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Yang JX, Peng YM, Zeng HT, Lin XM, Xu ZL. Drainage of ascites in cirrhosis. World J Hepatol 2024; 16:1245-1257. [DOI: 10.4254/wjh.v16.i9.1245] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/03/2024] [Revised: 07/20/2024] [Accepted: 07/29/2024] [Indexed: 09/23/2024] Open
Abstract
For cirrhotic refractory ascites, diuretics combined with albumin and vasoactive drugs are the first-line choice for ascites management. However, their therapeutic effects are limited, and most refractory ascites do not respond to medication treatment, necessitating consideration of drainage or surgical interventions. Consequently, numerous drainage methods for cirrhotic ascites have emerged, including large-volume paracentesis, transjugular intrahepatic portosystemic shunt, peritoneovenous shunt, automated low-flow ascites pump, cell-free and concentrated ascites reinfusion therapy, and peritoneal catheter drainage. This review introduces the advantages and disadvantages of these methods in different aspects, as well as indications and contraindications for this disease.
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Affiliation(s)
- Jia-Xing Yang
- Department of Gastroenterology, The Second Clinical Medical College, Jinan University, Shenzhen 518000, Guangdong Province, China
| | - Yue-Ming Peng
- Department of Nursing, Shenzhen People’s Hospital, The Second Clinical Medical College, Jinan University, Shenzhen 518000, Guangdong Province, China
| | - Hao-Tian Zeng
- Department of Gastroenterology, The Second Clinical Medical College, Jinan University, Shenzhen 518000, Guangdong Province, China
| | - Xi-Min Lin
- Department of Gastroenterology, The Second Clinical Medical College, Jinan University, Shenzhen 518000, Guangdong Province, China
| | - Zheng-Lei Xu
- Department of Gastroenterology, Shenzhen People’s Hospital, The Second Clinical Medical College, Jinan University, Shenzhen 518000, Guangdong Province, China
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Wong F, Blendis L. Historical Aspects of Ascites and the Hepatorenal Syndrome. Clin Liver Dis (Hoboken) 2021; 18:14-27. [PMID: 34745581 PMCID: PMC8555459 DOI: 10.1002/cld.1090] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/22/2020] [Accepted: 01/03/2021] [Indexed: 02/04/2023] Open
Abstract
Content available: Author Interview and Audio Recording.
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Affiliation(s)
- Florence Wong
- Department of MedicineDivision of GastroenterologyUniversity of TorontoTorontoONCanada
| | - Laurence Blendis
- Department of MedicineDivision of GastroenterologyUniversity of TorontoTorontoONCanada
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Zamberg I, Maillard J, Assouline B, Tomala S, Keli-Barcelos G, Aldenkortt F, Mavrakanas T, Andres A, Schiffer E. Perioperative Evolution of Sodium Levels in Cirrhotic Patients Undergoing Liver Transplantation: An Observational Cohort and Literature Review. Hepat Med 2021; 13:71-82. [PMID: 34393524 PMCID: PMC8357403 DOI: 10.2147/hmer.s320127] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/13/2021] [Accepted: 07/08/2021] [Indexed: 11/23/2022] Open
Abstract
Background & Aims Hyponatremia is an important predictor of early death among cirrhotic patients in the orthotopic liver transplantation (OLT) waiting list. Evidence exists that prioritizing OLT waiting list according to the MELD score combined with plasma sodium concentration might prevent pre transplantation death. However, the evolution of plasma sodium concentrations during the perioperative period of OLT is not well known. We aimed to describe the evolution of perioperative sodium concentration during OLT and its relation to perioperative neurohormonal responses. Methods Twenty-seven consecutive cirrhotic patients who underwent OLT were prospectively included in the study over a period of 27 months. We studied the evolution of plasma sodium levels, the hemodynamics, the neurohormonal response and other biological markers during the perioperative period of OLT. Results Among study's population, four patients had hyponatremia before OLT, all with Child cirrhosis. In patients with hyponatremia, plasmatic sodium reached normal levels during surgery, and sodium levels remained within normal ranges 1 day, 7 days, as well as 6 months after surgery for all patients. Creatinine clearance was decreased significantly during the perioperative period, while creatinine and cystatin C levels increased significantly. Neutrophil gelatinase-associated lipocalin (NGAL) and vasopressin levels did not change significantly in this period. Plasma renin activity, concentrations of norepinephrine and brain natriuretic peptide varied significantly during the perioperative period. Conclusion In our study, plasmatic sodium concentrations among hyponatremic cirrhotic patients undergoing OLT seem to reach normal levels after OLT and remain stable six months after surgery providing more evidence for the importance of sodium levels in prioritization of liver transplant candidates. Further investigation of rapid correction and stabilization of sodium levels after OLT, as observed in our study, would be of interest in order to fully understand the mechanisms involved in cirrhosis-related hyponatremia, its prognostic value and clinical implications.
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Affiliation(s)
- Ido Zamberg
- Division of Anesthesiology, Department of Anesthesiology, Clinical Pharmacology, Intensive Care and Emergency Medicine, Geneva University Hospitals, Geneva, Switzerland.,Faculty of Medicine University of Geneva, Geneva, Switzerland
| | - Julien Maillard
- Division of Anesthesiology, Department of Anesthesiology, Clinical Pharmacology, Intensive Care and Emergency Medicine, Geneva University Hospitals, Geneva, Switzerland
| | - Benjamin Assouline
- Division of Anesthesiology, Department of Anesthesiology, Clinical Pharmacology, Intensive Care and Emergency Medicine, Geneva University Hospitals, Geneva, Switzerland
| | - Simon Tomala
- Division of Anesthesiology, Department of Anesthesiology, Clinical Pharmacology, Intensive Care and Emergency Medicine, Geneva University Hospitals, Geneva, Switzerland
| | - Gleicy Keli-Barcelos
- Division of Anesthesiology, Department of Anesthesiology, Clinical Pharmacology, Intensive Care and Emergency Medicine, Geneva University Hospitals, Geneva, Switzerland
| | - Florence Aldenkortt
- Division of Anesthesiology, Department of Anesthesiology, Clinical Pharmacology, Intensive Care and Emergency Medicine, Geneva University Hospitals, Geneva, Switzerland
| | - Thomas Mavrakanas
- Faculty of Medicine University of Geneva, Geneva, Switzerland.,Department of Medicine, McGill University Health Centre, Montreal, QC, Canada
| | - Axel Andres
- Faculty of Medicine University of Geneva, Geneva, Switzerland.,Division of Transplantation, Department of Surgery, University Hospitals of Geneva, Geneva, Switzerland
| | - Eduardo Schiffer
- Division of Anesthesiology, Department of Anesthesiology, Clinical Pharmacology, Intensive Care and Emergency Medicine, Geneva University Hospitals, Geneva, Switzerland.,Faculty of Medicine University of Geneva, Geneva, Switzerland
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Reilly CR, Babushok DV, Martin K, Spivak JL, Streiff M, Bahirwani R, Mondschein J, Stein B, Moliterno A, Hexner EO. Multicenter analysis of the use of transjugular intrahepatic portosystemic shunt for management of MPN-associated portal hypertension. Am J Hematol 2017; 92:909-914. [PMID: 28543980 DOI: 10.1002/ajh.24798] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2017] [Accepted: 05/18/2017] [Indexed: 12/21/2022]
Abstract
BCR-ABL1-negative myeloproliferative neoplasms (MPNs) are clonal stem cell disorders defined by proliferation of one or more myeloid lineages, and carry an increased risk of vascular events and progression to myelofibrosis and leukemia. Portal hypertension (pHTN) occurs in 7-18% of MPN patients via both thrombotic and nonthrombotic mechanisms and portends a poor prognosis. Transjugular intrahepatic portosystemic shunt (TIPS) has been used in the management of MPN-associated pHTN; however, data on long-term outcomes of TIPS in this setting is limited and the optimal management of medically refractory MPN-associated pHTN is not known. In order to assess the efficacy and long-term outcomes of TIPS in MPN-associated pHTN, we performed a retrospective analysis of 29 MPN patients who underwent TIPS at three academic medical centers between 1997 and 2016. The majority of patients experienced complete clinical resolution of pHTN and its clinical sequelae following TIPS. One, two, three, and four-year overall survival post-TIPS was 96.4%, 92.3%, 84.6%, and 71.4%, respectively. However, despite therapeutic anticoagulation, in-stent thrombosis occurred in 31.0% of patients after TIPS, necessitating additional interventions. In conclusion, TIPS can be an effective intervention for MPN-associated pHTN regardless of etiology. However, TIPS thrombosis is a frequent complication in the MPN population and indefinite anticoagulation post-TIPS should be considered.
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Affiliation(s)
- Christopher R. Reilly
- Department of Medicine; Hospital of the University of Pennsylvania; Philadelphia Pennsylvania
| | - Daria V. Babushok
- Department of Medicine; Hospital of the University of Pennsylvania; Philadelphia Pennsylvania
- Abramson Cancer Center and the Division of Hematology & Oncology; Philadelphia Pennsylvania
| | - Karlyn Martin
- Division of Hematology and Oncology; Northwestern University; Chicago Illinois
| | - Jerry L. Spivak
- Department of Medicine; Johns Hopkins Hospital; Baltimore Maryland
| | - Michael Streiff
- Department of Medicine; Johns Hopkins Hospital; Baltimore Maryland
| | - Ranjeeta Bahirwani
- Liver Consultants of Texas, Baylor University Medical Center; Dallas Texas
| | - Jeffrey Mondschein
- Department of Interventional Radiology; Hospital of the University of Pennsylvania; Philadelphia Pennsylvania
| | - Brady Stein
- Division of Hematology and Oncology; Northwestern University; Chicago Illinois
| | - Alison Moliterno
- Department of Medicine; Johns Hopkins Hospital; Baltimore Maryland
| | - Elizabeth O. Hexner
- Department of Medicine; Hospital of the University of Pennsylvania; Philadelphia Pennsylvania
- Abramson Cancer Center and the Division of Hematology & Oncology; Philadelphia Pennsylvania
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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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Hayek G, Ronot M, Plessier A, Sibert A, Abdel-Rehim M, Zappa M, Rautou PE, Valla D, Vilgrain V. Long-term Outcome and Analysis of Dysfunction of Transjugular Intrahepatic Portosystemic Shunt Placement in Chronic Primary Budd-Chiari Syndrome. Radiology 2016; 283:280-292. [PMID: 27797679 DOI: 10.1148/radiol.2016152641] [Citation(s) in RCA: 46] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Purpose To evaluate the long-term safety, technical success, and efficacy of transjugular intrahepatic portosystemic shunt (TIPS) in a series of patients with Budd-Chiari syndrome (BCS), and to determine the predictors of shunt dysfunction. Materials and Methods From 2004 to 2013, all patients with primary BCS referred for TIPS placement were included in the study. The primary and secondary technical success rates and the number and types of early (ie, before day 7) complications were noted. Factors associated with dysfunction were analyzed with uni- and multivariate analyses. Survival was analyzed with Kaplan-Meier curves. Results Fifty-four patients (34 women [63%]; mean age, 36 years ± 12 [standard deviation]) were included. Twenty-eight patients (52%) had myeloproliferative neoplasms. The mean Model for End-Stage Liver Disease score was 14.5 ± 4. The most frequent indication for TIPS was refractory ascites (50 of 54; 93%). Primary and secondary technical success rates were 93% and 98%, respectively. Early complications occurred in 17 patients (32%). After a mean follow-up of 56 months ± 41 (interquartile range, 22-92), 22 patients (42%) experienced at least one episode of TIPS dysfunction (median delay between administration of TIPS and first episode of dysfunction, 10.8 months). Cumulative 1-, 2-, 3-, 5-, and 10-year primary patency rates were 64%, 59%, 54%, 45%, and 45%, respectively. Dysfunction was associated with a myeloproliferative neoplasm (hazard ratio, 8.18; 95% confidence interval: 1.45, 46.18; P = .017), more than two initial stents (hazard ratio, 3.90; 95% confidence interval:1.16, 13.10; P = .027), and the occurrence of early complications (hazard ratio, 11.34; 95% confidence interval: 1.82, 70.69; P = .009). The 10-year survival rate was 76%. Conclusion TIPS placement in patients with chronic primary BCS was associated with a nonnegligible rate of early complications and required endovascular revision or revisions in 42% of patients. Nevertheless, secondary patency was close to 100%, and long-term survival was good. © RSNA, 2016 Online supplemental material is available for this article.
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Affiliation(s)
- Georges Hayek
- From the Departments of Radiology (G.H., M.R., A.S., M.A.R., M.Z., V.V.) and Hepatology (A.P., P.E.R., D.V.), APHP, University Hospitals Paris Nord Val de Seine, Beaujon Hospital, 100 Boulevard du Général Leclerc, 92118 Clichy, Hauts-de-Seine, France; University Paris Diderot, Sorbonne Paris Cité, Paris, France (M.R., P.E.R., D.V., V.V.); and INSERM U1149, Centre de Recherche Biomédicale Bichat-Beaujon, CRB3, Paris, France (M.R., V.V.)
| | - Maxime Ronot
- From the Departments of Radiology (G.H., M.R., A.S., M.A.R., M.Z., V.V.) and Hepatology (A.P., P.E.R., D.V.), APHP, University Hospitals Paris Nord Val de Seine, Beaujon Hospital, 100 Boulevard du Général Leclerc, 92118 Clichy, Hauts-de-Seine, France; University Paris Diderot, Sorbonne Paris Cité, Paris, France (M.R., P.E.R., D.V., V.V.); and INSERM U1149, Centre de Recherche Biomédicale Bichat-Beaujon, CRB3, Paris, France (M.R., V.V.)
| | - Aurélie Plessier
- From the Departments of Radiology (G.H., M.R., A.S., M.A.R., M.Z., V.V.) and Hepatology (A.P., P.E.R., D.V.), APHP, University Hospitals Paris Nord Val de Seine, Beaujon Hospital, 100 Boulevard du Général Leclerc, 92118 Clichy, Hauts-de-Seine, France; University Paris Diderot, Sorbonne Paris Cité, Paris, France (M.R., P.E.R., D.V., V.V.); and INSERM U1149, Centre de Recherche Biomédicale Bichat-Beaujon, CRB3, Paris, France (M.R., V.V.)
| | - Annie Sibert
- From the Departments of Radiology (G.H., M.R., A.S., M.A.R., M.Z., V.V.) and Hepatology (A.P., P.E.R., D.V.), APHP, University Hospitals Paris Nord Val de Seine, Beaujon Hospital, 100 Boulevard du Général Leclerc, 92118 Clichy, Hauts-de-Seine, France; University Paris Diderot, Sorbonne Paris Cité, Paris, France (M.R., P.E.R., D.V., V.V.); and INSERM U1149, Centre de Recherche Biomédicale Bichat-Beaujon, CRB3, Paris, France (M.R., V.V.)
| | - Mohamed Abdel-Rehim
- From the Departments of Radiology (G.H., M.R., A.S., M.A.R., M.Z., V.V.) and Hepatology (A.P., P.E.R., D.V.), APHP, University Hospitals Paris Nord Val de Seine, Beaujon Hospital, 100 Boulevard du Général Leclerc, 92118 Clichy, Hauts-de-Seine, France; University Paris Diderot, Sorbonne Paris Cité, Paris, France (M.R., P.E.R., D.V., V.V.); and INSERM U1149, Centre de Recherche Biomédicale Bichat-Beaujon, CRB3, Paris, France (M.R., V.V.)
| | - Magaly Zappa
- From the Departments of Radiology (G.H., M.R., A.S., M.A.R., M.Z., V.V.) and Hepatology (A.P., P.E.R., D.V.), APHP, University Hospitals Paris Nord Val de Seine, Beaujon Hospital, 100 Boulevard du Général Leclerc, 92118 Clichy, Hauts-de-Seine, France; University Paris Diderot, Sorbonne Paris Cité, Paris, France (M.R., P.E.R., D.V., V.V.); and INSERM U1149, Centre de Recherche Biomédicale Bichat-Beaujon, CRB3, Paris, France (M.R., V.V.)
| | - Pierre-Emmanuel Rautou
- From the Departments of Radiology (G.H., M.R., A.S., M.A.R., M.Z., V.V.) and Hepatology (A.P., P.E.R., D.V.), APHP, University Hospitals Paris Nord Val de Seine, Beaujon Hospital, 100 Boulevard du Général Leclerc, 92118 Clichy, Hauts-de-Seine, France; University Paris Diderot, Sorbonne Paris Cité, Paris, France (M.R., P.E.R., D.V., V.V.); and INSERM U1149, Centre de Recherche Biomédicale Bichat-Beaujon, CRB3, Paris, France (M.R., V.V.)
| | - Dominique Valla
- From the Departments of Radiology (G.H., M.R., A.S., M.A.R., M.Z., V.V.) and Hepatology (A.P., P.E.R., D.V.), APHP, University Hospitals Paris Nord Val de Seine, Beaujon Hospital, 100 Boulevard du Général Leclerc, 92118 Clichy, Hauts-de-Seine, France; University Paris Diderot, Sorbonne Paris Cité, Paris, France (M.R., P.E.R., D.V., V.V.); and INSERM U1149, Centre de Recherche Biomédicale Bichat-Beaujon, CRB3, Paris, France (M.R., V.V.)
| | - Valérie Vilgrain
- From the Departments of Radiology (G.H., M.R., A.S., M.A.R., M.Z., V.V.) and Hepatology (A.P., P.E.R., D.V.), APHP, University Hospitals Paris Nord Val de Seine, Beaujon Hospital, 100 Boulevard du Général Leclerc, 92118 Clichy, Hauts-de-Seine, France; University Paris Diderot, Sorbonne Paris Cité, Paris, France (M.R., P.E.R., D.V., V.V.); and INSERM U1149, Centre de Recherche Biomédicale Bichat-Beaujon, CRB3, Paris, France (M.R., V.V.)
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Bannas P, Roldán-Alzate A, Johnson KM, Woods MA, Ozkan O, Motosugi U, Wieben O, Reeder SB, Kramer H. Longitudinal Monitoring of Hepatic Blood Flow before and after TIPS by Using 4D-Flow MR Imaging. Radiology 2016; 281:574-582. [PMID: 27171019 DOI: 10.1148/radiol.2016152247] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Purpose To demonstrate the feasibility of four-dimensional (4D)-flow magnetic resonance (MR) imaging for noninvasive longitudinal hemodynamic monitoring of hepatic blood flow before and after transjugular intrahepatic portosystemic shunt (TIPS) placement. Materials and Methods The institutional review board approved this prospective Health Insurance Portability and Accountability Act compliant study with written informed consent. Four-dimensional-flow MR imaging was performed in seven patients with portal hypertension and refractory ascites before and 2 and 12 weeks after TIPS placement by using a time-resolved three-dimensional radial phase-contrast acquisition. Flow and peak velocity measurements were obtained in the superior mesenteric vein (SMV), splenic vein (SV), portal vein (PV), and the TIPS. Flow volumes and peak velocities in each vessel, as well as the ratio of in-stent to PV flow, were compared before and after TIPS placement by using analysis of variance. Results Flow volumes significantly increased in the SMV (0.24 L/min; 95% confidence interval [CI]: 0.07, 0.41), SV (0.31 L/min; 95% CI: 0.07, 0.54), and PV (0.88 L/min; 95% CI: 0.06, 1.70) after TIPS placement (all P < .05), with no significant difference between the first and second post-TIPS placement acquisitions (all P > .11). Ascites resolved in six of seven patients. In those with resolved ascites, the TIPS-to-PV flow ratio was 0.8 ± 0.2 and 0.9 ± 0.2 at the two post-TIPS time points, respectively, while the observed ratios were 4.6 and 4.3 in the patient with refractory ascites at the two post-TIPS time points, respectively. In this patient, 4D-flow MR imaging demonstrated arterio-portal-venous shunting, with draining into the TIPS. Conclusion Four-dimensional-flow MR imaging is feasible for noninvasive longitudinal hemodynamic monitoring of hepatic blood flow before and after TIPS placement. © RSNA, 2016 Online supplemental material is available for this article.
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Affiliation(s)
- Peter Bannas
- From the Departments of Radiology (P.B., A.R.A., M.A.W., O.O., U.M., O.W., S.B.R., H.K.), Medical Physics (K.M.J., O.W., S.B.R.), Biomedical Engineering (S.B.R.), Medicine (S.B.R.), Emergency Medicine (S.B.R.), and Mechanical Engineering (A.R.A.) University of Wisconsin-Madison, Madison, Wis
| | - Alejandro Roldán-Alzate
- From the Departments of Radiology (P.B., A.R.A., M.A.W., O.O., U.M., O.W., S.B.R., H.K.), Medical Physics (K.M.J., O.W., S.B.R.), Biomedical Engineering (S.B.R.), Medicine (S.B.R.), Emergency Medicine (S.B.R.), and Mechanical Engineering (A.R.A.) University of Wisconsin-Madison, Madison, Wis
| | - Kevin M Johnson
- From the Departments of Radiology (P.B., A.R.A., M.A.W., O.O., U.M., O.W., S.B.R., H.K.), Medical Physics (K.M.J., O.W., S.B.R.), Biomedical Engineering (S.B.R.), Medicine (S.B.R.), Emergency Medicine (S.B.R.), and Mechanical Engineering (A.R.A.) University of Wisconsin-Madison, Madison, Wis
| | - Michael A Woods
- From the Departments of Radiology (P.B., A.R.A., M.A.W., O.O., U.M., O.W., S.B.R., H.K.), Medical Physics (K.M.J., O.W., S.B.R.), Biomedical Engineering (S.B.R.), Medicine (S.B.R.), Emergency Medicine (S.B.R.), and Mechanical Engineering (A.R.A.) University of Wisconsin-Madison, Madison, Wis
| | - Orhan Ozkan
- From the Departments of Radiology (P.B., A.R.A., M.A.W., O.O., U.M., O.W., S.B.R., H.K.), Medical Physics (K.M.J., O.W., S.B.R.), Biomedical Engineering (S.B.R.), Medicine (S.B.R.), Emergency Medicine (S.B.R.), and Mechanical Engineering (A.R.A.) University of Wisconsin-Madison, Madison, Wis
| | - Utaroh Motosugi
- From the Departments of Radiology (P.B., A.R.A., M.A.W., O.O., U.M., O.W., S.B.R., H.K.), Medical Physics (K.M.J., O.W., S.B.R.), Biomedical Engineering (S.B.R.), Medicine (S.B.R.), Emergency Medicine (S.B.R.), and Mechanical Engineering (A.R.A.) University of Wisconsin-Madison, Madison, Wis
| | - Oliver Wieben
- From the Departments of Radiology (P.B., A.R.A., M.A.W., O.O., U.M., O.W., S.B.R., H.K.), Medical Physics (K.M.J., O.W., S.B.R.), Biomedical Engineering (S.B.R.), Medicine (S.B.R.), Emergency Medicine (S.B.R.), and Mechanical Engineering (A.R.A.) University of Wisconsin-Madison, Madison, Wis
| | - Scott B Reeder
- From the Departments of Radiology (P.B., A.R.A., M.A.W., O.O., U.M., O.W., S.B.R., H.K.), Medical Physics (K.M.J., O.W., S.B.R.), Biomedical Engineering (S.B.R.), Medicine (S.B.R.), Emergency Medicine (S.B.R.), and Mechanical Engineering (A.R.A.) University of Wisconsin-Madison, Madison, Wis
| | - Harald Kramer
- From the Departments of Radiology (P.B., A.R.A., M.A.W., O.O., U.M., O.W., S.B.R., H.K.), Medical Physics (K.M.J., O.W., S.B.R.), Biomedical Engineering (S.B.R.), Medicine (S.B.R.), Emergency Medicine (S.B.R.), and Mechanical Engineering (A.R.A.) University of Wisconsin-Madison, Madison, Wis
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Bilbao Jaureguízar J. Twenty-five years after the first TIPS in Spain. RADIOLOGIA 2016. [DOI: 10.1016/j.rxeng.2016.05.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
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9
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Bilbao Jaureguízar JI. Twenty-five years after the first TIPS in Spain. RADIOLOGIA 2016; 58:178-88. [PMID: 26908250 DOI: 10.1016/j.rx.2016.01.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2015] [Revised: 01/04/2016] [Accepted: 01/07/2016] [Indexed: 02/07/2023]
Abstract
The incorporation, 25 years ago, of transjugular intrahepatic portosystemic shunting, better known by the acronym TIPS, represents an indisputable improvement in the treatment and management of patients with symptoms due to portal hypertension. This article discusses the origins of the technique and the technical innovations that have been progressively added through the years. The implantation of coated stents, which protect the stent from processes in the parenchymal track that can lead to stenosis, have helped ensure long-term patency, thus reducing the need for reintervention. Solid evidence from valuable publications has situated TIPS at the forefront of the treatment options in a wide variety of clinical situations associated with portal hypertension.
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Téllez Villajos L, Martínez González J, Moreira Vicente V, Albillos Martínez A. Hipertensión pulmonar y cirrosis hepática. Rev Clin Esp 2015; 215:324-30. [DOI: 10.1016/j.rce.2015.02.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2014] [Revised: 02/14/2015] [Accepted: 02/23/2015] [Indexed: 02/07/2023]
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Téllez Villajos L, Martínez González J, Moreira Vicente V, Albillos Martínez A. Pulmonary hypertension and hepatic cirrhosis. Rev Clin Esp 2015. [DOI: 10.1016/j.rceng.2015.02.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
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Kochhar G, Navaneethan U, Parungao JM, Hartman J, Gupta R, Lopez R, McCullough AJ, Kapoor B, Shen B. Impact of transjugular intrahepatic portosystemic shunt on post-colectomy complications in patients with ulcerative colitis and primary sclerosing cholangitis. Gastroenterol Rep (Oxf) 2014; 3:228-33. [PMID: 25519485 PMCID: PMC4527263 DOI: 10.1093/gastro/gou085] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/11/2014] [Accepted: 10/26/2014] [Indexed: 02/07/2023] Open
Abstract
Objective: Primary sclerosing cholangitis (PSC) occurs in approximately 5% of patients with ulcerative colitis (UC). The risk of colon cancer is higher in patients undergoing colectomy, who have simultaneous PSC & UC. Our aim was to study the impact, in terms of post-colectomy survival and complications, of transjugular intrahepatic portosystemic shunt (TIPS) before colectomy in these patients. Methods: In this retrospective, case-control study, information was obtained on demographics, disease characteristics, TIPS characteristics, and post-colectomy complications. Nine patients with PSC and UC who underwent TIPS prior to colectomy (the Study group) and 37 patients with PSC and UC who underwent only colectomy without TIPS (the Control group) were included. Either an analysis of variance or the non-parametric Kruskal-Wallis test were used for continuous variables and Fisher’s Exact test or Pearson’s chi-squared test was used for categorical factors. Results: There was no difference in the mean age between the two groups; however patients in the Study group had lower platelet count (P = 0.005) as well as higher Model for End- Stage Liver disease (MELD) scores (P < 0.001). Also, patients in the Study group had increased PSC severity as determined by Mayo PSC Risk Scores (1.50 vs. 0.20) (P = 0.001). Total bilirubin levels were higher in the Study group (2.3 vs. 0.8 mg/dL) (P = 0.011). Comparing the post-operative complication rates without adjusting for disease severity, the Study group had more wound infections (P = 0.034), more wound dehiscence (P = 0.022), and a higher re-admission rate within 30 days (P = 0.032); however, the post-operative mortality was not significantly different. Conclusion: Patients with PSC and UC who underwent TIPS prior to colectomy had higher rates of complications; however, this was probably due to the greater severity of cirrhosis and PSC in this population.
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Affiliation(s)
- Gursimran Kochhar
- Department of Gastroenterology and Hepatology, The Cleveland Clinic, Cleveland, OH, USA
| | | | - Jose Mari Parungao
- Department of Gastroenterology and Hepatology, The Cleveland Clinic, Cleveland, OH, USA
| | - Jason Hartman
- Case Western Reserve University School of Medicine, Cleveland, OH, USA
| | - Ranjan Gupta
- Department of Gastroenterology and Hepatology, The Cleveland Clinic, Cleveland, OH, USA
| | - Rocio Lopez
- Department of Gastroenterology and Hepatology, The Cleveland Clinic, Cleveland, OH, USA
| | - Arthur J McCullough
- Department of Gastroenterology and Hepatology, The Cleveland Clinic, Cleveland, OH, USA
| | - Baljiendra Kapoor
- Department of Vascular and Interventional Radiology, The Cleveland Clinic, Cleveland, OH, USA
| | - Bo Shen
- Department of Gastroenterology and Hepatology, The Cleveland Clinic, Cleveland, OH, USA
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Copelan A, Kapoor B, Sands M. Transjugular intrahepatic portosystemic shunt: indications, contraindications, and patient work-up. Semin Intervent Radiol 2014; 31:235-42. [PMID: 25177083 DOI: 10.1055/s-0034-1382790] [Citation(s) in RCA: 70] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
The transjugular intrahepatic portosystemic shunt (TIPS) procedure is effective in achieving portal decompression and in managing some of the major complications of portal hypertension. While many clinicians are familiar with the two most common indications for TIPS placement, secondary prophylaxis of esophageal variceal hemorrhage and treatment of refractory ascites, evidence for its usefulness is growing in other entities, where it has been less extensively studied but demonstrates promising results. Newer indications include early utilization in the treatment of esophageal variceal hemorrhage, Budd-Chiari syndrome, ectopic varices, and portal vein thrombosis. The referring clinician and interventionist must remain cognizant of the contraindications to the procedure to avoid complications and potential harm to the patient. This review is designed to provide an in-depth analysis of the most common as well as less typical indications for TIPS placement, and to discuss the contraindications and appropriate patient evaluation for this procedure.
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Affiliation(s)
- Alexander Copelan
- Diagnostic Radiology Department, William Beaumont Hospital, Royal Oak, Michigan
| | | | - Mark Sands
- Imaging Institute, Cleveland Clinic, Cleveland, Ohio
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Prophylactic use of transjugular intrahepatic portosystemic shunt aids in the treatment of refractory ascites: metaregression and trial sequential meta-analysis. J Clin Gastroenterol 2014; 48:290-9. [PMID: 24030734 DOI: 10.1097/mcg.0b013e3182a115e9] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
GOALS The aim of this study was to explore whether prophylactic use of transjugular intrahepatic portosystemic shunt (TIPS) could aid in the treatment of refractory ascites on the basis of current randomized controlled trials. BACKGROUND TIPS is more effective for refractory ascites versus large-volume paracentesis. At present, however, the survival advantage is not clear within populations of undifferentiated patients. STUDY Correlative studies were searched through online journal databases, and a manual search was done from 1974 to 2012. Six trials involving 390 patients were included. RESULTS TIPS could ameliorate refractory ascites on the basis of short-term analysis [odds ratio (OR) 8.66; 95% confidence interval (CI), 5.27-14.24] and long-term analysis (OR 6.07; 95% CI, 3.60-10.22). Hepatic encephalopathy (HE) appeared more common in the TIPS arm (OR 2.95; 95% CI, 1.87-4.66). Mortality in the 2 groups did not show any difference (OR 0.82; 95% CI, 0.46-1.50). Trial sequential analysis confirmed the effect of TIPS upon ascites control and upon the risk of HE recurrence, whereas insufficient trials were available to distinguish between the arms on mortality. Metaregression analysis showed that the level of urine sodium, serum bilirubin, and portal pressure gradient reduction value could be used as survival predictors. Subgroup analysis showed an elevated survival effect in TIPS (OR 0.45; 95% CI, 0.24-0.81), and patients survived longer with recurrent ascites (OR 0.40; 95% CI, 0.19-0.83). CONCLUSIONS TIPS was confirmed to improve ascites control in both the short term and the long term. Although HE frequently appeared in the TIPS group, patients with better hepatic and renal function survived longer when they were treated with TIPS. Serum bilirubin and urine sodium could be used as pre-TIPS predictors for patient survival. Portal pressure gradient reduction values could be used as post-TIPS predictors of survival.
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Bai M, Qi X, Yang Z, Yin Z, Nie Y, Yuan S, Wu K, Han G, Fan D. Predictors of hepatic encephalopathy after transjugular intrahepatic portosystemic shunt in cirrhotic patients: a systematic review. J Gastroenterol Hepatol 2011; 26:943-51. [PMID: 21251067 DOI: 10.1111/j.1440-1746.2011.06663.x] [Citation(s) in RCA: 118] [Impact Index Per Article: 9.1] [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 Hepatic encephalopathy (HE) is a very common complication in patients after transjugular intrahepatic portosystemic shunt (TIPS). The purpose of this study is to determine the most robust predictors of post-TIPS HE by performing a systematic review of studies that identified the risk factors for patients with post-TIPS HE. METHODS A PUBMED search was performed using the predefined rule. Studies were selected for analysis based on certain inclusion and exclusion criteria. Data were extracted from each study on the basis of predefined items. Meta-analyses were executed to verify the relevant risk factors. RESULTS Thirty studies were included in this systematic review. In the 30 studies, the numbers of variables evaluated by univariate and multivariate analyses were 60 and 32, respectively. The numbers of variables found to be significant in univariate and multivariate analyses were 18 and 14, respectively. According to the accumulated number of studies that identified these variables as significant, the three most vigorous predictors of post-TIPS HE were age, prior HE and Child-Pugh class/score in both univariate analysis and multivariate analysis. Our meta-analysis showed that patients with HE before TIPS or higher Child-Pugh class/score had increased risk of post-TIPS HE. CONCLUSIONS Increased age, prior HE and higher Child-Pugh class/score were the most robust predictors for post-TIPS HE.
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Affiliation(s)
- Ming Bai
- Department of Digestive Interventional Radiology, Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an, China
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De Gottardi A, Thévenot T, Spahr L, Morard I, Bresson-Hadni S, Torres F, Giostra E, Hadengue A. Risk of complications after abdominal paracentesis in cirrhotic patients: a prospective study. Clin Gastroenterol Hepatol 2009; 7:906-9. [PMID: 19447197 DOI: 10.1016/j.cgh.2009.05.004] [Citation(s) in RCA: 154] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/19/2009] [Revised: 04/27/2009] [Accepted: 05/04/2009] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS Complications and technical problems of paracentesis in cirrhotic patients are infrequent. However, the severity and the incidence of these events and their risk factors have not been assessed prospectively. METHODS Cirrhotic patients (n = 171) undergoing paracentesis were included. Of the 515 paracenteses, 8.8% were diagnostic, and 91.2% were therapeutic. Technical features, demographic data, and adverse events during a period of 72 hours after the procedure were examined. RESULTS Major complications occurred in 1.6% of procedures and included 5 bleedings and 3 infections, resulting in death in 2 cases. Major complications were associated with therapeutic but not diagnostic procedures and tended to be more prevalent in patients with low platelet count (<50 10(9)/L), Child-Pugh stage C, and in alcoholic cirrhosis patients. Technical problems occurred in 5.6%. The most frequent complication was a leak of ascites at the puncture site (5.0%), and in 89.5% there were no complications. CONCLUSIONS The safety of paracentesis in cirrhotic patients might be decreased if risk factors, which depend on the characteristics of the patient and of the procedure itself, are present.
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Affiliation(s)
- Andrea De Gottardi
- Division of Gastroenterology and Hepatology, University Hospital of Geneva, Geneva, Switzerland.
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Garcia-Tsao G, Lim JK. Management and treatment of patients with cirrhosis and portal hypertension: recommendations from the Department of Veterans Affairs Hepatitis C Resource Center Program and the National Hepatitis C Program. Am J Gastroenterol 2009; 104:1802-29. [PMID: 19455106 DOI: 10.1038/ajg.2009.191] [Citation(s) in RCA: 170] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Cirrhosis represents the end stage of any chronic liver disease. Hepatitis C and alcohol are currently the main causes of cirrhosis in the United States. Although initially cirrhosis is compensated, it eventually becomes decompensated, as defined by the presence of ascites, variceal hemorrhage, encephalopathy, and/or jaundice. These management recommendations are divided according to the status, compensated or decompensated, of the cirrhotic patient, with a separate section for the screening, diagnosis, and management of hepatocellular carcinoma (HCC), as this applies to patients with both compensated and decompensated cirrhosis. In the compensated patient, the main objective is to prevent variceal hemorrhage and any practice that could lead to decompensation. In the decompensated patient, acute variceal hemorrhage and spontaneous bacterial peritonitis are severe complications that require hospitalization. Hepatorenal syndrome is also a severe complication of cirrhosis but one that usually occurs in patients who are already in the hospital and, as it represents an extreme of the hemodynamic alterations that lead to ascites formation, it is placed under treatment of ascites. Recent advances in the pathophysiology of the complications of cirrhosis have allowed for a more rational management of cirrhosis and also for the stratification of patients into different risk groups that require different management. These recommendations are based on evidence in the literature, mainly from randomized clinical trials and meta-analyses of these trials. When few or no data exist from well-designed prospective trials, emphasis is given to results from large series and consensus conferences with involvement of recognized experts. A rational management of cirrhosis will result in improvements in quality of life, treatment adherence, and, ultimately, in outcomes.
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Liu F, Zhang CQ. Pathogenesis of hepatic encephalopathy and its prevention after transjugular intrahepatic portosystemic shunt. Shijie Huaren Xiaohua Zazhi 2009; 17:798-804. [DOI: 10.11569/wcjd.v17.i8.798] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
With the increasing use of transjugular intrahepatic portosystemic shunt (TIPS), we have obtained a breakout progress in the therapy of acute esophageal and gastric-fundus variceal bleeding and refractory ascites. whereas the patency of stent and hepatic encephalopathy (or namely portal-systemic encephalopathy, PSE) after TIPS become two great problems for TIPS. The patency of stent has been improved greatly after the use of covered stent such as Viator stents or covered vascular stents. But the problem of hepatic encephalopathy has not been well solved. In this review, we try to explore the pathogenesis of hepatic encephalopathy and its prevention after TIPS.
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The role of transjugular intrahepatic portosystemic shunt (TIPS) in the management of portal hypertension. J Clin Gastroenterol 2007; 41 Suppl 3:S344-51. [PMID: 17975487 DOI: 10.1097/mcg.0b013e318157e500] [Citation(s) in RCA: 105] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Transjugular intrahepatic portosystemic shunt (TIPS) is an interventional radiology technique that has shown a 90% success rate to decompress the portal circulation. As a non-surgical intervention, without requirement for anesthesia and very low procedure-related mortality, TIPS is applicable to severe cirrhotic patients, who are otherwise untreatable, for example, nonsurgical candidates. TIPS constitutes the most frequently employed tool to achieve portosystemic shunting. TIPS acts by lowering portal pressure, which is the main underlying pathophysiologic determinant of the major complications of cirrhosis. Regarding esophagogastric variceal bleeding, TIPS has excellent hemostatic effect (95%) with low rebleeding rate (<20%). TIPS is an accepted rescue therapy for first line treatment failures in 2 settings (1) acute variceal bleeding and (2) secondary prophylaxis. In addition, TIPS offers 70% to 90% hemostasis to patients presenting with recurrent active variceal bleeding. TIPS is more effective than standard therapy for patients with hepatic venous pressure gradient >20mm Hg. TIPS is particularly useful to treat bleeding from varices inaccessible to endoscopy. TIPS should not be applied for primary prophylaxis of variceal bleeding. Portosystemic encephalopathy and stent dysfunction are TIPS major drawbacks. The weakness of the TIPS procedure is the frequent need for endovascular reintervention to ensure stent patency. The circulatory effects of TIPS are an attractive approach for the treatment of refractory ascites and hepatorenal syndrome, yet TIPS is not considered first line therapy for refractory ascites owing to unacceptable incidence of portosystemic encephalopathy. Pre-TIPS evaluation taking into account predictors of outcome is mandatory. The improved results achieved with covered-stents might expand the currently accepted recommendations for TIPS use.
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