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Wang G, Zhang F, Ojeda A, Shalaby S, Hernandez-Gea V, Garcia-Pagan JC. The evolution of the TIPS placement technique and its applications over four decades. Dig Liver Dis 2024; 56:1980-1988. [PMID: 38853090 DOI: 10.1016/j.dld.2024.05.018] [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: 03/14/2024] [Revised: 05/16/2024] [Accepted: 05/19/2024] [Indexed: 06/11/2024]
Abstract
Transjugular intrahepatic portosystemic shunt (TIPS), a highly effective procedure reducing portal hypertension, has been in use for over seven decades and is now a cornerstone in managing portal hypertension-related complications such as variceal bleeding and ascites. Historically, TIPS has dealt with two main challenges: ensuring stent patency and preventing post-TIPS hepatic encephalopathy. The introduction of PTFE-coated stents markedly reduced the risk of TIPS dysfunction and stent patency is no longer a major concern. However, despite improved patient selection criteria, hepatic encephalopathy continues to be a significant and persistent issue. In addition, the broader application of TIPS in recent decades has brought to light additional, albeit less common, complications, such as post-TIPS heart failure. This review offers a comprehensive overview of TIPS historical evolution, advancements in technique, and its application in the treatment of portal hypertension.
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Affiliation(s)
- Guangchuan Wang
- Barcelona Hepatic Hemodynamic Laboratory, Liver Unit, Hospital Clínic, Institut de Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Spain; Department of Gastroenterology, Shandong Provincial Hospital Affiliated to Shandong First Medical University, PR China
| | - Feng Zhang
- Barcelona Hepatic Hemodynamic Laboratory, Liver Unit, Hospital Clínic, Institut de Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Spain; Department of Gastroenterology, Nanjing Drum Tower Hospital, Affiliated Hospital of Medical School, Nanjing University, PR China
| | - Asuncion Ojeda
- Barcelona Hepatic Hemodynamic Laboratory, Liver Unit, Hospital Clínic, Institut de Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Spain; CIBEREHD (Centro de Investigación Biomédica en Red Enfermedades Hepáticas y Digestivas), Spain; Health Care Provider of the European Reference Network on Rare Liver Disorders (ERN-Rare Liver)
| | - Sarah Shalaby
- Barcelona Hepatic Hemodynamic Laboratory, Liver Unit, Hospital Clínic, Institut de Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Spain; CIBEREHD (Centro de Investigación Biomédica en Red Enfermedades Hepáticas y Digestivas), Spain; Health Care Provider of the European Reference Network on Rare Liver Disorders (ERN-Rare Liver)
| | - Virginia Hernandez-Gea
- Barcelona Hepatic Hemodynamic Laboratory, Liver Unit, Hospital Clínic, Institut de Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Spain; CIBEREHD (Centro de Investigación Biomédica en Red Enfermedades Hepáticas y Digestivas), Spain; Health Care Provider of the European Reference Network on Rare Liver Disorders (ERN-Rare Liver); Departament de Medicina i Ciències de la Salut, Universitat de Barcelona, Spain
| | - Juan Carlos Garcia-Pagan
- Barcelona Hepatic Hemodynamic Laboratory, Liver Unit, Hospital Clínic, Institut de Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Spain; CIBEREHD (Centro de Investigación Biomédica en Red Enfermedades Hepáticas y Digestivas), Spain; Health Care Provider of the European Reference Network on Rare Liver Disorders (ERN-Rare Liver); Departament de Medicina i Ciències de la Salut, Universitat de Barcelona, Spain.
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Joueidi F, Alhanaee A, Alsuhaibani H, Albenmousa A, Joueidi A, Elhassan A, Nasir AN, Marquez KAH, Alghamdi S, Al Hamoudi W, Abualganam S, Broering D, Bzeizi KI. Transjugular Intrahepatic Portosystemic Shunt for Budd-Chiari Syndrome: A Single-Centre Experience. J Clin Med 2024; 13:5858. [PMID: 39407918 PMCID: PMC11478255 DOI: 10.3390/jcm13195858] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2024] [Revised: 08/08/2024] [Accepted: 09/14/2024] [Indexed: 10/20/2024] Open
Abstract
Background: Despite several challenges in clinical management, there has been significant progress in understanding the aetiology, natural history and outcomes of Budd-Chiari syndrome (BCS) treatments. This study aims to evaluate the outcomes of transjugular intrahepatic portosystemic shunt (TIPS) using covered stent in management of BCS. Methods: We conducted a retrospective analysis of 70 BCS patients who underwent TIPS using covered stents between January 2010 and December 2022 at a single tertiary liver transplant centre. Patients' clinical features, laboratory parameters, and imagine findings were collected before and after TIPS. The primary endpoint was overall survival. Results: TIPS was performed on 70 patients with BCS out of a total of 88 patients. The remaining patients (18) underwent liver transplantation. The mean age was 37.7 ± 11.2 years at time of diagnosis and the majority were female (64.35). The most common symptoms and signs at presentation were abdominal pain, jaundice, ascites, and variceal bleeding. Over a median followup of 76 months, the survival rates at 1, 3, and 5 years were 98.8%, 97.9%, and 97.7%, respectively. Patients who underwent TIPS alone had better survival that patients with BCS who required liver transplantation (LTx) (p = 0.003). Conclusions: In our study TIPS provided a highly effective treatment option for BCS patients. The long-term favourability of the outcome was not impacted by the need for repeated TIPS revision. Use of covered stents was instrumental in reducing shunt dysfunction rates. Prospective and larger studies are needed to further optimize therapeutic strategies in this challenging population.
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Affiliation(s)
- Faisal Joueidi
- College of Medicine, Alfaisal University, Riyadh 11451, Saudi Arabia; (A.J.); (A.E.); (A.N.N.)
| | - Amnah Alhanaee
- Department of Liver & Small Bowel Health Centre, Organ Transplant Centre of Excellence, King Faisal Specialist Hospital & Research Centre, Riyadh 11451, Saudi Arabia; (A.A.); (A.A.); (K.A.H.M.); (S.A.); (W.A.H.); (D.B.); (K.I.B.)
| | - Hamad Alsuhaibani
- Radiology Department, King Faisal Specialist Hospital & Research Centre, Riyadh 11451, Saudi Arabia; (H.A.); (S.A.)
| | - Ali Albenmousa
- Department of Liver & Small Bowel Health Centre, Organ Transplant Centre of Excellence, King Faisal Specialist Hospital & Research Centre, Riyadh 11451, Saudi Arabia; (A.A.); (A.A.); (K.A.H.M.); (S.A.); (W.A.H.); (D.B.); (K.I.B.)
| | - Ahmad Joueidi
- College of Medicine, Alfaisal University, Riyadh 11451, Saudi Arabia; (A.J.); (A.E.); (A.N.N.)
| | - Ahmed Elhassan
- College of Medicine, Alfaisal University, Riyadh 11451, Saudi Arabia; (A.J.); (A.E.); (A.N.N.)
| | - Abdallah Nabeel Nasir
- College of Medicine, Alfaisal University, Riyadh 11451, Saudi Arabia; (A.J.); (A.E.); (A.N.N.)
| | - Kris Ann Hervera Marquez
- Department of Liver & Small Bowel Health Centre, Organ Transplant Centre of Excellence, King Faisal Specialist Hospital & Research Centre, Riyadh 11451, Saudi Arabia; (A.A.); (A.A.); (K.A.H.M.); (S.A.); (W.A.H.); (D.B.); (K.I.B.)
| | - Saad Alghamdi
- Department of Liver & Small Bowel Health Centre, Organ Transplant Centre of Excellence, King Faisal Specialist Hospital & Research Centre, Riyadh 11451, Saudi Arabia; (A.A.); (A.A.); (K.A.H.M.); (S.A.); (W.A.H.); (D.B.); (K.I.B.)
| | - Waleed Al Hamoudi
- Department of Liver & Small Bowel Health Centre, Organ Transplant Centre of Excellence, King Faisal Specialist Hospital & Research Centre, Riyadh 11451, Saudi Arabia; (A.A.); (A.A.); (K.A.H.M.); (S.A.); (W.A.H.); (D.B.); (K.I.B.)
| | - Saad Abualganam
- Radiology Department, King Faisal Specialist Hospital & Research Centre, Riyadh 11451, Saudi Arabia; (H.A.); (S.A.)
| | - Dieter Broering
- Department of Liver & Small Bowel Health Centre, Organ Transplant Centre of Excellence, King Faisal Specialist Hospital & Research Centre, Riyadh 11451, Saudi Arabia; (A.A.); (A.A.); (K.A.H.M.); (S.A.); (W.A.H.); (D.B.); (K.I.B.)
| | - Khalid Ibrahim Bzeizi
- Department of Liver & Small Bowel Health Centre, Organ Transplant Centre of Excellence, King Faisal Specialist Hospital & Research Centre, Riyadh 11451, Saudi Arabia; (A.A.); (A.A.); (K.A.H.M.); (S.A.); (W.A.H.); (D.B.); (K.I.B.)
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Lv YF, Zhu B, Meng MM, Wu YF, Dong CB, Zhang Y, Liu BW, You SL, Lv S, Yang YP, Liu FQ. Development of a new Cox model for predicting long-term survival in hepatitis cirrhosis patients underwent transjugular intrahepatic portosystemic shunts. World J Gastrointest Surg 2024; 16:491-502. [PMID: 38463355 PMCID: PMC10921221 DOI: 10.4240/wjgs.v16.i2.491] [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: 11/21/2023] [Revised: 12/23/2023] [Accepted: 01/12/2024] [Indexed: 02/25/2024] Open
Abstract
BACKGROUND Transjugular intrahepatic portosystemic shunt (TIPS) placement is a procedure that can effectively treat complications of portal hypertension, such as variceal bleeding and refractory ascites. However, there have been no specific studies on predicting long-term survival after TIPS placement. AIM To establish a model to predict long-term survival in patients with hepatitis cirrhosis after TIPS. METHODS A retrospective analysis was conducted on a cohort of 224 patients who underwent TIPS implantation. Through univariate and multivariate Cox regression analyses, various factors were examined for their ability to predict survival at 6 years after TIPS. Consequently, a composite score was formulated, encompassing the indication, shunt reasonability, portal venous pressure gradient (PPG) after TIPS, percentage decrease in portal venous pressure (PVP), indocyanine green retention rate at 15 min (ICGR15) and total bilirubin (Tbil) level. Furthermore, the performance of the newly developed Cox (NDC) model was evaluated in an internal validation cohort and compared with that of a series of existing models. RESULTS The indication (variceal bleeding or ascites), shunt reasonability (reasonable or unreasonable), ICGR15, postoperative PPG, percentage of PVP decrease and Tbil were found to be independent factors affecting long-term survival after TIPS placement. The NDC model incorporated these parameters and successfully identified patients at high risk, exhibiting a notably elevated mortality rate following the TIPS procedure, as observed in both the training and validation cohorts. Additionally, in terms of predicting the long-term survival rate, the performance of the NDC model was significantly better than that of the other four models [Child-Pugh, model for end-stage liver disease (MELD), MELD-sodium and the Freiburg index of post-TIPS survival]. CONCLUSION The NDC model can accurately predict long-term survival after the TIPS procedure in patients with hepatitis cirrhosis, help identify high-risk patients and guide follow-up management after TIPS implantation.
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Affiliation(s)
- Yi-Fan Lv
- Liver Disease Minimally Invasive Diagnosis and Treatment Center, Beijing Shijitan Hospital, Capital Medical University, Beijing 100038, China
| | - Bing Zhu
- Liver Vascular Disease Diagnosis and Treatment Center, The Fifth Medical Center of Chinese People's Liberation Army General Hospital, Beijing 100039, China
| | - Ming-Ming Meng
- Liver Disease Minimally Invasive Diagnosis and Treatment Center, Beijing Shijitan Hospital, Capital Medical University, Beijing 100038, China
| | - Yi-Fan Wu
- Liver Disease Minimally Invasive Diagnosis and Treatment Center, Beijing Shijitan Hospital, Capital Medical University, Beijing 100038, China
| | - Cheng-Bin Dong
- Liver Disease Minimally Invasive Diagnosis and Treatment Center, Beijing Shijitan Hospital, Capital Medical University, Beijing 100038, China
| | - Yu Zhang
- Liver Disease Minimally Invasive Diagnosis and Treatment Center, Beijing Shijitan Hospital, Capital Medical University, Beijing 100038, China
| | - Bo-Wen Liu
- Liver Disease Minimally Invasive Diagnosis and Treatment Center, Beijing Shijitan Hospital, Capital Medical University, Beijing 100038, China
| | - Shao-Li You
- Liver Vascular Disease Diagnosis and Treatment Center, The Fifth Medical Center of Chinese People's Liberation Army General Hospital, Beijing 100039, China
| | - Sa Lv
- Liver Vascular Disease Diagnosis and Treatment Center, The Fifth Medical Center of Chinese People's Liberation Army General Hospital, Beijing 100039, China
| | - Yong-Ping Yang
- Liver Vascular Disease Diagnosis and Treatment Center, The Fifth Medical Center of Chinese People's Liberation Army General Hospital, Beijing 100039, China
| | - Fu-Quan Liu
- Liver Disease Minimally Invasive Diagnosis and Treatment Center, Beijing Shijitan Hospital, Capital Medical University, Beijing 100038, China
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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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Swersky A, Knight G, Salem R. Interventional radiology and the liver vasculature: A personal perspective. Clin Liver Dis (Hoboken) 2024; 23:e0239. [PMID: 38919865 PMCID: PMC11199010 DOI: 10.1097/cld.0000000000000239] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/19/2024] [Accepted: 03/29/2024] [Indexed: 06/27/2024] Open
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Valla DC. Hepatic vein thrombosis and PVT: A personal view on the contemporary development of ideas. Clin Liver Dis (Hoboken) 2024; 23:e0246. [PMID: 38988821 PMCID: PMC11236412 DOI: 10.1097/cld.0000000000000246] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/11/2024] [Accepted: 05/10/2024] [Indexed: 07/12/2024] Open
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Carroll A, Boike JR. TIPS: indications, Contraindications, and Evaluation. Curr Gastroenterol Rep 2023; 25:232-241. [PMID: 37603109 DOI: 10.1007/s11894-023-00884-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/09/2023] [Indexed: 08/22/2023]
Abstract
PURPOSE OF REVIEW This review summarizes the current and emerging indications, contraindications, and evaluation for TIPS. In the last three decades of use, there have been substantial changes and progress in this field, including the use of controlled-expansion, covered stents, which has broadened the clinical uses of TIPS. RECENT FINDINGS Recent findings have rapidly expanded the indications for TIPS, including emerging uses in hepatorenal syndrome, hepatopulmonary syndrome and before abdominal surgery. The widespread use of controlled-expansion, covered stents has decreased rates of post-TIPS hepatic encephalopathy, opening TIPS to a larger patient population. Overall, with newer stent technology and more research in this area, the clinical utility and potential of TIPS has rapidly expanded. Going forward, a renewed focus on randomized-control trials and long-term outcomes will be a crucial element to selecting appropriate TIPS recipients and recommending emerging indications for this procedure.
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Affiliation(s)
- Allison Carroll
- Department of Medicine, Division of Gastroenterology & Hepatology, Northwestern University Feinberg School of Medicine, 676 N. St. Clair, Suite 1900, Chicago, IL, 60611, USA
- Feinberg School of Medicine, Northwestern University, Chicago, USA
| | - Justin R Boike
- Department of Medicine, Division of Gastroenterology & Hepatology, Northwestern University Feinberg School of Medicine, 676 N. St. Clair, Suite 1900, Chicago, IL, 60611, USA.
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Lapenna L, Di Cola S, Gazda J, De Felice I, Gioia S, Merli M. New Indications for TIPSs: What Do We Know So Far? J Clin Exp Hepatol 2023; 13:794-803. [PMID: 37693277 PMCID: PMC10483008 DOI: 10.1016/j.jceh.2023.01.017] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/08/2022] [Accepted: 01/29/2023] [Indexed: 09/12/2023] Open
Abstract
Since 1988, transjugular intrahepatic portosystemic shunt (TIPS) has been an effective therapy for portal hypertension in many settings. Thanks to continuous technical improvements and a wiser selection of patients, excellent results have been achieved with this therapeutic strategy. The historical indications for TIPS placement, in the context of liver cirrhosis, such as refractory ascites and variceal bleeding are now well established and known. However, in recent years, new indications are emerging. These have been investigated and approved in some studies but are not yet included in guidelines and clinical practice. This review aims to highlight what is new for the role of TIPS in portal vein thrombosis (especially in patients awaiting liver transplantation), in recurrent ascites and not only refractory ascites, as a neoadjuvant therapy before abdominal surgery and, finally, in the setting of noncirrhotic portal hypertension. All these new aspects are addressed in this review with a critical approach based on the literature revision and clinical practice. Future research is needed to explore and validate the new role of TIPS in these scenarios.
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Affiliation(s)
- Lucia Lapenna
- Department of Translational and Precision Medicine, Sapienza University of Rome, Italy
| | - Simone Di Cola
- Department of Translational and Precision Medicine, Sapienza University of Rome, Italy
| | - Jakub Gazda
- 2nd Department of Internal Medicine, PJ Safarik University and L. Pasteur University Hospital in Kosice, Slovakia
| | - Ilaria De Felice
- Department of Translational and Precision Medicine, Sapienza University of Rome, Italy
| | - Stefania Gioia
- Department of Translational and Precision Medicine, Sapienza University of Rome, Italy
| | - Manuela Merli
- Department of Translational and Precision Medicine, Sapienza University of Rome, Italy
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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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Zhu W, Wang X, Lv Y, Chen H, Chen X, Li X, Zhu S, Lin Z, Wang G. Comparison of long-term outcomes of splenectomy with periesophagogastric devascularization and transjugular intrahepatic portosystemic shunt in treating cirrhotic portal hypertension patients with recurrent variceal bleeding. Langenbecks Arch Surg 2023; 408:215. [PMID: 37247018 PMCID: PMC10227160 DOI: 10.1007/s00423-023-02933-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2022] [Accepted: 05/07/2023] [Indexed: 05/30/2023]
Abstract
PURPOSE Transjugular intrahepatic portosystemic shunt (TIPS) and splenectomy with periesophagogastric devascularization (SPD) are widely used to treat cirrhotic portal hypertension (PH) and prevent variceal rebleeding. However, direct comparisons between these two approaches are rare. This study was designed to compare the long-term outcomes of TIPS and SPD in patients with cirrhotic PH and variceal rebleeding. METHODS The study included cirrhotic PH patients with a history of gastroesophageal variceal bleeding between 18 and 80 years of age who were admitted to the Third Affiliated Hospital of Sun Yat-sen University from January 2012 to January 2022. Patients were enrolled into two groups according to TIPS or SPD was performed. Baseline characteristics were matched using propensity score matching (PSM). RESULTS A total of 230 patients underwent TIPS, while 184 underwent SPD. PSM was carried out to balance available covariates, resulting in a total of 83 patients in the TIPS group and 83 patients in the SPD group. Patients in SPD group had better liver function during 60 months follow-up. Five-year overall survival rates in SPD group and TIPS group were 72 and 27%, respectively, at 2 years were 88 and 86%, respectively. The 2- and 5-year freedom from variceal rebleeding rates were 95 and 80% in SPD group and 80 and 54% in TIPS group. CONCLUSIONS SPD is clearly superior to TIPS in terms of OS and freedom from variceal rebleeding in patients with cirrhotic PH. In addition, SPD improved liver function in patients with cirrhotic PH.
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Affiliation(s)
- Wenfeng Zhu
- Department of Hepatic Surgery, The Third Affiliated Hospital of Sun Yat-Sen University, Liver Transplantation, Guangzhou, 510630, China
- Guangdong Key Laboratory of Liver Disease Research, The Third Affiliated Hospital of Sun Yat-Sen University, Guangzhou, 510630, China
| | - Xiaowen Wang
- Department of Hepatic Surgery, The Third Affiliated Hospital of Sun Yat-Sen University, Liver Transplantation, Guangzhou, 510630, China
- Guangdong Key Laboratory of Liver Disease Research, The Third Affiliated Hospital of Sun Yat-Sen University, Guangzhou, 510630, China
| | - Yun Lv
- Department of Hepatic Surgery, The Third Affiliated Hospital of Sun Yat-Sen University, Liver Transplantation, Guangzhou, 510630, China
| | - Haoqi Chen
- Department of Hepatic Surgery, The Third Affiliated Hospital of Sun Yat-Sen University, Liver Transplantation, Guangzhou, 510630, China
- Guangdong Key Laboratory of Liver Disease Research, The Third Affiliated Hospital of Sun Yat-Sen University, Guangzhou, 510630, China
| | - Xiaolong Chen
- Department of Hepatic Surgery, The Third Affiliated Hospital of Sun Yat-Sen University, Liver Transplantation, Guangzhou, 510630, China
- Guangdong Key Laboratory of Liver Disease Research, The Third Affiliated Hospital of Sun Yat-Sen University, Guangzhou, 510630, China
| | - Xuejiao Li
- Guangdong Key Laboratory of Liver Disease Research, The Third Affiliated Hospital of Sun Yat-Sen University, Guangzhou, 510630, China
| | - Shuguang Zhu
- Department of Hepatic Surgery, The Third Affiliated Hospital of Sun Yat-Sen University, Liver Transplantation, Guangzhou, 510630, China
- Guangdong Key Laboratory of Liver Disease Research, The Third Affiliated Hospital of Sun Yat-Sen University, Guangzhou, 510630, China
| | - Zexin Lin
- Department of Hepatic Surgery, The Third Affiliated Hospital of Sun Yat-Sen University, Liver Transplantation, Guangzhou, 510630, China
| | - Genshu Wang
- Guangdong Provincial Hospital of Chinese Medicine, Guangzhou, 510630, China.
- The Second Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangdong, China.
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11
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Nardelli S, Bellafante D, Ridola L, Faccioli J, Riggio O, Gioia S. Prevention of post-tips hepatic encephalopathy: The search of the ideal candidate. Metab Brain Dis 2022; 38:1729-1736. [PMID: 36445629 DOI: 10.1007/s11011-022-01131-0] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/26/2022] [Accepted: 11/22/2022] [Indexed: 11/30/2022]
Abstract
Transjugular intrahepatic portosystemic shunt (TIPS) has been used since more than 25 years to treat some of the complications of portal hypertension, especially variceal bleeding and ascites refractory to conventional therapy. TIPS establishes a communication between the portal and hepatic veins, inducing the blood to shift from the splanchnic circulation into the systemic vascular bed with the aim of decompressing the portal venous system, and avoids the major complications of portal hypertension. However, the shunt of the portal blood into the systemic circulation is the cause of one of the major complications of the procedure: the post-TIPS hepatic encephalopathy (HE). To date, few pharmacological treatment has been proven effective to prevent this complication and thus, the identification of patients at high risk of post-TIPS hepatic encephalopathy and the patients' carefully selection is the only way to prevent this frequent complication.
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Affiliation(s)
- Silvia Nardelli
- Department of Translational and Precision Medicine, "Sapienza" University of Rome, Viale Dell'Università 37, Rome, Italy.
| | - Daniele Bellafante
- Department of Translational and Precision Medicine, "Sapienza" University of Rome, Viale Dell'Università 37, Rome, Italy
| | - Lorenzo Ridola
- Department of Translational and Precision Medicine, "Sapienza" University of Rome, Viale Dell'Università 37, Rome, Italy
| | - Jessica Faccioli
- Department of Translational and Precision Medicine, "Sapienza" University of Rome, Viale Dell'Università 37, Rome, Italy
| | - Oliviero Riggio
- Department of Translational and Precision Medicine, "Sapienza" University of Rome, Viale Dell'Università 37, Rome, Italy
| | - Stefania Gioia
- Department of Translational and Precision Medicine, "Sapienza" University of Rome, Viale Dell'Università 37, Rome, Italy
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12
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Thimme R. EASL Innovation Award Recipient 2022: Prof. Martin Rössle. J Hepatol 2022; 77:287-289. [PMID: 35750547 DOI: 10.1016/j.jhep.2022.05.025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/27/2022] [Accepted: 05/27/2022] [Indexed: 12/04/2022]
Affiliation(s)
- Robert Thimme
- Department of Medicine II, Gastroenterology, Hepatology, Endocrinology and Infectious Diseases, University Hospital Freiburg, Freiburg, Germany.
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Single Puncture TIPS—A 3D Fusion Image-Guided Transjugular Intrahepatic Portosystemic Shunt (TIPS): An Experimental Study. APPLIED SCIENCES-BASEL 2022. [DOI: 10.3390/app12105267] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
Abstract
Background: The use of a transjugular intrahepatic portosystemic shunt (TIPS) has been established as an effective treatment for portal hypertension. Despite the rapid development of this use, serious peri-procedural complications have been reported in over 10% of cases. This has largely been attributed to the access to the portal vein, also referred to as a “blind puncture”, which often requires multiple attempts. The aim of this study was to demonstrate the safety, reproducibility and accuracy of the use of real-time 3D fusion image-guided (3DFIG) single puncture TIPS to minimize the complications that are related to the “blind puncture” of TIPS procedures. Methods: A 3DFIG TIPS approach was utilized on 22 pigs by combining pre-procedural cross-sectional imaging (CT, MR or CBCT) with intra-procedural cone beam CT or angiogram imaging, which allowed for the improved 3D visual spatial orientation of the portal vein and real-time tracking of the needle in 3D. Results: Thirty-five portosystemic shunts were successfully deployed in all 22 subjects without any peri-procedural complications. Overall, 91% (32/35) of the procedures were carried out using a single puncture. In addition, the mean fluoroscopy time in our study was more than 12 times lower than the proposed reference level that has previously been proposed for TIPS procedures. Conclusion: Multi-modality real-time 3DFIG TIPS can be performed safely using a single puncture, without complications, and can potentially be used in both emergency and non-emergency clinical situations.
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Mousa OY, Kamath PS. A History of the Assessment of Liver Performance. Clin Liver Dis (Hoboken) 2021; 18:28-48. [PMID: 34745582 PMCID: PMC8555456 DOI: 10.1002/cld.1100] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/15/2021] [Accepted: 01/19/2021] [Indexed: 02/04/2023] Open
Abstract
Content available: Author Interview and Audio Recording.
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Affiliation(s)
- Omar Y. Mousa
- Division of Gastroenterology and HepatologyDepartment of Internal MedicineMayo ClinicRochesterMN
| | - Patrick S. Kamath
- Division of Gastroenterology and HepatologyDepartment of Internal MedicineMayo ClinicRochesterMN
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Liu J, Ma J, Zhou C, Yang C, Huang S, Shi Q, Xiong B. Potential Benefits of Underdilation of 8-mm Covered Stent in Transjugular Intrahepatic Portosystemic Shunt Creation. Clin Transl Gastroenterol 2021; 12:e00376. [PMID: 34140457 PMCID: PMC8216680 DOI: 10.14309/ctg.0000000000000376] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/02/2021] [Accepted: 05/26/2021] [Indexed: 12/14/2022] Open
Abstract
INTRODUCTION Hepatic encephalopathy (HE) is a major complication of transjugular intrahepatic portosystemic shunt (TIPS) creation. This study was aimed to determine whether underdilated TIPS with 8-mm polytetrafluoroethylene-covered stents could reduce the risk of HE and liver damage yet maintain clinical and hemodynamic efficacy. METHODS This retrospective case-controlled study included 134 patients treated with TIPS from March 2017 to November 2019. All the TIPS procedures were created using 8-mm covered stents, and according to the diameter of expansion balloon catheters, the patients were divided into 2 groups, an underdilated group (6-mm balloon catheter, n = 73) and a control group (8-mm balloon catheter, n = 61). RESULTS The Kaplan-Meier analysis indicated that the cumulative incidence of overt HE in the underdilated group was significantly lower than that in the control group (11.0% vs 29.5%, log rank P = 0.007), but no statistical differences were found toward variceal rebleeding, shunt dysfunction, and survival between groups. In multivariate analysis, the independent risk factors for overt HE were identified as age (hazard ratio [HR] = 1.036, 95% confidence interval [CI] = 1.003-1.069, P = 0.032), Child-Pugh score (HR = 1.519, 95% CI = 1.212-1.905, P < 0.001), and group assignment (HR = 0.291, 95% CI = 0.125-0.674, P = 0.004). DISCUSSION Underdilated TIPS with 8-mm polytetrafluoroethylene-covered stents could reduce the risk of HE and liver function impairment compared with completely dilated TIPS, but not increase the risk of variceal rebleeding, shunt dysfunction, and death.
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Affiliation(s)
- Jiacheng Liu
- Department of Radiology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China;
- Hubei Province Key Laboratory of Molecular Imaging, Wuhan, China
| | - Jinqiang Ma
- Department of Radiology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China;
- Hubei Province Key Laboratory of Molecular Imaging, Wuhan, China
| | - Chen Zhou
- Department of Radiology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China;
- Hubei Province Key Laboratory of Molecular Imaging, Wuhan, China
| | - Chongtu Yang
- Department of Radiology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China;
- Hubei Province Key Laboratory of Molecular Imaging, Wuhan, China
| | - Songjiang Huang
- Department of Radiology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China;
- Hubei Province Key Laboratory of Molecular Imaging, Wuhan, China
| | - Qin Shi
- Department of Radiology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China;
- Hubei Province Key Laboratory of Molecular Imaging, Wuhan, China
| | - Bin Xiong
- Department of Radiology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China;
- Hubei Province Key Laboratory of Molecular Imaging, Wuhan, China
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Tamarozzi F, Fittipaldo VA, Orth HM, Richter J, Buonfrate D, Riccardi N, Gobbi FG. Diagnosis and clinical management of hepatosplenic schistosomiasis: A scoping review of the literature. PLoS Negl Trop Dis 2021; 15:e0009191. [PMID: 33764979 PMCID: PMC7993612 DOI: 10.1371/journal.pntd.0009191] [Citation(s) in RCA: 28] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND Hepatosplenic schistosomiasis (HSS) is a disease caused by chronic infection with Schistosma spp. parasites residing in the mesenteric plexus; portal hypertension causing gastrointestinal bleeding is the most dangerous complication of this condition. HSS requires complex clinical management, but no specific guidelines exist. We aimed to provide a comprehensive picture of consolidated findings and knowledge gaps on the diagnosis and treatment of HSS. METHODOLOGY/PRINCIPAL FINDINGS We reviewed relevant original publications including patients with HSS with no coinfections, published in the past 40 years, identified through MEDLINE and EMBASE databases. Treatment with praziquantel and HSS-associated pulmonary hypertension were not investigated. Of the included 60 publications, 13 focused on diagnostic aspects, 45 on therapeutic aspects, and 2 on both aspects. Results were summarized using effect direction plots. The most common diagnostic approaches to stratify patients based on the risk of variceal bleeding included the use of ultrasonography and platelet counts; on the contrary, evaluation and use of noninvasive tools to guide the choice of therapeutic interventions are lacking. Publications on therapeutic aspects included treatment with beta-blockers, local management of esophageal varices, surgical procedures, and transjugular intrahepatic portosystemic shunt. Overall, treatment approaches and measured outcomes were heterogeneous, and data on interventions for primary prevention of gastrointestinal bleeding and on the long-term follow-up after interventions were lacking. CONCLUSIONS Most interventions have been developed on the basis of individual groups' experiences and almost never rigorously compared; furthermore, there is a lack of data regarding which parameters can guide the choice of intervention. These results highlight a dramatic need for the implementation of rigorous prospective studies with long-term follow-up in different settings to fill such fundamental gaps, still present for a disease affecting millions of patients worldwide.
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Affiliation(s)
- Francesca Tamarozzi
- Department of Infectious-Tropical Diseases and Microbiology, IRCCS (Istituto di Ricovero e Cura a Carattere Scientifico) Sacro Cuore Don Calabria Hospital, Negrar di Valpolicella, Verona, Italy
| | - Veronica A. Fittipaldo
- Department of Infectious-Tropical Diseases and Microbiology, IRCCS (Istituto di Ricovero e Cura a Carattere Scientifico) Sacro Cuore Don Calabria Hospital, Negrar di Valpolicella, Verona, Italy
| | - Hans Martin Orth
- Department of Gastroenterology, Hepatology and Infectious Diseases, Duesseldorf University Hospital, Heinrich Heine University, Düsseldorf, Germany
| | - Joachim Richter
- Institute of Tropical Medicine and International Health, Charité Universitätsmedizin, Berlin, Germany
| | - Dora Buonfrate
- Department of Infectious-Tropical Diseases and Microbiology, IRCCS (Istituto di Ricovero e Cura a Carattere Scientifico) Sacro Cuore Don Calabria Hospital, Negrar di Valpolicella, Verona, Italy
| | - Niccolò Riccardi
- Department of Infectious-Tropical Diseases and Microbiology, IRCCS (Istituto di Ricovero e Cura a Carattere Scientifico) Sacro Cuore Don Calabria Hospital, Negrar di Valpolicella, Verona, Italy
| | - Federico G. Gobbi
- Department of Infectious-Tropical Diseases and Microbiology, IRCCS (Istituto di Ricovero e Cura a Carattere Scientifico) Sacro Cuore Don Calabria Hospital, Negrar di Valpolicella, Verona, Italy
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Evaluation of impact of elective invasive examinations in patients with transjugular intrahepatic portosystemic shunt in the long-term follow up. ZEITSCHRIFT FUR GASTROENTEROLOGIE 2021; 59:24-34. [PMID: 33429447 DOI: 10.1055/a-1330-9867] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
INTRODUCTION In the management of patients with decompensated liver cirrhosis, transjugular intrahepatic portosystemic shunt (TIPS) insertion is well-established but common recommendations in the follow up management are inconsistent. Doppler sonography is commonly used for detection for TIPS dysfunction whilst data on the impact of elective invasive examinations are scarce. AIM The aim of this retrospective analysis is to evaluate potential benefits of elective invasive examinations in the follow up management of patients after TIPS insertion METHODS: Data of all patients receiving TIPS at the university hospitals of Muenster and Bonn between 2013 and 2018 (n = 534) were collected. The impact of performance of elective invasive examinations at 12 months after TIPS insertion on the occurrence of liver related events (LREs) and frequency of TIPS revisions within 24 months after TIPS insertion was analyzed. RESULTS No significant differences were found concerning occurrence of liver related events after 24 months depending on whether an elective invasive examination was performed. Occurrence of hepatic encephalopathy, relapse of initial indication for TIPS, as well as death or liver transplantation all did not differ. These findings were verified by a subgroup analysis including only patients who did not experience a LRE or TIPS revision within the first 12 months after TIPS procedure. CONCLUSION The analyzed data suggest no evidence for a beneficial impact due to implementation of an elective invasive examination program after TIPS insertion. Invasive examinations should remain reserved to patients with suspected TIPS dysfunction.
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Yang J, Zhu J, Sze DY, Cui L, Li X, Bai Y, Ai D, Fan J, Song H, Duan F. Feasibility of Augmented Reality-Guided Transjugular Intrahepatic Portosystemic Shunt. J Vasc Interv Radiol 2020; 31:2098-2103. [PMID: 33261744 DOI: 10.1016/j.jvir.2020.07.025] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2020] [Revised: 07/14/2020] [Accepted: 07/16/2020] [Indexed: 02/07/2023] Open
Abstract
PURPOSE To investigate an augmented reality (AR)-guided endovascular puncture to facilitate successful transjugular intrahepatic portosystemic shunt (TIPS). MATERIALS AND METHODS An AR navigation system for TIPS was designed. Three-dimensional (3D) liver models including portal and hepatic vein anatomy were extracted from preoperative CT images. The 3D models, intraoperative subjects, and electromagnetic tracking information of the puncture needles were integrated through the system calibration. In the AR head-mounted display, the 3D models were overlaid on the subjects, which was a liver phantom in the first phase and live beagle dogs in the second phase. One life-size liver phantom and 9 beagle dogs were used in the experiments. Imaging after puncture was performed to validate whether the needle tip accessed the target hepatic vein successfully. RESULTS Endovascular punctures of the portal vein of the liver phantom were repeated 30 times under the guidance of the AR system, and the puncture needle successfully accessed the target vein during each attempt. In the experiments of live canine subjects, the punctures were successful in 2 attempts in 7 beagle dogs and in 1 attempt in the remaining 2 dogs. The puncture time of needle from hepatic vein to portal vein was 5-10 s in the phantom experiments and 10-30 s in the canine experiments. CONCLUSIONS The feasibility of AR-based navigation facilitating accurate and successful portal vein access in preclinical models of TIPS was validated.
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Affiliation(s)
- Jian Yang
- Beijing Engineering Research Center of Mixed Reality and Advanced Display, School of Optics and Photonics, Beijing Institute of Technology, Beijing, China
| | - Jianjun Zhu
- Beijing Engineering Research Center of Mixed Reality and Advanced Display, School of Optics and Photonics, Beijing Institute of Technology, Beijing, China
| | - Daniel Y Sze
- Division of Interventional Radiology, Stanford University School of Medicine, Palo Alto, California
| | - Li Cui
- Department of Interventional Radiology, Chinese PLA General Hospital, Fuxing Road 28, Haidian District, Beijing 100853, China
| | - Xiaohui Li
- Department of Interventional Radiology, Chinese PLA General Hospital, Fuxing Road 28, Haidian District, Beijing 100853, China
| | - Yanhua Bai
- Department of Interventional Radiology, Chinese PLA General Hospital, Fuxing Road 28, Haidian District, Beijing 100853, China
| | - Danni Ai
- Beijing Engineering Research Center of Mixed Reality and Advanced Display, School of Optics and Photonics, Beijing Institute of Technology, Beijing, China
| | - Jingfan Fan
- Beijing Engineering Research Center of Mixed Reality and Advanced Display, School of Optics and Photonics, Beijing Institute of Technology, Beijing, China
| | - Hong Song
- School of Computer Science and Technology, Beijing Institute of Technology, Beijing, China
| | - Feng Duan
- Department of Interventional Radiology, Chinese PLA General Hospital, Fuxing Road 28, Haidian District, Beijing 100853, China.
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Zanetto A, Barbiero G, Battistel M, Sciarrone SS, Shalaby S, Pellone M, Battistella S, Gambato M, Germani G, Russo FP, Burra P, Senzolo M. Management of portal hypertension severe complications. Minerva Gastroenterol (Torino) 2020; 67:26-37. [PMID: 33140623 DOI: 10.23736/s2724-5985.20.02784-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Portal hypertension is a clinical syndrome characterized by an increase in the portal pressure gradient, defined as the gradient between the portal vein at the site downstream of the site of obstruction and the inferior vena cava. The most frequent cause of portal hypertension is cirrhosis. In patients with cirrhosis, portal hypertension is the main driver of cirrhosis progression and development of hepatic decompensation (ascites, variceal hemorrhage and hepatic encephalopathy), which defines the transition from compensated to decompensated stage. In decompensated patients, treatments aim at lowering the risk of death by preventing further decompensation and/or development of acute-on-chronic liver failure. Decompensated patients often pose a complex challenge which typically requires a multidisciplinary approach. The aims of the present review were to discuss the current knowledge regarding interventional treatments for patients with portal hypertension complications as well as to highlight useful information to aid hepatologists in their clinical practice. Specifically, we discussed the indications and contraindications of transjugular intra-hepatic portosystemic shunt and for the treatment of gastro-esophageal variceal hemorrhage in patients with decompensated cirrhosis (first section); we reviewed the use of interventional treatments in patients with hepatic vein obstruction (Budd-Chiari Syndrome) and in those with portal vein thrombosis (second section); and we briefly comment on the most frequent applications of selective splenic embolization in patients with and without underlying cirrhosis (third section).
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Affiliation(s)
- Alberto Zanetto
- Unit of Gastroenterology and Multivisceral Transplant, Department of Surgery, Oncology, and Gastroenterology, University Hospital of Padua, Padua, Italy
| | - Giulio Barbiero
- Department of Medicine, Institute of Radiology, University Hospital of Padua, Padua, Italy
| | - Michele Battistel
- Department of Medicine, Institute of Radiology, University Hospital of Padua, Padua, Italy
| | - Salvatore S Sciarrone
- Unit of Gastroenterology and Multivisceral Transplant, Department of Surgery, Oncology, and Gastroenterology, University Hospital of Padua, Padua, Italy
| | - Sarah Shalaby
- Unit of Gastroenterology and Multivisceral Transplant, Department of Surgery, Oncology, and Gastroenterology, University Hospital of Padua, Padua, Italy
| | - Monica Pellone
- Unit of Gastroenterology and Multivisceral Transplant, Department of Surgery, Oncology, and Gastroenterology, University Hospital of Padua, Padua, Italy
| | - Sara Battistella
- Unit of Gastroenterology and Multivisceral Transplant, Department of Surgery, Oncology, and Gastroenterology, University Hospital of Padua, Padua, Italy
| | - Martina Gambato
- Unit of Gastroenterology and Multivisceral Transplant, Department of Surgery, Oncology, and Gastroenterology, University Hospital of Padua, Padua, Italy
| | - Giacomo Germani
- Unit of Gastroenterology and Multivisceral Transplant, Department of Surgery, Oncology, and Gastroenterology, University Hospital of Padua, Padua, Italy
| | - Francesco P Russo
- Unit of Gastroenterology and Multivisceral Transplant, Department of Surgery, Oncology, and Gastroenterology, University Hospital of Padua, Padua, Italy
| | - Patrizia Burra
- Unit of Gastroenterology and Multivisceral Transplant, Department of Surgery, Oncology, and Gastroenterology, University Hospital of Padua, Padua, Italy
| | - Marco Senzolo
- Unit of Gastroenterology and Multivisceral Transplant, Department of Surgery, Oncology, and Gastroenterology, University Hospital of Padua, Padua, Italy -
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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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Sterpetti AV, Kappes SK. Cirrhosis and Bleeding Esophageal Varices: Historic Perspectives. J Gastrointest Surg 2020; 24:1929-1936. [PMID: 32500417 DOI: 10.1007/s11605-020-04674-8] [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: 03/17/2020] [Accepted: 05/25/2020] [Indexed: 01/31/2023]
Abstract
The paper describes the fundamental discoveries in the definition and treatment of patients with bleeding esophageal varices and cirrhosis.
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Affiliation(s)
- Antonio V Sterpetti
- University of Rome Sapienza, Rome, Italy. .,Policlinico Umberto I, Viale del Policlinico, 00167, Rome, Italy.
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Du H, Yao Y, He S, Feng L, Wu H. Effect of VIATORR stent in early ultrasound evaluation after transjugular intrahepatic portosystemic shunt (TIPS): A case report. J Interv Med 2020; 3:106-108. [PMID: 34805918 PMCID: PMC8562229 DOI: 10.1016/j.jimed.2020.03.010] [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] [Indexed: 11/30/2022] Open
Abstract
Shunt dysfunction is a major complication of transjugular intrahepatic portosystemic shunt (TIPS). Ultrasonography is a preferred method of shunt follow-up after TIPS, but some misjudgments can occur in cases of shunt dysfunction due to peculiarities of the VIATORR stent. Here we report one case and suggest that the first ultrasound evaluation for patients who received TIPS procedure with VIATORR stent should be performed one month after the procedure.
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Affiliation(s)
- Heng Du
- Department of Gastroenterology, Suining Central Hospital, Suining, 629000, China
- Corresponding author. Suining Central Hospital, No.127, West Desheng Road, Suining, 629000, Sichuan Province, China.
| | - Yong Yao
- Department of Gastroenterology, Suining Central Hospital, Suining, 629000, China
| | - Suyu He
- Department of Gastroenterology, Suining Central Hospital, Suining, 629000, China
| | - Lei Feng
- Department of Gastroenterology, Suining Central Hospital, Suining, 629000, China
| | - Hang Wu
- Department of Ultrasonography, Suining Central Hospital, Suining, 629000, China
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Henderson JM, Anderson CD. The Surgical Treatment of Portal Hypertension. Clin Liver Dis (Hoboken) 2020; 15:S52-S63. [PMID: 32140214 PMCID: PMC7050955 DOI: 10.1002/cld.877] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/15/2019] [Accepted: 08/25/2019] [Indexed: 02/04/2023] Open
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Allegretti AS, Frenk NE, Li DK, Seethapathy H, Vela Parada XF, Long J, Endres P, Pratt DS, Chung RT, Ganguli S, Irani Z, Yamada K. Evaluation of model performance to predict survival after transjugular intrahepatic portosystemic shunt placement. PLoS One 2019; 14:e0217442. [PMID: 31120995 PMCID: PMC6533008 DOI: 10.1371/journal.pone.0217442] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2019] [Accepted: 05/10/2019] [Indexed: 12/14/2022] Open
Abstract
Background/Aims The MELD score was developed to predict survival after transjugular intrahepatic portosystemic shunt (TIPS) placement. Given changes in practice patterns and development of new prognostic tools in cirrhosis, we aimed to evaluate common models to predict mortality after TIPS placement. Methods Analysis of consecutive patients who underwent TIPS placement for ascites or bleeding. Performance to predict 90-day mortality was assessed by C statistic for six models (MELD, MELD-Na, CLIF-C ACLF, Child-Pugh, Platelet-Albumin-Bilirubin, and Emory score). Added predictive value to MELD score was assessed for univariate predictors of 90-day mortality. Stratified analysis by TIPS indication, emergent placement status, and TIPS stent type was performed. Results 413 patients were analyzed (248 with variceal bleeding, 165 with refractory ascites). 90-day mortality was 27% (113/413). Mean MELD score was 15 ± 7.9. MELD score best predicted mortality for all patients (c = 0.779), for variceal bleeding (c = 0.844), and for emergent TIPS (c = 0.817). CLIF-C ACLF score best predicted mortality for refractory ascites (c = 0.707). Addition of sodium to the MELD score did not improve predictive value across multiple strata. Addition of hemoglobin improved MELD score’s predictive value in variceal bleeding. Addition of age improved MELD score’s predictive value in refractory ascites. Conclusions MELD score best predicted 90-day mortality. Addition of sodium to the MELD score did not improve its performance, though mortality prediction was improved using Age-MELD for ascites and Hemoglobin-MELD for bleeding. An individualized risk stratification approach may be best when considering candidates for TIPS placement.
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Affiliation(s)
- Andrew S. Allegretti
- Division of Nephrology, Department of Medicine, Massachusetts General Hospital, Boston, MA, United States of America
- * E-mail:
| | - Nathan E. Frenk
- Division of Interventional Radiology, Department of Radiology, Massachusetts General Hospital, Boston, MA, United States of America
| | - Darrick K. Li
- Liver Center and Gastrointestinal Division, Department of Medicine, Massachusetts General Hospital, Boston, MA, United States of America
| | - Harish Seethapathy
- Division of Nephrology, Department of Medicine, Massachusetts General Hospital, Boston, MA, United States of America
| | - Xavier F. Vela Parada
- Division of Nephrology, Department of Medicine, Massachusetts General Hospital, Boston, MA, United States of America
- Department of Medicine, Mount Sinai West and St. Luke’s Hospital, New York, NY, United States of America
| | - Joshua Long
- Division of Nephrology, Department of Medicine, Massachusetts General Hospital, Boston, MA, United States of America
| | - Paul Endres
- Division of Nephrology, Department of Medicine, Massachusetts General Hospital, Boston, MA, United States of America
| | - Daniel S. Pratt
- Liver Center and Gastrointestinal Division, Department of Medicine, Massachusetts General Hospital, Boston, MA, United States of America
| | - Raymond T. Chung
- Liver Center and Gastrointestinal Division, Department of Medicine, Massachusetts General Hospital, Boston, MA, United States of America
| | - Suvranu Ganguli
- Division of Interventional Radiology, Department of Radiology, Massachusetts General Hospital, Boston, MA, United States of America
| | - Zubin Irani
- Division of Interventional Radiology, Department of Radiology, Massachusetts General Hospital, Boston, MA, United States of America
| | - Kei Yamada
- Division of Interventional Radiology, Department of Radiology, Massachusetts General Hospital, Boston, MA, United States of America
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Manekeller S, Kalff JC. [Esophageal variceal bleeding: management and tips on transjugular intrahepatic portosystemic shunt]. Chirurg 2019; 90:614-620. [PMID: 30963209 DOI: 10.1007/s00104-019-0949-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
BACKGROUND Esophageal variceal bleeding is a life-threatening complication in patients with liver cirrhosis, which is pathophysiologically explained by the presence of portal hypertension. The incidence of such bleeding greatly depends on the severity of the underlying liver disease. OBJECTIVE The aim of this article is to present the current treatment concepts for acute esophageal variceal bleeding, the management in acute situations and the indications for treatment of the causal portal hypertension with a transjugular intrahepatic portosystemic shunt (TIPS). RESULTS In patients with liver cirrhosis or any other disease causing portal hypertension, a staging examination by esophagogastroduodenoscopy is first carried out for determination of the stage of the varices and the resulting necessary treatment. In addition, determination of the portal pressure gradient is useful. In patients with varices a medicinal or endoscopic bleeding prophylaxis should subsequently additionally be initiated. After an acute variceal bleeding event, under clearly defined prerequisites an evaluation for TIPS implantation should be considered. This is the only effective treatment for reducing portal hypertension. CONCLUSION With appropriate indications implantation of a TIPS is an effective strategy to lower portal hypertension and therefore prevent recurrent variceal bleeding. The resulting improvement of the portal hemodynamics leads to an improvement in kidney function; however, it also leads to deterioration of liver function with subsequent development or deterioration of a previously existing hepatic encephalopathy.
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Affiliation(s)
- S Manekeller
- Klinik und Poliklinik für Allgemein‑, Viszeral‑, Thorax- und Gefäßchirurgie, Universitätsklinikum der Rheinischen Friedrich-Wilhelms-Universität Bonn, Sigmund-Freud-Straße 25, 53127, Bonn, Deutschland.
| | - J C Kalff
- Klinik und Poliklinik für Allgemein‑, Viszeral‑, Thorax- und Gefäßchirurgie, Universitätsklinikum der Rheinischen Friedrich-Wilhelms-Universität Bonn, Sigmund-Freud-Straße 25, 53127, Bonn, Deutschland
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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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Image-guided treatment of Budd-Chiari syndrome: a giant leap from the past, a small step towards the future. Abdom Radiol (NY) 2018; 43:1908-1919. [PMID: 28988356 DOI: 10.1007/s00261-017-1341-y] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Budd-Chiari syndrome (BCS) is a relatively rare vascular disease characterized by hepatic outflow tract obstruction, and image-guided endovascular treatment, namely percutaneous angioplasty, stenting, and transjugular intrahepatic portosystemic shunt (TIPS), has proven to be effective treatment modalities to alleviate symptoms and markedly improve the prognosis of the disease. Specifically, a step-wise approach is recommended, i.e., angioplasty and stenting are the prioritized choice for patients with membranous obstruction and short-length stenosis, whereas TIPS is the option for patients who fail this treatment. Currently, 5-year survival with the step-wise approach is about 75%, and the most promising way to further improve this value is to identify candidates who are at high risk of failing angioplasty, and perform pre-emptive TIPS in these patients.
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Hüsing-Kabar A, Meister T, Köhler M, Domschke W, Kabar I, Wilms C, Hild B, Schmidt HH, Heinzow HS. Is de novo hepatocellular carcinoma after transjugular intrahepatic portosystemic shunt increased? United European Gastroenterol J 2018; 6:413-421. [PMID: 29774155 PMCID: PMC5949971 DOI: 10.1177/2050640617732886] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/21/2017] [Accepted: 08/30/2017] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND Portal hypertension is a major complication of liver cirrhosis. Transjugular intrahepatic portosystemic shunt is effective in treatment of portal hypertension. However, decreased parenchymal portal venous flow after transjugular intrahepatic portosystemic shunt insertion favours ischaemic liver injury which has been discussed to induce hepatocarcinogenesis causing hepatocellular cancer. AIM This study aimed to explore the association between transjugular intrahepatic portosystemic shunt placement and the development of hepatocellular cancer. METHODS A total of 1338 consecutive liver cirrhosis patients were included in this retrospective study between January 2004-December 2015. Data were analysed with regard to development of hepatocellular cancer during follow-up. Binary logistic regression and Kaplan-Meier analyses were conducted for the assessment of risk factors for hepatocellular cancer development. In a second step, to rule out confounders of group heterogeneity, case-control matching was performed based on gender, age, model of end-stage liver disease score and underlying cause of cirrhosis (non-alcoholic steatohepatitis, alcoholic liver disease and viral hepatitis). RESULTS Besides established risk factors such as older age, male gender and underlying viral hepatitis, statistical analysis revealed the absence of transjugular intrahepatic portosystemic shunt insertion as a risk factor for hepatocellular cancer development. Furthermore, matched-pair analysis of 432 patients showed a significant difference (p = 0.003) in the emergence of hepatocellular cancer regarding transjugular intrahepatic portosystemic shunt placement versus the non-transjugular intrahepatic portosystemic shunt cohort. CONCLUSION In patients with end-stage liver disease, transjugular intrahepatic portosystemic shunt insertion is significantly associated with reduced rates of hepatocellular cancer development.
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Affiliation(s)
- A Hüsing-Kabar
- Department of Transplant Medicine, University Hospital
Muenster, Muenster, Germany
| | - T Meister
- Department of Gastroenterology, HELIOS
Albert-Schweitzer-Hospital Northeim, Northeim, Germany
| | - M Köhler
- Department of Clinical Radiology, University Hospital
Muenster, Muenster, Germany
| | - W Domschke
- Department of Medicine B, University Hospital
Muenster, Muenster, Germany
| | - I Kabar
- Department of Transplant Medicine, University Hospital
Muenster, Muenster, Germany
| | - C Wilms
- Department of Transplant Medicine, University Hospital
Muenster, Muenster, Germany
| | - B Hild
- Department of Transplant Medicine, University Hospital
Muenster, Muenster, Germany
| | - HH Schmidt
- Department of Transplant Medicine, University Hospital
Muenster, Muenster, Germany
| | - HS Heinzow
- Department of Transplant Medicine, University Hospital
Muenster, Muenster, Germany
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Triantafyllou T, Aggarwal P, Gupta E, Svetanoff WJ, Bhirud DP, Singhal S. Polytetrafluoroethylene-Covered Stent Graft Versus Bare Stent in Transjugular Intrahepatic Portosystemic Shunt: Systematic Review and Meta-Analysis. J Laparoendosc Adv Surg Tech A 2018; 28:867-879. [PMID: 29356589 DOI: 10.1089/lap.2017.0560] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND & AIMS Transjugular Intrahepatic Portosystemic Shunt (TIPS) is used to control refractory variceal bleeding secondary to portal hypertension. This meta-analysis was conducted to systematically review polytetrafluoroethylene-covered stent grafts (CS) versus bare stents (BS) in TIPS procedure. METHODS Systematic search of literature databases was done from January-1990 till April-2017, using predecided keywords. Outcome measures studied were (1) primary-patency (PP) at 1 year (defined as absence of shunt insufficiency at 1 year), (2) rebleeding (RE) (3) new-onset hepatic encephalopathy ([HE] new-onset or worsening encephalopathy following the procedure), and (4) survival at 1 year (SU). Odds ratio (OR) was calculated for each outcome variable. Between-study heterogeneity was assessed by the I2 statistics and χ2 Q-test. RESULTS Fourteen studies (4 RCTs, 2 prospective nonrandomized, and 8 retrospective) were included with 2519 patients (1548 patients in BS group and 971 patients in CS group). Three-quarter outcome measures showed significantly better results with CS. PP was pooled from 13 studies and showed an OR = 4.75 (95% confidence interval [CI] = 3.32-6.79; P < .00001; I2 = 44%) in favor of CS. RE was pooled from six studies with odds ratio (OR) = 0.37(95% CI = 0.24-0.56; P < .00001; I2 = 0%) in favor of CS. SU was pooled from 11 studies with OR = 1.85 (95% CI = 1.44-2.38; P < .00001; I2 = 0%) in favor of CS. On subset analysis for RCTs, three outcome variables favored CS with minimal heterogeneity [PP: OR = 4.18 (95% CI = 2.66-6.55; P < .00001; I2 = 0%). RE: OR = 0.43 (95% CI = 0.25-0.72; P < .001; I2 = 0%). SU: OR = 1.85 (95% CI = 1.44-2.38, P < .00001; I2 = 0%)]. HE showed no difference between two stents on the overall and subset pooled analysis. Overall: OR = 0.86 (95% CI = 0.68-1.08; P = .19; I2 = 4%). Only RCTs: OR = 0.91 (95% CI = 0.63-1.32, P = .63; I2 = 0%). CONCLUSIONS CS is associated with better primary patency and survival and lesser rate of rebleeding than BS in patients undergoing TIPS procedure. There is no difference in new-onset hepatic encephalopathy.
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Affiliation(s)
| | - Piyush Aggarwal
- 2 All India Institute of Medical Sciences , New Delhi, India
| | - Ekansh Gupta
- 2 All India Institute of Medical Sciences , New Delhi, India
| | - Wendy Jo Svetanoff
- 3 Boston Children's Hospital , Harvard Medical School, Boston, Massachusetts
| | | | - Saurabh Singhal
- 5 St. Joseph's Hospital and Medical Centre , Phoenix, Arizona
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Tang Y, Zheng S, Yang J, Bao W, Yang L, Li Y, Xu Y, Yang J, Tong Y, Gao J, Tang C. Use of concomitant variceal embolization and prophylactic antiplatelet/anticoagulative in transjugular intrahepatic portosystemic shunting: A retrospective study of 182 cirrhotic portal hypertension patients. Medicine (Baltimore) 2017; 96:e8678. [PMID: 29245228 PMCID: PMC5728843 DOI: 10.1097/md.0000000000008678] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
Transjugular intrahepatic portosystemic shunting (TIPS) is an effective treatment modality for refractory variceal bleeding and ascites in patients with cirrhotic portal hypertension (CPH). Variceal rebleeding and shunt dysfunction are major post-TIPS morbidities. This study aimed to retrospectively evaluate the effectiveness and safety of use of concomitant variceal embolization and prophylactic antiplatelet/anticoagulative in patients with CPH undergoing TIPS. Between October 2006 and October 2011, 182 patients with CPH were retrospectively and consecutively hospitalized for elective TIPS with Fluency stenting. Concomitant variceal embolization was given after establishing the shunt. Subcutaneous heparin was given after TIPS and replaced by oral clopidogrel, aspirin, or warfarin for at least 6 months. Main outcome measures included shunt patency rate, recurrence of CPH (rebleeding and/or refractory ascites), hepatic encephalopathy (HE) frequency, and post-TIPS survival. The cumulative primary patency rate was 96%, 94%, 90%, 88%, and 88% at 6, 12, 24, 36, and 48 months, respectively. Shunt stenosis occurred in 16 (9%) patients, gastrointestinal (GI) rebleeding in 32 (17.5%) patients, recurrence of refractory ascites 44 (48%) patients, HE in 42 (23%) patients, and death in 36 (20%) patients during the follow-up period. Use of concomitant variceal embolization and prophylactic antiplatelet/anticoagulative was associated with a favorable shunt patency and a low risk of GI rebleeding.
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Affiliation(s)
- Yingmei Tang
- Department of Gastroenterology and Yunnan Research Center for Liver Diseases, The 2nd Affiliated Hospital of Kunming Medical University
| | - Sheng Zheng
- Department of Gastroenterology, Yunnan Provincial 3rd People's Hospital
| | - Jinhui Yang
- Department of Gastroenterology and Yunnan Research Center for Liver Diseases, The 2nd Affiliated Hospital of Kunming Medical University
| | - Weimin Bao
- Department of General Surgery, Yunnan Provincial 1st People's Hospital
| | - Lihong Yang
- Department of Gastroenterology and Yunnan Research Center for Liver Diseases, The 2nd Affiliated Hospital of Kunming Medical University
| | - Yingchun Li
- Department of Interventional Radiology, The 2nd Affiliated Hospital of Kunming Medical University, Kunming, Yunnan
| | - Ying Xu
- Department of Gastroenterology and Yunnan Research Center for Liver Diseases, The 2nd Affiliated Hospital of Kunming Medical University
| | - Jing Yang
- Department of Gastroenterology and Yunnan Research Center for Liver Diseases, The 2nd Affiliated Hospital of Kunming Medical University
| | - Yuyun Tong
- Department of Interventional Radiology, The 2nd Affiliated Hospital of Kunming Medical University, Kunming, Yunnan
| | - Jinhang Gao
- Department of Gastroenterology, West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Chengwei Tang
- Department of Gastroenterology, West China Hospital, Sichuan University, Chengdu, Sichuan, China
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Yin X, Lei X, Xu C, Yang J, Zhao Y, Li K. Hepatic artery embolization cures the acute pancreatitis associated with a tiny arteriobiliary fistula after TIPS: A case report. Medicine (Baltimore) 2017; 96:e9267. [PMID: 29390375 PMCID: PMC5815787 DOI: 10.1097/md.0000000000009267] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
RATIONALE Esophageal variceal bleeding caused by portal hypertension is massive and life-threatening to those patients with decompensated liver cirrhosis. A transjugular intrahepatic portosystemic shunt (TIPS) can effectively stop bleeding. But the process of puncture may lead to bile duct injury and even form fistulas between the hepatic artery and bile duct. PATIENT CONCERNS The case report illustrated a 52-year-old Chinese female patient who underwent TIPS. DIAGNOSES She suffered from acute upper gastrointestinal hemorrhage and acute pancreatitis because of the bile duct injury after TIPS. INTERVENTIONS The fistulas between the hepatic artery and bile duct was embolized. OUTCOMES The acute upper gastrointestinal hemorrhage and acute pancreatitis of the patient were cured. LESSONS The arteriobiliary fistula should be paid more attention after TIPS while early-stage prevention should be carried out.
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Affiliation(s)
- Xiuli Yin
- Department of Gastroenterology, Shandong Provincial Rongjun Hospital
| | - Xiaofei Lei
- Department of Gastroenterology, Shandong Provincial Qianfoshan Hospital of Shandong University, Jinan, Shandong Province, China
| | - Changqing Xu
- Department of Gastroenterology, Shandong Provincial Qianfoshan Hospital of Shandong University, Jinan, Shandong Province, China
| | - Jing Yang
- Department of Gastroenterology, Shandong Provincial Qianfoshan Hospital of Shandong University, Jinan, Shandong Province, China
| | - Yingying Zhao
- Department of Gastroenterology, Shandong Provincial Qianfoshan Hospital of Shandong University, Jinan, Shandong Province, China
| | - Kun Li
- Department of Gastroenterology, Shandong Provincial Qianfoshan Hospital of Shandong University, Jinan, Shandong Province, China
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Wang Q, Lv Y, Bai M, Wang Z, Liu H, He C, Niu J, Guo W, Luo B, Yin Z, Bai W, Chen H, Wang E, Xia D, Li X, Yuan J, Han N, Cai H, Li T, Xie H, Xia J, Wang J, Zhang H, Wu K, Fan D, Han G. Eight millimetre covered TIPS does not compromise shunt function but reduces hepatic encephalopathy in preventing variceal rebleeding. J Hepatol 2017; 67:508-516. [PMID: 28506905 DOI: 10.1016/j.jhep.2017.05.006] [Citation(s) in RCA: 140] [Impact Index Per Article: 17.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/04/2017] [Revised: 04/20/2017] [Accepted: 05/03/2017] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS Currently, there are no recommendations in guidelines concerning the preferred diameter of stents for transjugular intrahepatic portosystemic shunt (TIPS), owing to the lack of adequate evidence. We therefore compared 8mm stents with 10mm stents, to evaluate whether 8mm stents would achieve similar shunt function, with less hepatic encephalopathy (HE) and better liver function. METHODS Cirrhotic patients were randomly assigned to receive TIPS with an 8mm or 10mm covered stent to prevent variceal rebleeding. The primary endpoint was shunt dysfunction. All-cause rebleeding, orthotopic liver transplantation (OLT)-free survival, their composite endpoint, overt HE (overall and spontaneous) and liver function were designated as the secondary endpoints. RESULTS From July 2012 to January 2014, 64 and 63 patients were allocated to the 8mm and 10mm groups, respectively. During a median follow-up of 27months in both arms, dysfunction rates (16% vs. 16% at two years, p=0.62), two-year rebleeding (16% vs. 17%, p=0.65), OLT-free survival (95% vs. 86%, p=0.37), and the composite endpoint (p=0.62) were not statistically different between the groups. Despite a marginal decrease in overall overt HE, there were significantly fewer spontaneous overt HE incidents in the 8mm group within two years (27% vs. 43%, p=0.03), with a risk reduction of 47%. Notably, patients receiving 8mm stents also developed less hepatic impairment. CONCLUSIONS TIPS with 8mm covered stents showed similar shunt function to TIPS with 10mm stents, but halved the risk of spontaneous overt HE and reduced hepatic impairment. Therefore, 8mm TIPS stents should be preferred for the prevention of variceal rebleeding in cirrhotic patients. Lay summary: The optimal diameter for transjugular intrahepatic portosystemic shunt (TIPS) remained uncertain. This study showed that TIPS with 8mm covered stents did not compromise shunt patency, or influence the efficacy of variceal rebleeding prevention compared to TIPS with 10mm stents, but reduced the risk of spontaneous overt hepatic encephalopathy and the incidence of severe encephalopathy. Moreover, liver function reserve was also better in the 8mm stents group, suggesting that 8mm TIPS stents should be preferred for the prevention of variceal rebleeding in cirrhotic patients.
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Affiliation(s)
- Qiuhe Wang
- Department of Liver Disease and Digestive Interventional Radiology, National Clinical Research Center for Digestive Diseases and Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an 710032, China
| | - Yong Lv
- Department of Liver Disease and Digestive Interventional Radiology, National Clinical Research Center for Digestive Diseases and Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an 710032, China
| | - Ming Bai
- Department of Liver Disease and Digestive Interventional Radiology, National Clinical Research Center for Digestive Diseases and Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an 710032, China
| | - Zhengyu Wang
- Department of Liver Disease and Digestive Interventional Radiology, National Clinical Research Center for Digestive Diseases and Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an 710032, China
| | - Haibo Liu
- Department of Liver Disease and Digestive Interventional Radiology, National Clinical Research Center for Digestive Diseases and Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an 710032, China
| | - Chuangye He
- Department of Liver Disease and Digestive Interventional Radiology, National Clinical Research Center for Digestive Diseases and Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an 710032, China
| | - Jing Niu
- Department of Liver Disease and Digestive Interventional Radiology, National Clinical Research Center for Digestive Diseases and Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an 710032, China
| | - Wengang Guo
- Department of Liver Disease and Digestive Interventional Radiology, National Clinical Research Center for Digestive Diseases and Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an 710032, China
| | - Bohan Luo
- Department of Liver Disease and Digestive Interventional Radiology, National Clinical Research Center for Digestive Diseases and Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an 710032, China
| | - Zhanxin Yin
- Department of Liver Disease and Digestive Interventional Radiology, National Clinical Research Center for Digestive Diseases and Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an 710032, China
| | - Wei Bai
- Department of Liver Disease and Digestive Interventional Radiology, National Clinical Research Center for Digestive Diseases and Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an 710032, China
| | - Hui Chen
- Department of Liver Disease and Digestive Interventional Radiology, National Clinical Research Center for Digestive Diseases and Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an 710032, China
| | - Enxin Wang
- Department of Liver Disease and Digestive Interventional Radiology, National Clinical Research Center for Digestive Diseases and Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an 710032, China
| | - Dongdong Xia
- Department of Liver Disease and Digestive Interventional Radiology, National Clinical Research Center for Digestive Diseases and Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an 710032, China
| | - Xiaomei Li
- Department of Liver Disease and Digestive Interventional Radiology, National Clinical Research Center for Digestive Diseases and Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an 710032, China
| | - Jie Yuan
- Department of Liver Disease and Digestive Interventional Radiology, National Clinical Research Center for Digestive Diseases and Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an 710032, China
| | - Na Han
- Department of Liver Disease and Digestive Interventional Radiology, National Clinical Research Center for Digestive Diseases and Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an 710032, China
| | - Hongwei Cai
- Department of Medical Statistics, Fourth Military Medical University, Xi'an 710032, China
| | - Tao Li
- Department of Ultrasound, Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an 710032, China
| | - Huahong Xie
- Department of Digestive Endoscopy, Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an 710032, China
| | - Jielai Xia
- Department of Medical Statistics, Fourth Military Medical University, Xi'an 710032, China
| | - Jianhong Wang
- Department of Ultrasound, Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an 710032, China
| | - Hongbo Zhang
- Department of Digestive Endoscopy, Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an 710032, China
| | - Kaichun Wu
- State Key Laboratory of Cancer Biology, National Clinical Research Center for Digestive Disease and Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an 710032, China
| | - Daiming Fan
- State Key Laboratory of Cancer Biology, National Clinical Research Center for Digestive Disease and Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an 710032, China
| | - Guohong Han
- Department of Liver Disease and Digestive Interventional Radiology, National Clinical Research Center for Digestive Diseases and Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an 710032, China.
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Pateria P, Jeffrey GP, Garas G, Tibballs J, Ferguson J, Delriviere L, Huang Y, Adams LA, MacQuillan G. Transjugular intrahepatic portosystemic shunt: Indications, complications, survival and its use as a bridging therapy to liver transplant in Western Australia. J Med Imaging Radiat Oncol 2017; 61:441-447. [DOI: 10.1111/1754-9485.12563] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2016] [Accepted: 10/28/2016] [Indexed: 12/23/2022]
Affiliation(s)
- Puraskar Pateria
- Department of Gastroenterology and Hepatology; Sir Charles Gairdner Hospital; Nedlands Western Australia Australia
| | - Gary P Jeffrey
- Department of Gastroenterology and Hepatology; Sir Charles Gairdner Hospital; Nedlands Western Australia Australia
- School of Medicine and Pharmacology; University of Western Australia; Nedlands Western Australia Australia
| | - George Garas
- Department of Gastroenterology and Hepatology; Sir Charles Gairdner Hospital; Nedlands Western Australia Australia
- School of Medicine and Pharmacology; University of Western Australia; Nedlands Western Australia Australia
| | - Jonathan Tibballs
- Department of Radiology; Sir Charles Gairdner Hospital; Nedlands Western Australia Australia
| | - John Ferguson
- Department of Radiology; Sir Charles Gairdner Hospital; Nedlands Western Australia Australia
| | - Luc Delriviere
- School of Medicine and Pharmacology; University of Western Australia; Nedlands Western Australia Australia
- Department of Surgery; Sir Charles Gairdner Hospital; Nedlands Western Australia Australia
| | - Yi Huang
- School of Medicine and Pharmacology; University of Western Australia; Nedlands Western Australia Australia
| | - Leon A Adams
- Department of Gastroenterology and Hepatology; Sir Charles Gairdner Hospital; Nedlands Western Australia Australia
- School of Medicine and Pharmacology; University of Western Australia; Nedlands Western Australia Australia
| | - Gerry MacQuillan
- Department of Gastroenterology and Hepatology; Sir Charles Gairdner Hospital; Nedlands Western Australia Australia
- School of Medicine and Pharmacology; University of Western Australia; Nedlands Western Australia Australia
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Transjugular intrahepatic portosystemic shunt in refractory hydrothorax - a contribution to an unexplored indication. Eur J Gastroenterol Hepatol 2016; 28:661-6. [PMID: 27002676 DOI: 10.1097/meg.0000000000000623] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
BACKGROUND AND AIMS Hepatic hydrothorax is a rare complication of portal hypertension, but may be potentially severe. Although conservative therapy may be effective, it is not without risk and refractory cases are not rare. The portal decompression achieved by transjugular intrahepatic portosystemic shunts (TIPS) has shown positive results in the treatment of refractory ascites, and in that sense, the analysis of their value in other complications of portal hypertension becomes relevant. The aim of this study was to evaluate the efficacy and safety of TIPS in patients with refractory hydrothorax. METHODS This was a retrospective study including patients with refractory hydrothorax undergoing TIPS in a tertiary hospital in the period between 2000 and 2014, and evaluated the following: demographic characteristics, liver disease, and outcomes (efficacy and safety, including complications after TIPS, liver transplantation, 30-day, and 1-year mortality). RESULTS Nineteen patients with hydrothorax underwent TIPS; most had previously undergone multiple thoracocentesis and all had hypoalbuminemia. In all, 57.9% of the patients were men, with a mean age 63±9 years, and 84.2% had cirrhosis of alcoholic etiology and a mean Model for End-Stage Liver Disease-16, Child-Pugh B in 42.1%/Child-Pugh C in 47.4%. TIPS was effective in 73.3% of the cases. Portosystemic encephalopathy was recorded in 66.6% of the cases. Mortality was 25% at 30 days and 42.8% at 1 year with septic complications or progression of liver disease. Two patients underwent liver transplantation. The mean follow-up duration was 704 days (3-3485 days). CONCLUSION TIPS appears to be a relatively efficient method to control hydrothorax, making it a valid option in refractory cases despite the high risk of portosystemic encephalopathy and mortality.
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Pereira K, Carrion AF, Martin P, Vaheesan K, Salsamendi J, Doshi M, Yrizarry JM. Current diagnosis and management of post-transjugular intrahepatic portosystemic shunt refractory hepatic encephalopathy. Liver Int 2015; 35:2487-94. [PMID: 26332169 DOI: 10.1111/liv.12956] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/23/2015] [Accepted: 08/24/2015] [Indexed: 02/07/2023]
Abstract
Transjugular intrahepatic portosystemic shunt has evolved into an important option for management of complications of portal hypertension. The use of polytetrafluoroethylene covered stents enhances shunt patency. Hepatic encephalopathy (HE) remains a significant problem after TIPS placement. The approach to management of patients with refractory hepatic encephalopathy typically requires collaboration between different specialties. Patient selection for TIPS requires careful evaluation of risk factors for HE. TIPS procedure-related technical factors like stent size, attention to portosystemic pressure gradient reduction and use of adjunctive variceal embolization maybe important. Conservative medical therapy in combination with endovascular therapies often results in resolution or substantial reduction of symptoms. Liver transplantation is, however, the ultimate treatment.
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Affiliation(s)
- Keith Pereira
- Department of Interventional Radiology, Jackson Memorial Hospital, University of Miami Hospital, Miami, FL, USA
| | - Andres F Carrion
- Division of Hepatology, Jackson Memorial Hospital, University of Miami Hospital, Miami, FL, USA
| | - Paul Martin
- Division of Hepatology, Jackson Memorial Hospital, University of Miami Hospital, Miami, FL, USA
| | - Kirubahara Vaheesan
- Department of Interventional Radiology, Saint Louis University School of medicine, St Louis, MO, USA
| | - Jason Salsamendi
- Department of Interventional Radiology, Jackson Memorial Hospital, University of Miami Hospital, Miami, FL, USA
| | - Mehul Doshi
- Department of Interventional Radiology, Jackson Memorial Hospital, University of Miami Hospital, Miami, FL, USA
| | - Jose M Yrizarry
- Department of Interventional Radiology, Jackson Memorial Hospital, University of Miami Hospital, Miami, FL, USA
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Pereira K, Baker R, Salsamendi J, Doshi M, Kably I, Bhatia S. An Approach to Endovascular and Percutaneous Management of Transjugular Intrahepatic Portosystemic Shunt (TIPS) Dysfunction: A Pictorial Essay and Clinical Practice Algorithm. Cardiovasc Intervent Radiol 2015; 39:639-651. [DOI: 10.1007/s00270-015-1247-4] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/25/2015] [Accepted: 11/07/2015] [Indexed: 12/22/2022]
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Charalel RA, McGinty G, Brant-Zawadzki M, Goodwin SC, Khilnani NM, Matsumoto AH, Min RJ, Soares GM, Cook PS. Interventional Radiology Delivers High-Value Health Care and Is an Imaging 3.0 Vanguard. J Am Coll Radiol 2015; 12:501-6. [DOI: 10.1016/j.jacr.2014.10.024] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2014] [Accepted: 10/29/2014] [Indexed: 02/01/2023]
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Barbier L, Hardwigsen J, Borentain P, Biance N, Daghfous A, Louis G, Botta-Fridlund D, Le Treut YP. Impact of transjugular intrahepatic portosystemic shunting on liver transplantation: 12-year single-center experience. Clin Res Hepatol Gastroenterol 2014; 38:155-63. [PMID: 24183545 DOI: 10.1016/j.clinre.2013.09.003] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/06/2013] [Revised: 09/17/2013] [Accepted: 09/20/2013] [Indexed: 02/07/2023]
Abstract
BACKGROUND The purpose of this study was to assess the impact of transjugular intrahepatic portosystemic shunting (TIPS) on liver transplantation (LT). METHODS Seventy-two patients transplanted after TIPS insertion between 1996 and 2008 were compared with 136 matched patients transplanted without prior TIPS. RESULTS At time of LT, 10% of the TIPS were occluded and 32% were misplaced. Shunt removal was difficult in 17% of the TIPS patients and required vena cava clamping in 10%. Collateral venous circulation was less extensive and intra-operative portocaval anastomosis was required more frequently in the TIPS group. No significant difference in transfusion requirements and operative times were observed between the two groups. Postoperatively, liver and renal function tests, in-hospital stay, graft rejection, re-transplantation and 1-year mortality rates were not statistically different. Ascites volume in the first week was greater in the TIPS group (7.6 L vs 6.9 L, P=0.036). In the TIPS group, ascites and collateral circulation were greater if the shunt was occluded at the time of LT. Shunt misplacement or occlusion was not associated with higher intra-operative or postoperative complication rates. CONCLUSION TIPS did not impair LT and can provide a safe bridge for LT in the end-stage cirrhotic patients.
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Affiliation(s)
- Louise Barbier
- Department of Digestive Surgery and Liver Transplantation, AP-HM, Hôpital La Conception, 13005 Marseille, France; Aix-Marseille University, 13284 Marseille, France.
| | - Jean Hardwigsen
- Department of Digestive Surgery and Liver Transplantation, AP-HM, Hôpital La Conception, 13005 Marseille, France; Aix-Marseille University, 13284 Marseille, France
| | - Patrick Borentain
- Department of Hepato-Gastro-Enterology, AP-HM, Hôpital La Conception, 13005 Marseille, France; Aix-Marseille University, 13284 Marseille, France
| | - Nicolas Biance
- Department of Digestive Surgery and Liver Transplantation, AP-HM, Hôpital La Conception, 13005 Marseille, France; Aix-Marseille University, 13284 Marseille, France
| | - Amine Daghfous
- Department of Digestive Surgery and Liver Transplantation, AP-HM, Hôpital La Conception, 13005 Marseille, France; Aix-Marseille University, 13284 Marseille, France
| | - Guillaume Louis
- Department of Radiology, AP-HM, Hôpital La Timone, 13005 Marseille, France; Aix-Marseille University, 13284 Marseille, France
| | - Danielle Botta-Fridlund
- Department of Hepato-Gastro-Enterology, AP-HM, Hôpital La Conception, 13005 Marseille, France; Aix-Marseille University, 13284 Marseille, France
| | - Yves-Patrice Le Treut
- Department of Digestive Surgery and Liver Transplantation, AP-HM, Hôpital La Conception, 13005 Marseille, France; Aix-Marseille University, 13284 Marseille, France
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The Evolution of Transjugular Intrahepatic Portosystemic Shunt: Tips. ISRN HEPATOLOGY 2014; 2014:762096. [PMID: 27335841 PMCID: PMC4890882 DOI: 10.1155/2014/762096] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 10/20/2013] [Accepted: 01/16/2014] [Indexed: 02/07/2023]
Abstract
Since Richter's description in the literature in 1989 of the first procedure on human patients, transjugular intrahepatic portosystemic shunt (TIPS) has been worldwide considered as a noninvasive technique to manage portal hypertension complications. TIPS succeeds in lowering the hepatic sinusoidal pressure and in increasing the circulatory flow, thus reducing sodium retention, ascites recurrence, and variceal bleeding. Required several revisions of the shunt TIPS can be performed in case of different conditions such as hepatorenal syndrome, hepatichydrothorax, portal vein thrombosis, and Budd-Chiari syndrome. Most of the previous studies on TIPS procedure were based on the use of bare stents and most patients chose TIPS 2-3 years after traditional treatment, thus making TIPS appear to be not superior to endoscopy in survival rates. Bare stents were associated with higher incidence of shunt failure and consequently patients required several revisions during the follow-up. With the introduction of a dedicated e-PTFE covered stent-graft, these problems were completely solved, No more reinterventions are required with a tremendous improvement of patient's quality of life. One of the main drawbacks of the use of e-PTFE covered stent-graft is higher incidence of hepatic encephalopathy. In those cases refractory to the conventional medical therapy, a shunt reduction must be performed.
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Qin JP, Jiang MD, Tang W, Wu XL, Yao X, Zeng WZ, Xu H, He QW, Gu M. Clinical effects and complications of TIPS for portal hypertension due to cirrhosis: A single center. World J Gastroenterol 2013; 19:8085-8092. [PMID: 24307804 PMCID: PMC3848158 DOI: 10.3748/wjg.v19.i44.8085] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/06/2013] [Revised: 06/17/2013] [Accepted: 08/01/2013] [Indexed: 02/06/2023] Open
Abstract
AIM: To determine the clinical effects and complications of transjugular intrahepatic portosystemic shunt (TIPS) for portal hypertension due to cirrhosis.
METHODS: Two hundred and eighty patients with portal hypertension due to cirrhosis who underwent TIPS were retrospectively evaluated. Portal trunk pressure was measured before and after surgery. The changes in hemodynamics and the condition of the stent were assessed by ultrasound and the esophageal and fundic veins observed endoscopically.
RESULTS: The success rate of TIPS was 99.3%. The portal trunk pressure was 26.8 ± 3.6 cmH2O after surgery and 46.5 ± 3.4 cmH2O before surgery (P < 0.01). The velocity of blood flow in the portal vein increased. The internal diameters of the portal and splenic veins were reduced. The short-term hemostasis rate was 100%. Esophageal varices disappeared completely in 68% of patients and were obviously reduced in 32%. Varices of the stomach fundus disappeared completely in 80% and were obviously reduced in 20% of patients. Ascites disappeared in 62%, were markedly reduced in 24%, but were still apparent in 14% of patients. The total effective rate of ascites reduction was 86%. Hydrothorax completely disappeared in 100% of patients. The incidence of post-operative stent stenosis was 24% at 12 mo and 34% at 24 mo. The incidence of post-operative hepatic encephalopathy was 12% at 3 mo, 17% at 6 mo and 19% at 12 mo. The incidence of post-operative recurrent hemorrhage was 9% at 12 mo, 19% at 24 mo and 35% at 36 mo. The cumulative survival rate was 86% at 12 mo, 81% at 24 mo, 75% at 36 mo, 57% at 48 mo and 45% at 60 mo.
CONCLUSION: TIPS can effectively lower portal hypertension due to cirrhosis. It is significantly effective for hemorrhage of the digestive tract due to rupture of esophageal and fundic veins and for ascites and hydrothorax caused by portal hypertension.
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Abstract
In the 25 years since the first TIPS intervention has been performed, technical standards, indications, and contraindications have been set up. The previous considerable problem of shunt failure by thrombosis or intimal proliferation in the stent or in the draining hepatic vein has been reduced considerably by the availability of polytetrafluoroethylene (PTFE)-covered stents resulting in reduced rebleeding and improved survival. Unfortunately, most clinical studies have been performed prior to the release of the covered stent and, therefore, do not represent the present state of the art. In spite of this, TIPS has gained increasing acceptance in the treatment of the various complications of portal hypertension and vascular diseases of the liver.
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Affiliation(s)
- Martin Rössle
- Praxiszentrum and University Hospital, Freiburg, Germany.
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Riggio O, Nardelli S, Moscucci F, Pasquale C, Ridola L, Merli M. Hepatic encephalopathy after transjugular intrahepatic portosystemic shunt. Clin Liver Dis 2012; 16:133-46. [PMID: 22321469 DOI: 10.1016/j.cld.2011.12.008] [Citation(s) in RCA: 110] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
Transjugular intrahepatic portosystemic shunt (TIPS) has been used for more than 20 years to treat some of the complications of portal hypertension. When TIPS was initially proposed, it was claimed that the optimal calibration of the shunt could allow an adequate reduction of portal hypertension, avoiding, at the same time, the occurrence of hepatic encephalopathy (HE), a neurologic syndrome. However, several clinical observations have shown that HE occurred rather frequently after TIPS, and HE has become an important issue to be taken into consideration in TIPS candidates and a problem to be faced after the procedure.
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Affiliation(s)
- Oliviero Riggio
- Department of Clinical Medicine, Centre for the Diagnosis and Treatment of Portal Hypertension, Sapienza University of Rome, Viale dell'Università 37, 00185 Rome, Italy
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The transjugular intrahepatic portosystemic shunt in the treatment of portal hypertension: current status. Int J Hepatol 2012; 2012:167868. [PMID: 22888442 PMCID: PMC3408669 DOI: 10.1155/2012/167868] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/17/2012] [Accepted: 05/18/2012] [Indexed: 02/06/2023] Open
Abstract
The transjugular intrahepatic portosystemic shunt (TIPS) represents a major advance in the treatment of complications of portal hypertension. Technical improvements and increased experience over the past 24 years led to improved clinical results and a better definition of the indications for TIPS. Randomized clinical trials indicate that the TIPS procedure is not a first-line therapy for variceal bleeding, but can be used when medical treatment fails, both in the acute situation or to prevent variceal rebleeding. The role of TIPS to treat refractory ascites is probably more justified to improve the quality of life rather than to improve survival, except for patients with preserved liver function. It can be helpful for hepatic hydrothorax and can reverse hepatorenal syndrome in selected cases. It is a good treatment for Budd Chiari syndrome uncontrollable by medical treatment. Careful selection of patients is mandatory before TIPS, and clinical followup is essential to detect and treat complications that may result from TIPS stenosis (which can be prevented by using covered stents) and chronic encephalopathy (which may in severe cases justify reduction or occlusion of the shunt). A multidisciplinary approach, including the resources for liver transplantation, is always required to treat these patients.
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AHLUWALIA J, LABRECQUE D. Management of Ascites in Cirrhosis and Portal Hypertension. SURGERY OF THE LIVER, BILIARY TRACT AND PANCREAS 2007:1554-1562. [DOI: 10.1016/b978-1-4160-3256-4.50110-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/04/2025]
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McAvoy NC, Hayes PC. The use of transjugular intrahepatic portosystemic stent shunt in the management of acute oesophageal variceal haemorrhage. Eur J Gastroenterol Hepatol 2006; 18:1135-41. [PMID: 17033431 DOI: 10.1097/01.meg.0000236877.98472.58] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
Variceal haemorrhage is a common and serious complication of portal hypertension. Endoscopic therapy is successful in the majority in controlling bleeding but in those who continue to bleed transjugular intrahepatic portosystemic stent shunt is highly effective in achieving haemostasis, although the evidence base that this is associated with improved survival is limited. This review discusses initial management and then the particular role of transjugular intrahepatic portosystemic stent shunt. A management algorithm is proposed. The timing of intervention is emphasized and the importance of admission to specialized centres. Regional protocols are probably essential for the latter to be organized effectively.
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Affiliation(s)
- Norma C McAvoy
- Department of Hepatology and Scottish Liver Transplant Unit, Royal Infirmary of Edinburgh, Edinburgh, UK.
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46
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Saravanan R, Nayar M, Gilmore IT, Smart H, McWilliams RG, Rowlands PC, Evans J, Murphy M, Gould D, Taylor S, Sutton R, Lombard MG. Transjugular intrahepatic portosystemic stent shunt: 11 years' experience at a regional referral centre. Eur J Gastroenterol Hepatol 2005; 17:1165-71. [PMID: 16215427 DOI: 10.1097/00042737-200511000-00003] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
OBJECTIVES Transjugular intrahepatic portosystemic stent shunt (TIPSS) is now widely used in the treatment of uncontrolled and recurrent variceal haemorrhage. This study reports the outcome and long-term follow-up of 125 patients who were referred to a single centre for TIPSS. METHODS One hundred and twenty-five patients were referred to undergo TIPSS. All but 10 had variceal haemorrhage. The 10 patients referred with refractory ascites were excluded from the analysis. Our follow-up protocol was to assess shunt patency only if bleeding recurred or there was a clinical indication. The mean age was 51.5 years (range 18-87 years) and 64 patients (56%) were male. The commonest aetiology for chronic liver disease was alcohol (80%). At referral, 19 patients (16%) were Child-Pugh class A, 26 patients (23%) were Child-Pugh class B and 70 patients (61%) were Child-Pugh class C. The mean follow-up period was 20.4 months (range 0-95 months). RESULTS TIPSS was successfully placed in 108 of 115 patients (94%). The thirty-day mortality was 30%. One-year and 2-year overall cumulative survival was 52% (survival ratio, 0.525; 95% confidence interval, 0.432-0.619) and 43% (survival ratio, 0.436; 95% confidence interval, 0.340-0.532), respectively. CONCLUSION TIPSS is effective in the treatment of uncontrolled or recurrent variceal bleeding. In comparison with previously published studies, our study suggests no value in regular or routine shunt surveillance to reduce rebleeding episodes or mortality, but this needs to be further assessed in prospective randomized studies.
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Affiliation(s)
- Ramasamy Saravanan
- Department of Gastroenterology, Royal Liverpool & Broadgreen University Hospitals, UK
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Boyer TD, Haskal ZJ. American Association for the Study of Liver Diseases Practice Guidelines: the role of transjugular intrahepatic portosystemic shunt creation in the management of portal hypertension. J Vasc Interv Radiol 2005; 16:615-29. [PMID: 15872315 DOI: 10.1097/01.rvi.0000157297.91510.21] [Citation(s) in RCA: 96] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Affiliation(s)
- Thomas D Boyer
- Liver Research Institute, University of Arizona School of Medicine, AHSC 245136, Tucson, 85750, USA.
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The role of transjugular intrahepatic portosystemic shunt in the management of portal hypertension. Hepatology 2005; 41:386-400. [PMID: 15660434 DOI: 10.1002/hep.20559] [Citation(s) in RCA: 288] [Impact Index Per Article: 14.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
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Guevara M, Alessandria C, Uriz J. [Transjugular intrahepatic portosystemic shunt and refractory ascites]. GASTROENTEROLOGIA Y HEPATOLOGIA 2004; 27:285-91. [PMID: 15056416 DOI: 10.1016/s0210-5705(03)70459-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Affiliation(s)
- M Guevara
- Servicio de Hepatología, Institut de Malalties Digestives, Hospital Clínic, Barcelona, España.
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