Parallel TIPS for treatment of refractory ascites and hepatic hydrothorax

Refractory portal hypertension complications successfully managed by parallel transjugular intrahepatic portosystemic shunt (TIPS): a case report

Background

Transjugular intrahepatic portosystemic shunt (TIPS) is an established intervention to treat complicated portal hypertension refractory to medical or endoscopic management. TIPS dysfunction results in the recurrence of portal hypertension symptoms. In cases of TIPS dysfunction or persistent portal hypertension despite a patent primary TIPS, the creation of parallel TIPS may be the only intervention to effectively reduce portal pressure. Since the introduction of dedicated TIPS stents (Viatorr®) the incidence of TIPS dysfunction has reduced profoundly. Nevertheless, the creation of a parallel TIPS can still be necessary in the current dedicated TIPS stent era.

Case presentation

We report one such patient who experienced ongoing portal hypertension induced upper gastro-intestinal haemorrhage despite multiple TIPS revisions and a patent primary TIPS.

Conclusion

Following creation of a parallel TIPS, the patient remains in clinical remission with no further bleeding.

Transjugular intrahepatic portosystemic shunt in cirrhosis: An exhaustive critical update

More than five decades after it was originally conceptualized as rescue therapy for patients with intractable variceal bleeding, the transjugular intrahepatic portosystemic shunt (TIPS) procedure continues to remain a focus of intense clinical and biomedical research. By the impressive reduction in portal pressure achieved by this intervention, coupled with its minimally invasive nature, TIPS has gained increasing acceptance in the treatment of complications of portal hypertension. The early years of TIPS were plagued by poor long-term patency of the stents and increased incidence of hepatic encephalopathy. Moreover, the diversion of portal flow after placement of TIPS often resulted in derangement of hepatic functions, which was occasionally severe. While the incidence of shunt dysfunction has markedly reduced with the advent of covered stents, hepatic encephalopathy and instances of early liver failure continue to remain a significant issue after TIPS. It has emerged over the years that careful selection of patients and diligent post-procedural care is of paramount importance to optimize the outcome after TIPS. The past twenty years have seen multiple studies redefining the role of TIPS in the management of variceal bleeding and refractory ascites while exploring its application in other complications of cirrhosis like hepatic hydrothorax, portal hypertensive gastropathy, ectopic varices, hepatorenal and hepatopulmonary syndromes, non-tumoral portal vein thrombosis and chylous ascites. It has also been utilized to good effect before extrahepatic abdominal surgery to reduce perioperative morbidity and mortality. The current article aims to review the updated literature on the status of TIPS in the management of patients with liver cirrhosis.

Transjugular Intrahepatic Portosystemic Shunt for Portal Hypertension in Hepatocellular Carcinoma with Portal Vein Tumor Thrombus

PURPOSE

In patients with hepatocellular carcinoma (HCC), limited therapeutic options are available for portal hypertension resulted from portal vein tumor thrombus (PVTT). We aimed to determine safety and efficacy of TIPS for treatment of symptomatic portal hypertension in HCC with PVTT.

METHODS

We evaluated clinical characteristics of 95 patients with HCC and PVTT out of 992 patients who underwent TIPS. The primary endpoints included success rate, procedural mortality, serious complications, decrease in portosystemic pressure gradient, and symptom relief. The secondary endpoints included recurrence of portal hypertension, overall survival, adverse events related to treatments for HCC, and quality of life measured by Karnofsky Performance Status Scale (KPS).

RESULTS

Success rate of TIPS was 95.8% (91/95), with procedural mortality of 1.1%. Serious complications related to TIPS procedure occurred in 2.1% (2/95) of patients. The symptoms of portal hypertension were well relieved. Variceal bleeding was successfully controlled and terminated in 100% of patients, with a recurrence rate of 39.2% in 12 months. Refractory ascites/hydrothorax was controlled partially or completely in 92.9% of patients during 1 month after TIPS, with a recurrence rate of 17.9% in 12 months. Survival rate at 6, 12, 24, and 36 months was 75.8, 52.7, 26.4, and 3.3%, respectively. No unexpected adverse event related to treatments for HCC was observed. The KPS score was 49 ± 4.5 and 63 ± 4.7 before and 1 month after TIPS, respectively (p < 0.001).

CONCLUSIONS

TIPS is a safe and efficacious treatment for symptomatic portal hypertension in HCC with PVTT.

An Algorithm for Management After Transjugular Intrahepatic Portosystemic Shunt Placement According to Clinical Manifestations

We propose an algorithm for management after transjugular intrahepatic portosystemic shunt (TIPS) placement according to clinical manifestations. For patients with an initial good clinical response, surveillance Doppler ultrasound is recommended to detect stenosis or occlusion. A TIPS revision can be performed using basic or advanced techniques to treat stenosis or occlusion. In patients with an initial poor clinical response, a TIPS venogram with pressure measurements should be performed to assess shunt patency. The creation of a parallel TIPS may also be required if the patient is symptomatic and the portal pressure remains high after TIPS revision. Additional procedures may also be necessary, such as peritoneovenous shunt (Denver shunt) placement for refractory ascites, tunneled pleural catheter for hepatic hydrothorax, and balloon-occluded retrograde transvenous obliteration procedure for gastric variceal bleeding. A TIPS reduction procedure can also be performed in patients with uncontrolled hepatic encephalopathy or hepatic failure.

Parallel shunt for management of transjugular intrahepatic portosystemic shunt occlusion

AIM

To evaluate the security and efficacy of parallel shunt in the treatment of transjugular intrahepatic portosystemic shunt (TIPS) occlusion.

METHODS

From March 2012 to October 2015, 18 cirrhotic patients who underwent TIPS revision with the creation of parallel shunt were investigated retrospectively in our institution. Parallel shunt was established due to the original shunt occlusion. The mean follow-up period was 16.7 mo ± 10.8 mo (range, 6-42 mo). Technical success and the duration of the first and second operation were recorded. Branch of hepatic vein receiving TIPS, portal pressure gradient and shunt patency were also assessed.

RESULTS

Technical success rate of parallel shunt creation was 100%. The mean duration of the second operation was 57.1 min ± 12.9 min, which was significantly shorter than that of the first operation (89.2 min ± 29.4 min, t = 4.24, P < 0.01). The mean portosystemic pressure gradient significantly decreased from 25.5 mmHg ± 7.4 mmHg (range, 16-37 mmHg) to 10.9 mmHg ± 2.4 mmHg (range, 7-16 mmHg) after the parallel shunt was created (t = 10.1, P < 0.01). Four patients developed recurrent TIPS dysfunction during the follow-up period, of whom three presented with stenosis in the portal vein and one with stenosis in the liver vein. One patient received angioplasty. Insertion of an additional stent-graft was performed in the other three patients. The shunt patency rates at 12 mo after the creation of parallel shunt was 70.1% with Fluency endoprostheses and 87.6% with Fluency endoprostheses and bare stent.

CONCLUSION

The creation of parallel shunt is a safe and effective approach for managing TIPS occlusion.

Transjugular intrahepatic portosystemic shunt in refractory hydrothorax - a contribution to an unexplored indication

BACKGROUND AND AIMS

Hepatic hydrothorax is a rare complication of portal hypertension, but may be potentially severe. Although conservative therapy may be effective, it is not without risk and refractory cases are not rare. The portal decompression achieved by transjugular intrahepatic portosystemic shunts (TIPS) has shown positive results in the treatment of refractory ascites, and in that sense, the analysis of their value in other complications of portal hypertension becomes relevant. The aim of this study was to evaluate the efficacy and safety of TIPS in patients with refractory hydrothorax.

METHODS

This was a retrospective study including patients with refractory hydrothorax undergoing TIPS in a tertiary hospital in the period between 2000 and 2014, and evaluated the following: demographic characteristics, liver disease, and outcomes (efficacy and safety, including complications after TIPS, liver transplantation, 30-day, and 1-year mortality).

RESULTS

Nineteen patients with hydrothorax underwent TIPS; most had previously undergone multiple thoracocentesis and all had hypoalbuminemia. In all, 57.9% of the patients were men, with a mean age 63±9 years, and 84.2% had cirrhosis of alcoholic etiology and a mean Model for End-Stage Liver Disease-16, Child-Pugh B in 42.1%/Child-Pugh C in 47.4%. TIPS was effective in 73.3% of the cases. Portosystemic encephalopathy was recorded in 66.6% of the cases. Mortality was 25% at 30 days and 42.8% at 1 year with septic complications or progression of liver disease. Two patients underwent liver transplantation. The mean follow-up duration was 704 days (3-3485 days).

CONCLUSION

TIPS appears to be a relatively efficient method to control hydrothorax, making it a valid option in refractory cases despite the high risk of portosystemic encephalopathy and mortality.

Parallel transjugular intrahepatic portosystemic shunt for controlling portal hypertension complications in cirrhotic patients

AIM: To evaluate the feasibility of a second parallel transjugular intrahepatic portosystemic shunt (TIPS) to reduce portal venous pressure and control complications of portal hypertension.

METHODS: From January 2011 to December 2012, 10 cirrhotic patients were treated for complications of portal hypertension. The demographic data, operative data, postoperative recovery data, hemodynamic data, and complications were analyzed.

RESULTS: Ten patients underwent a primary and parallel TIPS. Technical success rate was 100% with no technical complications. The mean duration of the first operation was 89.20 ± 29.46 min and the second operation was 57.0 ± 12.99 min. The mean portal system pressure decreased from 54.80 ± 4.16 mmHg to 39.0 ± 3.20 mmHg after the primary TIPS and from 44.40 ± 3.95 mmHg to 26.10 ± 4.07 mmHg after the parallel TIPS creation. The mean portosystemic pressure gradient decreased from 43.80 ± 6.18 mmHg to 31.90 ± 2.85 mmHg after the primary TIPS and from 35.60 ± 2.72 mmHg to 15.30 ± 3.27 mmHg after the parallel TIPS creation. Clinical improvement was seen in all patients after the parallel TIPS creation. One patient suffered from transient grade I hepatic encephalopathy (HE) after the primary TIPS and four patients experienced transient grade I-II after the parallel TIPS procedure. Mean hospital stay after the first and second operations were 15.0 ± 3.71 d and 16.90 ± 5.11 d (P = 0.014), respectively. After a mean 14.0 ± 3.13 mo follow-up, ascites and bleeding were well controlled and no stenosis of the stents was found.

CONCLUSION: Parallel TIPS is an effective approach for controlling portal hypertension complications.