Pulmonary hypertension after transjugular intrahepatic portosystemic shunt: effects on right ventricular function

Transjugular intrahepatic portosystemic shunt in refractory ascites: a meta-analysis

Transjugular intrahepatic portosystemic shunt (TIPS) is a more effective treatment for refractory ascites than large volume paracentesis (LVP), but the magnitude of its effect in terms of control of ascites, encephalopathy and survival has not been established.

AIM

This meta-analysis compare TIPS to LVP in terms of control of ascites at 4 and 12 months, encephalopathy and survival at 1 and 2 years.

RESULTS

Five randomized controlled trials involving 330 patients were included. In the TIPS group, control of ascites was more frequently achieved at 4 months (66% vs 23.8%, mean difference: 41.4%, 95% confidence interval (CI): 29.5-53.2%, P < 0.001) and 12 months (54.8% vs 18.9%, mean difference: 35%, 95% CI: 24.9-45.1%, P < 0.001), whereas encephalopathy was higher (54.9% vs 38.1%, mean difference: 17%, 95% CI: 7.3-26.6%, P < 0.001). Survival at 1 year (61.7% vs 56.5%, mean difference: 3.2%, 95% CI: -14.7 to 21.9%) and 2 years (50% vs 42.8%, mean difference: 6.8%, 95% CI: -10 to 23.6%) were not significantly different.

CONCLUSIONS

TIPS is a more effective treatment for refractory ascites than LVP. However, TIPS increase encephalopathy and does not improve survival.

Cardiopulmonary consequences of transjugular intrahepatic portosystemic shunts: role of increased pulmonary artery pressure

GOALS

To determine whether increased pulmonary artery pressure (PAP) following transjugular intrahepatic portosystemic shunting (TIPSS) results in short-term mortality or cardiorespiratory complications.

BACKGROUND

TIPSS is frequently performed for complications of cirrhosis. PAP increases following TIPSS; however consequences of this phenomenon are unknown.

STUDY

Demographics, disease severity and etiology were recorded among patients undergoing TIPSS. PAP before and following TIPSS were measured and the relationship between PAP before and after TIPSS, and subsequent cardiorespiratory complications and mortality was examined.

RESULTS

Thirty-one patients were enrolled (mean age 53 years, 74% men, 55% Child-Pugh class C cirrhosis). TIPSS was performed for variceal bleeding in 84% of cases. Ten patients (32%) died 5-20 days following TIPSS. PAP increased significantly following TIPSS (mean 20.8 mm Hg pre-TIPSS (95% CI 18.2-23.4) to 26.9 mm Hg post-TIPSS (95% CI 24.2-29.6, P = 0.0016). Congestive heart failure developed in 4 patients (13%), sepsis in 4 (13%), and ARDS in 8 (26%). Increased PAP following TIPSS was not associated with early mortality (P = 0.13), CHF (P = 0.31), or ARDS (P = 0.43). ARDS was the only significant predictor of short-term mortality following TIPSS (OR 18.7, P = 0.02 (95% CI: 1.5-232).

CONCLUSION

PAP increases after TIPSS and cardiorespiratory complications are common, yet unrelated to increased PAP. ARDS is independently associated with increased risk of mortality after TIPSS.

Modifications of cardiac function in cirrhotic patients treated with transjugular intrahepatic portosystemic shunt (TIPS)

OBJECTIVES

The implantation of a transjugular intrahepatic portosystemic shunt (TIPS) has been shown to exacerbate the hyperdynamic circulation and might induce a significant cardiac overload. We investigated cardiac function before and 1, 3, 6, and 12 months after the TIPS procedure in cirrhotic patients.

METHODS

Eleven patients with nonalcoholic cirrhosis were evaluated. Cardiovascular parameters were assessed by two-dimensional Doppler echocardiography.

RESULTS

After TIPS, the left ventricular diastolic diameter increased from 26.5 +/- 1.8 mm (basal) to 30.0 +/- 2.8 mm (6 months) (p < 0.05), whereas the ejection fraction showed a slight increase (basal, 64.5 +/- 3.3; 6 months, 68.1 +/- 3.2). The left ventricular pre-ejection period and the isovolumetric relaxation time decreased transiently at 1 month (p < 0.05). An increased velocity in all of the components of pulmonary venous flow (systolic, diastolic, and atrial) documented the accelerated fluxes induced by the procedure. The estimated pulmonary systolic arterial pressure also increased at 1 month (29.5 +/- 1.4 vs 44.1 +/- 1.4 mm Hg, p < 0.05). All of these modifications reverted after 6 months.

CONCLUSIONS

Our study demonstrates that nonalcoholic cirrhotic patients, without cardiovascular pathologies, show transient modifications in cardiac dimension and function for 3-6 months after TIPS caused by the increased volume load shunted to the heart.

Esophageal varices. II. TIPS (transjugular intrahepatic portosystemic shunt) and surgical therapy

The role of surgery in the prevention and treatment of variceal hemorrhage is reviewed. Types of available surgery, their physiologic basis, and literature supporting their use are discussed in the context of the natural history of variceal hemorrhage. The evolution of transjugular intrahepatic portosystemic shunt (TIPS) as a treatment modality for variceal hemorrhage is reviewed. The effects of TIPS on portal and systemic hemodynamics and clinical usefulness in the management of variceal hemorrhage are discussed. A treatment algorithm for the integrated use of the various treatments is provided.

Hepatic hydrothorax: pathogenesis, diagnosis, and management

Hepatic hydrothorax is defined as a pleural effusion in a patient with cirrhosis of the liver and no cardiopulmonary disease. The estimated prevalence of this often debilitating complication in patients with liver cirrhosis is 4% to 10%. Its pathophysiology involves movement of ascitic fluid from the peritoneal cavity into the pleural space through diaphragmatic defects. As a result patients are at increased risk of respiratory infection. Initial management consists of sodium restriction, diuretics, and thoracentesis. A transjugular intrahepatic portosystemic shunt may be required. Because most patients with hepatic hydrothorax have end-stage liver disease, a liver transplant should be considered if these options fail.

Current status of transjugular intrahepatic portosystemic shunts

The use of the transjugular intrahepatic portosystemic shunt (TIPS) has emerged as an important nonoperative modality for variceal bleeding, intractable ascites, and for selected cases of hepatic venous obstruction. We believe that TIPS should be viewed as a 'bridge' to liver transplantation and should be carried out only in experienced centres. The adverse haemodynamic changes on the cardiopulmonary system after TIPS should be borne in mind. Prospective trials to evaluate the role of TIPS versus sclerotherapy in variceal bleeding will be watched with interest. There is, however, an urgent need to improve long-term results of TIPS as stent thrombosis and stenosis occur frequently. We advocate routine surveillance to detect these problems at an early stage.

Renal effects of transjugular intrahepatic portosystemic shunt in cirrhosis: comparison of patients with ascites, with refractory ascites, or without ascites

Renal effects of the transjugular intrahepatic portosystemic shunt (TIPS) were compared in 6 patients without ascites (group 1), 11 patients with ascites responding to diuretic treatment (group 2), and 6 patients with refractory ascites (group 3). Seven days after insertion of TIPS, 24-hour urinary sodium excretion had increased in patients with ascites: 113 +/- 16 mmol to 170 +/- 30 mmol (P = .012) in group 2, and 22 +/- 8 mmol to 77 +/- 27 mmol (P = .050) in group 3. In group 3, fractional sodium excretion tended to increase from 0.26% +/- 0.14% to 0.62% +/- 18% (P = .081). The relative increase of urinary sodium excretion (to 444% +/- 122%) and fractional sodium excretion (to 413% +/- 127%) in group 3 was significantly (P < .05) higher than in group 1 and group 2, respectively. Creatinine clearance and 24-hour urinary volume were not significantly changed in either group. Patients with Child-Pugh class C had a more pronounced effect of TIPS on urinary sodium excretion (increase to 396% +/- 115% vs. 139% +/- 15%; P = .066) and on fractional sodium excretion (increase to 415% +/- 103% vs. 94% +/- 15%; P = .020) than patients with less-severe liver disease. Fractional sodium excretion of less than 0.35% before TIPS was found to be an indicator of renal response to TIPS. The effect of TIPS on urinary sodium excretion and on fractional sodium excretion was related to the patients' Child-Pugh score (r = .55; P = .007 and r = .68; P = .001, respectively) and inversely to their fractional sodium excretion (r = -.44; P = .047 and r = -.54; P = .012, respectively) before TIPS. These data demonstrate that TIPS affects renal sodium handling in patients with ascites, particularly in patients with refractory ascites. Severity of liver disease and fractional sodium excretion before TIPS are parameters to predict the extent of the renal response.

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.

Effects of L-arginine on the systemic, mesenteric, and hepatic circulation in patients with cirrhosis

Nitric oxide (NO) is known to play an important role in modulating both the hepatic and mesenteric circulation under physiological and pathological conditions. We investigated how L-arginine, a precursor of NO, modifies the hepatic and mesenteric circulation in patients with cirrhosis. The study design was a single-blind controlled study. We measured the systemic and portal hemodynamics before and following intravenous L-arginine and saline infusion using pulsed Doppler ultrasonography in 20 patients with cirrhosis, and then the effects were compared with those found in 20 healthy subjects. In these patients, the effects of L-arginine on hepatic circulation were investigated using hepatic catheterization. L-Arginine infusion induced systemic vasodilation in both the healthy controls and the cirrhotic patients in a similar hemodynamic manner. In these patients, the L-arginine-induced increase in the portal flow was significantly higher than that of cardiac output (CO); however, the relation was the inverse in healthy subjects. Moreover, the L-arginine-induced increase in the portal flow was greater in the cirrhotic patients than that seen in healthy subjects. As a result, L-arginine infusion was thus found to selectively augment the hepatopetal portal blood flow in the cirrhotic liver. In patients, L-arginine infusion induced marked hepatic vasodilation as demonstrated by the reduced hepatic sinusoidal resistance (HSR) and increased estimated hepatic blood flow (EHBF) associated with the ameliorated intrinsic clearance of indocyanine green. Despite the fall in HSR, the hepatic venous pressure gradient (HVPG) increased following L-arginine infusion. The mesenteric and hepatic vascular areas of cirrhosis exhibited an increased susceptibility to the dilator action of L-arginine. These findings suggest that the enhanced NO production in the splanchnic vascular area has an important role in the hepatic circulation in patients with cirrhosis.

Transjugular intrahepatic portosystemic shunts (TIPS)

Transjugular intrahepatic portosystemic shunt (TIPS) is a procedure recently introduced for the management of complications of portal hypertension. TIPS can be placed in the liver with relative ease by a skilled radiologist with a low risk of mortality. The major complications following the procedure are infection, especially in patients undergoing emergency TIPS, intra-abdominal haemorrhage from capsular punctures, and long-term problems related to encephalopathy and stenosis of the shunt. Encephalopathy is more of a problem in older patients with wide diameter shunts. Stenosis of the shunt is related to pseudo-intimal hyperplasia, probably related to transection of bile ductules during placement of the shunt. In view of the high rate of encephalopathy and stenosis following the shunt, a careful follow-up of all patients, including ultrasonographic and angiographic examination of the shunt, is mandatory. TIPS is used predominantly for the control of acute variceal haemorrhage, prevention of recurrent variceal bleeding, and refractory ascites when conventional treatment has failed. However, the role of TIPS in the management of complications of portal hypertension still awaits the outcome of clinical trials.

The role of the transjugular intrahepatic portal-systemic shunt in the management of variceal bleeding

For patients who present with variceal bleeding refractory to endoscopic and pharmacologic methods, TIPS is a new and effective therapy. Stents are used in selected patients with decompensated liver disease and those who anticipate liver transplantation within 6 to 12 months. Surveillance of TIPS with ultrasound, with or without venography, is recommended to diagnose and treat stenosis or occlusion before variceal hemorrhage recurs. Hepatic encephalopathy may develop in a subset of patients, but it is usually well controlled with conservative measures. Child-Pugh and APACHE scores are predictive of patient survival after TIPS. Randomized controlled trials will be necessary to assess whether TIPS is useful, safe, and cost effective for the management of variceal bleeding in patients with end stage liver disease.