Targeted puncture of left branch of intrahepatic portal vein in transjugular intrahepatic portosystemic shunt to reduce hepatic encephalopathy

Non-contrast-enhanced MR angiography of left gastric vein in patients with gastroesophageal varices: morphology and blood supply analysis

OBJECTIVES

To investigate the feasibility of non-contrast-enhanced MR angiography (NCE-MRA) in evaluating the morphology and blood supply of left gastric vein (LGV) in patients with gastroesophageal varices.

METHODS

Between March 2021 and October 2022, patients with gastroesophageal varices and who underwent NCE-MRA were retrospectively reviewed. In order to evaluate the blood supply of LGV, superior mesenteric vein (SMV) and splenic vein (SV) were visualized separately by using inflow-sensitive inversion recovery sequence. Two radiologists independently assessed the image quality, determined the origination and the blood supply of LGV, and measured the diameter of LGV. The origination and diameter of LGV were compared between NCE-MRA and contrast-enhanced CT. Differences in blood supply were compared between LGVs with different originations.

RESULTS

A total of 53 patients were enrolled in this study and the image quality was categorized as good or excellent in 52 patients. No significant differences were observed in visualizing the origination and the diameter of LGV between NCE-MRA and contrast-enhanced CT (p > .05). The blood supply of LGV was related to its origination (p < .001). Most LGVs with SV origination were supplied by SV. If LGV was originated from the portal vein (PV), about 70% of them were supplied by both SV and SMV. Compared with LGVs with SV origination, LGVs with PV origination showed more chance to receive blood from SMV (p < .001).

CONCLUSION

Non-contrast-enhanced MR angiography appears to be a reliable technique in evaluating the morphology and blood supply of LGV in patients with gastroesophageal varices.

CLINICAL RELEVANCE STATEMENT

Non-contrast-enhanced MR angiography provides valuable information for the management of gastroesophageal varices. Especially, it benefits patients with renal insufficiency.

KEY POINTS

• Non-contrast-enhanced MR angiography using inflow-sensitive inversion recovery technique can be used for evaluating not only morphology as CT but also blood supply of left gastric vein. • The blood supply of left gastric vein is related to its origination and left gastric vein with portal vein origination shows more chance to receive blood from superior mesenteric vein.

Prevention and treatment of hepatic encephalopathy during the perioperative period of transjugular intrahepatic portosystemic shunt

Transjugular intrahepatic portosystemic shunt (TIPS) is an established procedure for treating the complications of portal hypertension in liver cirrhosis. While the pathogenesis of postoperative TIPS-related hepatic encephalopathy (HE) has yet to be fully understood, intraoperative portosystemic shunts may provide a pathological basis for the occurrence of postoperative HE in patients with liver cirrhosis. Studies at home and abroad have expressed mixed opinions about TIPS-related HE. This study presents a literature review on the risk factors for and prevention and treatment of perioperative TIPS-related HE in patients with liver cirrhosis, aiming to optimize the procedure and reduce the incidence of postoperative HE.

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.

Combined transjugular/percutaneous intrahepatic portosystemic shunts (cTIPS) for cavernous transformation of the portal vein after conventional transjugular approach TIPS failure

This study aim was to compare the safety and efficacy of combined transjugular/percutaneous intrahepatic portosystemic shunts (cTIPS) and transjugular intrahepatic portosystemic shunt (TIPS) in cirrhotic patients with cavernous transformation of the portal vein (CTPV) after conventional transjugular approach TIPS failure. Cirrhotic patients who were diagnosed as CTPV and treated by cTIPS or TIPS between July 2012 and April 2022 were retrospectively analyzed. Patients' characteristics and clinical data were recorded. The clinical outcomes, long-term survival rates and patency rates between the 2 groups were compared. A total of 68 patients with CTPV were enrolled, of whom 23 were treated with TIPS and 45 with cTIPS. The initial technical success was 30.9% in TIPS group and 91.1% in cTIPS group. The hospitalization days increased significantly in the cTIPS group compared with TIPS group (P = .0131). However, the complication rate, patency rates and survival rates were similar between the 2 groups. In conclusion, cTIPS appeared to be safe and effective in cirrhotic patients with CTPV after conventional transjugular approach TIPS failure.

Right vs left portal branch puncture in TIPS creation with controlled expansion covered stent: comparison of hemodynamic and clinical outcomes

PURPOSE

To retrospectively compare outcomes of TIPS performed by puncturing left portal vein (LPV) vs right portal vein (RPV) to access the portal system.

MATERIALS AND METHODS

One hundred ninety-three consecutive patients underwent TIPS with controlled expansion covered stent by using the LPV (37 patients) or the RPV (156 patients). Patients were followed until the last clinical evaluation, liver transplantation, or death.

RESULTS

Demographics and clinical characteristics of the two groups were comparable. The median follow-up was 9.6 months (range 0.1-50.6). Portosystemic pressure gradient (PSG) before TIPS 15.7 mmHg ± 4.7 in RPV group (RPVG) vs 15.4 mmHg ± 4.5 in LPV group (LPVG) (p = 0.725). After TIPS, PSG 6.3 mmHg ± 2.8 in RPVG vs 6.2 mmHg ± 2.2 (p = 0.839). In LPVG, the stent was dilated to 8-mm in 95% of patients vs 77% of RPVG (p = 0.015). Two (5.4%) and 22 (14%) patients underwent TIPS revision in LPVG and RPVG (p = 0.15). The incidence of overt HE was 13% in LPVG and 24% in RPVG (p = 0.177). Rebleeding occurred in 3 of 49 patients (6%) with variceal bleeding as an indication: 2/41 patients (4.9%) in RPVG vs 1/8 patients (12.5%) in LPVG (p = 0.417). Among 126 patients with refractory ascites 20 patients (15.9%) needed paracentesis 3 months after the procedure: 18/101 patients (17.8%) in RPVG vs 2/25 patients (8%) in LPVG (p = 0.231). Thirty-seven patients (19%) died: 32 (21%) in RPVG and 5 (14%) in LPVG (p = 0.337).

CONCLUSION

Compared with RPV puncture, in TIPS created through the LPV, the targeted PSG was reached with a smaller stent diameter. However, no significant difference in clinical outcomes was observed.

KEY POINTS

• A LPV approach for TIPS creation does not lead to better control of complications of portal hypertension as compared to a RPV approach.

Large Paraumbilical Vein Shunts Increase the Risk of Overt Hepatic Encephalopathy after Transjugular Intrahepatic Portosystemic Shunt Placement

Background: This study aimed to evaluate whether a large paraumbilical vein (L-PUV) was independently associated with the occurrence of overt hepatic encephalopathy (OHE) after the implantation of a transjugular intrahepatic portosystemic shunt (TIPS). Methods: This bi-center retrospective study included patients with cirrhotic variceal bleeding treated with a TIPS between December 2015 and June 2021. An L-PUV was defined in line with the following criteria: cross-sectional areas > 83 square millimeters, diameter ≥ 8 mm, or greater than half of the diameter of the main portal vein. The primary outcome was the 2-year OHE rate, and secondary outcomes included the 2-year mortality, all-cause rebleeding rate, and shunt dysfunction rate. Results: After 1:2 propensity score matching, a total of 27 patients with an L-PUV and 54 patients without any SPSS (control group) were included. Patients with an L-PUV had significantly higher 2-year OHE rates compared with the control group (51.9% vs. 25.9%, HR = 2.301, 95%CI 1.094−4.839, p = 0.028) and similar rates of 2-year mortality (14.8% vs. 11.1%, HR = 1.497, 95%CI 0.422−5.314, p = 0.532), as well as variceal rebleeding (11.1% vs. 13.0%, HR = 0.860, 95%CI 0.222−3.327, p = 0.827). Liver function parameters were similar in both groups during the follow-up, with a tendency toward higher shunt patency in the L-PUV group (p = 0.067). Multivariate analysis indicated that having an L-PUV (HR = 2.127, 95%CI 1.050−4.682, p = 0.037) was the only independent risk factor for the incidence of 2-year OHE. Conclusions: Having an L-PUV was associated with an increased risk of OHE after a TIPS. Prophylaxis management should be considered during clinical management.

Intravascular Ultrasound Guidance for TIPS Procedures: A Review

The most challenging and time-consuming step of TIPS procedures is obtaining appropriate portal vein (PV) access. Given the lack of real-time direct target visualization, conventional fluoroscopic guidance requires multiple passes, contributing to complications. In comparison, intravascular ultrasound (IVUS) guidance during TIPS procedures provides direct visualization of hepatic structures and real-time guidance for PV puncture. IVUS guidance during TIPS creation improves procedural metrics such as radiation dose, contrast agent volume, procedure time, and technical success rate and is particularly beneficial in technically challenging cases (e.g., in patients portal vein thrombosis, small or variant portal vein anatomy, Budd-Chiari syndrome, or liver masses). The purpose of this review is to summarize current IVUS technology, describe the technical aspects of IVUS-guided TIPS creation, and discuss the clinical indications for and benefits of using IVUS for TIPS creation, while presenting available evidence supporting the technique's use. Given the improved safety profile and overall success rate in comparison with conventional guidance methods, IVUS guidance has the future potential to become the standard practice for TIPS placement.

Influence of different portal vein branches on hepatic encephalopathy during intrahepatic portal shunt via jugular vein

This letter is regarding the study titled ‘Targeted puncture of left branch of intrahepatic portal vein in transjugular intrahepatic portosystemic shunt (TIPS) to reduce hepatic encephalopathy’. Prior to the approval of TIPS dedicated stents (Viatorr stents) in China in October 2015, Fluency covered stents were typically used. As Fluency covered stents have a strong support force and axial elastic tension, a ‘cap’ may form if the stent is located too low at the end of the hepatic vein or too short at the end of the portal vein during surgery, leading to stent dysfunction. Since the blood shunted by the stent is from the main trunk of the portal vein, the correlation between the incidence of postoperative hepatic encephalopathy and the location of the puncture target (left or right portal vein branch) is worth discussion. Notably, no studies in China or foreign countries have proven the occurrence of left and right blood stratification after the accumulation of splenic vein and mesenteric blood flow in the main trunk of the portal vein in patients with cirrhotic portal hypertension.

Portal flow diversion based on portography is superior than puncture site in the prediction of overt hepatic encephalopathy after TIPS creation

Background

Targeted puncture of an appropriate portal venous branch during transjugular intrahepatic portosystemic shunt (TIPS) procedure may reduce the risk of postprocedural overt hepatic encephalopathy (HE). This study aimed to describe blood distribution under portography and combined it with puncture site to determine portal flow diversion, and to evaluate its prognostic value in predicting post-TIPS overt HE.

Methods

In this retrospective analysis of patients with cirrhosis undergoing TIPS, we included 252 patients to describe blood distribution under portography and 243 patients to assess the association between portal flow diversion and post-TIPS overt HE.

Results

At the first stage, 51 (20.2%) patients were identified as type A (unilateral type with the right portal branch receives blood from splenic vein [SV]), 16 (6.4%) as type B (unilateral type with the right branch receives blood from superior mesenteric vein [SMV]) and 185 (73.4%) as type C (fully mixed type). At the second stage, 40 patients were divided into the SV group, 25 into the SMV group and 178 into the mixed group. Compared with the mixed group, the risk of post-TIPS overt HE was significantly higher in the SMV group (adjusted HR 3.70 [95% CI 2.01–6.80]; p < 0.001), whereas the SV group showed a non-significantly decreased risk (adjusted HR 0.57 [95% CI 0.22–1.48]; p = 0.25). Additionally, the SMV group showed a substantial increase in ammonia level at 3 days and 1 month after procedure.

Conclusions

Our results support the clinical use of portal flow diversion for risk stratification and decision-making in the management of post-TIPS overt HE.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12876-022-02447-y.

Refractory portal hypertension complications successfully managed by parallel transjugular intrahepatic portosystemic shunt (TIPS): a case report

Background

Transjugular intrahepatic portosystemic shunt (TIPS) is an established intervention to treat complicated portal hypertension refractory to medical or endoscopic management. TIPS dysfunction results in the recurrence of portal hypertension symptoms. In cases of TIPS dysfunction or persistent portal hypertension despite a patent primary TIPS, the creation of parallel TIPS may be the only intervention to effectively reduce portal pressure. Since the introduction of dedicated TIPS stents (Viatorr®) the incidence of TIPS dysfunction has reduced profoundly. Nevertheless, the creation of a parallel TIPS can still be necessary in the current dedicated TIPS stent era.

Case presentation

We report one such patient who experienced ongoing portal hypertension induced upper gastro-intestinal haemorrhage despite multiple TIPS revisions and a patent primary TIPS.

Conclusion

Following creation of a parallel TIPS, the patient remains in clinical remission with no further bleeding.

Hepatic Encephalopathy After TIPS Placement: Predictive Factors, Prevention Strategies, and Management

Hepatic encephalopathy (HE) is a challenging complication after transjugular intrahepatic portosystemic shunt (TIPS) placement. Despite recent advances, much is still uncertain regarding risk factors, preventative measures, and the management of HE after TIPS placement. Appropriate patient selection and pre-procedural risk stratification remain areas of focus. In this manuscript, we discuss the current state of research related to HE after TIPS placement, including information regarding risk stratification, complication prevention, and treatment options.

Evolution, progress, and prospects of research on transjugular intrahepatic portosystemic shunt applications

Transjugular intrahepatic portosystemic shun (TIPS) is an effective procedure for the treatment of portal hypertension complications such as esophagogastric variceal bleeding and refractory ascites. To date, its use by many experts and scholars at home and abroad has benefitted countless patients. In order to further promote the development and innovation of TIPS in China, this paper briefly reviews the development process of TIPS at home and abroad, objectively analyzes the bottlenecks and breakthrough achievements in the development of TIPS, and discusses the application status and research progress of TIPS technology for different indications. Finally, we provide an outlook about the development and application of TIPS in China.

Clinical efficacy of transjugular intrahepatic portosystemic shunt created through left or right branches of the portal vein: A meta-analysis

Background and aim

Transjugular intrahepatic portosystemic shunt (TIPS) is a technique successfully used to treat portal hypertension and its complications. However, the choice of the branch, left (L) or right (R), of the portal vein resulting in a better outcome is still under debate. Therefore, this meta-analysis aims to evaluate which branch has a better curative effect on patients treated with TIPS.

Methods

PubMed, EMBASE, Web of science, Cochrane Library databases, Wanfang database and CBM were used for our search in October 2019 and updated in June 2021. The following parameters were used in evaluation: overall mortality, hepatic encephalopathy, shunt dysfunction, variceal rebleeding and rate of postoperative ascites.

Results

There were seven studies included. The sample size was 1940. A lower risk of mortality was observed in TIPS-L-treated patients compared with TIPS-R-treated ones (OR ​= ​0.65, 95% CI ​= ​0.50–0.85, p ​= ​0.002). A lower risk of shunt dysfunction was observed in TIPS-L-treated patients compared with TIPS-R-treated ones (OR ​= ​0.53, 95% CI ​= ​0.33–0.87, p ​= ​0.01). And the TIPS-L group had a significantly higher hepatic encephalopathy-free rate than the TIPS-R group (OR ​= ​0.59, 95% CI ​= ​0.44–0.78, p ​= ​0.0002). However, the rate of rebleeding (OR ​= ​0.75, 95% CI ​= ​0.55–1.03, p ​= ​0.07) and incidence of postoperative ascites (OR ​= ​1.14, 95% CI ​= ​0.86–1.51, p ​= ​0.38) was not statistically significant between the two groups.

Conclusions

Based on the currently available evidence, the technique of TIPS through the left branch of the portal vein can significantly reduce the occurrence of overall postoperative mortality, hepatic encephalopathy and shunt dysfunction.

Efficacy of puncturing different portal vein branch during transjugular intrahepatic portosystemic shunt with 8 mm covered stent: a propensity-score analysis

BACKGROUND

Hepatic encephalopathy after transjugular intrahepatic portosystemic shunt (TIPS) remains an unsolved problem; therefore, this study aimed to compare the efficacy of shunting different portal vein branch during TIPS with 8 mm covered stent for preventing gastroesophageal variceal rebleeding in cirrhotic patients.

METHODS

Between November 2015 and December 2018, the medical records of consecutive cirrhotic patients who received TIPS with an 8 mm covered stent for preventing gastroesophageal variceal rebleeding were analyzed retrospectively. Shunting the left and right branches of the portal vein was performed in 58 (group A) and 104 patients (group B), respectively. Afterwards, 54 patients in each group were produced by the PSM method. The incidence of overt hepatic encephalopathy (OHE), shunt patency, variceal rebleeding and survival were compared between two groups by using Kaplan-Meier analysis and log-rank test.

RESULTS

The median follow-up time was 37 months (range 0.3-50 months). The 6-,12- and 24-months cumulative OHE free rates in groups A and B were 92.5, 86.2, 83.6% and 74.1, 70.2, 67.6%, respectively (P = 0.042; hazard ratio = 0.469; 95% CI, 0.223-0.988). Two (3.7%) and eight (14.8%) patients experienced severe OHE in groups A and B, respectively (P = 0.042). There were no significant differences between the two groups in terms of shunt patency, variceal rebleeding and survival.

CONCLUSION

Shunting the left portal vein branch during TIPS with an 8 mm covered stent for preventing gastroesophageal variceal rebleeding in cirrhotic patients might decrease the occurrence of OHE significantly. The prospective trial is needed to further provide evidence of this results in future.

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

BACKGROUND AND AIMS

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

METHODS

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

RESULTS

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

CONCLUSION

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

Transjugular intrahepatic portosystemic shunt through left branch versus right branch of portal vein: a meta-analysis

PURPOSE

To compare the clinical outcomes between patients that underwent transjugular intrahepatic portosystemic shunt (TIPS) via the left and right portal veins (PVs).

MATERIALS AND METHODS

All relevant studies in the Pubmed, Embase, and Cochrane Library databases published as of June 2020 were identified by searching, after which RevMan v5.3 was used to conduct the present meta-analysis. Relevant endpoint data were extracted from each study, related to postoperative hepatic encephalopathy (HE) rates, TIPS dysfunction, re-bleeding, and mortality.

RESULTS

A total of eight studies were identified as being relevant for inclusion in this meta-analysis. These studies included 2592 total patients suffering from liver cirrhosis that underwent TIPS treatment via the left (n = 1500) or right (n = 1092) PVs. Rates of postoperative HE were significantly lower in the left PV group relative to the right PV group (5.7% vs. 18.1%, OR 0.19; P < 0.00001), as were rates of TIPS dysfunction (8.1% vs. 16.5%, OR 0.41; P < 0.00001). In contrast, the rates of re-bleeding did not differ significantly between these groups (12.0% vs. 14.9%, OR 0.76; P = 0.11), nor did mortality rates (30.9% vs. 31.0%, OR 0.85, P = 0.22). We did not detect any significant heterogeneity among included studies for any analyzed endpoints, nor was any risk of publication bias pertaining to these studies detected through the use of funnel plots.

CONCLUSIONS

TIPS conducted via the left PV was associated with decreased rates of postoperative HE and TIPS dysfunction relative to TIPS conducted via the right PV.

Comparative study of indocyanine green-R15, Child-Pugh score, and model for end-stage liver disease score for prediction of hepatic encephalopathy after transjugular intrahepatic portosystemic shunt

BACKGROUND

Hepatic encephalopathy (HE) remains an enormous challenge in patients who undergo transjugular intrahepatic portosystemic shunt (TIPS) implantation. The preoperative indocyanine green retention rate at 15 min (ICG-R15), as one of the liver function assessment tools, has been developed as a prognostic indicator in patients undergoing surgery, but there are limited data on its role in TIPS.

AIM

To determine whether the ICG-R15 can be used for prediction of post-TIPS HE in decompensated cirrhosis patients with portal hypertension (PHT) and compare the clinical value of ICG-R15, Child-Pugh score (CPS), and model for end-stage liver disease (MELD) score in predicting post-TIPS HE with PHT.

METHODS

This retrospective study included 195 patients with PHT who underwent elective TIPS at Beijing Shijitan Hospital from January 2018 to June 2019. All patients underwent the ICG-R15 test, CPS evaluation, and MELD scoring 1 wk before TIPS. According to whether they developed HE or not, the patients were divided into two groups: HE group and non-HE group. The prediction of one-year post-TIPS HE by ICG-R15, CPS and MELD score was evaluated by the areas under the receiver operating characteristic curves (AUCs).

RESULTS

A total of 195 patients with portal hypertension were included and 23% (45/195) of the patients developed post-TIPS HE. The ICG-R15 was identified as an independent predictor of post-TIPS HE. The AUCs for the ICG-R15, CPS, and MELD score for predicting post-TIPS HE were 0.664 (95% confidence interval [CI]: 0.557-0.743, P = 0.0046), 0.596 (95%CI: 0.508-0.679, P = 0.087), and 0.641 (95%CI: 0.554-0.721, P = 0.021), respectively. The non-parametric approach (Delong-Delong & Clarke-Pearson) showed that there was statistical significance in pairwise comparison between AUCs of ICG-R15 and MELD score (P = 0.0229).

CONCLUSION

The ICG-R15 has appreciated clinical value for predicting the occurrence of post-TIPS HE and is a choice for evaluating the prognosis of patients undergoing TIPS.

Stent patency and outcome of TIPS through the left versus the right portal branches

Background

Our purpose is to compare the stent patency and clinical outcome of trans-jugular intra-hepatic porto-systemic shunt (TIPS) through the left branch portal vein (TIPS-LPV) to the standard TIPS through the right branch (TIPS-RPV). We retrospectively reviewed all patients (n = 54) with refractory portal hypertension who were subjected to TIPS-LPV at our institute (TIPS-LPV) between 2016 and 2018. These patients were matched with 56 control patients treated with the standard TIPS-RPV (TIPS-RPV). The 2 groups were compared regarding the stent patency rate, encephalopathy, and re-interventions for 1 year after the procedure.

Results

TIPS-LPV group showed 12 months higher patency rate (90.7% compared to 73.2%) (P < 0.005). The number of the encephalopathy attacks in the TIPS-LPV group was significantly lower than that of the TIPS-RPV group at 6 and 12 months of follow-up [P = 0.012 and 0.036, respectively]. Re-bleeding and improvement of ascites were the same in the two groups [P > 0.05]. Patients underwent TIPS-LPV needed less re-interventions and required less hospitalizations than those with TIPS-RPV [P = 0.039 and P = 0.03, respectively].

Conclusion

The new TIPS approach is to extend the stent to LPV. This new TIPS-LPV approach showed the same clinical efficiency as the standard TIPS-RPV in treating variceal bleeding and ascites. However, it proved a better stent patency with lower rates of re-interventions, encephalopathy, and hospital admissions than TIPS through the right branch.

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

Background

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

Results

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

Conclusion

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