 69.2 %, 52.1 % and 30.7 %, respectively. Survival was higher in Child-Pugh class A-B (P = 0.04), in the recurrent bleeding group (P = 0.008) and in patients with underlying alcoholic cirrhosis (P = 0.01).

CONCLUSION

Long term, primary patency of e-PTFE-covered TIPSS stents remains very high (>80 %); shunt revision was required more frequently in ascites patients. Overall survival was better in Child-Pugh A-B patients with recurrent variceal bleeding and alcoholic liver cirrhosis.

KEYPOINTS

• Long-term primary patency rate of e-PTFE-covered TIPSS stents remains very high. • No new shunt dysfunction was found after 5 years of follow-up. • Shunt revision was required more frequently in ascites patients. • Four and 10 years' overall survival was 50 and 30 %, respectively.

Efficacy of covered and bare stent in TIPS for cirrhotic portal hypertension: A single-center randomized trial

We conducted a single-center randomized trial to compare the efficacy of 8 mm Fluency covered stent and bare stent in transjugular intrahepatic portosystemic shunt (TIPS) for cirrhotic portal hypertension. From January 2006 to December 2010, the covered (experimental group) or bare stent (control group) was used in 131 and 127 patients, respectively. The recurrence rates of gastrointestinal bleeding (18.3% vs. 33.9%, P = 0.004) and refractory hydrothorax/ascites (6.9% vs. 16.5%, P = 0.019) in the experimental group were significantly lower than those in the control group. The cumulative restenosis rates in 1, 2, 3, 4, and 5-years in the experimental group (6.9%, 11.5%, 19.1%, 26.0%, and 35.9%, respectively) were significantly lower (P < 0.001) than those in the control group (27.6%, 37.0%, 49.6%, 59.8%, 74.8%, respectively). Importantly, the 4 and 5-year survival rates in the experimental group (83.2% and 76.3%, respectively) were significantly higher (P = 0.001 and 0.02) than those in the control group (71.7% and 62.2%, respectively). The rate of secondary interventional therapy in the experimental group was significantly lower than that in the control group (20.6% vs. 49.6%; P < 0.001). Therefore, Fluency covered stent has advantages over the bare stent in terms of reducing the restenosis, recurrence, and secondary interventional therapy, whereas improving the long-term survival for post-TIPS patients.

Shunt stenosis or occlusion after transjugular intrahepatic portosystemic shunt

Transjugular intrahepatic portosystemic shunt (TIPS) has been extensively used to treat the complications of portal hypertension and should be considered the first-line treatment for hemorrhage of acute esophagogastric varices caused by portal hypertension. However, stent stenosis or occlusion after TIPS is the main cause of shunt dysfunction and surgical failure. This paper aims to make a comprehensive review of stents, with the focus being on the development of stents and stent coat material, the reason of shunt stenosis or occlusion, and the revision of shunt.

Clinical Management of Chronic Portal/Mesenteric Vein Thrombosis: The Surgeon's Point of View

BACKGROUND

Bleeding from esophageal varices is a life-threatening complication of chronic portal hypertension (PH), occuring in 15% of patients with a mortality rate between 20 and 35%.

METHODS

Based on a literature review and personal experience in the therapy of PH, we recommend a therapy strategy for the secondary prophylaxis of variceal bleeding in PH.

RESULTS

The main causes for PH in western countries are alcoholic/viral liver cirrhosis and extrahepatic portal/mesenteric vein occlusion, mainly caused by myeloproliferative neoplasms or hypercoagulability syndromes. The primary therapy is medical; however, when recurrent bleeding occurs, a definitive therapy is required. In the case of parenchymal decompensation, liver transplantation is the causal therapy, but in case of good hepatic reserve or without underlying liver disease, a portal decompressive therapy is necessary. Transjugular intrahepatic portosystemic shunt has achieved a widespread acceptance, although evidence is comparable with or better for surgical shunting procedures in patients with good liver function. The type of surgical shunt should be chosen depending on the patent veins of the portovenous system and the personal expertise.

CONCLUSION

The therapy decision should be based on liver function, morphology of the portovenous system, and imminent liver transplantation and should be made by an interdisciplinary team of gastroenterologists, interventional radiologists, and visceral surgeons.

Endovascular Removal of the Viatorr Stent-Grafts. Report of Two Cases

BACKGROUND

The dysfunction of misplaced or dislodged endovascular endoprostheses, may be a serious complication, and endovascular removal may be attempted in some cases.

CASE REPORT

A Viatorr(®) stent-graft (Gore, Flagstaff, AR, USA) is an endoprosthesis designed and commonly used for creation of a transjugular intrahepatic portosystemic shunt (TIPS). Two Viatorrs were accidentally dislodged during TIPS procedure. In another patient, the Viatorr was malpositioned, with its distal end being placed in the bile duct. All endoprostheses were successfully removed without serious complications.

CONCLUSIONS

Removal of a misplaced or dislodged Viatorr endoprosthesis is possible using interventional methods.

Long-Term Patency and Clinical Analysis of Expanded Polytetrafluoroethylene-Covered Transjugular Intrahepatic Portosystemic Shunt Stent Grafts

PURPOSE

To evaluate long-term patency and symptomatic recurrence rates following transjugular intrahepatic portosystemic shunt (TIPS) creation with expanded polytetrafluoroethylene (ePTFE)-covered stent grafts and to determine the necessity of extended clinical follow-up beyond 2 years after TIPS creation.

MATERIALS AND METHODS

A retrospective review including 262 TIPSs created with ePTFE-covered stent grafts between July 2002 and October 2012 was performed. Primary, primary assisted, and secondary patency rates were calculated. Assessment of clinical data included technical, hemodynamic, and clinical success rates, as well as mortality after TIPS creation.

RESULTS

Primary patency rates at 2, 4, and 6 years were 74%, 62%, and 50%, respectively. Primary assisted patency rates at 2, 4, and 6 years were 93%, 85%, and 78%, respectively. Secondary patency rates at 2, 4, and 6 years were 99%, 91%, and 84%, respectively. Technical and hemodynamic success rates were 99% and 93%, respectively. Clinical success rates for refractory ascites were 66% (complete response) and 90% (partial response); clinical success rate for bleeding/varices was 90%. Mortality rates at 2, 4, and 6 years after TIPS creation were 27%, 38%, and 46%, respectively. At the median wait time until transplantation, patients had an 84% chance of being alive. TIPS dysfunction developed in 21% of patients; 30% of revisions occurred later than 2 years during follow-up.

CONCLUSIONS

Beyond 2 years after TIPS creation, patency rates gradually decrease, mortality rates continue to increase, and the chance of recurrent ascites or bleeding remains present. Together, these findings suggest that continued clinical follow-up beyond 2 years is necessary in patients with a TIPS created with an ePTFE-covered stent graft.

Expression of vasoactive proteins in gastric antral mucosa reflects vascular dysfunction in patients with cirrhosis and portal hypertension

BACKGROUND & AIMS

Patients with cirrhosis display hypocontractility of splanchnic vessels because of dysregulation of vasoactive proteins, such as decreased effect of RhoA/ROCK and increased activity of β-Arrestin-2 and eNOS. However, it is unknown whether the dysregulation of vasoactive proteins is displayed in other vessels. We investigated whether expression of vasoactive proteins can be evaluated in gastric mucosa vessels.

METHODS

Biopsies from the gastric mucosa of 111 patients with cirrhosis were collected at three different centres and from 13 controls. Forty-nine patients had received TIPS. Portal pressure gradient was measured in 49 patients with TIPS and in 16 patients without TIPS. Biopsies from the antrum were conserved in formaldehyde for immunohistochemistry or shock-frozen for PCR and Western blot.

RESULTS

The mucosal transcription of vascular markers (αSMA, CD31) was higher in cirrhotic patients than controls, which was confirmed by immunohistochemistry. On average, relative mucosal levels of RhoA and ROCK were lower, while β-Arrestin-2 levels were higher in cirrhotic patients compared to controls. Transcriptional levels of eNOS increased with presence of ascites and grade of oesophageal varices. Patients with TIPS showed less pronounced markers of vascular dysfunction in gastric mucosa.

CONCLUSION

This is the first evidence that the expression of vasoactive proteins in mucosa from the gastric antrum of patients with cirrhosis reflects their vascular dysfunction and possibly changes after therapeutic interventions.

Volumetric blood flow in transjugular intrahepatic portosystemic shunt revision using 3-dimensional Doppler sonography

OBJECTIVES

Three-dimensional (3D)/4-dimensional (4D) sonographic measurement of blood volume flow in transjugular intrahepatic porto systemic shunt revision with the intention of objective assessment of shunt patency.

METHODS

A total of 17 patients were recruited (12 male and 5 female; mean age, 55 years; range, 30-69 years). An ultrasound system equipped with a 2.0-5.0-MHz probe was used to acquire multivolume 3D/4D color Doppler data sets to assess prerevision and postrevision shunt volume flow. Volume flow was computed offline based on the principle of surface integration of Doppler-measured velocity vectors in a lateral-elevational c-surface positioned at the color flow focal depth (range, 8.0-11.5 cm). Volume flow was compared to routine measurements of the prerevision and postrevision portosystemic pressure gradient. Prerevision volume flow was compared with the outcome to determine whether a flow threshold for revision could be defined.

RESULTS

Linear regression of data from revised transjugular intrahepatic portosystemic shunt cases showed an inverse correlation between the mean-normalized change in prerevision and postrevision shunt volume flow and the mean-normalized change in the prerevision and postrevision portosystemic pressure gradient (r(2) = 0.51; P = .020). Increased shunt blood flow corresponded to a decreased pressure gradient. Comparison of prerevision flows showed preliminary threshold development at 1534 mL/min, below which a shunt revision may be recommended (P = .21; area under the receiver operating characteristic curve = 0.78).

CONCLUSIONS

Shunt volume flow measurement with 3D/4D Doppler sonography provides a potential alternative to standard pulsed wave Doppler metrics as an indicator of shunt function and predictor of revision.

Percutaneous Portosystemic Shunts: TIPS and Beyond

Percutaneous interventions for portal hypertension have been available since the 1990s. Over time, improved technology-including covered stent grafts-and clinical understanding has expanded the available procedures for percutaneous portal decompression. While transjugular intrahepatic portosystemic shunt creation is the most commonly cited percutaneous intervention, direct intrahepatic portocaval shunt and percutaneous mesocaval shunt creation are important alternatives with specific advantages and applications. This article reviews contemporary, minimally invasive interventional approaches to percutaneous portosystemic shunt creation in terms of procedure rationale, patient selection, interventional technique, and technical outcomes.

Selection of a TIPS stent for management of portal hypertension in liver cirrhosis: an evidence-based review

Nowadays, transjugular intrahepatic portosystemic shunt (TIPS) has become a mainstay treatment option for the management of portal hypertension-related complications in liver cirrhosis. Accumulated evidence has shown that its indications are being gradually expanded. Notwithstanding, less attention has been paid for the selection of an appropriate stent during a TIPS procedure. Herein, we attempt to review the current evidence regarding the diameter, type, brand, and position of TIPS stents. Several following recommendations may be considered in the clinical practice: (1) a 10-mm stent may be more effective than an 8-mm stent for the management of portal hypertension, and may be superior to a 12-mm stent for the improvement of survival and shunt patency; (2) covered stents are superior to bare stents for reducing the development of shunt dysfunction; (3) if available, Viatorr stent-grafts may be recommended due to a higher rate of shunt patency; and (4) the placement of a TIPS stent in the left portal vein branch may be more reasonable for decreasing the development of hepatic encephalopathy. However, given relatively low quality of evidence, prospective well-designed studies should be warranted to further confirm these recommendations.

Historical overview and review of current day treatment in the management of acute variceal haemorrhage

Variceal haemorrhage is one of the most devastating consequences of portal hypertension, with a 1-year mortality of 40%. With the passage of time, acute management strategies have developed with improved survival. The major historical treatment landmarks in the management of variceal haemorrhage can be divided into surgical, medical, endoscopic and radiological breakthroughs. We sought to provide a historical overview of the management of variceal haemorrhage and how treatment modalities over time have impacted on clinical outcomes. A PubMed search of the following terms: portal hypertension, variceal haemorrhage, gastric varices, oesophageal varices, transjugular intrahepatic portosystemic shunt was performed. To complement this, Google™ was searched with the aforementioned terms. Other relevant references were identified after review of the reference lists of articles. The review of therapeutic advances was conducted divided into pre-1970s, 1970/80s, 1990s, 2000-2010 and post-2010. Also, a summary and review on the pathophysiology of portal hypertension and clinical outcomes in variceal haemorrhage was performed. Aided by the development of endoscopic therapies, medication and improved radiological interventions; the management of variceal haemorrhage has changed over recent decades with improved survival from an often-terminating event in recent past.

Portal hypertensive gastropathy and colopathy

Portal hypertensive gastropathy (PHG) and colopathy (PHC) are considered complications of portal hypertension. Both entities are clinically relevant because they may cause insidious blood loss or even acute massive gastrointestinal hemorrhage. Endoscopic evaluation is necessary for the diagnosis of PHG and PHC. The existence of different endoscopic criteria for PHG and PHC makes consensus difficult and results in a broad range of reported prevalence. Therapy targeted at reduction of portal pressure and mucosal blood flow has been used to treat acute bleeding; nonselective β-blockers are the most frequently used agents. Further studies are needed to clarify the natural history, pathogenesis, and treatment of PHG and PHC.

Clinical outcomes of transjugular intrahepatic portosystemic shunt for portal hypertension: Korean multicenter real-practice data

Background/Aims

This retrospective study assessed the clinical outcome of a transjugular intrahepatic portosystemic shunt (TIPS) procedure for managing portal hypertension in Koreans with liver cirrhosis.

Methods

Between January 2003 and July 2013, 230 patients received a TIPS in 13 university-based hospitals.

Results

Of the 229 (99.6%) patients who successfully underwent TIPS placement, 142 received a TIPS for variceal bleeding, 84 for refractory ascites, and 3 for other indications. The follow-up period was 24.9±30.2 months (mean±SD), 74.7% of the stents were covered, and the primary patency rate at the 1-year follow-up was 78.7%. Hemorrhage occurred in 30 (21.1%) patients during follow-up; of these, 28 (93.3%) cases of rebleeding were associated with stent dysfunction. Fifty-four (23.6%) patients developed new hepatic encephalopathy, and most of these patients were successfully managed conservatively. The cumulative survival rates at 1, 6, 12, and 24 months were 87.5%, 75.0%, 66.8%, and 57.5%, respectively. A high Model for End-Stage Liver Disease (MELD) score was significantly associated with the risk of death within the first month after receiving a TIPS (P=0.018). Old age (P<0.001), indication for a TIPS (ascites vs. bleeding, P=0.005), low serum albumin (P<0.001), and high MELD score (P=0.006) were associated with overall mortality.

Conclusions

A high MELD score was found to be significantly associated with early and overall mortality rate in TIPS patients. Determining the appropriate indication is warranted to improve survival in these patients.

Shunting branch of portal vein and stent position predict survival after transjugular intrahepatic portosystemic shunt

AIM

To evaluate the effect of the shunting branch of the portal vein (PV) (left or right) and the initial stent position (optimal or suboptimal) of a transjugular intrahepatic portosystemic shunt (TIPS).

METHODS

We retrospectively reviewed 307 consecutive cirrhotic patients who underwent TIPS placement for variceal bleeding from March 2001 to July 2010 at our center. The left PV was used in 221 patients and the right PV in the remaining 86 patients. And, 224 and 83 patients have optimal stent position and sub-optimal stent positions, respectively. The patients were followed until October 2011 or their death. Hepatic encephalopathy, shunt dysfunction, and survival were evaluated as outcomes. The difference between the groups was compared by Kaplan-Meier analysis. A Cox regression model was employed to evaluate the predictors.

RESULTS

Among the patients who underwent TIPS to the left PV, the risk of hepatic encephalopathy (P = 0.002) and mortality were lower (P < 0.001) compared to those to the right PV. Patients who underwent TIPS with optimal initial stent position had a higher primary patency (P < 0.001) and better survival (P = 0.006) than those with suboptimal initial stent position. The shunting branch of the portal vein and the initial stent position were independent predictors of hepatic encephalopathy and shunt dysfunction after TIPS, respectively. And, both were independent predictors of survival.

CONCLUSION

TIPS placed to the left portal vein with optimal stent position may reduce the risk of hepatic encephalopathy and improve the primary patency rates, thereby prolonging survival.

Clinical effects and complications of TIPS for portal hypertension due to cirrhosis: A single center

AIM: To determine the clinical effects and complications of transjugular intrahepatic portosystemic shunt (TIPS) for portal hypertension due to cirrhosis.

METHODS: Two hundred and eighty patients with portal hypertension due to cirrhosis who underwent TIPS were retrospectively evaluated. Portal trunk pressure was measured before and after surgery. The changes in hemodynamics and the condition of the stent were assessed by ultrasound and the esophageal and fundic veins observed endoscopically.

RESULTS: The success rate of TIPS was 99.3%. The portal trunk pressure was 26.8 ± 3.6 cmH₂O after surgery and 46.5 ± 3.4 cmH₂O before surgery (P < 0.01). The velocity of blood flow in the portal vein increased. The internal diameters of the portal and splenic veins were reduced. The short-term hemostasis rate was 100%. Esophageal varices disappeared completely in 68% of patients and were obviously reduced in 32%. Varices of the stomach fundus disappeared completely in 80% and were obviously reduced in 20% of patients. Ascites disappeared in 62%, were markedly reduced in 24%, but were still apparent in 14% of patients. The total effective rate of ascites reduction was 86%. Hydrothorax completely disappeared in 100% of patients. The incidence of post-operative stent stenosis was 24% at 12 mo and 34% at 24 mo. The incidence of post-operative hepatic encephalopathy was 12% at 3 mo, 17% at 6 mo and 19% at 12 mo. The incidence of post-operative recurrent hemorrhage was 9% at 12 mo, 19% at 24 mo and 35% at 36 mo. The cumulative survival rate was 86% at 12 mo, 81% at 24 mo, 75% at 36 mo, 57% at 48 mo and 45% at 60 mo.

CONCLUSION: TIPS can effectively lower portal hypertension due to cirrhosis. It is significantly effective for hemorrhage of the digestive tract due to rupture of esophageal and fundic veins and for ascites and hydrothorax caused by portal hypertension.

Child-Na score: a predictive model for survival in cirrhotic patients with symptomatic portal hypertension treated with TIPS

BACKGROUND AND AIM

Several models have been developed to predict survival in patients with cirrhosis undergoing TIPS; however, few of these models have gained widespread acceptance, especially in the era of covered stents. The aim of this study was to establish an evidence-based model for predicting survival after TIPS procedures.

METHODS

A total of 210 patients with cirrhosis treated with TIPS were considered in the study. We comprehensively investigated factors associated with one-year survival and developed a new predictive model using the Cox regression model.

RESULTS

In the multivariate analysis, the Child-Pugh score and serum sodium levels were independent predictors of one-year survival. A new score incorporating serum sodium into the Child-Pugh score was developed: Child-Na score. We compared the predictive accuracy of Child-Na score with that of other scores; only the Child-Na and MELD-Na scores had adequate predictive ability in patients with serum Na levels <138 mmol/L. The best Child-Na cut-off score (15.5) differentiated two groups of patients with distinct prognoses (one-year cumulative survival rates of 80.6% and 45.5%); this finding was confirmed in a validation cohort (n = 86). In a subgroup analysis stratifying patients by indication for TIPS, the Child-Na score distinguished patients with different prognoses.

CONCLUSIONS

Patients with variceal bleeding and a Child-Na score ≤15 had a better prognosis than patients with a score ≥16. Patients with refractory ascites and a Child-Na score ≥16 had a high risk of death after the TIPS procedures; caution should be used when treating these patients with TIPS.

Protective value of TIPS against the development of hydrothorax/ascites and upper gastrointestinal bleeding after balloon-occluded retrograde transvenous obliteration (BRTO)

OBJECTIVES

The objective of this study was to evaluate the incidence of post-balloon-occluded retrograde transvenous obliteration (BRTO) ascites/hepatic hydrothorax and rebleeding rate (variceal and non-variceal) in the presence and absence of a transjugular intrahepatic portosystemic shunt (TIPS).

METHODS

A retrospective audit of consecutive patients undergoing BRTO was performed (August 2007-October 2010). The population was divided into two groups: patients who underwent BRTO only (BRTO-only group) and those who underwent BRTO in the presence of TIPS (BRTO+TIPS group). Post-BRTO rebleeding was categorized for the source of bleeding. Ascites and/or hepatic hydrothorax were categorized according to clinical severity. Comparisons, utilizing the Kaplan-Meier method, between both groups were made for patient survival, incidence of ascites/hydrothorax, and rebleeding.

RESULTS

Thirty-nine patients underwent BRTO (three technical failures of BRTO-only group). Of the 36 technically successful BRTO procedures, 27 patients (75%) underwent BRTO-only and 9 patients (25%) underwent BRTO in the presence of a TIPS. Pre-BRTO ascites/hydrothorax resolved in BRTO-only vs. BRTO+TIPS in 7% (N=2/27) and 56% (N=5/9), respectively (P=0.006). The ascites/hydrothorax free rate at 6, 12, and 24 months after BRTO for BRTO-only vs. BRTO+TIPS was 58%, 43%, 29%, and 100%, 100%, 100%, respectively (P=0.01). Recurrent hemorrhage for BRTO-only vs. BRTO+TIPS groups, and for the same time periods was 9%, 9%, 21% vs. 0%, 0%, 0%, respectively (P=0.03). The 1-year patient survival of both groups (80-88%) was similar (P>0.05).

CONCLUSIONS

This study concludes that the presence of TIPS has a protective value against the development of post-BRTO ascites/hydrothorax as well as recurrent hemorrhage but this does not translate to improved patient survival.

Diagnostic radiology of transjugular intrahepatic portosystemic shunts

Transjugular intrahepatic portosystemic shunts (TIPS) are an effective method for treating the complications of portal hypertension. Specific indications for TIPS include secondary prevention of variceal bleeding and refractory ascites. The purpose of this review is to summarize the role of diagnostic radiology in the creation and assessment of TIPS, to highlight the complications that can occur post-TIPS, and to critically evaluate the literature regarding ultrasound evaluation of TIPS.

Long-term follow-up of TIPS created with expanded poly-tetrafluoroethylene covered stents

BACKGROUND

Transjugular intrahepatic portosystemic shunts (TIPS) created with expanded poly-tetrafluoroethylene-covered stents have largely replaced bare metal stents. Short-term shunt patency is typically assessed with protocol Doppler ultrasound (US), while little information exists with regard to long-term patency.

AIM

We investigated the value of Doppler US in assessing TIPS patency as well as long-term clinical outcomes.

METHODS

A retrospective analysis of 59 patients with covered stents used for TIPS between January 2001 and December 2011 was performed.

RESULTS

Fifty-four patients had early (median 9 days) Doppler US follow-up. Seven of eight patients with an abnormal baseline US required stent revisions. None of the 46 patients with normal baseline Doppler US required revisions within the first 6 months; six of these patients subsequently had a portogram because of symptoms, but all TIPS were patent. Fifty-two patients survived for long-term (>6 months) follow-up, averaging 654 days and three Doppler US exams. Five of six patients with abnormal follow-up Doppler US required revisions, whereas none of the 46 patients with normal follow-up US had revisions. The recurrence of symptoms of portal hypertension and/or hepatic encephalopathy (HE) was low (4/52 patients). No significant predictors of long-term stenosis were identified. Post-TIPS HE was independent of pre-TIPS HE or Child-Pugh score.

CONCLUSIONS

Short-term patency and that at approximately 2 years after TIPS placement was 87 and 77 %, respectively. We conclude that Doppler US at least 1 week after TIPS is warranted, but repeated Doppler US follow-up is probably not necessary in the absence of clinical symptoms.

Recurrent variceal bleeding and shunt patency: prospective randomized controlled trial of transjugular intrahepatic portosystemic shunt alone or combined with coronary vein embolization

PURPOSE

To prospectively evaluate the efficacy of a transjugular intrahepatic portosystemic shunt (TIPS) alone and TIPS in association with embolotherapy (TIPS+E) in the variceal coronary vein to prevent recurrent variceal bleeding and stent dysfunction after TIPS creation.

MATERIALS AND METHODS

Institutional review board approval was obtained; all participants provided informed consent. A total of 106 patients (66 men, 40 women; age range, 18-70 years) with recurrent variceal bleeding due to hepatic cirrhosis were assigned randomly to the TIPS+E (n = 54) or TIPS (n = 52) group from May 2007 to July 2011. The TIPS was created by using covered stents. Patients in the TIPS+E group underwent embolotherapy via the jugular vein before TIPS implantation. Rates of recurrent variceal bleeding, stent patency, and survival were evaluated. Scores for liver function and life quality were calculated.

RESULTS

TIPS placement was successful in all patients. Recurrent variceal bleeding ranked second among causes of death after TIPS placement. Although the 3-year cumulative rates of shunt patency, recurrent variceal bleeding, and survival in the two groups were not significantly different (P > .05), the 6-month overall rate of shunt patency in the TIPS+E group was significantly higher than that in the TIPS group (96.2% vs 82.0%, P = .019), and the 6-month overall rate of recurrent variceal bleeding was also significantly lower than that in the TIPS group (5.7% vs 20.0%, P = .029).

CONCLUSION

The TIPS+E regimen may reduce the risk of recurrent variceal bleeding during the first 6 months after the TIPS procedure by preventing shunt dysfunction, which may improve liver function and quality of life. © RSNA, 2013.

Transjugular intrahepatic portosystemic shunts in liver transplant recipients: technical analysis and clinical outcome

OBJECTIVE

The purpose of this study is to compare the technical success of transjugular intrahepatic portosystemic shunt (TIPS) in transplanted versus nontransplanted livers and to assess the clinical outcome of TIPS in liver transplant recipients.

MATERIALS AND METHODS

A retrospective audit of patients receiving a TIPS was performed in two institutions during 1996-2009. The technical success of the TIPS was compared for transplanted versus nontransplanted livers. Clinical success was defined as graft survival longer than 1 month with improvement in symptoms. The cohort was divided into grafts that survived less than 3 months versus 3 months or more. The model for end-stage liver disease (MELD) scores and portosystemic gradients before and after TIPS creation were evaluated for predictive value for graft survival. The TIPS stent type, MELD scores and portosystemic gradients before and after TIPS creation, and causes of liver disease were evaluated for their predictive value for ascites response after TIPS creation.

RESULTS

Thirty-nine TIPS in transplanted livers were found, representing 5.5% (39/715) of all TIPS procedures performed and 2.0% (39/1992) of all liver transplant recipients. Ninety percent of TIPS in transplanted livers had ascites. The median time from transplant to creation of the TIPS was 29 months (2-127 months). The median MELD score was 16 before and 22 after the TIPS procedure. The technical success rates for TIPS were 97% (38/39) in transplanted livers versus 97% (657/676) in nontransplanted livers (p = 1.00). Intent-to-treat clinical success rates were 36% for all indications versus 31% for ascites only. There were no predictors for ascites response. Six-, 12-, and 24-month graft survival rates were 43%, 32%, and 22%, respectively. One-year graft survival for a MELD score less than 17 versus a score of 17 or higher was 54% versus 8%, respectively (p < 0.05).

CONCLUSION

Transplantation does not pose a technical challenge to TIPS creation. One third of patients have a favorable outcome. MELD score is the only predictor of graft survival.

Prognostic capability of different liver disease scoring systems for prediction of early mortality after transjugular intrahepatic portosystemic shunt creation

PURPOSE

To compare the performance of various liver disease scoring systems in predicting early mortality after transjugular intrahepatic portosystemic shunt (TIPS) creation.

MATERIALS AND METHODS

In this single-institution retrospective study, eight scoring systems were used to grade liver disease in 211 patients (male-to-female ratio = 131:80; mean age, 54 y) before TIPS creation from 1999-2011. Scoring systems included bilirubin level, Child-Pugh (CP) score, Model for End-Stage Liver Disease (MELD) and Model for End-Stage Liver Disease sodium (MELD-Na) score, Emory score, prognostic index (PI), Acute Physiology and Chronic Health Evaluation (APACHE) 2 score, and Bonn TIPS early mortality (BOTEM) score. Medical record review was used to identify 30-day and 90-day clinical outcomes. The relationship of scoring parameters with mortality outcomes was assessed with multivariate analysis, and the relative ability of systems to predict mortality after TIPS creation was evaluated by comparing area under receiver operating characteristic (AUROC) curves.

RESULTS

TIPS were successfully created for variceal hemorrhage (n = 121), ascites (n = 72), hepatic hydrothorax (n = 15), and portal vein thrombosis (n = 3). All scoring systems had a significant association with 30-day and 90-day mortality (P<.050 in each case) on multivariate analysis. Based on 30-day and 90-day AUROC, MELD (0.878, 0.816) and MELD-Na (0.863, 0.823) scores had the best capability to predict early mortality compared with bilirubin (0.786, 0.749), CP (0.822, 0.771), Emory (0.786, 0.681), PI (0.854, 0.760), APACHE 2 (0.836, 0.735), and BOTEM (0.798, 0.698), with statistical superiority over bilirubin, Emory, and BOTEM scores.

CONCLUSIONS

Several liver disease scoring systems have prognostic value for early mortality after TIPS creation. MELD and MELD-Na scores most effectively predict survival after TIPS creation.

Evaluation and management of transjugular intrahepatic portosystemic shunts

OBJECTIVE

The purpose of this article is to describe the evaluation of transjugular intrahepatic portosystemic shunts (TIPS) and the management of dysfunctional shunts.

CONCLUSION

TIPS can become dysfunctional if stenosis develops in the shunt or the hepatic vein above the shunt. Screening allows detection of stenoses before portal hypertensive-related complications recur. Revision of stenotic shunts can be easily accomplished in most cases. Techniques for screening and revision will be discussed.