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Yang JX, Peng YM, Zeng HT, Lin XM, Xu ZL. Drainage of ascites in cirrhosis. World J Hepatol 2024; 16:1245-1257. [PMID: 39351514 PMCID: PMC11438587 DOI: 10.4254/wjh.v16.i9.1245] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/03/2024] [Revised: 07/20/2024] [Accepted: 07/29/2024] [Indexed: 09/23/2024] Open
Abstract
For cirrhotic refractory ascites, diuretics combined with albumin and vasoactive drugs are the first-line choice for ascites management. However, their therapeutic effects are limited, and most refractory ascites do not respond to medication treatment, necessitating consideration of drainage or surgical interventions. Consequently, numerous drainage methods for cirrhotic ascites have emerged, including large-volume paracentesis, transjugular intrahepatic portosystemic shunt, peritoneovenous shunt, automated low-flow ascites pump, cell-free and concentrated ascites reinfusion therapy, and peritoneal catheter drainage. This review introduces the advantages and disadvantages of these methods in different aspects, as well as indications and contraindications for this disease.
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Affiliation(s)
- Jia-Xing Yang
- Department of Gastroenterology, The Second Clinical Medical College, Jinan University, Shenzhen 518000, Guangdong Province, China
| | - Yue-Ming Peng
- Department of Nursing, Shenzhen People's Hospital, The Second Clinical Medical College, Jinan University, Shenzhen 518000, Guangdong Province, China
| | - Hao-Tian Zeng
- Department of Gastroenterology, The Second Clinical Medical College, Jinan University, Shenzhen 518000, Guangdong Province, China
| | - Xi-Min Lin
- Department of Gastroenterology, The Second Clinical Medical College, Jinan University, Shenzhen 518000, Guangdong Province, China
| | - Zheng-Lei Xu
- Department of Gastroenterology, Shenzhen People's Hospital, The Second Clinical Medical College, Jinan University, Shenzhen 518000, Guangdong Province, China.
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Qi WL, Wen J, Wen TF, Peng W, Zhang XY, Shen JY, Li X, Li C. Prognosis after splenectomy plus pericardial devascularization vs transjugular intrahepatic portosystemic shunt for esophagogastric variceal bleeding. World J Gastrointest Surg 2023; 15:1641-1651. [PMID: 37701695 PMCID: PMC10494603 DOI: 10.4240/wjgs.v15.i8.1641] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/20/2023] [Revised: 06/04/2023] [Accepted: 06/26/2023] [Indexed: 08/25/2023] Open
Abstract
BACKGROUND Portal hypertension combined with esophagogastric variceal bleeding (EGVB) is a serious complication in patients with hepatitis B virus (HBV)-related cirrhosis in China. Splenectomy plus pericardial devascularization (SPD) and transjugular intrahepatic portosystemic shunt (TIPS) are effective treatments for EGVB. However, a comparison of the effectiveness and safety of those methods is lacking. AIM To compare the prognosis after SPD vs TIPS for acute EGVB after failure of endoscopic therapy or secondary prophylaxis of variceal rebleeding (VRB) in patients with HBV-related cirrhosis combined with portal hypertension. METHODS This retrospective cohort study included 318 patients with HBV-related cirrhosis and EGVB who underwent SPD or TIPS at West China Hospital of Sichuan University during 2009-2013. Propensity score-matched analysis (PSM), the Kaplan-Meier method, and multivariate Cox regression analysis were used to compare overall survival, VRB rate, liver function abnormality rate, and hepatocellular carcinoma (HCC) incidence between the two patient groups. RESULTS The median age was 45.0 years (n = 318; 226 (71.1%) males). During a median follow-up duration of 43.0 mo, 18 (11.1%) and 33 (21.2%) patients died in the SPD and TIPS groups, respectively. After PSM, SPD was significantly associated with better overall survival (OS) (P = 0.01), lower rates of abnormal liver function (P < 0.001), and a lower incidence of HCC (P = 0.02) than TIPS. The VRB rate did not differ significantly between the two groups (P = 0.09). CONCLUSION Compared with TIPS, SPD is associated with higher postoperative OS rates, lower rates of abnormal liver function and HCC, and better quality of survival as acute EGVB treatment after failed endoscopic therapy or as secondary prophylaxis of VRB in patients with HBV-related cirrhosis combined with portal hypertension. There is no significant between-group difference in VRB rates.
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Affiliation(s)
- Wei-Li Qi
- Department of Liver Surgery, West China Hospital, Sichuan University, Chengdu 610041, Sichuan Province, China
| | - Jun Wen
- Department of Liver Surgery, West China Hospital, Sichuan University, Chengdu 610041, Sichuan Province, China
- Section for HepatoPancreatoBiliary Surgery, Department of General Surgery, The Third People’s Hospital of Chengdu, Affiliated Hospital of Southwest Jiaotong University & The Second Affiliated Hospital of Chengdu, Chongqing Medical University, Chengdu 610041, Sichuan Province, China
| | - Tian-Fu Wen
- Department of Liver Surgery, West China Hospital, Sichuan University, Chengdu 610041, Sichuan Province, China
| | - Wei Peng
- Department of Liver Surgery, West China Hospital, Sichuan University, Chengdu 610041, Sichuan Province, China
| | - Xiao-Yun Zhang
- Department of Liver Surgery, West China Hospital, Sichuan University, Chengdu 610041, Sichuan Province, China
| | - Jun-Yi Shen
- Department of Liver Surgery, West China Hospital, Sichuan University, Chengdu 610041, Sichuan Province, China
| | - Xiao Li
- Department of Interventional Therapy, West China Hospital, Sichuan University, Chengdu 610041, Sichuan Province, China
- Department of Interventional Therapy, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100000, China
| | - Chuan Li
- Department of Liver Surgery, West China Hospital, Sichuan University, Chengdu 610041, Sichuan Province, China
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Jaber F, Beran A, Alsakarneh S, Ahmed K, Abdallah M, Elfert K, Almeqdadi M, Jaber M, Mohamed WT, Ahmed M, Al Momani L, Numan L, Bierman T, Helzberg JH, Ghoz H, Clarkston WK. Transjugular Intrahepatic Portosystemic Shunt With or Without Gastroesophageal Variceal Embolization for the Prevention of Variceal Rebleeding: A Systematic Review and Meta-Analysis. Gastroenterology Res 2023; 16:68-78. [PMID: 37187555 PMCID: PMC10181335 DOI: 10.14740/gr1618] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/27/2023] [Accepted: 04/14/2023] [Indexed: 05/17/2023] Open
Abstract
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.
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Affiliation(s)
- Fouad Jaber
- Department of Internal Medicine, University of Missouri Kansas City, Kansas City, MO, USA
- Corresponding Author: Fouad Jaber, Department of Internal Medicine, University of Missouri Kansas City, Kansas City, MO, USA.
| | - Azizullah Beran
- Department of Gastroenterology and Hepatology, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Saqr Alsakarneh
- Department of Internal Medicine, University of Missouri Kansas City, Kansas City, MO, USA
| | - Khalid Ahmed
- Department of Internal Medicine, The Wright Medical Center for Graduate Medical Education, Scranton, PA, USA
| | - Mohamed Abdallah
- Division of Gastroenterology and Hepatology, Department of Medicine, University of Minnesota, Minneapolis, MN, USA
| | - Khaled Elfert
- Department of Internal Medicine, SBH Health System, New York, NY, USA
| | - Mohammad Almeqdadi
- Department of Transplant Hepatobiliary Disease, Lahey Hospital and Medical Center, Burlington, MA, USA
| | - Mohammed Jaber
- Department of Medical Education, Al-Azhar University, Gaza, Palestine
| | - Wael T. Mohamed
- Department of Internal Medicine, University of Missouri Kansas City, Kansas City, MO, USA
| | - Mohamd Ahmed
- Department of Internal Medicine, University of Missouri Kansas City, Kansas City, MO, USA
| | - Laith Al Momani
- Department of Gastroenterology and Hepatology, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Laith Numan
- Department of Gastroenterology and Hepatology, Saint Louis University School of Medicine, Saint Louis, MO, USA
| | - Thomas Bierman
- Department of Gastroenterology and Hepatology, University of Missouri Kansas City, Kansas City, MO, USA
- Department of Gastroenterology and Hepatology, Saint Luke’s Hospital, Kansas City, MO, USA
| | - John H. Helzberg
- Department of Gastroenterology and Hepatology, University of Missouri Kansas City, Kansas City, MO, USA
- Department of Gastroenterology and Hepatology, Saint Luke’s Hospital, Kansas City, MO, USA
| | - Hassan Ghoz
- Department of Gastroenterology and Hepatology, University of Missouri Kansas City, Kansas City, MO, USA
| | - Wendell K. Clarkston
- Department of Gastroenterology and Hepatology, University of Missouri Kansas City, Kansas City, MO, USA
- Department of Gastroenterology and Hepatology, Saint Luke’s Hospital, Kansas City, MO, USA
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Chapin SE, Goldberg DS, Kaplan DE, Mahmud N. External Validation of the FIPS Score for Post-TIPS Mortality in a National Veterans Affairs Cohort. Dig Dis Sci 2022; 67:4581-4589. [PMID: 34797445 PMCID: PMC9117561 DOI: 10.1007/s10620-021-07307-5] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/03/2021] [Accepted: 10/25/2021] [Indexed: 02/07/2023]
Abstract
BACKGROUND The Freiburg index of post-TIPS survival (FIPS) score was recently demonstrated to improve prediction of post-TIPS mortality relative to existing standards. As this score was derived from a German cohort over an extended time period, it is unclear if performance will translate well to other settings. This study aimed to externally validate the FIPS score in a large Veterans Affairs (VA) cohort over two separate eras of TIPS-related care. METHODS This was a retrospective cohort study of patients with cirrhosis who underwent TIPS placement in the VA from 2008 to 2020. Cox regression models for post-TIPS survival were constructed using FIPS, MELD, MELD-Na, or CTP scores as predictors. Discrimination (Harrell's C) and calibration (joint tests of calibration curve slope and intercept) were evaluated for each score. A stratified analysis was performed for time periods between 2008-2013 and 2014-2020. RESULTS The cohort of 1,274 patients was 97.3% male with mean age 60.9 years and mean MELD-Na 14. The FIPS score demonstrated the highest overall discrimination versus MELD, MELD-Na, and CTP (0.634 vs. 0.585, 0.626, 0.612, respectively). However, in the modern treatment era (2014-2020), the FIPS score performed similarly to MELD-Na. Additionally, the FIPS score demonstrated poor calibration at one-month and six-month post-TIPS timepoints (joint p = 0.04 and 0.004, respectively). MELD, MELD-Na, and CTP were well-calibrated at each timepoint (each joint p > 0.05). CONCLUSION The FIPS score performed similarly to MELD-Na in the modern TIPS treatment era and demonstrated regions of poor calibration. Future models derived with contemporary data may improve prediction of post-TIPS mortality.
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Affiliation(s)
- Sara E Chapin
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - David S Goldberg
- Division of Digestive Health and Liver Diseases, Department of Medicine, University of Miami Miller School of Medicine, Miami, FL, USA
| | - David E Kaplan
- Division of Gastroenterology and Hepatology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
- Department of Medicine, Corporal Michael J. Crescenz VA Medical Center, Philadelphia, PA, USA
| | - Nadim Mahmud
- Division of Gastroenterology and Hepatology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA.
- Department of Medicine, Corporal Michael J. Crescenz VA Medical Center, Philadelphia, PA, USA.
- Leonard David Institute of Health Economics, University of Pennsylvania, Philadelphia, PA, USA.
- Center for Clinical Epidemiology and Biostatistics, Department of Biostatistics, Epidemiology & Informatics, Perelman School of Medicine, University of Pennsylvania, 3400 Civic Center Boulevard, 4th Floor, South Pavilion, Philadelphia, PA, 19104, USA.
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Retrospective evaluation of early thrombosis in transjugular intrahepatic portosystemic polytetrafluoroethylene-coated shunts under 2-day postinterventional heparinization. Sci Rep 2022; 12:10506. [PMID: 35732875 PMCID: PMC9217914 DOI: 10.1038/s41598-022-14388-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2021] [Accepted: 06/06/2022] [Indexed: 11/08/2022] Open
Abstract
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.
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Mostafa K, Trentmann J, Andersson J, Günther R, Braun F, Schäfer PJ. Percutaneous creation of direct intrahepatic portosystemic shunts - an alternative for failed TIPS creation. CVIR Endovasc 2022; 5:16. [PMID: 35278149 PMCID: PMC8918291 DOI: 10.1186/s42155-022-00292-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2021] [Accepted: 02/24/2022] [Indexed: 11/10/2022] Open
Abstract
INTRODUCTION Direct intrahepatic portosystemic shunt creation is a feasible and safe alternative for transjugular intrahepatic portosystemic shunt creation. It needs equipment like endovascular ultrasound with restricted availability. We performed the procedure percutaneously with a common interventional armamentarium to make it more feasible. METHODS Retrospective analysis of 8 percutaneous DIPS insertions between 2016 and 2020. RESULTS The procedure was successful in 8/8 patients. There was no short-term death reported within 30 days. The longest reported patency is 5 years. CONCLUSION Percutaneous DIPS creation is a feasible alternative for failed TIPS. Percutaneously the procedure can be completed faster than conventional DIPS using only minimal puncture equipment. LEVEL OF EVIDENCE Level 4, Case Series.
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Affiliation(s)
- Karim Mostafa
- Universitätsklinikum Schleswig-Holstein, Campus Kiel, Kiel, Schleswig-Holstein, Germany.
| | - Jens Trentmann
- Universitätsklinikum Schleswig-Holstein, Campus Kiel, Kiel, Schleswig-Holstein, Germany
| | - Julian Andersson
- Universitätsklinikum Schleswig-Holstein, Campus Kiel, Kiel, Schleswig-Holstein, Germany
| | - Rainer Günther
- Universitätsklinikum Schleswig-Holstein, Campus Kiel, Kiel, Schleswig-Holstein, Germany
| | - Felix Braun
- Universitätsklinikum Schleswig-Holstein, Campus Kiel, Kiel, Schleswig-Holstein, Germany
| | - Philipp Jost Schäfer
- Universitätsklinikum Schleswig-Holstein, Campus Kiel, Kiel, Schleswig-Holstein, Germany
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Saab S, Zhao M, Asokan I, Yum JJ, Lee EW. History of Hepatic Encephalopathy Is Not a Contraindication to Transjugular Intrahepatic Portosystemic Shunt Placement for Refractory Ascites. Clin Transl Gastroenterol 2021; 12:e00378. [PMID: 34333500 PMCID: PMC8323801 DOI: 10.14309/ctg.0000000000000378] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/05/2021] [Accepted: 05/28/2021] [Indexed: 12/19/2022] Open
Abstract
INTRODUCTION The outcomes of transjugular intrahepatic portosystemic shunt (TIPS) placement in patients with hepatic encephalopathy (HE) are controversial. We studied the relationship of pre-TIPS HE in patients undergoing TIPS for refractory ascites on all-cause mortality and development of post-TIPS HE. METHODS A single-center retrospective comparison study was performed for patients undergoing TIPS for refractory ascites. Survival by history of pre-TIPS HE was demonstrated with Kaplan-Meier curves. Univariate and multivariate logistic regression analyses were performed to identify the predictors of post-TIPS clinical outcomes for patients with and without pre-TIPS HE. RESULTS We identified 202 TIPS recipients (61% male, mean ± SD; age 59.1 ± 10.2 years; mean model for end-stage liver disease score 17.3 ± 6.9). Pre-TIPS HE did not predispose patients for increased all-cause mortality, increased risk of experiencing HE within 60 days, or increased risk of hospital admission for HE within 6 months. A multivariate analysis demonstrated that total bilirubin (odds ratio [OR] 1.03; P = 0.016) and blood urea nitrogen (OR 1.15; P = 0.002) were predictors for all-cause mortality within 6 months post-TIPS. Age ≥65 years (OR 3.92; P = 0.004), creatinine (OR 2.22; P = 0.014), and Child-Pugh score (OR 1.53; P = 0.006) were predictors for HE within 60 days post-TIPS. Predictors of intensive care admission for HE within 6 months post-TIPS included age ≥65 years (OR 8.84; P = 0.018), history of any admission for HE within 6 months pre-TIPS (OR 8.42; P = 0.017), and creatinine (OR 2.22; P = 0.015). DISCUSSION If controlled, pre-TIPS HE does not adversely impact patient survival or clinical outcomes, such as development of HE within 60 days of TIPS or hospital admission for HE within 6 months. Patients may be able to undergo TIPS for refractory ascites despite a history of HE.
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Affiliation(s)
- Sammy Saab
- Division of Hepatology, Department of Medicine, UCLA Medical Center, David Geffen School of Medicine at UCLA, Los Angeles, California, USA
- Division of Liver and Pancreas Transplantation, Department of Surgery, UCLA Medical Center, David Geffen School of Medicine at UCLA, Los Angeles, Los Angeles, California, USA
| | - Matthew Zhao
- Division of Hepatology, Department of Medicine, UCLA Medical Center, David Geffen School of Medicine at UCLA, Los Angeles, California, USA
| | - Ishan Asokan
- Division of Hepatology, Department of Medicine, UCLA Medical Center, David Geffen School of Medicine at UCLA, Los Angeles, California, USA
| | - Jung Jun Yum
- Division of Liver and Pancreas Transplantation, Department of Surgery, UCLA Medical Center, David Geffen School of Medicine at UCLA, Los Angeles, Los Angeles, California, USA
| | - Edward Wolfgang Lee
- Division of Liver and Pancreas Transplantation, Department of Surgery, UCLA Medical Center, David Geffen School of Medicine at UCLA, Los Angeles, Los Angeles, California, USA
- Division of Interventional Radiology, Department of Radiology, UCLA Medical Center, David Geffen School of Medicine at UCLA, Los Angeles, California, USA
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Perez I, Bolte FJ, Bigelow W, Dickson Z, Shah NL. Step by Step: Managing the Complications of Cirrhosis. Hepat Med 2021; 13:45-57. [PMID: 34079394 PMCID: PMC8164676 DOI: 10.2147/hmer.s278032] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/02/2021] [Accepted: 04/24/2021] [Indexed: 12/12/2022] Open
Abstract
According to the Centers for Disease Control and Prevention, chronic liver disease and cirrhosis is the 11th leading cause of death in the United States. Common causes of chronic liver disease include alcohol, viral hepatitis, and non-alcoholic steatohepatitis (NASH). Inflammation is a critical driver in the progression of liver disease to liver fibrosis and ultimately cirrhosis. While the severity of chronic liver disease extends over a continuum, the management is more easily differentiated between compensated and decompensated cirrhosis. In this review, we discuss pathophysiology, clinical features and management of common complications of liver cirrhosis based on literature review and the current clinical practice guidelines of the American Association for the Study of Liver Diseases (AASLD).
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Affiliation(s)
- Irene Perez
- Department of Internal Medicine, University of Virginia, Charlottesville, VA, USA
| | - Fabian J Bolte
- Department of Internal Medicine, University of Virginia, Charlottesville, VA, USA
| | - William Bigelow
- Department of Internal Medicine, University of Virginia, Charlottesville, VA, USA
| | - Zachary Dickson
- Division of Gastroenterology and Hepatology, University of Virginia, Charlottesville, VA, USA
| | - Neeral L Shah
- Division of Gastroenterology and Hepatology, University of Virginia, Charlottesville, VA, USA
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Inchingolo R, Posa A, Mariappan M, Tibana TK, Nunes TF, Spiliopoulos S, Brountzos E. Transjugular intrahepatic portosystemic shunt for Budd-Chiari syndrome: A comprehensive review. World J Gastroenterol 2020; 26:5060-5073. [PMID: 32982109 PMCID: PMC7495032 DOI: 10.3748/wjg.v26.i34.5060] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/19/2020] [Revised: 06/06/2020] [Accepted: 08/25/2020] [Indexed: 02/06/2023] Open
Abstract
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.
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Affiliation(s)
- Riccardo Inchingolo
- Interventional Radiology Unit, "F. Miulli" Regional Hospital, Acquaviva delle Fonti 70021, Italy
- Department of Radiology, King´s College Hospital, London SE5 9RS, United Kingdom
| | - Alessandro Posa
- Department of Radiology, Gemelli Hospital, Roma 00135, Italy
| | - Martin Mariappan
- Interventional Radiology Department, Aberdeen Royal Infirmary Hospital, Aberdeen AB25 2ZN, United Kingdom
| | - Tiago Kojun Tibana
- Interventional Radiology Department, Universidade Federal de Mato Grosso do Sul, Campo Grande 79070-900, Brazil
| | - Thiago Franchi Nunes
- Interventional Radiology Department, Universidade Federal de Mato Grosso do Sul, Campo Grande 79070-900, Brazil
| | - Stavros Spiliopoulos
- 2nd Department of Radiology, School of Medicine, National and Kapodistrian University of Athens, Chaidari Athens GR 12461, Greece
| | - Elias Brountzos
- 2nd Department of Radiology, School of Medicine, National and Kapodistrian University of Athens, Chaidari Athens GR 12461, Greece
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Wang HH, Ma J, Wang SP, Ma F, Lu JW, Xu XH, Lv Y, Yan XP. Magnetic Anastomosis Rings to Create Portacaval Shunt in a Canine Model of Portal Hypertension. J Gastrointest Surg 2019; 23:2184-2192. [PMID: 30132290 DOI: 10.1007/s11605-018-3888-5] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/16/2018] [Accepted: 07/15/2018] [Indexed: 01/31/2023]
Abstract
PURPOSE This study evaluated a novel magnetic compression technique (magnamosis) for creating a portacaval shunt in a canine model of portal hypertension, relative to traditional manual suture. METHODS Portal hypertension was induced in 18 dogs by partial ligation of the portal vein (baseline). Six weeks later, extrahepatic portacaval shunt implantation was performed with either magnetic anastomosis rings, or traditional manual suture (n = 9, each). The two groups were compared for operative time, portal vein pressure, and serum biochemical indices. Twenty-four weeks post-implantation, the established anastomoses were evaluated by color Doppler imaging, venography, and gross and microscopic histological examinations. RESULTS Anastomotic leakage did not occur in either group. The operative time to complete the anastomosis for magnamosis (4.12 ± 1.04 min) was significantly less than that needed for manual suture (24.47 ± 4.89 min, P < 0.01). The portal vein pressure in the magnamosis group was more stable than that in the manual suture group. The blood ammonia level at the end of the 24-week post-implantation observation period was significantly lower in the magnamosis group than in the manual suture group. Gross and microscopic histological examinations revealed that better smoothness and continuity of the vascular intima had been achieved via magnamosis than with manual suture. CONCLUSION Magnamosis was superior to manual suture for the creation of a portacaval shunt in this canine model of portal hypertension.
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Affiliation(s)
- Hao-Hua Wang
- Department of Hepatobiliary Surgery, The First Affiliated Hospital of Xi'an Jiaotong University, 277 West Yanta Road, Xi'an, 710061, Shaanxi, People's Republic of China
- National Local Joint Engineering Research Center for Precision Surgery & Regenerative Medicine, Xi'an, 710061, People's Republic of China
- Shaanxi Province Center for Regenerative Medicine and Surgery Engineering Research, Xi'an, 710061, People's Republic of China
| | - Jia Ma
- Department of Surgical Oncology, The Third Affiliated Hospital of Xi'an Jiaotong University (Shaanxi Provincial People's Hospital), Xi'an, China
| | - Shan-Pei Wang
- Department of Hepatobiliary Surgery, The First Affiliated Hospital of Xi'an Jiaotong University, 277 West Yanta Road, Xi'an, 710061, Shaanxi, People's Republic of China
- National Local Joint Engineering Research Center for Precision Surgery & Regenerative Medicine, Xi'an, 710061, People's Republic of China
- Shaanxi Province Center for Regenerative Medicine and Surgery Engineering Research, Xi'an, 710061, People's Republic of China
| | - Feng Ma
- National Local Joint Engineering Research Center for Precision Surgery & Regenerative Medicine, Xi'an, 710061, People's Republic of China
- Shaanxi Province Center for Regenerative Medicine and Surgery Engineering Research, Xi'an, 710061, People's Republic of China
| | - Jian-Wen Lu
- Department of Hepatobiliary Surgery, The First Affiliated Hospital of Xi'an Jiaotong University, 277 West Yanta Road, Xi'an, 710061, Shaanxi, People's Republic of China
- National Local Joint Engineering Research Center for Precision Surgery & Regenerative Medicine, Xi'an, 710061, People's Republic of China
- Shaanxi Province Center for Regenerative Medicine and Surgery Engineering Research, Xi'an, 710061, People's Republic of China
| | - Xiang-Hua Xu
- Department of Hepatobiliary Surgery, The First Affiliated Hospital of Xi'an Jiaotong University, 277 West Yanta Road, Xi'an, 710061, Shaanxi, People's Republic of China
- National Local Joint Engineering Research Center for Precision Surgery & Regenerative Medicine, Xi'an, 710061, People's Republic of China
- Shaanxi Province Center for Regenerative Medicine and Surgery Engineering Research, Xi'an, 710061, People's Republic of China
| | - Yi Lv
- Department of Hepatobiliary Surgery, The First Affiliated Hospital of Xi'an Jiaotong University, 277 West Yanta Road, Xi'an, 710061, Shaanxi, People's Republic of China.
- National Local Joint Engineering Research Center for Precision Surgery & Regenerative Medicine, Xi'an, 710061, People's Republic of China.
- Shaanxi Province Center for Regenerative Medicine and Surgery Engineering Research, Xi'an, 710061, People's Republic of China.
| | - Xiao-Peng Yan
- Department of Hepatobiliary Surgery, The First Affiliated Hospital of Xi'an Jiaotong University, 277 West Yanta Road, Xi'an, 710061, Shaanxi, People's Republic of China.
- National Local Joint Engineering Research Center for Precision Surgery & Regenerative Medicine, Xi'an, 710061, People's Republic of China.
- Shaanxi Province Center for Regenerative Medicine and Surgery Engineering Research, Xi'an, 710061, People's Republic of China.
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11
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Raissi D, Yu Q, Nisiewicz M, Krohmer S. Parallel transjugular intrahepatic portosystemic shunt with Viatorr ® stents for primary TIPS insufficiency: Case series and review of literature. World J Hepatol 2019; 11:217-225. [PMID: 30820271 PMCID: PMC6393714 DOI: 10.4254/wjh.v11.i2.217] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/31/2018] [Revised: 12/31/2018] [Accepted: 01/09/2019] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Transjugular intrahepatic portosystemic shunts (TIPS) can alleviate complications of portal hypertension such as ascites and variceal bleeding by decreasing the portosystemic gradient. In limited clinical situations, parallel TIPS may be only solution to alleviate either variceal bleeding or ascites secondary to portal hypertension when the primary TIPS fails to do so. Data specifically addressing the use of this partially polytetrafluoroethylene covered nitinol stent (Viatorr®) is largely lacking despite Viatorr® being the current gold standard for modern TIPS placement. CASE SUMMARY All three patients had portal hypertension and already had a primary Viatorr® TIPS placed previously. All patients have undergone failed endoscopy to manage acute variceal bleeding before referral for a parallel stent (PS). PS were placed in patients presenting with recurrent variceal bleeding despite existence of a widely patent primary TIPS. Primary stent patency was verified with either Doppler ultrasound or intra-procedural TIPS stent venography. Doppler ultrasound follow-up imaging demonstrated complete patency of both primary and parallel TIPS. All three patients did well on clinical follow-up of up to six months and no major complications were recorded. A review of existing literature on the role of PS in the management of portal hypertension complications is discussed. There are three case reports of use of primary and PS Viatorr® stents placement, only one of which is in a patient with gastrointestinal variceal bleeding despite a patent primary Viatorr® TIPS. CONCLUSION Viatorr® PS placement in the management of variceal hemorrhage is feasible with promising short term patency and clinical follow-up data.
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Affiliation(s)
- Driss Raissi
- Department of Radiology, University of Kentucky, Lexington, KY 40536, United States.
| | - Qian Yu
- Department of Radiology, University of Kentucky, Lexington, KY 40536, United States
| | - Michael Nisiewicz
- Department of Radiology, University of Kentucky, Lexington, KY 40536, United States
| | - Steven Krohmer
- Department of Radiology, University of Kentucky, Lexington, KY 40536, United States
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12
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Fukui H, Kawaratani H, Kaji K, Takaya H, Yoshiji H. Management of refractory cirrhotic ascites: challenges and solutions. Hepat Med 2018; 10:55-71. [PMID: 30013405 PMCID: PMC6039068 DOI: 10.2147/hmer.s136578] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
Among the various risky complications of liver cirrhosis, refractory ascites is associated with poor survival of cirrhotics and persistently worsens their quality of life (QOL). Major clinical guidelines worldwide define refractory ascites as ascites that cannot be managed by medical therapy either because of a lack of response to maximum doses of diuretics or because patients develop complications related to diuretic therapy that preclude the use of an effective dose of diuretics. Due to the difficulty in receiving a liver transplantation (LT), the ultimate solution for refractory ascites, most cirrhotic patients have selected the palliative therapy such as repeated serial paracentesis, transjugular intrahepatic portosystemic shunt, or peritoneovenous shunt to improve their QOL. During the past several decades, new interventions and methodologies, such as indwelling peritoneal catheter, peritoneal-urinary drainage, and cell-free and concentrated ascites reinfusion therapy, have been introduced. In addition, new medical treatments with vasoconstrictors or vasopressin V2 receptor antagonists have been proposed. Both the benefits and risks of these old and new modalities have been extensively studied in relation to the pathophysiological changes in ascites formation. Although the best solution for refractory ascites is to eliminate hepatic failure either by LT or by causal treatment, the selection of the best palliative therapy for individual patients is of utmost importance, aiming at achieving the longest possible, comfortable life. This review briefly summarizes the changing landscape of variable treatment modalities for cirrhotic patients with refractory ascites, aiming at clarifying their possibilities and limitations. Evolving issues with regard to the impact of gut-derived systemic and local infection on the clinical course of cirrhotic patients have paved the way for the development of a new gut microbiome-based therapeutics. Thus, it should be further investigated whether the early therapeutic approach to gut dysbiosis provides a better solution for the management of cirrhotic ascites.
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Affiliation(s)
- Hiroshi Fukui
- Department of Gastroenterology, Endocrinology and Metabolism, Nara Medical University, Nara, Japan,
| | - Hideto Kawaratani
- Department of Gastroenterology, Endocrinology and Metabolism, Nara Medical University, Nara, Japan,
| | - Kosuke Kaji
- Department of Gastroenterology, Endocrinology and Metabolism, Nara Medical University, Nara, Japan,
| | - Hiroaki Takaya
- Department of Gastroenterology, Endocrinology and Metabolism, Nara Medical University, Nara, Japan,
| | - Hitoshi Yoshiji
- Department of Gastroenterology, Endocrinology and Metabolism, Nara Medical University, Nara, Japan,
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13
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Bucsics T, Schoder M, Diermayr M, Feldner-Busztin M, Goeschl N, Bauer D, Schwabl P, Mandorfer M, Angermayr B, Cejna M, Ferlitsch A, Sieghart W, Trauner M, Peck-Radosavljevic M, Karner J, Karnel F, Reiberger T. Transjugular intrahepatic portosystemic shunts (TIPS) for the prevention of variceal re-bleeding - A two decades experience. PLoS One 2018; 13:e0189414. [PMID: 29315304 PMCID: PMC5760018 DOI: 10.1371/journal.pone.0189414] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2017] [Accepted: 11/24/2017] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND AND AIMS Transjugular intrahepatic portosystemic shunts (TIPS) are used in patients with cirrhosis for the prevention of variceal rebleeding. METHODS We retrospectively evaluated re-bleeding rate, patency, mortality, and transplant-free survival (TFS) in cirrhotic patients receiving TIPS implantation for variceal bleeding between 1994-2014. RESULTS 286 patients received TIPS (n = 119 bare metal stents, n = 167 polytetrafluorethylene (PTFE)-covered stents) for prevention of variceal re-bleeding. Mean age was 55.1 years, median MELD was 11.8, and the main etiology of cirrhosis was alcoholic liver disease (70%). Median follow-up was 821 days. 67 patients (23%) experienced at least one re-bleeding event. Patients with PTFE-TIPS were at significantly lower risk for variceal re-bleeding than patients with bare metal stents (14% vs. 37%, OR:0.259; p<0.001) and had less need for stent revision (21% vs. 37%; p = 0.024). Patients with PTFE stent grafts showed lower mortality than patients with bare stents after 1 year (19% vs. 31%, p = 0.020) and 2 years (29% vs. 40%; p = 0.041) after TIPS implantation. Occurrence of hepatic encephalopathy after TIPS was similar between groups (20% vs. 24%, p = 0.449). CONCLUSIONS PTFE-TIPS were more effective at preventing variceal re-bleeding than bare metal stents due to better patency. Since this tended to translate in improved survival, only covered stents should be implemented for bleeding prophylaxis when TIPS is indicated.
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Affiliation(s)
- Theresa Bucsics
- Division of Gastroenterology & Hepatology, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria
- Vienna Hepatic Hemodynamic Laboratory, Medical University of Vienna, Vienna, Austria
| | - Maria Schoder
- Department of Biomedical Imaging and Image-guided Therapy, Medical University of Vienna, Vienna, Austria
| | - Magdalena Diermayr
- Division of Gastroenterology & Hepatology, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria
- Vienna Hepatic Hemodynamic Laboratory, Medical University of Vienna, Vienna, Austria
| | - Maria Feldner-Busztin
- Division of Gastroenterology & Hepatology, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria
- Vienna Hepatic Hemodynamic Laboratory, Medical University of Vienna, Vienna, Austria
| | - Nicolas Goeschl
- Division of Gastroenterology & Hepatology, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria
- Vienna Hepatic Hemodynamic Laboratory, Medical University of Vienna, Vienna, Austria
| | - David Bauer
- Division of Gastroenterology & Hepatology, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria
- Vienna Hepatic Hemodynamic Laboratory, Medical University of Vienna, Vienna, Austria
| | - Philipp Schwabl
- Division of Gastroenterology & Hepatology, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria
- Vienna Hepatic Hemodynamic Laboratory, Medical University of Vienna, Vienna, Austria
| | - Mattias Mandorfer
- Division of Gastroenterology & Hepatology, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria
- Vienna Hepatic Hemodynamic Laboratory, Medical University of Vienna, Vienna, Austria
| | - Bernhard Angermayr
- Division of Gastroenterology & Hepatology, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria
| | - Manfred Cejna
- Department of Radiology, Landeskrankenhaus, Feldkirch, Austria
| | - Arnulf Ferlitsch
- Division of Gastroenterology & Hepatology, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria
- Vienna Hepatic Hemodynamic Laboratory, Medical University of Vienna, Vienna, Austria
| | - Wolfgang Sieghart
- Division of Gastroenterology & Hepatology, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria
- Vienna Hepatic Hemodynamic Laboratory, Medical University of Vienna, Vienna, Austria
| | - Michael Trauner
- Division of Gastroenterology & Hepatology, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria
| | - Markus Peck-Radosavljevic
- Division of Gastroenterology & Hepatology, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria
- Vienna Hepatic Hemodynamic Laboratory, Medical University of Vienna, Vienna, Austria
| | - Josef Karner
- Department of Surgery, Kaiser-Franz Josef Spital, Vienna, Austria
| | - Franz Karnel
- Department of Radiology, Kaiser-Franz Josef Spital, Vienna, Austria
| | - Thomas Reiberger
- Division of Gastroenterology & Hepatology, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria
- Vienna Hepatic Hemodynamic Laboratory, Medical University of Vienna, Vienna, Austria
- * E-mail:
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14
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Zhao R, Lu J, Shi Y, Zhao H, Xu K, Sheng J. Current management of refractory ascites in patients with cirrhosis. J Int Med Res 2017; 46:1138-1145. [PMID: 29210304 PMCID: PMC5972247 DOI: 10.1177/0300060517735231] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
Liver cirrhosis is a health problem worldwide, and ascites is its principal symptom. Refractory ascites is intractable and occurs in 5%-10% of all patients with ascites due to cirrhosis. Refractory ascites leads to a poor quality of life and high mortality rate. Ascites develops as a result of portal hypertension, which leads to water-sodium retention and renal failure. Various therapeutic measures can be used for refractory ascites, including large-volume paracentesis, transjugular intrahepatic portosystemic shunt, vasoconstrictive drugs, and an automated low-flow ascites pump system. However, ascites generally can be resolved only by liver transplantation. Because not all patients can undergo liver transplantation, traditional approaches are still used to treat refractory ascites. The choice of treatment modality for refractory ascites depends, among other factors, on the condition of the patient.
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Affiliation(s)
- Ruihong Zhao
- Department of Infectious Diseases, Collaborative Innovation Center for Diagnosis and Treatment of Infectious Diseases, The First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China
| | - Juan Lu
- Department of Infectious Diseases, Collaborative Innovation Center for Diagnosis and Treatment of Infectious Diseases, The First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China
| | - Yu Shi
- Department of Infectious Diseases, Collaborative Innovation Center for Diagnosis and Treatment of Infectious Diseases, The First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China
| | - Hong Zhao
- Department of Infectious Diseases, Collaborative Innovation Center for Diagnosis and Treatment of Infectious Diseases, The First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China
| | - Kaijin Xu
- Department of Infectious Diseases, Collaborative Innovation Center for Diagnosis and Treatment of Infectious Diseases, The First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China
| | - Jifang Sheng
- Department of Infectious Diseases, Collaborative Innovation Center for Diagnosis and Treatment of Infectious Diseases, The First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China
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15
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Austrian consensus guidelines on the management and treatment of portal hypertension (Billroth III). Wien Klin Wochenschr 2017; 129:135-158. [PMID: 29063233 PMCID: PMC5674135 DOI: 10.1007/s00508-017-1262-3] [Citation(s) in RCA: 100] [Impact Index Per Article: 12.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2017] [Accepted: 08/22/2017] [Indexed: 12/14/2022]
Abstract
The Billroth III guidelines were developed during a consensus meeting of the Austrian Society of Gastroenterology and Hepatology (ÖGGH) and the Austrian Society of Interventional Radiology (ÖGIR) held on 18 February 2017 in Vienna. Based on international guidelines and considering recent landmark studies, the Billroth III recommendations aim to help physicians in guiding diagnostic and therapeutic strategies in patients with portal hypertension.
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16
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Expanded polytetrafluoroethylene-covered stent-grafts for transjugular intrahepatic portosystemic shunts in cirrhotic patients: Long-term patency and clinical outcome results. Eur Radiol 2016; 27:1795-1803. [PMID: 27629421 DOI: 10.1007/s00330-016-4570-5] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2016] [Revised: 08/11/2016] [Accepted: 08/22/2016] [Indexed: 01/23/2023]
Abstract
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.
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17
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Glowka TR, Kalff JC, Schäfer N. Clinical Management of Chronic Portal/Mesenteric Vein Thrombosis: The Surgeon's Point of View. VISZERALMEDIZIN 2015; 30:409-15. [PMID: 26288608 PMCID: PMC4513833 DOI: 10.1159/000369575] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
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.
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Affiliation(s)
- Tim R Glowka
- Department of Surgery, University of Bonn, Bonn, Germany
| | - Jörg C Kalff
- Department of Surgery, University of Bonn, Bonn, Germany
| | - Nico Schäfer
- Department of Surgery, University of Bonn, Bonn, Germany
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18
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Abstract
Transjugular intrahepatic portosystemic shunt (TIPS) is an established procedure for the complications of portal hypertension. The largest body of evidence for its use has been supported for recurrent or refractory variceal bleeding and refractory ascites. Its use has also been advocated for acute variceal bleed, hepatic hydrothorax, and hepatorenal syndrome. With the replacement of bare metal stents with polytetrafluoroethylene-covered stents, shunt patency has improved dramatically, thus, improving outcomes. Therefore, reassessment of its utility, management of its complications, and understanding of various TIPS techniques is important.
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Affiliation(s)
- Kavish R Patidar
- Department of Internal Medicine, Virginia Commonwealth University Hospital, 1200 East Broad Street, MCV Box 980342, Richmond, VA 23298-0342, USA
| | - Malcolm Sydnor
- Radiology, Virginia Commonwealth University Hospital, 1200 East Broad Street, MCV Box 980615, Richmond, VA 23298-0615, USA; Surgery, Virginia Commonwealth University Hospital, 1200 East Broad Street, Richmond, VA 23298, USA; Vascular Interventional Radiology, Virginia Commonwealth University Hospital, 1200 East Broad Street, Richmond, VA 23298, USA
| | - Arun J Sanyal
- Division of Gastroenterology, Department of Internal Medicine, Virginia Commonwealth University School of Medicine, 1200 East Broad Street, MCV Box 980342, Richmond, VA 23298-0342, USA.
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19
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Lim N, Desarno MJ, Lidofsky SD, Ganguly E. Hospitalization for variceal hemorrhage in an era with more prevalent cirrhosis. World J Gastroenterol 2014; 20:11326-11332. [PMID: 25170218 PMCID: PMC4145772 DOI: 10.3748/wjg.v20.i32.11326] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/17/2014] [Revised: 03/11/2014] [Accepted: 05/23/2014] [Indexed: 02/06/2023] Open
Abstract
AIM To examine hospitalization rates for variceal hemorrhage and relation to cause of cirrhosis during an era of increased cirrhosis prevalence. METHODS We performed a retrospective review of patients with cirrhosis and gastroesophageal variceal hemorrhage who were admitted to a tertiary care referral center from 1998 to 2009. Subjects were classified according to the etiology of their liver disease: alcoholic cirrhosis and non-alcoholic cirrhosis. Rates of hospitalization for variceal bleeding were determined. Data were also collected on total hospital admissions per year and cirrhosis-related admissions per year over the same time period. These data were then compared and analyzed for trends in admission rates. RESULTS Hospitalizations for cirrhosis significantly increased from 611 per 100000 admissions in 1998-2001 to 1232 per 100000 admissions in 2006-9 (P value for trend < 0.0001). This increase was seen in admissions for both alcoholic and non-alcoholic cirrhosis (P values for trend < 0.001 and < 0.0001 respectively). During the same time period, there were 243 admissions for gastroesophageal variceal bleeding (68% male, mean age 54.3 years, 62% alcoholic cirrhosis). Hospitalizations for gastroesophageal variceal bleeding significantly decreased from 96.6 per 100000 admissions for the time period 1998-2001 to 70.6 per 100000 admissions for the time period 2006-2009 (P value for trend = 0.01). There were significant reductions in variceal hemorrhage from non-alcoholic cirrhosis (41.6 per 100000 admissions in 1998-2001 to 19.7 per 100000 admissions in 2006-2009, P value for trend = 0.007). CONCLUSION Hospitalizations for variceal hemorrhage have decreased, most notably in patients with non-alcoholic cirrhosis, and this may reflect broader use of strategies to prevent bleeding.
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20
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Rajoriya N, Tripathi D. Historical overview and review of current day treatment in the management of acute variceal haemorrhage. World J Gastroenterol 2014; 20:6481-6494. [PMID: 24914369 PMCID: PMC4047333 DOI: 10.3748/wjg.v20.i21.6481] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/13/2013] [Revised: 01/14/2014] [Accepted: 04/02/2014] [Indexed: 02/06/2023] Open
Abstract
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.
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21
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Nusrat S, Khan MS, Fazili J, Madhoun MF. Cirrhosis and its complications: Evidence based treatment. World J Gastroenterol 2014; 20:5442-5460. [PMID: 24833875 PMCID: PMC4017060 DOI: 10.3748/wjg.v20.i18.5442] [Citation(s) in RCA: 155] [Impact Index Per Article: 14.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/18/2013] [Revised: 01/17/2014] [Accepted: 02/20/2014] [Indexed: 02/06/2023] Open
Abstract
Cirrhosis results from progressive fibrosis and is the final outcome of all chronic liver disease. It is among the ten leading causes of death in United States. Cirrhosis can result in portal hypertension and/or hepatic dysfunction. Both of these either alone or in combination can lead to many complications, including ascites, varices, hepatic encephalopathy, hepatocellular carcinoma, hepatopulmonary syndrome, and coagulation disorders. Cirrhosis and its complications not only impair quality of life but also decrease survival. Managing patients with cirrhosis can be a challenge and requires an organized and systematic approach. Increasing physicians’ knowledge about prevention and treatment of these potential complications is important to improve patient outcomes. A literature search of the published data was performed to provide a comprehensive review regarding the management of cirrhosis and its complications.
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22
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Parker R. Role of transjugular intrahepatic portosystemic shunt in the management of portal hypertension. Clin Liver Dis 2014; 18:319-34. [PMID: 24679497 DOI: 10.1016/j.cld.2013.12.004] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
A transjugular intrahepatic portosystemic shunt (TIPS) is an expandable metal stent inserted via the jugular vein that creates a shunt from the portal vein to the systemic circulation via an artificial communication through the liver. It is used to treat complications of portal hypertension. In addition to rescue treatment in variceal bleeding, TIPS can play an important role in prevention of rebleeding. TIPS can improve symptoms if medical treatment of ascites or hepatic hydrothrorax has failed, but may not improve survival. Selected cases of Budd-Chiari syndrome improve with TIPS. This article discusses the indications, evidence, and complications of TIPS.
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Affiliation(s)
- Richard Parker
- NIHR Centre for Liver Research, University of Birmingham, Birmingham B15 2TT, UK.
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23
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Choe WH. Do cirrhotic patients with a high MELD score benefit from TIPS? Clin Mol Hepatol 2014; 20:15-7. [PMID: 24757654 PMCID: PMC3992325 DOI: 10.3350/cmh.2014.20.1.15] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/06/2014] [Accepted: 03/11/2014] [Indexed: 12/16/2022] Open
Affiliation(s)
- Won Hyeok Choe
- Department of Internal Medicine, Konkuk University Hospital, Konkuk University School of Medicine, Seoul, Korea
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Bai M, He CY, Qi XS, Yin ZX, Wang JH, Guo WG, Niu J, Xia JL, Zhang ZL, Larson AC, Wu KC, Fan DM, Han GH. Shunting branch of portal vein and stent position predict survival after transjugular intrahepatic portosystemic shunt. World J Gastroenterol 2014; 20:774-785. [PMID: 24574750 PMCID: PMC3921486 DOI: 10.3748/wjg.v20.i3.774] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/28/2013] [Revised: 10/22/2013] [Accepted: 11/01/2013] [Indexed: 02/06/2023] Open
Abstract
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.
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Chen H, Bai M, Qi X, Liu L, He C, Yin Z, Fan D, Han G. Child-Na score: a predictive model for survival in cirrhotic patients with symptomatic portal hypertension treated with TIPS. PLoS One 2013; 8:e79637. [PMID: 24244533 PMCID: PMC3823582 DOI: 10.1371/journal.pone.0079637] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2013] [Accepted: 10/03/2013] [Indexed: 02/07/2023] Open
Abstract
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.
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Affiliation(s)
- Hui Chen
- Department of Liver Disease and Digestive Interventional Radiology, Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi’an, China
| | - Ming Bai
- Department of Liver Disease and Digestive Interventional Radiology, Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi’an, China
| | - Xingshun Qi
- Department of Liver Disease and Digestive Interventional Radiology, Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi’an, China
| | - Lei Liu
- Department of Liver Disease and Digestive Interventional Radiology, Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi’an, China
| | - Chuangye He
- Department of Liver Disease and Digestive Interventional Radiology, Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi’an, China
| | - Zhanxin Yin
- Department of Liver Disease and Digestive Interventional Radiology, Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi’an, China
| | - Daiming Fan
- State Key Laboratory of Cancer Biology and Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi’an, China
| | - Guohong Han
- Department of Liver Disease and Digestive Interventional Radiology, Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi’an, China
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Parker MJ, Guha N, Stedman B, Hacking N, Wright M. Trans-jugular intrahepatic porto-systemic shunt placement for refractory ascites: a 'real-world' UK health economic evaluation. Frontline Gastroenterol 2013; 4:182-186. [PMID: 28839725 PMCID: PMC5370052 DOI: 10.1136/flgastro-2012-100283] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/15/2012] [Revised: 01/17/2013] [Accepted: 02/25/2013] [Indexed: 02/04/2023] Open
Abstract
OBJECTIVE To assess the benefit of trans-jugular intrahepatic porto-systemic shunt (TIPS) placement for refractory ascites. DESIGN A retrospective observational study of all patients undergoing TIPS for refractory ascites in our hospital between 2003 and 2012. SETTING Secondary care. PATIENTS Cirrhotic patients with refractory ascites. MAIN OUTCOME MEASURES We examined direct real-world (National Health Service) health related costs in the year before and after the TIPS procedure took place. Data were collected relating to the need for reintervention and hepatic encephalopathy. RESULTS Data were available for 24 patients who underwent TIPS for refractory ascites (86% of eligible patients). TIPS was technically successful in all cases. Mean number of bed days in the year prior to TIPS was 30.3 and 14.3 in the year following (p=0.005). No patient had ascites at the end of the year after the TIPS with less requirement for paracentesis over the course of the year (p<0.001). Mean reduction in cost was £2759 per patient. TIPS was especially cost-effective in patients requiring between 6 and 12 drains per year with a mean saving of £9204 per patient. CONCLUSIONS TIPS is both a clinically effective and economically advantageous therapeutic option for selected patients with refractory ascites.
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Affiliation(s)
- Matthew J Parker
- Deptartment of Hepatology, University Hospitals Southampton, Southampton, UK
| | - Neil Guha
- Deptartment of Hepatology, University of Nottingham, Nottingham, UK
| | - Brian Stedman
- Deptartment of Interventional Radiology, University Hospitals Southampton, Southampton, UK
| | - Nigel Hacking
- Deptartment of Interventional Radiology, University Hospitals Southampton, Southampton, UK
| | - Mark Wright
- Deptartment of Hepatology, University Hospitals Southampton, Southampton, UK
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Peter P, Andrej Z, Katarina ŠP, Manca G, Pavel S. Hepatic encephalopathy after transjugular intrahepatic portosystemic shunt in patients with recurrent variceal hemorrhage. Gastroenterol Res Pract 2013; 2013:398172. [PMID: 23606833 PMCID: PMC3625580 DOI: 10.1155/2013/398172] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/14/2012] [Accepted: 12/22/2012] [Indexed: 12/24/2022] Open
Abstract
Purpose. The purpose of this study was to determine the incidence and predictors of hepatic encephalopathy (HE) after transjugular intrahepatic portosystemic shunt (TIPS) and endoscopic therapy (ET) in the elective treatment of recurrent variceal hemorrhage. Methods. Seventy patients were treated with elective TIPS and fifty-six patients with ET. Median observation time was 46.28 months in the TIPS group and 42.31 months in the ET group. Results. 30 patients (42.8%) developed clinically evident portosystemic encephalopathy in TIPS group and 20 patients (35.6%) in ET group. The difference between the groups was not statistically significant (P = 0.542; χ (2) test). The incidence of new or worsening portosystemic encephalopathy was 24.3% in TIPS group and 10.7% in ET group. Multivariate analysis showed that ET treatment (P = 0.031), age of >65 years (P = 0.022), pre-existing HE (P = 0.045), and Child's class C (P = 0.051) values were independent predictors for the occurrence of HE. Conclusions. Procedure-related HE is a complication in a minority of patients treated with TIPS or ET. Patients with increased age, preexisting HE, and higher Child-Pugh score should be carefully observed after TIPS procedure because the risk of post-TIPS HE in these patients is higher.
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Affiliation(s)
- Popovič Peter
- Institute of Radiology, University Medical Centre Ljubljana, Zaloška cesta 7, 1525 Ljubljana, Slovenia
| | - Zore Andrej
- Department of Ginecology, University Medical Centre Ljubljana, Zaloška cesta 7, 1525 Ljubljana, Slovenia
| | - Šurlan Popovič Katarina
- Institute of Radiology, University Medical Centre Ljubljana, Zaloška cesta 7, 1525 Ljubljana, Slovenia
| | - Garbajs Manca
- Institute of Radiology, University Medical Centre Ljubljana, Zaloška cesta 7, 1525 Ljubljana, Slovenia
| | - Skok Pavel
- Department of Gastroenterology and Endoscopy, University Medical Centre Maribor, University of Maribor, Ljubljanska Ulica 5, 2000 Maribor and Medical Faculty, Slomškov trg 15, 2000 Maribor, Slovenia
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Sauerbruch T, Appenrodt B, Schmitz V, Spengler U. The conservative and interventional treatment of the complications of liver cirrhosis: Part 2 of a series on liver cirrhosis. DEUTSCHES ARZTEBLATT INTERNATIONAL 2013; 110:126-32, I. [PMID: 23505400 DOI: 10.3238/arztebl.2013.0126] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/04/2011] [Accepted: 05/30/2012] [Indexed: 12/14/2022]
Abstract
BACKGROUND It is estimated that 1 million persons in Germany suffer from hepatic cirrhosis, which is the final stage of chronic inflammation of the liver. Cirrhosis has multiple causes, all of which lead to structural changes of the liver and to portal hypertension. The main complications of cirrhosis arise in turn: These include bleeding from collateral veins, ascites, hepatocellular carcinoma, encephalopathy, and infection leading to organ failure. METHODS We present the treatment of the main complications of liver cirrhosis with reference to the relevant literature (phase II and III trials, meta-analyses, and reviews). RESULTS Endoscopic treatment (ligation) is used for the primary and secondary prophylaxis of variceal bleeding. Drugs to lower portal pressure (e.g., beta-blockers) are an established means of preventing initial or recurrent variceal bleeding over the long term. Vasoconstrictors such as terlipressin are mainly used to treat acute hemorrhage and type 1 hepatorenal syndrome. The main treatment of ascites is with spironolactone, in combination with a loop diuretic where indicated. A shunt (TIPS) is used to treat severe or repeat variceal hemorrhage or refractory ascites. Antibiotics play a well-established role in the treatment of acute hemorrhage, in the treatment and prevention of spontaneous bacterial peritonitis, and in the treatment of encephalopathy. The treatment of hepatocellular carcinoma depends on its extent of spread and on the degree of decompensation of cirrhosis. CONCLUSION For most of the main complications of liver cirrhosis, there are treatments that have been well-tested in randomized trials. Liver transplantation should also be considered in every case.
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Affiliation(s)
- Tilman Sauerbruch
- Department of Internal Medicine I at the University Hospital of Bonn, Bonn, Germany.
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Zhou J, Wu Z, Wu J, Wang X, Li Y, Wang M, Yang Z, Peng B, Zhou Z. Transjugular intrahepatic portosystemic shunt (TIPS) versus laparoscopic splenectomy (LS) plus preoperative endoscopic varices ligation (EVL) in the treatment of recurrent variceal bleeding. Surg Endosc 2013; 27:2712-20. [PMID: 23392981 DOI: 10.1007/s00464-013-2810-1] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2012] [Accepted: 12/26/2012] [Indexed: 02/07/2023]
Abstract
BACKGROUND The aim of the present study was to compare elective transjugular intrahepatic portosystemic shunt (TIPS) and laparoscopic splenectomy (LS) plus preoperative endoscopic varices ligation (EVL) in their efficacy in preventing recurrent bleeding and improving the long-term liver function in patients with liver cirrhosis and portal hypertension. METHODS Between January 2009 and March 2012, we enrolled 83 patients (55 with TIPS, defined as the TIPS group, and 28 with LS plus preoperative EVL, defined as the LS group) with portal hypertension and a history of gastroesophageal variceal bleeding resulting from liver cirrhosis. The clinical characteristics, perioperative outcomes, and follow-up were recorded. RESULTS No significant differences were observed between the two treatment groups with respect to the patients' characteristics and preoperative variables. Within 30 days after surgery, one patient in the TIPS group died of multiple organ dysfunction syndrome, whereas no patient in the LS group died. Complications occurred in 14 patients in the TIPS group, which included rebleeding, encephalopathy, ascites, bleeding from a pseudoaneurysm of the thoracoabdominal aorta, and pulmonary infection, compared with 5 patients in the LS group, which included pulmonary effusion, pancreatic leakage, and portal vein thrombosis. During a mean follow-up of 13.6 months in the TIPS group and 12.3 months in the LS group, the actuarial survival was 85.5 % in the TIPS group versus 100 % in the LS group. The long-term complications included rebleeding and encephalopathy in the TIPS group. CONCLUSIONS LS plus EVL was superior to TIPS in the prevention of gastroesophageal variceal rebleeding in cirrhotic patients. This treatment was associated with a low rate of portosystemic encephalopathy and improvements in the long-term liver function.
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Affiliation(s)
- Jin Zhou
- Department of Gastrointestinal Surgery, West China Hospital, Sichuan University, Chengdu 610041, China
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Corbett C, Mangat K, Olliff S, Tripathi D. The role of Transjugular Intrahepatic Portosystemic Stent-Shunt (TIPSS) in the management of variceal hemorrhage. Liver Int 2012; 32:1493-1504. [PMID: 22928699 DOI: 10.1111/j.1478-3231.2012.02861.x] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/28/2012] [Accepted: 07/12/2012] [Indexed: 12/18/2022]
Abstract
BACKGROUND Variceal bleeding in cirrhosis represents a lethal complication of their disease. In the last 20 years, management of AVH has improved greatly with reduction in mortality from 43% in 1980 to 15% in 2000. AIM Advances in endoscopic therapy, pharmacologic agents including vasoconstrictor therapy and antibiotics have played a large part in improving outcomes, but the role of Transjugular Intrahepatic Portosystemic Stent-Shunt (TIPSS) remains controversial, which this review will cover. METHODS MEDLINE search for the following terms was performed to July 2011: variceal hemorrhage, portal hypertension, cirrhosis, transjugular intrahepatic portosystemic stent-shunt (TIPSS), PTFE, covered stents. Where possible randomized controlled studies were used for this review, although uncontrolled studies were also included if they made a significant contribution to the literature. RESULTS Literature used for the present study was selected from a total of 252 publications and abstracts from meetings. RESULTS TIPSS has been used as a salvage therapy after initial medical and endoscopic therapy for the bleed given its high success rate in arresting uncontrolled variceal bleeding. The recent trial by Garcia- Pagan et al. suggested beneficial effects of an earlier covered TIPSS in those at high risk of treatment failure (Childs C and those who are Childs B with active bleeding). CONCLUSIONS TIPSS can reduce failure to control bleeding and rebleeding as well as mortality with no increase in the risk of hepatic encephalopathy.This needs to be confirmed in further trials. However, it is clear that prevention of rebleeding is the key to improved outcomes following a variceal bleed.
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Affiliation(s)
- Chris Corbett
- University Hospitals Birmingham NHS Trust, Birmingham, UK.
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Saad WEA, Darcy MD. Transjugular Intrahepatic Portosystemic Shunt (TIPS) versus Balloon-occluded Retrograde Transvenous Obliteration (BRTO) for the Management of Gastric Varices. Semin Intervent Radiol 2012; 28:339-49. [PMID: 22942552 DOI: 10.1055/s-0031-1284461] [Citation(s) in RCA: 83] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Variceal bleeding is one of the major complications of portal hypertension. Gastric variceal bleeding is less common than esophageal variceal bleeding; however, it is associated with a high morbidity and mortality rate and its management is largely uncharted due to a relatively less-established literature. In the West (United States and Europe), the primary school of management is to decompress the portal circulation utilizing the transjugular intrahepatic portosystemic shunt (TIPS). In the East (Japan and South Korea), the primary school of management is to address the gastric varices (GVs) specifically by sclerosing them utilizing the balloon-occluded retrograde transvenous obliteration (BRTO) procedure. The concept (1970s), evolution, and development (1980s-1990s) of both procedures run parallel to one another; neither is newer than the other is. The difference is that one was adopted mostly by the East (BRTO), while the other has been adopted mostly by the West (TIPS). TIPS is effective in emergently controlling bleeding for GVs even though the commonly referenced studies about managing GVs with TIPS are studies with TIPS created by bare stents. However, the results have improved with the use of stent grafts for creating TIPS. Nevertheless, TIPS cannot be tolerated by patients with poor hepatic reserve. BRTO is equally effective in controlling bleeding GVs as well as significantly reducing the GV rebleed rate. But the resultant diversion of blood flow into the portal circulation, and in turn the liver, increases the risk of developing esophageal varices and ectopic varices with their potential to bleed. Unlike TIPS, the blood diversion that occurs after BRTO improves, if not preserves, hepatic function for 6-9 months post-BRTO. The authors discuss the detailed results and critique the literature, which has evaluated and remarked on both procedures. Future research prospects and speculation as to the ideal patients for each procedure are discussed.
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Syed MI, Karsan H, Ferral H, Shaikh A, Waheed U, Akhter T, Gabbard A, Morar K, Tyrrell R. Transjugular intrahepatic porto-systemic shunt in the elderly: Palliation for complications of portal hypertension. World J Hepatol 2012; 4:35-42. [PMID: 22400084 PMCID: PMC3295850 DOI: 10.4254/wjh.v4.i2.35] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/17/2011] [Revised: 01/08/2012] [Accepted: 02/24/2012] [Indexed: 02/06/2023] Open
Abstract
AIM To present a dedicated series of transjugular intrahepatic porto-systemic shunts (TIPS) in the elderly since data is sparse on this population group. METHODS A retrospective review was performed of patients at least 65 years of age who underwent TIPS at our institutions between 1997 and 2010. Twenty-five patients were referred for TIPS. We deemed that 2 patients were not considered appropriate candidates due to their markedly advanced liver disease. Of the 23 patients suitable for TIPS, the indications for TIPS placement was portal hypertension complicated by refractory ascites alone (n = 9), hepatic hydrothorax alone (n = 2), refractory ascites and hydrothorax (n = 1), gastrointestinal bleeding alone (n = 8), gastrointestinal bleeding and ascites (n = 3). RESULTS Of these 23 attempted TIPS procedure patients, 21 patients had technically successful TIPS procedures. A total of 29 out of 32 TIPS procedures including revisions were successful in 21 patients with a mean age of 72.1 years (range 65-82 years). Three of the procedures were unsuccessful attempts at TIPS and 8 procedures were successful revisions of our existing TIPS. Sixteen of 21 patients who underwent successful TIPS (excluding 5 patients lost to follow-up) were followed for a mean of 14.7 mo. Ascites and/or hydrothorax was controlled following technically successful procedures in 12 of 13 patients. Bleeding was controlled following technically successful procedures in 10 out of 11 patients. CONCLUSION We have demonstrated that TIPS is an effective procedure to control refractory complications of portal hypertension in elderly patients.
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Affiliation(s)
- Mubin I Syed
- Mubin I Syed, Azim Shaikh, Uzma Waheed, Kamal Morar, Robert Tyrrell, Dayton Interventional Radiology, Dayton, OH 45409, United States
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TIPS for Treatment of Variceal Hemorrhage: Clinical Outcomes in 128 Patients at a Single Institution over a 12-Year Period. J Vasc Interv Radiol 2012; 23:227-35. [DOI: 10.1016/j.jvir.2011.10.015] [Citation(s) in RCA: 55] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2011] [Revised: 09/20/2011] [Accepted: 10/22/2011] [Indexed: 02/07/2023] Open
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Abstract
Ascites is a common complication of liver cirrhosis associated with a poor prognosis. The treatment of ascites requires dietary sodium restriction and the judicious use of distal and loop diuretics, sequential at an earlier stage of ascites, and a combination at a later stage of ascites. The diagnosis of refractory ascites requires the demonstration of diuretic non-responsiveness, despite dietary sodium restriction, or the presence of diuretic-related complications. Patients with refractory ascites require second-line treatments of repeat large-volume paracentesis (LVP) or the insertion of a transjugular intrahepatic portosystemic shunt (TIPS), and assessment for liver transplantation. Careful patient selection is paramount for TIPS to be successful as a treatment for ascites. Patients not suitable for TIPS insertion should receive LVP. The use of albumin as a volume expander is recommended for LVP of >5-6 L to prevent the development of circulatory dysfunction, although the clinical significance of post-paracentesis circulatory dysfunction is still debated. Significant mortality is still being observed in cirrhotic patients with ascites and relatively preserved liver and renal function, as indicated by a lower Model for End-Stage Liver Disease (MELD) score. It is proposed that patients with lower MELD scores and ascites should receive additional points in calculating their priority for liver transplantation. Potential new treatment options for ascites include the use of various vasoconstrictors, vasopressin V(2) receptor antagonists, or the insertion of a peritoneo-vesical shunt, all of which could possibly improve the management of ascites.
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Affiliation(s)
- Florence Wong
- Department of Medicine, Toronto General Hospital, University of Toronto, Toronto, Ontario, Canada.
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The transjugular intrahepatic portosystemic shunt in the treatment of portal hypertension: current status. Int J Hepatol 2012; 2012:167868. [PMID: 22888442 PMCID: PMC3408669 DOI: 10.1155/2012/167868] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/17/2012] [Accepted: 05/18/2012] [Indexed: 02/06/2023] Open
Abstract
The transjugular intrahepatic portosystemic shunt (TIPS) represents a major advance in the treatment of complications of portal hypertension. Technical improvements and increased experience over the past 24 years led to improved clinical results and a better definition of the indications for TIPS. Randomized clinical trials indicate that the TIPS procedure is not a first-line therapy for variceal bleeding, but can be used when medical treatment fails, both in the acute situation or to prevent variceal rebleeding. The role of TIPS to treat refractory ascites is probably more justified to improve the quality of life rather than to improve survival, except for patients with preserved liver function. It can be helpful for hepatic hydrothorax and can reverse hepatorenal syndrome in selected cases. It is a good treatment for Budd Chiari syndrome uncontrollable by medical treatment. Careful selection of patients is mandatory before TIPS, and clinical followup is essential to detect and treat complications that may result from TIPS stenosis (which can be prevented by using covered stents) and chronic encephalopathy (which may in severe cases justify reduction or occlusion of the shunt). A multidisciplinary approach, including the resources for liver transplantation, is always required to treat these patients.
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Xue H, Yuan J, Chao-Li Y, Palikhe M, Wang J, Shan-Lv L, Qiao W. Follow-up study of transjugular intrahepatic portosystemic shunt in the treatment of portal hypertension. Dig Dis Sci 2011; 56:3350-6. [PMID: 21643741 DOI: 10.1007/s10620-011-1744-5] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/10/2011] [Accepted: 04/26/2011] [Indexed: 12/18/2022]
Abstract
OBJECTIVE To evaluate efficacy and complications for cirrhotic patients with variceal bleeding receiving TIPS. METHODS Of 137 patients who underwent TIPS from 2002 to 2009, 80 patients were included in this study. Information about the incidence of portosystemic encephalopathy (PSE) and rebleeding, and factors then which affected them, was collected by telephone call, letters, or follow-up visits in the out-patient department. RESULTS (1) TIPS can significantly reduce portal pressure and the risk of variceal bleeding. (2) A coated stent during TIPS can significantly reduce the occurrence of rebleeding in contrast with use of a bare stent (13.51% vs. 32.56%, P < 0.05). (3) Incidence of PSE is related to the diameter of the stent; the wider the stent used, the greater the incidence of PSE. TIPS using the left branch of the portal vein can reduce the incidence of PSE. (4) TIPS combined with embolization has no effect on the incidence of rebleeding or PSE. (5) Mean survival was 77.098 months (95% CI, 68.568-85.628) and median survival 82.000 months (95% CI, 68.539-95.461) according to Kaplan-Meier survival analysis. CONCLUSION It is suggested that coated stents should be used to reduce rebleeding. It is recommended that 8 mm stents should be used for CHILD A and C patients and 8-10 mm stents for CHILD B patients during TIPS, and that TIPS should be considered as first-line therapy because it improves cumulative survival for cirrhotic patients with gastroesophageal variceal bleeding.
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Affiliation(s)
- Hui Xue
- Department of Gastroenterology, First Affiliated Hospital of Xi'an Jiaotong University, 277 West Yanta Road, 710061 Xi'an, China.
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Cejna M. Should stent-grafts replace bare stents for primary transjugular intrahepatic portosystemic shunts? Semin Intervent Radiol 2011; 22:287-99. [PMID: 21326707 DOI: 10.1055/s-2005-925555] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Transjugular intrahepatic portosystemic shunt (TIPS) creation using bare stents is a second-line treatment for complications of portal hypertension due in part to the relatively high number of reinterventions and the occurrence of new or worsened encephalopathy. Initially, custom-made stent-grafts were used for TIPS revision in cases of biliary fistulae. Subsequently, custom stent-grafts were used for de novo TIPS creation. With the introduction of the VIATORR(®) TIPS endoprosthesis a dedicated stent-graft became available for TIPS creation and revision. The VIATORR(®) demonstrated its efficacy and superiority to uncovered stents in retrospective analyses, case-matched analyses, and randomized studies. The improved patency of stent-grafts has led many to requestion the role of TIPS as a second-line therapy. Currently, randomized trials are warranted to redefine the role of TIPS in the treatment of complications of portal hypertension.
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Affiliation(s)
- Manfred Cejna
- Section of Interventional Radiology, Vienna Medical School, Austria; and Department of Radiology, LKH Feldkirch, Feldkirch, Austria
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Garcia-Tsao G. Transjugular intrahepatic portosystemic shunt in the management of refractory ascites. Semin Intervent Radiol 2011; 22:278-86. [PMID: 21326706 DOI: 10.1055/s-2005-925554] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
The purpose of this article is to describe the pathophysiological basis for the use of transjugular intrahepatic portosystemic shunt (TIPS) in patients with cirrhosis and refractory ascites, the short- and long-term hemodynamic, biochemical, and hormonal changes after TIPS, and the results of controlled trials of TIPS in cirrhotic patients with refractory ascites. TIPS placement is associated with normalization of sinusoidal pressure and a significant improvement in urinary sodium excretion that correlates with suppression of plasma renin activity (indicative of an improvement in effective arterial blood volume). Although effective in preventing the recurrence of ascites, the efficacy of TIPS is offset by an increase in the incidence of severe hepatic encephalopathy, a high incidence of shunt dysfunction, and a higher cost without an overall survival benefit, which should be reevaluated in light of polytetrafluoroethylene-covered stents. TIPS placement is currently indicated in seleceted cirrhotic patients with refractory ascites who require more than two to three large-volume paracenteses per month.
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Affiliation(s)
- Guadalupe Garcia-Tsao
- Professor of Medicine, Yale University School of Medicine, and VA-CT Healthcare System, New Haven, Connecticut
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Sharma P, Sarin SK. Improved survival with the patients with variceal bleed. Int J Hepatol 2011; 2011:356919. [PMID: 21994853 PMCID: PMC3170765 DOI: 10.4061/2011/356919] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/13/2011] [Accepted: 05/12/2011] [Indexed: 01/06/2023] Open
Abstract
Variceal hemorrhage is a major cause of death in patients with cirrhosis. Over the past two decades new treatment modalities have been introduced in the management of acute variceal bleeding (AVB) and several recent studies have suggested that the outcome of patients with cirrhosis and AVB has improved. Improved supportive measures, combination therapy which include early use of portal pressure reducing drugs with low rates of adverse effects (somatostatin, octerotide or terlipressin) and endoscopic variceal ligation has become the first line treatment in the management of AVB. Short-term antibiotic prophylaxis, early use of lactulose for prevention of hepatic encephalopathy, application of early transjugular intrahepatic portasystemic shunts (TIPS), fully covered self-expandable metallic stent in patients for AVB may be useful in those cases where balloon tamponade is considered. Early and wide availability of liver transplantation has changed the armamentarium of the clinician for patients with AVB. High hepatic venous pressure gradient (HVPG) >20 mmHg in AVB has become a useful predictor of outcomes and more aggressive therapies with early TIPS based on HVPG measurement may be the treatment of choice to reduce mortality further.
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Affiliation(s)
- Praveen Sharma
- Department of Hepatology and Transplant Hepatology, Institute of Liver & Biliary Sciences, New Delhi 110 070, India
| | - Shiv K. Sarin
- Department of Hepatology and Transplant Hepatology, Institute of Liver & Biliary Sciences, New Delhi 110 070, India
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Sussman AN, Boyer TD. Management of refractory ascites and hepatorenal syndrome. Curr Gastroenterol Rep 2011; 13:17-25. [PMID: 21080246 DOI: 10.1007/s11894-010-0156-6] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
One of the most common manifestations of the development of portal hypertension in the patient with cirrhosis is the appearance of ascites. Once ascites develops, the prognosis worsens and the patient becomes susceptible to complications such as bacterial peritonitis, hepatic hydrothorax, hyponatremia, and complications of diuretic therapy. As the liver disease progresses, the ascites becomes more difficult to treat and many patients develop renal failure. Most patients can be managed by diuretics which, when used correctly, will control the ascites. Spontaneous bacterial peritonitis can be treated effectively, but portends a worse prognosis. Once the ascites becomes refractory to diuretics, liver transplantation is the best option, although use of transjugular intrahepatic portosystemic shunts will control the ascites in many patients. Lastly, the development of hepatorenal syndrome indicates the patient's liver disease is advanced, and transplantation again is the best option. However, use of vasoconstrictors may improve renal function in some patients, helping in their management while they await a liver transplant.
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Affiliation(s)
- Amy N Sussman
- Department of Medicine, University of Arizona College of Medicine, Tucson, AZ 85724, USA
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Biecker E. Diagnosis and therapy of ascites in liver cirrhosis. World J Gastroenterol 2011; 17:1237-48. [PMID: 21455322 PMCID: PMC3068258 DOI: 10.3748/wjg.v17.i10.1237] [Citation(s) in RCA: 56] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/14/2010] [Revised: 12/22/2010] [Accepted: 12/29/2010] [Indexed: 02/06/2023] Open
Abstract
Ascites is one of the major complications of liver cirrhosis and is associated with a poor prognosis. It is important to distinguish noncirrhotic from cirrhotic causes of ascites to guide therapy in patients with noncirrhotic ascites. Mild to moderate ascites is treated by salt restriction and diuretic therapy. The diuretic of choice is spironolactone. A combination treatment with furosemide might be necessary in patients who do not respond to spironolactone alone. Tense ascites is treated by paracentesis, followed by albumin infusion and diuretic therapy. Treatment options for refractory ascites include repeated paracentesis and transjugular intrahepatic portosystemic shunt placement in patients with a preserved liver function. Potential complications of ascites are spontaneous bacterial peritonitis (SBP) and hepatorenal syndrome (HRS). SBP is diagnosed by an ascitic neutrophil count > 250 cells/mm3 and is treated with antibiotics. Patients who survive a first episode of SBP or with a low protein concentration in the ascitic fluid require an antibiotic prophylaxis. The prognosis of untreated HRS type 1 is grave. Treatment consists of a combination of terlipressin and albumin. Hemodialysis might serve in selected patients as a bridging therapy to liver transplantation. Liver transplantation should be considered in all patients with ascites and liver cirrhosis.
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Saad WEA, Darwish WM, Davies MG, Waldman DL. Stent-grafts for transjugular intrahepatic portosystemic shunt creation: specialized TIPS stent-graft versus generic stent-graft/bare stent combination. J Vasc Interv Radiol 2011; 21:1512-20. [PMID: 20801686 DOI: 10.1016/j.jvir.2010.06.009] [Citation(s) in RCA: 44] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2008] [Revised: 05/27/2010] [Accepted: 06/11/2010] [Indexed: 12/13/2022] Open
Abstract
PURPOSE To compare functional and anatomic outcomes of transjugular intrahepatic portosystemic shunts (TIPSs) created with the specialized Viatorr stent versus a Wallstent/Fluency stent combination. MATERIALS AND METHODS Retrospective review of patients who underwent TIPS creation with stent-grafts was conducted over a 54-month period ending in June 2008. Patients were divided into three groups: Viatorr only, Fluency only, and combined Viatorr/Fluency, the latter of which was included in the overall evaluation but excluded from the comparative analysis between the Viatorr and Fluency groups. Patient demographics, Child-Pugh scores, and portosystemic gradient (PSG) reduction were compared. Patencies were calculated using the Kaplan-Meier method and compared. RESULTS A total of 126 TIPSs created with stent-grafts were found: 28 with Fluency stents, 93 with Viatorr devices, and five combined. No significance in demographic factors or PSGs was found among groups (P > .05). Major encephalopathy rates were 3.6% and 4.3% in the Fluency and Viatorr groups, respectively (P = 1.000). Hemodynamic success rates were 93% and 98% in the Fluency and Viatorr groups, respectively (P = .099). The primary unassisted patency rates at 6, 9, and 12 months were 87%, 81%, and 81%, respectively, in the Fluency group and 95%, 93%, and 89%, respectively, in the Viatorr group (P = .03). Portal and hepatic end stenoses were the causes of TIPS narrowing in the Fluency and Viatorr groups, respectively. CONCLUSIONS The Wallstent/Fluency stent combination is associated with a 1-year patency rate greater than 80%, with no significant difference versus the Viatorr stent regarding technical and hemodynamic success and encephalopathy rate. However, the Viatorr stent is associated with improved patency (89%) versus this bare stent/stent-graft combination.
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Affiliation(s)
- Wael E A Saad
- Department of Radiology, University of Virginia Health System, 1215 Lee St, PO Box 800170, Charlottesville, VA 22908, USA
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Narahara Y, Kanazawa H, Fukuda T, Matsushita Y, Harimoto H, Kidokoro H, Katakura T, Atsukawa M, Taki Y, Kimura Y, Nakatsuka K, Sakamoto C. Transjugular intrahepatic portosystemic shunt versus paracentesis plus albumin in patients with refractory ascites who have good hepatic and renal function: a prospective randomized trial. J Gastroenterol 2011; 46:78-85. [PMID: 20632194 DOI: 10.1007/s00535-010-0282-9] [Citation(s) in RCA: 129] [Impact Index Per Article: 9.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/30/2010] [Accepted: 06/21/2010] [Indexed: 02/06/2023]
Abstract
BACKGROUND Transjugular intrahepatic portosystemic shunt (TIPS) has recently been reported to be effective in the treatment of cirrhotic patients with refractory ascites. However, the clinical utility of TIPS in the subset of refractory ascitic patients with good hepatic and renal function is uncertain. The aim of this study was to compare the efficacy of TIPS to that of large-volume paracentesis in cirrhotic patients with refractory ascites who have good hepatic and renal function. METHODS Sixty cirrhotic patients with refractory ascites who presented with a Child-Pugh score of <11, serum bilirubin of <3 mg/dl and creatinine of <1.9 mg/dl were assigned randomly to TIPS (n = 30) or large-volume paracentesis plus albumin (n = 30). The primary endpoint was survival. The secondary endpoints were response to treatment and development of hepatic encephalopathy. RESULTS The baseline characteristics were similar in the two groups. Seventeen patients treated with TIPS and 21 treated with paracentesis died during the study period. The cumulative probabilities of survival at 1 and 2 years were 80 and 64% in the TIPS group and 49 and 35% in the paracentesis group (p < 0.005). TIPS was significantly superior to paracentesis in the control of ascites (p < 0.005). Treatment failure was more frequent in the paracentesis group, whereas the frequency of hepatic encephalopathy was greater in the TIPS group. CONCLUSIONS In cirrhotic patients with refractory ascites who have good hepatic and renal function, TIPS improves survival and provides better control of ascites than large-volume paracentesis.
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Affiliation(s)
- Yoshiyuki Narahara
- Division of Gastroenterology, Department of Internal Medicine, Nippon Medical School, 1-1-5 Sendagi, Bunkyo-ku, Tokyo, 113-8603, Japan.
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Punamiya SJ, Amarapurkar DN. Role of TIPS in Improving Survival of Patients with Decompensated Liver Disease. Int J Hepatol 2011; 2011:398291. [PMID: 21994854 PMCID: PMC3170767 DOI: 10.4061/2011/398291] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/26/2011] [Accepted: 04/13/2011] [Indexed: 12/11/2022] Open
Abstract
Liver cirrhosis is associated with higher morbidity and reduced survival with appearance of portal hypertension and resultant decompensation. Portal decompression plays a key role in improving survival in these patients. Transjugular intrahepatic portosystemic shunts are known to be efficacious in reducing portal venous pressure and control of complications such as variceal bleeding and ascites. However, they have been associated with significant problems such as poor shunt durability, increased encephalopathy, and unchanged survival when compared with conservative treatment options. The last decade has seen a significant improvement in these complications, with introduction of covered stents, better selection of patients, and clearer understanding of procedural end-points. Use of TIPS early in the period of decompensation also appears promising in further improvement of survival of cirrhotic patients.
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Affiliation(s)
- Sundeep J. Punamiya
- Department of Radiology, Tan Tock Seng Hospital, 11 Jalan Tan Tock Seng, Singapore 308433,*Sundeep J. Punamiya:
| | - Deepak N. Amarapurkar
- Department of Gastroenterology, Bombay Hospital, 12 Marine Lines, Mumbai 400020, India
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Yang Z, Han G, Wu Q, Ye X, Jin Z, Yin Z, Qi X, Bai M, Wu K, Fan D. Patency and clinical outcomes of transjugular intrahepatic portosystemic shunt with polytetrafluoroethylene-covered stents versus bare stents: a meta-analysis. J Gastroenterol Hepatol 2010; 25:1718-1725. [PMID: 21039832 DOI: 10.1111/j.1440-1746.2010.06400.x] [Citation(s) in RCA: 111] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND AND AIM Transjugular intrahepatic portosystemic shunt (TIPS) with polytetrafluoroethylene-(PTFE)-covered stent has been increasingly used for patients with complications of portal hypertension. It is still debated whether the new endoprostheses will improve some clinical outcomes (except for shunt patency) compared to the bare stents. The aims of our meta-analysis were to explore the patency and clinical outcomes of TIPS with PTFE-covered stent-grafts versus bare stents. METHODS Pertinent studies were retrieved through PubMed (1950-2010), MEDLINE (1950-2010), and reference lists of key articles. Outcome measures were primary patency, risk of encephalopathy and survival. Time-to-event data analysis was used to calculate the overall hazard ratios (HR). RESULTS Six studies were identified including a total of 1275 patients (346 TIPS with PTFE-covered stent-grafts and 929 TIPS with bare stents). Pooled shunt patency data from four eligible studies suggested a significant improvement of primary patency in patients who were treated with PTFE-covered stent-grafts (HR = 0.28, 95% confidence interval [CI] 0.20-0.35). Pooled encephalopathy data from three eligible studies suggested a significant reduction of risk in the PTFE-covered group (HR = 0.65, 95%CI 0.45-0.86). Pooled survival data from four eligible studies also suggested a significant decrease of mortality in the PTFE-covered group (HR = 0.76, 95%CI 0.58-0.94). No statistical heterogeneity was observed between studies for either outcome. CONCLUSIONS This meta-analysis shows that the use of PTFE-covered stent-grafts clearly improves shunt patency without increasing the risk of hepatic encephalopathy and with a trend towards better survival.
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Affiliation(s)
- Zhiping Yang
- Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an, China
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Schenker MP, Majdalany BS, Funaki BS, Yucel EK, Baum RA, Burke CT, Foley WD, Koss SA, Lorenz JM, Mansour MA, Millward SF, Nemcek AA, Ray CE. ACR Appropriateness Criteria® on Upper Gastrointestinal Bleeding. J Am Coll Radiol 2010; 7:845-53. [DOI: 10.1016/j.jacr.2010.05.029] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2010] [Accepted: 05/25/2010] [Indexed: 12/14/2022]
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Huang Q, Wu X, Fan X, Cao J, Han J, Xu L, Li N. Comparison study of Doppler ultrasound surveillance of expanded polytetrafluoroethylene-covered stent versus bare stent in transjugular intrahepatic portosystemic shunt. JOURNAL OF CLINICAL ULTRASOUND : JCU 2010; 38:353-360. [PMID: 20533444 DOI: 10.1002/jcu.20709] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/29/2023]
Abstract
OBJECTIVE This prospectively randomized controlled study aimed to assess with Doppler ultrasound (US) the shunt function of expanded polytetrafluoroethylene (ePTFE)-covered transjugular intrahepatic portosystemic shunt (TIPS) stent versus bare stent and to evaluate the usefulness of routine TIPS follow-up of ePTFE-covered stents. METHODS Sixty consecutive patients were randomized for bare or covered transjugular TIPS stenting in our institution between April 2007 and April 2009. Data of follow-up Doppler US, angiography, and portosystemic pressure gradient measurements were collected and analyzed. RESULTS The follow-up period was 8.34 + or - 4.42 months in the bare-stent group and 6.16 + or - 3.89 months in the covered-stent group. Baseline clinical characteristics were similar in both groups. Two hundred three US studies were performed in 60 patients, with a mean of 3.4 per patient, and demonstrated abnormalities in 28 patients (21 bare stents, 7 ePTFE-covered stents), 19 of them (13 in bare-stent group, 6 in covered-stent group) showing no clinical evidence of recurrence. Ten of 13 patients in the bare-stent group underwent balloon angioplasty or additional stent placement, whereas only one of six patients in the covered-stent group needed reintervention for intimal hyperplasia. The average peak velocity in the midshunt of ePTFE-covered stent was 139 + or - 26 cm/s after TIPS creation and 125 + or - 20 cm/s during follow-up, which was significantly higher than the bare-stent group (p < 0.05). The main portal vein and hepatic artery showed higher flow velocities in the ePTFE-covered stent group than in the bare-stent group. ePTFE-covered stents maintained lower portosystemic pressure gradient than bare stents (9.5 + or - 2.9 versus 13.2 + or - 1.5 mmHg, p < 0.05). CONCLUSIONS ePTFE-covered stents resulted in higher patency rates and better hemodynamics than bare stents. Routine US surveillance may not be necessary in patients with ePTFE-covered TIPS stent.
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Affiliation(s)
- Qian Huang
- Research Institute of General Surgery, Jinling Hospital, Nanjing, China
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Rebleeding rates following TIPS for variceal hemorrhage in the Viatorr era: TIPS alone versus TIPS with variceal embolization. Hepatol Int 2010; 4:749-56. [PMID: 21286346 DOI: 10.1007/s12072-010-9206-2] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/30/2009] [Accepted: 07/13/2010] [Indexed: 12/23/2022]
Abstract
PURPOSE To compare rebleeding rates following treatment of variceal hemorrhage with TIPS alone versus TIPS with variceal embolization in the covered stent-graft era. METHODS In this retrospective study, 52 patients (M:F 29:23, median age 52 years) with hepatic cirrhosis and variceal hemorrhage underwent TIPS insertion between 2003 and 2008. Median Child-Pugh and MELD scores were 8.5 and 13.5. Generally, 10-mm diameter TIPS were created using covered stent-grafts (Viatorr; W.L. Gore and Associates, Flagstaff, AZ). A total of 37 patients underwent TIPS alone, while 15 patients underwent TIPS with variceal embolization. The rates of rebleeding and survival were compared. RESULTS All TIPS were technically successful. Median portosystemic pressure gradient reductions were 13 versus 11 mmHg in the embolization and non-embolization groups. There were no statistically significant differences in Child-Pugh and MELD score, or portosystemic pressure gradients between each group. A trend toward increased rebleeding was present in the non-embolization group, where 8/37 (21.6%) patients rebled while 1/15 (6.7%) patients in the TIPS with embolization group rebled (P = 0.159) during median follow-up periods of 199 and 252 days (P = 0.374). Rebleeding approached statistical significance among patients with acute hemorrhage, where 8/32 (25%) versus 0/14 (0%) rebled in the non-embolization and embolization groups (P = 0.055). A trend toward increased bleeding-related mortality was seen in the non-embolization group (P = 0.120). CONCLUSIONS TIPS alone showed a high incidence of rebleeding in this series, whereas TIPS with variceal embolization resulted in reduced recurrent hemorrhage. The efficacy of embolization during TIPS performed for variceal hemorrhage versus TIPS alone should be further compared with larger prospective randomized trials.
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Riggio O, Ridola L, Lucidi C, Angeloni S. Emerging issues in the use of transjugular intrahepatic portosystemic shunt (TIPS) for management of portal hypertension: time to update the guidelines? Dig Liver Dis 2010; 42:462-7. [PMID: 20036625 DOI: 10.1016/j.dld.2009.11.007] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/06/2009] [Accepted: 11/15/2009] [Indexed: 02/06/2023]
Abstract
Since its first introduction in the 1980s, transjugular intrahepatic portosystemic shunt has played an increasingly important role in the management and treatment of the complications of portal hypertension. In 2005, the American Association for the Study of Liver Diseases published the Practice Guidelines for the use of transjugular intrahepatic portosystemic shunt in the management of portal hypertension. Since then, technical advances and new interesting data on transjugular intrahepatic portosystemic shunt have been presented in the literature. The present review focus on the applications of transjugular intrahepatic portosystemic shunt and examines more recent studies on this topic; the current guidelines on the use of transjugular intrahepatic portosystemic shunt are also discussed. From the data presented in the most recent publications, it has become increasingly clear that the recommendations stemming from the current guidelines need to be reviewed and updated in several points. Changes in the American Association for the Study of Liver Diseases Practice Guidelines are needed for both common indications (variceal bleeding and refractory ascites) as well as uncommon ones (i.e., Budd-Chiari syndrome and portal cavernoma). In addition, a relevant technical advance has been the introduction of the polytetrafluoroethylene-covered stents, which greatly improved the patency and clinical efficacy of transjugular intrahepatic portosystemic shunt. Consequently, new studies are required to re-assess the role of transjugular intrahepatic portosystemic shunt performed with new covered stents as compared with other strategies in the management of portal hypertension.
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Affiliation(s)
- Oliviero Riggio
- II Gastroenterologia, Dipartimento di Medicina Clinica, Università di Roma La Sapienza, Viale dell'Università 37, 00185 Rome, Italy.
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Saad WEA, Darwish WM, Davies MG, Waldman DL. Transjugular intrahepatic portosystemic shunts in liver transplant recipients for management of refractory ascites: clinical outcome. J Vasc Interv Radiol 2010; 21:218-23. [PMID: 20123207 DOI: 10.1016/j.jvir.2009.10.025] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2008] [Revised: 10/24/2009] [Accepted: 10/30/2009] [Indexed: 12/25/2022] Open
Abstract
PURPOSE To determine the effectiveness of transjugular intrahepatic portosystemic shunt (TIPS) creation in liver transplant recipients with recurrent portal hypertension presenting with refractory ascites. MATERIALS AND METHODS A retrospective review of transplant recipients undergoing TIPS creation was performed over a 6-year period. Recipients were noted for age, sex, TIPS indication, Model for End-stage Liver Disease (MELD) score, cause of initial liver disease, and time between first transplantation and TIPS creation. Clinical success was defined as graft survival of longer than 1 month with improvement in ascites. New-onset or worsening encephalopathy was noted. Graft survival and patency were calculated according to the Kaplan-Meier method. MELD score and portosystemic gradient (PSG) before and after TIPS creation were evaluated for prediction of graft loss less than 3 months after TIPS creation. RESULTS Nineteen liver transplant recipients underwent TIPS creation for ascites. Mean time from transplantation was 3.5 years (range, 3.7-112.2 months). Mean MELD score before TIPS creation was 17 (range, 7-24). The technical, hemodynamic, and clinical success rates were 100%, 95%, and 16%, respectively. Encephalopathy developed in five patients (26%). Thirty- and 90-day mortality rates were 16% (n = 3) and 21% (n = 4), respectively. Primary unassisted patency and graft survival rates at 1, 3, and 6 months were 100%, 90%, and 90% and 79%, 58%, and 47%, respectively. MELD score parameters were significant indicators (P < .05) for graft survival beyond 3 months, but PSG parameters were not. CONCLUSIONS TIPS for the management of ascites in liver transplant recipients is not as clinically effective as it is in patients with native livers (16% vs 50%-80% in the literature). MELD score is a predictor of graft survival; PSG parameters are not.
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Affiliation(s)
- Wael E A Saad
- Department of Imaging Sciences, University of Rochester Medical Center, Rochester, New York, USA.
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