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Piecha F, Jahn B, Köntopf J, Koop A, Ozga A, Al‐Jawazneh A, Harberts A, Riedel C, Buggisch P, Benten D, Hübener P, Adam G, Huber S, Lohse AW, Bannas P, Kluwe J. Recompensation of Liver Cirrhosis by TIPS Reduces Epithelial Cell Death Markers, Translating Into Improved Clinical Outcome. Liver Int 2025; 45:e16156. [PMID: 39533838 PMCID: PMC11897859 DOI: 10.1111/liv.16156] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/05/2024] [Revised: 10/09/2024] [Accepted: 10/24/2024] [Indexed: 11/16/2024]
Abstract
BACKGROUND AND AIMS Portal hypertension is the main pathophysiological driver of decompensation in patients with liver cirrhosis. Epithelial cell death markers, m30 and m65, correlate with hepatic injury and predict outcomes across various stages of liver disease. We aim (i) to evaluate whether portal hypertension itself contributes to liver outcome-relevant epithelial injury, and (ii) to analyse the capacity of m30/m65 to predict outcome in patients receiving a transjugular intrahepatic portosystemic shunt (TIPS) for refractory ascites. METHODS Sixty-six patients undergoing TIPS placement for refractory ascites and 20 patients with compensated cirrhosis as controls were prospectively enrolled in this monocentric cohort study. Epithelial cell death markers were analysed pre-TIPS, as well as 1-3 and 6-9 months post-TIPS. The capacity of baseline levels of m30/m65 in predicting six-month transplant-free survival rates was analysed by multivariable Cox proportional hazards regression. RESULTS Levels of m30 and m65 were higher in patients with decompensated cirrhosis (pre-TIPS) compared with compensated cirrhosis (controls). Following correction of portal hypertension by TIPS and recompensation, both markers decreased over time, reaching levels comparable to patients with compensated cirrhosis. On multivariable analysis, pre-TIPS baseline levels of m30 and m65 were not predictive for six-month survival. CONCLUSION Correction of portal hypertension via TIPS reduces levels of epithelial cell death markers, indicating that portal hypertension is a driver of outcome-relevant, hepatic cell death in patients with decompensated cirrhosis. Baseline m30/m65 values do not affect six-month survival rates, which suggests that TIPS placement overcomes the unfavourable spontaneous prognosis otherwise indicated by elevated baseline m30/65 levels.
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Affiliation(s)
- Felix Piecha
- Department of MedicineUniversity Medical Center Hamburg‐EppendorfHamburgGermany
- German Center for Infection Research (DZIF), Partner Site Hamburg‐Lübeck‐Borstel‐RiemsHamburgGermany
| | | | - Johannes Köntopf
- Department of MedicineUniversity Medical Center Hamburg‐EppendorfHamburgGermany
| | - Anja Koop
- Department of MedicineUniversity Medical Center Hamburg‐EppendorfHamburgGermany
| | - Ann‐Kathrin Ozga
- Center for Experimental Medicine, Institute of Medical Biometry and EpidemiologyUniversity Medical Center Hamburg‐EppendorfHamburgGermany
| | - Amirah Al‐Jawazneh
- Department of MedicineUniversity Medical Center Hamburg‐EppendorfHamburgGermany
- Protozoa Immunology, Bernhard Nocht Institute for Tropical MedicineHamburgGermany
| | - Aenne Harberts
- Department of MedicineUniversity Medical Center Hamburg‐EppendorfHamburgGermany
| | - Christoph Riedel
- Department of Diagnostic and Interventional Radiology and Nuclear MedicineUniversity Medical Center Hamburg‐EppendorfHamburgGermany
| | - Peter Buggisch
- Ifi‐Institute for Interdisciplinary MedicineHamburgGermany
| | - Daniel Benten
- Department of MedicineUniversity Medical Center Hamburg‐EppendorfHamburgGermany
- Department of GastroenterologyAsklepios Hospital HarburgHamburgGermany
| | - Peter Hübener
- Department of MedicineUniversity Medical Center Hamburg‐EppendorfHamburgGermany
| | - Gerhard Adam
- Department of Diagnostic and Interventional Radiology and Nuclear MedicineUniversity Medical Center Hamburg‐EppendorfHamburgGermany
| | - Samuel Huber
- Department of MedicineUniversity Medical Center Hamburg‐EppendorfHamburgGermany
| | - Ansgar W. Lohse
- Department of MedicineUniversity Medical Center Hamburg‐EppendorfHamburgGermany
| | - Peter Bannas
- Department of Diagnostic and Interventional Radiology and Nuclear MedicineUniversity Medical Center Hamburg‐EppendorfHamburgGermany
| | - Johannes Kluwe
- Department of MedicineUniversity Medical Center Hamburg‐EppendorfHamburgGermany
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Sturm L, Schultheiss M, Stöhr F, Labenz C, Maasoumy B, Tiede A, Praktiknjo M, Seifert LL, Auer TA, Fehrenbach U, Piecha F, Harberts A, Kluwe J, Bruns T, Pollmanns MR, Chang J, Grobelski J, Jansen C, Meyer C, Reincke M, Rohrer C, Philipp Arbabi SR, Kimmann M, Ripoll C, Zipprich A, Hinrichs J, Koehler M, Trebicka J, Kloeckner R, Engelmann C, Thimme R, Bettinger D. Freiburg index of post-TIPS survival (FIPS) identifies patients at risk of further decompensation and ACLF after TIPS. J Hepatol 2025:S0168-8278(25)00067-4. [PMID: 39914747 DOI: 10.1016/j.jhep.2025.01.030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/07/2024] [Revised: 01/15/2025] [Accepted: 01/23/2025] [Indexed: 04/04/2025]
Abstract
BACKGROUND & AIMS The Freiburg index of post-TIPS survival (FIPS) defines a high-risk group of patients with significantly reduced survival following transjugular intrahepatic portosystemic shunt (TIPS) implantation. However, the clinical hallmarks responsible for these patients' unfavorable outcome remain to be identified. Therefore, the present study aimed to characterize the clinical course after TIPS implantation according to the FIPS. METHODS A total of 1,359 patients with cirrhosis allocated to TIPS implantation for treatment of recurrent or refractory ascites or secondary prophylaxis of variceal bleeding from eight tertiary centers were retrospectively included. The patients' clinical course following TIPS placement was analyzed, stratified according to the FIPS. The primary study outcome was further decompensation within 90 days after TIPS; secondary outcomes were acute-on-chronic liver failure (ACLF) within 90 days and 1-year transplant-free survival. RESULTS Further decompensation after TIPS implantation was significantly more frequent in FIPS high-risk patients compared to low-risk patients (cumulative incidence function 0.58 vs. 0.38, p <0.001). Moreover, FIPS high-risk patients developed ACLF significantly more often (0.18 vs. 0.08; p = 0.008). Uni- and multivariable competing risk regression analyses confirmed that high-risk FIPS independently predicted further decompensation (subdistribution hazard ratio 1.974; 95% CI 1.531-2.544; p <0.001) and ACLF (subdistribution hazard ratio 2.586; 95% CI 1.449-4.616; p = 0.001) after TIPS. Importantly, further decompensation and ACLF after TIPS were associated with significantly reduced transplant-free survival. CONCLUSIONS The present study reveals that the FIPS predicts development of further decompensation and ACLF after TIPS implantation. These events are responsible for impaired transplant-free survival in FIPS high-risk patients. These results pave the way for the development of tailored clinical management strategies. IMPACT AND IMPLICATIONS Prognostication after transjugular intrahepatic portosystemic shunt (TIPS) implantation is challenging. Several clinical scores have been proposed in this context, such as the Freiburg index of post-TIPS survival (FIPS). The FIPS can identify a high-risk group of patients with significantly reduced survival after TIPS. However, to understand the reasons for these patients' unfavorable outcome, their clinical course after TIPS needs to be characterized. This study reveals that the FIPS predicts development of further decompensation and acute-on-chronic liver failure after TIPS implantation, which are responsible for the poor prognosis of FIPS high-risk patients. Therefore, the present results may be useful for tailored decision making in patients allocated to TIPS implantation.
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Affiliation(s)
- Lukas Sturm
- Department of Medicine II, Medical Center University of Freiburg, Faculty of Medicine, University of Freiburg, Hugstetter Str. 55, D-79106 Freiburg, Germany; Berta-Ottenstein-Programme, Faculty of Medicine, University of Freiburg, Germany
| | - Michael Schultheiss
- Department of Medicine II, Medical Center University of Freiburg, Faculty of Medicine, University of Freiburg, Hugstetter Str. 55, D-79106 Freiburg, Germany; Berta-Ottenstein-Programme, Faculty of Medicine, University of Freiburg, Germany
| | - Fabian Stöhr
- Department of Diagnostic and Interventional Radiology, University Medical Center of the Johannes Gutenberg University Mainz, Germany
| | - Christian Labenz
- Department of Internal Medicine, University Medical Center of the Johannes Gutenberg-University Mainz, Mainz, Germany
| | - Benjamin Maasoumy
- Department of Gastroenterology, Hepatology, Infectious Diseases and Endocrinology, Hannover Medical School, Hannover, Germany
| | - Anja Tiede
- Department of Gastroenterology, Hepatology, Infectious Diseases and Endocrinology, Hannover Medical School, Hannover, Germany
| | - Michael Praktiknjo
- Department of Medicine B, Gastroenterology, Hepatology, Endocrinology, Infectious Diseases, Universitätsklinikum Münster, Münster, Germany
| | - Leon Louis Seifert
- Department of Medicine B, Gastroenterology, Hepatology, Endocrinology, Infectious Diseases, Universitätsklinikum Münster, Münster, Germany; Center for Clinical and Translational Science, The Rockefeller University, New York, USA
| | - Timo Alexander Auer
- Department of Radiology, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Uli Fehrenbach
- Department of Radiology, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Felix Piecha
- I. Department of Medicine, Gastroenterology and Hepatology, University Medical Center Hamburg-Eppendorf, Martinistr. 42, 20246, Hamburg, Germany
| | - Aenne Harberts
- I. Department of Medicine, Gastroenterology and Hepatology, University Medical Center Hamburg-Eppendorf, Martinistr. 42, 20246, Hamburg, Germany
| | - Johannes Kluwe
- I. Department of Medicine, Gastroenterology and Hepatology, University Medical Center Hamburg-Eppendorf, Martinistr. 42, 20246, Hamburg, Germany
| | - Tony Bruns
- Department of Internal Medicine III, University Hospital RWTH Aachen, Aachen, Germany
| | | | - Johannes Chang
- Department of Internal Medicine I, University Hospital Bonn, Bonn, Germany
| | - Jakub Grobelski
- Department of Internal Medicine I, University Hospital Bonn, Bonn, Germany
| | - Christian Jansen
- Department of Internal Medicine I, University Hospital Bonn, Bonn, Germany
| | - Carsten Meyer
- Department of Radiology, University Hospital, University Bonn, Bonn, Germany
| | - Marlene Reincke
- Department of Medicine II, Medical Center University of Freiburg, Faculty of Medicine, University of Freiburg, Hugstetter Str. 55, D-79106 Freiburg, Germany
| | - Charlotte Rohrer
- Department of Medicine II, Medical Center University of Freiburg, Faculty of Medicine, University of Freiburg, Hugstetter Str. 55, D-79106 Freiburg, Germany
| | - Sina Rastin Philipp Arbabi
- Department of Medicine II, Medical Center University of Freiburg, Faculty of Medicine, University of Freiburg, Hugstetter Str. 55, D-79106 Freiburg, Germany
| | - Markus Kimmann
- Department of Medicine B, Gastroenterology, Hepatology, Endocrinology, Infectious Diseases, Universitätsklinikum Münster, Münster, Germany
| | - Cristina Ripoll
- Internal Medicine IV, Department for Gastroenterology, Hepatology, Interdisciplinary Endoscopy and Infectious Diseases, Jena University Hospital, Friedrich-Schiller University, Jena, Germany
| | - Alexander Zipprich
- Internal Medicine IV, Department for Gastroenterology, Hepatology, Interdisciplinary Endoscopy and Infectious Diseases, Jena University Hospital, Friedrich-Schiller University, Jena, Germany
| | - Jan Hinrichs
- St. Bernward Krankenhaus, Klinik für diagnostische und interventionelle Radiologie und Neuroradiologie, Hildesheim, Germany
| | - Michael Koehler
- Department of Radiology, University Hospital Muenster, Muenster, Germany
| | - Jonel Trebicka
- Department of Medicine B, Gastroenterology, Hepatology, Endocrinology, Infectious Diseases, Universitätsklinikum Münster, Münster, Germany
| | - Roman Kloeckner
- Department of Diagnostic and Interventional Radiology, University of Lübeck, Lübeck, Germany
| | - Cornelius Engelmann
- Charité - Universitaetsmedizin Berlin; Campus Virchow Klinikum; Department of Hepatology and Gastroenterology, Berlin, Germany
| | - Robert Thimme
- Department of Medicine II, Medical Center University of Freiburg, Faculty of Medicine, University of Freiburg, Hugstetter Str. 55, D-79106 Freiburg, Germany
| | - Dominik Bettinger
- Department of Medicine II, Medical Center University of Freiburg, Faculty of Medicine, University of Freiburg, Hugstetter Str. 55, D-79106 Freiburg, Germany.
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Kabelitz MA, Hartl L, Schaub G, Tiede A, Rieland H, Kornfehl A, Hübener P, Jachs M, Hinrichs J, Schütte SL, Riedel C, Mauz JB, Tergast TL, Meyer BC, Bannas P, Kappel J, Wedemeyer H, Kluwe J, Piecha F, Reiberger T, Sandmann L, Maasoumy B. Identification of optimal portal pressure decrease to control ascites while minimizing HE after TIPS: A multicenter study. Hepatology 2025:01515467-990000000-01132. [PMID: 39773850 DOI: 10.1097/hep.0000000000001219] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/27/2024] [Accepted: 12/11/2024] [Indexed: 01/11/2025]
Abstract
BACKGROUND AND AIMS Clinically significant portal hypertension in patients with liver cirrhosis can lead to refractory ascites. A TIPS treats clinically significant portal hypertension but may cause overt hepatic encephalopathy (oHE). Our aim was to determine the optimal reduction of the portal pressure gradient (PPG) through TIPS to control ascites without raising oHE risk. APPROACH AND RESULTS This multicenter study screened 1509 patients from 3 European centers (Hannover, Vienna, and Hamburg) undergoing TIPS implantation between 2000 and 2023. Patients with TIPS indications other than refractory ascites/hepatic hydrothorax, vascular liver disease, HCC, or insufficient PPG data were excluded. PPG was measured before and after TIPS insertion. Outcome data were assessed up to 1 year after TIPS insertion. Analyses were conducted utilizing a modern machine learning model, namely a competing-risk random survival forest, partial dependence plots, and competing risk analyses with liver transplantation/death as competitors. The cohort was divided into a 60% derivation and 40% validation cohort. Overall, 729 patients (median MELD: 13 [IQR 10-16], 66% male, 23% oHE before TIPS) were analyzed. The derivation cohort comprised 438 patients, and the validation cohort comprised 291 patients. The optimal PPG reduction, determined by maximally selected Gray statistic and PDP of the random survival forest, was 60%-80%. In this range, patients showed significantly fewer hepatic decompensations due to ascites (HDA) (subdistribution hazard ratio [sHR]: 0.7 [0.52-0.96]) with similar oHE incidences (sHR: 0.92 [0.67-1.27]). The PPG range was confirmed in the validation cohort (HDA: sHR: 0.66 [0.46-0.96]; oHE: sHR: 0.89 [0.61-1.32]). CONCLUSIONS A targeted PPG reduction of 60%-80% showed significantly reduced HDA without increased oHE risk. Therefore, PPG reduction within this range could be a valid reduction target.
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Affiliation(s)
- Martin A Kabelitz
- Department for Gastroenterology, Hepatology, Infectious Diseases and Endocrinology, Hannover Medical School, Hannover, Germany
| | - Lukas Hartl
- Department of Internal Medicine III, Division of Gastroenterology and Hepatology, Medical University of Vienna, Vienna, Austria
- Vienna Hepatic Hemodynamic Lab, Department of Internal Medicine III, Division of Gastroenterology and Hepatology, Medical University of Vienna, Vienna, Austria
| | - Golda Schaub
- I. Department of Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Anja Tiede
- Department for Gastroenterology, Hepatology, Infectious Diseases and Endocrinology, Hannover Medical School, Hannover, Germany
- German Center for Infection Research (DZIF), Hannover/Braunschweig, Germany
| | - Hannah Rieland
- Department for Gastroenterology, Hepatology, Infectious Diseases and Endocrinology, Hannover Medical School, Hannover, Germany
| | - Andrea Kornfehl
- Department of Internal Medicine III, Division of Gastroenterology and Hepatology, Medical University of Vienna, Vienna, Austria
- Vienna Hepatic Hemodynamic Lab, Department of Internal Medicine III, Division of Gastroenterology and Hepatology, Medical University of Vienna, Vienna, Austria
| | - Peter Hübener
- I. Department of Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Mathias Jachs
- Department of Internal Medicine III, Division of Gastroenterology and Hepatology, Medical University of Vienna, Vienna, Austria
- Vienna Hepatic Hemodynamic Lab, Department of Internal Medicine III, Division of Gastroenterology and Hepatology, Medical University of Vienna, Vienna, Austria
| | - Jan Hinrichs
- Department of Diagnostic and Interventional Radiology, Hannover Medical School, Hannover, Germany
| | - Sarah L Schütte
- Department for Gastroenterology, Hepatology, Infectious Diseases and Endocrinology, Hannover Medical School, Hannover, Germany
| | - Christoph Riedel
- Department of Diagnostic and Interventional Radiology and Nuclear Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Jim B Mauz
- Department for Gastroenterology, Hepatology, Infectious Diseases and Endocrinology, Hannover Medical School, Hannover, Germany
| | - Tammo L Tergast
- Department for Gastroenterology, Hepatology, Infectious Diseases and Endocrinology, Hannover Medical School, Hannover, Germany
| | - Bernhard C Meyer
- Department of Diagnostic and Interventional Radiology, Hannover Medical School, Hannover, Germany
| | - Peter Bannas
- Department of Diagnostic and Interventional Radiology and Nuclear Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Julia Kappel
- Department of Internal Medicine III, Division of Gastroenterology and Hepatology, Medical University of Vienna, Vienna, Austria
- Vienna Hepatic Hemodynamic Lab, Department of Internal Medicine III, Division of Gastroenterology and Hepatology, Medical University of Vienna, Vienna, Austria
| | - Heiner Wedemeyer
- Department for Gastroenterology, Hepatology, Infectious Diseases and Endocrinology, Hannover Medical School, Hannover, Germany
- German Center for Infection Research (DZIF), Hannover/Braunschweig, Germany
- Excellence Cluster RESIST, Excellence Initiative Hannover Medical School, Hannover, Germany
| | - Johannes Kluwe
- I. Department of Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
- Department of Internal Medicine and Gastroenterology, Amalie Sieveking Hospital, Hamburg, Germany
| | - Felix Piecha
- I. Department of Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Thomas Reiberger
- Department of Internal Medicine III, Division of Gastroenterology and Hepatology, Medical University of Vienna, Vienna, Austria
- Vienna Hepatic Hemodynamic Lab, Department of Internal Medicine III, Division of Gastroenterology and Hepatology, Medical University of Vienna, Vienna, Austria
| | - Lisa Sandmann
- Department for Gastroenterology, Hepatology, Infectious Diseases and Endocrinology, Hannover Medical School, Hannover, Germany
- German Center for Infection Research (DZIF), Hannover/Braunschweig, Germany
| | - Benjamin Maasoumy
- Department for Gastroenterology, Hepatology, Infectious Diseases and Endocrinology, Hannover Medical School, Hannover, Germany
- German Center for Infection Research (DZIF), Hannover/Braunschweig, Germany
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4
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İnce O, Önder H, Gençtürk M, Golzarian J, Young S. Improving Clinical Decisions in IR: Interpretable Machine Learning Models for Predicting Ascites Improvement after Transjugular Intrahepatic Portosystemic Shunt Procedures. J Vasc Interv Radiol 2025; 36:99-105.e1. [PMID: 39389232 DOI: 10.1016/j.jvir.2024.09.022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2023] [Revised: 08/12/2024] [Accepted: 09/28/2024] [Indexed: 10/12/2024] Open
Abstract
PURPOSE To evaluate the potential of interpretable machine learning (ML) models to predict ascites improvement in patients undergoing transjugular intrahepatic portosystemic shunt (TIPS) placement for refractory ascites. MATERIALS AND METHODS In this retrospective study, 218 patients with refractory ascites who underwent TIPS placement were analyzed. Data on 29 demographic, clinical, and procedural features were collected. Ascites improvement was defined as reduction in the need of paracentesis by 50% or more at the 1-month follow-up. Univariate statistical analysis was performed. Data were split into train and test sets. Feature selection was performed using a wrapper-based sequential feature selection algorithm. Two ML models were built using support vector machine (SVM) and CatBoost algorithms. Shapley additive explanations values were calculated to assess interpretability of ML models. Performance metrics were calculated using the test set. RESULTS Refractory ascites improved in 168 (77%) patients. Higher sodium (Na; 136 mEq/L vs 134 mEq/L; P = .001) and albumin (2.91 g/dL vs 2.68 g/dL; P = .03) levels, lower creatinine levels (1.01 mg/dL vs 1.17 mg/dL; P = .04), and lower Model for End-stage Liver Disease (MELD) (13 vs 15; P = .01) and MELD-Na (15 vs 17.5, P = .002) scores were associated with significant improvement, whereas main portal vein puncture was associated with a lower improvement rate (P = .02). SVM and CatBoost models had accuracy ratios of 83% and 87%, with area under the curve values of 0.83 and 0.87, respectively. No statistically significant difference was found between performances of the models in DeLong test (P = .3). CONCLUSIONS ML models may have potential in patient selection for TIPS placement by predicting the improvement in refractory ascites.
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Affiliation(s)
- Okan İnce
- Department of Radiology, Rush University Medical College, Chicago, Illinois.
| | - Hakan Önder
- Department of Radiology, Health Sciences University, Prof Dr Cemil Tascioglu City Hospital, Istanbul, Turkey
| | - Mehmet Gençtürk
- Department of Radiology, University of Minnesota, Medical School, Minneapolis, Minnesota
| | - Jafar Golzarian
- Department of Radiology, University of Minnesota, Medical School, Minneapolis, Minnesota
| | - Shamar Young
- Department of Radiology, University of Arizona, College of Medicine, Tucson, Arizona
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Lucatelli P, Krajina A, Loffroy R, Miraglia R, Pieper CC, Franchi-Abella S, Rocco B. CIRSE Standards of Practice on Transjugular Intrahepatic Portosystemic Shunts. Cardiovasc Intervent Radiol 2024; 47:1710-1726. [PMID: 39550753 DOI: 10.1007/s00270-024-03866-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/18/2023] [Accepted: 09/10/2024] [Indexed: 11/18/2024]
Abstract
BACKGROUND Proposed in the early 1980s as a solution for managing complications of portal hypertension, the percutaneous creation of transjugular intrahepatic portosystemic shunt has consistently gained a central role. Increasingly lower complication rates have been observed thanks to improvements in both technologies and the skills of interventional radiologists. PURPOSE This document is aimed at interventional radiologists and provides best practice recommendations for transjugular intrahepatic portosystemic shunt creation, describing patient selection, intraprocedural management and follow-up, in addition to recommendations in paediatric settings. METHODS The CIRSE Standards of Practice Committee established a writing group consisting of seven European clinicians with recognised expertise in the creation of transjugular intrahepatic portosystemic shunt. The writing group reviewed the existing literature performing a pragmatic evidence search using PubMed to select relevant publications in the English language and involving human subjects, preferably published from 2009 to 2024. The final recommendations were developed by consensus. RESULTS TIPS creation has an established role in the successful management of portal hypertension and its complications. This Standards of Practice document provides up-to-date recommendations for patient selection, materials, its safe performance, and follow-up with complications management.
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Affiliation(s)
- Pierleone Lucatelli
- Department of Diagnostic Medicine and Radiology, Interventional Radiology Unit, Azienda Policlinico Universitario Policlinico Umberto I, Rome, Italy
| | - Antonín Krajina
- Department of Radiology, University Hospital, Charles University, Faculty of Medicine, Hradec Kralove, Czech Republic
| | - Romaric Loffroy
- Department of Vascular and Interventional Radiology, François-Mitterrand University Hospital, Dijon, France
| | | | - Claus Christian Pieper
- Department of Diagnostic and Interventional Radiology, University Hospital Bonn, Bonn, Germany
| | - Stéphanie Franchi-Abella
- Paris-Saclay University, Faculty of Medicine - AP-HP, Pediatric Radiology Department, Bicêtre Hospital, Reference Center for Vascular Diseases of the Liver, FSMR Filfoie, ERN Rare Liver, FHU Hepatinov - Biomaps UMR 9011, CNRS-INSERM-CEA, Le Kremlin-Bicêtre, France
| | - Bianca Rocco
- Department of Diagnostic Medicine and Radiology, Interventional Radiology Unit, Sapienza University of Rome, Rome, Italy.
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Riedel C, Hoffmann M, Ismahil M, Lenz A, Piecha F, Ristow I, Kluwe J, Schlüter M, Adam G, Schoennagel BP, Reeder SB, Bannas P, Wolfe S. Four-dimensional Flow MRI-based Computational Fluid Dynamics Simulation for Noninvasive Portosystemic Pressure Gradient Assessment in Patients with Cirrhosis and Transjugular Intrahepatic Portosystemic Shunt. Radiology 2024; 313:e232989. [PMID: 39352287 PMCID: PMC11535865 DOI: 10.1148/radiol.232989] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2023] [Revised: 05/17/2024] [Accepted: 06/12/2024] [Indexed: 10/03/2024]
Abstract
Background Transjugular intrahepatic portosystemic shunt (TIPS) dysfunction in patients with liver cirrhosis and recurrent symptoms of portal hypertension is primarily assessed with US and confirmed with invasive catheter venography, which can be used to measure the portosystemic pressure gradient (PSPG) to identify TIPS-refractory portal hypertension. To avoid the risks and costs of invasive catheter venography, noninvasive PSPG evaluation strategies are needed. Purpose To demonstrate the feasibility of the combination of four-dimensional (4D) flow MRI with computational fluid dynamics (CFD) for noninvasive PSPG assessment in participants with cirrhosis and TIPS. Materials and Methods Abdominal 4D flow MRI was performed prospectively in participants with cirrhosis and TIPS between January 2019 and September 2020. Flow rates were measured within the TIPS and inferior vena cava (IVC). The portal vein (PV), TIPS, right hepatic vein, and IVC were segmented on MRI scans to create a CFD mesh. The PV and infrahepatic IVC were defined as inflows for 4D flow MRI-derived flow rates. The suprahepatic IVC was defined as the outflow. CFD simulations were used to noninvasively estimate PSPG as the difference between the simulated pressures in the PV and suprahepatic IVC. Invasive venographic measurements of the PSPG served as the reference standard, and Pearson correlation analysis was conducted to evaluate the relationship between noninvasive estimates and invasive measurements. Results In all 20 participants with cirrhosis (mean age, 58 years ± 9 [SD]; 11 men), 4D flow MRI-based CFD simulations enabled visualization of flow velocities and pressure distributions within the segmented vasculature and TIPS. Noninvasive estimates and invasive measures of PSPG were strongly correlated (r = 0.77; P < .001). The 4D flow MRI-based CFD simulations correctly classified the presence or absence of a post-TIPS PSPG greater than 12 mm Hg in 16 of 20 participants (80%). Conclusion The combination of 4D flow MRI and CFD was feasible for noninvasive PSPG assessment in participants with cirrhosis, portal hypertension, and TIPS. © RSNA, 2024 See also the editorial by Motosugi and Watanabe in this issue.
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Affiliation(s)
- Christoph Riedel
- From the Department of Diagnostic and Interventional Radiology and
Nuclear Medicine (C.R., A.L., I.R., G.A., B.P.S., P.B.) and I. Department of
Medicine (F.P., J.K.), University Medical Center Hamburg–Eppendorf,
Martinistrasse 52, 20246 Hamburg, Germany; Institute of Multiphase Flows,
Hamburg University of Technology, Hamburg, Germany (M.H., M.I., M.S.); and
Departments of Radiology, Medical Physics, Biomedical Engineering, Medicine, and
Emergency Medicine, University of Wisconsin–Madison, Madison, Wis
(S.B.R.)
| | - Marko Hoffmann
- From the Department of Diagnostic and Interventional Radiology and
Nuclear Medicine (C.R., A.L., I.R., G.A., B.P.S., P.B.) and I. Department of
Medicine (F.P., J.K.), University Medical Center Hamburg–Eppendorf,
Martinistrasse 52, 20246 Hamburg, Germany; Institute of Multiphase Flows,
Hamburg University of Technology, Hamburg, Germany (M.H., M.I., M.S.); and
Departments of Radiology, Medical Physics, Biomedical Engineering, Medicine, and
Emergency Medicine, University of Wisconsin–Madison, Madison, Wis
(S.B.R.)
| | - Muhammad Ismahil
- From the Department of Diagnostic and Interventional Radiology and
Nuclear Medicine (C.R., A.L., I.R., G.A., B.P.S., P.B.) and I. Department of
Medicine (F.P., J.K.), University Medical Center Hamburg–Eppendorf,
Martinistrasse 52, 20246 Hamburg, Germany; Institute of Multiphase Flows,
Hamburg University of Technology, Hamburg, Germany (M.H., M.I., M.S.); and
Departments of Radiology, Medical Physics, Biomedical Engineering, Medicine, and
Emergency Medicine, University of Wisconsin–Madison, Madison, Wis
(S.B.R.)
| | - Alexander Lenz
- From the Department of Diagnostic and Interventional Radiology and
Nuclear Medicine (C.R., A.L., I.R., G.A., B.P.S., P.B.) and I. Department of
Medicine (F.P., J.K.), University Medical Center Hamburg–Eppendorf,
Martinistrasse 52, 20246 Hamburg, Germany; Institute of Multiphase Flows,
Hamburg University of Technology, Hamburg, Germany (M.H., M.I., M.S.); and
Departments of Radiology, Medical Physics, Biomedical Engineering, Medicine, and
Emergency Medicine, University of Wisconsin–Madison, Madison, Wis
(S.B.R.)
| | - Felix Piecha
- From the Department of Diagnostic and Interventional Radiology and
Nuclear Medicine (C.R., A.L., I.R., G.A., B.P.S., P.B.) and I. Department of
Medicine (F.P., J.K.), University Medical Center Hamburg–Eppendorf,
Martinistrasse 52, 20246 Hamburg, Germany; Institute of Multiphase Flows,
Hamburg University of Technology, Hamburg, Germany (M.H., M.I., M.S.); and
Departments of Radiology, Medical Physics, Biomedical Engineering, Medicine, and
Emergency Medicine, University of Wisconsin–Madison, Madison, Wis
(S.B.R.)
| | - Inka Ristow
- From the Department of Diagnostic and Interventional Radiology and
Nuclear Medicine (C.R., A.L., I.R., G.A., B.P.S., P.B.) and I. Department of
Medicine (F.P., J.K.), University Medical Center Hamburg–Eppendorf,
Martinistrasse 52, 20246 Hamburg, Germany; Institute of Multiphase Flows,
Hamburg University of Technology, Hamburg, Germany (M.H., M.I., M.S.); and
Departments of Radiology, Medical Physics, Biomedical Engineering, Medicine, and
Emergency Medicine, University of Wisconsin–Madison, Madison, Wis
(S.B.R.)
| | - Johannes Kluwe
- From the Department of Diagnostic and Interventional Radiology and
Nuclear Medicine (C.R., A.L., I.R., G.A., B.P.S., P.B.) and I. Department of
Medicine (F.P., J.K.), University Medical Center Hamburg–Eppendorf,
Martinistrasse 52, 20246 Hamburg, Germany; Institute of Multiphase Flows,
Hamburg University of Technology, Hamburg, Germany (M.H., M.I., M.S.); and
Departments of Radiology, Medical Physics, Biomedical Engineering, Medicine, and
Emergency Medicine, University of Wisconsin–Madison, Madison, Wis
(S.B.R.)
| | - Michael Schlüter
- From the Department of Diagnostic and Interventional Radiology and
Nuclear Medicine (C.R., A.L., I.R., G.A., B.P.S., P.B.) and I. Department of
Medicine (F.P., J.K.), University Medical Center Hamburg–Eppendorf,
Martinistrasse 52, 20246 Hamburg, Germany; Institute of Multiphase Flows,
Hamburg University of Technology, Hamburg, Germany (M.H., M.I., M.S.); and
Departments of Radiology, Medical Physics, Biomedical Engineering, Medicine, and
Emergency Medicine, University of Wisconsin–Madison, Madison, Wis
(S.B.R.)
| | - Gerhard Adam
- From the Department of Diagnostic and Interventional Radiology and
Nuclear Medicine (C.R., A.L., I.R., G.A., B.P.S., P.B.) and I. Department of
Medicine (F.P., J.K.), University Medical Center Hamburg–Eppendorf,
Martinistrasse 52, 20246 Hamburg, Germany; Institute of Multiphase Flows,
Hamburg University of Technology, Hamburg, Germany (M.H., M.I., M.S.); and
Departments of Radiology, Medical Physics, Biomedical Engineering, Medicine, and
Emergency Medicine, University of Wisconsin–Madison, Madison, Wis
(S.B.R.)
| | - Bjoern P. Schoennagel
- From the Department of Diagnostic and Interventional Radiology and
Nuclear Medicine (C.R., A.L., I.R., G.A., B.P.S., P.B.) and I. Department of
Medicine (F.P., J.K.), University Medical Center Hamburg–Eppendorf,
Martinistrasse 52, 20246 Hamburg, Germany; Institute of Multiphase Flows,
Hamburg University of Technology, Hamburg, Germany (M.H., M.I., M.S.); and
Departments of Radiology, Medical Physics, Biomedical Engineering, Medicine, and
Emergency Medicine, University of Wisconsin–Madison, Madison, Wis
(S.B.R.)
| | - Scott B. Reeder
- From the Department of Diagnostic and Interventional Radiology and
Nuclear Medicine (C.R., A.L., I.R., G.A., B.P.S., P.B.) and I. Department of
Medicine (F.P., J.K.), University Medical Center Hamburg–Eppendorf,
Martinistrasse 52, 20246 Hamburg, Germany; Institute of Multiphase Flows,
Hamburg University of Technology, Hamburg, Germany (M.H., M.I., M.S.); and
Departments of Radiology, Medical Physics, Biomedical Engineering, Medicine, and
Emergency Medicine, University of Wisconsin–Madison, Madison, Wis
(S.B.R.)
| | - Peter Bannas
- From the Department of Diagnostic and Interventional Radiology and
Nuclear Medicine (C.R., A.L., I.R., G.A., B.P.S., P.B.) and I. Department of
Medicine (F.P., J.K.), University Medical Center Hamburg–Eppendorf,
Martinistrasse 52, 20246 Hamburg, Germany; Institute of Multiphase Flows,
Hamburg University of Technology, Hamburg, Germany (M.H., M.I., M.S.); and
Departments of Radiology, Medical Physics, Biomedical Engineering, Medicine, and
Emergency Medicine, University of Wisconsin–Madison, Madison, Wis
(S.B.R.)
| | - Shannyn Wolfe
- From the Department of Diagnostic and Interventional Radiology and
Nuclear Medicine (C.R., A.L., I.R., G.A., B.P.S., P.B.) and I. Department of
Medicine (F.P., J.K.), University Medical Center Hamburg–Eppendorf,
Martinistrasse 52, 20246 Hamburg, Germany; Institute of Multiphase Flows,
Hamburg University of Technology, Hamburg, Germany (M.H., M.I., M.S.); and
Departments of Radiology, Medical Physics, Biomedical Engineering, Medicine, and
Emergency Medicine, University of Wisconsin–Madison, Madison, Wis
(S.B.R.)
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Singh J, Ebaid M, Saab S. Advances in the management of complications from cirrhosis. Gastroenterol Rep (Oxf) 2024; 12:goae072. [PMID: 39104730 PMCID: PMC11299547 DOI: 10.1093/gastro/goae072] [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: 03/21/2024] [Revised: 05/29/2024] [Accepted: 06/15/2024] [Indexed: 08/07/2024] Open
Abstract
Cirrhosis with complications of liver decompensation and hepatocellular carcinoma (HCC) constitute a leading cause of morbidity and mortality worldwide. Portal hypertension is central to the progression of liver disease and decompensation. The most recent Baveno VII guidance included revision of the nomenclature for chronic liver disease, termed compensated advanced chronic liver disease, and leveraged the use of liver stiffness measurement to categorize the degree of portal hypertension. Additionally, non-selective beta blockers, especially carvedilol, can improve portal hypertension and may even have a survival benefit. Procedural techniques with interventional radiology have become more advanced in the management of refractory ascites and variceal bleeding, leading to improved prognosis in patients with decompensated liver disease. While lactulose and rifaximin are the preferred treatments for hepatic encephalopathy, many alternative treatment options may be used in refractory cases and even procedural interventions such as shunt embolization may be of benefit. The approval of terlipressin for the treatment of hepatorenal syndrome (HRS) in the USA has improved the way in which HRS is managed and will be discussed in detail. Malnutrition, frailty, and sarcopenia lead to poorer outcomes in patients with decompensated liver disease and should be addressed in this patient population. Palliative care interventions can lead to improved quality of life and clinical outcomes. Lastly, the investigation of systemic therapies, in particular immunotherapy, has revolutionized the management of HCC. These topics will be discussed in detail in this review.
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Affiliation(s)
- Jasleen Singh
- Department of Surgery, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
- Department of Medicine, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
| | - Mark Ebaid
- Department of Surgery, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
| | - Sammy Saab
- Department of Surgery, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
- Department of Medicine, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
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8
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Chinese Society of Gastroenterology, Chinese Medical Association. Chinese consensus on the management of liver cirrhosis. J Dig Dis 2024; 25:332-352. [PMID: 39044465 DOI: 10.1111/1751-2980.13294] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/19/2024] [Revised: 05/19/2024] [Accepted: 06/11/2024] [Indexed: 07/25/2024]
Abstract
Liver cirrhosis, characterized by diffuse necrosis, insufficient regeneration of hepatocytes, angiogenesis, severe fibrosis, and the formation of pseudolobules, is a progressive, chronic liver disease induced by a variety of causes. It is clinically characterized by liver function damage and portal hypertension, and many complications may occur in its late stage. Based on the updated practice guidelines, expert consensuses, and research advances on the diagnosis and treatment of cirrhosis, the Chinese Society of Gastroenterology of Chinese Medical Association established the current consensus to standardize the clinical diagnosis and management of liver cirrhosis and guide clinical practice. This consensus contains 43 statements on the etiology, pathology and pathogenesis, clinical manifestations, major complications, diagnosis, treatment, prognosis, and chronic disease control of liver cirrhosis. Since several practice guidelines and expert consensuses on the complications of liver cirrhosis have been published, this consensus emphasizes the research progress of liver cirrhosis itself.
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Li R, Sarin S. Advanced chronic renal disease is an independent risk factor for inpatient mortality following transjugular intrahepatic portosystemic shunt procedure. Eur J Gastroenterol Hepatol 2024; 36:332-337. [PMID: 38179873 DOI: 10.1097/meg.0000000000002703] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/06/2024]
Abstract
BACKGROUND Transjugular intrahepatic portosystemic shunt (TIPS) is a procedure used to alleviate portal hypertension in patients with decompensated liver cirrhosis. However, the risks and outcomes associated with TIPS in patients with advanced chronic kidney disease (CKD) remain uncertain. This study aimed to investigate the perioperative outcomes of TIPS procedures in patients with advanced CKD using the National Inpatient Sample (NIS) database, a comprehensive all-payer inpatient database in the US. METHODS The study identified patients who underwent TIPS procedures in the NIS database from Q4 2015 to 2020. Patients with advanced CKD were identified using specific ICD-10-CM codes, and they were compared to patients without CKD. Preoperative variables, including demographics, indications for TIPS, comorbidities, APR-DRG subclass, primary payer status, and hospital characteristics, were noted. Perioperative outcomes were examined by multivariable logistic regression. RESULTS A total of 248 patients with advanced CKD and 5511 patients without CKD undergoing TIPS procedures were identified in the NIS database. Compared to non-CKD, patients with advanced CKD had higher mortality (13.70% vs. 8.60%, aOR = 1.56, P = 0.03), acute kidney injury (51.21% vs. 29.34, aOR = 1.46, P < 0.01), transfer out (25.00% vs. 12.84%, aOR = 1.88, P < 0.01), and length of stay over 7 days (64.11% vs. 38.97%, aOR = 2.34, P < 0.01). However, there was no difference in hepatic encephalopathy (31.85% vs. 27.19%, aOR = 1.12, P = 0.42). CONCLUSION Advanced CKD patients undergoing TIPS are at higher risk of mortality and AKI compared to patients without CKD; HE was mildly elevated but NS. Long-term prognosis of patients with advanced CKD who had TIPS is needed in future studies.
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Affiliation(s)
- Renxi Li
- The George Washington University School of Medicine and Health Sciences, Washington, DC
| | - Shawn Sarin
- The George Washington University Hospital, Department of Interventional Radiology, Washington, DC, USA
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Rajan A, Boike J. TIPS for Refractory Ascites and Hepatic Hydrothorax. CURRENT HEPATOLOGY REPORTS 2024; 23:45-53. [DOI: 10.1007/s11901-023-00625-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 12/09/2023] [Indexed: 01/04/2025]
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Piecha F, Vonderlin J, Frühhaber F, Graß JK, Ozga AK, Harberts A, Benten D, Hübener P, Reeh M, Riedel C, Bannas P, Izbicki JR, Adam G, Huber S, Lohse AW, Kluwe J. Preoperative TIPS and in-hospital mortality in patients with cirrhosis undergoing surgery. JHEP Rep 2024; 6:100914. [PMID: 38074512 PMCID: PMC10698536 DOI: 10.1016/j.jhepr.2023.100914] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/15/2023] [Revised: 08/30/2023] [Accepted: 09/06/2023] [Indexed: 12/21/2024] Open
Abstract
BACKGROUND & AIMS Cirrhosis is associated with an increased surgical morbidity and mortality. Portal hypertension and the surgery type have been established as critical determinants of postoperative outcome. We aim to evaluate the hypothesis that preoperative transjugular intrahepatic portosystemic shunt (TIPS) placement in patients with cirrhosis is associated with a lower incidence of in-house mortality/liver transplantation (LT) after surgery. METHODS A retrospective database search for the years 2010-2020 was carried out. We identified 64 patients with cirrhosis who underwent surgery within 3 months after TIPS placement and 131 patients with cirrhosis who underwent surgery without it (controls). Operations were categorised into low-risk and high-risk procedures. The primary endpoint was in-house mortality/LT. We analysed the influence of high-risk surgery, preoperative TIPS placement, age, sex, baseline creatinine, presence of ascites, Chronic Liver Failure Consortium Acute Decompensation (CLIF-C AD), American Society of Anesthesiologists (ASA), and model for end-stage liver disease (MELD) scores on in-house mortality/LT by multivariable Cox proportional hazards regression. RESULTS In both the TIPS and the control cohort, most patients presented with a Child-Pugh B stage (37/64, 58% vs. 70/131, 53%) at the time of surgery, but the median MELD score was higher in the TIPS cohort (14 vs. 11 points). Low-risk and high-risk procedures amounted to 47% and 53% in both cohorts. The incidence of in-house mortality/LT was lower in the TIPS cohort (12/64, 19% vs. 52/131, 40%), also when further subdivided into low-risk (0/30, 0% vs. 10/61, 16%) and high-risk surgery (12/34, 35% vs. 42/70, 60%). Preoperative TIPS placement was associated with a lower rate for postoperative in-house mortality/LT (hazard ratio 0.44, 95% CI 0.19-1.00) on multivariable analysis. CONCLUSIONS A preoperative TIPS might be associated with reduced postoperative in-house mortality in selected patients with cirrhosis. IMPACT AND IMPLICATIONS Patients with cirrhosis are at risk for more complications and a higher mortality after surgical procedures. A transjugular intrahepatic portosystemic shunt (TIPS) is used to treat complications of cirrhosis, but it is unclear if it also helps to lower the risk of surgery. This study takes a look at complications and mortality of patients undergoing surgery with or without a TIPS, and we found that patients with a TIPS develop less complications and have an improved survival. Therefore, a preoperative TIPS should be considered in selected patients, especially if indicated by ascites.
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Affiliation(s)
- Felix Piecha
- I. Department of Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Joscha Vonderlin
- Department of Hepatology and Gastroenterology, Charité – Universitätsmedizin Berlin, Campus Virchow-Klinikum (CVK) and Campus Charité Mitte (CCM), Berlin, Germany
| | - Friederike Frühhaber
- I. Department of Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Julia-Kristin Graß
- Department of General, Visceral, and Thoracic Surgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Ann-Kathrin Ozga
- Center for Experimental Medicine, Institute of Medical Biometry and Epidemiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Aenne Harberts
- I. Department of Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Daniel Benten
- I. Department of Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
- Department of Gastroenterology, Asklepios Hospital Harburg, Hamburg, Germany
| | - Peter Hübener
- I. Department of Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Matthias Reeh
- Department of General, Visceral, and Thoracic Surgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Christoph Riedel
- Department of Diagnostic and Interventional Radiology and Nuclear Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Peter Bannas
- Department of Diagnostic and Interventional Radiology and Nuclear Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Jakob R. Izbicki
- Department of General, Visceral, and Thoracic Surgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Gerhard Adam
- Department of Diagnostic and Interventional Radiology and Nuclear Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Samuel Huber
- I. Department of Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Ansgar W. Lohse
- I. Department of Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Johannes Kluwe
- I. Department of Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
- Department of Internal Medicine and Gastroenterology, Amalie Sieveking Hospital, Hamburg, Germany
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Gu W, Zeleke Y, Hortlik H, Schaaf L, Uschner FE, Schulz M, Tischendorf M, Peiffer KH, Brol MJ, Kimmann M, Vogl T, Köhler M, Meyer C, Gerbes A, Rössle M, Laleman W, Zipprich A, Steib C, Praktiknjo M, Trebicka J. Use and outcome of TIPS in hospitalized patients in Germany: A Nationwide study (2007-2018). Hepatol Commun 2023; 7:e0237. [PMID: 37708430 PMCID: PMC10503680 DOI: 10.1097/hc9.0000000000000237] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/21/2023] [Accepted: 06/14/2023] [Indexed: 09/16/2023] Open
Abstract
BACKGROUND The number of complications in patients admitted for cirrhosis has increased over time. Portal hypertension is the driver of many complications of cirrhosis. TIPS placement is the most effective treatment of portal hypertension. The aim of this study was to analyze the use and impact of TIPS placement in the last decade in a nationwide study in Germany. METHODS We analyzed 14,598 admissions of patients for TIPS insertions in Germany from 2007 to 2018 using the DRG system, 12,877 out of 2,000,765 total admissions of patients with cirrhosis. All diagnoses and procedures were coded according to ICD-10-CM and OPS codes. The data were analyzed, focusing on the number of admissions and in-hospital mortality. RESULTS The number of TIPS placements increased over the last decade. In-hospital mortality of cirrhotic patients with TIPS decreased when it was placed for severe bleeding (15.2% [TIPS] vs. 19.5% [endoscopy treatment]), ascites (8.7% [TIPS] vs. 14.4% [paracentesis]), and hepatorenal syndrome (HRS) (17.1% [TIPS] vs. 43.3% [no-TIPS]). In the case of bleeding, TIPS significantly decreased in-hospital mortality and also in ascites and HRS. During hospitalization, 22.6% admissions of patients with TIPS insertion showed HE. However, in-hospital mortality in patients admitted with HE grades 1 or 2 and TIPS was lower than in patients without TIPS. In the logistic regression, a higher HE grade(3 and 4), infection, and circulatory disease were found to be independently associated with in-hospital mortality in patients with TIPS insertion. CONCLUSION Our nationwide study demonstrates that TIPS insertion is increasingly used in Germany. TIPS improves outcomes, especially in patients with ascites and HRS, regardless of lower HE grades, while higher HE grades, infection, and circulatory diseases seem to be associated with risk of in-hospital mortality.
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Affiliation(s)
- Wenyi Gu
- Department of Internal Medicine B, University Hospital Muenster, Muenster, Germany
- Department of Internal Medicine I, University Hospital Frankfurt, Goethe University Frankfurt, Frankfurt am Main, Germany
| | - Yasmin Zeleke
- Department of Internal Medicine I, University Hospital Frankfurt, Goethe University Frankfurt, Frankfurt am Main, Germany
| | - Hannah Hortlik
- Department of Internal Medicine I, University Hospital Frankfurt, Goethe University Frankfurt, Frankfurt am Main, Germany
| | - Louisa Schaaf
- Department of Internal Medicine I, University Hospital Frankfurt, Goethe University Frankfurt, Frankfurt am Main, Germany
| | - Frank E. Uschner
- Department of Internal Medicine B, University Hospital Muenster, Muenster, Germany
| | - Martin Schulz
- Department of Internal Medicine B, University Hospital Muenster, Muenster, Germany
| | - Michael Tischendorf
- Department of Internal Medicine B, University Hospital Muenster, Muenster, Germany
| | - Kai-Henrik Peiffer
- Department of Internal Medicine B, University Hospital Muenster, Muenster, Germany
| | | | - Markus Kimmann
- Department of Internal Medicine B, University Hospital Muenster, Muenster, Germany
| | - Thomas Vogl
- Institute of Diagnostic and Interventional Radiology, University Hospital Frankfurt, Frankfurt am Main, Germany
| | - Michael Köhler
- Clinic for Radiology, University Hospital Muenster, Muenster, Germany
| | - Carsten Meyer
- Clinic for Radiology, University Hospital Bonn, Bonn, Germany
| | - Alexander Gerbes
- Department of Medicine II, University Clinic Munich LMU, Munich, Germany
| | - Martin Rössle
- Department of Internal Medicine II, Faculty of Medicine, Medical Centre University of Freiburg, University of Freiburg, Freiburg, Germany
| | - Wim Laleman
- Department of Internal Medicine B, University Hospital Muenster, Muenster, Germany
- Department of Gastroenterology and Hepatology, University Hospitals Leuven, KU Leuven, Leuven, Belgium
| | - Alexander Zipprich
- Department of Internal Medicine IV (Gastroenterology, Hepatology and Infectious Diseases), Jena University Hospital, Friedrich-Schiller-University Jena, Jena, Germany
| | - Christian Steib
- Department of Medicine II, University Clinic Munich LMU, Munich, Germany
| | - Michael Praktiknjo
- Department of Internal Medicine B, University Hospital Muenster, Muenster, Germany
| | - Jonel Trebicka
- Department of Internal Medicine B, University Hospital Muenster, Muenster, Germany
- European Foundation for Study of Chronic Liver Failure, Barcelona, Spain
- Department of Gastroenterology and Hepatology, Odense University Hospital, Odense, Denmark
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13
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Bommena S, Mahmud N, Boike JR, Thornburg BG, Kolli KP, Lai JC, German M, Morelli G, Spengler E, Said A, Desai AP, Junna S, Paul S, Frenette C, Verna EC, Goel A, Gregory D, Padilla C, VanWagner LB, Fallon MB. The impact of right atrial pressure on outcomes in patients undergoing TIPS, an ALTA group study. Hepatology 2023; 77:2041-2051. [PMID: 36651170 PMCID: PMC10192025 DOI: 10.1097/hep.0000000000000283] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/20/2022] [Accepted: 12/08/2022] [Indexed: 01/19/2023]
Abstract
BACKGROUND AND AIMS Single-center studies in patients undergoing TIPS suggest that elevated right atrial pressure (RAP) may influence survival. We assessed the impact of pre-TIPS RAP on outcomes using the Advancing Liver Therapeutic Approaches (ALTA) database. APPROACH AND RESULTS Total 883 patients in ALTA multicenter TIPS database from 2010 to 2015 from 9 centers with measured pre-TIPS RAP were included. Primary outcome was mortality. Secondary outcomes were 48-hour post-TIPS complications, post-TIPS portal hypertension complications, and post-TIPS inpatient admission for heart failure. Adjusted Cox Proportional hazards and competing risk model with liver transplant as a competing risk were used to assess RAP association with mortality. Restricted cubic splines were used to model nonlinear relationship. Logistic regression was used to assess RAP association with secondary outcomes.Pre-TIPS RAP was independently associated with overall mortality (subdistribution HR: 1.04 per mm Hg, 95% CI, 1.01, 1.08, p =0.009) and composite 48-hour complications. RAP was a predictor of TIPS dysfunction with increased odds of post-90-day paracentesis in outpatient TIPS, hospital admissions for renal dysfunction, and heart failure. Pre-TIPS RAP was positively associated with model for end-stage liver disease, body mass index, Native American and Black race, and lower platelets. CONCLUSIONS Pre-TIPS RAP is an independent risk factor for overall mortality after TIPS insertion. Higher pre-TIPS RAP increased the odds of early complications and overall portal hypertensive complications as potential mechanisms for the mortality impact.
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Affiliation(s)
- Shoma Bommena
- Department of Internal Medicine, Banner University Medical Center, University of Arizona College of Medicine-Phoenix, Phoenix, Phoenix, Arizona, USA
| | - Nadim Mahmud
- Division of Gastroenterology, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - Justin R. Boike
- Division of Gastroenterology and Hepatology, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Bartley G. Thornburg
- Division of Vascular and Interventional Radiology, Department of Radiology, Northwestern University, Chicago, Illinois, USA
| | - Kanti P. Kolli
- Department of Radiology and Biomedical Imaging, University of California San Francisco, San Francisco, California, USA
| | - Jennifer C. Lai
- Division of Gastroenterology and Hepatology, Department of Medicine, University of California San Francisco, San Francisco, California, USA
| | - Margarita German
- Division of Gastroenterology and Hepatology, Department of Medicine, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, USA
| | - Giuseppe Morelli
- Division of Gastroenterology, Hepatology, Department of Medicine, and Nutrition, University of Florida Health, Gainesville, Florida, USA
| | - Erin Spengler
- Division of Gastroenterology and Hepatology, Department of Medicine, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, USA
| | - Adnan Said
- Division of Gastroenterology and Hepatology, Department of Medicine, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, USA
| | - Archita P. Desai
- Division of Gastroenterology and Hepatology, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Shilpa Junna
- Division of Gastroenterology and Hepatology, Department of Medicine, University of Michigan, Ann Arbor, Michigan, USA
| | - Sonali Paul
- Department of Internal Medicine, Section of Gastroenterology and Nutrition, The University of Chicago Medicine, Chicago, Illinois, USA
| | - Catherine Frenette
- Department for Organ and Cell Transplantation, The Scripps Clinic, La Jolla, California, USA
| | - Elizabeth C. Verna
- Department of Medicine, Center for Liver Disease and Transplantation, Columbia University College of Physicians & Surgeons, New York, New York, USA
| | - Aparna Goel
- Division of Gastroenterology and Hepatology, Department of Medicine, Stanford University, Stanford, California, USA
| | - Dyanna Gregory
- Division of Gastroenterology and Hepatology, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Cynthia Padilla
- Division of Gastroenterology and Hepatology, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Lisa B. VanWagner
- Division of Digestive and Liver Diseases, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Michael B. Fallon
- Department of Internal Medicine, Banner University Medical Center, University of Arizona College of Medicine-Phoenix, Phoenix, Phoenix, Arizona, USA
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Titton CM, Torikachvili M, Rêgo HMC, Medronha EF, Ziemiecki E, Ribas C, Ceratti CG, de Mattos AA, Tovo CV. Transjugular intrahepatic portosystemic shunt in decompensated cirrhotic patients in a tertiary hospital in southern Brazil. REVISTA DA ASSOCIACAO MEDICA BRASILEIRA (1992) 2023; 69:e20220944. [PMID: 37075438 PMCID: PMC10176653 DOI: 10.1590/1806-9282.20220944] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/12/2023] [Accepted: 01/13/2023] [Indexed: 04/21/2023]
Abstract
OBJECTIVE The aim of the present study was to evaluate the outcomes of cirrhotic patients undergoing transjugular intrahepatic portosystemic shunt. METHODS A retrospective longitudinal observational study was carried out evaluating 38 cirrhotic patients undergoing transjugular intrahepatic portosystemic shunt. The outcomes were evaluated in an outpatient follow-up period of 3 months. The assumed significance level was 5%. RESULTS The indications for transjugular intrahepatic portosystemic shunt were refractory ascites in 21 (55.3%), variceal hemorrhage in 13 (34.2%), and hydrothorax in 4 (10.5%) patients. There was development of hepatic encephalopathy in 10 (35.7%) patients after transjugular intrahepatic portosystemic shunt. From the 21 patients with refractory ascites, resolution was observed in 1 (3.1%) patient, and in 16 (50.0%) patients, there was ascites control. Regarding transjugular intrahepatic portosystemic shunt after variceal bleeding, 10 (76.9%) patients remained without new bleeding or hospitalizations in the follow-up period. The global survival in the follow-up period in patients with and without hepatic encephalopathy was 60 vs. 82%, respectively (p=0.032). CONCLUSION Transjugular intrahepatic portosystemic shunt can be considered in decompensated cirrhotic patients; however, the development of hepatic encephalopathy which can shorten survival should be focused.
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Affiliation(s)
| | | | | | | | - Enio Ziemiecki
- Hospital Nossa Senhora da Conceição – Porto Alegre (RS), Brazil
| | - Carolina Ribas
- Hospital Nossa Senhora da Conceição – Porto Alegre (RS), Brazil
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15
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Riedel C, Ristow I, Lenz A, Schoennagel BP, Hoffmann M, Piecha F, Adam G, Reeder SB, Bannas P. Validation of 4D flow cardiovascular magnetic resonance in TIPS stent grafts using a 3D-printed flow phantom. J Cardiovasc Magn Reson 2023; 25:9. [PMID: 36775827 PMCID: PMC9923912 DOI: 10.1186/s12968-023-00920-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2022] [Accepted: 01/16/2023] [Indexed: 02/14/2023] Open
Abstract
BACKGROUND Four-dimensional (4D) flow cardiovascular magnetic resonance (CMR) is feasible for portal blood flow evaluation after placement of transjugular intrahepatic portosystemic shunts (TIPS) in patients with liver cirrhosis. However, clinical acceptance of 4D flow CMR in TIPS patients is limited due to the lack of validation studies. The purpose of this study was to validate 4D flow CMR-derived measurements in TIPS stent grafts using a three-dimensional (3D)-printed flow phantom. METHODS A translucent flow phantom of the portal vasculature was 3D-printed. The phantom consisted of the superior mesenteric vein and the splenic vein draining into the portal vein, the TIPS-tract, and the hepatic vein. A TIPS stent graft (Gore® Viatorr®) was positioned within the TIPS-tract. Superior mesenteric vein and splenic vein served as inlets for blood-mimicking fluid. 4D flow CMR acquisitions were performed at 3T at preset flow rates of 0.8 to 2.8 l/min using velocity encoding of both 1.0 and 2.0 m/s. Flow rates and velocities were measured at predefined levels in the portal vasculature and within the stent graft. Accuracy of 4D flow CMR was assessed through linear regression with reference measurements obtained by flow sensors and two-dimensional (2D) phase contrast (PC) CMR. Intra- and interobserver agreement were assessed through Bland-Altman analyses. RESULTS At a velocity encoding of 2.0 m/s, 4D flow CMR-derived flow rates and velocities showed an excellent correlation with preset flow rates and 2D PC CMR-derived flow velocities at all vascular levels and within the stent graft (all r ≥ 0.958, p ≤ 0.003). At a velocity encoding of 1.0 m/s, aliasing artifacts were present within the stent graft at flow rates ≥ 2.0 l/min. 4D flow CMR-derived measurements revealed high intra- and interobserver agreement. CONCLUSIONS The in vitro accuracy and precision of 4D flow CMR is unaffected by the presence of TIPS stent grafts, suggesting that 4D flow CMR may be used to monitor TIPS patency in patients with liver cirrhosis.
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Affiliation(s)
- Christoph Riedel
- Department of Diagnostic and Interventional Radiology and Nuclear Medicine, University Medical Center Hamburg-Eppendorf, Martinistrasse 52, 20246, Hamburg, Germany.
| | - Inka Ristow
- Department of Diagnostic and Interventional Radiology and Nuclear Medicine, University Medical Center Hamburg-Eppendorf, Martinistrasse 52, 20246, Hamburg, Germany
| | - Alexander Lenz
- Department of Diagnostic and Interventional Radiology and Nuclear Medicine, University Medical Center Hamburg-Eppendorf, Martinistrasse 52, 20246, Hamburg, Germany
| | - Bjoern P Schoennagel
- Department of Diagnostic and Interventional Radiology and Nuclear Medicine, University Medical Center Hamburg-Eppendorf, Martinistrasse 52, 20246, Hamburg, Germany
| | - Marko Hoffmann
- Institute of Multiphase Flows, Hamburg University of Technology, Hamburg, Germany
| | - Felix Piecha
- I. Department of Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Gerhard Adam
- Department of Diagnostic and Interventional Radiology and Nuclear Medicine, University Medical Center Hamburg-Eppendorf, Martinistrasse 52, 20246, Hamburg, Germany
| | - Scott B Reeder
- Department of Radiology, University of Wisconsin-Madison, Madison, WI, USA
- Department of Medical Physics, University of Wisconsin-Madison, Madison, WI, USA
- Department of Biomedical Engineering, University of Wisconsin-Madison, Madison, WI, USA
- Department of Medicine, University of Wisconsin-Madison, Madison, WI, USA
- Department of Emergency Medicine, University of Wisconsin-Madison, Madison, WI, USA
| | - Peter Bannas
- Department of Diagnostic and Interventional Radiology and Nuclear Medicine, University Medical Center Hamburg-Eppendorf, Martinistrasse 52, 20246, Hamburg, Germany
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16
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Queck A, Schwierz L, Gu W, Ferstl PG, Jansen C, Uschner FE, Praktiknjo M, Chang J, Brol MJ, Schepis F, Merli M, Strassburg CP, Lehmann J, Meyer C, Trebicka J. Targeted decrease of portal hepatic pressure gradient improves ascites control after TIPS. Hepatology 2023; 77:466-475. [PMID: 35869810 DOI: 10.1002/hep.32676] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/02/2022] [Revised: 06/13/2022] [Accepted: 07/05/2022] [Indexed: 02/01/2023]
Abstract
BACKGROUND Ascites is a definitive sign of decompensated liver cirrhosis driven by portal hypertension. Although transjugular intrahepatic portosystemic shunt insertion (TIPS) is indicated for therapy of recurrent and refractory ascites, there is no evidence-based recommendation for a specific target of portal hepatic pressure gradient (PPG) decrease. METHODS In this single-center, retrospective trial, we investigated the decrease of PPG in 341 patients undergoing TIPS insertion for therapy of refractory or recurrent ascites until 2015. During each procedure, portal and inferior vena cava pressures were invasively measured and correlated with patients' outcome and ascites progression over time, according to the prespecified Noninvasive Evaluation Program for TIPS and Follow-Up Network protocol (NCT03628807). RESULTS Patients without ascites at 6 weeks after TIPS had significantly greater PPG reduction immediately after TIPS, compared to the patients with refractory ascites (median reduction 65% vs. 55% of pre-TIPS PPG; p = 0.001). Survival was significantly better if ascites was controlled, compared to patients with need for paracentesis 6 weeks after TIPS (median survival: 185 vs. 41 weeks; HR 2.0 [1.3-2.9]; p < 0.001). Therefore, higher PPG reduction by TIPS ( p = 0.005) and lower PPG after TIPS ( p = 0.02) correlated with resolution of severe ascites 6 weeks after TIPS. Multivariable analyses demonstrated that higher Child-Pugh score before TIPS (OR 1.3 [1.0-1.7]; p = 0.03) and lower serum sodium levels (OR 0.9 [0.9-1.0]; p = 0.004) were independently associated with ascites persistence 6 weeks after TIPS, whereas PPG reduction (OR 0.98 [0.97-1.00]; p = 0.02) was associated with resolution of ascites 6 weeks after TIPS. CONCLUSION Extent of PPG reduction and/or lowering of target PPG immediately after TIPS placement is associated with improved ascites control in the short term and with survival in the long term. A structured follow-up visit for patients should assess persistence of ascites at 6 weeks after TIPS.
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Affiliation(s)
- Alexander Queck
- Department of Internal Medicine 1 , University Hospital Frankfurt, Johann Wolfgang Goethe-University , Frankfurt am Main , Germany
| | - Louise Schwierz
- Department of Internal Medicine I , University Hospital Bonn , Bonn , Germany
| | - Wenyi Gu
- Department of Internal Medicine 1 , University Hospital Frankfurt, Johann Wolfgang Goethe-University , Frankfurt am Main , Germany.,Department of Internal Medicine B , University of Münster , Münster , Germany
| | - Philip G Ferstl
- Department of Internal Medicine 1 , University Hospital Frankfurt, Johann Wolfgang Goethe-University , Frankfurt am Main , Germany
| | - Christian Jansen
- Department of Internal Medicine I , University Hospital Bonn , Bonn , Germany
| | - Frank E Uschner
- Department of Internal Medicine 1 , University Hospital Frankfurt, Johann Wolfgang Goethe-University , Frankfurt am Main , Germany.,Department of Internal Medicine B , University of Münster , Münster , Germany
| | - Michael Praktiknjo
- Department of Internal Medicine I , University Hospital Bonn , Bonn , Germany.,Department of Internal Medicine B , University of Münster , Münster , Germany
| | - Johannes Chang
- Department of Internal Medicine I , University Hospital Bonn , Bonn , Germany
| | - Maximilian J Brol
- Department of Internal Medicine 1 , University Hospital Frankfurt, Johann Wolfgang Goethe-University , Frankfurt am Main , Germany.,Department of Internal Medicine B , University of Münster , Münster , Germany
| | - Filippo Schepis
- Division of Gastroenterology , Azienda Ospedaliero-Universitaria di Modena and University of Modena and Reggio Emilia , Modena , Italy
| | - Manuela Merli
- Gastroenterology, Department of Translational and Precision Medicine , Sapienza University of Rome , Rome , Italy
| | | | - Jennifer Lehmann
- Department of Internal Medicine I , University Hospital Bonn , Bonn , Germany
| | - Carsten Meyer
- Department of Radiology , University Hospital, University Bonn , Bonn , Germany
| | - Jonel Trebicka
- Department of Internal Medicine 1 , University Hospital Frankfurt, Johann Wolfgang Goethe-University , Frankfurt am Main , Germany.,Department of Internal Medicine B , University of Münster , Münster , Germany.,European Foundation for the Study of Chronic Liver Failure , Barcelona , Spain
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17
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Lv Y, Fan D, Han G. Transjugular intrahepatic portosystemic shunt for portal hypertension: 30 years experience from China. Liver Int 2023; 43:18-33. [PMID: 35593016 DOI: 10.1111/liv.15313] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/29/2021] [Revised: 04/05/2022] [Accepted: 05/15/2022] [Indexed: 01/04/2023]
Abstract
Liver diseases are a major cause of illness and death worldwide. In China, liver diseases, primarily viral hepatitis, affect approximately 300 million people, thus having a major impact on the global burden of liver diseases. Portal hypertension is the most severe complication of chronic liver diseases, including ascites, hepatic encephalopathy and bleeding from gastroesophageal varices. Transjugular intrahepatic portosystemic shunt (TIPS) represents a very effective treatment of these complications. Since its introduction 30 years ago in China, the use of TIPS has evolved and has played an increasingly important role in the management of the complications of portal hypertension. This review will focus on the history, current application and management of complications of TIPS in China.
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Affiliation(s)
- Yong Lv
- Department of Liver Diseases and Digestive Interventional Radiology, National Clinical Research Center for Digestive Diseases and Xijing Hospital of Digestive Diseases, Fourth Military Medical University, China.,Military Medical Innovation Center, Fourth Military Medical University, China
| | - Daiming Fan
- State Key Laboratory of Cancer Biology, National Clinical Research Center for Digestive Diseases and Xijing Hospital of Digestive Diseases, Fourth Military Medical University, China
| | - Guohong Han
- Department of Liver Diseases and Interventional Radiology, Digestive Diseases Hospital, Xi'an International Medical Center Hospital, Northwest University, China
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18
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Dhaliwal A, Merhzad H, Karkhanis S, Tripathi D. Covered transjugular intrahepatic portosystemic stent-shunt vs large volume paracentesis in patients with cirrhosis: A real-world propensity score-matched study. World J Clin Cases 2022; 10:11313-11324. [PMID: 36387790 PMCID: PMC9649539 DOI: 10.12998/wjcc.v10.i31.11313] [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: 05/14/2022] [Revised: 07/05/2022] [Accepted: 09/20/2022] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND Refractory ascites has a 1-year survival rate of 50%. In selected patients, treatment options include liver transplantation (LT) or transjugular intrahepatic portosystemic stent shunt (TIPSS). AIM To assess the outcomes of patients who underwent a TIPSS compared to large volume paracentesis (LVP). METHODS Retrospective study of patients who underwent a covered TIPSS or LVP for refractory or recurrent ascites over 7 years. Primary outcome was transplant-free survival (TFS). Further analysis was done with propensity score matching (PSM). RESULTS There were 150 patients [TIPSS group (n = 75), LVP group (n = 75)]. Seven patients in the TIPSS group underwent LT vs 22 patients in the LVP group. Overall median follow up, 20 (0.47-179.53) mo. In the whole cohort, there was no difference in TFS [hazard ratio (HR): 0.80, 95% confidence interval (CI): 0.54-1.21]; but lower de novo hepatic encephalopathy with LVP (HR: 95%CI: 0.20-0.96). These findings were confirmed following PSM analysis. On multivariate analysis albumin and hepatocellular carcinoma at baseline were associated with TFS. CONCLUSION Covered TIPSS results in similar TFS compared to LVP in cirrhotic patients with advanced liver failure. Liver transplant assessment should be considered in all potential candidates for TIPSS. Further controlled studies are recommended to select appropriate patients for TIPSS.
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Affiliation(s)
- Amritpal Dhaliwal
- Department of Hepatology, Queen Elizabeth Hospital Birmingham, Birmingham B15 2TT, United Kingdom
- National Institute of Health and Care Research, Biomedical Research Centre Birmingham, University of Birmingham, Birmingham B15 2WB, United Kingdom
| | - Homoyoon Merhzad
- Department of Radiology, Queen Elizabeth Hospital Birmingham, Birmingham B15 2TT, United Kingdom
| | - Salil Karkhanis
- Department of Radiology, Queen Elizabeth Hospital Birmingham, Birmingham B15 2TT, United Kingdom
| | - Dhiraj Tripathi
- Department of Hepatology, Queen Elizabeth Hospital Birmingham, Birmingham B15 2TT, United Kingdom
- National Institute of Health and Care Research, Biomedical Research Centre Birmingham, University of Birmingham, Birmingham B15 2WB, United Kingdom
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19
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Bettinger D, Thimme R, Schultheiß M. Implantation of transjugular intrahepatic portosystemic shunt (TIPS): indication and patient selection. Curr Opin Gastroenterol 2022; 38:221-229. [PMID: 35471813 DOI: 10.1097/mog.0000000000000831] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
Abstract
PURPOSE OF REVIEW This review summarizes indications and contraindications for implantation of transjugular intrahepatic portosystemic shunt (TIPS). Further, patient selection strategies are discussed. RECENT FINDINGS TIPS implantation is a highly effective treatment for portal hypertension. Main indications are ascites and variceal bleeding in patients with liver cirrhosis. There is growing evidence that early TIPS implantation after variceal bleeding is associated with an improved survival (preemptive TIPS).Preliminary data also suggest that an analogous concept of early TIPS implantation may be beneficial for patients with ascites. Further, well-selected patients with acute or chronic nonmalignant portal vein thrombosis can be effectively treated with TIPS implantation. In contrast, there is generally no recommendation for TIPS implantation in patients with hepatic veno-occlusive disease, noncirrhotic portal hypertension or prior before surgery to avoid complications of portal hypertension. Apart from evidence-based patient selection, the newly developed FIPS score can be an objective component in decision-making. SUMMARY Consideration of well-established indications and contraindications for TIPS implantation as well as concise patient selection criteria are essential for an optimal outcome after TIPS implantation.
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Affiliation(s)
- Dominik Bettinger
- Department of Medicine II, Medical Center University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
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20
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Stockhoff L, Muellner-Bucsics T, Markova AA, Schultalbers M, Keimburg SA, Tergast TL, Hinrichs JB, Simon N, Gerbel S, Manns MP, Mandorfer M, Cornberg M, Meyer BC, Wedemeyer H, Reiberger T, Maasoumy B. Low Serum Cholinesterase Identifies Patients With Worse Outcome and Increased Mortality After TIPS. Hepatol Commun 2022; 6:621-632. [PMID: 34585537 PMCID: PMC8870033 DOI: 10.1002/hep4.1829] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/28/2021] [Revised: 07/29/2021] [Accepted: 08/30/2021] [Indexed: 12/14/2022] Open
Abstract
Transjugular intrahepatic portosystemic shunt (TIPS) is an effective treatment for portal hypertension-related complications. However, careful selection of patients is crucial. The aim of this study was to evaluate the prognostic value of serum cholinesterase (CHE) for outcomes and mortality after TIPS insertion. In this multicenter study, 389 consecutive patients with cirrhosis receiving a TIPS at Hannover Medical School, University Hospital Essen, or Medical University of Vienna were included. The Hannover cohort (n = 200) was used to initially explore the role of CHE, whereas patients from Essen and Vienna served as a validation cohort (n = 189). Median age of the patients was 58 years and median Model for End-Stage Liver Disease (MELD) score was 12. Multivariable analysis identified MELD score (hazard ratio [HR]: 1.16; P < 0.001) and CHE (HR: 0.61; P = 0.008) as independent predictors for 1-year survival. Using the Youden Index, a CHE of 2.5 kU/L was identified as optimal threshold to predict post-TIPS survival in the Hannover cohort (P < 0.001), which was confirmed in the validation cohort (P = 0.010). CHE < 2.5 kU/L was significantly associated with development of acute-on-chronic liver failure (P < 0.001) and hepatic encephalopathy (P = 0.006). Of note, CHE was also significantly linked to mortality in the subgroup of patients with refractory ascites (P = 0.001) as well as in patients with high MELD scores (P = 0.012) and with high-risk FIPS scores (P = 0.004). After propensity score matching, mortality was similar in patients with ascites and CHE < 2.5 kU/L if treated by TIPS or by paracentesis. Contrarily, in patients with CHE ≥ 2.5 kU/L survival was significantly improved by TIPS as compared to treatment with paracentesis (P < 0.001). Conclusion: CHE is significantly associated with mortality and complications after TIPS insertion. Therefore, we suggest that CHE should be evaluated as an additional parameter for selecting patients for TIPS implantation.
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Affiliation(s)
- Lena Stockhoff
- Department of Gastroenterology, Hepatology and EndocrinologyHannover Medical SchoolHannoverGermany
| | - Theresa Muellner-Bucsics
- Division of Gastroenterology and HepatologyDepartment of Internal Medicine IIIMedical University of ViennaViennaAustria.,Vienna Hepatic Hemodynamic LaboratoryMedical University of ViennaViennaAustria
| | - Antoaneta A Markova
- Department of Gastroenterology and HepatologyUniversity Hospital EssenEssenGermany
| | - Marie Schultalbers
- Department of Gastroenterology, Hepatology and EndocrinologyHannover Medical SchoolHannoverGermany
| | - Simone A Keimburg
- Department of Gastroenterology and HepatologyUniversity Hospital EssenEssenGermany
| | - Tammo L Tergast
- Department of Gastroenterology, Hepatology and EndocrinologyHannover Medical SchoolHannoverGermany
| | - Jan B Hinrichs
- Institute for Diagnostic and Interventional RadiologyHannover Medical SchoolHannoverGermany
| | - Nicolas Simon
- Center for Information Management (ZIMt)Hannover Medical SchoolHannoverGermany
| | - Svetlana Gerbel
- Center for Information Management (ZIMt)Hannover Medical SchoolHannoverGermany
| | - Michael P Manns
- Department of Gastroenterology, Hepatology and EndocrinologyHannover Medical SchoolHannoverGermany
| | - Mattias Mandorfer
- Division of Gastroenterology and HepatologyDepartment of Internal Medicine IIIMedical University of ViennaViennaAustria.,Vienna Hepatic Hemodynamic LaboratoryMedical University of ViennaViennaAustria
| | - Markus Cornberg
- Department of Gastroenterology, Hepatology and EndocrinologyHannover Medical SchoolHannoverGermany
| | - Bernhard C Meyer
- Institute for Diagnostic and Interventional RadiologyHannover Medical SchoolHannoverGermany
| | - Heiner Wedemeyer
- Department of Gastroenterology, Hepatology and EndocrinologyHannover Medical SchoolHannoverGermany.,Department of Gastroenterology and HepatologyUniversity Hospital EssenEssenGermany
| | - Thomas Reiberger
- Division of Gastroenterology and HepatologyDepartment of Internal Medicine IIIMedical University of ViennaViennaAustria.,Vienna Hepatic Hemodynamic LaboratoryMedical University of ViennaViennaAustria
| | - Benjamin Maasoumy
- Department of Gastroenterology, Hepatology and EndocrinologyHannover Medical SchoolHannoverGermany
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21
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Storni F, Stirnimann J, Banz V, De Gottardi A, Stirnimann G. Treatment of refractory ascites with an automated low flow ascites pump in patients awaiting liver transplantation. JOURNAL OF LIVER TRANSPLANTATION 2021. [DOI: 10.1016/j.liver.2021.100037] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
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22
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Lee HL, Lee SW. The role of transjugular intrahepatic portosystemic shunt in patients with portal hypertension: advantages and pitfalls. Clin Mol Hepatol 2021; 28:121-134. [PMID: 34571587 PMCID: PMC9013617 DOI: 10.3350/cmh.2021.0239] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/03/2021] [Accepted: 09/25/2021] [Indexed: 12/31/2022] Open
Abstract
Transjugular intrahepatic portosystemic shunt (TIPS) is an effective interventional procedure to relieve portal hypertension, which is a main mechanism for the development of complications of liver cirrhosis (LC), such as variceal hemorrhage, ascites, and hepatorenal syndrome. However, the high incidence of adverse events after TIPS implementation limits its application in clinical practice. Esophageal variceal hemorrhage is one of the major indications for TIPS. Recently, preemptively performed TIPS has been recommended, as several studies have shown that TIPS significantly reduced mortality as well as rebleeding or failure to control bleeding in patients who are at high risk of treatment failure for bleeding control with endoscopic variceal ligation and vasoactive drugs. Meanwhile, recurrent ascites is another indication for TIPS with a proven survival benefit. TIPS may also be considered as an effective treatment for other LC complications, usually as an alternative therapy. Although there are concerns about the development of hepatic encephalopathy and hepatic dysfunction after TIPS implementation, careful patient selection using prognostic scores can lead to excellent outcomes. Assessments of cardiac and renal function prior to TIPS may also be considered to improve patient prognosis.
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Affiliation(s)
- Hae Lim Lee
- Department of Internal Medicine, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea.,The Catholic Liver Research Center, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Sung Won Lee
- Department of Internal Medicine, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea.,The Catholic Liver Research Center, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
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23
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Yeoh SW, Kok HK. Transjugular intrahepatic portosystemic shunts in portal vein thrombosis: A review. J Dig Dis 2021; 22:506-519. [PMID: 34323378 DOI: 10.1111/1751-2980.13035] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/17/2021] [Revised: 07/16/2021] [Accepted: 07/26/2021] [Indexed: 12/11/2022]
Abstract
The presence of portal vein thrombosis (PVT) has previously been considered a contraindication to the insertion of transjugular intrahepatic portosystemic shunts (TIPSS). However, patients with PVT may have portal hypertension complications and may thus benefit from TIPSS to reduce portal venous pressure. There is an increasing body of literature that discusses the techniques and outcomes of TIPSS in PVT. This review summarizes the techniques, indications and outcomes of TIPSS in PVT in published case reports, case series and comparative trials, especially regarding the reduction in portal hypertensive complications such as variceal bleeding. A comprehensive literature search was conducted using MEDLINE and PubMed databases. Manuscripts published in English between 1 January 1990 and 1 March 2021 were used. Abstracts were screened and data from potentially relevant articles analyzed. TIPSS in PVT has been reported with high levels of technical success, short-term portal vein recanalization and long-term PV patency and TIPSS patency outcomes. Several comparative studies, including randomized controlled trials, have shown favorable outcomes of TIPSS compared with non-TIPSS treatment of PVT complications. Outcomes of TIPSS with PVT appear similar to those in TIPSS without PVT. However, TIPSS may be more technically difficult in the presence of PVT, and such procedures should be performed in expert high-volume centers to mitigate the risk of procedural complications. The presence of PVT should no longer be considered a contraindication to TIPSS. TIPSS for PVT has been acknowledged as a therapeutic strategy in recent international guidelines, although further studies are needed before recommendations can be strengthened. KEY POINTS: Portal vein thrombosis (PVT) is no longer a contraindication to the insertion of transjugular intrahepatic portosystemic shunts (TIPSS) TIPSS often leads to the spontaneous dissolution of PVT, but can be combined with mechanical or pharmacological thrombectomy TIPSS reduces portal hypertensive complications of PVT, such as variceal bleeding, and can also facilitate liver transplantation where PVT may otherwise interfere with vascular anastomoses Studies have shown favorable long-term outcomes of TIPSS compared with TIPSS without PVT; as well as compared with non-TIPSS treatment of PVT complications TIPSS in PVT should be performed in high-volume specialist centers due to technical difficulties.
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Affiliation(s)
- Sern Wei Yeoh
- Department of Gastroenterology, Northern Health, Melbourne, Victoria, Australia.,School of Medical Education, University of Melbourne, Melbourne, Victoria, Australia
| | - Hong Kuan Kok
- Department of Radiology, Northern Health, Melbourne, Victoria, Australia.,School of Medicine, Deakin University, Melbourne, Victoria, Australia
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24
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Bakhtiar M, Forde KA, Nadolski GJ, Soulen MC, Weinberg EM. Radiologically Placed Peritoneovenous Shunt is an Acceptable Treatment Alternative for Refractory Ascites Due to End-Stage Liver Disease. J Vasc Interv Radiol 2021; 32:1606-1614. [PMID: 34416366 DOI: 10.1016/j.jvir.2021.08.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2020] [Revised: 08/03/2021] [Accepted: 08/09/2021] [Indexed: 11/15/2022] Open
Abstract
PURPOSE To compare patients treated with large-volume paracentesis (LVP), transjugular intrahepatic portosystemic shunt (TIPS), and peritoneovenous shunt (PVS) for ascites. MATERIALS AND METHODS A retrospective study of 192 patients treated with LVP (94), TIPS (75), or PVS (23) was performed. Records were reviewed for patient characteristics and outcomes. The patients' age differed (LVP, 59.5 years; TIPS, 58.8 years; and PVS, 65.6 years; P = .003). Nonalcoholic steatohepatitis was the most common etiology in the PVS cohort (11/23, 47%), and hepatitis C in the TIPS (27/75, 36%), and LVP cohorts (43/94, 46%) (P = .032). The model for end-stage liver disease score was significantly different (LVP, 14; TIPS, 13; and PVS, 8; P = .035). Hepatocellular carcinoma was higher in the PVS cohort (6/23 patients, 25%) than in the TIPS (4/75, 5%), and LVP (12/94, 12%) cohorts (P = .03). RESULTS Emergency department visits and hospital readmissions were the highest in the LVP cohort (40%, ≥2 readmissions, P < .001). Patients required fewer LVPs after TIPS (1.5 to 0.14, P < .001) or PVS (2.1 to 0.5, P = .019). In an unadjusted Cox model, patients in the TIPS cohort were found to have a 58% reduction in the risk of death compared with patients in the LVP cohort (P = .003). Transplant-free survival (PVS, 44 days; TIPS, 155 days; and LVP, 213 days) differed (log rank = 0.001). CONCLUSIONS The survival in the PVS and TIPS cohorts was similar, with less healthcare utilization than the LVP cohort. PVS is a satisfactory alternative to LVP.
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Affiliation(s)
- Mina Bakhtiar
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Kimberly A Forde
- Division of Gastroenterology and Hepatology, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania.
| | - Gregory J Nadolski
- Department of Radiology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Michael C Soulen
- Department of Radiology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Ethan M Weinberg
- Division of Gastroenterology and Hepatology, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
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Rajesh S, Philips CA, Betgeri SS, George T, Ahamed R, Mohanan M, Augustine P. Transjugular intrahepatic portosystemic shunt (TIPS) placement at index portal hypertensive decompensation (anticipant TIPS) in cirrhosis and the role of early intervention in variceal bleeding and ascites. Indian J Gastroenterol 2021; 40:361-372. [PMID: 34324168 DOI: 10.1007/s12664-021-01179-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/05/2020] [Accepted: 04/01/2021] [Indexed: 02/04/2023]
Abstract
BACKGROUND Transjugular intrahepatic portosystemic shunt (TIPS) placement improves survival in patients with refractory/recurrent acute variceal bleeding (RAVB) and refractory ascites/hydrothorax. Recently, early TIPS was shown to reduce rebleeding and improve survival compared to the conventional TIPS. We aimed to study outcomes in patients with cirrhosis undergoing TIPS at first significant portal hypertensive (PHT) decompensation (termed anticipant TIPS) compared to those undergoing TIPS for recurrent or persistent PHT complications (conventional) and compared the former to matched controls on standard medical management (SMT). METHODS We retrospectively analyzed the clinical, biochemical, and liver disease severity parameters and survival at baseline and post-intervention in cirrhosis patients at two major hepatobiliary intervention centers undergoing anticipant (n = 27) or conventional TIPS (n = 30) and compared the former group to matched historical controls on SMT (n = 35). RESULTS Baseline parameters were comparable between both the groups, including the Child-Pugh class and model for end-stage liver disease (MELD) scores. Length of stay in the intensive care unit, post-procedure admission rates, and sepsis events were higher among patients undergoing conventional TIPS (p < 0.05). Post-TIPS, at 1 year, overall and sub-grouped survivals were better in patients undergoing anticipant TIPS. On further sub-group analysis, based on the PHT events and stratified based on Child-Pugh and MELD scores, a higher proportion of patients survived after anticipant TIPS at 1 year. Compared to SMT, patients undergoing anticipant TIPS had significantly lesser hospitalizations, recurrence of varices, and ascites at 1 year, reducing hospital visits and financial burden. CONCLUSIONS Anticipant TIPS at the first significant PHT event could improve liver-related events and survival compared to standard medical management and conventional TIPS, respectively.
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Affiliation(s)
- Sasidharan Rajesh
- Interventional Radiology, Ernakulam Medical Center, Kochi 682 028, India
| | - Cyriac Abby Philips
- The Liver Unit and Monarch Liver Lab, Ernakulam Medical Center, Kochi 682 028, India.
- Philip Augustine Associates, Symphony, AMRA-15, Automobile Road, Palarivattom, Kochi, 682 025, India.
| | | | - Tom George
- Interventional Radiology, Ernakulam Medical Center, Kochi 682 028, India
| | - Rizwan Ahamed
- Gastroenterology and Advanced G.I. Endoscopy, Ernakulam Medical Center, Kochi 682 028, India
| | - Meera Mohanan
- Department of Anaesthesia and Critical Care, Ernakulam Medical Center, Kochi 682 028, India
| | - Philip Augustine
- Gastroenterology and Advanced G.I. Endoscopy, Ernakulam Medical Center, Kochi 682 028, India
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Stockhoff L, Schneider H, Tergast TL, Cornberg M, Maasoumy B. Freiburg index of post-TIPS survival (FIPS) a valid prognostic score in patients with cirrhosis but also an advisor against TIPS? J Hepatol 2021; 75:487-489. [PMID: 33716088 DOI: 10.1016/j.jhep.2021.02.031] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/15/2021] [Revised: 02/25/2021] [Accepted: 02/28/2021] [Indexed: 02/09/2023]
Affiliation(s)
- Lena Stockhoff
- Department of Gastroenterology, Hepatology and Endocrinology, Hannover Medical School, Carl-Neuberg-Str.1, 30625 Hannover, Germany
| | - Hannah Schneider
- Department of Gastroenterology, Hepatology and Endocrinology, Hannover Medical School, Carl-Neuberg-Str.1, 30625 Hannover, Germany
| | - Tammo Lambert Tergast
- Department of Gastroenterology, Hepatology and Endocrinology, Hannover Medical School, Carl-Neuberg-Str.1, 30625 Hannover, Germany
| | - Markus Cornberg
- Department of Gastroenterology, Hepatology and Endocrinology, Hannover Medical School, Carl-Neuberg-Str.1, 30625 Hannover, Germany
| | - Benjamin Maasoumy
- Department of Gastroenterology, Hepatology and Endocrinology, Hannover Medical School, Carl-Neuberg-Str.1, 30625 Hannover, Germany.
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Cardiovascular magnetic resonance demonstrates structural cardiac changes following transjugular intrahepatic portosystemic shunt. Sci Rep 2021; 11:12719. [PMID: 34135410 PMCID: PMC8209000 DOI: 10.1038/s41598-021-92064-8] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2020] [Accepted: 04/23/2021] [Indexed: 11/10/2022] Open
Abstract
Transjugular intrahepatic portosystemic shunt (TIPS) reduces portal hypertension in patients with liver cirrhosis. The exact cardiac consequences of subsequent increase of central blood volume are unknown. Cardiovascular magnetic resonance (CMR) imaging is the method of choice for quantifying cardiac volumes and ventricular function. The aim of this study was to investigate effects of TIPS on the heart using CMR, laboratory, and imaging cardiac biomarkers. 34 consecutive patients with liver cirrhosis were evaluated for TIPS. Comprehensive CMR with native T1 mapping, transthoracic echocardiography, and laboratory biomarkers were assessed before and after TIPS insertion. Follow-up (FU) CMR was obtained in 16 patients (47%) 207 (170–245) days after TIPS. From baseline (BL) to FU, a significant increase of all indexed cardiac chamber volumes was observed (all P < 0.05). Left ventricular (LV) end-diastolic mass index increased significantly from 45 (38–51) to 65 (51–73) g/m2 (P = < 0.01). Biventricular systolic function, NT-proBNP, high-sensitive troponin T, and native T1 time did not differ significantly from BL to FU. No patient experienced cardiac decompensation following TIPS. In conclusion, in patients without clinically significant prior heart disease, increased cardiac preload after TIPS resulted in increased volumes of all cardiac chambers and eccentric LV hypertrophy, without leading to cardiac impairment during follow-up in this selected patient population.
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Bettinger D, Sturm L, Pfaff L, Hahn F, Kloeckner R, Volkwein L, Praktiknjo M, Lv Y, Han G, Huber JP, Boettler T, Reincke M, Klinger C, Caca K, Heinzow H, Seifert LL, Weiss KH, Rupp C, Piecha F, Kluwe J, Zipprich A, Luxenburger H, Neumann-Haefelin C, Schmidt A, Jansen C, Meyer C, Uschner FE, Brol MJ, Trebicka J, Rössle M, Thimme R, Schultheiss M. Refining prediction of survival after TIPS with the novel Freiburg index of post-TIPS survival. J Hepatol 2021; 74:1362-1372. [PMID: 33508376 DOI: 10.1016/j.jhep.2021.01.023] [Citation(s) in RCA: 95] [Impact Index Per Article: 23.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/30/2020] [Revised: 01/12/2021] [Accepted: 01/12/2021] [Indexed: 02/08/2023]
Abstract
BACKGROUND & AIMS Transjugular intrahepatic portosystemic shunt (TIPS) implantation is an effective and safe treatment for complications of portal hypertension. Survival prediction is important in these patients as they constitute a high-risk population. Therefore, the aim of our study was to develop an alternative prognostic model for accurate survival prediction after planned TIPS implantation. METHODS A total of 1,871 patients with de novo TIPS implantation for ascites or secondary prophylaxis of variceal bleeding were recruited retrospectively. The study cohort was divided into a training set (80% of study patients; n = 1,496) and a validation set (20% of study patients; n = 375). Further, patients with early (preemptive) TIPS implantation due to variceal bleeding were included as another validation cohort (n = 290). Medical data and overall survival (OS) were assessed. A Cox regression model was used to create an alternative prediction model, which includes significant prognostic factors. RESULTS Age, bilirubin, albumin and creatinine were the most important prognostic factors. These parameters were included in a new score named the Freiburg index of post-TIPS survival (FIPS). The FIPS score was able to identify high-risk patients with a significantly reduced median survival of 5.0 (3.1-6.9) months after TIPS implantation in the training set. These results were confirmed in the validation set (median survival of 3.1 [0.9-5.3] months). The FIPS score showed better prognostic discrimination compared to the Child-Pugh, MELD, MELD-Na score and the bilirubin-platelet model. However, the FIPS score showed insufficient prognostic discrimination in patients with early TIPS implantation. CONCLUSIONS The FIPS score is superior to established scoring systems for the identification of high-risk patients with a worse prognosis following elective TIPS implantation. LAY SUMMARY Implantation of a transjugular intrahepatic portosystemic shunt (TIPS) is a safe and effective treatment for patients with cirrhosis and clinically significant portal hypertension. However, risk stratification is a major challenge in these patients as currently available scoring systems have major drawbacks. Age, bilirubin, albumin and creatinine were included in a new risk score which was named the Freiburg index of post-TIPS survival (FIPS). The FIPS score can identify patients at high risk and may guide clinical decision making.
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Affiliation(s)
- Dominik Bettinger
- Department of Medicine II, Medical Center University of Freiburg, Faculty of Medicine, University of Freiburg, Hugstetter Str. 55, 79106 Freiburg, Germany; Berta-Ottenstein Programme, Faculty of Medicine, University of Freiburg, Germany.
| | - Lukas Sturm
- Department of Medicine II, Medical Center University of Freiburg, Faculty of Medicine, University of Freiburg, Hugstetter Str. 55, 79106 Freiburg, Germany; Berta-Ottenstein Programme, Faculty of Medicine, University of Freiburg, Germany
| | - Lena Pfaff
- Department of Medicine II, Medical Center University of Freiburg, Faculty of Medicine, University of Freiburg, Hugstetter Str. 55, 79106 Freiburg, Germany
| | - Felix Hahn
- Department of Diagnostic and Interventional Radiology, University Medical Center of the Johannes Gutenberg University Mainz, Germany
| | - Roman Kloeckner
- Department of Diagnostic and Interventional Radiology, University Medical Center of the Johannes Gutenberg University Mainz, Germany
| | - Lara Volkwein
- Department of Medicine II, Medical Center University of Freiburg, Faculty of Medicine, University of Freiburg, Hugstetter Str. 55, 79106 Freiburg, Germany
| | | | - Yong Lv
- Department of Liver Diseases and Digestive Interventional Radiology, National Clinical Research Centre for Digestive Diseases and Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an, China
| | - Guohong Han
- Department of Liver Diseases and Digestive Interventional Radiology, National Clinical Research Centre for Digestive Diseases and Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an, China; Department of Liver Diseases and Digestive Interventional Radiology, Digestive Diseases Hospital, Xi'an International Medical Center Hospital of Northwestern University, Xi'an, China
| | - Jan Patrick Huber
- Department of Medicine II, Medical Center University of Freiburg, Faculty of Medicine, University of Freiburg, Hugstetter Str. 55, 79106 Freiburg, Germany
| | - Tobias Boettler
- Department of Medicine II, Medical Center University of Freiburg, Faculty of Medicine, University of Freiburg, Hugstetter Str. 55, 79106 Freiburg, Germany; Berta-Ottenstein Programme, Faculty of Medicine, University of Freiburg, Germany
| | - Marlene Reincke
- Department of Medicine II, Medical Center University of Freiburg, Faculty of Medicine, University of Freiburg, Hugstetter Str. 55, 79106 Freiburg, Germany
| | - Christoph Klinger
- Department of Gastroenterology, Hepatology and Oncology, Hospital of Ludwigsburg, Germany
| | - Karel Caca
- Department of Gastroenterology, Hepatology and Oncology, Hospital of Ludwigsburg, Germany
| | - Hauke Heinzow
- Department of Gastroenterology and Hepatology, University Hospital Münster, Germany
| | - Leon Louis Seifert
- Department of Gastroenterology and Hepatology, University Hospital Münster, Germany
| | - Karl Heinz Weiss
- Department of Internal Medicine IV, University Hospital Heidelberg, Heidelberg, Germany; Krankenhaus Salem der evang, Stadtmission Heidelberg, Heidelberg, Germany
| | - Christian Rupp
- Department of Internal Medicine IV, University Hospital Heidelberg, Heidelberg, Germany
| | - Felix Piecha
- I. Department of Medicine University Medical Center Hamburg-Eppendorf Hamburg, Germany
| | - Johannes Kluwe
- I. Department of Medicine University Medical Center Hamburg-Eppendorf Hamburg, Germany
| | - Alexander Zipprich
- Department of Internal Medicine I, Martin-Luther-University Halle-Wittenberg, Halle, Germany
| | - Hendrik Luxenburger
- Department of Medicine II, Medical Center University of Freiburg, Faculty of Medicine, University of Freiburg, Hugstetter Str. 55, 79106 Freiburg, Germany; IMM-PACT, Medizinische Fakultät, Albert-Ludwigs-Universität Freiburg, Germany
| | - Christoph Neumann-Haefelin
- Department of Medicine II, Medical Center University of Freiburg, Faculty of Medicine, University of Freiburg, Hugstetter Str. 55, 79106 Freiburg, Germany
| | - Arthur Schmidt
- Department of Medicine II, Medical Center University of Freiburg, Faculty of Medicine, University of Freiburg, Hugstetter Str. 55, 79106 Freiburg, Germany
| | - Christian Jansen
- Department of Internal Medicine I, University of Bonn, Bonn, Germany
| | - Carsten Meyer
- Department of Radiology, University Hospital Bonn, Bonn, Germany
| | - Frank E Uschner
- Department of Internal Medicine 1, University Hospital Frankfurt, Frankfurt, Germany
| | - Maximilian J Brol
- Department of Internal Medicine I, University of Bonn, Bonn, Germany
| | - Jonel Trebicka
- Department of Internal Medicine 1, University Hospital Frankfurt, Frankfurt, Germany; European Foundation for the Study of Chronic Liver Failure, Barcelona, Spain
| | - Martin Rössle
- Department of Medicine II, Medical Center University of Freiburg, Faculty of Medicine, University of Freiburg, Hugstetter Str. 55, 79106 Freiburg, Germany; PraxisZentrum für Gastroenterologie und Endokrinologie, Freiburg, Germany
| | - Robert Thimme
- Department of Medicine II, Medical Center University of Freiburg, Faculty of Medicine, University of Freiburg, Hugstetter Str. 55, 79106 Freiburg, Germany
| | - Michael Schultheiss
- Department of Medicine II, Medical Center University of Freiburg, Faculty of Medicine, University of Freiburg, Hugstetter Str. 55, 79106 Freiburg, Germany
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Praktiknjo M, Abu-Omar J, Chang J, Thomas D, Jansen C, Kupczyk P, Schepis F, Garcia-Pagan JC, Merli M, Meyer C, Strassburg CP, Pieper CC, Trebicka J. Controlled underdilation using novel VIATORR® controlled expansion stents improves survival after transjugular intrahepatic portosystemic shunt implantation. JHEP Rep 2021; 3:100264. [PMID: 34013182 PMCID: PMC8113713 DOI: 10.1016/j.jhepr.2021.100264] [Citation(s) in RCA: 45] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/12/2021] [Revised: 02/11/2021] [Accepted: 02/17/2021] [Indexed: 12/11/2022] Open
Abstract
Background & Aims Smaller 8-mm diameter transjugular intrahepatic portosystemic shunts (TIPS) appear to be more beneficial than larger 10-mm TIPS stent-grafts, but lack the ability for secondary dilation in cases of clinical ineffectiveness. Underdilated VIATORR® TIPS stent grafts (VTS) expand passively, whereas novel VIATORR Controlled Expansion (VCX) stent grafts do not. This study evaluated the impact on survival of underdilated VCX compared with VTS in patients with decompensated cirrhosis. Methods This was a prospective case-control study including patients with cirrhosis receiving TIPS using 10-mm VCX underdilated to 8 mm. Patients with cirrhosis receiving 10-mm VTS underdilated to 8 mm were matched for age, sex, indication for TIPS, and liver function. Results A total of 114 patients (47 VCX, 47 VTS, and 20 fully dilated VCX/VTS) were included. After TIPS implantation, underdilated VCX diameter was 8.0 (7.8-9.2) mm at a median time of 359 (87-450) days, compared with VTS at 9.9 (9.7-10.0) mm (p <0.001). The portosystemic pressure gradient immediately after TIPS procedure and after 7 days did not change significantly in VCX [mean 9.4 (± 0.8) vs. 10.4 (± 0.7) mmHg, p = 0.115). Hospital readmission rates for hepatic encephalopathy were 23% (n = 11) vs 51% (n = 24) for VCX and VTS (p <0.001), respectively. Patients with VCX had significantly lower rates of large-volume paracentesis (n = 5 [11%] vs. n = 10 [21%], p = 0.017) and heart failure (n = 1 [2%] vs. n = 7 [15%], p = 0.015). One-year mortality for underdilated VCX and VTS was 15% (n = 7) and 30% (n = 14) and, for fully dilated VCX/VTS, was 45% (n = 9) (log-rank p = 0.008), respectively. Conclusions This study demonstrated that VCX stent grafts underdilated to 8 mm do not passively expand to nominal diameter and suggests reduced hospital readmissions because of hepatic encephalopathy, uncontrolled ascites, and heart failure, and improved 1-year survival compared with underdilated VTS. Lay summary Transjugular intrahepatic portosystemic shunt (TIPS) improves survival in selected patients with liver cirrhosis and acute variceal bleeding or refractory ascites. Smaller 8-mm diameter TIPS stent grafts appear to improve patient outcome compared with larger 10-mm diameter stent grafts. Novel VIATORR® Controlled Expansion (VCX) stent grafts facilitate safe and stable underdilation to 8 mm of large 10-mm diameter stent grafts with improved patient outcome (survival, hepatic encephalopathy, ascites and heart failure) compared with legacy VIATORR TIPS stent graft (VTS). Thus, the use of underdilated VCX could preserve heart function. Clinical Trials Registration The study is registered at Clinicaltrials.govNCT03628807.
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Key Words
- Acute decompensation
- Ascites
- CT, computed tomography
- Cirrhosis
- HE, hepatic encephalopathy
- HF, heart failure
- Hepatic encephalopathy
- LV, left ventricular
- LV-GLS, LV global longitudinal strain
- LVP, large-volume paracentesis
- Liver
- MELD, model of end-stage liver disease
- NEPTUN, Non-invasive Evaluation Program for TIPS and follow Up Network
- PSPG, portosystemic pressure gradient
- PTFE, polytetrafluorethylene
- RA, recurrent/refractory ascites
- RAAS, renin-angiotensin-aldosterone system
- SPSS, spontaneous portosystemic shunt
- TIPS
- TIPS, transjugular intrahepatic portosystemic shunt
- TTE, transthoracic echocardiography
- Transjugular intrahepatic portosystemic shunt
- VB, variceal bleeding
- VCX, VIATORR controlled expansion
- VTS, VIATORR TIPS stent
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Affiliation(s)
- Michael Praktiknjo
- Department of Internal Medicine I, University Hospital Bonn, Bonn, Germany
| | - Jasmin Abu-Omar
- Department of Internal Medicine I, University Hospital Bonn, Bonn, Germany
| | - Johannes Chang
- Department of Internal Medicine I, University Hospital Bonn, Bonn, Germany
| | - Daniel Thomas
- Department of Radiology, University Hospital Bonn, Bonn, Germany
| | - Christian Jansen
- Department of Internal Medicine I, University Hospital Bonn, Bonn, Germany
| | - Patrick Kupczyk
- Department of Radiology, University Hospital Bonn, Bonn, Germany
| | - Filippo Schepis
- Division of Gastroenterology, Azienda Ospedaliero-Universitaria di Modena and University of Modena and Reggio Emilia, Modena, Italy
| | - Juan Carlos Garcia-Pagan
- Hepatic Hemodynamic Laboratory, Liver Unit, Hospital Clinic, IDIBAPS and CIBERehd, Barcelona, Spain
| | - Manuela Merli
- Department of Translational and Precision Medicine, Sapienza University of Rome, Rome, Italy
| | - Carsten Meyer
- Department of Radiology, University Hospital Bonn, Bonn, Germany
| | | | - Claus C Pieper
- Department of Radiology, University Hospital Bonn, Bonn, Germany
| | - Jonel Trebicka
- Department of Internal Medicine I, University of Frankfurt, Frankfurt, Germany.,European Foundation for the Study of Chronic Liver Failure - EF CLIF, Barcelona, Spain
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Alcohol Recidivism Following Transjugular Intrahepatic Portosystemic Shunt Placement: Frequency and Predictive Factors. Cardiovasc Intervent Radiol 2021; 44:758-765. [PMID: 33415418 DOI: 10.1007/s00270-020-02754-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/06/2020] [Accepted: 12/22/2020] [Indexed: 12/17/2022]
Abstract
PURPOSE To determine the frequency and predictive factors for alcohol recidivism following transjugular intrahepatic portosystemic shunts (TIPS) placed in patients with alcoholic cirrhosis. METHODS One hundred ninety-nine patients who had a TIPS placed at a single institution for different indications in the setting of alcoholic cirrhosis were reviewed. Length of sobriety prior to TIPS placement and maintained sobriety at 1, 3 and 6-12 months after TIPS placement were recorded. Smoking history, substance abuse and psychiatric comorbidities were also recorded as was ascitic response to TIPS at 1, 3 and 6-12 months. RESULTS At 1 month 11/199 (5.5%) patients had experienced a relapse while, 20/199 (10.1%) had at 3 months, and 44/199 (22.1%) had at 12 months. There was no difference in ascitic response in those who did and did not relapse at 1 month (p = 0.57), 3 months (p = 1.00) or 1 year (p = 0.44). The mean time of sobriety at the time of TIPS placement for those who relapsed by 12 months was significantly less than those who did not relapse (5.11 (1.10-7.90) months vs 18.32 (8.63-48.12) months, p < 0.001). Concurrent psychiatric comorbidity (p < 0.001), substance abuse (p < 0.001), age less than 40 (p = 0.004) and smoking history at the time of procedure (p < 0.001) were also associated with alcohol relapse. CONCLUSION Recidivism is a frequent issue for patients following TIPS placement; those who have concurrent psychiatric comorbidity, substance abuse, smoking history are younger than 40 and shorter sobriety duration prior to TIPS may be at increased risk.
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Riedel C, Lenz A, Fischer L, Li J, Piecha F, Kluwe J, Adam G, Bannas P. Abdominal Applications of 4D Flow MRI. ROFO-FORTSCHR RONTG 2020; 193:388-398. [PMID: 33264806 DOI: 10.1055/a-1271-7405] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
BACKGROUND Four-dimensional flow magnetic resonance imaging (4D flow MRI) provides volumetric and time-resolved visualization and quantification of blood flow. This review presents an overview of possible applications of 4D flow MRI for non-invasive assessment of abdominal hemodynamics. METHOD This review is based on the authors' experience and the current literature. A PubMed database literature research was performed in December 2019 focusing on abdominal applications of 4D flow MRI. We illustrated the review with exemplary figures and movies of clinical cases from our institution. RESULTS AND CONCLUSION 4D flow MRI offers the possibility of comprehensive assessment of abdominal blood flows in different vascular territories and organ systems. Results of recent studies indicate that 4D flow MRI improves understanding of altered hemodynamics in patients with abdominal disease and may be useful for monitoring therapeutic response. Future studies with larger cohorts aiming to integrate 4D flow MRI in the clinical routine setting are needed. KEY POINTS · 4D flow MRI enables comprehensive visualization of the complex abdominal vasculature. · 4D flow MRI enables quantification of abdominal blood flow velocities and flow rates. · 4D flow MRI may enable deeper understanding of altered hemodynamics in abdominal disease. · Further validation studies are needed prior to broad distribution of abdominal 4D flow MRI. CITATION FORMAT · Riedel C, Lenz A, Fischer L et al. Abdominal Applications of 4D Flow MRI. Fortschr Röntgenstr 2021; 193: 388 - 398.
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Affiliation(s)
- Christoph Riedel
- Department of Diagnostic and Interventional Radiology and Nuclear Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Alexander Lenz
- Department of Diagnostic and Interventional Radiology and Nuclear Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Lutz Fischer
- Department of Visceral Transplantation, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Jun Li
- Department of Visceral Transplantation, University Medical Center Hamburg-Eppendorf, Hamburg, Germany.,Department of General, Visceral and Thoracic Surgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Feilix Piecha
- I. Department of Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Johannes Kluwe
- I. Department of Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Gerhard Adam
- Department of Diagnostic and Interventional Radiology and Nuclear Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Peter Bannas
- Department of Diagnostic and Interventional Radiology and Nuclear Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
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Rajesh S, George T, Philips CA, Ahamed R, Kumbar S, Mohan N, Mohanan M, Augustine P. Transjugular intrahepatic portosystemic shunt in cirrhosis: An exhaustive critical update. World J Gastroenterol 2020; 26:5561-5596. [PMID: 33088154 PMCID: PMC7545393 DOI: 10.3748/wjg.v26.i37.5561] [Citation(s) in RCA: 68] [Impact Index Per Article: 13.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/05/2020] [Revised: 07/31/2020] [Accepted: 08/29/2020] [Indexed: 02/06/2023] Open
Abstract
More than five decades after it was originally conceptualized as rescue therapy for patients with intractable variceal bleeding, the transjugular intrahepatic portosystemic shunt (TIPS) procedure continues to remain a focus of intense clinical and biomedical research. By the impressive reduction in portal pressure achieved by this intervention, coupled with its minimally invasive nature, TIPS has gained increasing acceptance in the treatment of complications of portal hypertension. The early years of TIPS were plagued by poor long-term patency of the stents and increased incidence of hepatic encephalopathy. Moreover, the diversion of portal flow after placement of TIPS often resulted in derangement of hepatic functions, which was occasionally severe. While the incidence of shunt dysfunction has markedly reduced with the advent of covered stents, hepatic encephalopathy and instances of early liver failure continue to remain a significant issue after TIPS. It has emerged over the years that careful selection of patients and diligent post-procedural care is of paramount importance to optimize the outcome after TIPS. The past twenty years have seen multiple studies redefining the role of TIPS in the management of variceal bleeding and refractory ascites while exploring its application in other complications of cirrhosis like hepatic hydrothorax, portal hypertensive gastropathy, ectopic varices, hepatorenal and hepatopulmonary syndromes, non-tumoral portal vein thrombosis and chylous ascites. It has also been utilized to good effect before extrahepatic abdominal surgery to reduce perioperative morbidity and mortality. The current article aims to review the updated literature on the status of TIPS in the management of patients with liver cirrhosis.
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Affiliation(s)
- Sasidharan Rajesh
- Division of Hepatobiliary Interventional Radiology, Cochin Gastroenterology Group, Ernakulam Medical Center, Kochi 682028, Kerala, India
| | - Tom George
- Division of Hepatobiliary Interventional Radiology, Cochin Gastroenterology Group, Ernakulam Medical Center, Kochi 682028, Kerala, India
| | - Cyriac Abby Philips
- The Liver Unit and Monarch Liver Lab, Cochin Gastroenterology Group, Ernakulam Medical Center, Kochi 682028, Kerala, India
| | - Rizwan Ahamed
- Gastroenterology and Advanced GI Endoscopy, Cochin Gastroenterology Group, Ernakulam Medical Center, Kochi 682028, Kerala, India
| | - Sandeep Kumbar
- Gastroenterology and Advanced GI Endoscopy, Cochin Gastroenterology Group, Ernakulam Medical Center, Kochi 682028, Kerala, India
| | - Narain Mohan
- The Liver Unit and Monarch Liver Lab, Cochin Gastroenterology Group, Ernakulam Medical Center, Kochi 682028, Kerala, India
| | - Meera Mohanan
- Anesthesia and Critical Care, Cochin Gastroenterology Group, Ernakulam Medical Center, Kochi 682028, Kerala, India
| | - Philip Augustine
- Gastroenterology and Advanced GI Endoscopy, Cochin Gastroenterology Group, Ernakulam Medical Center, Kochi 682028, Kerala, India
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Schultheiß M, Bettinger D, Thimme R, Rössle M. 30 Jahre transjugulärer intrahepatischer portosystemischer Shunt (TIPS) – Rückblick und Perspektive. ZEITSCHRIFT FUR GASTROENTEROLOGIE 2020; 58:877-889. [PMID: 32947633 DOI: 10.1055/a-1217-7866] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
ZusammenfassungDer transjuguläre intrahepatische portosystemische Shunt (TIPS) wird seit 30 Jahren in der Therapie der portalen Hypertonie erfolgreich eingesetzt. In nationalen und internationalen Leitlinien ist die Indikation zur TIPS-Anlage bei Varizenblutung und refraktärem Aszites wissenschaftlich gut belegt und klar definiert. Bei seltenen Indikationen wie dem hepatorenalen Syndrom, der Pfortaderthrombose oder dem neoadjuvanten Einsatz fehlt derzeit noch eine eindeutige Studienlage. Eine wichtige Kontraindikation und klinisch bedeutendste Komplikation nach TIPS ist die hepatische Enzephalopathie (HE). Es wird versucht, die Post-TIPS HE mit technischen Weiterentwicklungen der Stents zu reduzieren.
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Affiliation(s)
- Michael Schultheiß
- Department Innere Medizin, Klinik für Innere Medizin II, Gastroenterologie, Hepatologie, Endokrinologie und Infektiologie, Universitätsklinikum Freiburg, Medizinische Fakultät, Albert-Ludwigs-Universität Freiburg
| | - Dominik Bettinger
- Department Innere Medizin, Klinik für Innere Medizin II, Gastroenterologie, Hepatologie, Endokrinologie und Infektiologie, Universitätsklinikum Freiburg, Medizinische Fakultät, Albert-Ludwigs-Universität Freiburg
| | - Robert Thimme
- Department Innere Medizin, Klinik für Innere Medizin II, Gastroenterologie, Hepatologie, Endokrinologie und Infektiologie, Universitätsklinikum Freiburg, Medizinische Fakultät, Albert-Ludwigs-Universität Freiburg
| | - Martin Rössle
- Department Innere Medizin, Klinik für Innere Medizin II, Gastroenterologie, Hepatologie, Endokrinologie und Infektiologie, Universitätsklinikum Freiburg, Medizinische Fakultät, Albert-Ludwigs-Universität Freiburg
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Santos S, Dantas E, Veloso Gomes F, Luz JH, Vasco Costa N, Bilhim T, Calinas F, Martins A, Coimbra É. Retrospective Study of Transjugular Intrahepatic Portosystemic Shunt Placement for Cirrhotic Portal Hypertension. GE-PORTUGUESE JOURNAL OF GASTROENTEROLOGY 2020; 28:5-12. [PMID: 33564700 DOI: 10.1159/000507894] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/24/2019] [Accepted: 04/13/2020] [Indexed: 12/14/2022]
Abstract
Background and Aims Transjugular intrahepatic portosystemic shunt (TIPS) is used for decompressing clinically significant portal hypertension. The aims of this study were to evaluate clinical outcomes and adverse events associated with this procedure. Methods Retrospective single-center study including 78 patients submitted to TIPS placement between January 2015 and November 2018. Follow-up data were missing in 27 patients, and finally 51 patients were included in the study sample. Data collected from individual registries included demographics, comorbidities, laboratory results, complications, and clinical results according to the indication. Results Average pre-TIPS portosystemic pressure gradient decreased from 18.1 ± 5 to 6 ± 3 mm Hg after TIPS placement. Indications for TIPS were refractory ascites (63%, n = 49), recurrent or uncontrolled variceal bleeding (36%, n = 28), and Budd-Chiari syndrome (1.3%, n = 1). TIPS-related adverse events occurred in 29/51 (56.8%) patients, with hepatic encephalopathy (HE) in 21 (41%) patients, sepsis in 3, liver failure in 2, hemolytic anemia in 1, acute pulmonary edema in 1, and capsular perforation in 1 patient. Mean follow-up was 15.7 ± 15 months. First-month mortality was 11.7% (n = 6) (sepsis, n = 3; acute liver failure, n = 2; and recurrence of variceal bleeding, n = 1) and was significantly higher for patients with Child-Pugh >9 points (p = 0.01), model of end-stage liver disease (MELD) scores >19 (p = 0.02), and for patients with a history of HE before the procedure (p = 0.001). Older age (p = 0.006) and higher levels of creatinine (p = 0.008) were significantly higher in patients developing HE after TIPS. Ascites persisted in 21.2% (7/33 patients) and was more frequent in patients with lower baseline albumin levels (p = 0.003). Recurrent variceal bleeding occurred in 22% (n = 4/18 patients) and was more frequent in patients with lower baseline hemoglobin levels (p = 0.03). Conclusion TIPS is effective in up to 80% of patients presenting with variceal bleeding or refractory ascites. Careful patient selection based on age and HE history may reduce adverse events after TIPS.
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Affiliation(s)
- Sara Santos
- Gastroenterology and Hepatology Department, Centro Hospitalar Universitário de Lisboa Central (CHULC), Lisbon, Portugal
| | - Eduardo Dantas
- Gastroenterology and Hepatology Department, Centro Hospitalar de Setúbal, Setúbal, Portugal
| | - Filipe Veloso Gomes
- NOVA Medical School, Lisbon, Portugal.,Interventional Radiology Unit, Curry Cabral Hospital, Centro Hospitalar Universitário de Lisboa Central (CHULC), Lisbon, Portugal
| | - José Hugo Luz
- NOVA Medical School, Lisbon, Portugal.,Interventional Radiology Unit, Curry Cabral Hospital, Centro Hospitalar Universitário de Lisboa Central (CHULC), Lisbon, Portugal
| | - Nuno Vasco Costa
- NOVA Medical School, Lisbon, Portugal.,Interventional Radiology Unit, Curry Cabral Hospital, Centro Hospitalar Universitário de Lisboa Central (CHULC), Lisbon, Portugal
| | - Tiago Bilhim
- NOVA Medical School, Lisbon, Portugal.,Interventional Radiology Unit, Curry Cabral Hospital, Centro Hospitalar Universitário de Lisboa Central (CHULC), Lisbon, Portugal
| | - Filipe Calinas
- Gastroenterology and Hepatology Department, Centro Hospitalar Universitário de Lisboa Central (CHULC), Lisbon, Portugal
| | - Américo Martins
- Surgery Department, Curry Cabral Hospital, Centro Hospitalar Universitário de Lisboa Central (CHULC), Lisbon, Portugal
| | - Élia Coimbra
- Interventional Radiology Unit, Curry Cabral Hospital, Centro Hospitalar Universitário de Lisboa Central (CHULC), Lisbon, Portugal
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Sherman M. Editorial musings. JHEP Rep 2019; 1:iv-v. [PMID: 32039362 PMCID: PMC7001547 DOI: 10.1016/j.jhepr.2019.07.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/03/2019] [Revised: 05/27/2019] [Accepted: 06/25/2019] [Indexed: 11/06/2022] Open
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Kraglund F, Jepsen P, Amanavicius N, Aagaard NK. Long-term effects and complications of the transjugular intrahepatic portosystemic shunt: a single-centre experience. Scand J Gastroenterol 2019; 54:899-904. [PMID: 31203699 DOI: 10.1080/00365521.2019.1630675] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
Background and aims: Accurate estimates of the long-term risks of adverse outcomes after transjugular intrahepatic portosystemic shunt (TIPS) treatment are needed. The aim of this cohort study was to estimate the risks of stent dysfunction, variceal bleeding, refractory ascites, hepatic encephalopathy (HE), and death after TIPS treatment. Methods: We extracted data from electronic medical records of 104 consecutive TIPS patients. Gore® Viatorr® TIPS endoprostheses were used in all patients. We conducted competing risks analysis of the risk of stent dysfunction and variceal bleeding, and Kaplan-Meier estimation of overall survival. Results: The overall 1-year survival after TIPS insertion was 82% (95% confidence interval [CI]: 73-88%), and the 1-year risk of stent dysfunction was 15% (95% CI: 9-22%). In patients who had a TIPS for variceal bleeding, the 1-year risk of rebleeding was 23% (95% CI: 13-35%). In patients who had a TIPS for refractory ascites, the risk of having an unsuccessful ascites outcome 1 year after TIPS for refractory ascites was 35% (95% CI: 21-52%). Overall, the 1-year risk of overt HE was 38% (95% CI: 32-43%). The risk of experiencing any of the defined complications during the first year was 56% (95% CI: 45-66%). Conclusion: TIPS is an effective treatment for variceal bleeding and refractory ascites in most cases, but more than half of the patients experience either death, stent dysfunction, recurrence of symptoms, or overt HE within the first year after the procedure.
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Affiliation(s)
- Frederik Kraglund
- Department of Hepatology and Gastroenterology, Aarhus University Hospital , Aarhus , Denmark
| | - Peter Jepsen
- Department of Hepatology and Gastroenterology, Aarhus University Hospital , Aarhus , Denmark.,Department of Clinical Epidemiology, Aarhus University Hospital , Aarhus , Denmark
| | | | - Niels Kristian Aagaard
- Department of Hepatology and Gastroenterology, Aarhus University Hospital , Aarhus , Denmark
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