Transjugular Intrahepatic Porto-Systemic Shunt in Patients with Liver Cirrhosis and Model for End-Stage Liver Disease ≥15

Transjugular Intrahepatic Portosystemic Shunt: An Update

It is more than 50 years since the concept of transjugular intrahepatic portosystemic shunt (TIPS) was first introduced as a percutaneous procedure for patients with refractory variceal bleeding and ascites. TIPS has become widely accepted in the management of complications of portal hypertension because it is less invasive than surgery. In the early days of TIPS, complications included the poor long-term patency of the stent and a high incidence of hepatic encephalopathy. In addition, an excessive shunt diameter after TIPS often resulted in severe hepatic encephalopathy. Although recent covered stents have significantly reduced shunt dysfunction, the development of hepatic encephalopathy and early liver failure remain to be crucial post-TIPS complications. This study reviews the current literature on the status of TIPS in the treatment of cirrhosis.

Transjugular intrahepatic portosystemic shunt vs conservative treatment for recurrent ascites: A propensity score matched comparison

BACKGROUND

Transjugular intrahepatic portosystemic shunt (TIPS) placement is an effective intervention for recurrent tense ascites. Some studies show an increased risk of acute on chronic liver failure (ACLF) associated with TIPS placement. It is not clear whether ACLF in this context is a consequence of TIPS or of the pre-existing liver disease.

AIM

To better understand the risks of TIPS in this challenging setting and to compare them with those of conservative therapy.

METHODS

Two hundred and fourteen patients undergoing their first TIPS placement for recurrent tense ascites at our tertiary-care center between 2007 and 2017 were identified (TIPS group). Three hundred and ninety-eight patients of the same time interval with liver cirrhosis and recurrent tense ascites not undergoing TIPS placement (No TIPS group) were analyzed as a control group. TIPS indication, diagnosis of recurrent ascites, further diagnoses and clinical findings were obtained from a database search and patient records. The in-hospital mortality and ACLF incidence of both groups were compared using 1:1 propensity score matching and multivariate logistic regressions.

RESULTS

After propensity score matching, the TIPS and No TIPS groups were comparable in terms of laboratory values and ACLF incidence at hospital admission. There was no detectable difference in mortality (TIPS: 11/214, No TIPS 13/214). During the hospital stay, ACLF occurred more frequently in the TIPS group than in the No TIPS group (TIPS: 70/214, No TIPS: 57/214, P = 0.04). This effect was confined to patients with severely impaired liver function at hospital admission as indicated by a significant interaction term of Child score and TIPS placement in multivariate logistic regression. The TIPS group had a lower ACLF incidence at Child scores < 8 points and a higher ACLF incidence at ≥ 11 points. No significant difference was found between groups in patients with Child scores of 8 to 10 points.

CONCLUSION

TIPS placement for recurrent tense ascites is associated with an increased rate of ACLF in patients with severely impaired liver function but does not result in higher in-hospital mortality.

North American Practice-Based Recommendations for Transjugular Intrahepatic Portosystemic Shunts in Portal Hypertension

Complications of portal hypertension, including ascites, gastrointestinal bleeding, hepatic hydrothorax, and hepatic encephalopathy, are associated with significant morbidity and mortality. Despite few high-quality randomized controlled trials to guide therapeutic decisions, transjugular intrahepatic portosystemic shunt (TIPS) creation has emerged as a crucial therapeutic option to treat complications of portal hypertension. In North America, the decision to perform TIPS involves gastroenterologists, hepatologists, and interventional radiologists, but TIPS creation is performed by interventional radiologists. This is in contrast to other parts of the world where TIPS creation is performed primarily by hepatologists. Thus, the successful use of TIPS in North America is dependent on a multidisciplinary approach and technical expertise, so as to optimize outcomes. Recently, new procedural techniques, TIPS stent technology, and indications for TIPS have emerged. As a result, practices and outcomes vary greatly across institutions and significant knowledge gaps exist. In this consensus statement, the Advancing Liver Therapeutic Approaches group critically reviews the application of TIPS in the management of portal hypertension. Advancing Liver Therapeutic Approaches convened a multidisciplinary group of North American experts from hepatology, interventional radiology, transplant surgery, nephrology, cardiology, pulmonology, and hematology to critically review existing literature and develop practice-based recommendations for the use of TIPS in patients with any cause of portal hypertension in terms of candidate selection, procedural best practices and, post-TIPS management; and to develop areas of consensus for TIPS indications and the prevention of complications. Finally, future research directions are identified related to TIPS for the management of portal hypertension.

Decision making for transjugular intrahepatic portosystemic stent shunt in refractory ascites and variceal bleeding: MELD, or not MELD, that is the question

PURPOSE

The model of end-stage liver disease (MELD) score has been shown to predict 3-month prognosis following transjugular intrahepatic portosystemic stent shunt (TIPS) in liver cirrhosis; however, that score was derived from a mixed cohort, including patients with refractory ascites and variceal bleeding. This study re-evaluates the role of the MELD score and focuses on differences between both groups of patients.

METHODS

A total of 301 patients (192 male and 109 female) received TIPS, 213 because of refractory ascites and 88 because of variceal bleeding. Univariate and multivariate Cox analyses were performed to identify predictors of mortality and area under the receiver operator characteristics (AUROC) were used to assess the prognostic capacity of the MELD score and of the results of predictors of the multivariate analyses.

RESULTS

In refractory ascites, age, bilirubin and albumin were independent predictors of mortality. In variceal bleeding, emergency TIPS during ongoing bleeding, concomitant grade III ascites, history of hepatic encephalopathy, spontaneous bacterial peritonitis, bilirubin and platelet count proved significant. AUROCs of the MELD score for 3-month survival yielded 0.543 and 0.836 for refractory ascites and variceal bleeding, respectively (P < 0.001). For 1-year survival, the respective AUROCs yielded 0.533 and 0.767 (P < 0.001). In contrast to MELD, the AUROCs based on the calculated risk scores of this study resulted in 0.660 and 0.876 for 3-month survival, and 0.665 and 0.835 for 1-year survival in patients with ascites and variceal bleeding, respectively.

CONCLUSION

In refractory ascites, the prognostic capability of MELD is significantly inferior compared to variceal bleeding. The results of our multivariate analyses and AUROC calculations corroborate the impact of different prognostic variables in patients undergoing TIPS for ascites and variceal bleeding.

Outcomes After TIPS for Ascites and Variceal Bleeding in a Contemporary Era-An ALTA Group Study

INTRODUCTION

Advances in transjugular intrahepatic portosystemic shunt (TIPS) technology have led to expanded use. We sought to characterize contemporary outcomes of TIPS by common indications.

METHODS

This was a multicenter, retrospective cohort study using data from the Advancing Liver Therapeutic Approaches study group among adults with cirrhosis who underwent TIPS for ascites/hepatic hydrothorax (ascites/HH) or variceal bleeding (2010-2015). Adjusted competing risk analysis was used to assess post-TIPS mortality or liver transplantation (LT).

RESULTS

Among 1,129 TIPS recipients, 58% received TIPS for ascites/HH and 42% for variceal bleeding. In patients who underwent TIPS for ascites/HH, the subdistribution hazard ratio (sHR) for death was similar across all Model for End-Stage Liver Disease Sodium (MELD-Na) categories with an increasing sHR with rising MELD-Na. In patients with TIPS for variceal bleeding, MELD-Na ≥20 was associated with increased hazard for death, whereas MELD-Na ≥22 was associated with LT. In a multivariate analysis, serum creatinine was most significantly associated with death (sHR 1.2 per mg/dL, 95% confidence interval [CI] 1.04-1.4 and 1.37, 95% CI 1.08-1.73 in ascites/HH and variceal bleeding, respectively). Bilirubin and international normalized ratio were most associated with LT in ascites/HH (sHR 1.23, 95% CI 1.15-1.3; sHR 2.99, 95% CI 1.76-5.1, respectively) compared with only bilirubin in variceal bleeding (sHR 1.06, 95% CI 1.00-1.13).

DISCUSSION

MELD-Na has differing relationships with patient outcomes dependent on TIPS indication. These data provide new insights into contemporary predictors of outcomes after TIPS.

Role of Transjugular Intrahepatic Portosystemic Shunt in the Management of Portal Hypertension: Review and Update of the Literature

Transjugular intrahepatic portosystemic shunt (TIPS) is a well-established procedure used in the management of complications of portal hypertension. Although the most robust evidence supports the use of TIPS as salvage therapy in variceal hemorrhage, secondary prophylaxis of variceal bleeding, and treatment of refractory ascites, there is also data to suggest its efficacy in other indications such as hepatic hydrothorax, hepatorenal syndrome, and Budd-Chiari syndrome. Recent literature also suggests that TIPS may improve survival for certain subpopulations if placed early after variceal bleeding. This article provides an updated evidence-based review of the indications for TIPS. Outcomes, complications, and adequate patient selection are also discussed.

Transjugular Intrahepatic Portosystemic Shunt:The Impact of Portal Venous Pressure Declines on Shunt Patency and Clinical Efficacy

RATIONALE AND OBJECTIVES

Transjugular intrahepatic portosystemic shunt (TIPS) placement using the same-diameter covered stents can lead to differed declines of portal venous pressure declines (PVDs). This study aimed to compare the long-term shunt patency and clinical efficacy of TIPS placement that caused low PVDs (≤9 mmHg) and high PVDs (>9 mmHg).

MATERIALS AND METHODS

A total of 129 patients treated by TIPS placement with 8 mm-diameter polytetrafluoroethylene covered stents were included and analyzed retrospectively. They were stratified into group A with low PVDs (n = 69) and group B with high PVDs (n = 60).

RESULTS

The 6-year actuarial probabilities of remaining free of shunt dysfunction (47.2% vs 64.6%; p = 0.007) and variceal rebleeding (48.3% vs 63.9%; p = 0.038) were significantly lower in group A than in group B. The 6-year actuarial probability of remaining free of hepatic encephalopathy was significantly higher in group A than in group B (44.5% vs 32.5%; p = 0.010), though the 6-year cumulative survival rate was similar in both groups (A vs B: 65.5% vs 56.0%; p = 0.240). The baseline portal vein thrombosis (hazard ratio [HR]: 6.045, 95% confidence interval [CI]: 2.762-13.233; p = 0.000) and stent type (HR: 4.447, 95%CI: 1.711-11.559, p = 0.002) were associated with shunt dysfunction, whereas only ascites was associated with mortality (HR: 1.373, 95%CI: 1.114-3.215; p = 0.024).

CONCLUSION

High PVDs (>9 mmHg) were associated with higher shunt patency, lower incidence of variceal rebleeding, but higher frequency of hepatic encephalopathy and similar survival rate than low PVDs (≤9 mmHg) after TIPS placement.

Transjugular Intrahepatic Portosystemic Shunt Placement for Refractory Ascites: Review and Update of the Literature

Ascites is the most common complication of cirrhosis, impairs quality of life, and carries a poor prognosis. Transjugular intrahepatic portosystemic shunt (TIPS) is a well-validated therapy for refractory ascites and is superior at reducing the accumulation of fluid compared with paracentesis. More recent evidence has shown that TIPS also provides an improved transplant-free survival compared with paracentesis. To maximize the clinical efficacy and survival advantage, proper patient selection is crucial. While current guidelines recommend that elective TIPS for ascites should be performed only in patients with MELD ≤ 18, recent literature suggests that elective TIPS safely and effectively controls ascites and potentially provides a survival advantage in patients with higher MELD scores (≤ 24). The evolution of these findings likely represents the combination of improved medical management of cirrhotic patients, improved devices, and a better knowledge of selection criteria for potential TIPS patients. This article will review the pathophysiology and management of ascites, with a focus on the evidence supporting TIPS placement for refractory ascites.

Management of portal hypertension before and after liver transplantation

Orthotopic liver transplantation (OLT) represents a curative treatment option for end-stage liver disease (ESLD). Although epidemiology of ESLD has recently changed due to the rising prevalence of nonalcoholic fatty liver disease and the decreased burden of hepatitis C virus infections due to highly effective antiviral regimens, the management of portal hypertension (PHT) remains a clinical challenge in the pre- and post-OLT setting. The measurement of the hepatic venous pressure gradient represents the most reliable but invasive tool for assessment of the severity of PHT. Although novel liver ultrasound and magnetic resonance-based elastography methods have been developed, their value to screen for liver fibrosis and PHT in transplanted patients remains to be established. Nonselective beta-blockers represent the cornerstone of medical treatment of PHT, but more studies on their effects on clinical endpoints after OLT are needed. Statins are widely used to treat hyperlipidemia, which is a common condition after OLT. Although a growing body of evidence suggests that statins decrease portal pressure and PHT-related complications in ESLD, studies on potential benefits of statins after OLT are lacking. Finally, transjugular intrahepatic portosystemic shunts (TIPS) are effective in decreasing PHT and seem to decrease mortality on the OLT waiting list. Moreover, TIPS does not have an impact on liver function nor complicate the transplant surgical procedures. TIPS may also be used after OLT, but the evidence is limited. In conclusion, whereas the management of PHT in patients with ESLD is based on strong evidence, further data on the value of noninvasive monitoring tools as well as on medical and invasive treatment options in the post-OLT setting are needed to improve management strategies in patients with recurrent PHT after liver transplantation. Liver Transplantation 24 112-121 2018 AASLD.