Early and long-term clinical and radiological follow-up results of expanded-polytetrafluoroethylene-covered stent-grafts for transjugular intrahepatic portosystemic shunt procedures

Prediction of mortality and overt hepatic encephalopathy undergoing transjugular intrahepatic portosystemic shunt: a retrospective cohort study

PURPOSE

Data on medium- and long-term efficacy and safety of Transjugular intrahepatic portosystemic shunt (TIPS) using Viatorr stents in Chinese patients are limited. This study aimed to evaluate the 5-year mortality and the incidence of overt hepatic encephalopathy (OHE) after Viatorr stent insertion, and construct a model to predict post-TIPS OHE preoperatively.

METHODS

One hundred thirty-two patients undergoing Viatorr stent insertion in our institution between August 2016 and December 2019 were included, and randomly divided into training and validation cohort at a 70/30 ratio. Patients were followed up until death or the end date of follow-up (December 31st, 2021). The primary end point was all-cause mortality, and the secondary end points were OHE, variceal rebleeding, recurrent ascites and shunt dysfunction.

RESULTS

The 1-, 2-, 3-, 4- and 5-year cumulative survival rates were 92.4%, 87.9%, 85.3%, 80.2% and 80.2%, respectively. Post-TIPS OHE and Child-Pugh grade were independent prognostic factors. The rates of variceal rebleeding, recurrent ascites, shunt dysfunction and post-TIPS OHE were 9.1%, 14.3%, 5.3% and 28.0%, respectively. The variables of nomogram predicting post-TIPS OHE included age, diabetes and ascites grade. The area under time-dependent receiver operation characteristic (ROC) curve (AUC) in training and validation cohort were 0.806 and 0.751, respectively. The decision curve analysis (DCA) showed good net benefit both in training and validation cohort.

CONCLUSION

Post-TIPS OHE and Child-Pugh grade are independent prognostic factors for early mortality in cirrhosis patients, thus we construct a simple and convenient prediction model for post-TIPS OHE to identify high-risk patients preoperatively.

Current treatment options of refractory ascites in liver cirrhosis - A systematic review and meta-analysis

BACKGROUND

Refractory ascites is a severe complication of liver cirrhosis and treatment options consist in large volume paracentesis, transjugular intrahepatic portosystemic shunt, alfapump®, peritoneovenous shunt and permanent indwelling peritoneal catheter.

AIM

Our aim was to assess the efficacy, mortality and complications of each treatment.

METHODS

We performed a systematic review using Pubmed and Embase. Frequencies were summarized with Comprehensive Meta-Analysis Software.

RESULTS

Seventy-seven studies were included. In patients with transjugular intrahepatic portosystemic shunt, 1-year mortality was 33% (95% CI 0.29-0.39, I²=82.1; τ² = 0.37; p<0.001) with lower mortality in newer studies (26% vs. 44%). At 6 months, mortality in patients with alfapump® was 24% (95% CI 0.16-0.33, I²=0.00; τ² = 0.00; p = 0.83), 31% developed acute kidney injury (95% CI 0.18-0.48, I²=44.0; τ² = 0.22; p = 0.15). Mortality at 12 months was 44% (95% CI 32%-58%, I²=76.7, τ² = 0.44, p<0.001) in peritoneovenous shunts and 45% (95% CI 38%-53%, I²=61.4, τ² = 0.18, p = 0.003) in large volume paracentesis, respectively. Overall mortality in patients with permanent indwelling catheters was 66% (95% CI 33%-89%, I²=82.5, τ² = 1.57, p = 0.001).

DISCUSSION

Mortality in patients with transjugular intrahepatic portosystemic shunt was lower in newer studies, probably due to a better patient selection. Acute kidney injury was frequent in patients with alfapump®. Permanent indwelling catheters seemed to be a good option in a palliative setting.

Performance of artificial intelligence for prognostic prediction with the albumin-bilirubin and platelet-albumin-bilirubin for cirrhotic patients with acute variceal bleeding undergoing early transjugular intrahepatic portosystemic shunt

PURPOSE

The aim of this study was to validate and compare the prognostic performance of the albumin-bilirubin (ALBI) grade, platelet-albumin-bilirubin (PALBI) grade, Child-Pugh (CP) grade, and Model for End-Stage Liver Disease (MELD) score in predicting the 1-year variceal rebleeding probability using artificial intelligence for patients with cirrhosis and variceal bleeding undergoing early transjugular intrahepatic portosystemic shunt (TIPS) procedures.

MATERIALS AND METHODS

This dual-center retrospective study included two cohorts, with patients enrolled between January 2016 and September 2018 in the training cohort and January 2017 and September 2018 in the validation cohort. In the training cohort, independent risk factors associated with the 1-year variceal rebleeding probability were identified using univariate and multivariate logistic analyses. ALBI-, PALBI-, Child-Pugh-, and MELD-based nomograms and an artificial neural network (ANN) model were established and validated internally in the training cohort and externally in the validation cohort, which included patients with variceal bleeding who were treated with preventive TIPS.

RESULTS

A total of 259 patients were included. The median follow-up periods were 24.1 and 18.9 months, and the 1-year variceal rebleeding rates were 12.3% (14/114) and 10.3% (15/145) in the training and validation cohorts, respectively. In the training cohort, all four variables were identified as independent risk factors. Four nomograms were then established and showed comparable prognostic performances after internal (C-index: 0.879, 0.829, 0.874, and 0.798) and external (C-index: 0.720, 0.719, 0.718, and 0.703) validation. The ANN demonstrated that these four variables had comparable importance in predicting the 1-year variceal rebleeding probability.

CONCLUSION

None of the four variables are optimal in predicting the 1-year variceal rebleeding probability for patients with cirrhosis and variceal bleeding undergoing early TIPS.

30 Jahre transjugulärer intrahepatischer portosystemischer Shunt (TIPS) – Rückblick und Perspektive

Der transjuguläre intrahepatische portosystemische Shunt (TIPS) wird seit 30 Jahren in der Therapie der portalen Hypertonie erfolgreich eingesetzt. In nationalen und internationalen Leitlinien ist die Indikation zur TIPS-Anlage bei Varizenblutung und refraktärem Aszites wissenschaftlich gut belegt und klar definiert. Bei seltenen Indikationen wie dem hepatorenalen Syndrom, der Pfortaderthrombose oder dem neoadjuvanten Einsatz fehlt derzeit noch eine eindeutige Studienlage. Eine wichtige Kontraindikation und klinisch bedeutendste Komplikation nach TIPS ist die hepatische Enzephalopathie (HE). Es wird versucht, die Post-TIPS HE mit technischen Weiterentwicklungen der Stents zu reduzieren.

Comparison of embolic agents for varices during transjugular intrahepatic portosystemic shunt for variceal bleeding: Tissue gel or coil?

Purpose

We aimed to compare treatment efficacy, safety and material cost between tissue gel and coil regarding variceal embolization during transjugular intrahepatic portosystemic shunt (TIPS).

Materials & Methods: This retrospective study including cirrhotic patients with variceal bleeding treated with TIPS combined with variceal embolization between January 2016 and August 2017. Patients were divided into three groups according to embolic agents used in variceal embolization: tissue gel group (Group A), combination group (Group B), and coil group (Group C). The primary endpoint was 1-year rebleeding rate after TIPS creation. The secondary endpoints included shunt dysfunction, overt hepatic encephalopathy, liver function, and embolic agents-related expense.

Results

A total of 60 patients (30, 10, and 20 in Group A, B, and C) were included. Variceal rebleeding occurred in 3 (10%), 0 (0%), and 4 (20%) patients within one year after TIPS creation in Group A, B, and C, respectively. Stent dysfunction occurred in 2 (3.3%) patients and 9 (15.0%) patients experienced overt hepatic encephalopathy. No significant differences were observed between three groups regarding primary and secondary endpoints except embolic agents-related expense, with a significantly lower cost in Group A when compared to the other two groups. Stent dysfunction occurred in two patients, with one patient in Group A developed acute occlusion caused by thrombus and another patient in Group C underwent stent stenosis during follow-up.

Conclusions

Compares to coil alone or combines with coil, tissue gel has similar treatment efficacy and safety, but with significantly lower cost for variceal bleeding during TIPS.

Long-term effects and complications of the transjugular intrahepatic portosystemic shunt: a single-centre experience

Background and aims: Accurate estimates of the long-term risks of adverse outcomes after transjugular intrahepatic portosystemic shunt (TIPS) treatment are needed. The aim of this cohort study was to estimate the risks of stent dysfunction, variceal bleeding, refractory ascites, hepatic encephalopathy (HE), and death after TIPS treatment. Methods: We extracted data from electronic medical records of 104 consecutive TIPS patients. Gore® Viatorr® TIPS endoprostheses were used in all patients. We conducted competing risks analysis of the risk of stent dysfunction and variceal bleeding, and Kaplan-Meier estimation of overall survival. Results: The overall 1-year survival after TIPS insertion was 82% (95% confidence interval [CI]: 73-88%), and the 1-year risk of stent dysfunction was 15% (95% CI: 9-22%). In patients who had a TIPS for variceal bleeding, the 1-year risk of rebleeding was 23% (95% CI: 13-35%). In patients who had a TIPS for refractory ascites, the risk of having an unsuccessful ascites outcome 1 year after TIPS for refractory ascites was 35% (95% CI: 21-52%). Overall, the 1-year risk of overt HE was 38% (95% CI: 32-43%). The risk of experiencing any of the defined complications during the first year was 56% (95% CI: 45-66%). Conclusion: TIPS is an effective treatment for variceal bleeding and refractory ascites in most cases, but more than half of the patients experience either death, stent dysfunction, recurrence of symptoms, or overt HE within the first year after the procedure.

The Effect of Puncture Sites of Portal Vein in TIPS with ePTFE-Covered Stents on Postoperative Long-Term Clinical Efficacy

Purpose

To evaluate the effect of puncture sites of the portal vein in transjugular intrahepatic portosystemic shunt (TIPS) on long-term clinical efficacy.

Methods

A retrospective review was performed, including consecutive 171 patients who underwent TIPS with ePTFE-covered stents. All patients were divided into 3 groups according to the puncture site of the portal vein: intrahepatic bifurcation of the portal vein (group A, n = 88), right branch of the portal vein (group B, n = 48), and left branch of the portal vein (group C, n = 35). The Kaplan-Meier analysis was performed to assess the effect of different puncture sites on primary patency, the incidence of hepatic encephalopathy (HE), and survival.

Results

The primary restenosis rate was 29.8% (51/171). The total HE rate was 31.6% (54/171). The cumulative death rate was 19.3% (33/171). The Kaplan-Meier analysis showed that group C versus group A, group C versus group B, and group A versus group B were significantly different on the primary restenosis rate, respectively (χ ² = 11.49, P = 0.001; χ ² = 4.54, P = 0.033; and χ ² = 4.12, P = 0.046), and group C is better than the other two groups. What is more, group C versus group A and group C versus group B were significantly different on the incidence of HE, respectively (χ ² = 8.07, P = 0.004; χ ² = 9.44, P = 0.002), and group C is better than the other two groups. There was no significant difference on survival.

Conclusion

Choosing the left branch of the portal vein as the puncture site to create the shunt in TIPS with ePTFE-covered stents may decrease the incident of primary restenosis and HE significantly.

The Feasibility of Using Volumetric Phase-Contrast MR Imaging (4D Flow) to Assess for Transjugular Intrahepatic Portosystemic Shunt Dysfunction

PURPOSE

To demonstrate the feasibility of detecting patency, stenosis, or occlusion of transjugular intrahepatic portosystemic shunt (TIPS) with four-dimensional (4D) flow MR imaging.

MATERIALS AND METHODS

Sequential adult patients with TIPS were eligible for enrollment. Volumetric phase-contrast sequence was used to image TIPS. Particle tracing cine images were used for qualitative assessment of stenosis. TIPS was segmented to generate quantitative data sets of peak velocity. Segmentation and quantitative measurement of flow throughout an entire TIPS defined technical success. Doppler US was used for comparison. Venography, when available, and 6-month clinical follow-up were used as reference standards.

RESULTS

4D flow MR imaging was performed in 23 patient encounters and was technically successful in 16/23 (69.6%) encounters. Three cases demonstrated both focal turbulence and abnormal velocities (> 190 cm/s or < 90 cm/s) on 4D flow and had venography-confirmed stenosis (true-positive cases). Seven cases had normal velocities and no turbulence on 4D flow, and all were confirmed negative with clinical follow-up or venography (true-negative cases). Six cases had discordant 4D flow results, with abnormal velocities but no turbulence or focal turbulence but normal velocities. All 6 discordant cases had no evidence of dysfunction during 6-month follow-up.

CONCLUSION

4D flow MR imaging can detect TIPS patency and stenosis, but further investigation is required before it can be used to assess for TIPS dysfunction.

Persistence of gastric or esophageal varices on final angiography increases transjugular intrahepatic portosystemic shunt revision rate after polytetrafluoroethylene-covered stent shunt creation

Background

To assess the association between final polytetrafluoroethylene (PTFE)-covered stent transjugular intrahepatic portosystemic shunt (TIPS) angiographic parameters and free shunt revision survey.

Methods

Series of two comparison groups were generated with persistence of varices or not, the 25^th, 50^th, and 75^th percentile as cutoff for each angle and a 15-mm distance as cutoff for distance D. Kaplan Meier free shunt revision curves were then created and compared with Log Rank test.

Results

Mean follow-up was 455 days. Thirteen (19.4%) patients had shunt revision. Significant free shunt revision survey difference was found between post-procedural angiographic persistent varices group and the group without varices (P=0.0001). Shunt revision rate at 3, 12 and 24 months was respectively 13%, 29%, and 39% in the group with varices versus 0%, 2.7% and 2.7% in the group without. No difference was found between groups for angles A, B, C and distance D.

Conclusions

Persistence of gastric or esophageal varices on final trans-TIPS angiography increases TIPS revision rate after PTFE-covered stent shunt creation whereas geometric parameters have no influence.

Hemorrhage risk with transjugular intrahepatic portosystemic shunt (TIPS) insertion at the main portal vein bifurcation with stent grafts

PURPOSE

The purpose of this study was to assess the incidence of major hemorrhage after transjugular intrahepatic portosystemic shunt (TIPS) insertion using a stent graft at the main portal vein bifurcation.

PATIENTS AND METHODS

TIPS insertion using stent grafts was performed in 215 patients due to non-variceal hemorrhage indications. There were 137 men and 78 women, with a mean age of 57 years±10.6 (SD) (range: 19-90 years). Based on retrospective review of portal venograms, TIPS inserted within 5mm from the portal vein bifurcation were considered "bifurcation TIPS", while those inserted 2cm or greater from the bifurcation were considered intrahepatic. Suspicion for acute major periprocedural hemorrhage were categorized as low, moderate, and high, based on the number of signs of hemorrhage.

RESULTS

Of 215 TIPS inserted for purposes other than hemorrhage, the TIPS was inserted at the portal bifurcation in 41 patients (29 men, 12 women; mean age, 55.9±11.7 (SD); range: 26-79 years) and intrahepatic in 62 patients (37 men, 25 women; mean age, 57.6±10.6 (SD), range: 34-82 years), whereas 112 were indeterminate in location. No active extravasations were identified on post-TIPS portal venograms. Suspicion for acute major hemorrhage was moderate or high in 3/41 (7%) of patients in the TIPS bifurcation group compared to 5/62 (8%) in the intrahepatic TIPS group (P>0.99). There were no significant differences in 30-day mortality rates (1/41 [2%] and 3/62 [5%] respectively; P> 0.99). No deaths or interventions were attributed to acute hemorrhage.

CONCLUSION

TIPS insertion at the portal bifurcation with stent grafts did not incur an elevated risk of hemorrhagic complications.

Effect of initial stent position on patency of transjugular intrahepatic portosystemic shunt

AIM

To evaluate the effect of initial stent position on transjugular intrahepatic portosystemic shunt (TIPS).

METHODS

We studied 425 patients from January 2004 to January 2015 with refractory ascites or variceal bleeding who required TIPS placement. Patients were randomly divided into group A (stent in hepatic vein, n = 57), group B (stent extended to junction of hepatic vein and inferior vena cava, n = 136), group C (stent in left branch of portal vein, n = 83) and group D (stent in main portal vein, n = 149). Primary unassisted patency was compared using Kaplan-Meier analysis, and incidence of recurrence of bleeding, ascites and hepatic encephalopathy (HE) were analyzed.

RESULTS

The mean primary unassisted patency rate in group B tended to be higher than in group A at 3, 6 and 12 mo (P = 0.001, 0.000 and 0.005), and in group D it tended to be lower than in group C at 3, 6 and 12 mo (P = 0.012, 0.000 and 0.028). The median shunt primary patency time for group A was shorter than for group B (5.2 mo vs 9.1 mo, 95%CI: 4.3-5.6, P = 0.013, log-rank test), while for group C it was longer than for group D (8.3 mo vs 6.9 mo, 95%CI: 6.3-7.6, P = 0.025, log-rank test). Recurrence of bleeding and ascites in group A was higher than in group B at 3 mo (P = 0.014 and 0.020), 6 mo (P = 0.014 and 0.019) and 12 mo (P = 0.024 and 0.034. Recurrence in group D was higher than in group C at 3 mo (P = 0.035 and 0.035), 6 mo (P = 0.038 and 0.022) and 12 mo (P = 0.017 and 0.009). The incidence of HE was not significantly different among any of the groups (P = 0.965).

CONCLUSION

The initial stent position can markedly affect stent patency, which potentially influences the risk of recurrent symptoms associated with shunt stenosis or occlusion.

Expanded polytetrafluoroethylene-covered stent-grafts for transjugular intrahepatic portosystemic shunts in cirrhotic patients: Long-term patency and clinical outcome results

PURPOSE

To retrospectively analyse long-term patency and overall survival of cirrhotic patients treated with TIPSS using e-PTFE-covered stents. Additionally, prognostic factors for better patency and survival were analysed.

MATERIALS AND METHODS

Two hundred and eighty-five consecutive cirrhotic patients with severe portal hypertension-related symptoms were included. Follow-up, including clinical assessment and duplex ultrasound, was analysed up to end of study, patient's death, liver transplantation or TIPSS-reduction. Patency rates and overall survival were estimated by the Kaplan-Meier method; potential differences in outcome between subgroups were calculated using the Pepe and Mori test.

RESULTS

The 1-, 2- and 5-year primary patencies were 91.5 %, 89.2 % and 86.2 %, respectively, with no new shunt dysfunctions after 5 years' follow-up. TIPSS revision was performed more often in ascites patients (P = 0.02). The 1-, 4- and 10-year survival rates were 69.2 %, 52.1 % and 30.7 %, respectively. Survival was higher in Child-Pugh class A-B (P = 0.04), in the recurrent bleeding group (P = 0.008) and in patients with underlying alcoholic cirrhosis (P = 0.01).

CONCLUSION

Long term, primary patency of e-PTFE-covered TIPSS stents remains very high (>80 %); shunt revision was required more frequently in ascites patients. Overall survival was better in Child-Pugh A-B patients with recurrent variceal bleeding and alcoholic liver cirrhosis.

KEYPOINTS

• Long-term primary patency rate of e-PTFE-covered TIPSS stents remains very high. • No new shunt dysfunction was found after 5 years of follow-up. • Shunt revision was required more frequently in ascites patients. • Four and 10 years' overall survival was 50 and 30 %, respectively.

Portal Venous Interventions: State of the Art

In recent decades, there have been numerous advances in the management of liver cancer, cirrhosis, and diabetes mellitus. Although these diseases are wide ranging in their clinical manifestations, each can potentially be treated by exploiting the blood flow dynamics within the portal venous system, and in some cases, adding cellular therapies. To aid in the management of these disease states, minimally invasive transcatheter portal venous interventions have been developed to improve the safety of major hepatic resection, to reduce the untoward effects of sequelae from end-stage liver disease, and to minimize the requirement of exogenously administered insulin for patients with diabetes mellitus. This state of the art review therefore provides an overview of the most recent data and strategies for utilization of preoperative portal vein embolization, transjugular intrahepatic portosystemic shunt placement, balloon retrograde transvenous obliteration, and islet cell transplantation.

Transjugular intrahepatic portosystemic shunt complications: prevention and management

Transjugular intrahepatic portosystemic shunt (TIPS) insertion has been well established as an effective treatment in the management of sequelae of portal hypertension. There are a wide variety of complications that can be encountered, such as hemorrhage, encephalopathy, TIPS dysfunction, and liver failure. This review article summarizes various approaches to preventing and managing these complications.

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.

The history and future of transjugular intrahepatic portosystemic shunt: food for thought

The origins of transjugular intrahepatic portosystemic shunt (TIPS) date back to the 1960s with inadvertent portal access during the early years of transjugular cholangiography. TIPS is now the most frequently performed portal hypertension decompressive procedure performed by interventional radiologists, and has become the primary portosystemic shunt (surgical or percutaneous) performed in the United States. One of the least discussed major advantages of TIPS in the transplant era is that it is intrahepatic and thus is removed in situ during a liver transplant, while extrahepatic shunts (surgical or percutaneous) have to be ligated or revised during the liver transplantation. However, since the widespread clinical utilization of TIPS in the 1990s, it has been plagued with two major problems, namely, patency and hepatic encephalopathy. With the advent of commercially available expanded polytetraflouroethylenne (e-PTFE) covered stents a decade ago, 12- to 24-month TIPS patency has improved significantly (by ∼20-30%). However, hepatic encephalopathy (although not proven to have increased due to e-PTFE covered stents grafts) remains a significant morbidity problem. The article discusses the history of TIPS, critiques the retrospective encephalopathy data in the literature, and discusses futuristic TIPS-design ideas about the management of post-TIPS hepatic encephalopathy.

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.

Efficacy of transjugular intrahepatic portosystemic shunt with adjunctive embolotherapy with cyanoacrylate for esophageal variceal bleeding

BACKGROUND

Transjugular intrahepatic portosystemic shunt (TIPS) with adjunctive embolotherapy has recently been reported to be effective in the prevention of variceal hemorrhage of cirrhotic patients. However, further investigation of its long-term efficacy is still needed.

AIM

To examine the rebleeding, survival, and hepatic encephalopathy (HE) after treatment with TIPS alone and TIPS with adjunctive embolotherapy using cyanoacrylate for esophageal variceal bleeding.

METHODS

Patients with refractory to endoscopic therapy for esophageal variceal bleeding were enrolled. TIPS was performed in 101 patients with adjunctive embolotherapy (n = 53) or alone (n = 48) between January 2006 and December 2011. Chart reviews were performed to determine rebleeding, survival rates, and the incidence of HE.

RESULTS

Recurrent hemorrhage occurred in 12 (11.9 %) patients during the mean follow-up periods of 35.8 months. Rebleeding was observed in 9/48 (18.8 %) patients in TIPS alone group and 3/53 (5.7 %) patients in TIPS with adjunctive embolotherapy group (p = 0.042). Death occurred in 30 patients during follow-up (TIPS alone: n = 16, TIPS with adjunctive embolotherapy: n = 14, p = 0.447). Twenty-six episodes of HE occurred in 18 patients in TIPS alone group and 16 episodes occurred in 10 patients in TIPS with embolotherapy group. The probability of HE was significantly higher in TIPS alone group than in TIPS with embolotherapy group (p = 0.019).

CONCLUSIONS

TIPS with adjunctive embolotherapy with cyanoacrylate is relatively safe and effective, with a lower rebleeding and HE incidence in comparison of TIPS alone.

Selection of a TIPS stent for management of portal hypertension in liver cirrhosis: An evidence-based review

Nowadays, transjugular intrahepatic portosystemic shunt (TIPS) has become a mainstay treatment option for the management of portal hypertension-related complications in liver cirrhosis. Accumulated evidence has shown that its indications are being gradually expanded. Notwithstanding, less attention has been paid for the selection of an appropriate stent during a TIPS procedure. Herein, we attempt to review the current evidence regarding the diameter, type, brand, and position of TIPS stents. Several following recommendations may be considered in the clinical practice: (1) a 10-mm stent may be more effective than an 8-mm stent for the management of portal hypertension, and may be superior to a 12-mm stent for the improvement of survival and shunt patency; (2) covered stents are superior to bare stents for reducing the development of shunt dysfunction; (3) if available, Viatorr stent-grafts may be recommended due to a higher rate of shunt patency; and (4) the placement of a TIPS stent in the left portal vein branch may be more reasonable for decreasing the development of hepatic encephalopathy. However, given relatively low quality of evidence, prospective well-designed studies should be warranted to further confirm these recommendations.

Long-term follow-up of TIPS created with expanded poly-tetrafluoroethylene covered stents

BACKGROUND

Transjugular intrahepatic portosystemic shunts (TIPS) created with expanded poly-tetrafluoroethylene-covered stents have largely replaced bare metal stents. Short-term shunt patency is typically assessed with protocol Doppler ultrasound (US), while little information exists with regard to long-term patency.

AIM

We investigated the value of Doppler US in assessing TIPS patency as well as long-term clinical outcomes.

METHODS

A retrospective analysis of 59 patients with covered stents used for TIPS between January 2001 and December 2011 was performed.

RESULTS

Fifty-four patients had early (median 9 days) Doppler US follow-up. Seven of eight patients with an abnormal baseline US required stent revisions. None of the 46 patients with normal baseline Doppler US required revisions within the first 6 months; six of these patients subsequently had a portogram because of symptoms, but all TIPS were patent. Fifty-two patients survived for long-term (>6 months) follow-up, averaging 654 days and three Doppler US exams. Five of six patients with abnormal follow-up Doppler US required revisions, whereas none of the 46 patients with normal follow-up US had revisions. The recurrence of symptoms of portal hypertension and/or hepatic encephalopathy (HE) was low (4/52 patients). No significant predictors of long-term stenosis were identified. Post-TIPS HE was independent of pre-TIPS HE or Child-Pugh score.

CONCLUSIONS

Short-term patency and that at approximately 2 years after TIPS placement was 87 and 77 %, respectively. We conclude that Doppler US at least 1 week after TIPS is warranted, but repeated Doppler US follow-up is probably not necessary in the absence of clinical symptoms.

Transjugular intrahepatic portosystemic shunt stent-graft placement: mean optimal portal venous projection view determined by three-dimensional portography

BACKGROUND

Suboptimal stent-graft placement at the lower anastomosis during transjugular intrahepatic portosystemic shunt (TIPS) may result in early shunt stenosis and occlusion owing to incomplete covering of the parenchymal tract by the covered part of the stent-graft.

PURPOSE

To determine the optimal portal venous projection view for stent-graft placement during TIPS and the potential influence of the portal vein anatomy.

MATERIAL AND METHODS

On 76 cirrhotic patients (48 men and 28 women) selected for TIPS, rotational, three-dimensional (3D), catheter-directed angiography of the portal vein was performed. The 3D portograms were reviewed by two independent interventional radiologists to determine the optimal angiographic projection views for stent-graft placement. Intra-observer and inter-observer reliabilities were tested and subgroups of patient portal vein anatomy were categorized.

RESULTS

Among all patients, the optimal portal venous projection views for stent-graft placement during TIPS centered around 27° (±14°) right oblique and 3° (±7°) craniocaudal. Of these, 56% were within the standard deviations. Intra-observer reliabilities were 0.60 and 0.62 for the two radiologists, respectively. Inter-observer reliability was 0.48. Anatomical variations in the patient population were: normal portal vein (67%), trifurcation at main portal vein (16%), right posterior portal vein as the first branch of main portal vein (3%), no right posterior portal vein (1%), and other variations (13%). Anatomical subgroups did not influence the best angiographic projection view significantly (F4,295 = 0.91, P = 0.457).

CONCLUSION

The mean optimal angiographic projection view for TIPS stent-graft placement was 27° right oblique and 3° craniocaudal. Patient anatomic variations do not play a significant role in determining the optimal angiographic view for TIPS stent-graft placement.

Recurrent variceal bleeding and shunt patency: prospective randomized controlled trial of transjugular intrahepatic portosystemic shunt alone or combined with coronary vein embolization

PURPOSE

To prospectively evaluate the efficacy of a transjugular intrahepatic portosystemic shunt (TIPS) alone and TIPS in association with embolotherapy (TIPS+E) in the variceal coronary vein to prevent recurrent variceal bleeding and stent dysfunction after TIPS creation.

MATERIALS AND METHODS

Institutional review board approval was obtained; all participants provided informed consent. A total of 106 patients (66 men, 40 women; age range, 18-70 years) with recurrent variceal bleeding due to hepatic cirrhosis were assigned randomly to the TIPS+E (n = 54) or TIPS (n = 52) group from May 2007 to July 2011. The TIPS was created by using covered stents. Patients in the TIPS+E group underwent embolotherapy via the jugular vein before TIPS implantation. Rates of recurrent variceal bleeding, stent patency, and survival were evaluated. Scores for liver function and life quality were calculated.

RESULTS

TIPS placement was successful in all patients. Recurrent variceal bleeding ranked second among causes of death after TIPS placement. Although the 3-year cumulative rates of shunt patency, recurrent variceal bleeding, and survival in the two groups were not significantly different (P > .05), the 6-month overall rate of shunt patency in the TIPS+E group was significantly higher than that in the TIPS group (96.2% vs 82.0%, P = .019), and the 6-month overall rate of recurrent variceal bleeding was also significantly lower than that in the TIPS group (5.7% vs 20.0%, P = .029).

CONCLUSION

The TIPS+E regimen may reduce the risk of recurrent variceal bleeding during the first 6 months after the TIPS procedure by preventing shunt dysfunction, which may improve liver function and quality of life. © RSNA, 2013.

Prognostic capability of different liver disease scoring systems for prediction of early mortality after transjugular intrahepatic portosystemic shunt creation

PURPOSE

To compare the performance of various liver disease scoring systems in predicting early mortality after transjugular intrahepatic portosystemic shunt (TIPS) creation.

MATERIALS AND METHODS

In this single-institution retrospective study, eight scoring systems were used to grade liver disease in 211 patients (male-to-female ratio = 131:80; mean age, 54 y) before TIPS creation from 1999-2011. Scoring systems included bilirubin level, Child-Pugh (CP) score, Model for End-Stage Liver Disease (MELD) and Model for End-Stage Liver Disease sodium (MELD-Na) score, Emory score, prognostic index (PI), Acute Physiology and Chronic Health Evaluation (APACHE) 2 score, and Bonn TIPS early mortality (BOTEM) score. Medical record review was used to identify 30-day and 90-day clinical outcomes. The relationship of scoring parameters with mortality outcomes was assessed with multivariate analysis, and the relative ability of systems to predict mortality after TIPS creation was evaluated by comparing area under receiver operating characteristic (AUROC) curves.

RESULTS

TIPS were successfully created for variceal hemorrhage (n = 121), ascites (n = 72), hepatic hydrothorax (n = 15), and portal vein thrombosis (n = 3). All scoring systems had a significant association with 30-day and 90-day mortality (P<.050 in each case) on multivariate analysis. Based on 30-day and 90-day AUROC, MELD (0.878, 0.816) and MELD-Na (0.863, 0.823) scores had the best capability to predict early mortality compared with bilirubin (0.786, 0.749), CP (0.822, 0.771), Emory (0.786, 0.681), PI (0.854, 0.760), APACHE 2 (0.836, 0.735), and BOTEM (0.798, 0.698), with statistical superiority over bilirubin, Emory, and BOTEM scores.

CONCLUSIONS

Several liver disease scoring systems have prognostic value for early mortality after TIPS creation. MELD and MELD-Na scores most effectively predict survival after TIPS creation.

Child-Na score: a predictive model for survival in cirrhotic patients with symptomatic portal hypertension treated with TIPS

BACKGROUND AND AIM

Several models have been developed to predict survival in patients with cirrhosis undergoing TIPS; however, few of these models have gained widespread acceptance, especially in the era of covered stents. The aim of this study was to establish an evidence-based model for predicting survival after TIPS procedures.

METHODS

A total of 210 patients with cirrhosis treated with TIPS were considered in the study. We comprehensively investigated factors associated with one-year survival and developed a new predictive model using the Cox regression model.

RESULTS

In the multivariate analysis, the Child-Pugh score and serum sodium levels were independent predictors of one-year survival. A new score incorporating serum sodium into the Child-Pugh score was developed: Child-Na score. We compared the predictive accuracy of Child-Na score with that of other scores; only the Child-Na and MELD-Na scores had adequate predictive ability in patients with serum Na levels <138 mmol/L. The best Child-Na cut-off score (15.5) differentiated two groups of patients with distinct prognoses (one-year cumulative survival rates of 80.6% and 45.5%); this finding was confirmed in a validation cohort (n = 86). In a subgroup analysis stratifying patients by indication for TIPS, the Child-Na score distinguished patients with different prognoses.

CONCLUSIONS

Patients with variceal bleeding and a Child-Na score ≤15 had a better prognosis than patients with a score ≥16. Patients with refractory ascites and a Child-Na score ≥16 had a high risk of death after the TIPS procedures; caution should be used when treating these patients with TIPS.

Portal hypertension after combined liver and intestinal transplantation, a diagnostic and therapeutic challenge?

A widely accepted technique to transplant the liver-bowel bloc is first to perform a piggyback anastomosis of the donor suprahepatic vena cava to the recipient vena cava; second to restore the arterial blood supply through an aortic interposition graft; and third to ensure venous drainage of the native foregut. The venous drainage of the native foregut can be restored through an end-to-end portocaval anastomosis between the donor infrahepatic vena cava and the recipient portal vein. Stenosis of this anastomosis can lead to portal hypertension presenting with upper GI congestion, bleeding, and hypersplenism. We report the successful treatment of this complication using an e-PTFE-covered stent inserted following balloon angioplasty.

[Portosystemic shunt surgery between TIPS and liver transplantation]

Portosystemic shunt surgery in addition to transjugular intrahepatic portosystemic shunt (TIPS) insertion must still be regarded as a current treatment option for portomesenteric decompression in patients with pharmacological and endoscopic treatment failure, where liver transplantation is not imminent. This applies to secondary prophylaxis of rebleeding from varices in patients with well preserved liver function, e.g. liver cirrhosis CHILD A or extrahepatic portal vein thrombosis. Even if emergency endoscopy represents the treatment of choice in the acute bleeding situation, latest data from San Diego on emergency portacaval shunt surgery are encouraging. Likewise, portacaval shunt procedures can be an attractive alternative to TIPS or liver transplantation for acute Budd-Chiari syndrome or veno-occlusive disease.This article is an update on the systematics and methodology of portacaval shunt surgery, emphasizing the significance of this treatment option based on latest studies.

Prospective study comparing different indirect methods to measure portal pressure

PURPOSE

To compare the accuracy of wedged hepatic venous pressure (WHVP) measurement with use of an end-hole catheter or an occlusion-balloon catheter versus direct portal pressure (PP) measurement in patients with cirrhosis with sinusoidal portal hypertension and to investigate the factors that affect the results of these indirect measurements.

MATERIALS AND METHODS

In a cohort of 174 patients with cirrhosis referred for transjugular intrahepatic portosystemic shunt creation, indirect PP was measured with an end-hole catheter and an occlusion-balloon catheter placed in the right hepatic vein. Direct PP was measured by a pigtail catheter in the main branch of the portal vein.

RESULTS

PP was more accurately estimated by the occlusion-balloon technique: mean WHVP measurements were 25.5 mm Hg ± 7.9 and 30.6 mm Hg ± 13.9, respectively, for the occlusion-balloon and end-hole catheter techniques, and the direct PP measurement was 25.0 mm Hg ± 7.0. The median absolute differences between direct and the indirect methods were 6.0 mm Hg with the end-hole catheter and 2.0 mm Hg with the occlusion-balloon catheter (P < .0001, signed-rank test). Relative to direct PP measurements, the occlusion-balloon technique overestimated pressures in cases of higher Model for End-Stage Liver Disease (MELD) scores (Spearman ρ = -0.24; P = .0005).

CONCLUSIONS

Compared with direct PP measurements, agreement was clearly higher for indirect WHVP measurement with occlusion-balloon catheters versus end-hole catheters. However, in patients with a high MELD score, there was an overestimation of PP with the occlusion-balloon method.

Transjugular intrahepatic portosystemic shunts in liver transplant recipients: technical considerations and review of the literature

Transjugular intrahepatic portosystemic shunt (TIPS) is an accepted therapeutic option for the treatment of complications of portal hypertension, such as refractory variceal bleeding, refractory ascites, refractory hepatic hydrothorax and Budd-Chiari syndrome, in cirrhotic livers. However, portal hypertension is uncommon after liver transplantation, and when it occurs, it has been related to hepatic vein outflow obstruction, small liver donor size, rejection, or recurrence of the original disease. There are few reports in the literature addressing TIPS experience in liver transplant patients. This review will address the published experience of TIPS procedures in liver transplant patients, including indications, technical issues, complications, and outcomes.

Should stent-grafts replace bare stents for primary transjugular intrahepatic portosystemic shunts?

Transjugular intrahepatic portosystemic shunt (TIPS) creation using bare stents is a second-line treatment for complications of portal hypertension due in part to the relatively high number of reinterventions and the occurrence of new or worsened encephalopathy. Initially, custom-made stent-grafts were used for TIPS revision in cases of biliary fistulae. Subsequently, custom stent-grafts were used for de novo TIPS creation. With the introduction of the VIATORR(®) TIPS endoprosthesis a dedicated stent-graft became available for TIPS creation and revision. The VIATORR(®) demonstrated its efficacy and superiority to uncovered stents in retrospective analyses, case-matched analyses, and randomized studies. The improved patency of stent-grafts has led many to requestion the role of TIPS as a second-line therapy. Currently, randomized trials are warranted to redefine the role of TIPS in the treatment of complications of portal hypertension.

Comprehensive review of TIPS technical complications and how to avoid them

OBJECTIVE

The goal of this article is to describe potential technical complications related to transjugular intrahepatic portosystemic shunts (TIPS) placement and to discuss strategies to avoid and manage complications if they arise.

CONCLUSION

TIPS is an established interventional therapy for complications of portal hypertension. Although TIPS remains a relatively safe procedure, direct procedure-related morbidity rates are as high as 20%. The technical complexity of this intervention increases the risk for methodologic mishaps during all phases of TIPS placement, including venous access and imaging, transhepatic needle puncture, shunt insertion, and variceal embolization. Thus, interventional radiologists require a thorough stepwise understanding of TIPS insertion, possible adverse sequela, and technical tips and tricks to maximize the safety of this procedure.

Cost-Effective Analysis of Transjugular Intrahepatic Portosystemic Shunt versus Surgical Portacaval Shunt for Variceal Bleeding in Early Cirrhosis

Upper gastrointestinal hemorrhage carries significant morbidity and mortality in patients with portal hypertension and cirrhosis. The optimal prevention strategy for rebleeding in these patients remains controversial with respect to the safety and efficacy of transjugular intrahepatic portosystemic shunt (TIPS) versus a portocaval surgical shunt (PC). We sought to determine the long-term cost-effectiveness of these two treatments. A Markov state transition decision analysis was created and Monte Carlo sensitivity analysis performed to follow patients with early cirrhosis who have an upper gastrointestinal bleed despite medical therapy into either TIPS or PC. Patients were followed throughout the transition states until either death or survival. Probabilities of gastrointestinal rebleed, hepatic encephalopathy, surgical and TIPS-related complications as well as death were obtained from an extensive literature review. Costs were derived from average Medicare reimbursements. The main outcome was dollars per life-year saved. For patients with mild to moderate cirrhosis with upper gastrointestinal variceal bleed, the average cost per life year saved was $17,771 (SD = 471) and $21,438 (SD = 308) for TIPS and PC, respectively. The average life expectancy was 5.0 years and 7.0 years for TIPS and PC, respectively. This yielded an incremental cost-effectiveness rate for portocaval shunt of $3,299 per life year saved. Compared with TIPS, surgical PC shunt resulted in improved survival with minimal increase in cost. Therefore, given the low incremental cost of PC, it should be adopted as a cost-effective strategy in managing this patient population.

Role of TIPS in Improving Survival of Patients with Decompensated Liver Disease

Liver cirrhosis is associated with higher morbidity and reduced survival with appearance of portal hypertension and resultant decompensation. Portal decompression plays a key role in improving survival in these patients. Transjugular intrahepatic portosystemic shunts are known to be efficacious in reducing portal venous pressure and control of complications such as variceal bleeding and ascites. However, they have been associated with significant problems such as poor shunt durability, increased encephalopathy, and unchanged survival when compared with conservative treatment options. The last decade has seen a significant improvement in these complications, with introduction of covered stents, better selection of patients, and clearer understanding of procedural end-points. Use of TIPS early in the period of decompensation also appears promising in further improvement of survival of cirrhotic patients.

Patency and clinical outcomes of transjugular intrahepatic portosystemic shunt with polytetrafluoroethylene-covered stents versus bare stents: a meta-analysis

BACKGROUND AND AIM

 Transjugular intrahepatic portosystemic shunt (TIPS) with polytetrafluoroethylene-(PTFE)-covered stent has been increasingly used for patients with complications of portal hypertension. It is still debated whether the new endoprostheses will improve some clinical outcomes (except for shunt patency) compared to the bare stents. The aims of our meta-analysis were to explore the patency and clinical outcomes of TIPS with PTFE-covered stent-grafts versus bare stents.

METHODS

Pertinent studies were retrieved through PubMed (1950-2010), MEDLINE (1950-2010), and reference lists of key articles. Outcome measures were primary patency, risk of encephalopathy and survival. Time-to-event data analysis was used to calculate the overall hazard ratios (HR).

RESULTS

Six studies were identified including a total of 1275 patients (346 TIPS with PTFE-covered stent-grafts and 929 TIPS with bare stents). Pooled shunt patency data from four eligible studies suggested a significant improvement of primary patency in patients who were treated with PTFE-covered stent-grafts (HR = 0.28, 95% confidence interval [CI] 0.20-0.35). Pooled encephalopathy data from three eligible studies suggested a significant reduction of risk in the PTFE-covered group (HR = 0.65, 95%CI 0.45-0.86). Pooled survival data from four eligible studies also suggested a significant decrease of mortality in the PTFE-covered group (HR = 0.76, 95%CI 0.58-0.94). No statistical heterogeneity was observed between studies for either outcome.

CONCLUSIONS

This meta-analysis shows that the use of PTFE-covered stent-grafts clearly improves shunt patency without increasing the risk of hepatic encephalopathy and with a trend towards better survival.

Rebleeding rates following TIPS for variceal hemorrhage in the Viatorr era: TIPS alone versus TIPS with variceal embolization

PURPOSE

To compare rebleeding rates following treatment of variceal hemorrhage with TIPS alone versus TIPS with variceal embolization in the covered stent-graft era.

METHODS

In this retrospective study, 52 patients (M:F 29:23, median age 52 years) with hepatic cirrhosis and variceal hemorrhage underwent TIPS insertion between 2003 and 2008. Median Child-Pugh and MELD scores were 8.5 and 13.5. Generally, 10-mm diameter TIPS were created using covered stent-grafts (Viatorr; W.L. Gore and Associates, Flagstaff, AZ). A total of 37 patients underwent TIPS alone, while 15 patients underwent TIPS with variceal embolization. The rates of rebleeding and survival were compared.

RESULTS

All TIPS were technically successful. Median portosystemic pressure gradient reductions were 13 versus 11 mmHg in the embolization and non-embolization groups. There were no statistically significant differences in Child-Pugh and MELD score, or portosystemic pressure gradients between each group. A trend toward increased rebleeding was present in the non-embolization group, where 8/37 (21.6%) patients rebled while 1/15 (6.7%) patients in the TIPS with embolization group rebled (P = 0.159) during median follow-up periods of 199 and 252 days (P = 0.374). Rebleeding approached statistical significance among patients with acute hemorrhage, where 8/32 (25%) versus 0/14 (0%) rebled in the non-embolization and embolization groups (P = 0.055). A trend toward increased bleeding-related mortality was seen in the non-embolization group (P = 0.120).

CONCLUSIONS

TIPS alone showed a high incidence of rebleeding in this series, whereas TIPS with variceal embolization resulted in reduced recurrent hemorrhage. The efficacy of embolization during TIPS performed for variceal hemorrhage versus TIPS alone should be further compared with larger prospective randomized trials.

Stepwise placement of a transjugular intrahepatic portosystemic shunt endograft

Endografts continue to evolve the role of transjugular intrahepatic portosystemic shunts for patients with complications of portal hypertension. Transjugular intrahepatic portosystemic shunt (TIPS) created with bare stents, although associated with high rates of short-term portal decompression, are plagued by shunt stenosis and thrombosis over the long term. In contrast, TIPS created with endografts achieve durable, sustained patency in most patients with portal hypertension. The technique of successful endograft placement does have technical nuances that differ from TIPS creation with bare stents. This article provides a step-by-step approach for the interventional radiologist for placement of the via Torr device, which is at currently the only US Food and Drug Administration approved endograft for TIPS. These techniques can also be applied to the creation of TIPS endografts using other off-label endograft devices.

Pathogenesis of hepatic encephalopathy and its prevention after transjugular intrahepatic portosystemic shunt

With the increasing use of transjugular intrahepatic portosystemic shunt (TIPS), we have obtained a breakout progress in the therapy of acute esophageal and gastric-fundus variceal bleeding and refractory ascites. whereas the patency of stent and hepatic encephalopathy (or namely portal-systemic encephalopathy, PSE) after TIPS become two great problems for TIPS. The patency of stent has been improved greatly after the use of covered stent such as Viator stents or covered vascular stents. But the problem of hepatic encephalopathy has not been well solved. In this review, we try to explore the pathogenesis of hepatic encephalopathy and its prevention after TIPS.

TIPS: comparison of shunt patency and clinical outcomes between bare stents and expanded polytetrafluoroethylene stent-grafts

PURPOSE

To compare shunt patency and clinical outcomes in two groups of patients who received a transjugular intrahepatic portosystemic shunt (TIPS): one group with bare stents and one with expanded polytetrafluoroethylene stent-grafts.

MATERIALS AND METHODS

TIPS were created with bare stents (n = 41) or stent-grafts (n = 40). Overall TIPS patency rates were compared between these two groups, as were clinical outcomes in patients with variceal bleeding and those with ascites.

RESULTS

In the bare stent group, primary shunt patency rates were 63%, 48%, and 24% at 3, 6, and 12 months, respectively. Secondary patency rates were 75% and 62% at 3 and 6 months, respectively. In the stent-graft group, primary patency rates were 94%, 67%, and 38% at 3, 6, and 12 months, respectively. Secondary patency rates were 100% and 92% at 3 and 6 months, respectively. All stent patency rates were higher in the stent-graft group, but only the difference in the 3-month primary patency rate (63% vs 94%) reached significance (P = .03). In patients with variceal bleeding as well as those with ascites, early and overall clinical success rates were higher in the stent-graft group, but only the 3-month and 12-month differences were statistically significant.

CONCLUSIONS

TIPS created with stent-grafts had better 3-month primary patency rates and better 3-month and 12-month clinical success rates compared with those created with bare stents.

Management of transjugular intrahepatic portosystemic shunt induced refractory hepatic encephalopathy with the parallel technique: results of a clinical follow-up study

PURPOSE

To retrospectively evaluate the safety, feasibility, and midterm clinical outcome of the use of the parallel technique to treat transjugular intrahepatic portosystemic shunt (TIPS)-induced hepatic encephalopathy (HE) refractory to medical treatment. Additionally, factors potentially influencing clinical results after shunt reduction are assessed.

MATERIALS AND METHODS

Seventeen patients (11 men and 6 women) presenting with TIPS-induced HE refractory to medical treatment underwent shunt reduction with use of the parallel technique. West Haven HE grades before shunt reduction were IV and III in seven patients each and II in three patients. Mean portosystemic pressure gradient (PSPG) before shunt reduction was 6.8 mm Hg (range, 2-16 mm Hg). Relations between change in patients' mental state and several clinical parameters were analyzed.

RESULTS

In all patients, it was technically feasible to reduce the shunt with use of the parallel technique. PSPG after reduction increased by a mean of 5.8 mm Hg (range, 1-12 mm Hg; P < .0001). Mental state grades with regard to HE after shunt reduction were 0 (n = 6), I (n = 4), II (n = 3), III (n = 1), and IV (n = 3). Clinical improvement (n = 7; 41%) or complete disappearance (n = 6; 35%) of HE occurred in 76% of the patients, which is statistically significant (P = .0002). No clear relation could be established between change in mental state regarding HE and any of the potentially influencing factors.

CONCLUSIONS

Management of TIPS-induced HE with use of the parallel technique is feasible and safe. It results in an increase of PSPG, which is associated with an improvement in neuropsychiatric status in most patients.

Use of the Viatorr expanded polytetrafluoroethylene-covered stent-graft for transjugular intrahepatic portosystemic shunt creation in children: initial clinical experience

Four children, three boys and one girl, with a median age of 9 years 8 months, underwent transjugular intrahepatic portosystemic shunt creation with an expanded polytetrafluoroethylene (e-PTFE)-covered nitinol stent. The stent-graft was successfully placed in all four patients without any complication. Clinical and biochemical improvement was noted in all four patients during follow-up. Radiological follow-up with use of duplex ultrasound showed a recurrent stenosis of the shunt 180 days after stent-graft implantation in one patient. This was treated with placement of an additional stent-graft, re-expanding completely the recurrent stenosis. In the other three patients, the stent-graft remained fully patent until the end of the study or until orthotopic liver transplantation. These preliminary results suggest that use of the Viatorr ePTFE-covered stent-graft in children is safe and feasible, with potentially the same high patency rate and improved clinical outcome as reported in adult patients.

Dynamic MR perfusion measurements before and after TIPS in cirrhotic patients with refractory ascites

RATIONALE AND OBJECTIVES

We sought to assess changes in liver perfusion parameters induced by transjugular intrahepatic portosystemic shunt (TIPS) creation in cirrhotic patients with refractory ascites using dynamic MR perfusion measurements.

MATERIALS AND METHODS

MR perfusion measurements were performed before and after TIPS creation in 15 cirrhotic patients all with refractory ascites. Measurements were performed over a time period of 120 seconds providing 60 images for each examination and calculations were done in both liver and splenic parenchyma. Different perfusion parameters were assessed: time to peak (TTP), time to inflow deceleration (TID), maximal or peak perfusion (C-peak) and the wash-in rate.

RESULTS

TIPS procedures were successful in all 15 patients but were complicated by hepatic encephalopathy in 3 patients (20%), and in another 4 patients (26%), persistent refractory ascites was still noted during follow-up. Overall, liver TID values decreased significantly (P = .001) after TIPS creation; liver wash-in values increased significantly (P = .04) after TIPS. TTP values did not decrease significantly (P = .16) and liver C-peak values did not change equally (P = .99).

CONCLUSION

In cirrhotic patients with refractory ascites, TIPS induced a faster, but not an increased, contrast enhancement in the liver.

Endovascular shunt reduction in the management of transjugular portosystemic shunt-induced hepatic encephalopathy: preliminary experience with reduction stents and stent-grafts

OBJECTIVE

The purpose of this study was to retrospectively evaluate the safety, feasibility, and midterm clinical outcome of the use of three types of reduction stents inserted to manage transjugular intrahepatic portosystemic shunt (TIPS)-induced hepatic encephalopathy refractory to medical treatment.

CONCLUSION

The use of a covered reduction stent-graft results in a greater increase in portosystemic gradient immediately after reduction than does use of a bare reduction stent. Relief of TIPS-induced hepatic encephalopathy tends to be greater in patients with reduction stent-grafts than in those with bare reduction stents.

TIPS in Florida: is its application a result of evidence-based medicine?

BACKGROUND

The typical resident in surgery in the US will not care for a patient with advanced portal hypertension and will not participate in a portacaval shunt. The aim of this study is to compare the number of transjugular intrahepatic portasystemic stent shunts (TIPS) with the number of surgical shunts undertaken in the State of Florida and to assess whether these numbers are consistent with today's evidence-based medicine.

METHODS

We examined the database of the Agency for Health Care Administration of the State of Florida from January 1, 2002, through September 30, 2005, for "intraabdominal venous shunt" (ICD-9 code, 39.1). Data collected include "case mix," "case severity," length of stay, total gross charges, and discharge status. Conclusions about longterm survival from a prospective randomized clinical trial comparing TIPS to surgical shunting were applied to this dataset to determine if the relative frequency of TIPS application in Florida was supported by evidence-based medicine.

RESULTS

TIPS was undertaken more than 12 times as often as surgical shunting (860 patients versus 70 patients). After TIPS versus surgical shunts, average length of stay and hospital charges were less, but case mix, case severity, and in-hospital mortality (11.4% for each) were not different. Applying survival data from a randomized trial comparing TIPS with surgical shunting to the State of Florida database, 129 more people (p < 0.0001) would be alive at 2 years and 137 more (p < 0.0001) would be alive at 5 years after shunting if surgical shunts had been used in lieu of TIPS.

CONCLUSIONS

TIPS leads to shorter hospitalizations and reduced hospital charges and is applied in numbers much greater than surgical shunts, despite evidence that suggests inferior longterm efficacy and survival. Current application of TIPS is not a result of evidence-based medicine, and application of surgical shunting is encouraged.

[Covered transjugular intrahepatic portosystemic shunts]

Transjugular intrahepatic portosystemic shunts (TIPS) consist of a connection created by methods of interventionist radiology between the vena porta and the vena cava through the hepatic parenchyma. By markedly decreasing the portal pressure gradient, TIPS are highly effective in controlling the complications of portal hypertension such as bleeding due to esophageal varices and refractory ascites. Nevertheless, with the use of uncovered stents, the probability of shunt dysfunction -with the consequent reappearance of portal hypertension and its complications- is very high. The use of expandable polytetrafluoroethylene (e-PTFE)-covered stents markedly reduces the incidence of dysfunction, thus decreasing the number of clinical recurrences of portal hypertension and the reinterventions required to maintain shunt patency. The greater effectiveness of e-PTFE-covered stents is not accompanied by a higher incidence of complications or hepatic encephalopathy. Therefore, e-PTFE-covered stents should be preferred over uncovered stents in the management of the complications of portal hypertension.

Percutaneous Transjugular Direct Porto-caval Shunt in Patients with Budd-Chiari Syndrome

The purpose of the study was to evaluate the feasibility and effectiveness of direct porto-caval shunts in patients with Budd-Chiari syndrome (BCS) in whom there is no access to the hepatic veins during transjugular intrahepatic portosystemic shunt (TIPSS). We included six consecutive patients with fulminant/acute Budd-Chiari syndrome (mean age: 35 years) in whom a conventional TIPSS was not possible due to inaccessible hepatic veins. We performed a direct porto-caval shunt via a transhepatic approach. Patients were followed up by means of clinical examination, laboratory investigations, and Doppler ultrasound. TIPSS implantation from the inferior vena cava (IVC) was successful in all six patients (100%). The median transhepatic shunt length was 9 cm (8-10 cm). No procedure-related complications were observed in our patients. Early shunt occlusion occurred in three out of six patients (50%). In all three of these patients, the stent used to stabilize the shunt ended 1-2 cm before reaching the IVC. All occlusions were successfully recanalized. One of these patients developed recurrent early shunt as well as mesenteric and splenic vein occlusions. She died 7 days after TIPSS placement due to an unmanageable coagulation disorder. The remaining five patients were followed up by planned clinical examination and laboratory investigations (mean follow-up time was 15 months; patient 1 was followed up for 13 months, patient 2 for 14 months, patient 3 for 15 months, and patients 4 and 5 for 16 months) and all displayed a complete and durable resolution of liver failure and ascites without reintervention. In patients with acute liver failure originating from BCS and inaccessible hepatic veins, a direct transhepatic porto-caval shunt can be performed safely and effectively under ultrasound guidance. Future studies in larger patient groups should investigate if the patency of transcaval TIPSS with long transhepatic shunt segments is similar compared to conventional TIPSS via the hepatic vein.