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Zhu P, Dong S, Sun P, Belgaumkar AP, Sun Y, Cheng X, Zheng Q, Li T. Expanded polytetrafluoroethylene (ePTFE)-covered stents versus bare stents for transjugular intrahepatic portosystemic shunt in people with liver cirrhosis. Cochrane Database Syst Rev 2023; 8:CD012358. [PMID: 37531575 PMCID: PMC10400379 DOI: 10.1002/14651858.cd012358.pub2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 08/04/2023]
Abstract
BACKGROUND Transjugular intrahepatic portosystemic shunt (TIPS) is a widely used procedure for management of uncontrolled upper gastrointestinal bleeding and refractory ascites in people with liver cirrhosis. However, nearly half of the people experience shunt dysfunction and recurrent symptoms within one year of the procedure. Expanded polytetrafluoroethylene (ePTFE)-covered stents are assumed to decrease shunt dysfunction by approximately 20% to 30%. OBJECTIVES To evaluate the benefits and harms associated with the use of expanded polytetrafluoroethylene (ePTFE)-covered stents versus bare stents in transjugular intrahepatic portosystemic shunts (TIPSs) for managing people with liver cirrhosis. SEARCH METHODS We used standard, extensive Cochrane search methods. The latest search date was 28 February 2023. SELECTION CRITERIA Randomised clinical trials comparing ePTFE-covered stents versus bare stents in TIPS for treatment of people with liver cirrhosis. DATA COLLECTION AND ANALYSIS We used standard Cochrane methods. Our primary outcomes were 1. all-cause mortality, 2. procedure-related complications, and 3. health-related quality of life. Our secondary outcomes were 4. upper gastrointestinal bleeding, 5. recurrence of ascites, 6. hepatic encephalopathy, 7. kidney failure, 8. early thrombosis, 9. non-serious adverse events, and 10. shunt dysfunction. We used GRADE to assess certainty of evidence. We analysed outcome data at the maximum follow-up, except for the 'early thrombosis' outcome for which it was within 12 weeks after the TIPS procedure. MAIN RESULTS We included four trials with 565 randomised participants (age range: 18 to 75 years; male range: 63.6% to 75.0%). A total of 527 participants provided data for analyses because of losses to follow-up. Two trials were conducted in China; one in France; and one in France, Spain, and Canada. Participants were classified with cirrhosis Child-Pugh class A, B, or C, and for some, the class was not reported. We used intention-to-treat principle (four trials) and per-protocol analysis (one trial) to meta-analyse the data. One trial compared ePTFE-covered stents versus bare stents of the same diameter and three trials compared ePTFE-covered stents versus stents of different diameters. ePTFE-covered stents versus bare stents of the same diameter One trial with 258 participants compared 8 mm covered stent versus 8 mm bare stent. Mortality in the covered stent group is possibly lower than in the bare stent group (risk ratio (RR) 0.63, 95% confidence interval (CI) 0.43 to 0.92; low-certainty evidence). Upper gastrointestinal bleeding (RR 0.54, 95% CI 0.35 to 0.84), recurrence of ascites (RR 0.42, 95% CI 0.20 to 0.87), and shunt dysfunction (RR 0.42, 95% CI 0.28 to 0.61) occurred more often in the bare stent group than in the covered stent group (all low-certainty evidence). There was no difference in hepatic encephalopathy between groups (RR 1.10, 95% CI 0.76 to 1.61; very low-certainty evidence). The trial did not report data on procedure-related complications, health-related quality of life, early thrombosis, and segmental liver ischaemia (a non-serious adverse event). ePTFE-covered stents versus bare stents of different stent diameters Three trials compared ePTFE-covered stents versus bare stents of different diameters (10.5 (standard deviation (SD) 0.9) mm versus 11.7 (SD 0.8) mm; 8 mm versus 10 mm; and one trial used 10-mm stents that could be dilated from 8 mm to 10 mm). There was no evidence of a difference between the ePTFE-covered stents versus bare stents groups in mortality (RR 0.75, 95% CI 0.48 to 1.16; 3 trials, 269 participants), procedure-related complications (RR 0.53, 95% CI 0.05 to 5.57; 1 trial, 80 participants), upper gastrointestinal bleeding (RR 0.46, 95% CI 0.15 to 1.38; 3 trials, 269 participants), hepatic encephalopathy (RR 0.93, 95% CI 0.66 to 1.30; 3 trials, 269 participants), and kidney failure (RR 7.59, 95% CI 0.40 to 143.92; 1 trial, 121 participants) (all very low-certainty evidence). Recurrence of ascites (RR 0.30, 95% CI 0.11 to 0.85; 3 trials, 269 participants; low-certainty evidence), shunt dysfunction (RR 0.50, 95% CI 0.28 to 0.92; 3 trials, 269 participants; low-certainty evidence), and early thrombosis (RR 0.28, 95% CI 0.09 to 0.82; I2 = 0%; 3 trials, 261 participants; very low-certainty evidence) occurred more often in the bare stents group. There was no evidence of a difference in segmental liver ischaemia (RR 5.25, 95% CI 0.26 to 106.01; 1 trial, 80 participants; very low-certainty evidence). No trial presented data on health-related quality of life. Funding One trial did not clearly report funding sources. The remaining three trials declared that they had no funding with vested interests. AUTHORS' CONCLUSIONS Based on the small number of trials with insufficient sample size and events, and study limitations, we assessed the overall certainty of evidence in the predefined outcomes as low or very low. Therefore, we are uncertain which of the two interventions (ePTFE-covered stents or bare stents of the same diameter and ePTFE-covered stents versus bare stents of different stent diameters) is effective for the evaluated outcomes. None of the four trials reported data on health-related quality of life, and data on complications were either missing or rarely reported. We lack high-quality trials to evaluate the role of ePTFE-covered stents for TIPS for managing people with liver cirrhosis.
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Affiliation(s)
- Peng Zhu
- Department of Gastrointestinal Surgery, The Second Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Sitong Dong
- Division of Psychiatry and Applied Psychology, School of Medicine, University of Nottingham, Nottingham, UK
| | - Ping Sun
- Department of Hepatobiliary Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Ajay P Belgaumkar
- Department of Upper GI Surgery, Ashford and St Peter's NHS Trust, Chertsey, UK
| | - Yi Sun
- School of Public Health, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Xiang Cheng
- Department of Hepatobiliary Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Qichang Zheng
- Department of Hepatobiliary Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Tong Li
- Department of Gastrointestinal Surgery, The Second Affiliated Hospital of Chongqing Medical University, Chongqing, China
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2
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Ishikawa T. Efficacy of interventional radiology in the management of portal hypertension: A narrative review. Medicine (Baltimore) 2022; 101:e30018. [PMID: 35984127 PMCID: PMC9387995 DOI: 10.1097/md.0000000000030018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/05/2023] Open
Abstract
Portal hypertension is associated with numerous adverse effects, including the formation of gastroesophageal varices and a portal vein general circulation shunt. Portal hypertension can lead to portal blood flow into the liver and a subsequent reduction in liver function. Clinical interventions can be hampered by a concurrent reduction in circulating platelets associated with increased splenic activity. Pharmaceutical interventions for the treatment of complications associated with portal hypertension have achieved various degrees of success. However, an effective therapeutic strategy for portal hypertension has not yet been established. A literature search was performed using "PubMed." Database between 1966 and January 2021 using the following keywords: portal hypertension, interventional radiology, balloon-occluded retrograde transvenous obliteration, transjugular retrograde obliteration of gastric varices, percutaneous transhepatic obliteration, partial splenic embolization, and transjugular intrahepatic portosystemic shunting. In this narrative review, we summarize the application of interventional radiology in patients with portal hypertension, including techniques for embolization of collateral veins and portal pressure reduction. These up-to-date interventional radiology techniques can be used to treat portal hypertension. The data that support the findings of this study are available from the corresponding author, upon reasonable request.
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Affiliation(s)
- Toru Ishikawa
- Department of Gastroenterology, Saiseikai Niigata Hospital, Niigata, Japan
- *Correspondence: Toru Ishikawa, Department of Gastroenterology, Saiseikai Niigata Hospital, Teraji 280-7, Niigata 950-1104, Japan (e-mail: )
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3
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Pinchot JW, Kalva SP, Majdalany BS, Kim CY, Ahmed O, Asrani SK, Cash BD, Eldrup-Jorgensen J, Kendi AT, Scheidt MJ, Sella DM, Dill KE, Hohenwalter EJ. ACR Appropriateness Criteria® Radiologic Management of Portal Hypertension. J Am Coll Radiol 2021; 18:S153-S173. [PMID: 33958110 DOI: 10.1016/j.jacr.2021.02.013] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2021] [Accepted: 02/10/2021] [Indexed: 12/17/2022]
Abstract
Cirrhosis is a heterogeneous disease that cannot be studied as a single entity and is classified in two main prognostic stages: compensated and decompensated cirrhosis. Portal hypertension, characterized by a pathological increase of the portal pressure and by the formation of portal-systemic collaterals that bypass the liver, is the initial and main consequence of cirrhosis and is responsible for the majority of its complications. A myriad of treatment options exists for appropriately managing the most common complications of portal hypertension, including acute variceal bleeding and refractory ascites. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.
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Affiliation(s)
| | - Sanjeeva P Kalva
- Panel Chair, Massachusetts General Hospital, Boston, Massachusetts, Chief, Division of Interventional Radiology, Massachusetts General Hospital
| | | | - Charles Y Kim
- Panel Vice-Chair, Duke University Medical Center, Durham, North Carolina, Chief, Division of Interventional Radiology, Duke University Medical Center
| | | | - Sumeet K Asrani
- Baylor University Medical Center, Dallas, Texas, American Association for the Study of Liver Diseases
| | - Brooks D Cash
- University of Texas Health Science Center at Houston and McGovern Medical School, Houston, Texas, American Gastroenterological Association
| | - Jens Eldrup-Jorgensen
- Tufts University School of Medicine, Boston, Massachusetts, Society for Vascular Surgery
| | - A Tuba Kendi
- Mayo Clinic, Rochester, Minnesota, Director of Nuclear Medicine Therapy at Mayo Clinic Rochester
| | | | | | - Karin E Dill
- Specialty Chair, Emory University Hospital, Atlanta, Georgia
| | - Eric J Hohenwalter
- Specialty Chair, Froedtert & The Medical College of Wisconsin, Milwaukee, Wisconsin, Chair, FMLH credentials committee, Division chief of IR at Medical College of Wisconsin
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4
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Pandhi MB, Kuei AJ, Lipnik AJ, Gaba RC. Emergent Transjugular Intrahepatic Portosystemic Shunt Creation in Acute Variceal Bleeding. Semin Intervent Radiol 2020; 37:3-13. [PMID: 32139965 DOI: 10.1055/s-0039-3402015] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Emergent transjugular intrahepatic portosystemic shunt (TIPS) creation is most commonly employed in the setting of acute variceal hemorrhage. Given a propensity for decompensation, these patients often require a multidisciplinary, multimodal approach involving prompt diagnosis, pharmacologic therapy, and endoscopic intervention. While successful in the majority of cases, failure to medically control initial bleeding can prompt interventional radiology consultation for emergent portal decompression via TIPS creation. This article discusses TIPS creation in emergent, acute variceal hemorrhage, reviewing the natural history of gastroesophageal varices, presentation and diagnosis of acute variceal hemorrhage, pharmacologic therapy, endoscopic approaches, patient selection and risk stratification for TIPS, technical considerations for TIPS creation, adjunctive embolotherapy, and the role of salvage TIPS versus early TIPS in acute variceal hemorrhage.
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Affiliation(s)
- Mithil B Pandhi
- Department of Radiology, University of Illinois at Chicago, Chicago, Illinois
| | - Andrew J Kuei
- Department of Radiology, University of Illinois at Chicago, Chicago, Illinois
| | - Andrew J Lipnik
- Department of Radiology, University of Illinois at Chicago, Chicago, Illinois
| | - Ron C Gaba
- Department of Radiology, University of Illinois at Chicago, Chicago, Illinois.,Division of Interventional Radiology, University of Illinois at Chicago, Chicago, Illinois
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5
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Luo SH, Chu JG, Huang H, Zhao GR, Yao KC. Targeted puncture of left branch of intrahepatic portal vein in transjugular intrahepatic portosystemic shunt to reduce hepatic encephalopathy. World J Gastroenterol 2019; 25:1088-1099. [PMID: 30862997 PMCID: PMC6406189 DOI: 10.3748/wjg.v25.i9.1088] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/16/2018] [Revised: 01/24/2019] [Accepted: 01/28/2019] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Transjugular intrahepatic portosystemic shunt (TIPS) is currently used for the treatment of complications of portal hypertension. The incidence of hepatic encephalopathy (HE) remains a problem in TIPS placement. It has been reported that the right branch mainly receives superior mesenteric venous blood while the left branch mainly receives blood from the splenic vein. We hypothesized that targeted puncture of the left portal vein would divert the non-nutritive blood from the splenic vein into the TIPS shunt; therefore, targeted puncture of the left branch of the intrahepatic portal vein during TIPS may reduce the risk of HE.
AIM To evaluate the influence of targeted puncture of left branch of portal vein in TIPS on HE.
METHODS A retrospective analysis of 1244 patients with portal-hypertension-related complications of refractory ascites or variceal bleeding who underwent TIPS from January 2000 to January 2013 was performed. Patients were divided into group A (targeting left branch of portal vein, n = 937) and group B (targeting right branch of portal vein, n = 307). TIPS-related HE and clinical outcomes were analyzed.
RESULTS The symptoms of ascites and variceal bleeding disappeared within a short time. By the endpoint of follow-up, recurrent bleeding and ascites did not differ significantly between groups A and B (P = 0.278, P = 0.561, respectively). Incidence of HE differed significantly between groups A and B at 1 mo (14.94% vs 36.80%, χ2 = 4.839, P = 0.028), 3 mo (12.48% vs 34.20%, χ2 = 5.054, P = 0.025), 6 mo (10.03% vs 32.24%, χ2 = 6.560, P = 0.010), 9 mo (9.17% vs 31.27%, χ2 = 5.357, P = 0.021), and 12 mo (8.21% vs 28.01, χ2 = 3.848, P = 0.051). There were no significant differences between groups A and B at 3 years (6.61% vs 7.16%, χ2 = 1.204, P = 0.272) and 5 years (5.01% vs 6.18%, χ2 = 0.072, P = 0.562). The total survival rate did not differ between groups A and B (χ2 = 0.226, P = 0.634, log-rank test).
CONCLUSION Targeted puncture of the left branch of the intrahepatic portal vein during TIPS may reduce the risk of HE but has no direct influence on prognosis of portal-hypertension-related complications.
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Affiliation(s)
- Shi-Hua Luo
- Department of Radiology, Zhongnan Hospital of Wuhan University, Wuhan 430071, Hubei Province, China
| | - Jian-Guo Chu
- Department of Radiology, Air Force Medical Center of PLA, Beijing 100142, China
| | - He Huang
- Department of Radiology, Air Force Medical Center of PLA, Beijing 100142, China
| | - Guo-Rui Zhao
- Department of Interventional Radiology, Henan Provincial Infectious Disease Hospital, Zhengzhou 450015, Henan Province, China
| | - Ke-Chun Yao
- Department of Ultrasound, Air Force Medical Center of PLA, Beijing 100142, China
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6
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Bertino F, Hawkins CM, Shivaram G, Gill AE, Lungren MP, Reposar A, Sze DY, Hwang GL, Koo K, Monroe E. Technical Feasibility and Clinical Effectiveness of Transjugular Intrahepatic Portosystemic Shunt Creation in Pediatric and Adolescent Patients. J Vasc Interv Radiol 2019; 30:178-186.e5. [PMID: 30717948 DOI: 10.1016/j.jvir.2018.10.003] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2018] [Revised: 09/28/2018] [Accepted: 10/06/2018] [Indexed: 12/24/2022] Open
Abstract
PURPOSE To examine the technical feasibility and clinical efficacy of transjugular intrahepatic portosystemic shunt (TIPS) creation in children and adolescents. MATERIALS AND METHODS Retrospective review was performed of 59 patients (mean age 12.6 y [range, 1.5-20 y], mean weight 47.5 kg [range, 11.4-112.2 kg], mean Model for End-stage Liver Disease/Pediatric End-stage Liver Disease score 12.5 [range, 6-33]) who underwent 61 TIPS attempts at 3 tertiary children's hospitals from 2001 to 2017 for acute esophageal or gastroesophageal variceal bleeding, primary and secondary prevention of variceal bleeding, and refractory ascites. Pediatric liver disease etiologies included biliary atresia, cystic fibrosis, and ductal plate anomalies. Technical, hemodynamic, and clinical success and patency rates were reported at 1, 6, 12, and 24 months. Statistical analysis evaluated reasons for clinical failure. Kaplan-Meier analysis measured clinical success, patency, and transplant-free survival. RESULTS Technical success was 93.4% (57/61) in 59 consecutive patients. Most common TIPS indications were treating and preventing esophageal and gastroesophageal variceal bleeding (57/59; 96.6%). Hemodynamic success was 94% (47/50). Clinical success was 80.7% (45/56). Two-year clinical success for acute variceal bleeding and ascites was 94.1% and 100%, respectively. Overall patency at 1, 6, 12, and 24 months was 98.0%, 97.8%, 94.3%, and 91.3%. Two-year transplant-free survival was 88.8%. Overall and major complication rates were 21.2% (13/61) and 8.2% (5/61), with 3 mortalities. Gradient reduction < 12 mm Hg correlated with clinical success (P < .01). CONCLUSIONS TIPS creation in pediatric patients is technically feasible and clinically efficacious for treatment and prevention of esophageal and gastroesophageal variceal hemorrhage. High 2-year clinical success, patency, and survival rates should encourage providers to consider portosystemic shunts as a bridge to liver transplantation.
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Affiliation(s)
- Frederic Bertino
- Divisions of Pediatric Radiology and Interventional Radiology and Image Guided Medicine, Department of Radiology and Imaging Sciences, Emory University School of Medicine, Atlanta, Georgia; Children's Healthcare of Atlanta, Atlanta, Georgia.
| | - C Matthew Hawkins
- Divisions of Pediatric Radiology and Interventional Radiology and Image Guided Medicine, Department of Radiology and Imaging Sciences, Emory University School of Medicine, Atlanta, Georgia; Children's Healthcare of Atlanta, Atlanta, Georgia
| | - Giri Shivaram
- Division of Interventional Radiology, Department of Radiology, University of Washington, Seattle, Washington; Seattle Children's Hospital, Seattle, Washington
| | - Anne E Gill
- Divisions of Pediatric Radiology and Interventional Radiology and Image Guided Medicine, Department of Radiology and Imaging Sciences, Emory University School of Medicine, Atlanta, Georgia; Children's Healthcare of Atlanta, Atlanta, Georgia
| | - Matthew P Lungren
- Department of Radiology, Stanford University School of Medicine, Stanford, California
| | - Aaron Reposar
- Department of Radiology, Stanford University School of Medicine, Stanford, California
| | - Daniel Y Sze
- Department of Radiology, Stanford University School of Medicine, Stanford, California
| | - Gloria L Hwang
- Department of Radiology, Stanford University School of Medicine, Stanford, California
| | - Kevin Koo
- Division of Interventional Radiology, Department of Radiology, University of Washington, Seattle, Washington; Seattle Children's Hospital, Seattle, Washington
| | - Eric Monroe
- Division of Interventional Radiology, Department of Radiology, University of Washington, Seattle, Washington; Seattle Children's Hospital, Seattle, Washington
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7
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Owen JW, Saad NE, Foster G, Fowler KJ. The Feasibility of Using Volumetric Phase-Contrast MR Imaging (4D Flow) to Assess for Transjugular Intrahepatic Portosystemic Shunt Dysfunction. J Vasc Interv Radiol 2018; 29:1717-1724. [PMID: 30396843 DOI: 10.1016/j.jvir.2018.07.022] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2018] [Revised: 07/09/2018] [Accepted: 07/23/2018] [Indexed: 02/07/2023] Open
Abstract
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.
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Affiliation(s)
- Joseph W Owen
- Department of Radiology, University of Kentucky College of Medicine, 800 Rose Street, HX315A, Lexington, KY 40536-0293.
| | - Nael E Saad
- Department of Imaging Sciences, University of Rochester Medical Center, Rochester, New York
| | - Glenn Foster
- Department of Radiology, Washington University School of Medicine, St. Louis, Missouri
| | - Kathryn J Fowler
- Department of Radiology, Washington University School of Medicine, St. Louis, Missouri
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8
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Lipnik AJ, Pandhi MB, Khabbaz RC, Gaba RC. Endovascular Treatment for Variceal Hemorrhage: TIPS, BRTO, and Combined Approaches. Semin Intervent Radiol 2018; 35:169-184. [PMID: 30087520 DOI: 10.1055/s-0038-1660795] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Variceal hemorrhage is a feared complication of portal hypertension, with high rates of morbidity and mortality. Optimal management requires a thoughtful, multidisciplinary approach. In cases of refractory or recurrent esophageal hemorrhage, endovascular approaches such as transjugular intrahepatic portosystemic shunt (TIPS) have a well-defined role. For hemorrhage related to gastric varices, the optimal treatment remains to be established; however, there is increasing adoption of balloon-occluded retrograde transvenous obliteration (BRTO). This article will review the concept, history, patient selection, basic technique, and outcomes for TIPS, BRTO, and combined TIPS + BRTO procedures for variceal hemorrhage.
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Affiliation(s)
- Andrew J Lipnik
- Department of Radiology, University of Illinois Hospital & Health Sciences System, Chicago, Illinois.,Division of Interventional Radiology, University of Illinois Hospital & Health Sciences System, Chicago, Illinois
| | - Mithil B Pandhi
- Department of Radiology, University of Illinois Hospital & Health Sciences System, Chicago, Illinois
| | - Ramzy C Khabbaz
- Department of Radiology, University of Illinois Hospital & Health Sciences System, Chicago, Illinois
| | - Ron C Gaba
- Department of Radiology, University of Illinois Hospital & Health Sciences System, Chicago, Illinois.,Division of Interventional Radiology, University of Illinois Hospital & Health Sciences System, Chicago, Illinois
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9
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Triantafyllou T, Aggarwal P, Gupta E, Svetanoff WJ, Bhirud DP, Singhal S. Polytetrafluoroethylene-Covered Stent Graft Versus Bare Stent in Transjugular Intrahepatic Portosystemic Shunt: Systematic Review and Meta-Analysis. J Laparoendosc Adv Surg Tech A 2018; 28:867-879. [PMID: 29356589 DOI: 10.1089/lap.2017.0560] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND & AIMS Transjugular Intrahepatic Portosystemic Shunt (TIPS) is used to control refractory variceal bleeding secondary to portal hypertension. This meta-analysis was conducted to systematically review polytetrafluoroethylene-covered stent grafts (CS) versus bare stents (BS) in TIPS procedure. METHODS Systematic search of literature databases was done from January-1990 till April-2017, using predecided keywords. Outcome measures studied were (1) primary-patency (PP) at 1 year (defined as absence of shunt insufficiency at 1 year), (2) rebleeding (RE) (3) new-onset hepatic encephalopathy ([HE] new-onset or worsening encephalopathy following the procedure), and (4) survival at 1 year (SU). Odds ratio (OR) was calculated for each outcome variable. Between-study heterogeneity was assessed by the I2 statistics and χ2 Q-test. RESULTS Fourteen studies (4 RCTs, 2 prospective nonrandomized, and 8 retrospective) were included with 2519 patients (1548 patients in BS group and 971 patients in CS group). Three-quarter outcome measures showed significantly better results with CS. PP was pooled from 13 studies and showed an OR = 4.75 (95% confidence interval [CI] = 3.32-6.79; P < .00001; I2 = 44%) in favor of CS. RE was pooled from six studies with odds ratio (OR) = 0.37(95% CI = 0.24-0.56; P < .00001; I2 = 0%) in favor of CS. SU was pooled from 11 studies with OR = 1.85 (95% CI = 1.44-2.38; P < .00001; I2 = 0%) in favor of CS. On subset analysis for RCTs, three outcome variables favored CS with minimal heterogeneity [PP: OR = 4.18 (95% CI = 2.66-6.55; P < .00001; I2 = 0%). RE: OR = 0.43 (95% CI = 0.25-0.72; P < .001; I2 = 0%). SU: OR = 1.85 (95% CI = 1.44-2.38, P < .00001; I2 = 0%)]. HE showed no difference between two stents on the overall and subset pooled analysis. Overall: OR = 0.86 (95% CI = 0.68-1.08; P = .19; I2 = 4%). Only RCTs: OR = 0.91 (95% CI = 0.63-1.32, P = .63; I2 = 0%). CONCLUSIONS CS is associated with better primary patency and survival and lesser rate of rebleeding than BS in patients undergoing TIPS procedure. There is no difference in new-onset hepatic encephalopathy.
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Affiliation(s)
| | - Piyush Aggarwal
- 2 All India Institute of Medical Sciences , New Delhi, India
| | - Ekansh Gupta
- 2 All India Institute of Medical Sciences , New Delhi, India
| | - Wendy Jo Svetanoff
- 3 Boston Children's Hospital , Harvard Medical School, Boston, Massachusetts
| | | | - Saurabh Singhal
- 5 St. Joseph's Hospital and Medical Centre , Phoenix, Arizona
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10
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Buechter M, Manka P, Gerken G, Canbay A, Blomeyer S, Wetter A, Altenbernd J, Kahraman A, Theysohn JM. Transjugular Intrahepatic Portosystemic Shunt in Patients with Portal Hypertension: Patency Depends on Coverage and Interventionalist's Experience. Dig Dis 2018; 36:218-227. [PMID: 29316565 DOI: 10.1159/000486030] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/13/2017] [Accepted: 11/29/2017] [Indexed: 02/02/2023]
Abstract
BACKGROUND AND AIMS Transjugular intrahepatic portosystemic shunt (TIPS) is the treatment of choice in decompensated portal hypertension. TIPS revision due to thrombosis or stenosis increases morbidity and mortality. Our aim was to investigate patient- and procedure-associated risk factors for TIPS-revision. PATIENTS AND METHODS We retrospectively evaluated 189 patients who underwent the TIPS procedure. Only patients who required TIPS revision within 1 year (Group I, 34 patients) and patients who did not require re-intervention within the first year (Group II [control group], 54 patients) were included. RESULTS Out of 88 patients, the majority were male (69.3%) and mean age was 56 ± 11 years. Indications for TIPS were refractory ascites (68%), bleeding (24%), and Budd-Chiari syndrome (8%). The most frequent liver disease was alcohol-induced cirrhosis (60%). Forty-three patients (49%) received bare and 45 patients (51%) covered stents, thus resulting in reduction of hepatic venous pressure gradient (HVPG) from 19.0 to 9.0 mm Hg. When comparing patient- and procedure-related factors, the type of stent (p < 0.01) and interventionalist's experience (number of performed TIPS implantations per year; p < 0.05) were the only factors affecting the risk of re-intervention due to stent dysfunction, while age, gender, indication, Child-Pugh, and model of end-stage liver disease score, platelet count, pre- and post-HVPG, additional variceal embolization, stent diameter, and number of stents did not significantly differ. CONCLUSION Patients undergoing TIPS procedure should be surveilled closely for shunt dysfunction while covered stents and high-level experience are associated with increased -patency.
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Affiliation(s)
- Matthias Buechter
- Department of Gastroenterology and Hepatology, University Hospital Essen, Essen, Germany
| | - Paul Manka
- Department of Gastroenterology and Hepatology, University Hospital Essen, Essen, Germany.,Regeneration and Repair, Institute of Hepatology, Division of Transplantation Immunology and Mucosal Biology, Faculty of Life Sciences and Medicine, King's College London, London, United Kingdom
| | - Guido Gerken
- Department of Gastroenterology and Hepatology, University Hospital Essen, Essen, Germany
| | - Ali Canbay
- Department of Gastroenterology, Hepatology and Infectious Diseases, Otto-von-Guericke University, Magdeburg, Germany
| | - Sandra Blomeyer
- Department of Gastroenterology and Hepatology, University Hospital Essen, Essen, Germany
| | - Axel Wetter
- Department of Diagnostic and Interventional Radiology and Neuroradiology, University Hospital Essen, Essen, Germany
| | - Jens Altenbernd
- Department of Radiology and Neuroradiology, Klinikum Vest Knappschaftskrankenhaus Recklinghausen, Recklinghausen, Germany
| | - Alisan Kahraman
- Department of Gastroenterology and Hepatology, University Hospital Essen, Essen, Germany
| | - Jens M Theysohn
- Department of Diagnostic and Interventional Radiology and Neuroradiology, University Hospital Essen, Essen, Germany
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Stent Dysfunction After Transjugular Intrahepatic Portosystemic Shunt: A 14-Year Experience from a Single Tertiary Medical Center. IRANIAN JOURNAL OF RADIOLOGY 2017. [DOI: 10.5812/iranjradiol.15579] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
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Griffin AS, Preece SR, Ronald J, Smith TP, Suhocki PV, Kim CY. Hemorrhage risk with transjugular intrahepatic portosystemic shunt (TIPS) insertion at the main portal vein bifurcation with stent grafts. Diagn Interv Imaging 2017; 98:837-842. [PMID: 28843589 DOI: 10.1016/j.diii.2017.07.006] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2017] [Revised: 07/20/2017] [Accepted: 07/20/2017] [Indexed: 02/07/2023]
Abstract
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.
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Affiliation(s)
- A S Griffin
- Division of Vascular & Interventional Radiology, Department of Radiology, Duke University Medical Center, 2311, Erwin Road, 27710 Durham, NC, United States
| | - S R Preece
- Vascular Institute, Teton Radiology, Idaho Falls, ID, United States
| | - J Ronald
- Division of Vascular & Interventional Radiology, Department of Radiology, Duke University Medical Center, 2311, Erwin Road, 27710 Durham, NC, United States
| | - T P Smith
- Division of Vascular & Interventional Radiology, Department of Radiology, Duke University Medical Center, 2311, Erwin Road, 27710 Durham, NC, United States
| | - P V Suhocki
- Division of Vascular & Interventional Radiology, Department of Radiology, Duke University Medical Center, 2311, Erwin Road, 27710 Durham, NC, United States
| | - C Y Kim
- Division of Vascular & Interventional Radiology, Department of Radiology, Duke University Medical Center, 2311, Erwin Road, 27710 Durham, NC, United States.
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Luo SH, Chu JG, Huang H, Yao KC. Effect of initial stent position on patency of transjugular intrahepatic portosystemic shunt. World J Gastroenterol 2017; 23:4779-4787. [PMID: 28765699 PMCID: PMC5514643 DOI: 10.3748/wjg.v23.i26.4779] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/09/2017] [Revised: 04/20/2017] [Accepted: 05/19/2017] [Indexed: 02/06/2023] Open
Abstract
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.
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Caly WR, Abreu RM, Bitelman B, Carrilho FJ, Ono SK. Clinical Features of Refractory Ascites in Outpatients. Clinics (Sao Paulo) 2017; 72:405-410. [PMID: 28792999 PMCID: PMC5525166 DOI: 10.6061/clinics/2017(07)03] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/18/2016] [Accepted: 02/16/2017] [Indexed: 02/06/2023] Open
Abstract
OBJECTIVES: To present the clinical features and outcomes of outpatients who suffer from refractory ascites. METHODS: This prospective observational study consecutively enrolled patients with cirrhotic ascites who submitted to a clinical evaluation, a sodium restriction diet, biochemical blood tests, 24 hour urine tests and an ascitic fluid analysis. All patients received a multidisciplinary evaluation and diuretic treatment. Patients who did not respond to the diuretic treatment were controlled by therapeutic serial paracentesis, and a transjugular intrahepatic portosystemic shunt was indicated for patients who required therapeutic serial paracentesis up to twice a month. RESULTS: The most common etiology of cirrhosis in both groups was alcoholism [49 refractory (R) and 11 non-refractory ascites (NR)]. The majority of patients in the refractory group had Child-Pugh class B cirrhosis (p=0.034). The nutritional assessment showed protein-energy malnutrition in 81.6% of the patients in the R group and 35.5% of the patients in the NR group, while hepatic encephalopathy, hernia, spontaneous bacterial peritonitis, upper digestive hemorrhage and type 2 hepatorenal syndrome were present in 51%, 44.9%, 38.8%, 38.8% and 26.5% of the patients in the R group and 9.1%, 18.2%, 0%, 0% and 0% of the patients in the NR group, respectively (p=0.016, p=0.173, p=0.012, p=0.012, and p=0.100, respectively). Mortality occurred in 28.6% of the patients in the R group and in 9.1% of the patients in the NR group (p=0.262). CONCLUSION: Patients with refractory ascites were malnourished, suffered from hernias, had a high prevalence of complications and had a high postoperative death frequency, which was mostly due to infectious processes.
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Affiliation(s)
- Wanda Regina Caly
- Departamento de Gastroenterologia, Divisao de Gastroenterologia e Hepatologia Clinica, Faculdade de Medicina FMUSP, Universidade de Sao Paulo, Sao Paulo, SP, BR
| | - Rodrigo Martins Abreu
- Departamento de Gastroenterologia, Divisao de Gastroenterologia e Hepatologia Clinica, Faculdade de Medicina FMUSP, Universidade de Sao Paulo, Sao Paulo, SP, BR
| | - Bernardo Bitelman
- Departamento de Gastroenterologia, Divisao de Gastroenterologia e Hepatologia Clinica, Faculdade de Medicina FMUSP, Universidade de Sao Paulo, Sao Paulo, SP, BR
| | - Flair José Carrilho
- Departamento de Gastroenterologia, Divisao de Gastroenterologia e Hepatologia Clinica, Faculdade de Medicina FMUSP, Universidade de Sao Paulo, Sao Paulo, SP, BR
| | - Suzane Kioko Ono
- Departamento de Gastroenterologia, Divisao de Gastroenterologia e Hepatologia Clinica, Faculdade de Medicina FMUSP, Universidade de Sao Paulo, Sao Paulo, SP, BR
- *Corresponding author. E-mail:
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15
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Gupta AC, Wang W, Shah C, Sands MJ, Bullen J, Remer EM, Bayona PM, Carey W, Kapoor B. Added Value of Covered Stents in Transjugular Intrahepatic Portosystemic Shunt: A Large Single-Center Experience. Cardiovasc Intervent Radiol 2017; 40:1723-1731. [PMID: 28512687 DOI: 10.1007/s00270-017-1694-1] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/11/2017] [Accepted: 05/08/2017] [Indexed: 01/19/2023]
Abstract
PURPOSE Transjugular intrahepatic portosystemic shunts (TIPS) were historically placed using uncovered bare-metal stents. Current practice has now shifted toward the use of polytetrafluoroethylene (PTFE)-covered stents, given the improved primary patency seen with these stents. The aim of this study was to determine whether there is any added value, such as overall survival or stent patency, when using covered stents versus uncovered stents in TIPS placement in a large cohort. MATERIALS AND METHODS From April 1995 to June 2012, a total of 744 consecutive adult patients underwent de novo TIPS placement (378 receiving uncovered stents, 366 receiving covered stents). Information was obtained on demographics, baseline clinical variables, and outcomes after TIPS placement. Data were collected, compared, and analyzed to assess outcomes including mortality, primary patency (determined via repeat intervention), and secondary patency (determined via ultrasound parameters). RESULTS Covered stents were associated with significantly improved primary patency (P < 0.001) and secondary patency (P < 0.001) when compared with uncovered stents in TIPS procedures. Additionally, covered stents were associated with higher estimated overall survival rates and higher survival rates when TIPS was performed emergently and in patients with higher Model for End-Stage Liver Disease (MELD) scores. For example, in patients with MELD scores between 11 and 18, there was a predicted survival of 59.2% with covered stents versus 42.8% with uncovered stents at 1 year. CONCLUSION This study demonstrated that covered stents offer the additional value of higher estimated overall survival and higher estimated survival in patients undergoing TIPS emergently and in those with higher MELD scores when compared to uncovered stents.
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Affiliation(s)
- Amar C Gupta
- Department of Vascular and Interventional Radiology, Cleveland Clinic, Cleveland, OH, USA.
| | - Weiping Wang
- Department of Radiology, Mayo Clinic, Jacksonville, FL, USA
| | - Chintan Shah
- Department of Diagnostic Radiology, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
| | - Mark J Sands
- Department of Vascular and Interventional Radiology, Cleveland Clinic, Cleveland, OH, USA
| | - Jennifer Bullen
- Department of Quantitative Health Sciences, Cleveland Clinic, Cleveland, OH, USA
| | - Erick M Remer
- Department of Abdominal Imaging, Cleveland Clinic, Cleveland, OH, USA
| | - Pilar M Bayona
- Department of Vascular and Interventional Radiology, Cleveland Clinic, Cleveland, OH, USA
| | - William Carey
- Department of Gastroenterology and Hepatology, Cleveland Clinic, Cleveland, OH, USA
| | - Baljendra Kapoor
- Department of Vascular and Interventional Radiology, Cleveland Clinic, Cleveland, OH, USA
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Wang CM, Li X, Fu J, Luan JY, Li TR, Zhao J, Dong GX. Construction of Transjugular Intrahepatic Portosystemic Shunt: Bare Metal Stent/Stent-graft Combination versus Single Stent-graft, a Prospective Randomized Controlled Study with Long-term Patency and Clinical Analysis. Chin Med J (Engl) 2017; 129:1261-7. [PMID: 27231160 PMCID: PMC4894033 DOI: 10.4103/0366-6999.182830] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
BACKGROUND Balanced adjustment of the portal vein shunt volume during a transjugular intrahepatic portosystemic shunt (TIPS) is critical for maintaining liver perfusion and decreasing the incidence of liver insufficiency. A stent-graft is proved to be superior to a bare metal stent (BMS) for the construction of a TIPS. However, the clinical results of the combination application of stents and stent-grafts have not been determined. This study aimed to compare the technique of using a combination of stents and stent-grafts with using a single stent-graft to construct a TIPS. METHODS From April 2011 to November 2014, a total of fifty patients were randomly assigned to a stents-combination group (Group I, n = 28) or a stent-graft group (Group II, n = 22). Primary patency rates were calculated. Clinical data, including the technical success rate, bleeding control results, incidence of encephalopathy, liver function preservation, and survival rate, were assessed. RESULTS Technically, the success rate was 100% for both groups. The primary patency rates at 1, 2, and 3 years for Group I were 96%, 84%, and 77%, respectively; for Group II, they were 90%, 90%, and 78%, respectively. The survival rates at 1, 2, and 3 years for Group I were 79%, 74%, and 68%, respectively; for Group II, they were 82%, 82%, and 74%, respectively. The incidence of hepatic encephalopathy was 14.3% for Group I and 13.6% for Group II. The Child-Pugh score in Group I was stable at the end of the follow-up but had significantly increased in Group II (t = -2.474, P = 0.022). CONCLUSIONS The construction of a TIPS with either the single stent-graft or BMS/stent-graft combination is effective for controlling variceal bleeding. The BMS/stent-graft combination technique is superior to the stent-graft technique in terms of hepatic function preservation indicated by the Child-Pugh score. However, considering the clinical results of the TIPS, the two techniques are comparable in their primary shunt patency, incidence of encephalopathy and patient survival during the long-term follow-up.
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Affiliation(s)
- Chang-Ming Wang
- Department of Interventional Radiology and Vascular Surgery, Peking University Third Hospital, Beijing 100191, China
| | - Xuan Li
- Department of Interventional Radiology and Vascular Surgery, Peking University Third Hospital, Beijing 100191, China
| | - Jun Fu
- Department of Interventional Radiology and Vascular Surgery, Peking University Third Hospital, Beijing 100191, China
| | - Jing-Yuan Luan
- Department of Interventional Radiology and Vascular Surgery, Peking University Third Hospital, Beijing 100191, China
| | - Tian-Run Li
- Department of Interventional Radiology and Vascular Surgery, Peking University Third Hospital, Beijing 100191, China
| | - Jun Zhao
- Department of Interventional Radiology and Vascular Surgery, Peking University Third Hospital, Beijing 100191, China
| | - Guo-Xiang Dong
- Department of Interventional Radiology and Vascular Surgery, Peking University Third Hospital, Beijing 100191, China
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Madoff DC, Gaba RC, Weber CN, Clark TWI, Saad WE. Portal Venous Interventions: State of the Art. Radiology 2016; 278:333-53. [PMID: 26789601 DOI: 10.1148/radiol.2015141858] [Citation(s) in RCA: 41] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
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.
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Affiliation(s)
- David C Madoff
- From the Department of Radiology, Division of Interventional Radiology, New York-Presbyterian Hospital/Weill Cornell Medical Center, 525 E 68th St, P-518, New York, NY 10065 (D.C.M.); Department of Radiology, Interventional Radiology Section, University of Illinois Hospital, Chicago, Ill (R.C.G.); Department of Radiology, University of Pennsylvania School of Medicine, Penn Presbyterian Medical Center, Philadelphia, Pa (C.N.W., T.W.I.C.); and Department of Radiology, Division of Vascular and Interventional Radiology, University of Michigan Medical Center, Ann Arbor, Mich (W.E.S.)
| | - Ron C Gaba
- From the Department of Radiology, Division of Interventional Radiology, New York-Presbyterian Hospital/Weill Cornell Medical Center, 525 E 68th St, P-518, New York, NY 10065 (D.C.M.); Department of Radiology, Interventional Radiology Section, University of Illinois Hospital, Chicago, Ill (R.C.G.); Department of Radiology, University of Pennsylvania School of Medicine, Penn Presbyterian Medical Center, Philadelphia, Pa (C.N.W., T.W.I.C.); and Department of Radiology, Division of Vascular and Interventional Radiology, University of Michigan Medical Center, Ann Arbor, Mich (W.E.S.)
| | - Charles N Weber
- From the Department of Radiology, Division of Interventional Radiology, New York-Presbyterian Hospital/Weill Cornell Medical Center, 525 E 68th St, P-518, New York, NY 10065 (D.C.M.); Department of Radiology, Interventional Radiology Section, University of Illinois Hospital, Chicago, Ill (R.C.G.); Department of Radiology, University of Pennsylvania School of Medicine, Penn Presbyterian Medical Center, Philadelphia, Pa (C.N.W., T.W.I.C.); and Department of Radiology, Division of Vascular and Interventional Radiology, University of Michigan Medical Center, Ann Arbor, Mich (W.E.S.)
| | - Timothy W I Clark
- From the Department of Radiology, Division of Interventional Radiology, New York-Presbyterian Hospital/Weill Cornell Medical Center, 525 E 68th St, P-518, New York, NY 10065 (D.C.M.); Department of Radiology, Interventional Radiology Section, University of Illinois Hospital, Chicago, Ill (R.C.G.); Department of Radiology, University of Pennsylvania School of Medicine, Penn Presbyterian Medical Center, Philadelphia, Pa (C.N.W., T.W.I.C.); and Department of Radiology, Division of Vascular and Interventional Radiology, University of Michigan Medical Center, Ann Arbor, Mich (W.E.S.)
| | - Wael E Saad
- From the Department of Radiology, Division of Interventional Radiology, New York-Presbyterian Hospital/Weill Cornell Medical Center, 525 E 68th St, P-518, New York, NY 10065 (D.C.M.); Department of Radiology, Interventional Radiology Section, University of Illinois Hospital, Chicago, Ill (R.C.G.); Department of Radiology, University of Pennsylvania School of Medicine, Penn Presbyterian Medical Center, Philadelphia, Pa (C.N.W., T.W.I.C.); and Department of Radiology, Division of Vascular and Interventional Radiology, University of Michigan Medical Center, Ann Arbor, Mich (W.E.S.)
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Gaba RC, Parvinian A, Minocha J, Casadaban LC, Knuttinen MG, Ray CE, Bui JT. Should transjugular intrahepatic portosystemic shunt stent grafts be underdilated? J Vasc Interv Radiol 2016; 26:382-7. [PMID: 25735521 DOI: 10.1016/j.jvir.2014.08.012] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2014] [Revised: 08/08/2014] [Accepted: 08/10/2014] [Indexed: 12/19/2022] Open
Abstract
Although underdilation of transjugular intrahepatic portosystemic shunt (TIPS) stent grafts is commonly performed to limit complications arising from excessive portosystemic shunting, it is uncertain whether underdilated stents retain their smaller diameter indefinitely or eventually expand to nominal caliber. In this investigation, postprocedure computed tomography (CT) was used to compare diameters of underdilated TIPSs and TIPSs expanded to a nominal diameter of 10 mm in 61 cases. The groups had comparable shunt diameters on post-TIPS imaging (9.8 mm vs 9.9 mm; P = .079), with similar incidences of hepatic encephalopathy (34% vs 20%; P = .372), indicating stent self-expansion over time, and bringing into question the advantages of underdilation for customization of shunt caliber.
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Affiliation(s)
- Ron C Gaba
- Department of Radiology and Division of Interventional Radiology, University of Illinois Hospital and Health Sciences System, 1740 W. Taylor St., MC 931, Chicago IL 60612.
| | - Ahmad Parvinian
- University of Illinois College of Medicine, University of Illinois Hospital and Health Sciences System, 1740 W. Taylor St., MC 931, Chicago IL 60612
| | - Jeet Minocha
- Department of Radiology and Division of Interventional Radiology, University of Illinois Hospital and Health Sciences System, 1740 W. Taylor St., MC 931, Chicago IL 60612
| | - Leigh C Casadaban
- University of Illinois College of Medicine, University of Illinois Hospital and Health Sciences System, 1740 W. Taylor St., MC 931, Chicago IL 60612
| | - M Grace Knuttinen
- Department of Radiology and Division of Interventional Radiology, University of Illinois Hospital and Health Sciences System, 1740 W. Taylor St., MC 931, Chicago IL 60612
| | - Charles E Ray
- Department of Radiology and Division of Interventional Radiology, University of Illinois Hospital and Health Sciences System, 1740 W. Taylor St., MC 931, Chicago IL 60612
| | - James T Bui
- Department of Radiology and Division of Interventional Radiology, University of Illinois Hospital and Health Sciences System, 1740 W. Taylor St., MC 931, Chicago IL 60612
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Kim E, Lee SW, Kim WH, Bae SH, Han NI, Oh JS, Chun HJ, Lee HG. Transjugular Intrahepatic Portosystemic Shunt Occlusion Complicated with Biliary Fistula Successfully Treated with a Stent Graft: A Case Report. IRANIAN JOURNAL OF RADIOLOGY : A QUARTERLY JOURNAL PUBLISHED BY THE IRANIAN RADIOLOGICAL SOCIETY 2016; 13:e28993. [PMID: 27127576 PMCID: PMC4841896 DOI: 10.5812/iranjradiol.28993] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/05/2015] [Revised: 08/24/2015] [Accepted: 10/07/2015] [Indexed: 12/16/2022]
Abstract
A 43-year-old man with liver cirrhosis received transjugular intrahepatic portosystemic shunt (TIPS) for the treatment of recurrent variceal bleeding and F3 esophageal varices. During routine follow up liver ultrasound examination, six months after the implantation, TIPS occlusion was suspected and TIPS revision was performed. During the revision, moderate to severe stenosis at the hepatic venous segment of the tract and a total occlusion at the parenchymal segment of TIPS tract near the portal vein with biliary-TIPS fistula were identified with a clear visualization of the common bile duct. After the successful TIPS revision with the placement of an additional stent-graft, the biliary fistula and common bile duct were no more delineated. We herein report a rare case with an obvious visualization of biliary-TIPS fistula associated with obstruction of TIPS shunt on the tractogram and recanalization with an additional stent-graft.
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Affiliation(s)
- Eunyoung Kim
- Department of Internal Medicine, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Sung Won Lee
- Department of Internal Medicine, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
- Corresponding author: Sung Won Lee, Division of Hepatology, Department of Internal Medicine, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea. Tel: +82-222582075, Fax: +82-255865589, E-mail:
| | - Woo Hyeon Kim
- Department of Internal Medicine, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Si Hyun Bae
- Department of Internal Medicine, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Nam Ik Han
- Department of Internal Medicine, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Jung Suk Oh
- Department of Radiology, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Ho Jong Chun
- Department of Radiology, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Hae Giu Lee
- Department of Radiology, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
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20
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Gaba RC. Transjugular Intrahepatic Portosystemic Shunt Creation With Embolization or Obliteration for Variceal Bleeding. Tech Vasc Interv Radiol 2016; 19:21-35. [DOI: 10.1053/j.tvir.2016.01.003] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
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Efficacy of covered and bare stent in TIPS for cirrhotic portal hypertension: A single-center randomized trial. Sci Rep 2016; 6:21011. [PMID: 26876503 PMCID: PMC4753460 DOI: 10.1038/srep21011] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2015] [Accepted: 01/14/2016] [Indexed: 12/21/2022] Open
Abstract
We conducted a single-center randomized trial to compare the efficacy of 8 mm Fluency covered stent and bare stent in transjugular intrahepatic portosystemic shunt (TIPS) for cirrhotic portal hypertension. From January 2006 to December 2010, the covered (experimental group) or bare stent (control group) was used in 131 and 127 patients, respectively. The recurrence rates of gastrointestinal bleeding (18.3% vs. 33.9%, P = 0.004) and refractory hydrothorax/ascites (6.9% vs. 16.5%, P = 0.019) in the experimental group were significantly lower than those in the control group. The cumulative restenosis rates in 1, 2, 3, 4, and 5-years in the experimental group (6.9%, 11.5%, 19.1%, 26.0%, and 35.9%, respectively) were significantly lower (P < 0.001) than those in the control group (27.6%, 37.0%, 49.6%, 59.8%, 74.8%, respectively). Importantly, the 4 and 5-year survival rates in the experimental group (83.2% and 76.3%, respectively) were significantly higher (P = 0.001 and 0.02) than those in the control group (71.7% and 62.2%, respectively). The rate of secondary interventional therapy in the experimental group was significantly lower than that in the control group (20.6% vs. 49.6%; P < 0.001). Therefore, Fluency covered stent has advantages over the bare stent in terms of reducing the restenosis, recurrence, and secondary interventional therapy, whereas improving the long-term survival for post-TIPS patients.
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Quality Improvement Guidelines for Transjugular Intrahepatic Portosystemic Shunts. J Vasc Interv Radiol 2015; 27:1-7. [PMID: 26614596 DOI: 10.1016/j.jvir.2015.09.018] [Citation(s) in RCA: 109] [Impact Index Per Article: 12.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2015] [Revised: 09/25/2015] [Accepted: 09/25/2015] [Indexed: 12/12/2022] Open
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Root Cause Analysis of Rebleeding Events following Transjugular Intrahepatic Portosystemic Shunt Creation for Variceal Hemorrhage. J Vasc Interv Radiol 2015; 26:1444-53. [DOI: 10.1016/j.jvir.2015.07.001] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2015] [Revised: 07/01/2015] [Accepted: 07/01/2015] [Indexed: 12/15/2022] Open
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Weber CN, Nadolski GJ, White SB, Clark TWI, Mondschein JI, Stavropoulos SW, Shlansky-Goldberg RD, Trerotola SO, Soulen MC. Long-Term Patency and Clinical Analysis of Expanded Polytetrafluoroethylene-Covered Transjugular Intrahepatic Portosystemic Shunt Stent Grafts. J Vasc Interv Radiol 2015; 26:1257-65; quiz 1265. [PMID: 25990133 DOI: 10.1016/j.jvir.2015.04.005] [Citation(s) in RCA: 43] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2014] [Revised: 04/05/2015] [Accepted: 04/06/2015] [Indexed: 02/07/2023] Open
Abstract
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.
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Affiliation(s)
- Charles N Weber
- Department of Radiology, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania..
| | - Gregory J Nadolski
- Department of Radiology, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Sarah B White
- Department of Radiology, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Timothy W I Clark
- Department of Radiology, Penn Presbyterian Medical Center, Philadelphia, Pennsylvania
| | - Jeffrey I Mondschein
- Department of Radiology, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - S William Stavropoulos
- Department of Radiology, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | | | - Scott O Trerotola
- Department of Radiology, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Michael C Soulen
- Department of Radiology, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
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Gaba R, Parvinian A, Casadaban L, Couture P, Zivin S, Lakhoo J, Minocha J, Ray C, Knuttinen M, Bui J. Survival benefit of TIPS versus serial paracentesis in patients with refractory ascites: a single institution case-control propensity score analysis. Clin Radiol 2015; 70:e51-7. [DOI: 10.1016/j.crad.2015.02.002] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2014] [Revised: 01/28/2015] [Accepted: 02/02/2015] [Indexed: 12/12/2022]
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Abstract
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.
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Affiliation(s)
- Leigh C Casadaban
- Division of Interventional Radiology, Department of Radiology, University of Illinois Hospital and Health Sciences System, Chicago, Illinois
| | - Ron C Gaba
- Division of Interventional Radiology, Department of Radiology, University of Illinois Hospital and Health Sciences System, Chicago, Illinois
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Saad WE. Combining Transjugular Intrahepatic Portosystemic Shunt with Balloon-Occluded Retrograde Transvenous Obliteration or Augmenting TIPS with Variceal Embolization for the Management of Gastric Varices: An Evolving Middle Ground? Semin Intervent Radiol 2014; 31:266-8. [PMID: 25177089 DOI: 10.1055/s-0034-1382796] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
The American College of Radiology Appropriateness Criteria Committee on interventional radiology has recently recognized balloon-occluded retrograde transvenous obliteration (BRTO) as a viable alternative to transjugular intrahepatic portosystemic shunt (TIPS) in certain anatomic and clinical scenarios for the management of gastric varices. However, it did not define these particular scenarios where BRTO would be a viable alternative. With the increased practice of BRTO in the United States, a debate ensues in the United States and Europe whether BRTO or TIPS should be the primary endovascular procedure of choice for gastric varices. From a conservative standpoint, BRTO is reserved for patients who are not TIPS candidates, while other institutions leave the decision to operator preference and "favorable anatomy" for either procedure. To add to the debate, there is a heightened interest in the improved efficacy of variceal embolization (metallic/bland embolization) concurrent with TIPS compared with TIPS without embolization, and a recent article describing a combination of TIPS and BRTO that demonstrated impressive results superior to BRTO or TIPS alone. This article discusses the most recent outcomes of TIPS and embolization of gastric varices as well as combining BRTO and TIPS.
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Affiliation(s)
- Wael E Saad
- Department of Radiology, University of Michigan Medical Center, Ann Arbor, Michigan
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Parvinian A, Gaba RC. Outcomes of TIPS for Treatment of Gastroesophageal Variceal Hemorrhage. Semin Intervent Radiol 2014; 31:252-7. [PMID: 25177086 DOI: 10.1055/s-0034-1382793] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Variceal hemorrhage is a life-threatening complication of cirrhosis that requires a multidisciplinary approach to management. The transjugular intrahepatic portosystemic shunt (TIPS) procedure is a minimally invasive image-guided intervention used for secondary prevention of bleeding and as salvage therapy in acute hemorrhage. This review focuses on the role of TIPS in the setting of variceal hemorrhage, with emphasis on the pathophysiology and conventional management of variceal hemorrhage, current and emerging indications for TIPS creation, TIPS clinical outcomes, and the role of adjuvant embolotherapy.
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Affiliation(s)
- Ahmad Parvinian
- Division of Interventional Radiology, Department of Radiology, University of Illinois Hospital and Health Sciences System, Chicago, Illinois
| | - Ron C Gaba
- Division of Interventional Radiology, Department of Radiology, University of Illinois Hospital and Health Sciences System, Chicago, Illinois
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Qi XS, Bai M, Yang ZP, Fan DM. Selection of a TIPS stent for management of portal hypertension in liver cirrhosis: An evidence-based review. World J Gastroenterol 2014; 20:6470-6480. [PMID: 24914368 PMCID: PMC4047332 DOI: 10.3748/wjg.v20.i21.6470] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/27/2013] [Revised: 01/18/2014] [Accepted: 02/20/2014] [Indexed: 02/06/2023] Open
Abstract
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.
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Covered transjugular intrahepatic portosystemic shunts: accuracy of ultrasound in detecting shunt malfunction. AJR Am J Roentgenol 2013; 200:904-8. [PMID: 23521468 DOI: 10.2214/ajr.12.8761] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
OBJECTIVE The purpose of this study was to determine the accuracy of ultrasound for detecting transjugular intrahepatic portosystemic shunt (TIPS) malfunction in covered stents in comparison with bare metal stents. MATERIALS AND METHODS During a 6-year period, 126 TIPS angiography examinations were performed in 78 patients who had undergone a recent TIPS ultrasound examination. Radiology reports and images were retrospectively reviewed, and the sensitivity and specificity of sonographic parameters for detecting TIPS dysfunction were calculated using TIPS angiography and portosystemic gradient as the reference standards. RESULTS Of 126 paired studies, 43 were in bare metal TIPS and 83 were in covered TIPS. Peak shunt velocity of covered and bare metal TIPS measured by ultrasound showed comparable sensitivities for detection of shunt dysfunction, using both depressed (< 90 cm/s) and elevated (> 200 cm/s) peak shunt velocity criteria. However, a depressed velocity was more specific in covered TIPS (0.939 vs 0.550, p < 0.001) whereas elevated velocity was more specific in bare TIPS (0.485 vs 0.800, p = 0.041). An interval change in peak TIPS velocity greater than 25% was significantly more sensitive in detection of dysfunction in covered TIPS (0.815 vs 0.400, p = 0.015) whereas detection based on main portal vein velocities (≤ 30 cm/s) was not statistically different in the two groups. CONCLUSION Our data suggest that the accuracy of ultrasound for detection of TIPS shunt malfunction is at least as high in covered stents as in bare metal stents. Diagnostic performance for several sonographic parameters varied significantly between bare and covered stents, suggesting the need for optimization of sonographic criteria for covered stents.
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Wang H, Zhang F, Meng Y, Zhang T, Willis P, Le T, Soriano S, Ray E, Valji K, Zhang G, Yang X. MRI-monitored intra-shunt local agent delivery of motexafin gadolinium: towards improving long-term patency of TIPS. PLoS One 2013; 8:e57419. [PMID: 23468986 PMCID: PMC3585394 DOI: 10.1371/journal.pone.0057419] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2012] [Accepted: 01/21/2013] [Indexed: 11/28/2022] Open
Abstract
Background Transjugular intrahepatic portosystemic shunt (TIPS) has become an important and effective interventional procedure in treatment of the complications related to portal hypertension. Although the primary patency of TIPS has been greatly improved due to the clinical application of cover stent-grafts, the long-term patency is still suboptimal. This study was to investigate the feasibility of using magnetic resonance imaging (MRI)-monitored intra-shunt local agent delivery of motexafin gadolinium (MGd) into shunt-vein walls of TIPS. This new technique aimed to ultimately inhibit shuntstenosis of TIPS. Methodology Human umbilical vein smooth muscle cells (SMCs) were incubated with various concentrations of MGd, and then examed by confocal microscopy and T1-map MRI. In addition, the proliferation of MGd-treated cells was evaluated. For in vivo validation, seventeen pigs underwent TIPS. Before placement of the stent, an MGd/trypan-blue mixture was locally delivered, via a microporous balloon, into eleven shunt-hepatic vein walls under dynamic MRI monitoring, while trypan-blue only was locally delivered into six shunt-hepatic vein walls as serve as controls. T1-weighted MRI of the shunt-vein walls was achieved before- and at different time points after agent injections. Contrast-to-noise ratio (CNR) of the shunt-vein wall at each time-point was measured. Shunts were harvested for subsequent histology confirmation. Principal Findings In vitro studies confirmed the capability of SMCs in uptaking MGds in a concentration-dependent fashion, and demonstrated the suppression of cell proliferation by MGds as well. Dynamic MRI displayed MGd/blue penetration into the shunt-vein walls, showing significantly higher CNR of shunt-vein walls on post-delivery images than on pre-delivery images (49.5±9.4 vs 11.2±1.6, P<0.01), which was confirmed by histology. Conclusion Results of this study indicate that MRI-monitored intra-shunt local MGd delivery is feasible and MGd functions as a potential therapeutic agent to inhibit the proliferation of SMCs, which may open alternative avenues to improve the long-term patency of TIPS.
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Affiliation(s)
- Han Wang
- Department of Radiology, Shanghai First People’s Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
- Image-Guided Bio-Molecular Interventions Section, Department of Radiology, Institute for Stem Cell and Regenerative Medicine, University of Washington School of Medicine, Seattle, Washington, United States of America
| | - Feng Zhang
- Image-Guided Bio-Molecular Interventions Section, Department of Radiology, Institute for Stem Cell and Regenerative Medicine, University of Washington School of Medicine, Seattle, Washington, United States of America
| | - Yanfeng Meng
- Image-Guided Bio-Molecular Interventions Section, Department of Radiology, Institute for Stem Cell and Regenerative Medicine, University of Washington School of Medicine, Seattle, Washington, United States of America
| | - Tong Zhang
- Image-Guided Bio-Molecular Interventions Section, Department of Radiology, Institute for Stem Cell and Regenerative Medicine, University of Washington School of Medicine, Seattle, Washington, United States of America
| | - Patrick Willis
- Image-Guided Bio-Molecular Interventions Section, Department of Radiology, Institute for Stem Cell and Regenerative Medicine, University of Washington School of Medicine, Seattle, Washington, United States of America
| | - Thomas Le
- Image-Guided Bio-Molecular Interventions Section, Department of Radiology, Institute for Stem Cell and Regenerative Medicine, University of Washington School of Medicine, Seattle, Washington, United States of America
| | - Stephanie Soriano
- Image-Guided Bio-Molecular Interventions Section, Department of Radiology, Institute for Stem Cell and Regenerative Medicine, University of Washington School of Medicine, Seattle, Washington, United States of America
| | - Erik Ray
- Image-Guided Bio-Molecular Interventions Section, Department of Radiology, Institute for Stem Cell and Regenerative Medicine, University of Washington School of Medicine, Seattle, Washington, United States of America
| | - Karim Valji
- Image-Guided Bio-Molecular Interventions Section, Department of Radiology, Institute for Stem Cell and Regenerative Medicine, University of Washington School of Medicine, Seattle, Washington, United States of America
| | - Guixiang Zhang
- Department of Radiology, Shanghai First People’s Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Xiaoming Yang
- Image-Guided Bio-Molecular Interventions Section, Department of Radiology, Institute for Stem Cell and Regenerative Medicine, University of Washington School of Medicine, Seattle, Washington, United States of America
- Department of Radiology, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou, China
- * E-mail:
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Gaba RC, Couture PM, Bui JT, Knuttinen MG, Walzer NM, Kallwitz ER, Berkes JL, Cotler SJ. Prognostic capability of different liver disease scoring systems for prediction of early mortality after transjugular intrahepatic portosystemic shunt creation. J Vasc Interv Radiol 2013; 24:411-20, 420.e1-4; quiz 421. [PMID: 23312989 DOI: 10.1016/j.jvir.2012.10.026] [Citation(s) in RCA: 55] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2012] [Revised: 10/31/2012] [Accepted: 10/31/2012] [Indexed: 12/13/2022] Open
Abstract
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.
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Affiliation(s)
- Ron C Gaba
- Department of Radiology, University of Illinois Medical Center at Chicago, 1740 West Taylor Street, MC 931, Chicago, IL 60612, USA.
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Heinzow HS, Lenz P, Köhler M, Reinecke F, Ullerich H, Domschke W, Domagk D, Meister T. Clinical outcome and predictors of survival after TIPS insertion in patients with liver cirrhosis. World J Gastroenterol 2012; 18:5211-8. [PMID: 23066315 PMCID: PMC3468853 DOI: 10.3748/wjg.v18.i37.5211] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/31/2012] [Revised: 03/20/2012] [Accepted: 04/09/2012] [Indexed: 02/06/2023] Open
Abstract
AIM: To determine the clinical outcome and predictors of survival after transjugular intrahepatic portosystemic stent shunt (TIPS) implantation in cirrhotic patients.
METHODS: Eighty-one patients with liver cirrhosis and consequential portal hypertension had TIPS implantation (bare metal) for either refractory ascites (RA) (n = 27) or variceal bleeding (VB) (n = 54). Endpoints for the study were: technical success, stent occlusion and stent stenosis, rebleeding, RA and mortality. Clinical records of patients were collected and analysed. Baseline characteristics [e.g., age, sex, CHILD score and the model for end-stage liver disease score (MELD score), underlying disease] were retrieved. The Kaplan-Meier method was employed to calculate survival from the time of TIPS implantation and comparisons were made by log rank test. A multivariate analysis of factors influencing survival was carried out using the Cox proportional hazards regression model. Results were expressed as medians and ranges. Comparisons between groups were performed by using the Mann-Whitney U-test and the χ2 test as appropriate.
RESULTS: No difference could be seen in terms of age, sex, underlying disease or degree of portal pressure gradient (PPG) reduction between the ascites and the bleeding group. The PPG significantly decreased from 23.4 ± 5.3 mmHg (VB) vs 22.1 ± 5.5 mmHg (RA) before TIPS to 11.8 ± 4.0 vs 11.7 ± 4.2 after TIPS implantation (P = 0.001 within each group). There was a tendency towards more patients with stage CHILD A in the bleeding group compared to the ascites group (24 vs 6, P = 0.052). The median survival for the ascites group was 29 mo compared to > 60 mo for the bleeding group (P = 0.009). The number of radiological controls for stent patency was 6.3 for bleeders and 3.8 for ascites patients (P = 0.029). Kaplan-Meier calculation indicated that stent occlusion at first control (P = 0.027), ascites prior to TIPS implantation (P = 0.009), CHILD stage (P = 0.013), MELD score (P = 0.001) and those patients not having undergone liver transplantation (P = 0.024) were significant predictors of survival. In the Cox regression model, stent occlusion (P = 0.022), RA (P = 0.043), CHILD stage (P = 0.015) and MELD score (P = 0.004) turned out to be independent prognostic factors of survival. The anticoagulation management (P = 0.097), the porto-systemic pressure gradient (P = 0.460) and rebleeding episodes (P = 0.765) had no significant effect on the overall survival.
CONCLUSION: RA, stent occlusion, initial CHILD stage and MELD score are independent predictors of survival in patients with TIPS, speaking for a close follow-up in these circumstances.
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TIPS for Treatment of Variceal Hemorrhage: Clinical Outcomes in 128 Patients at a Single Institution over a 12-Year Period. J Vasc Interv Radiol 2012; 23:227-35. [DOI: 10.1016/j.jvir.2011.10.015] [Citation(s) in RCA: 55] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2011] [Revised: 09/20/2011] [Accepted: 10/22/2011] [Indexed: 02/07/2023] Open
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Abstract
Ascites is a common complication of liver cirrhosis associated with a poor prognosis. The treatment of ascites requires dietary sodium restriction and the judicious use of distal and loop diuretics, sequential at an earlier stage of ascites, and a combination at a later stage of ascites. The diagnosis of refractory ascites requires the demonstration of diuretic non-responsiveness, despite dietary sodium restriction, or the presence of diuretic-related complications. Patients with refractory ascites require second-line treatments of repeat large-volume paracentesis (LVP) or the insertion of a transjugular intrahepatic portosystemic shunt (TIPS), and assessment for liver transplantation. Careful patient selection is paramount for TIPS to be successful as a treatment for ascites. Patients not suitable for TIPS insertion should receive LVP. The use of albumin as a volume expander is recommended for LVP of >5-6 L to prevent the development of circulatory dysfunction, although the clinical significance of post-paracentesis circulatory dysfunction is still debated. Significant mortality is still being observed in cirrhotic patients with ascites and relatively preserved liver and renal function, as indicated by a lower Model for End-Stage Liver Disease (MELD) score. It is proposed that patients with lower MELD scores and ascites should receive additional points in calculating their priority for liver transplantation. Potential new treatment options for ascites include the use of various vasoconstrictors, vasopressin V(2) receptor antagonists, or the insertion of a peritoneo-vesical shunt, all of which could possibly improve the management of ascites.
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Affiliation(s)
- Florence Wong
- Department of Medicine, Toronto General Hospital, University of Toronto, Toronto, Ontario, Canada.
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Yoshikawa T, Mitchell DG. MR evaluation of portal hypertensive collateral shunting vessels for predicting outcome after transjugular intrahepatic portosystemic shunt. Magn Reson Med Sci 2011; 10:21-7. [PMID: 21441724 DOI: 10.2463/mrms.10.21] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Abstract
PURPOSE We assessed whether magnetic resonance (MR) imaging evaluation of portosystemic collateral shunts can aid prediction of therapeutic effectiveness and complications after creation of a transjugular portosystemic shunt (TIPS), and technical difficulty during the TIPS procedure. MATERIALS AND METHODS We retrospectively reviewed 32 patients (27 men, 5 women; mean age, 56.4 years) who underwent TIPS creation following gadolinium-enhanced MR examination. We measured the diameters of pre-existing portosystemic collateral shunting vessels, added the measurements together to generate a shunting collateral score for each patient, and divided patients into 2 groups by score of 4 or greater or less than 4. We then compared therapeutic effectiveness, technical difficulty and complications of the TIPS procedure, and portal venous (PV) pressure, PV-inferior vena cava (IVC) pressure gradient, and PV diameter between the groups. RESULTS The patients with a pre-existing large portosystemic shunt showed insignificant trends toward higher technical difficulty of the shunt procedure and rate of shunt dysfunction. The 2 groups showed no significant difference in early mortality rate, onset or worsening rate of hepatic encephalopathy after TIPS creation, PV pressure, PV-IVC pressure gradient, or PV diameter. CONCLUSION Gadolinium-enhanced MR imaging may help in predicting technical difficulty and complications of TIPS.
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Affiliation(s)
- Takeshi Yoshikawa
- Division of Magnetic Resonance Imaging, Department of Radiology, Thomas Jefferson University, Philadelphia, Pennsylvania, USA.
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Comprehensive review of TIPS technical complications and how to avoid them. AJR Am J Roentgenol 2011; 196:675-85. [PMID: 21343513 DOI: 10.2214/ajr.10.4819] [Citation(s) in RCA: 80] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
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.
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Yang Z, Han G, Wu Q, Ye X, Jin Z, Yin Z, Qi X, Bai M, Wu K, Fan D. Patency and clinical outcomes of transjugular intrahepatic portosystemic shunt with polytetrafluoroethylene-covered stents versus bare stents: a meta-analysis. J Gastroenterol Hepatol 2010; 25:1718-25. [PMID: 21039832 DOI: 10.1111/j.1440-1746.2010.06400.x] [Citation(s) in RCA: 98] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
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.
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Affiliation(s)
- Zhiping Yang
- Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an, China
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Schenker MP, Majdalany BS, Funaki BS, Yucel EK, Baum RA, Burke CT, Foley WD, Koss SA, Lorenz JM, Mansour MA, Millward SF, Nemcek AA, Ray CE. ACR Appropriateness Criteria® on Upper Gastrointestinal Bleeding. J Am Coll Radiol 2010; 7:845-53. [DOI: 10.1016/j.jacr.2010.05.029] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2010] [Accepted: 05/25/2010] [Indexed: 12/14/2022]
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Huang Q, Wu X, Fan X, Cao J, Han J, Xu L, Li N. Comparison study of Doppler ultrasound surveillance of expanded polytetrafluoroethylene-covered stent versus bare stent in transjugular intrahepatic portosystemic shunt. JOURNAL OF CLINICAL ULTRASOUND : JCU 2010; 38:353-360. [PMID: 20533444 DOI: 10.1002/jcu.20709] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/29/2023]
Abstract
OBJECTIVE This prospectively randomized controlled study aimed to assess with Doppler ultrasound (US) the shunt function of expanded polytetrafluoroethylene (ePTFE)-covered transjugular intrahepatic portosystemic shunt (TIPS) stent versus bare stent and to evaluate the usefulness of routine TIPS follow-up of ePTFE-covered stents. METHODS Sixty consecutive patients were randomized for bare or covered transjugular TIPS stenting in our institution between April 2007 and April 2009. Data of follow-up Doppler US, angiography, and portosystemic pressure gradient measurements were collected and analyzed. RESULTS The follow-up period was 8.34 + or - 4.42 months in the bare-stent group and 6.16 + or - 3.89 months in the covered-stent group. Baseline clinical characteristics were similar in both groups. Two hundred three US studies were performed in 60 patients, with a mean of 3.4 per patient, and demonstrated abnormalities in 28 patients (21 bare stents, 7 ePTFE-covered stents), 19 of them (13 in bare-stent group, 6 in covered-stent group) showing no clinical evidence of recurrence. Ten of 13 patients in the bare-stent group underwent balloon angioplasty or additional stent placement, whereas only one of six patients in the covered-stent group needed reintervention for intimal hyperplasia. The average peak velocity in the midshunt of ePTFE-covered stent was 139 + or - 26 cm/s after TIPS creation and 125 + or - 20 cm/s during follow-up, which was significantly higher than the bare-stent group (p < 0.05). The main portal vein and hepatic artery showed higher flow velocities in the ePTFE-covered stent group than in the bare-stent group. ePTFE-covered stents maintained lower portosystemic pressure gradient than bare stents (9.5 + or - 2.9 versus 13.2 + or - 1.5 mmHg, p < 0.05). CONCLUSIONS ePTFE-covered stents resulted in higher patency rates and better hemodynamics than bare stents. Routine US surveillance may not be necessary in patients with ePTFE-covered TIPS stent.
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Affiliation(s)
- Qian Huang
- Research Institute of General Surgery, Jinling Hospital, Nanjing, China
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Rebleeding rates following TIPS for variceal hemorrhage in the Viatorr era: TIPS alone versus TIPS with variceal embolization. Hepatol Int 2010; 4:749-56. [PMID: 21286346 DOI: 10.1007/s12072-010-9206-2] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/30/2009] [Accepted: 07/13/2010] [Indexed: 12/23/2022]
Abstract
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.
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Pull-through technique for recanalization of occluded portosystemic shunts (TIPS): technical note and review of the literature. Cardiovasc Intervent Radiol 2010; 34:406-12. [PMID: 20440498 DOI: 10.1007/s00270-010-9874-2] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/15/2010] [Accepted: 04/15/2010] [Indexed: 02/07/2023]
Abstract
Transjugular intrahepatic portosystemic shunt (TIPS) dysfunction is an important problem after creation of shunts. Most commonly, TIPS recanalization is performed via the jugular vein approach. Occasionally it is difficult to cross the occlusion. We describe a hybrid technique for TIPS revision via a direct transhepatic access combined with a transjugular approach. In two cases, bare metal stents or polytetrafluoroethylene (PTFE)-covered stent grafts had been placed in TIPS tract previously, and they were completely obstructed. The tracts were inaccessible via the jugular vein route alone. In each case, after fluoroscopy or computed tomography-guided transhepatic puncture of the stented segment of the TIPS, a wire was threaded through the shunt and snared into the right jugular vein. The TIPS was revised by balloon angioplasty and additional in-stent placement of PTFE-covered stent grafts. The patients were discharged without any complications. Doppler sonography 6 weeks after TIPS revision confirmed patency in the TIPS tract and the disappearance of ascites. We conclude that this technique is feasible and useful, even in patients with previous PTFE-covered stent graft placement.
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Wu X, Ding W, Cao J, Han J, Huang Q, Li N, Li J. Favorable clinical outcome using a covered stent following transjugular intrahepatic portosystemic shunt in patients with portal hypertension. JOURNAL OF HEPATO-BILIARY-PANCREATIC SCIENCES 2010; 17:701-8. [PMID: 20703849 DOI: 10.1007/s00534-010-0270-8] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/04/2009] [Accepted: 02/01/2010] [Indexed: 12/13/2022]
Abstract
AIMS To compare retrospectively the clinical outcomes in patients treated with transjugular intrahepatic portosystemic shunt (TIPS) using the novel polytetrafluoroethylene-covered stents (Fluency) and bare stents. MATERIALS AND METHODS Sixty consecutive patients with portal hypertension treated with TIPS from April 2007 to April 2009 were included. TIPS creation was performed with Fluency stent grafts in 30 patients (group A) and with bare stents in 30 patients (group B). Liver function, TIPS patency and clinical outcomes were evaluated every 3 months after procedures. RESULTS During hospitalization, there were no cases of hepatic encephalopathy (HE) and recurrence of variceal bleedings. Acute shunt occlusion was found in one patient in each group. Follow-ups were performed in group A with average time of 6.16 +/- 3.89 months and in group B with 8.34 +/- 4.42 months. The rates of recurrent bleeding, shunt occlusion, HE and mortality were 0.03, 0.0, 16.7 and 0% in group A, and 20.0, 30.0, 20.0 and 13.3% in group B, respectively. There was no difference of HE between group A and group B. The decrease of portal pressure and portosystemic pressure gradient, and the increase of portal flow were 34.1 and 23.3%, 60.0 and 52.8%, and 189.5 and 111.1% in group A and B, respectively. There were no differences of liver function between group A and B. CONCLUSION The Fluency stent graft is relatively safe and effective in TIPS creation, with a high patency rate compared with bare stents.
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Affiliation(s)
- Xingjiang Wu
- Research Institute of General Surgery, Jinling Hospital, Nanjing University School of Medicine, 305 East Zhongshan Road, Nanjing, 210002, Jiangsu, China.
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