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Li W, Liu M, Guan S, Ding P, Yuan J, Zhao Y, Li P, Ma F, Xue H. Comparison of outcomes for transjugular intrahepatic portosystemic shunt creation: Viatorr versus Fluency versus a bare stent/Fluency stent combination. CVIR Endovasc 2024; 7:76. [PMID: 39422844 PMCID: PMC11489360 DOI: 10.1186/s42155-024-00489-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2024] [Accepted: 10/12/2024] [Indexed: 10/19/2024] Open
Abstract
PURPOSE To compare clinical outcomes of transjugular intrahepatic portosystemic shunt (TIPS) created with the single covered-uncovered stent (Viatorr TIPS Endoprosthesis) versus covered stent (Fluency) versus a combination of covered and uncovered stent. MATERIALS AND METHODS From May 2016 and July 2019, a total of 180 liver cirrhosis patients with recurrent variceal bleeding underwent TIPS creation with single covered-uncovered stent (n = 63) or covered stent (n = 41) or a covered and uncovered stent combination (n = 76). Shunt dysfunction, rebleeding, overt hepatic encephalopathy and mortality was estimated using the Kaplan-Meier method and compared with the log-rank test. RESULTS The difference of baseline characteristics among these three groups were not significant. The included patients had a median age of 51 years (IQR 43-61), and 101 (56.1%) were men. The 1-year and 2-year shunt dysfunction rates were 1.6% and 3.2% in the single covered-uncovered stent group, 7.3% and 7.3% in the covered stent group and 5.3% and 6.6% in the combination group, respectively. There was no significant difference among groups [Hazard Ratio (HR) (95%CI): 1 vs 2.29 (0.38 - 13.72) vs 2.10 (0.41 - 10.83); P = 0.913]. No significant differences in the incidence of all-cause rebleeding were observed between the groups at 1 year (Viatorr vs Fluency vs combination: 11.1% vs 17.1% vs 10.5%) as well as 2 years (15.9% vs 17.1% vs 11.8%), with the HR (95%CI) being 1 vs 1.27 (0.5-3.21) vs 0.74 (0.30-1.82); P = 0.475). The 1-year and 2-year incidence of overt hepatic encephalopathy were 30.2% and 30.2% in the single covered-uncovered stent group, 22.0% and 22.0% in the covered stent group and 25.0% and 25.0% in the combination group, respectively. However, there was no significant difference among these three groups (P = 0.402). In addition, there was no significant difference in the 1-year and 2-year mortality (6.3% and 7.9% vs. 4.9% and 9.8% vs. 6.6% and 9.2%, P = 0.606). CONCLUSION No significant difference was observed among different stent groups. Fluency covered stent and the generic bare stent/Fluency covered stent was not an unreasonable alternative to the Viatorr stent for TIPS creation.
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Affiliation(s)
- Weizhi Li
- Department of Gastroenterology, First Affiliated Hospital of Xi'an Jiaotong University, 277 West Yanta Road, Xi'an, Shaanxi, 710061, China
| | - Mengying Liu
- Department of Gastroenterology, First Affiliated Hospital of Xi'an Jiaotong University, 277 West Yanta Road, Xi'an, Shaanxi, 710061, China
| | - Sheng Guan
- Department of Vascular Surgery, People's Hospital of Xinjiang Uygur Autonomous Region, Urumqi, China
| | - Pengxu Ding
- Department of Intervention, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Jia Yuan
- Department of Gastroenterology, Second Affiliated Hospital of Xi'an Jiaotong University, Xi'an, China
| | - Yan Zhao
- Department of Gastroenterology, First Affiliated Hospital of Xi'an Jiaotong University, 277 West Yanta Road, Xi'an, Shaanxi, 710061, China
| | - Peijie Li
- Department of Gastroenterology, First Affiliated Hospital of Xi'an Jiaotong University, 277 West Yanta Road, Xi'an, Shaanxi, 710061, China
| | - Fuquan Ma
- Department of Gastroenterology, First Affiliated Hospital of Xi'an Jiaotong University, 277 West Yanta Road, Xi'an, Shaanxi, 710061, China
| | - Hui Xue
- Department of Gastroenterology, First Affiliated Hospital of Xi'an Jiaotong University, 277 West Yanta Road, Xi'an, Shaanxi, 710061, China.
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Bai Y, Liu J, Wu W, Zhou B, Sun B, Yao W, Liu X, Zhao H, Guo Y, Jiang X, Liang B, Yang L, Zheng C. Transjugular intrahepatic portosystemic shunt (TIPS) with variceal embolization reduces rebleeding risk for patients with portal pressure gradient over 12 mmHg: A long-term follow-up study. Eur J Radiol 2024; 181:111740. [PMID: 39288645 DOI: 10.1016/j.ejrad.2024.111740] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2024] [Revised: 08/22/2024] [Accepted: 09/14/2024] [Indexed: 09/19/2024]
Abstract
OBJECTIVE The consensus on whether Transjugular intrahepatic portosystemic shunt (TIPS) should be combined with variceal embolization in the treatment of portal hypertension-induced bleeding has not yet been reached. This study aimed to compare the difference in rebleeding incidence between TIPS and TIPS combined with variceal embolization and to analyze the optimal population for variceal embolization. METHODS Clinical data of 721 patients undergoing TIPS were retrospectively collected. Patients were divided into two groups: TIPS alone (n = 155) and TIPS with embolization (TIPS+E, n = 251). Kaplan-Meier (KM) curves were used to analyze prognostic differences between the two groups, and subgroup analysis was conducted based on post-TIPS portal pressure gradient (PPG) exceeding 12 mmHg. RESULTS After TIPS placement, the mean PPG significantly decreased for all patients. A total of 51 patients (12.6 %) experienced rebleeding, with 24 cases (15.9 %) in the TIPS group and 27 cases (10.6 %) in the TIPS+E group. There was no significant difference in cumulative rebleeding incidence between the TIPS+E and TIPS groups. In the subgroup with post-TIPS PPG greater than 12 mmHg, the cumulative rebleeding incidence was significantly lower in the TIPS+E group compared to the TIPS group (HR = 0.47, 95 %CI = 0.24-0.93, Log rank P = 0.026). No significant difference was found in patients with a post-TIPS PPG less than 12 mmHg. CONCLUSION For patients with post-TIPS PPG exceeding 12 mmHg, simultaneous variceal embolization with TIPS placement significantly reduces the risk of rebleeding.
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Affiliation(s)
- Yaowei Bai
- Department of Radiology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430022, China; Hubei Province Key Laboratory of Molecular Imaging, Wuhan 430022, China
| | - Jiacheng Liu
- Department of Radiology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430022, China; Hubei Province Key Laboratory of Molecular Imaging, Wuhan 430022, China
| | - Wenlong Wu
- Department of Radiology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430022, China; Hubei Province Key Laboratory of Molecular Imaging, Wuhan 430022, China
| | - Binqian Zhou
- Department of Ultrasound, The Central Hospital of Wuhan, Tong ji Medical College, Huazhong University of Science and Technology, Wuhan 430014, China
| | - Bo Sun
- Department of Radiology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430022, China; Hubei Province Key Laboratory of Molecular Imaging, Wuhan 430022, China
| | - Wei Yao
- Department of Radiology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430022, China; Hubei Province Key Laboratory of Molecular Imaging, Wuhan 430022, China
| | - Xiaoming Liu
- Department of Radiology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430022, China; Hubei Province Key Laboratory of Molecular Imaging, Wuhan 430022, China
| | - Hu Zhao
- Department of Anatomy, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430022, China
| | - Yusheng Guo
- Department of Radiology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430022, China; Hubei Province Key Laboratory of Molecular Imaging, Wuhan 430022, China
| | - Xin Jiang
- Hospital of Honghe State Affiliated to Kunming Medical University, Kunming 650500, China
| | - Bin Liang
- Department of Radiology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430022, China; Hubei Province Key Laboratory of Molecular Imaging, Wuhan 430022, China.
| | - Lian Yang
- Department of Radiology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430022, China; Hubei Province Key Laboratory of Molecular Imaging, Wuhan 430022, China.
| | - Chuansheng Zheng
- Department of Radiology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430022, China; Hubei Province Key Laboratory of Molecular Imaging, Wuhan 430022, China.
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Zhao L, Tie J, Wang G, Li Z, Xu J, Zhuge Y, Zhang F, Wu H, Wei B, Xue H, Li P, Wu W, Chen C, Wu Q, Xia Y, Sun X, Zhang C. Efficacy of TIPS plus extrahepatic collateral embolisation in real-world data: a validation study. BMJ Open Gastroenterol 2024; 11:e001310. [PMID: 38395452 PMCID: PMC10895241 DOI: 10.1136/bmjgast-2023-001310] [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: 11/21/2023] [Accepted: 01/23/2024] [Indexed: 02/25/2024] Open
Abstract
OBJECTIVES The efficacy of transjugular intrahepatic portosystemic shunt (TIPS) plus extrahepatic collateral embolisation (TIPS+E) in reducing rebleeding and hepatic encephalopathy (HE) post-TIPS was recently reported in a meta-analysis, but further validation is essential. This study aims to confirm the effectiveness of TIPS+E using real-world data. METHODS The multicentre retrospective cohort included 2077 patients with cirrhosis who underwent TIPS±E (TIPS: 631, TIPS+E: 1446) between January 2010 and December 2022. Regression and propensity score matching (PSM) were used to adjust for baseline characteristic differences. After PSM, clinical outcomes, including rebleeding, HE, survival and further decompensation (FDC), were analysed. Baseline data from all patients contributed to the construction of prognostic models. RESULTS After PSM, 1136 matched patients (TIPS+E: TIPS=568:568) were included. TIPS+E demonstrated a significant reduction in rebleeding (HR 0.77; 95% CI 0.59 to 0.99; p=0.04), HE (HR 0.82; 95% CI 0.68 to 0.99; p=0.04) and FDC (HR 0.85; 95% CI 0.73 to 0.99; p=0.04), comparing to TIPS. Significantly, TIPS+E also reduced rebleeding, HE and FDC in subgroup of using 8 mm diameter stents and embolising of gastric varices+spontaneous portosystemic shunts (GV+SPSS). However, there were no differences in overall or subgroup survival analysis. Additionally, the random forest models showed higher accuracy and AUROC comparing to other models. Controlling post-TIPS portal pressure gradient (pPPG) within 7 mm Hg CONCLUSION Our real-world data validation confirms the high efficacy of TIPS+E in reducing rebleeding and HE, particularly when using 8 mm diameter stents, embolising GV+SPSS and maintaining an optimal pPPG.
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Affiliation(s)
- Lianhui Zhao
- Gastroenterology, Shandong Provincial Hospital, Shandong University, Jinan, Shandong Province, People's Republic of China
- Gastroenterology, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, Shandong Province, People's Republic of China
| | - Jun Tie
- 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, Xian, Shaanxi, People's Republic of China
| | - Guangchuan Wang
- Gastroenterology, Shandong Provincial Hospital, Shandong University, Jinan, Shandong Province, People's Republic of China
- Gastroenterology, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, Shandong Province, People's Republic of China
- Department of Biostatistics, School of Public Health, Shandong University, Jinan, Shandong Province, People's Republic of China
| | - Zhengjie Li
- School of Automation, Qingdao University, Qingdao, Shandong Province, People's Republic of China
| | - Jiao Xu
- 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, Xian, Shaanxi, People's Republic of China
| | - Yuzheng Zhuge
- Gastroenterology, Nanjing Drum Tower Hospital, Affiliated Hospital of Medical School, Nanjing University, Nanjing, Jiangsun Province, People's Republic of China
| | - Feng Zhang
- Gastroenterology, Nanjing Drum Tower Hospital, Affiliated Hospital of Medical School, Nanjing University, Nanjing, Jiangsun Province, People's Republic of China
| | - Hao Wu
- Gastroenterology, West China Hospital, Sichuan University, Chengdu, Sichuan Province, People's Republic of China
| | - Bo Wei
- Gastroenterology, West China Hospital, Sichuan University, Chengdu, Sichuan Province, People's Republic of China
| | - Hui Xue
- Gastroenterology, First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, Shaanxi Province, China
| | - Peijie Li
- Gastroenterology, First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, Shaanxi Province, China
| | - Wei Wu
- Gastroenterology, First Affiliated Hospital of Wenzhou Medical University, Wenzhou, Zhejiang Province, People's Republic of China
| | - Chao Chen
- Gastroenterology, First Affiliated Hospital of Wenzhou Medical University, Wenzhou, Zhejiang Province, People's Republic of China
| | - Qiong Wu
- Gastroenterology, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, Shandong Province, People's Republic of China
| | - Yifu Xia
- Gastroenterology, Shandong Provincial Hospital, Shandong University, Jinan, Shandong Province, People's Republic of China
| | - Xiubin Sun
- Department of Biostatistics, School of Public Health, Shandong University, Jinan, Shandong Province, People's Republic of China
| | - Chunqing Zhang
- Gastroenterology, Shandong Provincial Hospital, Shandong University, Jinan, Shandong Province, People's Republic of China
- Gastroenterology, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, Shandong Province, People's Republic of China
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Abuelazm MT, Cheema HA, Jafar U, Awad AK, Atef M, Abdalshafy H, Alashwah M, Shahid A, Awan RU, Afifi AM, Jalal PK, Aziz H. Transjugular intrahepatic portosystemic shunt with or without variceal embolization to prevent variceal rebleeding: an updated meta-analysis. Expert Rev Gastroenterol Hepatol 2023; 17:741-751. [PMID: 37306478 DOI: 10.1080/17474124.2023.2223974] [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: 12/11/2022] [Accepted: 06/07/2023] [Indexed: 06/13/2023]
Abstract
BACKGROUND Transjugular intrahepatic portosystemic shunt (TIPS) is an established treatment for portal hypertension complications. Still, the role of adjuvant variceal embolization is a matter of debate. Thus, we aim to evaluate the efficacy and safety of TIPS with variceal embolization versus TIPS alone to prevent variceal rebleeding. RESEARCH DESIGN AND METHODS We used PubMed, CENTRAL, and OVID to search for all randomized controlled trials (RCTs) and comparative observational studies up to 17 June 20221117 June 2022. We pooled binary outcomes using risk ratios (RRs) presented with 95% confidence intervals (CIs) using RevMan 5.4. RESULTS We included 11 studies (two RCTs and nine observational studies) with 1024 patients. Pooled RR favored TIPS with embolization in preventing variceal rebleeding (RR 0.58, 95% CI: 0.44, 0.76); however, there was no difference between the two groups regarding shunt dysfunction (RR 0.92, 95% CI: 0.68, 1.23), encephalopathy (RR 0.88, 95% CI: 0.70, 1.11), and death (RR 0.97, 95% CI: 0.77, 1.22). CONCLUSIONS TIPS with embolization can be an effective strategy for preventing variceal rebleeding; however, our results should be interpreted cautiously as most data were observational and the technical quality of the embolization is questionable. Further RCTs are required using the proper techniques of embolization and comparing TIPS with embolization with other treatment modalities such as endoscopic ligation, and balloon-occluded retrograde transvenous obliteration.
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Affiliation(s)
| | - Huzaifa Ahmad Cheema
- Department of Radiology, King Edward Medical University, Lahore, Pakistan
- Department of Surgery, King Edward Medical University, Lahore, Pakistan
| | - Uzair Jafar
- Department of Surgery, King Edward Medical University, Lahore, Pakistan
| | - Ahmed K Awad
- Faculty of Medicine, Ain-Shams University, Cairo, Egypt
| | - Mostafa Atef
- Faculty of Medicine, Cairo University, Cairo, Egypt
| | | | | | - Abia Shahid
- Department of Surgery, King Edward Medical University, Lahore, Pakistan
| | - Rehmat Ullah Awan
- Department of Medicine, Ochsner Rush Medical Center, Meridian, MS, USA
| | - Ahmed M Afifi
- Department of Gastroenterology, Hepatology & Nutrition, University of Texas, Houston, TX, USA
| | - Prasun K Jalal
- Section of Gastroenterology and Hepatology, Department of Medicine, Baylor College of Medicine, Houston, TX, USA
| | - Hassan Aziz
- Division of Transplant and Hepatobiliary Surgery, University of Iowa Hospitals and Clinics, Iowa City, Iowa, USA
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Ma J, Luo J, Zhang W, Zhou Y, Zhang Z, Yang M, Zhuang Z, Ma L, Yu J, Zhou X, Yan Z. The influence of shunting left/right portal vein branch on post-TIPS hepatic encephalopathy: a study protocol for multicenter randomized blinded controlled trial. Trials 2023; 24:312. [PMID: 37149647 PMCID: PMC10164303 DOI: 10.1186/s13063-023-07326-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2021] [Accepted: 04/24/2023] [Indexed: 05/08/2023] Open
Abstract
INTRODUCTION Gastroesophageal varices (GOV) bleeding is a common and serious complication of advanced liver cirrhosis with a median survival of less than 2 years. Multiple guidelines have pointed out that transjugular intrahepatic portosystemic shunt (TIPS) is the rescue treatment of acute variceal hemorrhage (AVB) after failure of standard therapy and an effective second-line treatment for preventing patients with high risks from rebleeding of GOV. The safety and stability of TIPS have been greatly improved due to the improvements of related technologies and the emergence of various novel devices, but the incidence of hepatic encephalopathy (HE) after shunting (10-50%) hindered the widespread use of TIPS. The target portal vein branch might affect the incidence of HE after TIPS. The aim of this study is to compare the rate of HE in patients with hepatitis B virus (HBV) related cirrhosis receiving TIPS either the left or right branch of the portal vein with 8mm Viatorr stent for preventing rebleeding from GOV. METHODS AND ANALYSIS This study is a multicenter randomized controlled trial comparing the influence of shunting left or right portal vein branch on post-TIPS hepatic encephalopathy for preventing rebleeding from GOV in patients with HBV-related cirrhosis. A total of 130 patients will be recruited over a period of 24 months across 5 centers in China. Eligible patients will be stratified 1:1 to constructing either a left or right portal vein shunt with an 8-mm Viatorr stent. The primary objective was to compare the incidence of post-TIPS hepatic encephalopathy between the two groups. The secondary objectives were to compare the grade and duration of hepatic encephalopathy, the rate of shunt dysfunction, the rate of variceal rebleeding, the HE-free survival, the cumulative patency rate of the stent, and the overall survival at 12 months and 24 months between two groups. ETHICS AND DISSEMINATION This study was approved by the ethics committee of Zhongshan Hospital of Fudan University (No. B2018-292R) and was registered at ClinicalTrials.gov (NCT03825848). All participants give written informed consent. TRIAL REGISTRATION ClinicalTrials.gov NCT03825848. Registered on January 31, 2019 TRIAL STATUS: The first patient was recruited into our study on June 19, 2019. A total of 55 patients were recruited till May 27, 2021 (27 and 28 patients assigned to shunting the left (L Group) and right (R Group) branches of the portal vein, respectively).
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Affiliation(s)
- Jingqin Ma
- Department of Interventional Radiology, Zhongshan Hospital, Fudan University, Shanghai, China
- Shanghai Institution of Medical Imaging, Shanghai, China
- National Clinical Research Center for Interventional Medicine, Shanghai, China
| | - Jianjun Luo
- Department of Interventional Radiology, Zhongshan Hospital, Fudan University, Shanghai, China.
- Shanghai Institution of Medical Imaging, Shanghai, China.
- National Clinical Research Center for Interventional Medicine, Shanghai, China.
- Department of Center for Tumor Diagnosis and Therapy, Jinshan Hospital of Fudan University, Shanghai, China.
| | - Wen Zhang
- Department of Interventional Radiology, Zhongshan Hospital, Fudan University, Shanghai, China
- Shanghai Institution of Medical Imaging, Shanghai, China
- National Clinical Research Center for Interventional Medicine, Shanghai, China
| | - Yongjie Zhou
- Department of Interventional Radiology, Zhongshan Hospital, Fudan University, Shanghai, China
- Shanghai Institution of Medical Imaging, Shanghai, China
- National Clinical Research Center for Interventional Medicine, Shanghai, China
| | - Zihan Zhang
- Department of Interventional Radiology, Zhongshan Hospital, Fudan University, Shanghai, China
- Shanghai Institution of Medical Imaging, Shanghai, China
- National Clinical Research Center for Interventional Medicine, Shanghai, China
| | - Minjie Yang
- Department of Interventional Radiology, Zhongshan Hospital, Fudan University, Shanghai, China
- Shanghai Institution of Medical Imaging, Shanghai, China
- National Clinical Research Center for Interventional Medicine, Shanghai, China
| | - Zhiquan Zhuang
- Department of Interventional Radiology, Zhongshan Hospital, Fudan University, Shanghai, China
- Shanghai Institution of Medical Imaging, Shanghai, China
- National Clinical Research Center for Interventional Medicine, Shanghai, China
| | - Li Ma
- Department of Interventional Radiology, Zhongshan Hospital, Fudan University, Shanghai, China
- Shanghai Institution of Medical Imaging, Shanghai, China
- National Clinical Research Center for Interventional Medicine, Shanghai, China
| | - Jiaze Yu
- Department of Interventional Radiology, Zhongshan Hospital, Fudan University, Shanghai, China
- Shanghai Institution of Medical Imaging, Shanghai, China
- National Clinical Research Center for Interventional Medicine, Shanghai, China
| | - Xin Zhou
- Department of Interventional Radiology, Zhongshan Hospital, Fudan University, Shanghai, China
- Shanghai Institution of Medical Imaging, Shanghai, China
- National Clinical Research Center for Interventional Medicine, Shanghai, China
| | - Zhiping Yan
- Department of Interventional Radiology, Zhongshan Hospital, Fudan University, Shanghai, China
- Shanghai Institution of Medical Imaging, Shanghai, China
- National Clinical Research Center for Interventional Medicine, Shanghai, China
- Department of Center for Tumor Diagnosis and Therapy, Jinshan Hospital of Fudan University, Shanghai, China
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Right vs left portal branch puncture in TIPS creation with controlled expansion covered stent: comparison of hemodynamic and clinical outcomes. Eur Radiol 2023; 33:2647-2654. [PMID: 36454260 DOI: 10.1007/s00330-022-09280-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2022] [Revised: 11/03/2022] [Accepted: 11/04/2022] [Indexed: 12/03/2022]
Abstract
PURPOSE To retrospectively compare outcomes of TIPS performed by puncturing left portal vein (LPV) vs right portal vein (RPV) to access the portal system. MATERIALS AND METHODS One hundred ninety-three consecutive patients underwent TIPS with controlled expansion covered stent by using the LPV (37 patients) or the RPV (156 patients). Patients were followed until the last clinical evaluation, liver transplantation, or death. RESULTS Demographics and clinical characteristics of the two groups were comparable. The median follow-up was 9.6 months (range 0.1-50.6). Portosystemic pressure gradient (PSG) before TIPS 15.7 mmHg ± 4.7 in RPV group (RPVG) vs 15.4 mmHg ± 4.5 in LPV group (LPVG) (p = 0.725). After TIPS, PSG 6.3 mmHg ± 2.8 in RPVG vs 6.2 mmHg ± 2.2 (p = 0.839). In LPVG, the stent was dilated to 8-mm in 95% of patients vs 77% of RPVG (p = 0.015). Two (5.4%) and 22 (14%) patients underwent TIPS revision in LPVG and RPVG (p = 0.15). The incidence of overt HE was 13% in LPVG and 24% in RPVG (p = 0.177). Rebleeding occurred in 3 of 49 patients (6%) with variceal bleeding as an indication: 2/41 patients (4.9%) in RPVG vs 1/8 patients (12.5%) in LPVG (p = 0.417). Among 126 patients with refractory ascites 20 patients (15.9%) needed paracentesis 3 months after the procedure: 18/101 patients (17.8%) in RPVG vs 2/25 patients (8%) in LPVG (p = 0.231). Thirty-seven patients (19%) died: 32 (21%) in RPVG and 5 (14%) in LPVG (p = 0.337). CONCLUSION Compared with RPV puncture, in TIPS created through the LPV, the targeted PSG was reached with a smaller stent diameter. However, no significant difference in clinical outcomes was observed. KEY POINTS • A LPV approach for TIPS creation does not lead to better control of complications of portal hypertension as compared to a RPV approach.
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Jaber F, Beran A, Alsakarneh S, Ahmed K, Abdallah M, Elfert K, Almeqdadi M, Jaber M, Mohamed WT, Ahmed M, Al Momani L, Numan L, Bierman T, Helzberg JH, Ghoz H, Clarkston WK. Transjugular Intrahepatic Portosystemic Shunt With or Without Gastroesophageal Variceal Embolization for the Prevention of Variceal Rebleeding: A Systematic Review and Meta-Analysis. Gastroenterology Res 2023; 16:68-78. [PMID: 37187555 PMCID: PMC10181335 DOI: 10.14740/gr1618] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/27/2023] [Accepted: 04/14/2023] [Indexed: 05/17/2023] Open
Abstract
Background The role of variceal embolization (VE) during transjugular intrahepatic portosystemic shunt (TIPS) creation for preventing gastroesophageal variceal rebleeding remains controversial. Therefore, we performed a meta-analysis to compare the incidence of variceal rebleeding, shunt dysfunction, encephalopathy, and death between patients treated with TIPS alone and those treated with TIPS in combination with VE. Methods We performed a literature search using PubMed, EMBASE, Scopus, and Cochrane databases for all studies comparing the incidence of complications between TIPS alone and TIPS with VE. The primary outcome was variceal rebleeding. Secondary outcomes include shunt dysfunction, encephalopathy, and death. Subgroup analysis was performed based on the type of stent (covered vs. bare metal). The random-effects model was used to calculate the relative risk (RR) with the corresponding 95% confidence intervals (CIs) of outcome. A P value < 0.05 was considered statistically significant. Results Eleven studies with a total of 1,075 patients were included (597: TIPS alone and 478: TIPS plus VE). Compared to the TIPS alone, the TIPS with VE had a significantly lower incidence of variceal rebleeding (RR: 0.59, 95% CI: 0.43 - 0.81, P = 0.001). Subgroup analysis revealed similar results in covered stents (RR: 0.56, 95% CI: 0.36 - 0.86, P = 0.008) but there was no significant difference between the two groups in the subgroup analysis of bare stents and combined stents. There was no significant difference in the risk of encephalopathy (RR: 0.84, 95% CI: 0.66 - 1.06, P = 0.13), shunt dysfunction (RR: 0.88, 95% CI: 0.64 - 1.19, P = 0.40), and death (RR: 0.87, 95% CI: 0.65 - 1.17, P = 0.34). There were similarly no differences in these secondary outcomes between groups when stratified according to type of stent. Conclusions Adding VE to TIPS reduced the incidence of variceal rebleeding in patients with cirrhosis. However, the benefit was observed with covered stents only. Further large-scale randomized controlled trials are warranted to validate our findings.
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Affiliation(s)
- Fouad Jaber
- Department of Internal Medicine, University of Missouri Kansas City, Kansas City, MO, USA
- Corresponding Author: Fouad Jaber, Department of Internal Medicine, University of Missouri Kansas City, Kansas City, MO, USA.
| | - Azizullah Beran
- Department of Gastroenterology and Hepatology, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Saqr Alsakarneh
- Department of Internal Medicine, University of Missouri Kansas City, Kansas City, MO, USA
| | - Khalid Ahmed
- Department of Internal Medicine, The Wright Medical Center for Graduate Medical Education, Scranton, PA, USA
| | - Mohamed Abdallah
- Division of Gastroenterology and Hepatology, Department of Medicine, University of Minnesota, Minneapolis, MN, USA
| | - Khaled Elfert
- Department of Internal Medicine, SBH Health System, New York, NY, USA
| | - Mohammad Almeqdadi
- Department of Transplant Hepatobiliary Disease, Lahey Hospital and Medical Center, Burlington, MA, USA
| | - Mohammed Jaber
- Department of Medical Education, Al-Azhar University, Gaza, Palestine
| | - Wael T. Mohamed
- Department of Internal Medicine, University of Missouri Kansas City, Kansas City, MO, USA
| | - Mohamd Ahmed
- Department of Internal Medicine, University of Missouri Kansas City, Kansas City, MO, USA
| | - Laith Al Momani
- Department of Gastroenterology and Hepatology, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Laith Numan
- Department of Gastroenterology and Hepatology, Saint Louis University School of Medicine, Saint Louis, MO, USA
| | - Thomas Bierman
- Department of Gastroenterology and Hepatology, University of Missouri Kansas City, Kansas City, MO, USA
- Department of Gastroenterology and Hepatology, Saint Luke’s Hospital, Kansas City, MO, USA
| | - John H. Helzberg
- Department of Gastroenterology and Hepatology, University of Missouri Kansas City, Kansas City, MO, USA
- Department of Gastroenterology and Hepatology, Saint Luke’s Hospital, Kansas City, MO, USA
| | - Hassan Ghoz
- Department of Gastroenterology and Hepatology, University of Missouri Kansas City, Kansas City, MO, USA
| | - Wendell K. Clarkston
- Department of Gastroenterology and Hepatology, University of Missouri Kansas City, Kansas City, MO, USA
- Department of Gastroenterology and Hepatology, Saint Luke’s Hospital, Kansas City, MO, USA
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Giri S, Patel RK, Varghese J, Agarwal D, Tripathy T. Comparative outcome of transjugular intrahepatic portosystemic shunt with or without variceal obliteration: a systematic review and meta-analysis. Abdom Radiol (NY) 2023; 48:1429-1437. [PMID: 36821005 DOI: 10.1007/s00261-023-03843-y] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2022] [Revised: 01/27/2023] [Accepted: 01/30/2023] [Indexed: 02/24/2023]
Abstract
BACKGROUND Transjugular intrahepatic portosystemic shunt (TIPS) has been used for the secondary prevention of variceal bleeding. TIPS can be combined with variceal embolization (TIPS-VO), but its benefit remains controversial. The present systematic review and meta-analysis were conducted to compare the incidence of rebleeding, adverse events, and mortality among patients with TIPS alone and with TIPS-VO. METHODS A literature search from January 2000 to June 2022 was done for studies comparing the outcome of patients undergoing TIPS alone or TIPS-VO. A subgroup analysis was conducted for patients undergoing TIPS with covered stents. RESULTS A total of 11 studies with data from 1044 patients were included. The incidence of rebleeding was significantly higher in the TIPS alone group in both overall population OR 2.01 (1.42-2.83) and the subgroup (OR 1.92, 95% CI 1.21-3.04). There was no difference between the two groups concerning the risk of hepatic encephalopathy (OR 1.15, 95% CI 0.83-1.59), procedural adverse events (OR 0.86, 95% CI 0.54-1.39), shunt dysfunction (OR 1.20, 95% CI 0.82-1.75), overall mortality (OR 1.03, 95% CI 0.73-1.46), and mortality due to variceal rebleeding (OR 1.58, 95% CI 0.44-5.64). There was no significant heterogeneity or publication bias among the included studies. The certainty of evidence remains low for all the outcome expect for variceal rebleeding. CONCLUSION The present meta-analysis provides a moderate-quality evidence for the benefit of TIPS-VO in reducing the incidence of rebleeding. However, the decision for combining variceal embolization with TIPS should be made on a case-to-case basis.
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Affiliation(s)
- Suprabhat Giri
- Department of Gastroenterology, Nizam's Institute of Medical Sciences, Hyderabad, India
| | - Ranjan Kumar Patel
- Department of Radiodiagnosis, All India Institute of Medical Sciences, Sijua, Patrapada, Bhubaneswar, Odisha, 751019, India
| | - Jijo Varghese
- Department of Gastroenterology, KM Cherian Institute of Medical Sciences, Kallissery, India
| | - Dhiraj Agarwal
- Department of Gastroenterology, PACE Hospital, Hyderabad, India
| | - Taraprasad Tripathy
- Department of Radiodiagnosis, All India Institute of Medical Sciences, Sijua, Patrapada, Bhubaneswar, Odisha, 751019, India.
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9
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Trivedi S, Lam K, Ganesh A, Hasnain Y, Hassan W, Herren J, Gaba RC. Hepatic Encephalopathy after Transjugular Intrahepatic Portosystemic Shunt Creation. Semin Intervent Radiol 2023; 40:9-14. [PMID: 37152788 PMCID: PMC10159723 DOI: 10.1055/s-0043-1764282] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/09/2023]
Abstract
Transjugular intrahepatic portosystemic shunt (TIPS) creation is effective in treating the sequelae of decompensated liver cirrhosis-including medically refractory ascites and variceal bleeding-by decompressing the portal venous system through a manmade portosystemic conduit within the liver. However, the altered physiology in which splenomesenteric blood bypasses intrahepatic portal venous perfusion can precipitate varying degrees of hepatic encephalopathy (HE). While the majority of post-TIPS HE cases can be treated medically, some require escalated management strategies, including endovascular interventions to modify the indwelling TIPS and/or occlude competitive physiologic spontaneous portosystemic shunts. This review article details the epidemiology, risk factors, diagnosis, classification, and treatment of post-TIPS HE.
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Affiliation(s)
- Surbhi Trivedi
- Department of Radiology, University of Illinois at Chicago College of Medicine, Chicago, Illinois
- University of Illinois at Chicago College of Medicine, Chicago, Illinois
| | - Katie Lam
- University of Illinois at Chicago College of Medicine, Chicago, Illinois
| | - Ashwin Ganesh
- University of Illinois at Chicago College of Medicine, Chicago, Illinois
| | - Yasir Hasnain
- University of Illinois at Chicago College of Medicine, Chicago, Illinois
| | - Wassim Hassan
- University of Illinois at Chicago College of Medicine, Chicago, Illinois
| | - Josi Herren
- Department of Radiology, University of Illinois at Chicago College of Medicine, Chicago, Illinois
- University of Illinois at Chicago College of Medicine, Chicago, Illinois
| | - Ron C. Gaba
- Department of Radiology, University of Illinois at Chicago College of Medicine, Chicago, Illinois
- University of Illinois at Chicago College of Medicine, Chicago, Illinois
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10
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Lv Y, Chen H, Luo B, Bai W, Li K, Wang Z, Xia D, Guo W, Wang Q, Li X, Yuan J, Cai H, Xia J, Yin Z, Fan D, Han G. Transjugular intrahepatic portosystemic shunt with or without gastro-oesophageal variceal embolisation for the prevention of variceal rebleeding: a randomised controlled trial. Lancet Gastroenterol Hepatol 2022; 7:736-746. [PMID: 35588750 DOI: 10.1016/s2468-1253(22)00087-5] [Citation(s) in RCA: 30] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/30/2021] [Revised: 03/04/2022] [Accepted: 03/08/2022] [Indexed: 06/15/2023]
Abstract
BACKGROUND The role of variceal embolisation at the time of transjugular intrahepatic portosystemic shunt (TIPS) creation for the prevention of gastro-oesophageal variceal rebleeding remains controversial. This study aimed to evaluate whether adding variceal embolisation to TIPS placement could reduce the incidence of rebleeding after TIPS in patients with cirrhosis. METHODS We did an open-label, randomised controlled trial at one university hospital in China. Eligible patients were aged 18-75 years with cirrhosis and had variceal bleeding in the past 6 weeks, and they were randomly assigned (1:1) to receive TIPS (with a covered stent in both groups) plus variceal embolisation (TIPS plus embolisation group) or TIPS alone (TIPS group) to prevent variceal rebleeding. Randomisation was done using a web-based randomisation system using a Pocock and Simon's minimisation method, stratified by Child-Pugh class (A vs B vs C). Clinicians and patients were not masked to treatment allocation; individuals involved in data analysis were masked to treatment assignment. The primary endpoint was the 2-year cumulative incidence of variceal rebleeding after randomisation, and analysis was by intention to treat. The trial is registered with ClinicalTrials.gov, NCT02119988. FINDINGS Between June 16, 2014, and Feb 3, 2016, 205 patients were screened, of whom 134 were randomly allocated to the TIPS plus embolisation group (n=69) and the TIPS group (n=65). TIPS placement and variceal embolisation was successful in all 134 patients, all were included in the analysis. There was no significant difference in the 2-year cumulative incidence of variceal rebleeding between the two groups (TIPS plus embolisation 11·6% [95% CI 4·0-19·1] vs TIPS 13·8% [5·4-22·2]; hazard ratio 0·82 [95% CI 0·42-1·61]; p=0·566). Adverse events were similar between the two groups; the most common adverse events were peptic ulcer or gastritis (12 [17%] of patients in the TIPS plus embolisation group vs 13 [20%] of patients in the TIPS group), new or worsening ascites (ten [14%] vs six [9%]), and hepatocellular carcinoma (four [6%] vs six [9%]). The numbers of deaths were also similar between groups (24 [35%] vs 25 [38%]) INTERPRETATION: Adding variceal embolisation to TIPS did not significantly reduce the incidence of variceal rebleeding in patients with cirrhosis. Our findings do not support concomitant variceal embolisation during TIPS for the prevention of variceal rebleeding. FUNDING National Key Technology R&D Program, Boost Program of Xijing Hospital, and China Postdoctoral Science Foundation.
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Affiliation(s)
- 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; Military Medical Innovation Center, Fourth Military Medical University, Xi'an, China
| | - Hui Chen
- 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
| | - Bohan Luo
- 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 Interventional Radiology, Digestive Diseases Hospital, Xi'an International Medical Center Hospital, Northwest University, Xi'an, China
| | - Wei Bai
- 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 Interventional Radiology, Digestive Diseases Hospital, Xi'an International Medical Center Hospital, Northwest University, Xi'an, China
| | - Kai Li
- 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
| | - Zhengyu Wang
- 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 Interventional Radiology, Digestive Diseases Hospital, Xi'an International Medical Center Hospital, Northwest University, Xi'an, China
| | - Dongdong Xia
- 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 Interventional Radiology, Digestive Diseases Hospital, Xi'an International Medical Center Hospital, Northwest University, Xi'an, China
| | - Wengang Guo
- 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 Interventional Radiology, Digestive Diseases Hospital, Xi'an International Medical Center Hospital, Northwest University, Xi'an, China
| | - Qiuhe Wang
- 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
| | - Xiaomei Li
- 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 Interventional Radiology, Digestive Diseases Hospital, Xi'an International Medical Center Hospital, Northwest University, Xi'an, China
| | - Jie Yuan
- 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 Interventional Radiology, Digestive Diseases Hospital, Xi'an International Medical Center Hospital, Northwest University, Xi'an, China
| | - Hongwei Cai
- Department of Technology, the First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, China
| | - Jielai Xia
- Department of Medical Statistics, School of Preventive Medicine, Fourth Military Medical University, Xi'an, China
| | - Zhanxin Yin
- 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 Interventional Radiology, Digestive Diseases Hospital, Xi'an International Medical Center Hospital, Northwest University, Xi'an, China
| | - Daiming Fan
- State Key Laboratory of Cancer Biology, 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 Interventional Radiology, Digestive Diseases Hospital, Xi'an International Medical Center Hospital, Northwest University, Xi'an, China.
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11
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Yang C, Chen Y, Wang C, Liu J, Huang S, Zhou C, Wang Y, Ju S, Li T, Bai Y, Yao W, Xiong B. Portal flow diversion based on portography is superior than puncture site in the prediction of overt hepatic encephalopathy after TIPS creation. BMC Gastroenterol 2022; 22:363. [PMID: 35906529 PMCID: PMC9336111 DOI: 10.1186/s12876-022-02447-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/05/2022] [Accepted: 07/19/2022] [Indexed: 11/29/2022] Open
Abstract
Background Targeted puncture of an appropriate portal venous branch during transjugular intrahepatic portosystemic shunt (TIPS) procedure may reduce the risk of postprocedural overt hepatic encephalopathy (HE). This study aimed to describe blood distribution under portography and combined it with puncture site to determine portal flow diversion, and to evaluate its prognostic value in predicting post-TIPS overt HE. Methods In this retrospective analysis of patients with cirrhosis undergoing TIPS, we included 252 patients to describe blood distribution under portography and 243 patients to assess the association between portal flow diversion and post-TIPS overt HE. Results At the first stage, 51 (20.2%) patients were identified as type A (unilateral type with the right portal branch receives blood from splenic vein [SV]), 16 (6.4%) as type B (unilateral type with the right branch receives blood from superior mesenteric vein [SMV]) and 185 (73.4%) as type C (fully mixed type). At the second stage, 40 patients were divided into the SV group, 25 into the SMV group and 178 into the mixed group. Compared with the mixed group, the risk of post-TIPS overt HE was significantly higher in the SMV group (adjusted HR 3.70 [95% CI 2.01–6.80]; p < 0.001), whereas the SV group showed a non-significantly decreased risk (adjusted HR 0.57 [95% CI 0.22–1.48]; p = 0.25). Additionally, the SMV group showed a substantial increase in ammonia level at 3 days and 1 month after procedure. Conclusions Our results support the clinical use of portal flow diversion for risk stratification and decision-making in the management of post-TIPS overt HE. Supplementary Information The online version contains supplementary material available at 10.1186/s12876-022-02447-y.
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Affiliation(s)
- Chongtu Yang
- Department of Radiology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Jiefang Avenue #1277, Wuhan, 430022, China.,Hubei Province Key Laboratory of Molecular Imaging, Wuhan, 430022, China
| | - Yang Chen
- Department of Radiology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Jiefang Avenue #1277, Wuhan, 430022, China.,Hubei Province Key Laboratory of Molecular Imaging, Wuhan, 430022, China
| | - Chaoyang Wang
- Department of Radiology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Jiefang Avenue #1277, Wuhan, 430022, China.,Hubei Province Key Laboratory of Molecular Imaging, Wuhan, 430022, China
| | - Jiacheng Liu
- Department of Radiology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Jiefang Avenue #1277, Wuhan, 430022, China.,Hubei Province Key Laboratory of Molecular Imaging, Wuhan, 430022, China
| | - Songjiang Huang
- Department of Radiology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Jiefang Avenue #1277, Wuhan, 430022, China.,Hubei Province Key Laboratory of Molecular Imaging, Wuhan, 430022, China
| | - Chen Zhou
- Department of Radiology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Jiefang Avenue #1277, Wuhan, 430022, China.,Hubei Province Key Laboratory of Molecular Imaging, Wuhan, 430022, China
| | - Yingliang Wang
- Department of Radiology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Jiefang Avenue #1277, Wuhan, 430022, China.,Hubei Province Key Laboratory of Molecular Imaging, Wuhan, 430022, China
| | - Shuguang Ju
- Department of Radiology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Jiefang Avenue #1277, Wuhan, 430022, China.,Hubei Province Key Laboratory of Molecular Imaging, Wuhan, 430022, China
| | - Tongqiang Li
- Department of Radiology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Jiefang Avenue #1277, Wuhan, 430022, China.,Hubei Province Key Laboratory of Molecular Imaging, Wuhan, 430022, China
| | - Yaowei Bai
- Department of Radiology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Jiefang Avenue #1277, Wuhan, 430022, China.,Hubei Province Key Laboratory of Molecular Imaging, Wuhan, 430022, China
| | - Wei Yao
- Department of Radiology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Jiefang Avenue #1277, Wuhan, 430022, China.,Hubei Province Key Laboratory of Molecular Imaging, Wuhan, 430022, China
| | - Bin Xiong
- Department of Radiology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Jiefang Avenue #1277, Wuhan, 430022, China. .,Hubei Province Key Laboratory of Molecular Imaging, Wuhan, 430022, China.
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12
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Zhai S, Cui Q, Dong F, Wen S, Si M, Chen Q. Clinical efficacy of transjugular intrahepatic portosystemic shunt created through left or right branches of the portal vein: A meta-analysis. J Interv Med 2021; 4:190-196. [PMID: 35586382 PMCID: PMC8947996 DOI: 10.1016/j.jimed.2021.08.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2021] [Revised: 08/04/2021] [Accepted: 08/11/2021] [Indexed: 02/07/2023] Open
Abstract
Background and aim Transjugular intrahepatic portosystemic shunt (TIPS) is a technique successfully used to treat portal hypertension and its complications. However, the choice of the branch, left (L) or right (R), of the portal vein resulting in a better outcome is still under debate. Therefore, this meta-analysis aims to evaluate which branch has a better curative effect on patients treated with TIPS. Methods PubMed, EMBASE, Web of science, Cochrane Library databases, Wanfang database and CBM were used for our search in October 2019 and updated in June 2021. The following parameters were used in evaluation: overall mortality, hepatic encephalopathy, shunt dysfunction, variceal rebleeding and rate of postoperative ascites. Results There were seven studies included. The sample size was 1940. A lower risk of mortality was observed in TIPS-L-treated patients compared with TIPS-R-treated ones (OR = 0.65, 95% CI = 0.50–0.85, p = 0.002). A lower risk of shunt dysfunction was observed in TIPS-L-treated patients compared with TIPS-R-treated ones (OR = 0.53, 95% CI = 0.33–0.87, p = 0.01). And the TIPS-L group had a significantly higher hepatic encephalopathy-free rate than the TIPS-R group (OR = 0.59, 95% CI = 0.44–0.78, p = 0.0002). However, the rate of rebleeding (OR = 0.75, 95% CI = 0.55–1.03, p = 0.07) and incidence of postoperative ascites (OR = 1.14, 95% CI = 0.86–1.51, p = 0.38) was not statistically significant between the two groups. Conclusions Based on the currently available evidence, the technique of TIPS through the left branch of the portal vein can significantly reduce the occurrence of overall postoperative mortality, hepatic encephalopathy and shunt dysfunction.
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13
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Zhou Y, Ma J, Ju S, Zhang Z, Zhang W, Yang M, Zhou X, Yan Z, Luo J. Efficacy of puncturing different portal vein branch during transjugular intrahepatic portosystemic shunt with 8 mm covered stent: a propensity-score analysis. Eur J Gastroenterol Hepatol 2021; 33:1110-1116. [PMID: 33741800 DOI: 10.1097/meg.0000000000002133] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND Hepatic encephalopathy after transjugular intrahepatic portosystemic shunt (TIPS) remains an unsolved problem; therefore, this study aimed to compare the efficacy of shunting different portal vein branch during TIPS with 8 mm covered stent for preventing gastroesophageal variceal rebleeding in cirrhotic patients. METHODS Between November 2015 and December 2018, the medical records of consecutive cirrhotic patients who received TIPS with an 8 mm covered stent for preventing gastroesophageal variceal rebleeding were analyzed retrospectively. Shunting the left and right branches of the portal vein was performed in 58 (group A) and 104 patients (group B), respectively. Afterwards, 54 patients in each group were produced by the PSM method. The incidence of overt hepatic encephalopathy (OHE), shunt patency, variceal rebleeding and survival were compared between two groups by using Kaplan-Meier analysis and log-rank test. RESULTS The median follow-up time was 37 months (range 0.3-50 months). The 6-,12- and 24-months cumulative OHE free rates in groups A and B were 92.5, 86.2, 83.6% and 74.1, 70.2, 67.6%, respectively (P = 0.042; hazard ratio = 0.469; 95% CI, 0.223-0.988). Two (3.7%) and eight (14.8%) patients experienced severe OHE in groups A and B, respectively (P = 0.042). There were no significant differences between the two groups in terms of shunt patency, variceal rebleeding and survival. CONCLUSION Shunting the left portal vein branch during TIPS with an 8 mm covered stent for preventing gastroesophageal variceal rebleeding in cirrhotic patients might decrease the occurrence of OHE significantly. The prospective trial is needed to further provide evidence of this results in future.
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Affiliation(s)
- Yongjie Zhou
- Department of Interventional Radiology, Zhongshan Hospital, Fudan University
- Shanghai Institution of Medical Imaging, Fudan University
- National Clinical Research Center for Interventional Medicine, Zhongshan Hospital, Fudan University
| | - Jingqin Ma
- Department of Interventional Radiology, Zhongshan Hospital, Fudan University
- Shanghai Institution of Medical Imaging, Fudan University
- National Clinical Research Center for Interventional Medicine, Zhongshan Hospital, Fudan University
| | - Shuai Ju
- Center for Tumor Diagnosis and Therapy, Jinshan Hospital, Fudan University, Shanghai, China
| | - Zihan Zhang
- Department of Interventional Radiology, Zhongshan Hospital, Fudan University
- Shanghai Institution of Medical Imaging, Fudan University
- National Clinical Research Center for Interventional Medicine, Zhongshan Hospital, Fudan University
| | - Wen Zhang
- Department of Interventional Radiology, Zhongshan Hospital, Fudan University
- Shanghai Institution of Medical Imaging, Fudan University
- National Clinical Research Center for Interventional Medicine, Zhongshan Hospital, Fudan University
| | - Minjie Yang
- Department of Interventional Radiology, Zhongshan Hospital, Fudan University
- Shanghai Institution of Medical Imaging, Fudan University
- National Clinical Research Center for Interventional Medicine, Zhongshan Hospital, Fudan University
| | - Xin Zhou
- Department of Interventional Radiology, Zhongshan Hospital, Fudan University
- Shanghai Institution of Medical Imaging, Fudan University
- National Clinical Research Center for Interventional Medicine, Zhongshan Hospital, Fudan University
| | - Zhiping Yan
- Department of Interventional Radiology, Zhongshan Hospital, Fudan University
- Shanghai Institution of Medical Imaging, Fudan University
- National Clinical Research Center for Interventional Medicine, Zhongshan Hospital, Fudan University
| | - Jianjun Luo
- Department of Interventional Radiology, Zhongshan Hospital, Fudan University
- Shanghai Institution of Medical Imaging, Fudan University
- National Clinical Research Center for Interventional Medicine, Zhongshan Hospital, Fudan University
- Center for Tumor Diagnosis and Therapy, Jinshan Hospital, Fudan University, Shanghai, China
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14
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Li Z, Han X. Re: Zuo K, Wang C, Wang J, et al. Transjugular intrahepatic portosystemic shunt through left branch versus right branch of portal vein: a meta-analysis. Abdom Radiol (NY) 2020. Abdom Radiol (NY) 2021; 46:2991. [PMID: 33210161 DOI: 10.1007/s00261-020-02843-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2020] [Revised: 10/17/2020] [Accepted: 10/24/2020] [Indexed: 11/30/2022]
Affiliation(s)
- Zhaonan Li
- Department of Interventional Radiology, First Affiliated Hospital of Zhengzhou University, No. 1 Jianshe East Road, Zhengzhou City, 450000, Henan Province, China
| | - Xinwei Han
- Department of Interventional Radiology, First Affiliated Hospital of Zhengzhou University, No. 1 Jianshe East Road, Zhengzhou City, 450000, Henan Province, China.
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15
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Transjugular intrahepatic portosystemic shunt through left branch versus right branch of portal vein: a meta-analysis. Abdom Radiol (NY) 2021; 46:1718-1725. [PMID: 33009924 DOI: 10.1007/s00261-020-02789-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2020] [Revised: 09/11/2020] [Accepted: 09/27/2020] [Indexed: 02/07/2023]
Abstract
PURPOSE To compare the clinical outcomes between patients that underwent transjugular intrahepatic portosystemic shunt (TIPS) via the left and right portal veins (PVs). MATERIALS AND METHODS All relevant studies in the Pubmed, Embase, and Cochrane Library databases published as of June 2020 were identified by searching, after which RevMan v5.3 was used to conduct the present meta-analysis. Relevant endpoint data were extracted from each study, related to postoperative hepatic encephalopathy (HE) rates, TIPS dysfunction, re-bleeding, and mortality. RESULTS A total of eight studies were identified as being relevant for inclusion in this meta-analysis. These studies included 2592 total patients suffering from liver cirrhosis that underwent TIPS treatment via the left (n = 1500) or right (n = 1092) PVs. Rates of postoperative HE were significantly lower in the left PV group relative to the right PV group (5.7% vs. 18.1%, OR 0.19; P < 0.00001), as were rates of TIPS dysfunction (8.1% vs. 16.5%, OR 0.41; P < 0.00001). In contrast, the rates of re-bleeding did not differ significantly between these groups (12.0% vs. 14.9%, OR 0.76; P = 0.11), nor did mortality rates (30.9% vs. 31.0%, OR 0.85, P = 0.22). We did not detect any significant heterogeneity among included studies for any analyzed endpoints, nor was any risk of publication bias pertaining to these studies detected through the use of funnel plots. CONCLUSIONS TIPS conducted via the left PV was associated with decreased rates of postoperative HE and TIPS dysfunction relative to TIPS conducted via the right PV.
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Pandhi MB, Kuei AJ, Lipnik AJ, Gaba RC. Emergent Transjugular Intrahepatic Portosystemic Shunt Creation in Acute Variceal Bleeding. Semin Intervent Radiol 2020; 37:3-13. [PMID: 32139965 DOI: 10.1055/s-0039-3402015] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Emergent transjugular intrahepatic portosystemic shunt (TIPS) creation is most commonly employed in the setting of acute variceal hemorrhage. Given a propensity for decompensation, these patients often require a multidisciplinary, multimodal approach involving prompt diagnosis, pharmacologic therapy, and endoscopic intervention. While successful in the majority of cases, failure to medically control initial bleeding can prompt interventional radiology consultation for emergent portal decompression via TIPS creation. This article discusses TIPS creation in emergent, acute variceal hemorrhage, reviewing the natural history of gastroesophageal varices, presentation and diagnosis of acute variceal hemorrhage, pharmacologic therapy, endoscopic approaches, patient selection and risk stratification for TIPS, technical considerations for TIPS creation, adjunctive embolotherapy, and the role of salvage TIPS versus early TIPS in acute variceal hemorrhage.
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Affiliation(s)
- Mithil B Pandhi
- Department of Radiology, University of Illinois at Chicago, Chicago, Illinois
| | - Andrew J Kuei
- Department of Radiology, University of Illinois at Chicago, Chicago, Illinois
| | - Andrew J Lipnik
- Department of Radiology, University of Illinois at Chicago, Chicago, Illinois
| | - Ron C Gaba
- Department of Radiology, University of Illinois at Chicago, Chicago, Illinois.,Division of Interventional Radiology, University of Illinois at Chicago, Chicago, Illinois
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Schultheiß M, Giesler M, Maruschke L, Schmidt A, Sturm L, Thimme R, Rössle M, Bettinger D. Adjuvant Transjugular Variceal Occlusion at Creation of a Transjugular Intrahepatic Portosystemic Shunt (TIPS): Efficacy and Risks of Bucrylate Embolization. Cardiovasc Intervent Radiol 2019; 42:729-736. [PMID: 30788517 DOI: 10.1007/s00270-019-02176-y] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/17/2018] [Accepted: 01/31/2019] [Indexed: 02/06/2023]
Abstract
Adjuvant embolization of varices may reduce rebleeding in patients with a transjugular intrahepatic portosystemic shunt (TIPS). The aim of this study was to investigate the efficacy and the risks of adjuvant variceal embolization at TIPS implantation using bucrylate. PATIENTS AND METHODS The retrospective study evaluated 104 of 237 cirrhotic patients with TIPS for variceal bleeding who received adjuvant bucrylate embolization. For TIPS creation, bare stents were used in 35 patients (33.7%) and covered stents in 69 patients (66.3%) patients. Isolated gastric varices were seen in 10 patients (9.6%). RESULTS Six patients (5.8%) rebled during a median follow-up time of 26 months (1-57 months). Rebleeding occurred in 14% (5/35) of patients with a bare stent but only in 1.4% (1/69) of patients with a covered stent. The 1- and 2-year rebleeding rates of all patients were 0.9 and 2.9% and of patients receiving a bare stent were 2.9 and 8.6%, respectively. Bucrylate migration was seen in 13 patients (12.5%). In 9 of these patients (8.7%), asymptomatic lung embolization occurred. This was rare in patients with esophageal varices (3.1%) but frequent (60%) in patients with isolated gastric varices and a spontaneous splenorenal shunt. CONCLUSIONS Our results suggest that adjuvant embolization using bucrylate is effective and delays variceal rebleeding. The general use of covered stents, however, alleviates the utility of adjuvant bucrylate embolization which may be restricted to patients with a high risk of rebleeding indicated by large varices, active, acute or recent variceal bleeding and advanced cirrhosis. Bucrylate should not be used in isolated gastric varices because it bears a high risk of migration into the lungs.
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Affiliation(s)
- Michael Schultheiß
- Department of Gastroenterology, University Hospital of Freiburg, Hugstetter Str. 55, 79106, Freiburg, Germany
| | - Max Giesler
- Department of Gastroenterology, University Hospital of Freiburg, Hugstetter Str. 55, 79106, Freiburg, Germany
| | - Lars Maruschke
- Department of Radiology, University Hospital of Freiburg, Hugstetter Str. 55, 79106, Freiburg, Germany
| | - Arthur Schmidt
- Department of Gastroenterology, University Hospital of Freiburg, Hugstetter Str. 55, 79106, Freiburg, Germany
| | - Lukas Sturm
- Department of Gastroenterology, University Hospital of Freiburg, Hugstetter Str. 55, 79106, Freiburg, Germany
| | - Robert Thimme
- Department of Gastroenterology, University Hospital of Freiburg, Hugstetter Str. 55, 79106, Freiburg, Germany
| | - Martin Rössle
- Department of Gastroenterology, University Hospital of Freiburg, Hugstetter Str. 55, 79106, Freiburg, Germany.
| | - Dominik Bettinger
- Department of Gastroenterology, University Hospital of Freiburg, Hugstetter Str. 55, 79106, Freiburg, Germany
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The Effect of Puncture Sites of Portal Vein in TIPS with ePTFE-Covered Stents on Postoperative Long-Term Clinical Efficacy. Gastroenterol Res Pract 2019; 2019:2935498. [PMID: 30728835 PMCID: PMC6343182 DOI: 10.1155/2019/2935498] [Citation(s) in RCA: 6] [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: 06/12/2018] [Revised: 08/26/2018] [Accepted: 10/18/2018] [Indexed: 12/15/2022] Open
Abstract
Purpose To evaluate the effect of puncture sites of the portal vein in transjugular intrahepatic portosystemic shunt (TIPS) on long-term clinical efficacy. Methods A retrospective review was performed, including consecutive 171 patients who underwent TIPS with ePTFE-covered stents. All patients were divided into 3 groups according to the puncture site of the portal vein: intrahepatic bifurcation of the portal vein (group A, n = 88), right branch of the portal vein (group B, n = 48), and left branch of the portal vein (group C, n = 35). The Kaplan-Meier analysis was performed to assess the effect of different puncture sites on primary patency, the incidence of hepatic encephalopathy (HE), and survival. Results The primary restenosis rate was 29.8% (51/171). The total HE rate was 31.6% (54/171). The cumulative death rate was 19.3% (33/171). The Kaplan-Meier analysis showed that group C versus group A, group C versus group B, and group A versus group B were significantly different on the primary restenosis rate, respectively (χ 2 = 11.49, P = 0.001; χ 2 = 4.54, P = 0.033; and χ 2 = 4.12, P = 0.046), and group C is better than the other two groups. What is more, group C versus group A and group C versus group B were significantly different on the incidence of HE, respectively (χ 2 = 8.07, P = 0.004; χ 2 = 9.44, P = 0.002), and group C is better than the other two groups. There was no significant difference on survival. Conclusion Choosing the left branch of the portal vein as the puncture site to create the shunt in TIPS with ePTFE-covered stents may decrease the incident of primary restenosis and HE significantly.
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Lipnik AJ, Pandhi MB, Khabbaz RC, Gaba RC. Endovascular Treatment for Variceal Hemorrhage: TIPS, BRTO, and Combined Approaches. Semin Intervent Radiol 2018; 35:169-184. [PMID: 30087520 DOI: 10.1055/s-0038-1660795] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Variceal hemorrhage is a feared complication of portal hypertension, with high rates of morbidity and mortality. Optimal management requires a thoughtful, multidisciplinary approach. In cases of refractory or recurrent esophageal hemorrhage, endovascular approaches such as transjugular intrahepatic portosystemic shunt (TIPS) have a well-defined role. For hemorrhage related to gastric varices, the optimal treatment remains to be established; however, there is increasing adoption of balloon-occluded retrograde transvenous obliteration (BRTO). This article will review the concept, history, patient selection, basic technique, and outcomes for TIPS, BRTO, and combined TIPS + BRTO procedures for variceal hemorrhage.
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Affiliation(s)
- Andrew J Lipnik
- Department of Radiology, University of Illinois Hospital & Health Sciences System, Chicago, Illinois.,Division of Interventional Radiology, University of Illinois Hospital & Health Sciences System, Chicago, Illinois
| | - Mithil B Pandhi
- Department of Radiology, University of Illinois Hospital & Health Sciences System, Chicago, Illinois
| | - Ramzy C Khabbaz
- Department of Radiology, University of Illinois Hospital & Health Sciences System, Chicago, Illinois
| | - Ron C Gaba
- Department of Radiology, University of Illinois Hospital & Health Sciences System, Chicago, Illinois.,Division of Interventional Radiology, University of Illinois Hospital & Health Sciences System, Chicago, Illinois
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Jiang Q, Wang MQ, Zhang GB, Wu Q, Xu JM, Kong DR. Transjugular intrahepatic portosystemic shunt combined with esophagogastric variceal embolization in the treatment of a large gastrorenal shunt. World J Hepatol 2016; 8:850-857. [PMID: 27458505 PMCID: PMC4945505 DOI: 10.4254/wjh.v8.i20.850] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/27/2016] [Revised: 04/26/2016] [Accepted: 06/02/2016] [Indexed: 02/06/2023] Open
Abstract
AIM: To evaluate the efficacy and safety of transjugular intrahepatic portosystemic shunt (TIPS) combined with stomach and esophageal variceal embolization (SEVE) in cirrhotic patients with a large gastrorenal vessel shunt (GRVS).
METHODS: Eighty-one cirrhotic patients with gastric variceal bleeding (GVB) associated with a GRVS were enrolled in the study and accepted TIPS combined with SEVE (TIPS + SEVE), by which portosystemic pressure gradient (PPG), biochemical, TIPS-related complications, shunt dysfunction, rebleeding, and death were evaluated.
RESULTS: The PPGs before TIPS were greater than 12 mmHg in 81 patients. TIPS + SEVE treatment caused a significant decrease in PPG (from 37.97 ± 6.36 mmHg to 28.15 ± 6.52 mmHg, t = 19.22, P < 0.001). The percentage of reduction in PPG was greater than 20% from baseline. There were no significant differences in albumin, alanine aminotransferase, aspartate aminotransferase, bilirubin, prothrombin time, or Child-Pugh score before and after operation. In all patients, rebleeding rates were 3%, 6%, 12%, 18%, and 18% at 1, 3, 6, 12, and 18 mo, respectively. Five patients (6.2%) were diagnosed as having hepatic encephalopathy. The rates of shunt dysfunction were 0%, 4%, 9%, 26%, and 26%, at 1, 3, 6, 12, and 18 mo, respectively. The cumulative survival rates in 1, 3, 6, 12, and 18 mo were 100%, 100%, 95%, 90%, and 90%, respectively.
CONCLUSION: Our preliminary results indicated that the efficacy and safety of TIPS + SEVE were satisfactory in cirrhotic patients with GVB associated with a GRVS (GVB + GRVS).
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Gaba RC. Transjugular Intrahepatic Portosystemic Shunt Creation With Embolization or Obliteration for Variceal Bleeding. Tech Vasc Interv Radiol 2016; 19:21-35. [DOI: 10.1053/j.tvir.2016.01.003] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
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Qi X, Liu L, Bai M, Chen H, Wang J, Yang Z, Han G, Fan D. Transjugular intrahepatic portosystemic shunt in combination with or without variceal embolization for the prevention of variceal rebleeding: a meta-analysis. J Gastroenterol Hepatol 2014; 29:688-696. [PMID: 24117967 DOI: 10.1111/jgh.12391] [Citation(s) in RCA: 54] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/31/2013] [Indexed: 02/05/2023]
Abstract
BACKGROUND AND AIM Transjugular intrahepatic portosystemic shunt (TIPS) is the mainstay treatment option for the complications of portal hypertension. Whether or not variceal embolization should be performed during TIPS procedures remains controversial. A meta-analysis to compare the incidence of shunt dysfunction, variceal rebleeding, encephalopathy, and death between patients treated with TIPS alone and those treated with TIPS combined with variceal embolization was conducted. METHODS All relevant studies were searched via PubMed, EMBASE, and Cochrane Library databases. Odds ratios (ORs) with 95% confidence intervals (CIs) were pooled. Heterogeneity among studies and publication bias were assessed. RESULTS Six articles were included in our study. Type of stents was covered (n = 2), bare (n = 2), mixed (n = 1), and unknown (n = 1). Varices were angiographically embolized by coils in six studies. Additional liquids agents were employed in three studies. Compared with TIPS alone group, TIPS combined with variceal embolization group had a significantly lower incidence of variceal rebleeding (OR 2.02, 95% CI 1.29-3.17, P = 0.002), but a similar incidence of shunt dysfunction (OR 1.26, 95% CI 0.76-2.08, P = 0.38), encephalopathy (OR 0.81, 95% CI 0.46-1.43, P = 0.47), and death (OR 0.90, 95% CI 0.55-1.47, P = 0.68). Neither any significant heterogeneity nor proof of publication bias among studies was found in all meta-analyses. CONCLUSIONS Adjunctive variceal embolization during TIPS procedures might be beneficial in the prevention of variceal rebleeding. However, given the heterogeneity of type of stents, embolic agents, type of varices, and indications of variceal embolization among studies, additional well-designed randomized, controlled trials with larger sample size and use of covered stents should be warranted to confirm these findings.
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Affiliation(s)
- Xingshun Qi
- Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an, China; Department of Gastroenterology, No. 463 Hospital of Chinese PLA, Shenyang, China
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Bai M, He CY, Qi XS, Yin ZX, Wang JH, Guo WG, Niu J, Xia JL, Zhang ZL, Larson AC, Wu KC, Fan DM, Han GH. Shunting branch of portal vein and stent position predict survival after transjugular intrahepatic portosystemic shunt. World J Gastroenterol 2014; 20:774-785. [PMID: 24574750 PMCID: PMC3921486 DOI: 10.3748/wjg.v20.i3.774] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/28/2013] [Revised: 10/22/2013] [Accepted: 11/01/2013] [Indexed: 02/06/2023] Open
Abstract
AIM To evaluate the effect of the shunting branch of the portal vein (PV) (left or right) and the initial stent position (optimal or suboptimal) of a transjugular intrahepatic portosystemic shunt (TIPS). METHODS We retrospectively reviewed 307 consecutive cirrhotic patients who underwent TIPS placement for variceal bleeding from March 2001 to July 2010 at our center. The left PV was used in 221 patients and the right PV in the remaining 86 patients. And, 224 and 83 patients have optimal stent position and sub-optimal stent positions, respectively. The patients were followed until October 2011 or their death. Hepatic encephalopathy, shunt dysfunction, and survival were evaluated as outcomes. The difference between the groups was compared by Kaplan-Meier analysis. A Cox regression model was employed to evaluate the predictors. RESULTS Among the patients who underwent TIPS to the left PV, the risk of hepatic encephalopathy (P = 0.002) and mortality were lower (P < 0.001) compared to those to the right PV. Patients who underwent TIPS with optimal initial stent position had a higher primary patency (P < 0.001) and better survival (P = 0.006) than those with suboptimal initial stent position. The shunting branch of the portal vein and the initial stent position were independent predictors of hepatic encephalopathy and shunt dysfunction after TIPS, respectively. And, both were independent predictors of survival. CONCLUSION TIPS placed to the left portal vein with optimal stent position may reduce the risk of hepatic encephalopathy and improve the primary patency rates, thereby prolonging survival.
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