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Stoffel E, Hwang SY, Qian X, Geller B, Morelli G, Zhang W. Sarcopenia is an independent risk factor for short-term mortality in patients undergoing transjugular intrahepatic portosystemic shunt. Eur J Gastroenterol Hepatol 2024; 36:1010-1015. [PMID: 38808872 DOI: 10.1097/meg.0000000000002790] [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: 05/30/2024]
Abstract
BACKGROUND Sarcopenia is common in patients with cirrhosis and is a risk factor for increased mortality. Transjugular intrahepatic portosystemic shunt (TIPS) placement has been utilized in cirrhosis patients with decompensation . We investigated the role of sarcopenia in predicting mortality in patients undergoing TIPS. METHODS We conducted a single-center retrospective study of 232 patients with cirrhosis who underwent TIPS between January 2010 and December 2015. Sarcopenia was defined by the psoas muscle index (PMI) cutoff value, calculated based on dynamic time-dependent outcomes using X-tile software. Kaplan-Meier analysis demonstrated the difference in survival in the sarcopenia group versus the non-sarcopenia group. . Univariate and multivariate analyses were used to identify the relationship between sarcopenia and post-TIPS mortality during a follow-up period of 1 year. RESULTS For TIPS indications, 111 (47.84%) patients had refractory ascites, 69 (29.74%) patients had variceal bleeding, 12 (5.17%) patients had ascites, and 40 (17.24%) for other indications. The mean PMI was 4.40 ± 1.55. Sarcopenia was defined as a PMI value of <4.36 in males, and <3.23 in females. Sarcopenia was present in 96 (41.38%) of patients. . Kaplan-Meier analysis showed thatsarcopenia is associated with worse survival (log-rank P < 0.01). Multivariate Cox regression analysis showed that sarcopenia is independently associated with worse survival during the 1-year follow-up period with an hazard ratio of 2.435 (95% CI 1.346-4.403) ( P < 0.01), after adjusting for age, BMI, indications for TIPS, etiology for cirrhosis, and MELD score and stratified by sex. CONCLUSION Sarcopenia is an independent risk factor for 1-year mortality in patients undergoing TIPS and should be considered when patients are evaluated as a candidate for TIPS.
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Affiliation(s)
- Elina Stoffel
- Division of Digestive and Liver Diseases, Columbia University Irving Medical Center, New York City, New York
| | - Soo Young Hwang
- Gastroenterology Unit, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
- University of Maryland Medical System, Baltimore, Maryland
| | - Xia Qian
- Department of Radiology, University of Florida, Gainesville, Florida
- Department of Pathology, Beth Israel Deaconess Hospital, Boston, Massachusetts
| | - Brian Geller
- Division of Gastroenterology and Hepatology, University of Florida, Gainesville, Florida, USA
| | - Giuseppe Morelli
- Department of Radiology, University of Florida, Gainesville, Florida
| | - Wei Zhang
- Gastroenterology Unit, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
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Li R, Lee S, Rienas W, Sarin S. Higher risk of in-hospital mortality and hepatic encephalopathy during weekend admission in Transjugular Intrahepatic Portosystemic Shunt procedure. Clin Res Hepatol Gastroenterol 2024; 48:102396. [PMID: 38876265 DOI: 10.1016/j.clinre.2024.102396] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/18/2024] [Revised: 04/26/2024] [Accepted: 06/05/2024] [Indexed: 06/16/2024]
Abstract
OBJECTIVES Transjugular intrahepatic portosystemic shunt (TIPS) is a procedure used to alleviate portal hypertension in patients with decompensated liver cirrhosis. The weekend effect refers to a higher risk of adverse outcomes associated with procedures performed on weekends compared to weekdays. The goal of this study is to determine whether a weekend effect is evident in TIPS procedures. MATERIALS AND METHOD The study identified patients who underwent TIPS procedures in the NIS database from 2015 to 2020. Patients who were admitted on the weekday or weekends were classified into two cohorts. Preoperative variables, including demographics, comorbidities, primary payer status, and hospital characteristics, were noted. Multivariable analysis was used to assess outcomes. RESULTS Compared to patients admitted on the weekdays, weekend patients had higher in-hospital mortality (12.87 % vs. 7.96 %, aOR = 1.62, 95 CI 1.32-1.00, p < 0.01), hepatic encephalopathy (33.24 % vs. 26.18 %, aOR = 1.41, 95 CI 1.23-1.63, p < 0.01), acute kidney injury (39.03 % vs. 28.36 %, aOR = 1.68, 95 CI 1.46-1.93, p < 0.01), and transfer out (15.91 % vs. 12.76 %, aOR=1.33, 95 CI 1.11-1.60, p < 0.01). It was also found that weekend patients had longer wait from admission to operation (3.83 ± 0.15 days vs 2.82 ± 0.07 days, p < 0.01), longer LOS (11.22 ± 0.33 days vs 8.38 ± 0.15 days, p < 0.01), and higher total hospital charge (219,973 ± 7,352 dollars vs 172,663 ± 3,183 dollars, p < 0.01). CONCLUSION Our research unveiled a significant relationship between weekend admission and a higher risk of mortality and morbidity post-TIPS procedure. Eliminating delays in treatment associated with the weekend effect may mitigate this gap to deliver consistent and high-quality care to all patients.
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Affiliation(s)
- Renxi Li
- The George Washington University School of Medicine and Health Sciences, Washington, D.C., USA.
| | - SeungEun Lee
- The George Washington University School of Medicine and Health Sciences, Washington, D.C., USA
| | - William Rienas
- The George Washington University School of Medicine and Health Sciences, Washington, D.C., USA
| | - Shawn Sarin
- The George Washington University Hospital, Department of Interventional Radiology, Washington, D.C., USA
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Li R, Sarin S. The smoker's paradox in transjugular intrahepatic portosystemic shunt procedure: A national inpatient sample analysis from 2015 to 2020. Clin Res Hepatol Gastroenterol 2024; 48:102323. [PMID: 38537866 DOI: 10.1016/j.clinre.2024.102323] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/21/2023] [Revised: 02/07/2024] [Accepted: 03/19/2024] [Indexed: 05/06/2024]
Abstract
OBJECTIVES Transjugular intrahepatic portosystemic shunt (TIPS) is a procedure used to alleviate patients with chronic liver cirrhosis and portal hypertension. Smoking can adversely impact liver function and has been shown to influence liver-related outcomes. This study aimed to examine the impact of smoking on the immediate outcomes of TIPS procedure. MATERIALS AND METHOD The study compared smokers and non-smokers who underwent TIPS procedures in the National Inpatient Sample (NIS) database from the last quarter of 2015 to 2020. Multivariable analysis was used to compare the in-hospital outcomes post-TIPS. Adjusted pre-procedural variables included sex, age, race, socioeconomic status, indications for TIPS, liver disease etiologies, comorbidities, and hospital characteristics. RESULTS Compared to non-smokers, smokers had lower risks of in-hospital mortality (7.36% vs 9.88 %, aOR 0.662, p < 0.01), acute kidney injury (25.57% vs 33.66 %, aOR 0.68, p < 0.01), shock (0.45% vs 0.98 %, aOR 0.467, p = 0.02), and transfer out to other hospital facilities (11.35% vs 14.78 %, aOR 0.732, p < 0.01). There was no difference in hepatic encephalopathy or bleeding. Also, smokers had shorter wait from admission to operation (2.76±0.09 vs 3.17±0.09 days, p = 0.01), shorter length of stay (7.50±0.15 vs 9.89±0.21 days, p < 0.01), and lower total hospital cost (148,721± 2,740.7 vs 204,911±4,683.5 US dollars, p < 0.01). Subgroup analyses revealed consistent patterns among both current and past smokers. CONCLUSION This study compared the immediate outcomes of smokers and non-smokers after undergoing the TIPS procedure. Interestingly, we observed a smokers' paradox, where smoker patients had better outcomes following TIPS. The underlying causes for this smoker's paradox warrant further in-depth exploration.
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Affiliation(s)
- Renxi Li
- The George Washington University School of Medicine and Health Sciences, Washington, DC, United States.
| | - Shawn Sarin
- The George Washington University Hospital, Department of Interventional Radiology, Washington, DC, United State
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Li R, Sarin S. Disparity Among African Americans in Transjugular Intrahepatic Portosystemic Shunt Procedure: A National Inpatient Sample Analysis from 2015 to 2020. Dig Dis Sci 2024; 69:713-719. [PMID: 38319431 DOI: 10.1007/s10620-024-08273-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/04/2023] [Accepted: 01/02/2024] [Indexed: 02/07/2024]
Abstract
BACKGROUND Transjugular intrahepatic portosystemic shunt (TIPS) is a procedure used to alleviate patients with chronic liver cirrhosis and portal hypertension. Racial disparities were present in TIPS where numerous studies suggested African American patients experience higher in-hospital mortality rates. However, the incidence of post-TIPS surgical complications, such as HE, has yet to be examined among African Americans. Therefore, this study aimed to provide a comprehensive examination of the disparities in TIPS procedures among African American patients. METHODS The study compared African American and Caucasian patients who underwent TIPS procedures in the National Inpatient Sample (NIS) database from the last quarter of 2015-2020 after ICD-10 change. Preoperative variables, including demographics, comorbidities, primary payer status, and hospital characteristics, were examined and multivariable analysis was used to assess outcomes correcting preoperative variables with p < 0.1. RESULTS Compared to Caucasians, African Americans had higher in-hospital mortality (16.18 vs 8.22%, aOR 1.781, p < 0.01), hepatic encephalopathy (33.09 vs 27.44%, aOR 1.300, p = 0.05), and acute kidney injury (45.59 vs 29.60%, aOR 2.019, p < 0.01). Using the generalized linear model, African Americans have longer length of stay (11.04 ± 0.77 days vs 8.54 ± 0.16 days, p < 0.01). CONCLUSION Despite a higher prevalence of cirrhosis, African Americans continue to have marked underrepresentation in TIPS procedures in recent years. Their underrepresentation, in conjunction with higher mortality, morbidity, and increased comorbidity conditions, could imply disparity in accessing care. This finding underscores the necessity for improved access to diagnostic and therapeutic services for African Americans with liver cirrhosis.
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Affiliation(s)
- Renxi Li
- The George Washington University School of Medicine and Health Sciences, 2300 I St NW, Washington, DC, 20052, USA.
| | - Shawn Sarin
- Department of Interventional Radiology, George Washington University Hospital, Washington, DC, USA
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Berengy MS, Abd El-Hamid Hassan EM, Ibrahim AH, Mohamed EF. Safety and efficacy of transjugular intrahepatic portosystemic shunts vs endoscopic band ligation plus propranolol in patients with cirrhosis with portal vein thrombosis: a systematic review and meta-analysis. J Gastrointest Surg 2024; 28:316-326. [PMID: 38445926 DOI: 10.1016/j.gassur.2023.12.031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/21/2023] [Revised: 12/20/2023] [Accepted: 12/30/2023] [Indexed: 03/07/2024]
Abstract
BACKGROUND This systematic review and meta-analysis aimed to assess the efficacy and safety of transjugular intrahepatic portosystemic shunts (TIPS) against the combined treatment of endoscopic band ligation (EBL) and propranolol in managing patients with cirrhosis diagnosed with portal vein thrombosis (PVT). METHODS A literature search from inception to September 2023 was performed using MEDLINE, the Cochrane Library, Web of Science, and Scopus. Independent screening, data extraction, and quality assessment were performed. The main measured outcomes were the incidence and recurrence of variceal bleeding (VB), hepatic encephalopathy, and overall survival. RESULTS A total of 5 studies were included. For variceal eradication, there was initially no significant difference between the groups; however, after sensitivity analysis, a significant effect emerged (risk ratio [RR], 1.55; P < .0001). TIPS was associated with a significant decrease in the incidence of VB (RR, 0.34; P < .0001) and a higher probability of remaining free of VB in the first 2 years after the procedure (first year: RR, 1.41; P < .0001; second year: RR, 1.58; P < .0001). TIPS significantly reduced the incidence of death due to acute GI bleeding compared with EBL + propranolol (RR, 0.37; P = .05). CONCLUSION TIPS offers a comprehensive therapeutic advantage over the combined EBL and propranolol regimen, especially for patients with cirrhosis with PVT. Its efficacy in variceal eradication, reducing rebleeding, and mitigating death risks due to acute GI bleeding is evident.
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Affiliation(s)
- Mahmoud Saad Berengy
- Department of Internal Medicine, Damietta Faculty of Medicine, Al-Azhar University, Damietta, Egypt.
| | | | - Amal H Ibrahim
- Department of Internal Medicine, Faculty of Medicine for Girls, Al-Azhar University, Cairo, Egypt
| | - Eman F Mohamed
- Department of Internal Medicine, Faculty of Medicine for Girls, Al-Azhar University, Cairo, Egypt
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Wilkins H, Britt E, Bhatnagar M, Pippard B. Hepatic hydrothorax. J Thorac Dis 2024; 16:1662-1673. [PMID: 38505059 PMCID: PMC10944768 DOI: 10.21037/jtd-23-1649] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2023] [Accepted: 01/17/2024] [Indexed: 03/21/2024]
Abstract
Hepatic hydrothorax (HH) refers to the presence of a pleural effusion that develops in the context of underlying liver cirrhosis and portal hypertension. It carries a high risk of morbidity and mortality, with a median survival of 8-12 months. Diagnosis is usually confirmed by pleural aspiration, demonstrating typical features of a transudative effusion in the absence of co-existent cardio-pulmonary or renal pathology. The clinical presentation is quite variable, with some patients remaining relatively asymptomatic in the presence of small or incidental effusions, while others present with frank respiratory failure requiring pleural intervention. The development of spontaneous bacterial empyema (SBEM) is a significant and not infrequent complication, requiring prompt recognition and treatment. While the mainstay of management is focused on optimising fluid balance through dietary salt restriction and diuretic therapy, liver transplantation remains the definitive treatment option. As such, it is crucial to adopt a multi-disciplinary approach-involving pulmonologists, hepatologists, dieticians, and palliative care physicians-in order to optimise care for this often complex group of patients. This review will discuss the basic pathophysiology of HH, its clinical presentation and diagnosis, as well as the approach to management of HH in clinical practice, focussing on both interventional and non-interventional treatment modalities.
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Affiliation(s)
- Hannah Wilkins
- Department of Gastroenterology, The Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK
| | - Ellie Britt
- Department of Respiratory Medicine, The Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK
| | - Malvika Bhatnagar
- Department of Respiratory Medicine, South Tyneside and Sunderland NHS Foundation Trust, South Tyneside, UK
| | - Benjamin Pippard
- Department of Respiratory Medicine, South Tyneside and Sunderland NHS Foundation Trust, South Tyneside, UK
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Wang TJ, Ryou M. Gastric varices. Curr Opin Gastroenterol 2023; 39:490-495. [PMID: 37678207 DOI: 10.1097/mog.0000000000000974] [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] [Indexed: 09/09/2023]
Abstract
PURPOSE OF REVIEW Gastric varices are a rare cause of gastrointestinal bleeding in patients with portal hypertension. There have been significantly advances within endoscopic ultrasound for treatment of gastric varices over the past 5 years in addition to the conventional endoscopic and endovascular therapies. In this review, we will review the latest literature on gastric varices with emphasis on changes to the conventional classification systems and comparisons among the different treatment options for gastric varices in terms of efficacy and safety. RECENT FINDINGS There have been new guidelines proposed by the American Gastrointestinal Association on a simpler classification system compared to the conventional Sarin classification. In addition, endoscopic ultrasound guided coil embolization, a novel treatment pioneered over the past 5 years for gastric varices, has shown increased efficacy and reduced adverse event profile compared to cyanoacrylate glue, the more traditional therapy for gastric variceal bleeding. Options for endovascular therapy overall have not significantly changed over the recent years. SUMMARY Based on our literature review, we recommend a step-up approach with initial medical and endoscopic management with consideration of endovascular therapies when initial therapies fail.
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Affiliation(s)
- Thomas J Wang
- Brigham and Women's Hospital, Department of Gastroenterology, Hepatology and Endoscopy
- Harvard Medical School, Boston, Massachusetts, USA
| | - Marvin Ryou
- Brigham and Women's Hospital, Department of Gastroenterology, Hepatology and Endoscopy
- Harvard Medical School, Boston, Massachusetts, USA
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Corona A, Dominguez M, Eti S. Palliative Care in Kidney and Liver Diseases. ADVANCES IN KIDNEY DISEASE AND HEALTH 2023; 30:387-395. [PMID: 37657885 DOI: 10.1053/j.akdh.2023.07.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/07/2022] [Revised: 07/13/2023] [Accepted: 07/17/2023] [Indexed: 09/03/2023]
Abstract
The role of palliative care is to recognize patients with advanced illnesses who are at risk for poor outcomes and to alleviate their pain and suffering. Patients with both kidney and liver disease are a very vulnerable population due to the unique pathophysiologic relationship these two organs share, which often leads to an abbreviated life expectancy and a significant symptom burden. These patients face many challenges in their care. This article discusses the importance of prognostication for early palliative care referrals as well as the management of the two most common complaints patients with kidney and liver disease face: pain and ascites.
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Affiliation(s)
- Antonio Corona
- Albert Einstein College of Medicine at Montefiore Medical Center.
| | - Mary Dominguez
- Albert Einstein College of Medicine at Montefiore Medical Center
| | - Serife Eti
- Albert Einstein College of Medicine at Montefiore Medical Center
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Faccioli J, Nardelli S, Gioia S, Riggio O, Ridola L. Primary Prophylaxis of Overt Hepatic Encephalopathy: Is It Time to Consider It? J Clin Med 2023; 12:3903. [PMID: 37373598 DOI: 10.3390/jcm12123903] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2023] [Accepted: 05/29/2023] [Indexed: 06/29/2023] Open
Abstract
Hepatic encephalopathy (HE) represents one of the most frequent complications of liver cirrhosis and one of the most debilitating clinical manifestations of liver disease due to the accumulation of toxic substances in the blood and central nervous system [...].
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Affiliation(s)
- Jessica Faccioli
- Department of Translational and Precision Medicine, Sapienza University of Rome, 00185 Rome, Italy
| | - Silvia Nardelli
- Department of Translational and Precision Medicine, Sapienza University of Rome, 00185 Rome, Italy
| | - Stefania Gioia
- Department of Translational and Precision Medicine, Sapienza University of Rome, 00185 Rome, Italy
| | - Oliviero Riggio
- Department of Translational and Precision Medicine, Sapienza University of Rome, 00185 Rome, Italy
| | - Lorenzo Ridola
- Department of Translational and Precision Medicine, Sapienza University of Rome, 00185 Rome, Italy
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Pavel V, Scharf G, Mester P, Krauss LU, Gülow K, Mehrl A, Müller M, Schmid S. Partial splenic embolization as a rescue and emergency treatment for portal hypertension and gastroesophageal variceal hemorrhage. BMC Gastroenterol 2023; 23:180. [PMID: 37226088 DOI: 10.1186/s12876-023-02808-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/31/2022] [Accepted: 05/09/2023] [Indexed: 05/26/2023] Open
Abstract
BACKGROUND Partial splenic embolization (PSE) is a non-surgical procedure which was initially used to treat hypersplenism. Furthermore, partial splenic embolization can be used for the treatment of different conditions, including gastroesophageal variceal hemorrhage. Here, we evaluated the safety and efficacy of emergency and non-emergency PSE in patients with gastroesophageal variceal hemorrhage and recurrent portal hypertensive gastropathy bleeding due to cirrhotic (CPH) and non-cirrhotic portal hypertension (NCPH). METHODS From December 2014 to July 2022, twenty-five patients with persistent esophageal variceal hemorrhage (EVH) and gastric variceal hemorrhage (GVH), recurrent EVH and GVH, controlled EVH with a high risk of recurrent bleeding, controlled GVH with a high risk of rebleeding, and portal hypertensive gastropathy due to CPH and NCPH underwent emergency and non-emergency PSE. PSE for treatment of persistent EVH and GVH was defined as emergency PSE. In all patients pharmacological and endoscopic treatment alone had not been sufficient to control variceal bleeding, and the placement of a transjugular intrahepatic portosystemic shunt (TIPS) was contraindicated, not reasonable due to portal hemodynamics, or TIPS failure with recurrent esophageal bleeding had occurred. The patients were followed-up for six months. RESULTS All twenty-five patients, 12 with CPH and 13 with NCPH were successfully treated with PSE. In 13 out of 25 (52%) patients, PSE was performed under emergency conditions due to persistent EVH and GVH, clearly stopping the bleeding. Follow-up gastroscopy showed a significant regression of esophageal and gastric varices, classified as grade II or lower according to Paquet's classification after PSE in comparison to grade III to IV before PSE. During the follow-up period, no variceal re-bleeding occurred, neither in patients who were treated under emergency conditions nor in patients with non-emergency PSE. Furthermore, platelet count increased starting from day one after PSE, and after one week, thrombocyte levels had improved significantly. After six months, there was a sustained increase in the thrombocyte count at significantly higher levels. Fever, abdominal pain, and an increase in leucocyte count were transient side effects of the procedure. Severe complications were not observed. CONCLUSION This is the first study analyzing the efficacy of emergency and non-emergency PSE for the treatment of gastroesophageal hemorrhage and recurrent portal hypertensive gastropathy bleeding in patients with CPH and NCPH. We show that PSE is a successful rescue therapy for patients in whom pharmacological and endoscopic treatment options fail and the placement of a TIPS is contraindicated. In critically ill CPH and NCPH patients with fulminant gastroesophageal variceal bleeding, PSE showed good results and is therefore an effective tool for the rescue and emergency management of gastroesophageal hemorrhage.
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Affiliation(s)
- Vlad Pavel
- Department of Internal Medicine I, Gastroenterology, Hepatology, Endocrinology, Rheumatology and Infectious Diseases, University Hospital Regensburg, Franz-Josef-Strauß-Allee 11, 93053, Regensburg, Germany
| | - Gregor Scharf
- Department of Radiology, University Hospital Regensburg, Regensburg, Germany
| | - Patricia Mester
- Department of Internal Medicine I, Gastroenterology, Hepatology, Endocrinology, Rheumatology and Infectious Diseases, University Hospital Regensburg, Franz-Josef-Strauß-Allee 11, 93053, Regensburg, Germany
| | - Lea U Krauss
- Department of Internal Medicine I, Gastroenterology, Hepatology, Endocrinology, Rheumatology and Infectious Diseases, University Hospital Regensburg, Franz-Josef-Strauß-Allee 11, 93053, Regensburg, Germany
| | - Karsten Gülow
- Department of Internal Medicine I, Gastroenterology, Hepatology, Endocrinology, Rheumatology and Infectious Diseases, University Hospital Regensburg, Franz-Josef-Strauß-Allee 11, 93053, Regensburg, Germany
| | - Alexander Mehrl
- Department of Internal Medicine I, Gastroenterology, Hepatology, Endocrinology, Rheumatology and Infectious Diseases, University Hospital Regensburg, Franz-Josef-Strauß-Allee 11, 93053, Regensburg, Germany
| | - Martina Müller
- Department of Internal Medicine I, Gastroenterology, Hepatology, Endocrinology, Rheumatology and Infectious Diseases, University Hospital Regensburg, Franz-Josef-Strauß-Allee 11, 93053, Regensburg, Germany
| | - Stephan Schmid
- Department of Internal Medicine I, Gastroenterology, Hepatology, Endocrinology, Rheumatology and Infectious Diseases, University Hospital Regensburg, Franz-Josef-Strauß-Allee 11, 93053, Regensburg, Germany.
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Laurent C, Rayar M, Maulat C, Muscari F, Marichez A, Gregoire E, Chopinet S, Mabrut JY, Boudjema K, Lesurtel M, Adam JP, Mohkam K, Chiche L. Liver transplantation and hepatocellular carcinoma: is TIPS deleterious? A multicentric retrospective study of the ARCHET research group with propensity score matching. Langenbecks Arch Surg 2023; 408:149. [PMID: 37052722 DOI: 10.1007/s00423-023-02875-8] [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: 12/16/2021] [Accepted: 03/30/2023] [Indexed: 04/14/2023]
Abstract
PURPOSE A transjugular intrahepatic portosystemic shunt (TIPS) before the liver transplantation (LT) has been considered a contraindication in cases of hepatocellular carcinoma (HCC) because of the risk of tumour growth. We aimed to assess the impact of TIPS on incidental HCC and oncological outcomes in transplanted patients with pre-existing HCC. METHODS All consecutive transplanted patients for cirrhosis who had a previous TIPS with or without HCC were included. Between 2007 and 2014, 1912 patients were transplanted. We included 122 (6.3%) patients having TIPS before LT. A 1:3 matched cohort of 366 patients (18.9%) having LT without previous TIPS was selected using a propensity score. Incidental HCC rate and risk factor of HCC recurrence were evaluated using multivariate analysis with a competing risk model. RESULTS Before LT, in the TIPS group, 27 (22.1%) had an HCC vs. 81 (22.1%) in the control group (p = 1). The incidental HCC rate was similar: 10.5% (10/95) in the TIPS group vs. 6.3% (18/285) in the control group (p = 0.17). Recurrence occurred in 1/27 (3.7%) patient in the TIPS group and in 7/81 (8.6%) patients in the control group, without significant difference (p = 0.51). After multivariate regression, patient's gender (p < 0.01) was significantly associated with HCC recurrence while a tumour within Milan criteria (p = 0.01, sHR: 0.17 [0.04; 0.7]) and an incidental HCC (p<0.01) were found to be protector factors against HCC recurrence. CONCLUSION TIPS did not worsen the prognosis of transplanted patients for HCC. TIPS should no longer be contraindicated for oncological reasons in patients with HCC waiting for an LT.
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Affiliation(s)
- Christophe Laurent
- Department of Digestive Surgery and Liver Transplantation, Bordeaux University Hospital, Pessac, France.
| | - Michel Rayar
- Department of Visceral Surgery, University Hospital of Rennes, Rennes, France
| | - Charlotte Maulat
- Department of Visceral Surgery, Toulouse-Rangueil University Hospital, Toulouse, France
| | - Fabrice Muscari
- Department of Visceral Surgery, Toulouse-Rangueil University Hospital, Toulouse, France
| | - Arthur Marichez
- Department of Digestive Surgery and Liver Transplantation, Bordeaux University Hospital, Pessac, France
| | - Emilie Gregoire
- Department of General Surgery and Liver Transplantation, Hôpital de la Timone, Aix-Marseille University, Marseille, France
| | - Sophie Chopinet
- Department of General Surgery and Liver Transplantation, Hôpital de la Timone, Aix-Marseille University, Marseille, France
| | - Jean Yves Mabrut
- Department of General Surgery & Liver Transplantation, Hospices Civils de Lyon, Croix-Rousse University Hospital, Claude-Bernard Lyon 1 University, Lyon, France
| | - Karim Boudjema
- Department of Visceral Surgery, University Hospital of Rennes, Rennes, France
| | - Mickael Lesurtel
- Department of General Surgery & Liver Transplantation, Hospices Civils de Lyon, Croix-Rousse University Hospital, Claude-Bernard Lyon 1 University, Lyon, France
| | - Jean-Philippe Adam
- Department of Digestive Surgery and Liver Transplantation, Bordeaux University Hospital, Pessac, France
| | - Kayvan Mohkam
- Department of General Surgery & Liver Transplantation, Hospices Civils de Lyon, Croix-Rousse University Hospital, Claude-Bernard Lyon 1 University, Lyon, France
| | - Laurence Chiche
- Department of Digestive Surgery and Liver Transplantation, Bordeaux University Hospital, Pessac, France
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Posa A, Tenore L, Barbieri P, Mazza G, Sala E, Iezzi R. The Role of the Transjugular Intrahepatic Porto-Systemic Shunt in an Emergency Setting. Life (Basel) 2023; 13:life13040868. [PMID: 37109397 PMCID: PMC10146175 DOI: 10.3390/life13040868] [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: 02/11/2023] [Revised: 03/14/2023] [Accepted: 03/23/2023] [Indexed: 04/29/2023] Open
Abstract
Transjugular intrahepatic porto-systemic shunt (TIPSS) is an interventional radiology procedure whose aim is to create artificial communication between the portal and the hepatic blood flow in order to reduce the pressure gradient in portal hypertension. The indications to perform a TIPSS procedure can be framed in an elective or emergency setting: refractory ascites to diuretic therapy and secondary prophylaxis of variceal hemorrhage are the most frequent reasons for executing a TIPSS in an election context, while acute uncontrolled variceal bleeding is the principal indication that a TIPSS needs to be performed in an emergency setting. In recent years, the role of the TIPSS has been redefined for several conditions, such as ectopic varices, portal vein thrombosis, Budd-Chiari syndrome, hepatic veno-occlusive disease, and many others. This review aims to perform a deep analysis of when and why a TIPSS procedure should be carried out in an emergency, pointing out the related most common technical difficulties and complications.
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Affiliation(s)
- Alessandro Posa
- Department of Diagnostic Imaging, Oncologic Radiotherapy and Hematology, A. Gemelli University Hospital Foundation IRCCS, L.go A. Gemelli 8, 00168 Rome, Italy
| | - Lorenzo Tenore
- Department of Diagnostic Imaging, Oncologic Radiotherapy and Hematology, A. Gemelli University Hospital Foundation IRCCS, L.go A. Gemelli 8, 00168 Rome, Italy
| | - Pierluigi Barbieri
- Department of Diagnostic Imaging, Oncologic Radiotherapy and Hematology, A. Gemelli University Hospital Foundation IRCCS, L.go A. Gemelli 8, 00168 Rome, Italy
| | - Giulia Mazza
- Department of Diagnostic Imaging, Oncologic Radiotherapy and Hematology, A. Gemelli University Hospital Foundation IRCCS, L.go A. Gemelli 8, 00168 Rome, Italy
| | - Evis Sala
- Department of Diagnostic Imaging, Oncologic Radiotherapy and Hematology, A. Gemelli University Hospital Foundation IRCCS, L.go A. Gemelli 8, 00168 Rome, Italy
- Istituto di Radiodiagnostica, Catholic University of the Sacred Heart, L.go F. Vito 1, 00168 Rome, Italy
| | - Roberto Iezzi
- Department of Diagnostic Imaging, Oncologic Radiotherapy and Hematology, A. Gemelli University Hospital Foundation IRCCS, L.go A. Gemelli 8, 00168 Rome, Italy
- Istituto di Radiodiagnostica, Catholic University of the Sacred Heart, L.go F. Vito 1, 00168 Rome, Italy
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Radadiya D, Devani K, Dziadkowiec KN, Reddy C, Rockey DC. Improved Mortality But Increased Economic Burden of Disease in Compensated and Decompensated Cirrhosis: A US National Perspective. J Clin Gastroenterol 2023; 57:300-310. [PMID: 34974491 PMCID: PMC9243188 DOI: 10.1097/mcg.0000000000001652] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/08/2021] [Accepted: 11/06/2021] [Indexed: 12/23/2022]
Abstract
INTRODUCTION Cirrhosis remains a major burden on the health care system despite substantial advances in therapy and care. Studies simultaneously examining mortality, readmission, and cost of care are not available. Here, we hypothesized that improved patient care in the last decade might have led to improved outcomes and reduced costs in patients with cirrhosis. MATERIALS AND METHODS We identified compensated cirrhosis (CC) and decompensated cirrhosis (DC) patients using carefully chosen ICD-9/ICD-10 codes from the Nationwide Readmission Database (NRD) (years 2010 to 2016). We evaluated trends of 30-day all-cause mortality, 30-day readmission, and inflation-adjusted index hospitalization and readmission costs. Factors associated with mortality and readmission were identified using regression analyses. RESULTS A total of 3,374,038 patients with cirrhosis were identified, of whom nearly 50% had a decompensating event on initial admission. The 30-day inpatient mortality rate for both CC and DC patients decreased from 2010 to 2016. The 30-day readmission rate remained stable for DC and declined for CC. Over the study period, 30-day readmission costs increased for DC and remained unchanged for CC. The median cost for index hospitalization remained nearly unchanged, but the cost of readmission increased for both CC and DC groups. Gastrointestinal diseases and infections were the leading cause of readmission in CC and DC patient groups. CONCLUSION Inpatient mortality has decreased for CC and DC patients. Readmission has declined for CC patients and remained stable for DC patients. However, the economic burden of cirrhosis is rising.
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Affiliation(s)
- Dhruvil Radadiya
- Division of Gastroenterology, Hepatology and Motility, Department of Internal Medicine, University of Kansas – School of Medicine, Kansas City, KS, USA
| | - Kalpit Devani
- Prisma Health, Gastroenterology & Liver Center, Greenville, SC, USA
- University of South Carolina School of Medicine Greenville Campus, Division of Gastroenterology & Hepatology, Department of Internal Medicine, Greenville, SC, USA
| | - Karolina N. Dziadkowiec
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, University of Texas at San Antonio, San Antonio, TX, USA
| | - Chakradhar Reddy
- Division of Gastroenterology, Department of Internal Medicine, East Tennessee State University, Johnson City, TN, USA
| | - Don C. Rockey
- Digestive Disease Research Center, Medical University of South Carolina, Charleston, SC, USA
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14
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Brown MA, Gueyikian S, Huffman S, Donahue L. Transjugular Intrahepatic Portosystemic Shunt Reduction Techniques. Semin Intervent Radiol 2023; 40:27-32. [PMID: 37152803 PMCID: PMC10159697 DOI: 10.1055/s-0043-1764286] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/09/2023]
Abstract
Transjugular intrahepatic portosystemic shunt (TIPS) creation treats complications of portal hypertension in appropriately selected patients by lowering the portal venous pressure. While this can be a lifesaving intervention, portal venous flow diversion is not without potential consequences. Overshunting can lead to hepatic decompensation and encephalopathy. TIPS reduction and TIPS occlusion are therapeutic options used to mitigate overshunting, with reduction being the initial alternative due to retained shunt patency and lower potential for venous thrombosis. Patient selection, techniques for TIPS reduction, and patient outcomes are reviewed in this article.
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Affiliation(s)
- Mason A. Brown
- Department of Vascular and Interventional Radiology, Aurora St. Luke's Medical Center, Milwaukee, Wisconsin
| | - Sebouh Gueyikian
- Department of Vascular and Interventional Radiology, NorthShore University HealthSystem, Evanston, Illinois
| | - Steven Huffman
- Department of Vascular and Interventional Radiology, Aurora St. Luke's Medical Center, Milwaukee, Wisconsin
| | - Laurence Donahue
- Department of Vascular and Interventional Radiology, Aurora St. Luke's Medical Center, Milwaukee, Wisconsin
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15
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Bayona Molano MDP, Rice S. The Use of Intracardiac Echocardiography in Transjugular Intrahepatic Portosystemic Shunt Procedure. Semin Intervent Radiol 2023; 40:15-18. [PMID: 37152794 PMCID: PMC10159727 DOI: 10.1055/s-0043-1764283] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/09/2023]
Abstract
Transjugular intrahepatic portosystemic shunt (TIPS) is a complex intervention with a steep learning curve that requires centers of expertise to improve technical success and reduce complications. Portal venous access is the most challenging step of the procedure and requires planning and image guidance strategies to prevent vascular or bile duct injury and further complications. Intracardiac echocardiography (ICE) has been reported to be a safe and accurate tool that provides images of the portal vein anatomy in real time. The use of ICE has become the standard of care in several centers. It is now frequently used to target the portal vein in complex TIPS procedures. This review article describes some technical aspects and indications of ICE-guided TIPS.
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Affiliation(s)
| | - Samuel Rice
- Interventional Radiology Division, UT Southwestern Medical Center, Dallas, Texas
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16
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Schneider D, Kojecký V. Transient hemodynamic instability caused by TIPS. VNITRNI LEKARSTVI 2023; 69:16-19. [PMID: 37468318 DOI: 10.36290/vnl.2023.053] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 07/21/2023]
Abstract
Variceal bleeding belongs to the one of the complications of portal hypertension and is a life-threatening condition. A transjugular intrahepatic portosystemic shunt (TIPS) is indicated in case of failure of the pharmacological and endoscopic therapy, even if it is associated with complications. Stent migration to the heart, is a rare event which may cause perforation of the right cardiac chambers or damage to the tricuspid valve. However, it may not be a problem in some cases. There are two approaches to extraction - percutaneous or surgical. Leaving the stent in situ is possible, especially in polymorbid patients. Choosing an optimal approach often requires interdisciplinary cooperation.
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Titton CM, Torikachvili M, Rêgo HMC, Medronha EF, Ziemiecki Junior E, Ribas C, Ceratti CG, Mattos AAD, Tovo CV. Transjugular intrahepatic portosystemic shunt in decompensated cirrhotic patients in a tertiary hospital in southern Brazil. REVISTA DA ASSOCIACAO MEDICA BRASILEIRA (1992) 2023; 69:e20220944. [PMID: 37075438 PMCID: PMC10176653 DOI: 10.1590/1806-9282.20220944] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/12/2023] [Accepted: 01/13/2023] [Indexed: 04/21/2023]
Abstract
OBJECTIVE The aim of the present study was to evaluate the outcomes of cirrhotic patients undergoing transjugular intrahepatic portosystemic shunt. METHODS A retrospective longitudinal observational study was carried out evaluating 38 cirrhotic patients undergoing transjugular intrahepatic portosystemic shunt. The outcomes were evaluated in an outpatient follow-up period of 3 months. The assumed significance level was 5%. RESULTS The indications for transjugular intrahepatic portosystemic shunt were refractory ascites in 21 (55.3%), variceal hemorrhage in 13 (34.2%), and hydrothorax in 4 (10.5%) patients. There was development of hepatic encephalopathy in 10 (35.7%) patients after transjugular intrahepatic portosystemic shunt. From the 21 patients with refractory ascites, resolution was observed in 1 (3.1%) patient, and in 16 (50.0%) patients, there was ascites control. Regarding transjugular intrahepatic portosystemic shunt after variceal bleeding, 10 (76.9%) patients remained without new bleeding or hospitalizations in the follow-up period. The global survival in the follow-up period in patients with and without hepatic encephalopathy was 60 vs. 82%, respectively (p=0.032). CONCLUSION Transjugular intrahepatic portosystemic shunt can be considered in decompensated cirrhotic patients; however, the development of hepatic encephalopathy which can shorten survival should be focused.
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Affiliation(s)
| | | | | | | | | | - Carolina Ribas
- Hospital Nossa Senhora da Conceição - Porto Alegre (RS), Brazil
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18
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Jung EM, Jung F, Verloh N, Haimerl M, Lürken L, Jage S, Stroszczynski C, Scharf G. High resolution flow with glazing flow for optimized flow detection in transjugular intrahepatic portosystemic stent shunt (TIPS): First results. Clin Hemorheol Microcirc 2022; 82:231-238. [PMID: 35723091 DOI: 10.3233/ch-221427] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
BACKGROUND Ultrasound follow-up of transjugular intrahepatic portosystemic shunt (TIPS) is challenging due to the bent course of the stent-graft. OBJECTIVE Aim of this retrospective study was to assess to which extent the combination of HR flow with Glazing Flow improves hemodynamic assessment in the ultrasound follow-up of TIPS. METHODS Comparative studies with CCDS and High Resolution (HR)-Flow with Glazing Flow were evaluated regarding image quality and artifacts on a 5-point scale (0 = cannot be assessed up to 5 = maximum image quality without artifacts). In all cases, an experienced examiner performed the examinations with a 1-6 MHz probe (Resona 7, Mindray). RESULTS 61 ultrasound examinations in 48 patients were performed; the mean patient age was 54±14.2 years. The use of HR-Flow with Glazing Flow resulted in an improved flow display in 55/61 cases (90.2%). Both methods correlated well (r = 0.71), but HR flow with Glazing flow values were in general higher than CCDS values. The reading resulted in an average value of 2.52±0.54 for CCDS and 3.52±0.57 for HR flow with Glazing flow (p = 0.013). CONCLUSION The combination of HR-Flow and Glazing Flow results in improved flow representation and reduction of artifacts in the ultrasound follow-up of TIPS.
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Affiliation(s)
- Ernst-Michael Jung
- Department of Radiology, Interdisciplinary Ultrasound Department, University Hospital Regensburg, Regensburg, Germany
| | - Friedrich Jung
- Institute of Biotechnology, Molecular Cell Biology, Brandenburg University of Technology, Senftenberg, Germany
| | - Niklas Verloh
- Department of Radiology, University Hospital Freiburg, Freiburg, Germany
| | - Michael Haimerl
- Department of Radiology, Interdisciplinary Ultrasound Department, University Hospital Regensburg, Regensburg, Germany
| | - Lukas Lürken
- Department of Radiology, Interdisciplinary Ultrasound Department, University Hospital Regensburg, Regensburg, Germany
| | - Simon Jage
- Department of Radiology, Interdisciplinary Ultrasound Department, University Hospital Regensburg, Regensburg, Germany
| | - Christian Stroszczynski
- Department of Radiology, Interdisciplinary Ultrasound Department, University Hospital Regensburg, Regensburg, Germany
| | - Gregor Scharf
- Department of Radiology, Interdisciplinary Ultrasound Department, University Hospital Regensburg, Regensburg, Germany
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Clinical Outcomes and Patency after Transjugular Intrahepatic Portosystemic Shunt Reduction for Overshunting Adverse Events. J Vasc Interv Radiol 2022; 33:1507-1512. [PMID: 35964879 DOI: 10.1016/j.jvir.2022.08.007] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2022] [Revised: 06/20/2022] [Accepted: 08/05/2022] [Indexed: 11/21/2022] Open
Abstract
PURPOSE To assess clinical outcomes and patency after transjugular intrahepatic portosystemic shunt (TIPS) reduction for overshunting adverse events. MATERIALS AND METHODS This multicenter, retrospective observational study included 33 patients (male-to-female ratio, 20:13; mean age, 59 years; mean Model for End-Stage Liver Disease [MELD] score, 15) who underwent TIPS reduction between 2007 and 2020. Procedure indications included medically refractory hepatic encephalopathy (HE) (85%), post-TIPS hepatic insufficiency (HI) (12%), and heart failure (3%). The measured outcomes included improvement in HE (classified using the West Haven system) and HI, patency of reduced TIPS, and transplant-free survival (TFS). RESULTS TIPS reductions were successfully performed using parallel stent (94%) or other (6%) techniques at a median of 120 days after TIPS creation (HE, median, 164 days; HI, median, 5 days). The portosystemic pressure gradient increased from a mean of 10 to 17 mm Hg (P < .001). The overall HE rate after TIPS reduction was 54%; HE was persistent, improved, and resolved in 21%, 32%, and 46% cases, respectively. In patients with HI, the MELD score increased from a mean of 22 before TIPS to 34 after TIPS (P = .061), but without improvement (0%) in HI after TIPS reduction (mean MELD score, 30; P = .266). Recurrent ascites occurred in 14% of the patients. The median shunt patency was 961 days (95% confidence interval, 476-1,447). The 30-day, 6-month, 1-year, and 3-year shunt patency rates were 92%, 81%, 74%, and 37%, respectively. The median TFS was not reached. The 30-day, 6-month, 1-year, and 3-year survival rates were 97%, 90%, 81%, and 60%, respectively. CONCLUSIONS Although TIPS reduction may be an effective and durable approach to treat post-TIPS medically refractory HE, shunt reduction may not achieve meaningful benefit for HI.
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20
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Giri S, Kale A, Shukla A. Efficacy and Safety of Transjugular Intrahepatic Portosystemic Shunt Creation for Budd-Chiari Syndrome: A Systematic Review and Meta-Analysis. J Vasc Interv Radiol 2022; 33:1301-1312.e13. [PMID: 35940361 DOI: 10.1016/j.jvir.2022.07.022] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2022] [Revised: 07/04/2022] [Accepted: 07/22/2022] [Indexed: 12/15/2022] Open
Abstract
PURPOSE To assess the critical role of transjugular intrahepatic portosystemic shunt (TIPS) in the management of Budd-Chiari syndrome (BCS), as the data with respect to the safety and outcome of TIPS in patients with BCS are scarce because of the rarity of the disease. MATERIALS AND METHODS A comprehensive search of literature of various databases from 2000 to October 2021 was conducted for studies evaluating the outcome of TIPS in patients with BCS. The primary outcomes of the analysis were technical and clinical success, adverse events and mortality associated with TIPS, dysfunction of TIPS, need for TIPS revision, need for liver transplantation (LT), and 1-year survival. RESULTS A total of 33 studies (1,395 patients) were included in this meta-analysis. The pooled rates and 95% confidence intervals of various outcomes were 98.6% (97.6-99.7) for technical success, 90.3% (86.0-94.6) for clinical success, 10.0% (6.5-13.6) for major adverse events, 0.5% (0.2-1.0) for TIPS-related mortality, 11.6% (7.8-15.4) for post-TIPS hepatic encephalopathy (HE), 40.1% (32.5-47.7) for TIPS dysfunction, 8.6% (4.9-12.4) for the need for TIPS revision, 4.5% (2.8-6.2) for the need for LT, and 94.6% (93.1-96.1) for 1-year survival. Publication bias was seen with all outcomes except for post-TIPS HE, TIPS dysfunction, and the need for LT. CONCLUSIONS The existing literature supports the feasibility, safety, and efficacy of TIPS in the treatment of BCS. Deciding the optimal timing of TIPS in BCS needs further studies.
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Affiliation(s)
- Suprabhat Giri
- Department of Gastroenterology, Nizam's Institute of Medical Sciences, Hyderabad, Telangana, India.
| | - Aditya Kale
- Department of Gastroenterology, Seth GS Medical College and KEM Hospital, Mumbai, Maharashtra, India
| | - Akash Shukla
- Department of Gastroenterology, Seth GS Medical College and KEM Hospital, Mumbai, Maharashtra, India
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Stirnimann G, Berg T, Spahr L, Zeuzem S, McPherson S, Lammert F, Storni F, Banz V, Babatz J, Vargas V, Geier A, Engelmann C, Herber A, Trepte C, Capel J, De Gottardi A. Final safety and efficacy results from a 106 real-world patients registry with an ascites-mobilizing pump. Liver Int 2022; 42:2247-2259. [PMID: 35686702 PMCID: PMC9543940 DOI: 10.1111/liv.15337] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/19/2021] [Revised: 05/02/2022] [Accepted: 05/16/2022] [Indexed: 02/13/2023]
Abstract
BACKGROUND AND AIMS Patients with cirrhotic refractory ascites ineligible for transjugular intrahepatic shunt (TIPSS) have limited treatment options apart from repeated large volume paracentesis. The alfapump® is an implantable device mobilizing ascites from the peritoneal cavity to the bladder, from where it can be excreted. The aim of this observational cohort study was to prospectively investigate safety and efficacy of the device in a real-world cohort with cirrhotic refractory ascites and contraindications for TIPSS. METHODS A total of 106 patients received an implant at 12 European centres and were followed up for up to 24 months. Complications, device deficiencies, frequency of paracentesis, clinical status and survival were recorded prospectively. RESULTS Approximately half of the patients died on-study, about a quarter was withdrawn because of serious adverse events leading to explant, a sixth were withdrawn because of liver transplant or recovery, and nine completed follow-up. The most frequent causes of on-study death and complication-related explant were progression of liver disease and infection. The device reduced the requirement for large-volume paracentesis significantly, with more than half of patients not having required any post-implant. Survival benefits were not observed. Device-related reinterventions were predominantly caused by device deficiencies. A post-hoc comparison of the first 50 versus the last 50 patients enrolled revealed a decreased reintervention rate in the latter, mainly related to peritoneal catheter modifications. CONCLUSIONS The device reduced paracentesis frequency in a real-world setting. Technical complications were successfully decreased by optimization of management and device modification (NCT01532427).
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Affiliation(s)
- Guido Stirnimann
- University Clinic for Visceral Surgery and Medicine, Inselspital University HospitalUniversity of BernBernSwitzerland
| | - Thomas Berg
- Division of Hepatology, Department of Medicine IILeipzig University Medical CenterLeipzigGermany
| | - Laurent Spahr
- Department of Medical Specialties, Service of GastroenterologyGeneva University HospitalsGenevaSwitzerland
| | - Stefan Zeuzem
- Department of MedicineUniversity HospitalFrankfurtGermany
| | - Stuart McPherson
- Liver Unit, Freeman Hospital, Newcastle upon Tyne Hospitals NHS Foundation Trust, and Translational and Clinical Research InstituteNewcastle UniversityNewcastleUK
| | - Frank Lammert
- Department of Medicine IISaarland University Medical CenterHomburgGermany,Medizinische Hochschule HannoverHannoverGermany
| | - Federico Storni
- University Clinic for Visceral Surgery and Medicine, Inselspital University HospitalUniversity of BernBernSwitzerland
| | - Vanessa Banz
- University Clinic for Visceral Surgery and Medicine, Inselspital University HospitalUniversity of BernBernSwitzerland
| | - Jana Babatz
- Medizinische Klinik IUniversitätsklinikum Carl Gustav CarusDresdenGermany
| | - Victor Vargas
- Liver Unit, Hospital Vall d'HebronUniversitat Autònoma Barcelona, CIBERehdBarcelonaSpain
| | - Andreas Geier
- Division of Hepatology, Department of Medicine IIUniversity Hospital WürzburgWürzburgGermany
| | - Cornelius Engelmann
- Division of Hepatology, Department of Medicine IILeipzig University Medical CenterLeipzigGermany,Medical Department, Division of Hepatology and GastroenterologyCharité—Universitätsmedizin BerlinBerlinGermany
| | - Adam Herber
- Division of Hepatology, Department of Medicine IILeipzig University Medical CenterLeipzigGermany
| | | | | | - Andrea De Gottardi
- University Clinic for Visceral Surgery and Medicine, Inselspital University HospitalUniversity of BernBernSwitzerland,Servizio di Gastroenterologia e Epatologia, Ente Ospedaliero CantonaleLuganoSwitzerland,Facoltà di Scienze BiomedicheUniversità della Svizzera ItalianaLuganoSwitzerland
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22
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Zurcher KS, Smith MV, Naidu SG, Saini G, Patel IJ, Knuttinen MG, Kriegshauser JS, Oklu R, Alzubaidi SJ. Transsplenic Portal System Catheterization: Review of Current Indications and Techniques. Radiographics 2022; 42:1562-1576. [PMID: 35984753 DOI: 10.1148/rg.220042] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
Multiple diseases of the portal system require effective portal vein access for endovascular management. While percutaneous transhepatic and transjugular approaches remain the standard methods of portal vein access, transsplenic access (TSA) has gained recognition as an effective and safe technique to access the portal system in patients with contraindications to traditional approaches. Recently, the utility of percutaneous TSA has grown, with described treatments including recanalization of chronic portal vein occlusion, placement of stents for portal vein stenosis, portal vein embolization of the liver, embolization of gastric varices, placement of complicated transjugular intrahepatic portosystemic shunts, and interventions after liver transplant. The authors provide a review of percutaneous TSA, including indications, a summary of related portal vein diseases, and the different techniques used for access and closure. In addition, an imaging-based review of technical considerations of TSA interventions is presented, with a review of potential procedural complications. With technical success rates that mirror or rival the standard methods and reported low rates of major complications, TSA can be a safe and effective option in clinical scenarios where traditional approaches are not feasible. ©RSNA, 2022.
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Affiliation(s)
- Kenneth S Zurcher
- From the Division of Vascular and Interventional Radiology, Mayo Clinic, 5777 E Mayo Blvd, Phoenix, AZ 85054
| | - Mathew V Smith
- From the Division of Vascular and Interventional Radiology, Mayo Clinic, 5777 E Mayo Blvd, Phoenix, AZ 85054
| | - Sailendra G Naidu
- From the Division of Vascular and Interventional Radiology, Mayo Clinic, 5777 E Mayo Blvd, Phoenix, AZ 85054
| | - Gia Saini
- From the Division of Vascular and Interventional Radiology, Mayo Clinic, 5777 E Mayo Blvd, Phoenix, AZ 85054
| | - Indravadan J Patel
- From the Division of Vascular and Interventional Radiology, Mayo Clinic, 5777 E Mayo Blvd, Phoenix, AZ 85054
| | - M Grace Knuttinen
- From the Division of Vascular and Interventional Radiology, Mayo Clinic, 5777 E Mayo Blvd, Phoenix, AZ 85054
| | - J Scott Kriegshauser
- From the Division of Vascular and Interventional Radiology, Mayo Clinic, 5777 E Mayo Blvd, Phoenix, AZ 85054
| | - Rahmi Oklu
- From the Division of Vascular and Interventional Radiology, Mayo Clinic, 5777 E Mayo Blvd, Phoenix, AZ 85054
| | - Sadeer J Alzubaidi
- From the Division of Vascular and Interventional Radiology, Mayo Clinic, 5777 E Mayo Blvd, Phoenix, AZ 85054
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23
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Scalzo N, Canastar M, Lebovics E. Part 1: Disease of the Heart and Liver: A Relationship That Cuts Both Ways. Cardiol Rev 2022; 30:111-122. [PMID: 33337654 DOI: 10.1097/crd.0000000000000379] [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: 12/10/2022]
Abstract
The heart and the liver display multifaceted, complex interactions that can be divided into cardiac effects of liver disease, hepatic effects of heart disease, and disease processes affecting both organs. In part 1 of this 2 part series, we discuss how acute and chronic heart failure can have devastating effects on the liver, such as acute cardiogenic liver injury and congestive hepatopathy. On the other hand, primary liver disease, such as cirrhosis, can lead to a plethora of cardiac insults representative in cirrhotic cardiomyopathy as systolic dysfunction, diastolic dysfunction, and electrophysiological disturbances. Nonalcoholic fatty liver disease has long been associated with cardiovascular events that increase mortality. The management of both disease processes changes when the other organ system becomes involved. This consideration is important with regard to a variety of interventions, most notably transplantation of either organ, as risk of complications dramatically rises in the setting of both heart and liver disease (discussed in part 2). As our understanding of the intricate communication between the heart and liver continues to expand so does our management.
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Affiliation(s)
- Nicholas Scalzo
- From the Department of Medicine, Section of Gastroenterology & Hepatobiliary Diseases, New York Medical College and Westchester Medical Center, Valhalla, NY
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24
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Prognostic value of neutrophil-to-lymphocyte ratio in cirrhosis patients undergoing transjugular intrahepatic portosystemic shunt. Eur J Gastroenterol Hepatol 2022; 34:435-442. [PMID: 34750323 DOI: 10.1097/meg.0000000000002295] [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] [Indexed: 12/10/2022]
Abstract
BACKGROUND AND AIMS The neutrophil-to-lymphocyte-ratio (NLR) is used as an inflammatory index and has proven to be an accurate prognostic indicator for decompensated cirrhotics; however, its role in patients undergoing transjugular intrahepatic portosystemic shunt (TIPS) has not been evaluated. We examined whether NLR is associated with mortality in decompensated cirrhosis patients undergoing TIPS. METHODS We performed a retrospective review of 268 decompensated cirrhotics who underwent TIPS from January 2011 to December 2015 at an academic medical center. NLR, patient demographics, manifestations of cirrhosis, TIPS indications and mortality were recorded. Univariate and multivariate Cox regression analyses for prognostic factors associated with 30-day and 90-day post TIPS mortality were performed. RESULTS A total of 129 (48%) patients received TIPS for refractory ascites with 79 (29%) for variceal bleeding, 14 (5%) for hepatic hydrothorax, and 46 (17%) for other indications. Cirrhosis etiology included hepatitis C (36%), alcohol (28%), nonalcoholic steatohepatitis (20%), or other (15%). Median NLR was 4.42 (IQR 2.75-7.19). Univariate and multivariate analysis showed NLR as an independent predictive factor of 30-day and 90-day mortality. Furthermore, in patients with a Model of End-Stage Liver Disease (MELD) ≤ 15, NLR is superior to MELD/MELD-Na score in predicting 30-day and 90-day mortality. In patients with MELD > 15, MELD/MELD-Na score is superior to NLR. CONCLUSION Our data indicate that elevated NLR independently predicts 30-day and 90-day mortality. In patients with a MELD ≤ 15, NLR is a better prognostic factor than MELD or MELD-Na in predicting short-term mortality.
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Safety and efficacy of outpatient continuous terlipressin infusion for the treatment of portal hypertensive complications in cirrhosis. Eur J Gastroenterol Hepatol 2022; 34:206-212. [PMID: 32976193 DOI: 10.1097/meg.0000000000001950] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
BACKGROUND/AIM Therapeutic options are limited for patients with hepatorenal syndrome (HRS), diuretic refractory ascites and hepatic hydrothorax who are awaiting liver transplant. We assessed the safety and efficacy of continuous terlipressin infusion (CTI) for treating these conditions in an outpatient setting. METHOD All patients treated with CTI from May 2013 through March 2018 at our institution were initiated in-hospital on bolus dose terlipressin therapy for 24-72 h prior to commencing CTI for home therapy. Daily home visits for clinical assessment and medication administration were provided. Adverse events, effects of treatment on renal function, model for end-stage liver disease (MELD) score, and paracentesis/thoracentesis requirements were assessed. RESULTS Twenty-three patients were included (HRS = 17; refractory ascites = 4; refractory hepatic hydrothorax = 2). Median (range) duration of outpatient CTI was 50 (1-437) days with a total of 2482 patient days of treatment. Fourteen patients (60.9%) received a liver transplant; of whom 13 (92.9%) were alive at the end of the study period. There were no cardiac or ischemic complications and no serious adverse events reported. In patients with HRS, median serum creatinine significantly decreased from 202.0 μmol/L at baseline to 125.5 μmol/L at day 14 of CTI (P = 0.0003) and remained stable thereafter. Median MELD score decreased from 22.5 to 19.0 at end of CTI (P = 0.008). Median frequency of paracentesis/thoracentesis was 4 per month prior to CTI versus 1.52 during treatment. CONCLUSION Transplant-eligible and otherwise stable patients can be managed with CTI at home for an extended duration under supervision without adverse consequences.
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Helzberg JH, Parish A, Niedzwiecki D, Kim CY, Patel YA, Wilder JM, Muir AJ. Racial disparities in transjugular intrahepatic portosystemic shunt procedure outcomes. BMJ Open Gastroenterol 2022; 9:bmjgast-2021-000747. [PMID: 35086849 PMCID: PMC8796249 DOI: 10.1136/bmjgast-2021-000747] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/17/2021] [Accepted: 12/29/2021] [Indexed: 12/24/2022] Open
Abstract
Objective The transjugular intrahepatic portosystemic shunt (TIPS) procedure is an important intervention for management of complications of portal hypertension. The objective of this study was to identify predictors of mortality from the TIPS procedure with a focus on race and ethnicity. Design TIPS procedures from 2012 to 2014 in the National Inpatient Sample were identified. Weighting was applied to generate nationally representative results. In-hospital mortality was the primary outcome of interest. χ2 and Student’s t-tests were performed for categorical and continuous variables, respectively. Predictors of mortality following TIPS were assessed by survey-weighted logistic regression. Results 17 175 (95% CI 16 254 to 18 096) TIPS cases were identified. Approximately 71% were non-Hispanic (NH) white, 6% were NH black, 16% were Hispanic and 7% were other. NH black patients undergoing TIPS had an in-hospital mortality rate of 20.1%, nearly double the in-hospital mortality of any other racial or ethnic group. NH black patients also had significantly longer median postprocedure and total lengths of stay (p=0.03 and p<0.001, respectively). The interaction of race by clinical indication was a significant predictor of in-hospital mortality (p<0.001). NH black patients had increased mortality compared with other racial/ethnic groups when presenting with bleeding oesophageal varices (OR 3.85, 95% CI 2.14 to 6.95). Conclusion This cohort study presents important findings in end-stage liver disease care, with clear racial disparities in in-hospital outcomes following the TIPS procedure. Specifically, black patients had significantly higher in-hospital mortality and longer lengths of stay. Further research is needed to understand how we can better care for black patients with liver disease.
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Affiliation(s)
- James H Helzberg
- Department of Medicine, Duke University School of Medicine, Durham, North Carolina, USA
| | - Alice Parish
- Department of Biostatistics and Bioinformatics, Duke University School of Medicine, Durham, North Carolina, USA
| | - Donna Niedzwiecki
- Department of Biostatistics and Bioinformatics, Duke University School of Medicine, Durham, North Carolina, USA
| | - Charles Y Kim
- Department of Radiology, Division of Interventional Radiology, Duke University School of Medicine, Durham, North Carolina, USA
| | - Yuval A Patel
- Department of Medicine, Division of Gastroenterology, Duke University School of Medicine, Durham, North Carolina, USA
| | - Julius M Wilder
- Department of Medicine, Division of Gastroenterology, Duke University School of Medicine, Durham, North Carolina, USA.,Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina, USA
| | - Andrew J Muir
- Department of Medicine, Division of Gastroenterology, Duke University School of Medicine, Durham, North Carolina, USA .,Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina, USA
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Transjugular intrahepatic portosystemic shunt with transhepatic portal vein puncture guided by ultrasound: a technical alternative. Eur J Gastroenterol Hepatol 2022; 34:112-116. [PMID: 34748302 DOI: 10.1097/meg.0000000000002174] [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] [Indexed: 12/10/2022]
Abstract
OBJECTIVE Evaluation of an alternative technique to perform transjugular intrahepatic portosystemic shunt (TIPS), using abdominal ultrasound to guide portal puncture. METHODS Retrospective analysis of TIPS performed from January 2014 to December 2018 in an interventional radiology service. TIPS were performed according to the classic technique, except at the moment of portal branch puncture, when abdominal ultrasound was used to guide it, visualized its path within the parenchyma in real-time. Qualitative and quantitative variables were analyzed considering a 95% confidence interval and application of the Student's t-test with a significance level of P < 0.05. RESULTS Forty-one TIPS were performed. The technical success rate of ultrasound guidance in portal puncture was 100.0%. After its performance, a reduction in the portosystemic pressure gradient was observed, with an initial gradient average of 18.8 mmHg (12-25 ± 3.6 mmHg) and a final gradient of 9.2 mmHg (5-14 ± 2.4 mmHg). The mean values for the TIPS execution time, fluoroscopy time and the radiation dose, verified through the dose area product, were 65.2 ± 46.7 min, 25 ± 14.1 min and 85.6 ± 70 Gy cm2, respectively. There were no complications related to the inadvertent puncture of nontarget structures or deaths due to complications resulting from TIPS. CONCLUSION The results demonstrate that the portal transhepatic puncture guided by the abdominal ultrasound is an effective and safe procedure and results in time of execution, time of fluoroscopy and radiation dose below the current reference values of the conventional procedure.
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Khan A, Bailey CW. Unique Method of Transjugular Intrahepatic Portosystemic Shunt Reduction for Refractory Hepatic Encephalopathy. Cureus 2021; 13:e18838. [PMID: 34804693 PMCID: PMC8592787 DOI: 10.7759/cureus.18838] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/16/2021] [Indexed: 12/03/2022] Open
Abstract
We report the case of a 27-year-old female patient with a history of cryptogenic cirrhosis who was admitted to the hospital due to multiple episodes of hematemesis secondary to bleeding esophageal varices. The varices were persistent and refractory to endoscopic intervention, so an emergent transjugular intrahepatic portosystemic shunt (TIPS) was performed by interventional radiology (IR). Months later, the patient returned to the hospital unresponsive with acute intermittent hepatic encephalopathy which required a TIPS reduction by IR. Once the TIPS reduction was performed, the patient’s hepatic encephalopathy declined, and her symptoms improved. Here, we present a unique method of TIPS reduction utilizing a single Viabahn VBX balloon-expandable stent (W. L. Gore & Associates, Inc; Flagstaff, AZ) to constrain the existing TIPS stent.
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Affiliation(s)
- Ayub Khan
- Medicine, West Virginia School of Osteopathic Medicine, Lewisburg, USA
| | - Christopher W Bailey
- Interventional Radiology, Virginia Commonwealth University School of Medicine, Richmond, USA
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Patel RK, Chandel K, Tripathy TP, Mukund A. Complications of transjugular intrahepatic portosystemic shunt (TIPS) in the era of the stent graft - What the interventionists need to know? Eur J Radiol 2021; 144:109986. [PMID: 34619618 DOI: 10.1016/j.ejrad.2021.109986] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2021] [Revised: 09/22/2021] [Accepted: 09/27/2021] [Indexed: 02/07/2023]
Abstract
Transjugular intrahepatic portosystemic shunt (TIPS) is created between a hepatic vein (HV) and the portal vein (PV) to alleviate the symptoms of portal hypertension. Despite high procedural success rates, a myriad of complications may occur at every step of TIPS creation. These complications may be attributable to the procedure itself or the shunt. Portal vein puncture is the most challenging and rate-limiting step, with extrahepatic portal vein puncture being the most devastating tabletop complication. Hepatic encephalopathy is the most common shunt-related complication after TIPS. Unlike bare metallic stents, covered stents have a longer patency rate and lower incidence of TIPS dysfunction. Most of the TIPS dysfunction that occurs with stent-grafts is due to technical errors and mechanical factors. TIPS revision often requires a combination of angioplasty, mechanical thrombectomy, and thrombolytics with a need for additional stenting in some cases. This review article focuses on procedure and shunt-related complications, as well as preventive and management strategies.
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Affiliation(s)
- Ranjan Kumar Patel
- Department of Interventional Radiology, Institute of Liver and Biliary Sciences, New Delhi 110070, India.
| | - Karamvir Chandel
- Department of Interventional Radiology, Institute of Liver and Biliary Sciences, New Delhi 110070, India
| | - Tara Prasad Tripathy
- Department of Interventional Radiology, Institute of Liver and Biliary Sciences, New Delhi 110070, India
| | - Amar Mukund
- Department of Interventional Radiology, Institute of Liver and Biliary Sciences, New Delhi 110070, India.
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Storni F, Stirnimann J, Banz V, De Gottardi A, Stirnimann G. Treatment of refractory ascites with an automated low flow ascites pump in patients awaiting liver transplantation. JOURNAL OF LIVER TRANSPLANTATION 2021. [DOI: 10.1016/j.liver.2021.100037] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
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Lang M, Lang AL, Tsui BQ, Wang W, Erly BK, Shen B, Kapoor B. Renal-function change after transjugular intra-hepatic portosystemic shunt placement and its relationship with survival: a single-center experience. Gastroenterol Rep (Oxf) 2021; 9:306-312. [PMID: 34567562 PMCID: PMC8460113 DOI: 10.1093/gastro/goaa081] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/24/2020] [Revised: 09/15/2020] [Accepted: 09/27/2020] [Indexed: 01/06/2023] Open
Abstract
Background The effect of transjugular intra-hepatic portosystemic shunt (TIPS) placement on renal function and the correlation of post-TIPS Cr with mortality remain unclear. This study aimed to assess the effect of TIPS placement on renal function and to examine the relationship between post-TIPS Cr and mortality risk. Methods A total of 593 patients who underwent de novo TIPS placement between 2004 and 2017 at a single institution were included in the study. The pre-TIPS Cr level (T0; within 7 days before TIPS placement) and post-TIPS Cr levels, at 1–2 days (T1), 5–12 days (T2), and 15–40 days (T3), were collected. Predictors of Cr change after TIPS placement and the 1-year mortality rate were analysed using multivariable linear-regression and Cox proportional-hazards models, respectively. Results Overall, 21.4% of patients (n = 127) had elevated baseline Cr (≥1.5 mg/dL; mean, 2.51 ± 1.49 mg/dL) and 78.6% (n = 466) had normal baseline Cr (<1.5 mg/dL; mean, 0.92 ± 0.26 mg/dL). Patients with elevated pre-TIPS Cr demonstrated a decrease in post-TIPS Cr (difference, −0.60 mg/dL), whereas patients with normal baseline Cr exhibited no change (difference, <0.01 mg/dL). The 30-day, 90-day, and 1-year mortality rates were 13%, 20%, and 32%, respectively. Variceal bleeding as a TIPS-placement indication (hazard ratio = 1.731; P = 0.036), higher T0 Cr (hazard ratio = 1.834; P = 0.012), and higher T3 Cr (hazard ratio = 3.524; P < 0.001) were associated with higher 1-year mortality risk. Conclusion TIPS placement improved renal function in patients with baseline renal dysfunction and the post-TIPS Cr level was a strong predictor of 1-year mortality risk.
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Affiliation(s)
- Min Lang
- Department of Radiology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Angela L Lang
- Department of Anesthesia, Critical Care, and Pain Management, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Brian Q Tsui
- Department of Radiology, UCLA Medical Center, Los Angeles, CA, USA
| | - Weiping Wang
- Department of Radiology, Mayo Clinic, Jacksonville, FL, USA
| | - Brian K Erly
- Colorado School of Public Health, Aurora, Colorado, USA
| | - Bo Shen
- The Inflammatory Bowel Disease Center at Columbia, Columbia University Irving Medical Center, New York, NY, USA
| | - Baljendra Kapoor
- Division of Vascular and Interventional Radiology, Imaging Institute, Cleveland Clinic, Cleveland, OH, USA
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Marschner CA, Geyer T, Froelich MF, Rübenthaler J, Schwarze V, Clevert DA. Diagnostic Value of Contrast-Enhanced Ultrasound for Evaluation of Transjugular Intrahepatic Portosystemic Shunt Perfusion. Diagnostics (Basel) 2021; 11:1593. [PMID: 34573935 PMCID: PMC8472159 DOI: 10.3390/diagnostics11091593] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2021] [Revised: 08/11/2021] [Accepted: 08/25/2021] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND In patients with liver cirrhosis, transjugular intrahepatic portosystemic shunt (TIPS) displays an effective method for treating portal hypertension. Main indications include refractory ascites and secondary prevention of esophageal bleeding. Color Doppler ultrasound (CDUS) plays a leading role in the follow-up management, whereas contrast-enhanced ultrasound (CEUS) is not routinely considered. We compared the efficacy of CEUS to CDUS and highlighted differences compared to findings of corresponding computed tomography (CT) and magnetic resonance imaging (MRI). (2) Methods: On a retrospective basis, 106 patients with CEUS examination after TIPS were included. The enrollment period was 12 years (between 2008 and 2020) and the age group ranged from 23.3 to 82.1 years. In addition, 92 CDUS, 43 CT and 58 MRI scans were evaluated for intermodal comparison. (3) Results: Intermodal analysis and comparison revealed a high level of concordance between CDUS, CT and MRI in the vast majority of cases. In comparison to CDUS, the correlation of the relevant findings was 92.5%, 95.3% for CT and 87.9% for MRI. In some cases, however, additional information was provided by CEUS (4) Conclusions: CEUS depicts a safe and effective imaging modality for follow-up after TIPS. In addition to CDUS, CEUS enables specific assessment of stent pathologies and stent dysfunction due to its capacity to dynamically visualize single microbubbles at high spatial and temporal resolution. Due to the low number of adverse events regarding the application of contrast agents, CEUS can be administered to a very broad patient population, thus avoiding additional radiation exposure compared to CT angiography in cases with divergent findings during follow-up.
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Affiliation(s)
- Constantin A. Marschner
- Department of Radiology, University Hospital, LMU Munich, 81377 Munich, Germany; (T.G.); (J.R.); (V.S.); (D.-A.C.)
| | - Thomas Geyer
- Department of Radiology, University Hospital, LMU Munich, 81377 Munich, Germany; (T.G.); (J.R.); (V.S.); (D.-A.C.)
| | - Matthias F. Froelich
- Department of Clinical Radiology and Nuclear Medicine, University Medical Centre Mannheim, 68167 Mannheim, Germany;
| | - Johannes Rübenthaler
- Department of Radiology, University Hospital, LMU Munich, 81377 Munich, Germany; (T.G.); (J.R.); (V.S.); (D.-A.C.)
| | - Vincent Schwarze
- Department of Radiology, University Hospital, LMU Munich, 81377 Munich, Germany; (T.G.); (J.R.); (V.S.); (D.-A.C.)
| | - Dirk-André Clevert
- Department of Radiology, University Hospital, LMU Munich, 81377 Munich, Germany; (T.G.); (J.R.); (V.S.); (D.-A.C.)
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Barath S, Kheradia D, Gopalkrishnan SP, R. RK, K. MRP. Review of Applied Anatomy, Hemodynamics, and Endovascular Management of Ectopic Varices. JOURNAL OF CLINICAL INTERVENTIONAL RADIOLOGY ISVIR 2021. [DOI: 10.1055/s-0041-1730868] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022] Open
Abstract
AbstractPortal hypertension leads to the opening up of collateral pathways to bypass the occlusion or resistance in the portal system. Ectopic varices are formed by such collaterals at many various sites along the gastrointestinal tract other than the usual location, that is, gastroesophageal region. Early diagnosis of ectopic varices needs strong clinical suspicion and contrast-enhanced computed tomography scan as endoscopy may often fail to pinpoint a source. In contrast to gastric varices where the understanding of the disease, as well as endovascular management, is widely studied and documented, the same is not true for ectopic varices due to low incidence. Understanding the applied anatomy and hemodynamic classification is important to decide the most suitable therapy. Interventional radiological procedures are aimed at either decompressing the varices or obliterating them and depend on the patency of the portal system, underlying etiology, and local expertise.
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Affiliation(s)
- Sitaram Barath
- Interventional Radiology Subdivision, Department of Radiology, Geetanjali Medical College & Hospital, Udaipur, Rajasthan, India
| | | | | | - Rahul K. R.
- Government Medical College, Kozhikode, Kerala, India
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Zhang JB, Chen J, Zhou J, Wang XM, Chen S, Chu JG, Liu P, Ye ZD. Systematic review and meta-analysis of trans-jugular intrahepatic portosystemic shunt for cirrhotic patients with portal vein thrombosis. World J Clin Cases 2021; 9:5179-5190. [PMID: 34307565 PMCID: PMC8283597 DOI: 10.12998/wjcc.v9.i19.5179] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/13/2021] [Revised: 03/21/2021] [Accepted: 04/25/2021] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Portal vein thrombosis (PVT) was previously a contraindication for trans-jugular intrahepatic portosystemic shunt (TIPS).
AIM To perform a systematic review and meta-analysis of the current available studies investigating outcomes of TIPS for cirrhotic patient with PVT.
METHODS Multiple databases were systematically searched to identify studies investigating the outcomes of TIPS for cirrhotic patients with PVT. The quality of studies was assessed by Cochrane Collaboration method and Methodological Index for Non-Randomized Studies. The demographic data, outcomes, combined treatment, and anticoagulation strategy were extracted.
RESULTS Twelve studies were identified with 460 patients enrolled in the analysis. The technical success rate was 98.9% in patients without portal vein cavernous transformation and 92.3% in patients with portal vein cavernous transformation. One-year portal vein recanalization rate was 77.7%, and TIPS patency rate was 84.2%. The cumulative encephalopathy rate was 16.4%. One-year overall survival was 87.4%.
CONCLUSION TIPS is indicated for portal hypertension related complications and the restoration of pre-transplantation portal vein patency in cirrhotic patients with PVT. Cavernous transformation is an indicator for technical failure. Post-TIPS anticoagulation seems not mandatory. Simultaneous TIPS and percutaneous mechanical thrombectomy device could achieve accelerated portal vein recanalization and decreased thrombolysis-associated complications, but further investigation is still needed.
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Affiliation(s)
- Jian-Bin Zhang
- Department of Cardiovascular Surgery, China-Japan Friendship Hospital, Beijing 100029, China
| | - Jie Chen
- Department of Cardiovascular Surgery, China-Japan Friendship Hospital, Beijing 100029, China
| | - Jin Zhou
- Department of Cardiovascular Surgery, China-Japan Friendship Hospital, Beijing 100029, China
| | - Xu-Ming Wang
- Department of Cardiovascular Surgery, China-Japan Friendship Hospital, Beijing 100029, China
| | - Shu Chen
- Department of Interventional Radiology, Affiliated People’s Hospital of Inner Mongolia Medical University, Hohhot 010020, Inner Mongolia Autonomous Region, China
| | - Jian-Guo Chu
- Department of Radiology, Air Force Medical Center of PLA, Beijing 100142, China
| | - Peng Liu
- Department of Cardiovascular Surgery, China-Japan Friendship Hospital, Beijing 100029, China
| | - Zhi-Dong Ye
- Department of Cardiovascular Surgery, China-Japan Friendship Hospital, Beijing 100029, China
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Lim STJM, Kelly M, Selvarajah L, Murray M, Scanlon T. Transjugular intrahepatic portosystemic shunt (TIPS) procedure: an assessment of the quality and readability of online information. BMC Med Inform Decis Mak 2021; 21:149. [PMID: 33952225 PMCID: PMC8101024 DOI: 10.1186/s12911-021-01513-x] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2020] [Accepted: 04/27/2021] [Indexed: 12/15/2022] Open
Abstract
Purpose Transjugular intrahepatic portosystemic shunt (TIPS) procedure is an established procedure carried out by interventional radiologists to achieve portal decompression and to manage the complications of portal hypertension. The aim of this study was to evaluate the quality and readability of information available online for TIPS procedure. Methods Websites were identified using the search terms “TIPS procedure”, “TIPSS procedure”, “transjugular intrahepatic portosystemic shunt procedure”, with the first 25 pages from the three most popular search engines (Google, Bing and Yahoo) being selected for evaluation with a total of 225. Each Website was grouped by authorship into one of five categories: (1) Physician, (2) Academic, (3) For-profit, (4) Non-profit (including government and public health), or (5) Other (discussion/social media). Readability of each Website was assessed using the Flesch-Reading Ease score, Flesch–Kincaid grade level, Gunning-Fog Index, Coleman–Liau and SMOG index. Quality was calculated using the DISCERN instrument, the Journal of the American Medical Association (JAMA) benchmark criteria and the presence of Health on the Net (HON) code certification. Results After disregarding duplicate and non-accessible Websites a total of 81 were included. The mean DISCERN score assessing the quality of information provided by Websites was “good” (59.3 ± 10.2) with adherence to the JAMA Benchmark being 54.3%. Websites with HON-code certification were statistically significantly higher in terms of DISCERN (p = 0.034) and JAMA scores (p = 0.003) compared to HON-code negative sites. The readability scores of Websites ranged from 10 to 12th grade across calculators. Thirty-two out of the 81 Websites were targeted towards patients (39.5%), 46 towards medical professionals (56.8%) and 3 were aimed at neither (3.7%). The medical professional aimed Websites were statistically significantly more difficulty to read across all readability formulas (all p < 0.001). Conclusion While quality of online information available to patients is “good”, the average readability for information on the internet for TIPS is set far above the recommended 7th-grade level. Academic Websites were of the highest quality, yet most challenging for the general public to read. These findings call for the production of high-quality and comprehensible content around TIPS procedure, where physicians can reliably direct their patients for information.
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Affiliation(s)
- Sean-Tee J M Lim
- Department of Surgery, Limerick University Hospital, St Nessan's Rd, Dooradoyle, Co. Limerick, V94 F858, Ireland.
| | - Martin Kelly
- Department of Surgery, Limerick University Hospital, St Nessan's Rd, Dooradoyle, Co. Limerick, V94 F858, Ireland
| | - Logeswaran Selvarajah
- Department of Radiology, Limerick University Hospital, St Nessan's Rd, Dooradoyle, Co. Limerick, V94 F858, Ireland
| | - Michael Murray
- Department of Radiology, Limerick University Hospital, St Nessan's Rd, Dooradoyle, Co. Limerick, V94 F858, Ireland
| | - Timothy Scanlon
- Department of Radiology, Limerick University Hospital, St Nessan's Rd, Dooradoyle, Co. Limerick, V94 F858, Ireland
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Pena Polanco NA, Martin P, Carrion AF. Advances in the Management of Renal Dysfunction in Patients With Cirrhosis. Gastroenterol Hepatol (N Y) 2021; 17:211-220. [PMID: 34924889 PMCID: PMC8667379] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/14/2023]
Abstract
Renal dysfunction frequently develops in patients with advanced liver disease. Renal dysfunction in this setting is associated with adverse outcomes and an unfavorable prognosis. Hepatorenal syndrome (HRS), defined as worsening renal function in patients with advanced cirrhosis that can present either acutely (<3 months) or more indolently in the absence of other etiologies, remains a common cause of acute kidney injury. If reversal is not promptly achieved, rapid decline to mortality is common. Volume expansion and vasoconstrictors are the mainstays of therapy. Terlipressin, a vasopressin analogue licensed in several countries but not in the United States, is currently used for the treatment of HRS. Timely liver transplantation remains the only effective therapeutic option for a large group of patients with persistent renal dysfunction despite pharmacotherapy. In patients with underlying chronic renal dysfunction, simultaneous liver-kidney transplantation should be considered. The aim of this article is to present an overview of renal dysfunction in patients with cirrhosis, including diagnosis and management.
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Affiliation(s)
- Nathalie A Pena Polanco
- Division of Digestive Health and Liver Diseases, University of Miami Miller School of Medicine, Miami, Florida
| | - Paul Martin
- Division of Digestive Health and Liver Diseases, University of Miami Miller School of Medicine, Miami, Florida
| | - Andres F Carrion
- Division of Digestive Health and Liver Diseases, University of Miami Miller School of Medicine, Miami, Florida
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Khan A, Maheshwari S, Gupta K, Naseem K, Chowdry M, Singh S. Rate, reasons, predictors, and burden of readmissions after transjugular intrahepatic portosystemic shunt placement. J Gastroenterol Hepatol 2021; 36:775-781. [PMID: 32710679 PMCID: PMC8385676 DOI: 10.1111/jgh.15194] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/08/2020] [Revised: 06/22/2020] [Accepted: 07/18/2020] [Indexed: 12/20/2022]
Abstract
BACKGROUND AND AIM Nationwide data on readmissions after the transjugular intrahepatic portosystemic shunt (TIPS) procedure are lacking. We aimed to investigate the 30-day readmission rate after TIPS procedure, reasons, and predictors for readmissions and its impact on resource utilization and mortality in the USA. METHODS We identified all adults who underwent an inpatient TIPS procedure between 2010 and 2014 using the National Readmission Database. Outcomes included all-cause 30-day readmission rate, reasons and predictors of readmissions, mortality rate, and mean hospitalization charges. RESULTS Out of a total of 31 230 hospitalizations with TIPS procedure, 28 021 patients met the study criteria and were finally included. The mean age of patients was 56.90 years, and 63.84% were men. All-cause 30-day readmission rate was 27.81%. Hepatic encephalopathy with or without coma was the most common reason for readmissions in at least 36.43% patients. The in-hospital mortality for index hospitalization and 30-day readmission was 10.69% and 5.85%, respectively. The mean hospitalization charges for index hospitalization and readmissions were $153 357 and $45 751, respectively. Advanced age, Medicaid insurance, higher Charlson comorbidy index, ascites as indication of TIPS, and nonspecific or hepatitis C cirrhosis etiologies for cirrhosis were found to be independent predictors of 30-day readmissions after a TIPS procedure. CONCLUSIONS Our study found a high rate of readmission for patients undergoing TIPS procedure, and the majority of these readmissions were related to hepatic encephalopathy. Further studies highlighting areas for improvement, particularly for patient selection and post-discharge care, are needed to reduce readmissions.
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Affiliation(s)
- Ahmad Khan
- Department of Medicine, West Virginia University Health Sciences Center Charleston Division, Charleston, West Virginia
| | - Sanjay Maheshwari
- Department of Medicine, Maimonides Medical Center, New York, New York
| | - Kamesh Gupta
- Department of Medicine, Baystate Medical Center, Springfield, Massachusetts, USA
| | - Khadija Naseem
- Department of Medicine, Charleston Area Medical Center, Charleston, West Virginia
| | - Monica Chowdry
- Department of Medicine, West Virginia University Health Sciences Center Charleston Division, Charleston, West Virginia
| | - Shailendra Singh
- Charleston Gastroenterology Associates, Charleston, West Virginia
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Mu X, Winsor W, Trahey J. Use of Non-Selective Beta-Blocker for Refractory Stomal Variceal Hemorrhage. Case Rep Gastroenterol 2021; 15:87-91. [PMID: 33613168 PMCID: PMC7879264 DOI: 10.1159/000510921] [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: 08/05/2020] [Accepted: 08/13/2020] [Indexed: 11/23/2022] Open
Abstract
Bleeding stomal varices are often difficult to manage given the comorbidities that are associated with their presentation. Here, we report a case of a 62-year-old female with stomal variceal hemorrhage in the setting of chronic portal vein thrombosis who was ineligible for transhepatic intrajugular portosystemic shunt or surgery as a result of her challenging anatomy and peri-operative risks. Despite coil embolization, this patient experienced refractory bleeds which ceased following the initiation of a non-selective beta-blocker (NSBB). This case provides further evidence for the expanding role of NSBBs as an important therapeutic agent for complicated ectopic varices.
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Affiliation(s)
- Xin Mu
- Faculty of Medicine, Memorial University of Newfoundland, St. John's, Newfoundland, Canada
| | - Wendy Winsor
- Faculty of Medicine, Memorial University of Newfoundland, St. John's, Newfoundland, Canada
| | - Julia Trahey
- Faculty of Medicine, Memorial University of Newfoundland, St. John's, Newfoundland, Canada
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Briggler A, Simmons LQ, Lane M. The Importance of Sonographic Imaging With Alcoholic Liver Disease: A Case Study. JOURNAL OF DIAGNOSTIC MEDICAL SONOGRAPHY 2021. [DOI: 10.1177/8756479320944150] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Alcoholic liver disease (ALD), a precursor to alcohol-induced cirrhosis, is a disease caused by excessive ingestion of alcoholic substances that directly affects liver functions. Abnormal liver function can cause the liver to damage other organs within the abdomen. This case study examines the physiological nature of alcohol-induced cirrhosis and its pathogenesis, external and internal clinical presentations, and treatment options. Treatments for alcohol-induced cirrhosis include liver transplant for permanent correction as well as varied options to manage symptoms. This case study analyzes alcoholic liver disease within one male patient whose condition highlights the importance of sonography in routinely monitoring patients with ALD.
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Affiliation(s)
- Amber Briggler
- Imaging & Radiation Sciences, University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | - Layla Q. Simmons
- Imaging & Radiation Sciences, University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | - Megan Lane
- Imaging & Radiation Sciences, University of Arkansas for Medical Sciences, Little Rock, AR, USA
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Banini BA, Alwatari Y, Stovall M, Ogden N, Gershman E, Shah RD, Strife BJ, Shojaee S, Sterling RK. Multidisciplinary Management of Hepatic Hydrothorax in 2020: An Evidence-Based Review and Guidance. Hepatology 2020; 72:1851-1863. [PMID: 32585037 DOI: 10.1002/hep.31434] [Citation(s) in RCA: 39] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/01/2020] [Revised: 05/08/2020] [Accepted: 06/04/2020] [Indexed: 12/12/2022]
Affiliation(s)
- Bubu A Banini
- Division of Gastroenterology, Hepatology and Nutrition, Department of Internal Medicine, Virginia Commonwealth University, Richmond, VA
| | - Yahya Alwatari
- Division of Cardiothoracic Surgery, Department of Surgery, Virginia Commonwealth University, Richmond, VA
| | - Madeline Stovall
- Division of Cardiothoracic Surgery, Department of Surgery, Virginia Commonwealth University, Richmond, VA
| | - Nathan Ogden
- Division of Interventional Radiology, Department of Radiology, Virginia Commonwealth University, Richmond, VA
| | - Evgeni Gershman
- Division of Pulmonary Disease and Critical Care Medicine, Department of Internal Medicine, Virginia Commonwealth University, Richmond, VA
| | - Rachit D Shah
- Division of Cardiothoracic Surgery, Department of Surgery, Virginia Commonwealth University, Richmond, VA
| | - Brian J Strife
- Division of Interventional Radiology, Department of Radiology, Virginia Commonwealth University, Richmond, VA
| | - Samira Shojaee
- Division of Pulmonary Disease and Critical Care Medicine, Department of Internal Medicine, Virginia Commonwealth University, Richmond, VA
| | - Richard K Sterling
- Division of Gastroenterology, Hepatology and Nutrition, Department of Internal Medicine, Virginia Commonwealth University, Richmond, VA
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Lewis SB, Johnson GE, Valji K, Monroe EJ, Ingraham CR, Chick JFB, Shin DS. Transjugular intrahepatic portosystemic shunt creation via isolated persistent left superior vena cava: a case series. CVIR Endovasc 2020; 3:75. [PMID: 33025347 PMCID: PMC7538481 DOI: 10.1186/s42155-020-00169-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2020] [Accepted: 09/29/2020] [Indexed: 12/23/2022] Open
Abstract
BACKGROUND Isolated persistent left superior vena cava (PLSVC) is a rare vascular anatomic variant, which can be an incidental finding at the time of an endovascular procedure. CASE PRESENTATION This report describes the technical success, adverse events, and clinical outcomes of transjugular intrahepatic portosystemic shunt (TIPS) creation via isolated PLSVC. Three adult patients with cirrhosis and isolated PLSVC underwent TIPS placement successfully with one major adverse event. Two patients required TIPS revision within 90 days. There were no deaths within 90 days. CONCLUSIONS TIPS creation via isolated PLSVC is feasible using standard techniques with a left jugular vein approach. Caution is warranted during the procedure to assess for any aberrant drainage pattern to the left atrium and to prepare for potentially challenging instrument navigation through the coronary sinus.
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Affiliation(s)
- Spencer B Lewis
- Division of Interventional Radiology, Department of Radiology, University of Washington, 1959 Northeast Pacific Street, Seattle, WA, 98195, USA
| | - Guy E Johnson
- Division of Interventional Radiology, Department of Radiology, University of Washington, 1959 Northeast Pacific Street, Seattle, WA, 98195, USA
| | - Karim Valji
- Division of Interventional Radiology, Department of Radiology, University of Washington, 1959 Northeast Pacific Street, Seattle, WA, 98195, USA
| | - Eric J Monroe
- Division of Interventional Radiology, Department of Radiology, University of Washington, 1959 Northeast Pacific Street, Seattle, WA, 98195, USA
- Division of Interventional Radiology, Department of Radiology, Seattle Children's Hospital, 4800 Sand Point Way Northeast, Seattle, WA, 9810, USA
| | - Christopher R Ingraham
- Division of Interventional Radiology, Department of Radiology, University of Washington, 1959 Northeast Pacific Street, Seattle, WA, 98195, USA
| | - Jeffrey Forris Beecham Chick
- Division of Interventional Radiology, Department of Radiology, University of Washington, 1959 Northeast Pacific Street, Seattle, WA, 98195, USA
- Division of Interventional Radiology, Department of Radiology, Seattle Children's Hospital, 4800 Sand Point Way Northeast, Seattle, WA, 9810, USA
| | - David S Shin
- Division of Interventional Radiology, Department of Radiology, University of Washington, 1959 Northeast Pacific Street, Seattle, WA, 98195, USA.
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Fontan-associated liver disease: pathophysiology, investigations, predictors of severity and management. Eur J Gastroenterol Hepatol 2020; 32:907-915. [PMID: 31851099 DOI: 10.1097/meg.0000000000001641] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Cardiac hepatopathy is the liver injury resulting from congestion and ischaemia associated with acute or chronic heart failure. The improved longevity of adults with operated congenital heart disease who develop heart failure as an increasingly late event makes this form of liver injury increasingly clinically relevant. Patients with congenital heart disease with a single ventricle anomaly, who require creation of a Fontan circulation, are particularly vulnerable as they have elevated venous filling pressures with chronic liver congestion. Progression to liver fibrosis and eventually cirrhosis may occur, with its associated risks of liver failure and hepatocellular carcinoma. This risk likely increases over the patient's lifetime, related to the duration post-surgical repair and reflects the chronicity of congestion. Liver biopsy is rarely performed due to a higher risk of complications in the setting of elevated venous pressures, and the frequent use of anticoagulation. Non-invasive methods of liver assessment are poorly validated and different factors require consideration compared to other chronic liver diseases. This review discusses the current understanding of cardiac hepatopathy in congenital heart disease patients with a Fontan circulation. This entity has recently been called Fontan Associated Liver Disease in the literature, with the term useful in recognising that the pathophysiology is incompletely understood, and that long-standing venous pressure elevation and hypoxaemia are presumed to play an additional significant role in the pathogenesis of the liver injury.
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Park C, Patel YA, Suhocki P, Dorsey C, Kapila N, Tang L, Gilner J. High-risk third trimester pregnancy with decompensated cirrhosis safely delivered following emergent preoperative interventional radiology for mitigation of variceal bleeding. Clin Imaging 2020; 68:143-147. [PMID: 32615516 DOI: 10.1016/j.clinimag.2020.06.032] [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: 05/03/2020] [Revised: 06/11/2020] [Accepted: 06/16/2020] [Indexed: 11/26/2022]
Abstract
Coagulopathy coupled with severe portal hypertension in the setting of cirrhosis increases the risk of mortality from variceal bleeding in pregnant women. Studies suggest transjugular intrahepatic portosystemic shunt (TIPS) creation to be a safe procedure during pregnancy in preventing variceal bleeding complications; however, it is not typically employed in severely decompensated cirrhosis. This case report of a pregnant woman presenting at 34.7 weeks' gestation demonstrates successful variceal mapping, emergent TIPS creation and variceal embolization to allow safe cesarean delivery despite severe hypofibrinogenemia and decompensated alcoholic cirrhosis. With careful medical optimization, angiographic imaging and vascular interventional radiology may be employed outside of usual indications to achieve safe pregnancy delivery and postpartum recovery.
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Affiliation(s)
- Christine Park
- Department of Obstetrics and Gynecology, Duke University Medical Center, Durham, NC, USA
| | - Yuval A Patel
- Division of Gastroenterology, Duke University Medical Center, Durham, NC, USA
| | - Paul Suhocki
- Department of Interventional Radiology, Duke University Medical Center, Durham, NC, USA
| | - Claire Dorsey
- Division of Gastroenterology, Duke University Medical Center, Durham, NC, USA
| | - Nikhil Kapila
- Division of Gastroenterology, Duke University Medical Center, Durham, NC, USA
| | - Linnan Tang
- Department of Interventional Radiology, Duke University Medical Center, Durham, NC, USA
| | - Jennifer Gilner
- Department of Obstetrics and Gynecology, Duke University Medical Center, Durham, NC, USA.
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Combined treatment of refractory ascites with an alfapump® plus hernia repair in the same surgical session: A retrospective, multicentre, European pilot study in cirrhotic patients. J Visc Surg 2020; 158:27-37. [PMID: 32553558 DOI: 10.1016/j.jviscsurg.2020.06.003] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
INTRODUCTION The treatment of symptomatic hernia in cirrhotic patients with refractory ascites is critical but challenging. The objective of this study was to assess the feasibility and safety of the implantation of alfapump® combined with concomitant hernia repair in cirrhotic patients with refractory ascites. METHODS Using data from six European centres, we retrospectively compared patients treated with alfapump® system implantation and concomitant hernia repair [the combined treatment group (CT group, n=12)] or with intermittent paracentesis hernia repair [the standard treatment group (ST group, n=26)]. Some patients of the ST group had hernia repair in an elective setting (STel group) and others in emergency (STem group). The endpoints were requirement of peritoneal drainage, the rate of infectious complications, the in-hospital mortality, the length of stay, paracentesis-free survival. RESULTS Postoperatively, none of the patients in the CT group and 21 patients (80%) in the ST group underwent peritoneal drainage for the evacuation of ascites fluid (P<0.0001). The overall incidence of infectious complications was not different between groups but there were fewer infections in the CT group than in the STem group (33% vs. 81%; P=0.01). There was no difference for in-hospital mortality. The length of stay was shorter in the CT group (P=0.03). Paracentesis-free survival was significantly better (P=0.0003) in the CT group than in the ST group. CONCLUSION Implantation of alfapump combined with concomitant hernia repair seems feasible and safe in cirrhotic patients; however, larger and randomized study are required.
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Jesudian AB, Ahmad M, Bozkaya D, Migliaccio-Walle K. Cost-Effectiveness of Rifaximin Treatment in Patients with Hepatic Encephalopathy. J Manag Care Spec Pharm 2020; 26:750-757. [PMID: 32463782 PMCID: PMC10391162 DOI: 10.18553/jmcp.2020.26.6.750] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND Hepatic encephalopathy (HE) is a complication of cirrhosis of the liver causing neuropsychiatric abnormalities. Clinical manifestations of overt HE result in increased health care resource utilization and effects on patient quality of life. While lactulose has historically been the mainstay of treatment for acute HE and maintenance of remission, there is an unmet need for additional therapeutic options with a favorable adverse event profile. Compared with lactulose alone, rifaximin has demonstrated proven efficacy in complete reversal of HE and reduction in the incidence of HE recurrence, mortality, and hospitalizations. Evidence suggests the benefit of long-term prophylactic therapy with rifaximin; however, there is a need to assess the economic impact of rifaximin treatment in patients with HE. OBJECTIVE To assess the incremental cost-effectiveness of rifaximin ± lactulose versus lactulose monotherapy in patients with overt HE. METHODS A Markov model was developed in Excel with 4 health states (remission, overt HE, liver transplantation, and death) to predict costs and outcomes of patients with HE after initiation of maintenance therapy with rifaximin ± lactulose to avoid recurrent HE episodes. Cost-effectiveness of rifaximin was evaluated through estimation of incremental cost per quality-adjusted life-year (QALY) or life-year (LY) gained. Analyses were conducted over a lifetime horizon. One-way deterministic and probabilistic sensitivity analyses were conducted to assess uncertainty in results. RESULTS The rifaximin ± lactulose regimen provided added health benefits despite an additional cost versus lactulose monotherapy. Model results showed an incremental benefit of $29,161 per QALY gained and $27,762 per LY gained with rifaximin ± lactulose versus lactulose monotherapy. Probabilistic sensitivity analyses demonstrated that the rifaximin ± lactulose regimen was cost-effective ~99% of the time at a threshold of $50,000 per QALY/LY gained, which falls within the commonly accepted threshold for incremental cost-effectiveness. CONCLUSIONS The clinical benefit of rifaximin, combined with an acceptable economic profile, demonstrates the advantages of rifaximin maintenance therapy as an important option to consider for patients at risk of recurrent HE. DISCLOSURES This analysis was funded by Salix Pharmaceuticals, a division of Bausch Health US. Salix and Xcenda collaborated on the methods, and Salix, Xcenda, Jesudian, and Ahmad collaborated on the writing of the manuscript and interpretation of results. Bozkaya and Migliaccio-Walle are employees of Xcenda. Ahmad reports speaker fees from Salix Pharmaceuticals, unrelated to this study. Jesudian reports consulting and speaker fees from Salix Pharmaceuticals, unrelated to this study. The results from this model were presented at AASLD: The Liver Meeting 2014; November 7-11; Boston, MA.
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Perello MP, Mur JP, Vives MS, Riutort JMM, Artigues AP, Garcia CN, Vidal MLB, Gelabert AE, Garau MV. Long-term follow-up of transjugular intrahepatic portosystemic shunt (TIPS) with stent-graft. ACTA ACUST UNITED AC 2020; 25:346-352. [PMID: 31322502 DOI: 10.5152/dir.2019.18416] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
PURPOSE We aimed to retrospectively evaluate the long-term clinical and patency results after the placement of transjugular intrahepatic portosystemic shunts (TIPS) using stent-graft. Many studies show the clinical results and the patency follow-up of TIPS with stent-graft in the short and medium term. However, few studies show long-term results. METHODS Between 2002 and 2016, TIPS with stent-grafts were placed in 132 patients. The median age was 59.5 years. The median Model for End-stage Liver Disease (MELD) score was 13, and 71% were Child-Pugh B. Indications for TIPS were bleeding (83%) and ascites or hydrothorax (17%). The technical and clinical success rates were calculated, as were the rates of patency, survival and complications. The median follow-up period was 43 months. RESULTS The technical success rate was 98%, and the clinical success rates were 85% in patients with indication for bleeding and 95% in patients with indication for ascites or hydrothorax. Primary patency did not decrease from 66% after 6 years (95% confidence interval [CI], 56.2%-75.8%) primary assisted patency remained stable at 87% after 6 years (95% CI, 77.2%-96.8%) and secondary patency did not decrease from 98% after 4 years (95% CI, 95.1%-100%). The median overall survival was 42.8 months (95% CI, 33.8-51.8 months). A total of 54 patients suffered some type of complication, minor (28 patients) or major (26 patients), during the follow-up. CONCLUSION The clinical success rate was high. The choice of the maximum initial limit of portosystemic gradient and the diameter of the post-TIPS shunt, together with the number of shunt reductions, are important to be able to compare results between publications. In our study, the patency rates did not decrease after 6 years; hence, long-term follow-up of these patients may not be necessary.
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Affiliation(s)
| | - Javier Pueyo Mur
- Department of Radiology, Hospital Universitari Son Espases, Palma de Mallorca, Spain
| | | | | | | | - Carolina Nieto Garcia
- Department of Radiology, Hospital Universitari Son Espases, Palma de Mallorca, Spain
| | | | - Ana Escarda Gelabert
- Department of Gastroenterology, Hospital Universitari Son Espases, Palma de Mallorca, Spain
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Fallahzadeh MA, Rahimi RS. Hepatic Encephalopathy and Nutrition Influences: A Narrative Review. Nutr Clin Pract 2019; 35:36-48. [PMID: 31872484 DOI: 10.1002/ncp.10458] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023] Open
Abstract
Hepatic encephalopathy (HE) is a potentially reversible neurocognitive condition seen in patients with advanced liver disease. The overt form of HE has been reported in up to 45% of patients with cirrhosis. This debilitating condition is associated with increased morbidity and mortality and imposes a significant burden on the caregivers and healthcare system. After providing an overview of HE epidemiology and pathophysiology, this review focuses on the interaction of HE and frailty, nutrition requirements and recommendations in cirrhotic patients with HE, and current dietary and pharmacologic options for HE treatment.
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Affiliation(s)
- Mohammad Amin Fallahzadeh
- Division of Hepatology, Baylor University Medical Center, Baylor Scott & White Health, Dallas, Texas, USA
| | - Robert S Rahimi
- Division of Hepatology, Baylor University Medical Center, Baylor Scott & White Health, Dallas, Texas, USA
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Vozzo CF, Singh T, Bullen J, Sarvepalli S, McCullough A, Kapoor B. Hospital readmission following transjugular intrahepatic portosystemic shunt: a 14-year single-center experience. Gastroenterol Rep (Oxf) 2019; 8:98-103. [PMID: 32280469 PMCID: PMC7136714 DOI: 10.1093/gastro/goz062] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/24/2019] [Revised: 07/01/2019] [Accepted: 07/24/2019] [Indexed: 12/17/2022] Open
Abstract
Background Placement of a transjugular intrahepatic portosystemic shunt (TIPS) is a relatively common procedure used to treat complications of portal hypertension. However, only limited data exist regarding the hospital-readmission rate after TIPS placement and no studies have addressed the causes of hospital readmission. We therefore sought to identify the 30-day hospital-readmission rate after TIPS placement at our institution and to determine potential causes and predictors of readmission. Methods We reviewed our electronic medical-records system at our institution between 2004 and 2017 to identify patients who had undergone primary TIPS placement with polytetrafluoroethylene-covered stents and to determine the 30-day readmission rate among these patients. A series of univariable logistic-regression models were fit to assess potential predictors of 30-day readmission. Results A total of 566 patients were included in the analysis. The 30-day readmission rate after TIPS placement was 36%. The most common causes for readmission were confusion (48%), infection (15%), bleeding (11%), and fluid overload (7%). A higher Model for End-Stage Liver Disease (MELD) score corresponded with a higher rate of readmission (odds ratio associated with each 1-unit increase in MELD score: 1.06; 95% confidence interval: 1.02–1.09; P = 0.001). Other potential predictors, including indication for TIPS placement, were not significantly associated with a higher readmission rate. Conclusions The 30-day readmission rate after TIPS placement with covered stents is high, with nearly half of these readmissions due to hepatic encephalopathy—a known complication of TIPS placement. Novel interventions to help reduce the TIPS readmission rate should be prioritized in future research.
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Affiliation(s)
- Catherine F Vozzo
- Department of Internal Medicine, Cleveland Clinic, Cleveland, OH, USA
| | - Tavankit Singh
- Department of Gastroenterology and Hepatology, Cleveland Clinic, Cleveland, OH, USA
| | - Jennifer Bullen
- Department of Quantitative Health Sciences, Cleveland Clinic, Cleveland, OH, USA
| | | | - Arthur McCullough
- Department of Gastroenterology and Hepatology, Cleveland Clinic, Cleveland, OH, USA.,Department of Inflammation and Immunity, Cleveland Clinic, Cleveland, OH, USA
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Jindal A, Mukund A, Kumar G, Sarin SK. Efficacy and safety of transjugular intrahepatic portosystemic shunt in difficult-to-manage hydrothorax in cirrhosis. Liver Int 2019; 39:2164-2173. [PMID: 31356712 DOI: 10.1111/liv.14200] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/16/2018] [Revised: 07/08/2019] [Accepted: 07/18/2019] [Indexed: 12/14/2022]
Abstract
BACKGROUND Pleural effusions (PE) complicate cirrhosis in ~5% of patients. Identification of cause and related complications is imperative. Unlike refractory ascites, large-scale studies on interventions for refractory PE are limited. METHODS Consecutive hospitalized cirrhotics having PE were retrospectively analysed. None had liver transplantation (LT) within 6-month follow-up. We determined safety, efficacy and mortality predictors for PE managed with standard medical treatment (SMT), thoracentesis, catheter drainage and TIPS. RESULTS Of 1149 cirrhotics with PE (mean Child-Pugh 10.6 ± 1.8 and MELD 21.2 ± 7.4), 82.6% had hepatic hydrothorax (HH) and 12.3% were suspected tubercular PE (TBPE). Despite comparable HVPG and MELD scores, patients with HH developed more AKI, encephalopathy and septic shock (all P < .01) on follow-up. Among HH, 73.5% were symptomatic, 53.2% isolated right-sided PE and 21.3% had SBE. Presence of SBP [Odd's ratio, OR: 4.5] and catheter drainage [OR: 2.1] were independent predictors for SBE. In 70.3% of admissions, HH responded to SMT alone, 12.9% required thoracentesis and 11.5% underwent catheter drainage. Fifty-one patients were selected for TIPS [lower mean CTP 9.9 ± 1.6 and MELD score 18.7 ± 5.4]. Despite reduction in pressure gradient from 23.1 ± 3.8 mm Hg to 7.2 ± 2.5 mm Hg, 25 patients had partial response, 10 had complete HH resolution. Major post-TIPS complications were portosystemic encephalopathy (eight patients, six resolved) and ischaemic hepatitis (four patients, two resolved). Overall, 35.9% patients with HH had 6-month mortality and independent predictors were MELD > 25, SBP and septic shock. CONCLUSION Refractory PE in cirrhosis requiring interventions including TIPS has poor outcome. The role of haemodynamics in predicting post-TIPS response and complications is limited. Early referral for LT is imperative.
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Affiliation(s)
- Ankur Jindal
- Department of Hepatology, Institute of Liver & Biliary Sciences, New Delhi, India
| | - Amar Mukund
- Departments of Intervention Radiology, Institute of Liver & Biliary Sciences, New Delhi, India
| | - Guresh Kumar
- Department of Biostatistics and Clinical Research, Institute of Liver & Biliary Sciences, New Delhi, India
| | - Shiv K Sarin
- Department of Hepatology, Institute of Liver & Biliary Sciences, New Delhi, India
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Siau K, Chapman W, Sharma N, Tripathi D, Iqbal T, Bhala N. Management of acute upper gastrointestinal bleeding: an update for the general physician. J R Coll Physicians Edinb 2019; 47:218-230. [PMID: 29465096 DOI: 10.4997/jrcpe.2017.303] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
Acute upper gastrointestinal bleed (AUGIB) is one of the most common medical emergencies in the UK, with roughly one presentation every 6 min. Despite advances in therapeutics and endoscopy provision, mortality following AUGIB over the last two decades has remained high, with over 9,000 deaths annually in the UK; consequently, several national bodies have published UK-relevant guidelines. Despite this, the 2015 UK National Confidential Enquiry into Patient Outcome and Death in AUGIB highlighted variations in practice, raised concerns regarding suboptimal patient care and released a series of recommendations. This review paper incorporates the latest available evidence and UK-relevant guidelines to summarise the optimal pre-endoscopic, endoscopic, and post-endoscopic approach to and management of non-variceal and variceal AUGIB that will be of practical value to both general physicians and gastroenterologists.
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Affiliation(s)
- K Siau
- N Bhala, Department of Gastroenterology, University Hospital, Birmingham, Mindelsohn Way, Birmingham B15 2TH, UK.
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