Clinical events after transjugular intrahepatic portosystemic shunt: correlation with hemodynamic findings

Changes in Doppler parameters of portal pressure after interventional management of hepatocellular carcinoma

Hepatocellular carcinoma (HCC) has many options for management; some of them are complicated by development of portal hypertension (PHT). Doppler ultrasound is an effective method to diagnose and monitor PHT changes after HCC ablation procedures. The aim of this study is to investigate changes in portal pressure hemodynamics of HCC patients following treatment with different interventional strategies: radiofrequency ablation (RFA), microwave ablation (MWA), and transarterial chemoembolization (TACE). A total of 60 patients with HCC were divided into three main groups, and each group received a different type of therapy (RFA, MWA, and TACE). Full medical record and basic investigations were performed including Doppler ultrasound and upper GIT endoscopy for evaluation of PHT parameters, and then repeated after three months of ablation. RFA is associated with the increased splenic artery resistive index, while MWA has no significant impact on PHT indices. TACE has led to a marked increase in liver vascular index with significant decrease in hepatic artery resistive index and PHI after treatment. No significant changes in esophageal varices were observed by upper GIT endoscopy following all ablation methods. RFA is quite safe but associated with degree of PHT. On the contrary, TACE is associated with improved PHT parameters. MWA has no significant association to development of PHT following the technique. Doppler ultrasound could be used as a reliable and effective method of evaluation of PHT post ablation for HCC.

Transjugular Intrahepatic Portosystemic Shunt Dysfunction: Concordance of Clinical Findings, Doppler Ultrasound Examination, and Shunt Venography

Objectives:

The objective of this study was to evaluate the concordance between clinical symptoms, Doppler ultrasound (US), and shunt venography for the detection of stent-graft transjugular intrahepatic portosystemic shunt (TIPS) dysfunction.

Materials and Methods:

Forty-one patients (M:F 30:11, median age 55 years) who underwent contemporaneous clinical exam, Doppler US, and TIPS venography between 2003 and 2014 were retrospectively studied. Clinical symptoms (recurrent ascites or variceal bleeding) were dichotomously classified as present/absent, and US and TIPS venograms were categorized in a binary fashion as normal/abnormal. US abnormalities included high/low (>190 or <90 cm/s) TIPS velocity, significant velocity rise/fall (>50 cm/s), absent flow, and return of antegrade intra-hepatic portal flow. Venographic abnormalities included shunt stenosis/occlusion and/or pressure gradient elevation. Clinical and imaging concordance rates were calculated.

Results:

Fifty-two corresponding US examinations and venograms were assessed. The median time between studies was 3 days. Forty of 52 (77%) patients were symptomatic, 33/52 (64%) US examinations were abnormal, and 20/52 (38%) TIPS venograms were abnormal. Concordance between clinical symptoms and TIPS venography was 48% (25/52), while the agreement between US and shunt venography was 65% (34/52). Clinical symptoms and the US concurred in 60% (31/52) of the patients. The sensitivity of clinical symptoms and US for the detection of venographically abnormal shunts was 80% (16/20) and 85% (17/20), respectively. Both clinical symptoms and the US had low specificity (25%, 8/32 and 50%, 16/32) for venographically abnormal shunts.

Conclusion:

Clinical findings and the US had low concordance rates with TIPS venography, with acceptable sensitivity but poor specificity. These findings suggest the need for improved noninvasive imaging methods for stent-graft TIPS surveillance.

Three-dimensional C-arm CT-guided transjugular intrahepatic portosystemic shunt placement: Feasibility, technical success and procedural time

OBJECTIVES

Establishment of transjugular intrahepatic portosystemic shunts (TIPS) constitutes a standard procedure in patients suffering from portal hypertension. The most difficult step in TIPS placement is blind puncture of the portal vein. This study aimed to evaluate three-dimensional mapping of portal vein branches and targeted puncture of the portal vein.

METHODS

Twelve consecutive patients suffering from refractory ascites by liver cirrhosis were included in this retrospective study to evaluate feasibility, technical success and procedural time of C-arm CT-targeted puncture of the portal vein. As a control, 22 patients receiving TIPS placement with fluoroscopy-guided blind puncture were included to compare procedural time.

RESULTS

Technical success could be obtained in 100 % of the study group (targeted puncture) and in 95.5 % of the control group (blind puncture). Appropriate, three-dimensional C-arm CT-guided mapping of the portal vein branches could be achieved in all patients. The median number of punctures in the C-arm CT-guided study group was 2 ± 1.3 punctures. Procedural time was significantly lower in the study group (14.8 ± 8.2 min) compared to the control group (32.6 ± 22.7 min) (p = 0.02).

CONCLUSIONS

C-arm CT-guided portal vein mapping is technically feasible and a promising tool for TIPS placement resulting in a significant reduction of procedural time.

KEY POINTS

• C-arm CT-mapping of the portal vein for 3D TIPS guidance is feasible. • Targeted punctures of the portal vein by C-arm CT reduce procedural time. • A decreased number of punctures could improve patient safety.

Cognitive Impairment Predicts The Occurrence Of Hepatic Encephalopathy After Transjugular Intrahepatic Portosystemic Shunt

OBJECTIVES

Hepatic encephalopathy (HE) is a major problem in patients treated with TIPS. The aim of the study was to establish whether pre-TIPS covert HE is an independent risk factor for the development of HE after TIPS.

METHODS

Eighty-two consecutive cirrhotic patients submitted to TIPS were included. All patients underwent the PHES to identify those affected by covert HE before a TIPS. The incidence of the first episode of HE was estimated, taking into account the nature of the competing risks in the data (death or liver transplantation).

RESULTS

Thirty-five (43%) patients developed overt HE. The difference of post-TIPS HE was highly significant (P=0.0003) among patients with or without covert HE before a TIPS. Seventy-seven percent of patients with post-TIPS HE were classified as affected by covert HE before TIPS. Age: (sHR 1.05, CI 1.02-1.08, P=0.002); Child-Pugh score: (sHR 1.29, CI 1.06-1.56, P=0.01); and covert HE: (sHR 3.16, CI: 1.43-6.99 P=0.004) were associated with post-TIPS HE. Taking into consideration only the results of PHES evaluation, the negative predicting value was 0.80 for all patients and 0.88 for the patients submitted to TIPS because of refractory ascites. Thus, a patient with refractory ascites, without covert HE before a TIPS, has almost 90% probability of being free of HE after TIPS.

CONCLUSIONS

Psychometric evaluation before TIPS is able to identify most of the patients who will develop HE after a TIPS and can be used to select patients in order to have the lowest incidence of this important complication.

Laparoscopic Splenectomy and Azygoportal Disconnection: a Systematic Review

Background and Objectives:

Given the technical difficulty of laparoscopic splenectomy and azygoportal disconnection (LSD), data are limited that compare the laparoscopic to the open procedure. As the technique becomes more widespread, questions regarding its safety, feasibility, and reproducibility must be addressed. This review assesses the current status of LSD.

Methods:

We conducted our literature review with a search of the PubMed database. All published series of 5 or more laparoscopic splenectomy and azygoportal disconnection procedures were examined. The demographic, intraoperative, and postoperative data analyzed included number of ports, conversion rate, operative duration, estimated intraoperative blood loss, postoperative hospital stay, and complications.

Results:

Fifteen articles met the review criteria. Of 412 laparoscopic procedures, traditional laparoscopic splenectomy and azygoportal disconnection (TLSD) was used in 322 patients (78.2%), a modified laparoscopic procedure (MLSD) in 79 (19.2%), and a single-incision laparoscopic procedure (SLSD) in 11 (2.7%). Compared with the traditional and single-incision laparoscopic procedures, the MLSD procedure was associated with shorter operative duration and less blood loss. Furthermore, although the incidence of postoperative portal vein system thrombosis was higher in the laparoscopic than in the open splenectomy with azygoportal disconnection (OSD) procedure, the LSD procedure was associated with less pulmonary infection and pleural effusion and fewer incisional and overall complications than the open procedure. The rate of conversion to an open procedure was 5.4%.

Conclusions:

LSD is feasible and safe for selected patients when performed by an expert laparoscopic surgeon. It has perioperative advantages over OSD, but studies with longer follow-up periods and larger samples of patients are needed.

Balloon-Occluded Antegrade Transvenous Sclerotherapy to Treat Rectal Varices: A Direct Puncture Approach to the Superior Rectal Vein Through the Greater Sciatic Foramen Under CT Fluoroscopy Guidance

Rectal varices occur in 44.5 % of patients with ectopic varices caused by portal hypertension, and 48.6 % of these patients are untreated and followed by observation. However, bleeding occurs in 38 % and shock leading to death in 5 % of such patients. Two patients, an 80-year-old woman undergoing treatment for primary biliary cirrhosis (Child-Pugh class A) and a 63-year-old man with class C hepatic cirrhosis (Child-Pugh class A), in whom balloon-occluded antegrade transvenous sclerotherapy was performed to treat rectal varices are reported. A catheter was inserted by directly puncturing the rectal vein percutaneously through the greater sciatic foramen under computed tomographic fluoroscopy guidance. In both cases, the rectal varices were successfully treated without any significant complications, with no bleeding from rectal varices after embolization.

New Cutoff Point for Platelet Count/Spleen Diameter Ratio to Predict Esophageal Varices in Patients with Hepatitis C Virus-related Hepatic Cirrhosis

The esophagogastroduodenoscopy (EGD) with all its hazards remains the gold standard screening tool for esophageal varices. Noninvasive tools have been proposed and studied to replace the EGD. Platelet count (PC)/spleen diameter (SD) ratio as a noninvasive tool for predicting the presence of esophageal varices was proposed and studied in many previous studies.

Transjugular intrahepatic portosystemic shunt for acute variceal gastrointestinal bleeding: Indications, techniques and outcomes

Acute variceal bleeding is a life-threatening condition that requires a multidisciplinary approach for effective therapy. The transjugular intrahepatic portosystemic shunt (TIPS) procedure is a minimally invasive image-guided intervention used for secondary prevention of bleeding and as salvage therapy in acute bleeding. Emergency TIPS should be considered early in patients with refractory variceal bleeding once medical treatment and endoscopic sclerotherapy fail, before the clinical condition worsens. Furthermore, admission to specialized centers is mandatory in such a setting and regional protocols are essential to be organized effectively. This procedure involves establishment of a direct pathway between the hepatic veins and the portal veins to decompress the portal venous hypertension that is the source of the patient's bleeding. The procedure is technically challenging, especially in critically ill patients, and has a mortality of 30%-50% in the emergency setting, but has an effectiveness greater than 90% in controlling bleeding from gastro-esophageal varices. This review focuses on the role of TIPS in the setting of variceal bleeding, with emphasis on current indications and techniques for TIPS creation, TIPS clinical outcomes, and the role of adjuvant embolization of varices.

Long-Term Patency and Clinical Analysis of Expanded Polytetrafluoroethylene-Covered Transjugular Intrahepatic Portosystemic Shunt Stent Grafts

PURPOSE

To evaluate long-term patency and symptomatic recurrence rates following transjugular intrahepatic portosystemic shunt (TIPS) creation with expanded polytetrafluoroethylene (ePTFE)-covered stent grafts and to determine the necessity of extended clinical follow-up beyond 2 years after TIPS creation.

MATERIALS AND METHODS

A retrospective review including 262 TIPSs created with ePTFE-covered stent grafts between July 2002 and October 2012 was performed. Primary, primary assisted, and secondary patency rates were calculated. Assessment of clinical data included technical, hemodynamic, and clinical success rates, as well as mortality after TIPS creation.

RESULTS

Primary patency rates at 2, 4, and 6 years were 74%, 62%, and 50%, respectively. Primary assisted patency rates at 2, 4, and 6 years were 93%, 85%, and 78%, respectively. Secondary patency rates at 2, 4, and 6 years were 99%, 91%, and 84%, respectively. Technical and hemodynamic success rates were 99% and 93%, respectively. Clinical success rates for refractory ascites were 66% (complete response) and 90% (partial response); clinical success rate for bleeding/varices was 90%. Mortality rates at 2, 4, and 6 years after TIPS creation were 27%, 38%, and 46%, respectively. At the median wait time until transplantation, patients had an 84% chance of being alive. TIPS dysfunction developed in 21% of patients; 30% of revisions occurred later than 2 years during follow-up.

CONCLUSIONS

Beyond 2 years after TIPS creation, patency rates gradually decrease, mortality rates continue to increase, and the chance of recurrent ascites or bleeding remains present. Together, these findings suggest that continued clinical follow-up beyond 2 years is necessary in patients with a TIPS created with an ePTFE-covered stent graft.

Management of cirrhotic ascites

The most common complication to chronic liver failure is ascites. The formation of ascites in the cirrhotic patient is caused by a complex chain of pathophysiological events involving portal hypertension and progressive vascular dysfunction. Since ascites formation represents a hallmark in the natural history of chronic liver failure it predicts a poor outcome with a 50% mortality rate within 3 years. Patients with ascites are at high risk of developing complications such as spontaneous bacterial peritonitis, hyponatremia and progressive renal impairment. Adequate management of cirrhotic ascites and its complications betters quality of life and increases survival. This paper summarizes the pathophysiology behind cirrhotic ascites and the diagnostic approaches, as well as outlining the current treatment options. Despite improved medical treatment of ascites, liver transplantation remains the ultimate treatment and early referral of the patient to a highly specialized hepatology unit should always be considered.

Cirrhosis and portal hypertension: The importance of risk stratification, the role of hepatic venous pressure gradient measurement

Portal hypertension is the main prognostic factor in cirrhosis. The recent emergence of potent antiviral drugs and new algorithm of treatment for the management of complications due to portal hypertension have sensibly changed our perception of cirrhosis that can be now considered as a multistage liver disease whose mortality risk can be reduced by a tailored approach for any stage of risk. Experts recommend to move toward a pathophysiological classification of cirrhosis that considers both structural and functional changes. The hepatic venous pressure gradient HVPG, is the reference gold standard to estimate the severity of portal hypertension in cirrhosis. It correlates with both structural and functional changes that occur in cirrhosis and carries valuable prognostic information to stratify the mortality risk. This article provides a general overview of the pathophysiology and natural course of cirrhosis and portal hypertension. We propose a simplified classification of cirrhosis based on low, intermediate and high mortality stage. The prognostic information provided by HVPG is presented according to each stage. A comparison with prognostic models based on clinical and endoscopic variables is discussed in order to evidence the additional contribute given by HVPG on top of other clinical and instrumental variables widely used in clinical practice.

The modified Sugiura procedure as bridge surgery for liver transplantation: a case report

Introduction

Esophagogastric varices bleeding is a common complication due to portal hypertension in patients with liver cirrhosis. With the advancement of nonoperative management including vasoactive agents, endoscopic hemostasis or transjugular intrahepatic portosystemic shunt, surgical management has played a lesser role in recent decades. The present report describes a patient with hepatitis B (HBV)-related liver cirrhosis and portal vein thrombosis with recurrent esophagogastric varices bleeding despite the use of medical and endoscopic therapy. The modified Sugiura procedure was performed as an alternative bridge surgery for liver transplantation in order not to change the anatomic structure of the great vessels and to avoid hepatic encephalopathy related to shunting procedures like the transjugular intrahepatic portosystemic shunt.

Case presentation

A 56-year-old Chinese man with a history of portal hypertension due to HBV-related liver cirrhosis and known former recurrent esophageal varices bleeding status post Sengstaken-Blakemore tube tamponade was referred to our hospital for liver transplantation evaluation because of persistent esophagogastric varices bleeding with hypovolemic shock, even after medical and endoscopic therapies in a local hospital. As a result, liver cirrhosis with Child-Pugh class B function was diagnosed. Despite the use of vasoactive agents, and endoscopic hemostasis management, esophagogastric varices bleeding still occurred episodically with hypovolemic shock, which could not be reversed by blood transfusion or Sengstaken-Blakemore tube tamponade. The modified Sugiura procedure, as an alternative bridge therapy for patients who are candidates for liver transplantation, was performed, despite the fact that his liver transplantation was not yet completed. He then received a living donor liver transplantation with the right lobe of liver from his daughter. The postoperative course was uneventful, and he was discharged two weeks later. He had no evidence of recurrent esophagogastric varices bleeding during the six-month follow-up.

Conclusions

The treatment experience of this case gave us not only the idea but also the practical way of applying the modified Sugiura operation as a bridge and rescue therapy without alteration of the vascular anatomy and hemodynamic stability for patients who have experienced refractory esophagogastric varices bleeding, despite the use of medication and endoscopic treatment, and are candidates for receiving a liver transplantation.

Characteristic haemodynamic changes of cirrhosis may influence the diagnosis of portopulmonary hypertension

BACKGROUND & AIMS

Diagnosis of portopulmonary hypertension (POPH) is based on the presence of portal hypertension and the same haemodynamic criteria as pulmonary arterial hypertension (PAH). However, the typical hyperdynamic circulation of cirrhosis may have some impact on the diagnosis of POPH. The aim was to compare the haemodynamic pattern of the pulmonary circulation between cirrhotics and non-cirrhotics, including patients with PAH.

PATIENTS AND METHODS

600 patients with cirrhosis [male 77.5%, age 54 (47-60) years, Child A: 14.7%, B: 54.3%, C: 31%] received right heart catheterization. For comparison, 118 non-cirrhotic patients [male 60%, age 64 (53-65) years] with right heart catheterization and PCWP <20 mmHg were included. Both were divided into 3 groups, A: absence of pulmonary arterial hypertension; B or intermediate group: MPAP >25 mmHg, PVR 120-240 dyn s cm(-5) and PCWP <15 mmHg (or PCWP >15 mmHg with TPG ≥12 mmHg); C: pulmonary arterial hypertension (same criteria as B except PVR ≥240 dyn s cm(-5) ).

RESULTS

Distribution of patients with cirrhosis was A 583, B 7 and C 10. Prevalence of POPH was 1.7%. Cirrhotics had lower SVR and greater CO than non-cirrhotics (P < 0.05). Interestingly, patients with cirrhosis without PAH (groups A and B) had lower PVR (P < 0.05) when comparing with non-cirrhotics, while no differences in PVR were observed in group C. However, mean TPG was greater in group C of cirrhotics [36.6 mmHg (12.2) vs. 27.1 mmHg (10.1); P = 0.034].

CONCLUSIONS

Patients with cirrhosis have lower PVR. TPG is greater in POPH than PAH. Characteristic haemodynamic changes of cirrhosis may influence the diagnosis of POPH.

Postinterventional passive expansion of partially dilated transjugular intrahepatic portosystemic shunt stents

PURPOSE

To investigate passive transjugular intrahepatic portosystemic shunt (TIPS) stent expansion in patients with intentional "underdilation" (eg, 10-mm stent, 8-mm balloon) during TIPS creation.

MATERIALS AND METHODS

Custom in-house software was developed for objective quantification of cross-sectional stent area from computed tomography (CT) data. The technique was validated by in vitro experiments. The study included 39 patients (22 men; mean age, 59.2 y) who underwent TIPS creation (VIATORR stent graft [W. L. Gore & Associates, Flagstaff, Arizona]; n = 29; WALLSTENT endoprosthesis [Boston Scientific, Marlborough, Massachusetts], n = 10) with stent underdilation. Follow-up CT data of the patients were used to quantify in vivo stent area changes. Data were analyzed by variance analysis and entered into a general linear model to test for interrelations between stent area changes and clinical (eg, cirrhosis grade) and procedural parameters.

RESULTS

In vitro validation of the in-house software showed good agreement and reproducibility without overestimation of stent area. Mean clinical follow-up time in patients was 787 days (range, 7-2,450 d). At the time of intervention, VIATORR stent grafts and WALLSTENT endoprostheses were dilated to an average of 64.4% ± 2.3% and 65.63% ± 8.52% of nominal area, respectively. At the last imaging follow-up evaluation, this value had increased in all stents to a mean of 87.8% ± 7.9% (VIATORR) and 82.34% ± 19.6% (WALLSTENT) in the TIPS tract (P < .05). Multivariate analysis revealed the time after intervention to be the only predictor of stent area in the TIPS tract. There was no significant association between stent expansion and clinical or procedure-related parameters.

CONCLUSIONS

The area of self-expanding stents implanted in the liver for TIPS creation with dilation to less than nominal diameter significantly increases over time. This increase has to be considered as an additional factor influencing the long-term portosystemic gradient.

Measurement of portal pressure

Portal pressure is estimated through measuring the hepatic venous pressure gradient (HVPG). The main clinical applications of HVPG measurements include diagnosis, classification, and monitoring of portal hypertension, risk stratification, identification of candidates for liver resection, and monitoring efficacy of β-adrenergic blockers. Clinically significant portal hypertension is defined as an HVPG of 10 mm Hg or greater. Patients who experience a reduction in the HVPG of 20% or greater or to lower than 12 mm Hg in response to β-blocker therapy have a markedly decreased risk of bleeding (or rebleeding), ascites, and spontaneous bacterial peritonitis, resulting in improved survival rates.

Impact of splenic circulation: non-invasive microbubble-based assessment of portal hemodynamics

OBJECTIVE

The objective was to examine the effect of splenic circulation using a microbubble agent to assess the severity of portal hypertension.

METHODS

This prospective study consisted of 91 subjects (63.0 ± 12.6 years, 30-86; 60 males, 31 females), 62 cirrhosis and 29 controls, who underwent both Doppler ultrasound and contrast-enhanced ultrasound with a perflubutane microbubble agent. Two microbubble-based parameters for splenic circulation, the minimum circulation time (MCT, s) and the peak enhancement time (PET, s), were assessed with respect to the hepatic venous pressure gradient (HVPG) and other clinical findings.

RESULTS

The MCT and PET showed significant differences between cirrhosis (5.7 ± 1.8; 14.6 ± 3.0) and controls (4.0 ± 1.9, p < 0.0001; 8.9 ± 2.3, p < 0.0001), respectively. However, only PET offered positive correlations with wedged hepatic venous pressure (r = 0.4648, p = 0.0001) and HVPG (r = 0.4573, p = 0.0001). The area under the receiver operating characteristics curve to identify HVPG ≥ 10 mmHg, and 12 mmHg was 0.76 and 0.76, respectively.

CONCLUSIONS

The microbubble-based non-invasive assessment of the splenic circulation is effective to identify the severity of portal hypertension presumably by reflecting congestion of splenic venous flow due to increased portal venous pressure.

Transjugular intrahepatic portosystemic shunt

Transjugular intrahepatic portosystemic shunt (TIPS) is an established procedure for the complications of portal hypertension. The largest body of evidence for its use has been supported for recurrent or refractory variceal bleeding and refractory ascites. Its use has also been advocated for acute variceal bleed, hepatic hydrothorax, and hepatorenal syndrome. With the replacement of bare metal stents with polytetrafluoroethylene-covered stents, shunt patency has improved dramatically, thus, improving outcomes. Therefore, reassessment of its utility, management of its complications, and understanding of various TIPS techniques is important.

Percutaneous Portosystemic Shunts: TIPS and Beyond

Percutaneous interventions for portal hypertension have been available since the 1990s. Over time, improved technology-including covered stent grafts-and clinical understanding has expanded the available procedures for percutaneous portal decompression. While transjugular intrahepatic portosystemic shunt creation is the most commonly cited percutaneous intervention, direct intrahepatic portocaval shunt and percutaneous mesocaval shunt creation are important alternatives with specific advantages and applications. This article reviews contemporary, minimally invasive interventional approaches to percutaneous portosystemic shunt creation in terms of procedure rationale, patient selection, interventional technique, and technical outcomes.

Outcomes of TIPS for Treatment of Gastroesophageal Variceal Hemorrhage

Variceal hemorrhage is a life-threatening complication of cirrhosis that requires a multidisciplinary approach to management. The transjugular intrahepatic portosystemic shunt (TIPS) procedure is a minimally invasive image-guided intervention used for secondary prevention of bleeding and as salvage therapy in acute hemorrhage. This review focuses on the role of TIPS in the setting of variceal hemorrhage, with emphasis on the pathophysiology and conventional management of variceal hemorrhage, current and emerging indications for TIPS creation, TIPS clinical outcomes, and the role of adjuvant embolotherapy.

Transjugular intrahepatic portosystemic shunt: indications, contraindications, and patient work-up

The transjugular intrahepatic portosystemic shunt (TIPS) procedure is effective in achieving portal decompression and in managing some of the major complications of portal hypertension. While many clinicians are familiar with the two most common indications for TIPS placement, secondary prophylaxis of esophageal variceal hemorrhage and treatment of refractory ascites, evidence for its usefulness is growing in other entities, where it has been less extensively studied but demonstrates promising results. Newer indications include early utilization in the treatment of esophageal variceal hemorrhage, Budd-Chiari syndrome, ectopic varices, and portal vein thrombosis. The referring clinician and interventionist must remain cognizant of the contraindications to the procedure to avoid complications and potential harm to the patient. This review is designed to provide an in-depth analysis of the most common as well as less typical indications for TIPS placement, and to discuss the contraindications and appropriate patient evaluation for this procedure.

Clinically severe portal hypertension: role of multi-detector row CT features in diagnosis

BACKGROUND AND AIM

To explore the CT signs which permit estimation of clinically severe portal hypertension (PH) [≥ 12 of hepatic vein pressure gradient (HVPG)].

METHODS

One-hundred and seven consecutive patients who underwent HVPG measurement in the PH group and 52 controls were included. The diameters of main portal vein (øMPV), superior mesenteric vein (øSMV), splenic vein (øSV), and left gastric vein, øMPV/øSV, øSMV/øSV, as well as estimated spleen volumes were evaluated on the CT scan. The grade of varix and ascites were also evaluated semi-quantitatively. We explored the statistically significant CT features related to severe PH and performed a logistic regression analysis for an estimation model for severe PH.

RESULTS

øMPV/øSV and øSMV/øSV tended to gradually increase as the PH became severer, and the difference between severe and not severe groups was statistically significant (p = 0.015 and 0.038, respectively). According to the regression analysis, øSMV/øSV and the grade of esophageal varix and ascites were finally included as related variables for predicting severe PH. The odds ratio (OR) of øSMV/øSV was 4.596, and large esophageal varix (OR 4.135) and mild (OR 3.051) and large amount of ascites (OR 21.781) were statistically significantly related to severe PH.

CONCLUSION

Changing diameters of portal system, the grades of esophageal varices and ascites on multi-detector row computed tomography might be indicative features for clinically severe PH.

Cirrhosis and its complications: Evidence based treatment

Cirrhosis results from progressive fibrosis and is the final outcome of all chronic liver disease. It is among the ten leading causes of death in United States. Cirrhosis can result in portal hypertension and/or hepatic dysfunction. Both of these either alone or in combination can lead to many complications, including ascites, varices, hepatic encephalopathy, hepatocellular carcinoma, hepatopulmonary syndrome, and coagulation disorders. Cirrhosis and its complications not only impair quality of life but also decrease survival. Managing patients with cirrhosis can be a challenge and requires an organized and systematic approach. Increasing physicians’ knowledge about prevention and treatment of these potential complications is important to improve patient outcomes. A literature search of the published data was performed to provide a comprehensive review regarding the management of cirrhosis and its complications.

Covered vs. uncovered stents for transjugular intrahepatic portosystemic shunt: a randomized controlled trial

BACKGROUND & AIMS

The first studies comparing covered stents (CS) and bare stents (BS) to achieve Transjugular Intrahepatic Portosystemic Shunt (TIPS) were in favor of CS, but only one randomized study has been performed. Our aim was to compare the primary patency of TIPS performed with CS and BS.

METHODS

The study was planned as a multicenter, pragmatic (with centers different in size and experience), randomized, single-blinded (with blinding of patients only), parallel group trial. The primary endpoint was TIPS dysfunction defined as either a portocaval gradient ⩾12mmHg, or a stent lumen stenosis ⩾50%. A transjugular angiography with portosystemic pressure gradient measurement was scheduled every 6months after TIPS insertion.

RESULTS

137 patients were randomized: 66 to receive CS, and 71 BS. Patients who were found to have a hepato-cellular carcinoma, or whose procedure was cancelled were excluded, giving a sample of 129 patients (62 vs. 67). Median follow-up for CS and BS were 23.6 and 21.8months, respectively. Compared to BS, the risk of TIPS dysfunction with CS was 0.60 95% CI [0.38-0.96], (p=0.032). The 2-year rate of shunt dysfunction was 44.0% for CS vs. 63.6% for BS. Early post TIPS complications (22.4% vs. 34.9%), risk of hepatic encephalopathy (0.89 [0.53-1.49]) and 2-year survival (70% vs. 67.5%) did not differ in the two groups. The 2-year cost/patient was 20k€ [15.9-27.5] for CS vs. 23.4k€ [18-37] for BS (p=0.52).

CONCLUSIONS

CS provided a significant 39% reduction in dysfunction compared to BS. We did not observe any significant difference with regard to hepatic encephalopathy or death.

Good clinical outcomes following transjugular intrahepatic portosystemic stent-shunts in Budd-Chiari syndrome

BACKGROUND

There have been encouraging reports on transjugular intrahepatic portosystemic stent-shunt (TIPSS) for Budd-Chiari syndrome (BCS). Long-term data are lacking.

AIM

To assess long-term outcomes and validate prognostic scores following TIPSS for BCS.

METHODS

A single centre retrospective study. Patients underwent TIPSS using bare or polytertrafluoroethane (PTFE)-covered stents.

RESULTS

Sixty-seven patients received successful TIPSS between 1996 and 2012 using covered (n = 40) or bare (n = 27) stents. Patients included had a Male: Female ratio of 21:46, and were characterised (mean ± s.d.) by age 39.9 ± 14.3 years, Model of end stage liver disease (MELD) 16.1 ± 7.0 and Child's score 8.8 ± 2.0. Seventy-eight percent had haematological risk factors. Presenting symptoms were ascites (n = 61) and variceal bleeding (n = 6). Nine patients underwent hepatic vein dilatation or stenting prior to TIPSS. Mean follow-up was 82 months (range 0.5-184 months). Fifteen percent had post-TIPSS encephalopathy. Two have been transplanted. Primary patency rates (76% vs. 27%, P < 0.001) and shunt re-interventions (22% vs. 100%, P < 0.001) significantly favoured covered stents. Secondary patency was 99%. Six-, 12-, 24-, 60- and 120-month survival was 97%, 92%, 87%, 80% and 72% respectively. Six patients had liver related deaths. Two patients developed hepatocellular carcinoma. The BCS TIPS PI independently predicted mortality in the whole cohort, but no prognostic score was a significant predictor of mortality after subgroup validation.

CONCLUSIONS

Long-term outcomes following TIPSS for Budd-Chiari syndrome are very good. PTFE-covered stents have significantly better primary patency. The value of prognostic scores is controversial. TIPSS should be considered as first line therapy in symptomatic patients in whom hepatic vein patency cannot be restored.

Clinical outcomes of transjugular intrahepatic portosystemic shunt for portal hypertension: Korean multicenter real-practice data

Background/Aims

This retrospective study assessed the clinical outcome of a transjugular intrahepatic portosystemic shunt (TIPS) procedure for managing portal hypertension in Koreans with liver cirrhosis.

Methods

Between January 2003 and July 2013, 230 patients received a TIPS in 13 university-based hospitals.

Results

Of the 229 (99.6%) patients who successfully underwent TIPS placement, 142 received a TIPS for variceal bleeding, 84 for refractory ascites, and 3 for other indications. The follow-up period was 24.9±30.2 months (mean±SD), 74.7% of the stents were covered, and the primary patency rate at the 1-year follow-up was 78.7%. Hemorrhage occurred in 30 (21.1%) patients during follow-up; of these, 28 (93.3%) cases of rebleeding were associated with stent dysfunction. Fifty-four (23.6%) patients developed new hepatic encephalopathy, and most of these patients were successfully managed conservatively. The cumulative survival rates at 1, 6, 12, and 24 months were 87.5%, 75.0%, 66.8%, and 57.5%, respectively. A high Model for End-Stage Liver Disease (MELD) score was significantly associated with the risk of death within the first month after receiving a TIPS (P=0.018). Old age (P<0.001), indication for a TIPS (ascites vs. bleeding, P=0.005), low serum albumin (P<0.001), and high MELD score (P=0.006) were associated with overall mortality.

Conclusions

A high MELD score was found to be significantly associated with early and overall mortality rate in TIPS patients. Determining the appropriate indication is warranted to improve survival in these patients.

The Evolution of Transjugular Intrahepatic Portosystemic Shunt: Tips

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.

Impact of deep sedation on the accuracy of hepatic and portal venous pressure measurements in patients with cirrhosis

BACKGROUND & AIMS

Measurement of the hepatic venous pressure gradient (HVPG) offers valuable prognostic information in patients with cirrhosis. In specific circumstances, (children, agitated patients, TIPS placement) deep sedation is required. This study aims to assess the impact of deep sedation on the accuracy of hepatic/portal pressure measurements.

METHODS

Forty-four patients were included. Measurements of baseline HVPG (n = 30), HVPG response to i.v. propranolol (n = 11), portal pressure gradient (PPG) after TIPS (n = 27) and of cardio-pulmonary pressures (n = 25) were obtained in awake conditions and under deep sedation with propofol and remifentanil.

RESULTS

During deep sedation, a marked oscillation within respiratory cycle was observed in abdominal pressures. End-expiratory sedated HVPG showed a better agreement with awake HVPG (intra-class correlation coefficient - ICC 0.864) than end-inspiratory HVPG (ICC 0.796). However, in almost half of the patients both values differed by more than 10%. Accuracy was not improved by using mean HVPG along the respiratory cycle. Similarly, changes in HVPG caused by propranolol while under sedation had a poor agreement to those obtained in awake conditions. Indeed, about a half of patients were misclassified according to the 10% HVPG reduction target. After TIPS, PPG values obtained under sedation were significantly different to awake PPG, usually underestimating the awake value. The systemic hemodynamic changes induced by sedation were not associated to a greater variability of PPG/HVPG measurements.

CONCLUSION

Deep sedation with propofol and remifentanil adds substantial variability and uncertainty to HVPG/PPG measurements. This must be considered when using these values to estimate prognosis, or targeting HVPG/PPG reductions.

Clinical effects and complications of TIPS for portal hypertension due to cirrhosis: A single center

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.

TIPS: 25 years later

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.

Covered transjugular intrahepatic portosystemic shunts: accuracy of ultrasound in detecting shunt malfunction

OBJECTIVE

The purpose of this study was to determine the accuracy of ultrasound for detecting transjugular intrahepatic portosystemic shunt (TIPS) malfunction in covered stents in comparison with bare metal stents.

MATERIALS AND METHODS

During a 6-year period, 126 TIPS angiography examinations were performed in 78 patients who had undergone a recent TIPS ultrasound examination. Radiology reports and images were retrospectively reviewed, and the sensitivity and specificity of sonographic parameters for detecting TIPS dysfunction were calculated using TIPS angiography and portosystemic gradient as the reference standards.

RESULTS

Of 126 paired studies, 43 were in bare metal TIPS and 83 were in covered TIPS. Peak shunt velocity of covered and bare metal TIPS measured by ultrasound showed comparable sensitivities for detection of shunt dysfunction, using both depressed (< 90 cm/s) and elevated (> 200 cm/s) peak shunt velocity criteria. However, a depressed velocity was more specific in covered TIPS (0.939 vs 0.550, p < 0.001) whereas elevated velocity was more specific in bare TIPS (0.485 vs 0.800, p = 0.041). An interval change in peak TIPS velocity greater than 25% was significantly more sensitive in detection of dysfunction in covered TIPS (0.815 vs 0.400, p = 0.015) whereas detection based on main portal vein velocities (≤ 30 cm/s) was not statistically different in the two groups.

CONCLUSION

Our data suggest that the accuracy of ultrasound for detection of TIPS shunt malfunction is at least as high in covered stents as in bare metal stents. Diagnostic performance for several sonographic parameters varied significantly between bare and covered stents, suggesting the need for optimization of sonographic criteria for covered stents.

[Mexican consensus on portal hypertension]

The aim of the Mexican Consensus on Portal Hypertension was to develop documented guidelines to facilitate clinical practice when dealing with key events of the patient presenting with portal hypertension and variceal bleeding. The panel of experts was made up of Mexican gastroenterologists, hepatologists, and endoscopists, all distinguished professionals. The document analyzes themes of interest in the following modules: preprimary and primary prophylaxis, acute variceal hemorrhage, and secondary prophylaxis. The management of variceal bleeding has improved considerably in recent years. Current information indicates that the general management of the cirrhotic patient presenting with variceal bleeding should be carried out by a multidisciplinary team, with such an approach playing a major role in the final outcome. The combination of drug and endoscopic therapies is recommended for initial management; vasoactive drugs should be started as soon as variceal bleeding is suspected and maintained for 5 days. After the patient is stabilized, urgent diagnostic endoscopy should be carried out by a qualified endoscopist, who then performs the corresponding endoscopic variceal treatment. Antibiotic prophylaxis should be regarded as an integral part of treatment, started upon hospital admittance and continued for 5 days. If there is treatment failure, rescue therapies should be carried out immediately, taking into account that interventional radiology therapies are very effective in controlling refractory variceal bleeding. These guidelines have been developed for the purpose of achieving greater clinical efficacy and are based on the best evidence of portal hypertension that is presently available.

Effects of transjugular intrahepatic portosystemic shunt on changes in the small bowel mucosa of cirrhotic patients with portal hypertension

BACKGROUND

The introduction of capsule endoscopy (CE) has facilitated the detection of mucosal changes in the small bowel, and such mucosal changes have been noted in cirrhotic patients with portal hypertension; these changes are described as portal hypertensive enteropathy. The aim of this study was to assess the effects of transjugular intrahepatic portosystemic shunt (TIPS) on the small bowel mucosal changes detected by CE in cirrhotic patients with portal hypertension.

METHODS

TIPS was performed in fifteen cirrhotic patients with portal hypertension. All patients underwent CE before and 2 weeks after TIPS. The small bowel mucosal changes were defined as edema, angiodysplasia-like lesions, red spots, and small bowel varices. Changes in the portosystemic pressure gradient (PSG) and CE findings were evaluated.

RESULTS

Before TIPS, small bowel edema was detected in all 15 patients, angiodysplasia-like lesions in 7, and red spots in 14 patients. The PSG decreased significantly, from 21.2 ± 2.6 before TIPS to 8.9 ± 3.3 mmHg (p < 0.001) after the procedure. After TIPS, the small bowel edema was attenuated in 8 of the 15 patients. In two patients with angiodysplasia-like lesions and 4 with red spots, these lesions were attenuated after TIPS. The average score for small bowel edema and the grade of red spots were reduced significantly after TIPS (2.3 ± 0.7-1.8 ± 0.6, p < 0.005 and 1.6 ± 0.9-1.3 ± 0.7, p < 0.05, respectively). Small bowel varices were seen in 4 patients before TIPS and all these varices disappeared after TIPS.

CONCLUSIONS

In cirrhotic patients with portal hypertension, small bowel edema, red spots, and small bowel varices were attenuated after TIPS. Portal hypertension may be an important factor in the development of small bowel mucosal changes.

Hemodynamic response to propranolol in patients with recurrent hepatitis C virus-related cirrhosis after liver transplantation: a case-control study

Cirrhosis recurrence is frequent after orthotopic liver transplantation for hepatitis C virus (HCV). Because transplantation causes liver denervation, we hypothesized that the response to propranolol might differ in transplant patients versus nontransplant patients with cirrhosis and portal hypertension. Twenty-one patients with cirrhosis recurrence after orthotopic liver transplantation with portal hypertension were compared to 20 nontransplant patients with cirrhosis, HCV, and portal hypertension, and they were matched by sex, age, presence of varices, and Child-Pugh score. The patients underwent systemic and hepatic hemodynamic measurements at the baseline and 20 minutes after intravenous propranolol (0.15 mg/kg). At the baseline, the transplant patients with cirrhosis had a lower hepatic venous pressure gradient (HVPG) than the nontransplant patients with cirrhosis (14.8 ± 2.9 versus 17.3 ± 4.4 mm Hg, P = 0.03) but a higher mean arterial pressure (MAP; 100.3 ± 12.3 versus 91.8 ± 11.6 mm Hg, P = 0.04) and higher systemic vascular resistance (2253 ± 573 versus 1883 ± 525 dyn/second/cm(-5) , P = 0.03). There were no differences in the cardiac index (CI). Propranolol significantly decreased HVPG to similar extents in transplant patients and nontransplant patients with cirrhosis (-14.1% ± 8.0% versus -16.9% ± 9.5%, P > 0.99). MAP tended to increase in transplant patients with cirrhosis, whereas it slightly decreased in nontransplant patients (5.1% ± 14.2% versus -4.8% ± 6.4%, P = 0.007); however, the reduction in CI was less marked in transplant patients with cirrhosis (-18.6% ± 7.6% versus -26.9% ± 9.0%, P = 0.005). In conclusion, patients with HCV-related cirrhosis and portal hypertension after orthotopic liver transplantation have lower baseline HVPG values but similar HVPG responses to propranolol infusions in comparison with nontransplant patients with cirrhosis. In contrast to nontransplant patients, propranolol increases the systemic vascular resistance and arterial pressure in transplant patients with cirrhosis and attenuates the fall in CI.

Transjugular intrahepatic portosystemic shunt dysfunction

Transjugular intrahepaticportosystemic shunt (TIPS) is an effective method for the management of complications of portal hypertension, and it should be considered the first-line treatment for acute hemorrhage due to ruptured esophageal varices caused by portal hypertension. Keeping the stent unobstructed is key to the success of TIPS. Stent thrombosis is one of the main reasons for TIPS dysfunction. There has been no mention of TIPS postoperative anticoagulation in both domestic and foreign anticoagulation guidelines, because the consensus has not been reached yet. This paper reviews recent advances in research of TIPS dysfunction.

Assessing portal hypertension in liver diseases

Portal hypertension is a common complication of chronic liver diseases and is responsible for most clinical consequences of cirrhosis, which represent the more frequent causes of death and liver transplantation in these patients. This review is aimed at clarifying the state-of-the art assessment of portal hypertension and at discussing recent developments in this field. Particular attention is paid to new noninvasive techniques that will be soon available for potential routine use.

An update on the diagnosis and management of Budd-Chiari syndrome

Budd-Chiari syndrome is a rare disorder caused by hepatic venous outflow obstruction and resulting hepatic dysfunction. Despite a lack of prospective randomized trials, much progress has been made in its management over the last 20 years. The main goals of treatment are to ameliorate hepatic congestion and prevent further thrombosis. The selective use of anticoagulation, vascular stents, transjugular intrahepatic portosystemic stent-shunt and liver transplant has resulted in a significant increase in survival. The diagnosis, initial management and long-term follow-up of patients with Budd-Chiari syndrome is reviewed. The concept of individualization of treatment and a stepwise approach to invasive procedures is also discussed.

The transjugular intrahepatic portosystemic shunt: an update

OBJECTIVE

The purpose of this article is to review the indications, outcomes, complications, patient selection, and technical aspects of creating a transjugular intrahepatic portosystemic shunt (TIPS).

CONCLUSION

The best available evidence supports the use of TIPS in secondary prevention of variceal bleeding and in refractory ascites, although TIPS is also commonly used for other indications such as Budd-Chiari syndrome, hepatic hydrothorax, and acute variceal hemorrhage. The TIPS procedure was revolutionized by the introduction of covered stents, which dramatically improved long-term shunt patency.

The role of Transjugular Intrahepatic Portosystemic Stent-Shunt (TIPSS) in the management of variceal hemorrhage

BACKGROUND

Variceal bleeding in cirrhosis represents a lethal complication of their disease. In the last 20 years, management of AVH has improved greatly with reduction in mortality from 43% in 1980 to 15% in 2000.

AIM

Advances in endoscopic therapy, pharmacologic agents including vasoconstrictor therapy and antibiotics have played a large part in improving outcomes, but the role of Transjugular Intrahepatic Portosystemic Stent-Shunt (TIPSS) remains controversial, which this review will cover.

METHODS

MEDLINE search for the following terms was performed to July 2011: variceal hemorrhage, portal hypertension, cirrhosis, transjugular intrahepatic portosystemic stent-shunt (TIPSS), PTFE, covered stents. Where possible randomized controlled studies were used for this review, although uncontrolled studies were also included if they made a significant contribution to the literature.

RESULTS

Literature used for the present study was selected from a total of 252 publications and abstracts from meetings.

RESULTS

TIPSS has been used as a salvage therapy after initial medical and endoscopic therapy for the bleed given its high success rate in arresting uncontrolled variceal bleeding. The recent trial by Garcia- Pagan et al. suggested beneficial effects of an earlier covered TIPSS in those at high risk of treatment failure (Childs C and those who are Childs B with active bleeding).

CONCLUSIONS

TIPSS can reduce failure to control bleeding and rebleeding as well as mortality with no increase in the risk of hepatic encephalopathy.This needs to be confirmed in further trials. However, it is clear that prevention of rebleeding is the key to improved outcomes following a variceal bleed.

Clinical outcome and predictors of survival after TIPS insertion in patients with liver cirrhosis

AIM: To determine the clinical outcome and predictors of survival after transjugular intrahepatic portosystemic stent shunt (TIPS) implantation in cirrhotic patients.

METHODS: Eighty-one patients with liver cirrhosis and consequential portal hypertension had TIPS implantation (bare metal) for either refractory ascites (RA) (n = 27) or variceal bleeding (VB) (n = 54). Endpoints for the study were: technical success, stent occlusion and stent stenosis, rebleeding, RA and mortality. Clinical records of patients were collected and analysed. Baseline characteristics [e.g., age, sex, CHILD score and the model for end-stage liver disease score (MELD score), underlying disease] were retrieved. The Kaplan-Meier method was employed to calculate survival from the time of TIPS implantation and comparisons were made by log rank test. A multivariate analysis of factors influencing survival was carried out using the Cox proportional hazards regression model. Results were expressed as medians and ranges. Comparisons between groups were performed by using the Mann-Whitney U-test and the χ² test as appropriate.

RESULTS: No difference could be seen in terms of age, sex, underlying disease or degree of portal pressure gradient (PPG) reduction between the ascites and the bleeding group. The PPG significantly decreased from 23.4 ± 5.3 mmHg (VB) vs 22.1 ± 5.5 mmHg (RA) before TIPS to 11.8 ± 4.0 vs 11.7 ± 4.2 after TIPS implantation (P = 0.001 within each group). There was a tendency towards more patients with stage CHILD A in the bleeding group compared to the ascites group (24 vs 6, P = 0.052). The median survival for the ascites group was 29 mo compared to > 60 mo for the bleeding group (P = 0.009). The number of radiological controls for stent patency was 6.3 for bleeders and 3.8 for ascites patients (P = 0.029). Kaplan-Meier calculation indicated that stent occlusion at first control (P = 0.027), ascites prior to TIPS implantation (P = 0.009), CHILD stage (P = 0.013), MELD score (P = 0.001) and those patients not having undergone liver transplantation (P = 0.024) were significant predictors of survival. In the Cox regression model, stent occlusion (P = 0.022), RA (P = 0.043), CHILD stage (P = 0.015) and MELD score (P = 0.004) turned out to be independent prognostic factors of survival. The anticoagulation management (P = 0.097), the porto-systemic pressure gradient (P = 0.460) and rebleeding episodes (P = 0.765) had no significant effect on the overall survival.

CONCLUSION: RA, stent occlusion, initial CHILD stage and MELD score are independent predictors of survival in patients with TIPS, speaking for a close follow-up in these circumstances.

Management of refractory ascites

Ascites that does not respond or recurs after high-dose diuresis and sodium restriction should be considered refractory ascites. As cirrhosis advances, the escaping fluid overwhelms the lymphatic return. Decrease in renal plasma flow leads to increased sodium reabsorption at the proximal tubule leading to decreased responsiveness to loop diuretics and mineralocorticoid antagonists, which work distally. These complex hemodynamic alterations lead to refractory ascites. In refractory ascites, high-dose diuresis (400 mg of spironolactone and 160 mg of furosemide) and sodium restriction (<90 mmol/d) result in inadequate weight loss and sub optimal sodium excretion (<78 mmol/d). Further use of diuretics is limited by complications such as encephalopathy, azotemia, renal insufficiency, hyponatremia, and hyperkalemia. Therapy for refractory ascites is limited. The available therapies are repeated large volume paracentesis (LVP), transjugular intrahepatic portosystemic shunts, peritoneovenous shunts, investigational medical therapies, and liver transplantation. LVP with concomitant volume expanders is the initial treatment of choice. Transjugular intrahepatic portosystemic seems to be superior to LVP in reducing the need for repeated paracentesis and improves the quality of life. Several treatments that act at different steps in the pathogenesis of ascites are investigational, and some show promising results. Splanchnic and peripheral vasoconstrictors (Octreotide, Midodrine, and Terlipressin) increase effective arterial volume and decrease activation of the renin-angiotensin system with resultant increase in renal sodium excretion. Clonidine when given with spironolactone has been shown to cause rapid mobilization of ascites by significantly decreasing the sympathetic activity and renin-aldosterone levels. Natural aquaretics and synthetic V2 receptor antagonists (satavaptan) are being evaluated for mobilization of ascites by increasing the excretion of solute-free water. Liver transplantation remains the only definitive therapy for refractory ascites. Because refractory ascites is a poor prognostic sign, liver transplantation should be considered and incorporated early in the treatment plan.

Effects of the combined administration of propranolol plus sorafenib on portal hypertension in cirrhotic rats

Low doses of sorafenib have been shown to decrease portal pressure (PP), portal-systemic shunts, and liver fibrosis in cirrhotic rats. Nonselective beta blockers (NSBB) are the only drugs recommended for the treatment of portal hypertension. The aim of our study was to explore whether the combination of propranolol and sorafenib might show an additive effect reducing PP in cirrhotic rats. Groups of common bile duct-ligated cirrhotic rats (CBDL) and sham-operated control rats were treated by gavage with vehicle, propranolol (30 mg·kg(-1)·day(-1)), sorafenib (1 mg·kg(-1)·day(-1)), or propranolol+sorafenib. Treatment began 2 wk after the CBDL or sham operation. Hemodynamic evaluation was performed after 2 wk of treatment. In cirrhotic rats, propranolol and sorafenib produced a significant (P < 0.001) and similar reduction in PP (-19 and -15%, respectively). This was achieved through different mechanisms: whereas propranolol decreased PP by reducing portal blood flow (-35%; P = 0.03), sorafenib decreased PP without decreasing portal flow indicating decreased hepatic resistance. After propranolol+sorafenib, the fall in PP was significantly greater (-30%; P < 0.001) than with either drug alone, demonstrating an additive effect. However, the reduction in portal flow (-39%) under combined therapy was not significantly greater than after propranolol alone. Sorafenib, alone or in combination with propranolol, produced significant reduction in portal-systemic shunting (-25 and -33%, respectively), splanchnic vascularization (-37 and -41%, respectively), liver fibrosis (38%), and hepatic neovascularization (-42 and -51%, respectively). These effects were not observed after propranolol alone. In conclusion, the combination of propranolol+sorafenib causes a greater reduction in PP than either drug alone and decreases markedly the extent of portal-systemic shunting, splanchnic and hepatic neovascularization, and liver fibrosis, suggesting that this drug combination is a potentially useful strategy in the treatment of portal hypertension.

Quantitative modeling of the physiology of ascites in portal hypertension

Although the factors involved in cirrhotic ascites have been studied for a century, a number of observations are not understood, including the action of diuretics in the treatment of ascites and the ability of the plasma-ascitic albumin gradient to diagnose portal hypertension. This communication presents an explanation of ascites based solely on pathophysiological alterations within the peritoneal cavity. A quantitative model is described based on experimental vascular and intraperitoneal pressures, lymph flow, and peritoneal space compliance. The model's predictions accurately mimic clinical observations in ascites, including the magnitude and time course of changes observed following paracentesis or diuretic therapy.

Hepatic encephalopathy after transjugular intrahepatic portosystemic shunt

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.