Correlation of duplex sonography findings and portal pressure in 375 patients with portal hypertension

OBJECTIVE

The purpose of this study was to determine the potential usefulness of duplex sonography in the grading of portal hypertension.

SUBJECTS AND METHODS

Duplex sonography of the portal vein system and measurement of the portal pressure and portosystemic pressure gradient were performed in 375 patients before placement of transjugular intrahepatic portosystemic shunts. Subgroups included patients with recent variceal bleeding (n = 296) and patients with refractory ascites without previous variceal bleeding (n = 79). A matched cohort of 100 patients without portal hypertension was also examined. Differences between the groups in portal and splenic vein diameter, flow velocity, congestion index, and hepatic arterial resistive index were assessed using the Wilcoxon rank sum test.

RESULTS

Compared with healthy individuals, our patients had an increased portal vein diameter (+30%, p < .001), decreased portal vein flow velocity (-44%, p < .001), and increased congestion index (+185%, p < .001). A portal vein diameter greater than 1.25 cm or a portal vein flow velocity less than 21 cm/sec indicated portal hypertension with a sensitivity and specificity of 80%. If the congestion index exceeded 0.1, portal hypertension was diagnosed with a 95% sensitivity and specificity. The portal pressure and gradient correlated only weakly (r < .2, p < .05) with sonographic variables. Using multivariate analysis, subgroups with variceal bleeding or refractory ascites did not show differences in hemodynamics, including pressures.

CONCLUSION

Duplex sonography contributes to the diagnosis of portal hypertension but does not allow its grading. Similarity of portal hemodynamics between patients with variceal bleeding and patients with refractory ascites suggests that additional factors determine the respective clinical presentation.

Platelet aggregation and platelet-derived growth factor inhibition for prevention of insufficiency of the transjugular intrahepatic portosystemic shunt: a randomized study comparing trapidil plus ticlopidine with heparin treatment

Intimal proliferation at the interface between prosthetic material and tissue is an intrinsic phenomenon of stenting and the major cause of insufficiency of the transjugular intrahepatic portosystemic shunt (TIPS). For its prevention, a randomized study was performed comparing standard heparin treatment with a combination of trapidil, a drug with anti-platelet-derived growth factor (PDGF) activity, and ticlopidine, a platelet aggregation inhibitor. Ninety patients with cirrhosis who received a transjugular shunt were randomized, and 84 patients completed the trial. Group 1 (n = 42) received a bolus of heparin (12 to 24 U/kg) at shunt placement, followed by 1 week of intravenous and 4 weeks of subcutaneous heparin treatment. Group 2 (n = 42) received the same heparin bolus, followed by a 1-day intravenous heparin treatment and a 6-month treatment with trapidil (400 mg/d) and ticlopidine (250 mg/d). Shunt function was assessed by duplex-sonography and angiography. Stenoses were classified according to their location as type 1 (within the stent) and type 2 (in the draining hepatic vein). The estimated rate of overall stenoses (intention-to-treat analysis) at 1 year showed a significant reduction in patients receiving trapidil and ticlopidine (group 2) as compared with heparin (33 vs. 57%; P =.047). There was no difference in the estimated 1-year rate of type 1 stenoses between the two groups, but there was a significant reduction in type 2 stenoses (group 1: 58%, group 2: 19%; P =.016). The treatment effect continued after withdrawal of the drugs and was accompanied by a decreased incidence of rebleeding. The study demonstrates that the incidence of type 2 stenosis of the transjugular shunt can be reduced by combined inhibition of platelet aggregation and PDGF activity. The findings may be of relevance not only for the transjugular shunt, but also for other stent applications, e.g., vascular and biliary, as well as for bypass and shunt surgery.

MDM-2 oncoprotein overexpression, p53 gene mutation, and VEGF up-regulation in angiosarcomas

The endothelium is one of the largest cellular compartments of the human body and has a high proliferative potential. However, angiosarcomas are among the rarest malignancies. Despite this interesting contradiction, data on growth and angiogenesis control mechanisms of angiosarcomas are scarce. In this study of 19 angiosarcomas and 10 benign vascular control lesions we investigated the sequence and expression of the p53 tumor suppressor gene and the expression of the mdm-2 proto-oncogene, which is a negative regulator of p53 activity and of the vascular endothelial growth factor (VEGF), whose expression, among other factors, is regulated by the p53/MDM-2 pathway. Ten sarcomas (53%) exhibited clear nuclear p53 protein accumulation. Two of these cases revealed mutations in the sequence-specific DNA binding domain of the p53 gene. Thirteen angiosarcomas (68%) showed an increased amount of MDM-2 protein. Elevated expression of p53 and MDM-2 protein correlated with increased VEGF expression, which was found in nearly 80% of the angiosarcoma cases. Negative or clearly lower immunostaining was obtained in cases from the benign control collective. Only one case of a juvenile hemangioma reached the cutoff value of p53 positivity coincidentally with high VEGF expression. Our data suggest that the p53/ MDM-2 pathway is impaired in about two-thirds (14/ 19) of the angiosarcomas. This may be a key event in the pathogenesis of human angiosarcomas. The increased VEGF expression observed supports this hypothesis.

Risk factors and prevention of early infection after implantation or revision of transjugular intrahepatic portosystemic shunts: results of a randomized study

The aim of this study was to evaluate the efficacy of a single dose of a second-generation cephalosporine to prevent postinterventional infection and to identify risk factors for postinterventional infection in patients receiving implantation or revision of a transjugular intrahepatic portosystemic shunt (TIPS). Eighty-four patients (105 transjugular interventions) were randomized receiving no antibiotic treatment (46 interventions) or 2 g cefotiam (56 interventions) given at the beginning of the procedure. Patients with overt infection or those receiving antibiotic treatment in the preceding two weeks were excluded. Groups were comparable with respect to biographic and medical data. Postinterventional infection was defined as an increase in WBC count (> or =15,000/microl), fever (> or =38.5 degrees C), or a positive blood culture. Infection occurred in 17% of the patients. Patients not receiving cefotiam had a slightly higher incidence of infection (20%) than patients treated with cefotiam (14%, NS). Multivariate analysis demonstrated prognostic relevance for multiple stenting and periprocedural use of a central venous line. The clinical outcome of the patients was unaffected by cefotiam treatment. In conclusion, a single dose of intrainterventional cefotiam does not prevent postinterventional infection. This may be due to the antimicrobial spectrum and short half-time of cefotiam. Strict adherence to aseptic conditions during intervention and early removal of central venous lines may reduce the rate of post interventional infection considerably. Antibiotic prophylaxis with cefotiam does not seem to be useful since it will not influence outcome and costs.

The first decade of the transjugular intrahepatic portosystemic shunt (TIPS): state of the art

The transjugular intrahepatic portosystemic shunt (TIPS) is an interventional treatment resulting in decompression of the portal system by creation of a side-to-side portosystemic anastomosis. Since its introduction 10 years ago, more than 500 publications have appeared demonstrating rapid acceptance and increasing clinical use. This review summarizes the present knowledge of technical aspects and complications, follow-up of patients, and indications. With respect to the technique, the TIPS procedure is probably one of the most difficult interventions and, therefore, technical success and complications clearly depend on the skills of the operator. Thus, the number and kind of complications reported in this review do not necessarily relate to the procedural complications of an experienced center. The follow-up of the TIPS patient has to assess shunt patency, liver function and hepatic encephalopathy. Shunt patency can best be monitored by duplex-sonography. Routine radiological revision seems not to be helpful and does not improve results, i.e., rebleeding and survival. Short term patency may be improved by anticoagulation, while such a treatment does not influence long-term patency. With respect to the indications of TIPS, much is known about treatment of variceal bleeding. The nine randomized studies that are available to date show that survival is comparable between patients receiving TIPS or endoscopic treatment. The second group of patients is the group with refractory ascites and related complications, such as hepatorenal syndrome and hepatic hydrothorax. It has been demonstrated that TIPS improves these complications, but randomized studies are still lacking. In addition, TIPS has been applied successfully to patients with Budd-Chiari syndrome, portal vein thrombosis, before liver transplantation, and for the treatment of ectopic portal hypertensive bleeding.

[Treatment of portal hypertension by portosystemic shunts]

The use of shunts for the treatment of portal hypertension has been revived after the introduction of the transjugular intrahepatic portosystemic shunt (TIPS) into clinical practice. This interventional procedure has mainly been used as rescue treatment for variceal bleeding resistant to endoscopic therapy and for ascites refractory to diuretic treatment and paracentesis. With respect to variceal bleeding TIPS has a low rate of "operative" mortality of < 1% and variceal rebleeding of 6 to 18%. In patients with refractory ascites the response to treatment is 50 to 92%. The major problems of the TIPS procedure are the increased incidence of hepatic encephalopathy and the high rate of shunt insufficiency of about 50%. Therefore, control of shunt function by duplex-sonography is essential to detect malfunction of the shunt. Radiological revision is then indicated if the clinical symptoms of portal hypertension (varices, ascites) reappear. The TIPS treatment has partially replaced the surgical shunting procedures. This decision is based on the potentially higher mortality of the surgical procedure. However, this has not been proven by randomized studies and, therefore, surgical shunts may also be indicated in selected patients with low operative mortality.

Structural changes of the Escherichia coli GroEL-GroES chaperonins upon complex formation in solution: a neutron small angle scattering study

We applied neutron scattering in conjunction with deuterium (D-) labeling in order to obtain information about the domain structure of GroEL and GroES isolated and in the complex. Each subunit of the heptameric GroES consists of two domains, a core domain (Met1 to Lys15 and Lys34 to Ala97) and an intervening loop region (Glu16 to Ala33). Neutron scattering shows that both regions change their conformation upon GroEL/GroES complex formation. The interdomain angle between the core regions of the heptameric GroES increases from 120 to 140 degrees, leading to a less dome-like shape of GroES, and the loop regions turn inwards by 75 degrees. The 23 C-terminal amino acids of the 14 GroEL subunits (Lys526 to Met548), which are unresolved in the crystal structure, are located either at the bottom of the cavity formed by the seven-membered GroEL ring or at the inner wall of the cavity. Upon complex formation the apical domains of GroEL move outwards, which facilitates binding of GroES at a Gro-EL-GroES center-to-center distance of (87 +/- 8) A. These structural changes may be important for the dissociation of the unfolded protein bound to the central cavity upon GroES binding. The overall structure determined by neutron scattering in solution tallies with the crystallographic model published after completion of this study. Differences in the conformation of GroES observed in the complex by the two methods support the view that the chaperonin complex is a flexible molecule which might switch in solution between different conformations.

Acute hemoperitoneum after large-volume paracentesis

Hemoperitoneum resulting from rupture of mesenteric varices is a rare complication of portal hypertension with a high mortality of up to 70%. This case report describes the symptoms, clinical course, and treatment of 4 patients with acute hemoperitoneum caused by mesenteric variceal bleeding after large-volume paracentesis. Abdominal pain and/or hemorrhagic shock developed in 4 patients (age, 48-68 years), admitted for refractory ascites, 3 hours to 4 days after 1-4 large-volume paracenteses (> 4000 mL). Duplex sonography, performed in 3 of the 4 patients before onset of bleeding, showed retrograde flow in the mesenteric veins, suggesting large-caliber mesenteric collateralization. Treatment consisted of surgical ligation followed by transjugular intrahepatic portosystemic shunt (TIPS) (2 patients) and emergency TIPS with embolization of the bleeding vessel (1 patient). One patient died before any intervention could be initiated. In these 4 patients, the concurrence of large-volume paracentesis and hemoperitoneum suggests their causal relationship. The mechanism may be a sudden reduction in intraperitoneal pressure increasing the pressure gradient across the wall of the mesenteric varices, resulting in rupture and bleeding. The awareness of this complication may accelerate the diagnostic process and treatment.

The role of TIPS for the treatment of portal hypertension: effects and efficacy

In patients with variceal bleedings TIPS is effective even if the portal pressure is reduced only partially and the reduction does not reach the threshold of 12 mmHg. Since the post-TIPS pressure gradient is closely correlated to the incidence of hepatic encephalopathy, higher gradients should be favoured in patients with a higher risk of hepatic encephalopathy, e.g. patients > age 65 years, Child-class C patients, and active alcoholics. An 8 mm diameter-shunt is probably the adequate size for most of these patients. Regarding patients with ascites, the effect of TIPS is partially due to an improvement of renal blood flow and function. The reasons for this are unknown. The systemic hemodynamic effects of the TIPS are probably not the cause since the shunt did not result in an improvement of the arterial filling and peripheral resistance. The experimentally proven hepatorenal baro-reflex may be an explanation.

Transjugular intrahepatic portosystemic shunt (TIPS). Thrombogenicity in stents and its effect on shunt patency

PURPOSE

To compare the thrombogenicity and patency of the Palmaz stent and the Wallstent, and to evaluate the effect of periprocedural heparin therapy in cirrhotic patients with maintained coagulation capacity who receive a transjugular intrahepatic portosystemic shunt (TIPS).

MATERIAL AND METHODS

Twenty-four patients were randomized into 4 groups of 6 patients. Each received a Palmaz-stent or Wallstent TIPS with or without periprocedural heparin therapy. The groups receiving periprocedural heparin were given 24 U/kg b.w. just before stent placement, followed by 24 h therapeutic i.v. heparin. After 24 hours, all patients received i.v. heparin for 1 week followed by subcutaneous treatment with low-molecular-weight heparin (0.3 ml/day) for another 4 weeks. Stent thrombogenicity was determined scintigraphically after i.v. injection of 120-290 mBq of 99mTc-labeled platelets at the time of stent placement and expressed as the stent/heart ratio. Shunt patency was assessed by duplex sonography and confirmed radiologically.

RESULTS

The aggregation ratio was highest 90 min after stent implantation. Wallstents showed a significantly higher ratio than Palmaz stents. Heparin reduced the ratio in patients with a Wallstent (-41%) but had no effect on Palmaz stents. Patients with a Wallstent without heparin had a higher rate of early shunt insufficiency (66.6%) than the other patients (0-16.6%). Primary assisted long-term patency was similar in the 4 groups.

CONCLUSION

Wallstents were more thrombogenic than Palmaz stents and gave a significantly higher risk of early shunt insufficiency in cirrhotic patients with maintained coagulation capacity. Periprocedural heparin was effective in the prevention of shunt insufficiency and is therefore indicated in such patients.

[Transjugular intrahepatic portasystemic shunt (TIPS)--indications and outcome]

The use of the use of the transjugular intrahepatic portosystemic shunt (TIPS) and its indication for treatment of the various symptoms of portal hypertension is till under debate. This paper presents guidelines for its application based on randomized studies, case reports, and own experience. TIPS is indicated in acute variceal bleeding not responding to endoscopic treatment and medication. In this emergency situation TIPS has probably a lower early mortality rate than surgical shunts. The prophylactic treatment of first variceal bleeding is a domain for medical therapy. Due to its increased incidence of hepatic encephalopathy TIPS may only be indicated in very selected cases with a high risk of bleeding and associated severe complications. Five randomized trials including 402 patients exist comparing endoscopic treatment and TIPS. Except one study the results are conclusive demonstrating comparable survival of the groups. Despite these results, in view of the high rate of shunt-induced encephalopathy with its negative effect on life quality, TIPS may better be a secondary treatment as long as studies on life quality are lacking. However, im many patients additional complications, e.g., accompanying ascites or intolerance to bleedings, may justify the primary use of TIPS. TIPS is also effective in the treatment of refractory ascites. Conclusive randomized studies are not available, therefore, TIPS should be restricted to patients who are intolerant to or who fail paracentesis. In addition to the leading indications mentioned, rare indications for TIPS and the role of surgical shunts are discussed.

Randomised trial of transjugular-intrahepatic-portosystemic shunt versus endoscopy plus propranolol for prevention of variceal rebleeding

BACKGROUND

The transjugular-intrahepatic-portosystemic shunt is a new interventional treatment for portal hypertension. The aim of our study was to compare the transjugular shunt with endoscopic treatment for the prophylaxis of recurrent variceal bleeding.

METHODS

Between March, 1993, and March, 1996, 126 patients with variceal bleeding were randomly assigned either transjugular shunt (n = 61) or endoscopic treatment (n = 65). Patients were followed up for a median of 14 (IQR 8-25) months and 13 (8-25) months, respectively. In 31 (51%) of the shunted patients, simultaneous transjugular-variceal embolisation was done at the time of shunt placement. Endoscopic treatment consisted of sclerotherapy and/or banding ligation and was combined with propranolol medication.

FINDINGS

Technical success was achieved in all patients assigned to the shunt group. During follow-up, the cumulative 1-year variceal rebleeding rates in the shunted and endoscopically treated patients were 15% and 41% and the 2-year rates were 21% and 52% (p = 0.001), respectively. In nine (12%) patients from the endoscopic group treatment failed and the patients received the transjugular-shunt treatment. A total of 19 bleeding episodes from any source occurred in 15 patients in the shunt group compared with 100 episodes in 33 patients in the endoscopic group. There was no difference in survival with estimated 1-year survival rates for shunted and endoscopically treated patients of 90% and 89%, and 2-year survival rates of 79% and 82%, respectively. The incidence of clinically significant hepatic encephalopathy after 1 year was higher in the shunt group (36% vs 18%, p = 0.011).

INTERPRETATION

These results suggest, that the transjugular shunt is more effective than endoscopic treatment in prevention of variceal rebleeding but has a considerable risk of hepatic encephalopathy. Survival is similar in the two groups.

The transjugular intrahepatic portosystemic stent-shunt: a review of the literature and own experiences

The transjugular intrahepatic portosystemic stent-shunt (TIPS) technique consists of a transhepatic puncture of the portal vein and stenting of the parenchymal tract between the hepatic and portal veins. Complications of both puncture and stenting are observed in approximately 5% of procedures. Most of the complications are without clinical consequences and the procedural mortality is very low in experienced hands (1%). During a 1 year follow up, 35% of patients were seen to develop stenosis and 15% developed occlusion of the stent-shunt. However, in spite of the considerable incidence of stenosis/occlusion, the rate of variceal rebleeding is rare when patients are followed up carefully by duplex sonography, which allows accurate and early detection of shunt insufficiency. One of the major long-term clinical problems of TIPS is the induction or worsening of hepatic encephalopathy. Although most patients respond to medical treatment, some develop debilitating encephalopathy or progressive liver failure. In these patients, reduction of shunt flow by the implantation of a reducing stent, or its occlusion with a balloon catheter, may be indicated. In conclusion, in spite of many complications, TIPS is relatively safe and efficient and hepatic encephalopathy is manageable in most cases.

Transjugular intrahepatic portosystemic shunt and hepatic encephalopathy

Hepatic encephalopathy (HE) is a frequent complication of portosystemic shunts with an incidence of about 25%. In side-to-side shunts, such as the transjugular intrahepatic portosystemic shunt (TIPS), there is relation between the incidence of postshunt HE and the diameter of the shunt. A smaller shunt with a diameter of < 8 mm has a lower risk of HE by maintaining some prograde portal perfusion in most patients and preventing arterioportal blood flow which may be of disadvantage in most conditions. On the other hand, a smaller shunt diameter limits the reduction in the portal-systemic pressure gradient and, therefore, may have a higher risk of rebleeding. The size of the shunt must be based on these risks which may be estimated by factors such as age, Child class, previous episodes of HE, size of varices and severity of previous bleedings. In retrospect, the decision for a specific diameter, i.e. pressure reduction, was right if the patient's liver function remained stable after TIPS, no HE occurred, and the varices disappeared. If this is not the case, the shunt diameter needs fine tuning with reduction in case of HE or functional deterioration, or enlargement if rebleeding occurred or the varices show a higher risk of such an event. This potential of fine tuning at any time is the major advantage of TIPS over the surgical shunting procedures.

[Recurrent bleeding from colonic varices in portal hypertension. The successful prevention of recurrence by the implantation of a transjugular intrahepatic stent-shunt (TIPS)]

HISTORY AND CLINICAL FINDINGS

Sclerotherapy was performed in a 52-year-old patient with alcoholic liver cirrhosis (Child-Pugh stage A) for recurrent bleeding from oesophageal varices. Half a year later he again was admitted to hospital because of recurrent passage of bloody stools. The cardiovascular status was stable; the liver was enlarged by 15 cm in the medioclavicular line.

INVESTIGATIONS

Endoscopy revealed several varices in the colon near the right flexure. One of the varices had an ulcer of 5 mm size. Duplex sonography revealed portal hypertension with cirrhosis of the liver and partial thrombosis of the main trunk of the portal vein without any sign of cavernous transformation.

TREATMENT AND COURSE

Because of the partial portal vein thrombosis it was decided to insert a transjugular intrahepatic portosystemic stent shunt. This obviated the thrombosis and lowered the portosystemic pressure gradient by 6.8%. With the shunt functioning well there were no further bleedings in the subsequent year.

CONCLUSION

The only slightly invasive TIPS implantation is an effective therapeutic procedure for bleeding from colon varices caused by portal hypertension.

Budd-Chiari syndrome: technical, hemodynamic, and clinical results of treatment with transjugular intrahepatic portosystemic shunt

PURPOSE

To evaluate use of the transjugular intrahepatic portosystemic shunt (TIPS) as a nonsurgical approach for the management of Budd-Chiari syndrome (BCS).

MATERIALS AND METHODS

Twelve patients with fulminant (n = 2), subacute (n = 5), or chronic (n = 5) BCS underwent TIPS placement. Hepatic venous obstruction was demonstrated at computed tomography and color duplex sonography. BCS was confirmed histologically in all patients. Hemodynamic parameters and clinical characteristics were assessed.

RESULTS

TIPS creation was successful in all patients. Treatment reduced the portal venous pressure gradient by 75% and resulted in a mean shunt flow of 2,300 mL/min +/- 650 (standard deviation). No serious procedure-related complications were observed. The two patients with fulminant BCS died of septicemia or progressive liver failure despite intervention. The other 10 patients showed clinical improvement with reduction or disappearance of ascites. During follow-up, shunt dysfunction occurred in five of 10 patients with recurrence of ascites requiring repeat intervention.

CONCLUSION

TIPS placement is safe and effective in patients with portal hypertension caused by subacute or chronic BCS.

[Septic portal vein thrombosis. Its successful therapy by local fibrinolysis and a transjugular portasystemic stent-shunt (TIPS)]

HISTORY AND FINDINGS

A 68-year-old man, without any preceding hepatic or abdominal disease, suddenly developed a severe septic illness with consumptive coagulopathy and upper abdominal pain. B-mode and duplex ultrasonography revealed fresh portal vein thrombosis. Despite extensive conservative measures there was no significant improvement after one week and further thrombus extension with threatened acute mesenteric vein occlusion.

TREATMENT AND COURSE

Local fibrinolysis with recombinant plasminogen activator and urokinase via percutaneous transjugular intrahepatic catheterization of the portal vein achieved almost complete dissolution of the thrombus within 3 days. Subsequently the portal vein catheter was changed into a transjugular portosystemic stent shunt (TIPS).

CONCLUSIONS

While local or systemic fibrinolysis has been practised in previously reported cases of acute portal vein thrombosis, the described use of TIPS introduces a new element. The shunt between hepatic and portal veins assures therapeutic access to the portal venous bed. It lowers portal vein pressure and can diminish the danger of recurrent thrombosis by raising portal flow. This minimally invasive procedure may be a nearly ideal treatment even in the course of portal vein thrombosis which has a high complication rate.

The transjugular intrahepatic portosystemic stent-shunt procedure for refractory ascites

BACKGROUND

Previous studies have suggested that the transjugular placement of an intrahepatic stent to establish a portosystemic shunt is an effective treatment of uncomplicated ascites accompanying variceal bleeding. We studied the stent shunt for use in patients with liver cirrhosis and ascites refractory to medical treatment.

METHODS

Fifty of 62 consecutive patients with cirrhosis and refractory ascites (18 with Child-Pugh class B liver disease and 32 with class C) were treated with the stent shunt--an expandable stent of metallic mesh placed between a major branch of the portal vein and one of the hepatic veins. Patients were followed for a mean (+/- SD) of 426 +/- 333 days. Those with advanced cancer, severe heart failure, or severe liver failure were excluded.

RESULTS

The stent shunt was successfully placed in all patients and reduced the pressure gradient between the portal vein and the inferior vena cava by an average of 63 percent. Thirty-seven patients (74 percent) had complete responses (total remission of ascites within three months), and nine patients (18 percent) had partial responses (ascites detected by ultrasound but with no need for paracentesis). Four patients did not respond, including two who died within two weeks of shunt placement. After the procedure, 25 patients had hepatic encephalopathy, as compared with 20 patients before the procedure; although encephalopathy improved in 3 patients, new encephalopathy developed in 8 patients. In the 28 of the 33 patients followed for more than six months who were evaluated, the mean serum creatinine concentration was 1.5 +/- 0.09 mg per deciliter (133 +/- 8 mumol per liter) before placement of the stent shunt, 1.5 +/- 1.6 mg per deciliter (133 +/- 141 mumol per liter) one week after the procedure, and 0.9 +/- 0.3 mg per deciliter (80 +/- 27 mumol per liter) after six months (P = 0.008 for the comparison of concentrations before and six months after the procedure). Renal function did not improve in the six patients with organic kidney disease. Procedure-related complications developed in 16 patients, including intraabdominal bleeding requiring blood transfusions in 2 patients. Thrombotic occlusion of the stent shunt occurred within two weeks in 5 patients, and later insufficiency of the shunt occurred in 16 patients, including 12 with recurrence of ascites after complete remission. During followup, an additional 29 patients died--10 of progressive liver disease and 19 of other causes. Survival for at least one year was associated with a patient's being under 60 years of age, having a serum bilirubin level before placement of the stent shunt of less than 1.3 mg per deciliter (22 mumol per liter), and having a complete response.

CONCLUSIONS

Our findings in an uncontrolled prospective study suggest that the transjugular intrahepatic porto-systemic stent-shunt procedure was an effective treatment for many patients with liver cirrhosis and refractory ascites, but mortality from underlying diseases was substantial.

Noncavernomatous portal vein thrombosis in hepatic cirrhosis: treatment with transjugular intrahepatic portosystemic shunt and local thrombolysis

PURPOSE

To evaluate the use of the transjugular intrahepatic portosystemic shunt (TIPS) and local, low-dose thrombolysis in the treatment of complete, noncavernomatous portal vein occlusion.

MATERIALS AND METHODS

TIPS implantation and portal vein recanalization was attempted in seven patients with noncavernomatous portal vein obstruction and recurrent variceal bleeding. TIPS placement was followed by thrombolytic therapy to restore portal venous blood flow. Hemodynamic effects and clinical characteristics after the procedure and during follow-up were assessed.

RESULTS

The implantation of TIPS and the recanalization of the portal vein trunk were successful in all patients. The treatment reduced the portal venous pressure gradient and restored portal blood flow. No bleeding complications were observed.

CONCLUSION

TIPS placement and recanalization of the main portal vein is a safe and effective treatment option for patients with liver cirrhosis and noncavernomatous portal vein occlusion.

The reducing stent: treatment for transjugular intrahepatic portosystemic shunt-induced refractory hepatic encephalopathy and liver failure

PURPOSE

To examine the efficacy of a stent device in reducing the diameter of transjugular intrahepatic portosystemic shunts (TIPS) in patients with progressive liver failure or with shunt-induced hepatic encephalopathy.

MATERIALS AND METHODS

Seven patients with TIPS (four with severe hepatic encephalopathy, three with progressive liver failure) underwent transjugular implantation of a stent designed to reduce the flow through the original TIPS channel.

RESULTS

Implantation of the reducing stent proceeded without complication. Duplex sonography showed that stent flow decreased by 41% +/- 18 (mean +/- standard deviation). The four patients with hepatic encephalopathy showed substantial improvement. Concentrations of plasma ammonium and serum bilirubin improved considerably. In contrast, functional impairment progressed in the three patients treated for liver failure. The patients soon died.

CONCLUSION

With the limited experience of treating these seven patients, the authors suggest that shunt-induced hepatic encephalopathy can be effectively treated with implantation of a reducing stent. Hepatic failure, however, is a deleterious complication that seems to be irreversible.

[TIPS 1994: indications, results, complications]

TIPS is a new decompressive treatment for portal hypertension. Since the first treatment in 1988 of a patient with variceal bleeding its technique has been improved considerably, and increasing clinical experience now justifies the wider use in patients with recurrent variceal hemorrhage and treatment-refractory ascites. The results demonstrate that TIPS is a safe procedure and is as effective as other current treatments. In Budd-Chiari syndrome and in patients awaiting liver transplantation TIPS may also be indicated. Randomized studies are now needed to determine the place of TIPS among the spectrum of therapies of portal hypertension.

[Hemodynamics, liver function and clinical follow-up after TIPS]

In 126 patients with liver cirrhosis treated electively with transjugular intrahepatic portosystemic stent shunt (TIPS) to prevent variceal rebleeding, the portosystemic pressure gradient decreased by 60%. In spite of this incomplete effect the risk for variceal rebleeding was still under 20% after 2 years. Only 1 patient died of variceal rebleeding. Shunt insufficiency occurred in 50%, mainly during the first year, but shunt function was restored in nearly all cases by radiologic intervention, i.e., redilatation or implantation of an additional stent. During the follow-up of 16 +/- 9 months, 21 patients (17%) died, one-third of them from progressive liver failure aggravated in 4 cases by severe drinking. De novo hepatic encephalopathy was observed in 10%, especially in older patients and patients with impaired liver function before TIPS. In such patients it is recommended that the shunt be dilated to 0.8 cm at most, and the TIPS procedure can be combined with transjugular embolization of the varices. The advantages of TIPS over both endoscopic sclerotherapy and drug treatment must be clarified in randomized studies, which have already been initiated in several centers.

The transjugular intrahepatic portosystemic stent-shunt procedure for variceal bleeding

BACKGROUND

Transjugular placement of an intrahepatic stent is a new technique to establish a portosystemic shunt for treatment of portal hypertension. A puncture needle is advanced in a catheter through the inferior vena cava into a hepatic vein; then an intrahepatic branch of the portal vein is punctured and an expandable stent of metallic mesh is implanted to establish the shunt.

METHODS

We attempted the stent-shunt procedure in 100 of 112 consecutive patients with variceal bleeding due to cirrhosis, who were then followed for a mean (+/- SD) of 12 +/- 6 months. Of the 100 patients, 22 had Child-Pugh class C cirrhosis, 10 were treated on an emergency basis, and 68 had alcoholic cirrhosis. The shunt was established with use of Palmaz stents expanded to 8 to 12 mm in diameter.

RESULTS

Technical success was achieved in 93 percent of the patients. The mean (+/- SD) time for the procedure was 1.2 +/- 0.3 hours. The shunt reduced the portal venous pressure gradient by 57 percent. Major complications were hemorrhage (intraabdominal bleeding in six patients, biliary bleeding in four, and bleeding in the liver capsule in three) and migration of the stent into the pulmonary artery (in two patients). At follow-up, stenosis of the shunt was evident in 21 patients and occlusion in 10 patients; 10 of these 31 patients had variceal rebleeding. Stenoses and occlusions of the shunt were all treated successfully by redilation, thrombolysis, or implantation of an additional stent. Hepatic encephalopathy (stages I to III) developed in 25 percent of the patients. The proportion of patients with shunts who remained free of variceal rebleeding was 92 percent at six months and 82 percent at one year. The 30-day mortality was 3 percent. The cumulative one-year survival was 85 percent.

CONCLUSIONS

These results suggest that the transjugular placement of an intrahepatic portosystemic stent is an effective and safe treatment for variceal hemorrhage in patients with portal hypertension due to cirrhosis.

[Trans-jugular intrahepatic portosystemic stent-shunt (TIPS) in a patient with Budd-Chiari syndrome]

The surgical modalities for the management of Budd-Chiari syndrome are associated with high morbidity and mortality. The clinical course of a patient with subacute Budd-Chiari syndrome and a myeloproliferative disorder is described in whom, to reduce the portal hypertension, a transjugular intrahepatic portosystemic stent-shunt (TIPS) was implanted. TIPS is a new, still experimental procedure for the treatment of patients with portal hypertension which is used mainly for patients with recurrent variceal bleeding. An intrahepatic metal wire stent connects a main branch of the portal vein with a large hepatic vein and reduces the portal venous pressure as a side-to-side portosystemic shunt. In the patient described here the implantation of a TIPS was followed by rapid reduction of ascites production and a continuing general improvement.

Transjugular intrahepatic portosystemic stent-shunt (TIPS) in the treatment of Budd-Chiari syndrome

Budd-Chiari syndrome is characterized by splanchnic congestion due to obstruction of the hepatic venous outflow. A variety of treatment modalities have limited applicability due to their invasive nature, complications or low effectivity. The transjugular intrahepatic portosystemic stent-shunt (TIPS) offers a new treatment by creating an intraparenchymal duct between a main branch of the portal vein and hepatic vein i.e. the intrahepatic part of the inferior vena cava. This paper describes the treatment of two patients with fulminant and subacute Budd-Chiari syndrome treated 2 days and 2 months after the onset of clinical symptoms. It demonstrates that TIPS is a feasible treatment of Budd-Chiari syndrome that restores splanchnic blood flow, reduces collateral circulation and ascites and provides sufficient time to allow for elective liver transplantation, if indicated. Further studies are required to evaluate the effect of TIPS on liver function and survival.

[Pulsatile insulin secretion into the portal vein in liver cirrhosis]

To characterize the pulsatile liberation of pancreatic hormones, blood was taken from the portal vein of four patients (three men, one woman; aged 65-71 years) with alcoholic (n = 3) or posthepatitic (n = 1) liver cirrhosis. The concentrations of glucose, insulin, C-peptide and glucagon were measured within one minute. The concentrations of insulin, C-peptide and glucagon varied considerably in intervals of 4.1-6.5 min. The swings in insulin concentration ranged between 17 and 163.5 microU/ml. Oral glucose loading with 100 g increased the insulin and C-peptide swings, but not their periodicity. This indicates that pulsatile insulin secretion is amplitude not rate driven.

[Splenic size and duplex sonography determination of blood flow in the vena lienalis and vena portae in liver cirrhosis]

Splenomegaly is a common finding in patients with portal hypertension. In the present study the relation between spleen size and blood flow in the splenic and portal vein was evaluated in 33 patients with alcoholic liver cirrhosis and portal hypertension using pulsed Doppler sonography (Ultramark 9, ATL, Solingen, FRG). There was a significant positive correlation between hilar spleen diameter (HD) and splenic vein diameter (r = .73, p less than .001) as expected as the consequence of portal hypertension. However, a positive correlation between HD and splenic vein flow (SBF) was found (r = .67, p less than .001). Furthermore, there was no negative correlation between HD and flow velocity in the splenic vein (r = .01, n.s.). Portal blood flow (830 +/- 360 ml/min) was fairly constant in spite of considerable variations in SBF (range: 120 to 1200 ml/min). The data of the present study indicate that splenomegaly in patients with liver cirrhosis and portal hypertension is not simply the consequence of portal congestion resulting in decreased SBF. Rather, increased SBF serves to maintain portal blood flow and thereby contributes to portal hypertension. In few patients (15%) SBF increased to more than 11/min may be an important factor for the severity of portal hypertension. Surgical shunt treatment should be adjusted in these patients.

Interventional treatment of portal hypertension

For many years now, percutaneous transhepatic and transjugular approaches to the portal vein have been applied by gastroenterologists and radiologists for diagnosis and therapy. In patients with variceal bleeding these techniques were used to obliterate the varices, and have provided the knowledge for further developments, such as the creation of an intrahepatic portosystemic shunt by balloon dilatation of the needle tract between the portal vein and a hepatic vein. The recent development of expandable vascular stents has led to improvements in the efficiency and long-term patency of interventional shunts, and justified their clinical application. The rationales for this new approach to the treatment of portal hypertension are its relative safety, even in Child C patients, and the disabilities such as rebleeding or aggravation of hepatic encephalopathy of other current treatments. Since the first clinical application of the transjugular intrahepatic portosystemic stent-shunt in January 1988, the technique has been improved considerably, and the frequency of its application is increasing rapidly. This article attempts to summarize the current state of knowledge of this interventional technique, which will soon have its place among the various methods of treating portal hypertension.

[Intrahepatic portacaval anastomosis by the transjugular approach. Use of the Palmaz endoprosthesis]

This new, non-operative procedure has been devised to create an intrahepatic shunt between a main portal branch and the right hepatic vein. First, the portal bifurcation is located by sagittal sonography and its position is marked on the skin. Then one of the main portal branches is punctured from the right hepatic vein by the transjugular route, and the puncture tract is expanded by balloon dilatation. This channel is kept open by placement of one or several Palmaz stents. Ten cirrhotic patients (age range: 60-84 years) unfit for surgical portocaval shunting and presenting with recurrent variceal bleeding after sclerotherapy were successfully treated by this method without any related death. During a 1 to 8 months follow-up, 9 of the 10 shunts have remained perfectly patent, but more time is required to determine the place of this method for secondary management of cirrhotic variceal bleeding.

[Modelling the transjugular intrahepatic portosystemic shunt using a metal prosthesis: requirements of the stent]

Non-operative percutaneous treatment of portal hypertension as ultima ratio therapy in liver cirrhosis has now been established in 16 cases. After transjugular puncture of a main branch of the portal vein via a liver vein, recollapse of the parenchymal track after predilation was prevented by implantation of a Palmaz stent. This type of stent enables remodelling of the individual length of the parenchymal track in the liver by overlapping placement of several stents. In our experience the Palmaz stent seems to be very efficient in keeping the shunt patent. First, its smooth inner surface after dilation guarantees laminar flow within the stent as a precondition for homogeneous endothelialization of the inner surface. Second, overlapping placement of the stents allows precise covering of the individual length of the shunt. Third shunt diameters can be established by using different sized balloons. The range is 7-10 mm. Fourth this type of stent has a high degree of resistance to eccentric or concentric compression by the surrounding tissue.

[Hemodynamic consequences of portal decompression: which is the optimal shunt?]

Increased sinusoidal resistance in cirrhosis results in a decrease of the portal and a compensatory increase of the arterial blood supply to the liver. With increasing vascular resistance and development of extrahepatic collaterals stagnation and even reversion of the portal blood flow may occur. In the latter condition, the arterial blood leaves the liver through two routes: 1) through the sinusoids and the hepatic veins, and 2) through the portal vein. Experimental and clinical studies revealed that the arterio-portal pathway is metabolically inferior to the regular arterio-hepatic-venous pathway. This suggests a decrease in liver function with an increased incidence of hepatic encephalopathy (HE) in patients with reversed portal blood flow. Based on these findings, surgical shunts may be classified according to their effect on the arterial liver perfusion. The end-to-side shunt and the distal splenorenal shunt (DSRS) do not cause diversion of the arterial liver perfusion. In contrast, side-to-side shunts, with the portal vein available as an outflow tract, consistently lead to diversion of the arterial blood supply resulting in reversed portal blood flow. Thus, side-to-side shunts are supposed to have an increased incidence of HE due to decreased liver function. This hypothesis is supported by 7 controlled and randomized studies which reveal comparable results of end-to-side shunts and DSRS but significant disadvantages of side-to-side shunts compared to DSRS.

Synaptic membrane complex carbohydrates in experimental hepatic encephalopathy

To evaluate further the status of synaptic plasma membranes (SPMs) in the brain in the syndrome of hepatic encephalopathy (HE) lipid- and protein-bound sialic acid and ganglioside and protein composition were investigated in SPMs from the brains of six rabbits with galactosamine-induced fulminant hepatic failure and five normal rabbits. HE was associated with no appreciable changes in the chromatographic pattern of gangliosides or the concentration of protein-bound sialic acid, but the syndrome was associated with a 20% increase in lipid-bound sialic acid and, as assessed electrophoretically, an increase in the concentration of a protein with a molecular weight of about 70 kDa. Thus, changes in the composition of complex carbohydrates and protein in SPMs occur in a model of HE. The findings raise the possibility that nonhumoral factors, such as increased sialylation of glycolipids, contribute to the generation of abnormal neurotransmission in HE.

[Autoradiography determination of the GABA(A) receptor density in the brain of rats with portacaval shunt]

Quantitative autoradiography was used to assess the densities of gamma-aminobutyric acid (GABAA) receptors in the brains of rats with a portacaval end-to-side shunt (PCA). The shunt alone induced only mild encephalopathy with ataxia and decreased locomotion. Aggravation of the encephalopathy was achieved by gavage feeding of packed erythrocytes or by induction of severe hyperammonemia by intraperitoneal injection of urease. Gavage feeding of erythrocytes led to severe encephalopathy in about 50% of the animals with PCA. The combination of PCA and urease treatment caused severe encephalopathy in every animal. The serum ammonia concentration increased 5 times normal by PCA alone, 20 times normal by gavage feeding of erythrocytes and more than 30 times normal by urease-treatment of the PCA-animals. For autoradiography, coronal slices were cut at the level of the hippocampal formation and through the cerebellum. Radioligand binding was measured using as a ligand 3H-muscimol, a specific GABAA receptor agonist. The specific binding of 3H-muscimol was assessed densitometrically in several microregions of cerebral cortex, hippocampus and cerebellar cortex. No significant differences were observed between the magnitude of ligand binding to specific microregions of brains from normal animals, animals with PCA without overt encephalopathy and animals with severe encephalopathy induced by a combination of PCA and gavage feeding of erythrocytes or urease treatment.

[The intrahepatic portosystemic shunt. Initial clinical experiences with patients with liver cirrhosis]

A new nonoperative catheter technique to perform an intrahepatic portosystemic shunt by transjugular approach was applied to ten patients with recurrent bleeding from oesophageal and fundal varices. Therefore a balloon-expandable stent was placed between a portal vein and a hepatic vein. Implantation of the stent was successful in seven of the ten patients. Two of these seven patients died 10 and 11 days, respectively, after the procedure, one of them in consequence of respiratory failure, the other due to an uncontrollable bleeding from the site of the percutaneous transhepatic puncture because of a marked clotting disorder. The intrahepatic shunt construction led to a mean reduction of the pressure gradient between portal and hepatic vein of 40%. No recurrence of variceal haemorrhage occurred during the average follow-up time of 5.6 months (3-9 months). One patient developed several episodes of portosystemic encephalopathy. The transjugular intrahepatic portosystemic shunt is effective in the treatment of portal hypertension and might become an alternative to shunt surgery.

Cortical benzodiazepine receptor binding in a rabbit model of hepatic encephalopathy: the effect of Triton X-100 on receptor solubilization

Increased benzodiazepine (BZ) receptor density has been reported in brains of rabbits with hepatic encephalopathy (HE) due to galactosamine (GalN)-induced fulminant hepatic failure (FHF). These data were generated using detergent-Triton X-100-treated neural membranes. While performing further studies it was noted that the increase in BZ receptor density was not demonstrable when Triton X-100 preparation was not employed. Accordingly the binding of [3H] flunitrazepam, a BZ ligand, to neural membranes from cortices of normal rabbits and rabbits with HE due to (GalN)-induced FHF was studied with and without detergent preparation. Scatchard plot analysis of the binding data indicated that when no detergent was employed, the apparent affinity and density of BZ receptors were similar for control membranes and membranes from animals in HE. BZ receptors from animals in HE were shown to be more resistant to solubilization by Triton than control membranes. These findings (a) afford a potential explanation for the apparent increase in density of BZ receptors in this model when Triton treatment of neural membranes is utilized and (b) suggest that recent evidence for increased GABAergic tone in the syndrome of HE is not dependent on an increased density of BZ receptors.

[The transjugular intrahepatic portosystemic stent-shunt. A new nonsurgical percutaneous method]

In a 49-year-old male patient suffering from severe symptoms of end-stage portal hypertension and Child's stage C metabolic status, an intrahepatic stent-assisted portosystemic shunt was established for the first time exclusively by means of interventional radiology. Via transjugular access, a modified Brockenbrough needle was used to puncture the right branch of the portal vein via the right liver vein. As a target, a Dormia-basket was used that had previously been exposed in the right main portal branch. After successful puncture and balloon dilation of the artificial tract, two Palmaz stents were implanted to keep the tract permanently open. The portosystemic pressure gradient dropped from 38 to 18 mm Hg. The clinical status of the patient improved substantially during the following days. However, the patient died on day 11 after the procedure because of sudden onset of acute respiratory distress arising from acute nosocomial fungus and cytomegalovirus infection worsened by his primary immunoincompetence. Autopsy demonstrated a totally patent shunt without superficial thrombus. Microscopically, a thin endothelial layer on the inner shunt surface was found to be present.

Autoradiographic analysis of GABA-benzodiazepine receptors in an animal model of acute hepatic encephalopathy

To complement analogous studies using conventional ligand-membrane binding assays, the densities of gamma-aminobutyric acid and benzodiazepine receptors in the brain have been assessed using an autoradiographic technique in an animal model of hepatic encephalopathy. Hepatic encephalopathy due to fulminant hepatic failure was induced in rabbits by the intravenous injection of galactosamine. The specific binding of three radiolabeled ligands was assessed densitometrically in several microregions of cerebral cortex, hippocampus and cerebellum. [3H]Muscimol was used to assess gamma-aminobutyric acid receptor density and [3H]flunitrazepam or [3H]Ro 15-1788 was used to assess benzodiazepine receptor density. No significant differences were observed between the magnitude of binding of the three ligands to each of the microregions of brain from control rabbits and rabbits in Stage III or IV hepatic encephalopathy. These findings suggest that the behavioral expression of hepatic encephalopathy in the model studied is not dependent upon an increase in the number of gamma-aminobutyric acid or benzodiazepine receptors, but do not conflict with the hypothesis that gamma-aminobutyric acid-ergic tone is increased in hepatic encephalopathy.

The disposition of intravenous L-tryptophan in healthy subjects and in patients with liver disease

The disposition of free and of total tryptophan following an intravenous load of 1.5 g of L-tryptophan was evaluated in eight patients with non-cirrhotic liver disease, 40 patients with cirrhosis of the liver (21 Child's A, 15 Child's B, 4 Child's C) and in 14 healthy subjects. Cirrhosis affected disposition of tryptophan by (a) decreasing the clearance of both free and total tryptophan by 64% (P less than 0.001) and 34% (P less than 0.01), respectively, (b) by increasing the apparent volume of distribution of total tryptophan by 42% (P less than 0.01) by expansion of the peripheral compartment, resulting in (c) a threefold increase in the half-life of tryptophan. Apart from a reduction in free tryptophan clearance, these changes in tryptophan disposition were not apparent in patients with non-cirrhotic liver disease. Elevated fasting free tryptophan plasma concentrations are an indicator of impaired tryptophan metabolism in cirrhosis. They result from a decreased hepatic clearance of tryptophan rather than from a reduction in tryptophan protein binding. This study emphasises the markedly differing pharmacokinetic behaviour of tryptophan in cirrhotic patients compared with normal subjects and with patients with non-cirrhotic liver disease.