Reporting Standards for Transjugular Intrahepatic Portosystemic Shunts

Combined Transjugular Intrahepatic Portosystemic Shunt Plus Variceal Obliteration versus Transjugular Intrahepatic Portosystemic Shunt Alone for the Management of Gastric Varices: Comparative Single-Center Clinical Outcomes

PURPOSE

To compare the safety and clinical outcomes of combined transjugular intrahepatic portosystemic shunt (TIPS) plus variceal obliteration to those of TIPS alone for the treatment of gastric varices (GVs).

MATERIALS AND METHODS

A single-center, retrospective study of 40 patients with bleeding or high-risk GVs between 2008 and 2019 was performed. The patients were treated with combined therapy (n = 18) or TIPS alone (n = 22). There were no significant differences in age, sex, model for end-stage liver disease score, or GV type between the groups. The primary outcomes were the rates of GV eradication and rebleeding. The secondary outcomes included portal hypertensive complications and hepatic encephalopathy.

RESULTS

The mean follow-up period was 15.4 months for the combined therapy group and 22.9 months for the TIPS group (P = .32). After combined therapy, there was a higher rate of GV eradication (92% vs 47%, P = .01) and a trend toward a lower rate of GV rebleeding (0% vs 23%, P = .056). The estimated rebleeding rates were 0% versus 5% at 3 months, 0% versus 11% at 6 months, 0% versus 18% at 1 year, and 0% versus 38% at 2 years after combined therapy and TIPS, respectively (P = .077). There was no difference in ascites (13% vs 11%, P = .63), hepatic encephalopathy (47% vs 55%, P = .44), or esophageal variceal bleeding (0% vs 0%, P > .999) after the procedure between the groups.

CONCLUSIONS

The GV eradication rate is significantly higher after combined therapy, with no associated increase in portal hypertensive complications. This translates to a clinically meaningful trend toward a reduction in GV rebleeding. The value of a combined treatment strategy should be prospectively studied in a larger cohort to determine the optimal management of GVs.

Balloon-occluded Retrograde Transvenous Obliteration Versus Transjugular Intrahepatic Portosystemic Shunt for Gastric Varices: A Meta-Analysis

INTRODUCTION

Balloon-occluded retrograde transvenous obliteration (BRTO) and transjugular intrahepatic portosystemic shunt (TIPS) are well-validated techniques in the management of portal hypertensive gastric variceal bleeding when medical management alone is not sufficient. However, despite their effectiveness, the adverse effects from both procedures make each technique more suitable to different cohorts of patient's depending on presence or lack of certain comorbidities. This study aims to compare clinical outcomes of patients who have undergone both procedures for portal hypertensive gastric variceal bleeding.

MATERIALS AND METHODS

We conducted a search of electronic databases from their establishment to April 2019. The goal was to compare the efficacy of BRTO and TIPS in preventing variceal rebleeding and the risk of adverse events such as ascites and hepatic encephalopathy. Predictors of overall survival and rebleeding were also analyzed. Meta-analysis was performed with STATA 15.1.

RESULTS

Five randomized controlled trials and retrospective cohort studies were included in our meta-analysis. The number of patients who underwent BRTO and TIPS were 308 and 127, respectively. BRTO and TIPS have similar technical success rates (91.4% vs. 89.7%, P=0.995) and immediate bleeding control rates (97.7% vs. 95.9%, P=0.836). However, compared with TIPS, BRTO has lower likelihood of future cumulative rebleeding (10.6% vs. 18.7%, P=0.027) and hepatic encephalopathy (0.00% vs. 23.1%, P<0.001) but is more likely to aggravate ascites (22.4% vs. 4.3%, P=0.009). Serum albumin level and presence of hepatocellular carcinoma are both independent predictors of increased likelihood of rebleeding and overall survival (P<0.001).

CONCLUSIONS

Both BRTO and TIPS are safe and effective interventions in the management algorithm of portal hypertensive gastric variceal bleeding. Although BRTO may be more effective at the prevention of future variceal rebleeding, the choice of BRTO versus TIPS should be tailored according to patient's comorbidities.

Long-term Outcome of Transjugular Intrahepatic Portosystemic Shunt in Children With Portal Hypertension

OBJECTIVES

A proportion of children with chronic liver disease have severe portal hypertension (PH) and a preserved synthetic and biliary function. In our institution these children have been managed with transjugular intrahepatic portosystemic shunts (TIPS). We aimed to evaluate the long-term patency of TIPS placed in pediatric patients with PH.

METHODS

Retrospective study of children who underwent TIPS in the last 15 years. We compared patients with cirrhotic PH to those with noncirrhotic PH, and all with an historical cohort of children who underwent a surgical portosystemic shunt. Kaplan-Meier analysis measured long-term shunt patency.

RESULTS

Twenty-nine patients were recorded (cirrhotic PH = 11, noncirrhotic PH  = 18, mean age 10.3 years[±4.3], mean weight 36.7 kg [±20.1], mean pediatric end-stage liver disease score 4.1 [±7.1]); in 5 TIPS was placed after split liver transplantation. Indication for TIPS was variceal bleeding in 18, refractory ascites in 11. Primary patency rates at 6 months and at 1, 2, and 4 years were 91%, 83%, 60%, and 46%, respectively. At last follow-up (mean of 2.8 years [±2.4, range 0.1-8.1 years]) secondary patency (after radiological revision) was 100%. The patency rate of the historical cohort of patients who underwent a surgical portosystemic shunt was 26 of 31 (82%) at a median follow-up of 12.5 years (1.6-25.8).

CONCLUSION

TIPS appears to have a high mid-term patency rate, especially if monitored and revised. Its high clinical success rate, along with a minimally invasive approach, suggests that in this setting TIPS should not be regarded only as a bridge to liver transplantation.

Technical Feasibility and Clinical Effectiveness of Transjugular Intrahepatic Portosystemic Shunt Creation in Pediatric and Adolescent Patients

PURPOSE

To examine the technical feasibility and clinical efficacy of transjugular intrahepatic portosystemic shunt (TIPS) creation in children and adolescents.

MATERIALS AND METHODS

Retrospective review was performed of 59 patients (mean age 12.6 y [range, 1.5-20 y], mean weight 47.5 kg [range, 11.4-112.2 kg], mean Model for End-stage Liver Disease/Pediatric End-stage Liver Disease score 12.5 [range, 6-33]) who underwent 61 TIPS attempts at 3 tertiary children's hospitals from 2001 to 2017 for acute esophageal or gastroesophageal variceal bleeding, primary and secondary prevention of variceal bleeding, and refractory ascites. Pediatric liver disease etiologies included biliary atresia, cystic fibrosis, and ductal plate anomalies. Technical, hemodynamic, and clinical success and patency rates were reported at 1, 6, 12, and 24 months. Statistical analysis evaluated reasons for clinical failure. Kaplan-Meier analysis measured clinical success, patency, and transplant-free survival.

RESULTS

Technical success was 93.4% (57/61) in 59 consecutive patients. Most common TIPS indications were treating and preventing esophageal and gastroesophageal variceal bleeding (57/59; 96.6%). Hemodynamic success was 94% (47/50). Clinical success was 80.7% (45/56). Two-year clinical success for acute variceal bleeding and ascites was 94.1% and 100%, respectively. Overall patency at 1, 6, 12, and 24 months was 98.0%, 97.8%, 94.3%, and 91.3%. Two-year transplant-free survival was 88.8%. Overall and major complication rates were 21.2% (13/61) and 8.2% (5/61), with 3 mortalities. Gradient reduction < 12 mm Hg correlated with clinical success (P < .01).

CONCLUSIONS

TIPS creation in pediatric patients is technically feasible and clinically efficacious for treatment and prevention of esophageal and gastroesophageal variceal hemorrhage. High 2-year clinical success, patency, and survival rates should encourage providers to consider portosystemic shunts as a bridge to liver transplantation.

Race and Gradient Difference Are Associated with Increased Risk of Hepatic Encephalopathy Hospital Admission After Transjugular Intrahepatic Portosystemic Shunt Placement

BACKGROUND/AIMS

Hepatic encephalopathy (HE) is a well-recognized complication of transjugular intrahepatic portosystemic shunt (TIPS) placement. The aim of this investigation was to evaluate incidence and predictors of post-TIPS HE necessitating hospital admission in a non-clinical trial setting.

METHODS

We performed a retrospective cohort study identifying 273 consecutive patients undergoing TIPS from 2010 to 2015 for any indication; 210 met inclusion/exclusion criteria. The primary endpoint was incidence of post-TIPS HE defined as encephalopathy with no other identifiable cause requiring hospitalization within 90 days of TIPS. Clinical demographics and procedural variables were collected and analyzed to determine predictors of readmission for post-TIPS HE. Categorical variables were analyzed using Fisher's exact test; continuous variables were compared using Levene's t-test and student's t-test; P < 0.05, significant.

RESULTS

Forty-two of 210 patients (20%) developed post-TIPS HE requiring hospitalization within 90 days. On analysis of cohorts (post-TIPS HE vs. no post-TIPS HE): non-white race (31.0% vs. 17.5%, P = 0.022) and increased hepatic venous pressure gradient (HVPG) difference during TIPS (10.5 vs. 8.9 mmHg, P = 0.030) were associated with an increased incidence of HE requiring readmission within 90 days.

CONCLUSIONS

HE remains a common complication of TIPS. Non-Caucasian race is a significant clinical demographic associated with increased risk for readmission. Independent of initial or final HVPG, HVPG difference appears to be a significant modifiable technical risk factor. In the absence of clear preventative strategies for post-TIPS encephalopathy, non-Caucasians with HVPG reductions >9 mmHg may require targeted follow up evaluation to prevent hospital readmission.

Predictors of Shunt Dysfunction and Overall Survival in Patients with Variceal Bleeding Treated with Transjugular Portosystemic Shunt Creation Using the Fluency Stent Graft

RATIONALE AND OBJECTIVES

Transjugular intrahepatic portosystemic shunt (TIPS) is an established method for portal hypertension. This study was to investigate the long-term safety, technical success, and patency of TIPS, and to determine the risk factors and clinical impacts of shunt dysfunction.

MATERIALS AND METHODS

A total of 154 consecutive patients undergoing embolotherapy of gastric coronary vein and/or short gastric vein and TIPS creation were prospectively studied. Follow-up data included technical success, patency and revision of TIPS, and overall survival of patients.

RESULTS

During the study, the primary and secondary technical success rates were 98.7% and 100%, respectively. Sixty-three patients developed shunt dysfunction, 30 with shunt stenosis and 33 with shunt occlusion. The cumulative 60-month primary, primary assisted, and secondary patency rates were 19.6%, 43.0%, and 93.4%, respectively. The cumulative 60-month overall survival rates were similar between the TIPS dysfunction group and the TIPS non-dysfunction group (68.6% vs. 58.6%, P = .096). Baseline portal vein thrombosis (P < .001), use of bare stents (P = .018), and portal pressure gradient (PPG) (P = .020) were independent predictors for shunt dysfunction, hepatocellular carcinoma (P < .001), and ascites (P = .003) for overall survival. The accuracy of PPG for shunt dysfunction was statistically significant (P < .001), and a cutoff value of 8.5 had 77.8% sensitivity and 64.8% specificity.

CONCLUSIONS

The long-term safety, technical success, and patency of TIPS were good; baseline portal vein thrombosis, use of bare stents, and PPG were significantly associated with shunt dysfunction; shunt dysfunction has little impact on patients' long-term survival because of high secondary patency rates.

Comparison of treatment outcomes between balloon-occluded retrograde transvenous obliteration and transjugular intrahepatic portosystemic shunt for gastric variceal bleeding hemostasis

BACKGROUND AND AIM

Both balloon-occluded retrograde transvenous obliteration (BRTO) and transjugular intrahepatic portosystemic shunt (TIPS) are considered effective treatments for gastric variceal bleeding (GVB). In this study, outcomes of these two procedures were compared in managing patients with GVB.

METHODS

A total of 142 patients undergoing BRTO (n = 95) or TIPS (n = 47) between 2005 and 2012 at two tertiary centers were selected for retrospective review.

RESULTS

Mean patient age (male, 115; female, 27) was 58.1 years. Alcoholic liver cirrhosis was the most common underlying cause (n = 63, 44.4%), followed by hepatitis B (n = 60, 42.3%) and hepatitis C (n = 7, 4.9%) viral infections. Concurrent hepatocellular carcinoma (HCC) was identified in 64 (45.1%) patients. During the follow-up period (mean, 28.2 months), 27 patients (19%) experienced re-bleeding. Cumulative re-bleeding rates after BRTO (8.6% at 1 year; 22.7% at 3 years) were significantly lower than those after TIPS (19.8% at 1 year; 48.2% at 3 years; P = 0.006, log-rank test). In multivariate analysis, TIPS (vs BRTO) was found independently predictive of re-bleeding (hazard ratio [HR] = 2.174; P = 0.048), in addition to concurrent HCC and poor baseline Child-Pugh score (both P < 0.05). Although BRTO surpassed TIPS (P = 0.026, log-rank test) in terms of overall postprocedural survival, independent factors predictive of poor overall survival after hemostasis were concurrent HCC (HR = 3.106), high Child-Pugh score (HR = 1.886 per 1-point increase), and postprocedural hepatic encephalopathy (HR = 3.014; all P < 0.05).

CONCLUSION

Balloon-occluded retrograde transvenous obliteration proved more effective than TIPS in hemostasis of GVB, associated with significantly less risk of re-bleeding.

Consensus conference on TIPS management: Techniques, indications, contraindications

The trans jugular intrahepatic Porto systemic shunt (TIPS) is no longer viewed as a salvage therapy or a bridge to liver transplantation and is currently indicated for a number of conditions related to portal hypertension with positive results in survival. Moreover, the availability of self-expandable polytetrafluoroethylene (PTFE)-covered endoprostheses has dramatically improved the long-term patency of TIPS. However, since the last updated International guidelines have been published (year 2009) new evidence have come, which have open the field to new indications and solved areas of uncertainty. On this basis, the Italian Association of the Study of the Liver (AISF), the Italian College of Interventional Radiology-Italian Society of Medical Radiology (ICIR-SIRM), and the Italian Society of Anesthesia, Analgesia and Intensive Care (SIAARTI) promoted a Consensus Conference on TIPS. Under the auspices of the three scientific societies, the consensus process started with the review of the literature by a scientific board of experts and ended with a formal consensus meeting in Bergamo on June 4th and 5th, 2015. The final statements presented here were graded according to quality of evidence and strength of recommendations and were approved by an independent jury. By highlighting strengths and weaknesses of current indications to TIPS, the recommendations of AISF-ICIR-SIRM-SIAARTI may represent the starting point for further studies.

Minilaparotomy-Assisted Transmesenteric-Transjugular Intrahepatic Portosystemic Shunt: Comparison with Conventional Transjugular Approach

PURPOSE

This study was performed to compare the intrahepatic shunt function outcome and procedural complications of minilaparotomy-assisted transmesenteric (MAT)-transjugular intrahepatic portosystemic shunt (TIPS) placement with the conventional transjugular method.

METHODS

This is a retrospective review of all patients who had a MAT or conventional TIPS procedure over a 6-year period at our institute. The primary patency rate, fluoroscopy time, technical success, major procedure-related complications, and mortality data were compared between two treatment groups.

RESULTS

We included 49 patients with MAT-TIPS, and 63 with conventional TIPS, with an average follow-up of 21.43 months. The primary patency rates at 6 and 12 months were 82.9 and 66.7 % in the conventional TIPS group, and 81.0 and 76.5 % in the MAT-TIPS group (p = 1.000, and 0.529), respectively. There was no significant difference in technical success rate, post-procedure portosystemic pressure gradient, fluoroscopy time, and peri-procedural mortality rate between treatment groups. Major procedural-related complications were seen more frequently among MAT-TIPS patients (p = 0.012). In the MAT-TIPS group, 5 (10.2 %) patients developed post-procedure minilaparotomy, wound-related complications, and 5 (10.2 %) developed bacterial peritonitis; whereas, none of patients with conventional TIPS had either of these complications (p = 0.014).

CONCLUSION

While both MAT-TIPS and conventional TIPS had similar shunt primary patency rate and technical success rate, the MAT approach was associated with a significantly higher rate of minilaparotomy-related wound complications or infectious complications. These complications maybe prevented by a change in post-procedure monitoring and therapy.

Use of a transjugular intrahepatic portosystemic shunt combined with autologous bone marrow cell infusion in patients with decompensated liver cirrhosis: an exploratory study

BACKGROUND AIMS

Currently, there is no treatment for decompensated liver cirrhosis except for liver transplantation. The safety and effect on liver function of a transjugular intrahepatic portosystemic shunt (TIPS) with and without autologous bone marrow cell (BMC) infusion in patients with decompensated liver cirrhosis were determined.

METHODS

Ten patients who were diagnosed with decompensated liver cirrhosis during the period from September 2011 to July 2012 were enrolled in this study. The patients underwent TIPS (TIPS group) or combined treatment with TIPS and BMC infusion through the hepatic artery (TIPS+BMC group). All patients were monitored for adverse events, liver function and complications caused by portal hypertension during a period of 52 weeks.

RESULTS

The number of infused BMCs was 2.65 ± 1.20 ×10(9). Significant improvements in the serum levels of albumin and total bilirubin and decreased Child-Pugh scores were observed in patients treated with both TIPS and BMCs (P < 0.05), whereas no such changes were observed in the TIPS group. Endoscopic findings showed that varices in the esophagus and the gastric fundus were alleviated after either treatment. All 10 patients showed a complete or partial resolution of ascites at 4 weeks. No major adverse effects were noted during the follow-up period for patients in either group.

CONCLUSIONS

TIPS combined with BMC infusion is clinically safe; the treatment improved liver function and alleviated complications caused by portal hypertension; therefore, this combination has potential for treatment of patients with decompensated liver cirrhosis.

Long-Term Patency and Clinical Analysis of Expanded Polytetrafluoroethylene-Covered Transjugular Intrahepatic Portosystemic Shunt Stent Grafts

PURPOSE

To evaluate long-term patency and symptomatic recurrence rates following transjugular intrahepatic portosystemic shunt (TIPS) creation with expanded polytetrafluoroethylene (ePTFE)-covered stent grafts and to determine the necessity of extended clinical follow-up beyond 2 years after TIPS creation.

MATERIALS AND METHODS

A retrospective review including 262 TIPSs created with ePTFE-covered stent grafts between July 2002 and October 2012 was performed. Primary, primary assisted, and secondary patency rates were calculated. Assessment of clinical data included technical, hemodynamic, and clinical success rates, as well as mortality after TIPS creation.

RESULTS

Primary patency rates at 2, 4, and 6 years were 74%, 62%, and 50%, respectively. Primary assisted patency rates at 2, 4, and 6 years were 93%, 85%, and 78%, respectively. Secondary patency rates at 2, 4, and 6 years were 99%, 91%, and 84%, respectively. Technical and hemodynamic success rates were 99% and 93%, respectively. Clinical success rates for refractory ascites were 66% (complete response) and 90% (partial response); clinical success rate for bleeding/varices was 90%. Mortality rates at 2, 4, and 6 years after TIPS creation were 27%, 38%, and 46%, respectively. At the median wait time until transplantation, patients had an 84% chance of being alive. TIPS dysfunction developed in 21% of patients; 30% of revisions occurred later than 2 years during follow-up.

CONCLUSIONS

Beyond 2 years after TIPS creation, patency rates gradually decrease, mortality rates continue to increase, and the chance of recurrent ascites or bleeding remains present. Together, these findings suggest that continued clinical follow-up beyond 2 years is necessary in patients with a TIPS created with an ePTFE-covered stent graft.

Clearing the Confusion over Hepatic Encephalopathy After TIPS Creation: Incidence, Prognostic Factors, and Clinical Outcomes

PURPOSE

To assess the incidence, prognostic factors, and clinical outcomes of hepatic encephalopathy (HE) after transjugular intrahepatic portosystemic shunt (TIPS) creation.

MATERIALS AND METHODS

In this single-institution retrospective study, 191 patients (m:f = 114:77, median age 54 years, median Model for End-Stage Liver Disease or MELD score 14) who underwent TIPS creation between 1999 and 2013 were studied. Medical record review was used to identify demographic characteristics, liver disease, procedure, and outcome data. Post-TIPS HE within 30 days was defined by new mental status changes and was graded according to the West Haven classification system. The influence of data parameters on HE occurrence and 90-day mortality was assessed using binary logistic regression.

RESULTS

TIPS was successfully created with hemodynamic success in 99 % of cases. Median final PSG was 7 mmHg. HE incidence within 30 days was 42 % (81/191; 22 % de novo, 12 % stable, and 8 % worsening). Degrees of HE included grade 1 (46 %), grade 2 (29 %), grade 3 (18 %), and grade 4 (7 %). Medical therapy typically addressed HE, and shunt reduction was necessary in only three cases. MELD score (P = 0.020) and age (P = 0.009) were significantly associated with HE development on multivariate analysis. Occurrence of de novo HE post-TIPS did not associate with 90-day mortality (P = 0.400), in contrast to worsening HE (P < 0.001).

CONCLUSIONS

The incidence of post-TIPS HE is non-trivial, but symptoms are typically mild and medically managed. HE rates are higher in older patients and those with worse liver function and should be contemplated when counseling on expected TIPS outcomes and post-procedure course.

Nonendoscopic management strategies for acute esophagogastric variceal bleeding

Acute variceal bleeding is a potentially life-threatening complication of portal hypertension. Management consists of emergent hemostasis, therapy directed at hemodynamic resuscitation, protection of the airway, and prevention and treatment of complications including prophylactic use of antibiotics. Endoscopic treatment remains the mainstay in the management of acute variceal bleeding in combination with pharmacotherapy aimed at reducing portal pressure. This article intends to highlight only the current nonendoscopic treatment approaches for control of acute variceal bleeding.

Percutaneous Portosystemic Shunts: TIPS and Beyond

Percutaneous interventions for portal hypertension have been available since the 1990s. Over time, improved technology-including covered stent grafts-and clinical understanding has expanded the available procedures for percutaneous portal decompression. While transjugular intrahepatic portosystemic shunt creation is the most commonly cited percutaneous intervention, direct intrahepatic portocaval shunt and percutaneous mesocaval shunt creation are important alternatives with specific advantages and applications. This article reviews contemporary, minimally invasive interventional approaches to percutaneous portosystemic shunt creation in terms of procedure rationale, patient selection, interventional technique, and technical outcomes.

Clinical outcomes of transjugular intrahepatic portosystemic shunt for portal hypertension: Korean multicenter real-practice data

Background/Aims

This retrospective study assessed the clinical outcome of a transjugular intrahepatic portosystemic shunt (TIPS) procedure for managing portal hypertension in Koreans with liver cirrhosis.

Methods

Between January 2003 and July 2013, 230 patients received a TIPS in 13 university-based hospitals.

Results

Of the 229 (99.6%) patients who successfully underwent TIPS placement, 142 received a TIPS for variceal bleeding, 84 for refractory ascites, and 3 for other indications. The follow-up period was 24.9±30.2 months (mean±SD), 74.7% of the stents were covered, and the primary patency rate at the 1-year follow-up was 78.7%. Hemorrhage occurred in 30 (21.1%) patients during follow-up; of these, 28 (93.3%) cases of rebleeding were associated with stent dysfunction. Fifty-four (23.6%) patients developed new hepatic encephalopathy, and most of these patients were successfully managed conservatively. The cumulative survival rates at 1, 6, 12, and 24 months were 87.5%, 75.0%, 66.8%, and 57.5%, respectively. A high Model for End-Stage Liver Disease (MELD) score was significantly associated with the risk of death within the first month after receiving a TIPS (P=0.018). Old age (P<0.001), indication for a TIPS (ascites vs. bleeding, P=0.005), low serum albumin (P<0.001), and high MELD score (P=0.006) were associated with overall mortality.

Conclusions

A high MELD score was found to be significantly associated with early and overall mortality rate in TIPS patients. Determining the appropriate indication is warranted to improve survival in these patients.

Recurrent variceal bleeding and shunt patency: prospective randomized controlled trial of transjugular intrahepatic portosystemic shunt alone or combined with coronary vein embolization

PURPOSE

To prospectively evaluate the efficacy of a transjugular intrahepatic portosystemic shunt (TIPS) alone and TIPS in association with embolotherapy (TIPS+E) in the variceal coronary vein to prevent recurrent variceal bleeding and stent dysfunction after TIPS creation.

MATERIALS AND METHODS

Institutional review board approval was obtained; all participants provided informed consent. A total of 106 patients (66 men, 40 women; age range, 18-70 years) with recurrent variceal bleeding due to hepatic cirrhosis were assigned randomly to the TIPS+E (n = 54) or TIPS (n = 52) group from May 2007 to July 2011. The TIPS was created by using covered stents. Patients in the TIPS+E group underwent embolotherapy via the jugular vein before TIPS implantation. Rates of recurrent variceal bleeding, stent patency, and survival were evaluated. Scores for liver function and life quality were calculated.

RESULTS

TIPS placement was successful in all patients. Recurrent variceal bleeding ranked second among causes of death after TIPS placement. Although the 3-year cumulative rates of shunt patency, recurrent variceal bleeding, and survival in the two groups were not significantly different (P > .05), the 6-month overall rate of shunt patency in the TIPS+E group was significantly higher than that in the TIPS group (96.2% vs 82.0%, P = .019), and the 6-month overall rate of recurrent variceal bleeding was also significantly lower than that in the TIPS group (5.7% vs 20.0%, P = .029).

CONCLUSION

The TIPS+E regimen may reduce the risk of recurrent variceal bleeding during the first 6 months after the TIPS procedure by preventing shunt dysfunction, which may improve liver function and quality of life. © RSNA, 2013.

Percutaneous transportal outflow-vessel-occluded sclerotherapy for gastric varices unmanageable by balloon-occluded retrograde transvenous obliteration

In this report we introduce percutaneous transportal outflow-vessel-occluded sclerotherapy (PTOS) for gastric varices unmanageable by balloon-occluded retrograde transvenous obliteration (BRTO) in two cases and evaluate its safety and efficacy. The PTOS is a technique which could obstruct gastric varices subsequent to the occlusion of the outflow route, being based on the rationale of BRTO. In the PTOS procedure, coil embolization of the outflow vessel is first conducted through a microcatheter advanced beyond the gastric varices via the percutaneous transhepatic approach; sclerosing agent (5% ethanolamine oleate) is then injected into the gastric varices after confirmation of static blood flow in the varices. Two patients underwent initial BRTO that eventually failed because of the presence of numerous fine and abruptly angled outflow vessels (case 1), and the presence of a tortuous and elongated outflow vessel accompanied by numerous small collateral outflows that could not be occluded (case 2). Cases 1 and 2 received PTOS using 5% ethanolamine oleate (15 mL and 10 mL, respectively). Portal venous pressure following PTOS showed an increase from 29 to 34 mmHg in case 1 and remained at 24 mmHg in case 2. No major complication was encountered in either patient. One-year follow-up gastroendoscopy showed no recurrence of gastric varices in either patient. Although PTOS is slightly more invasive than BRTO, PTOS can be used as an alternative catheter treatment procedure for gastric varices that are unmanageable by BRTO.

Hepatotoxicity after transarterial chemoembolization and transjugular intrahepatic portosystemic shunt: do two rights make a wrong?

PURPOSE

To compare the rates of hepatotoxicity after transarterial chemoembolization for hepatocellular carcinoma (HCC) in patients with and without a transjugular intrahepatic portosystemic shunt (TIPS) who were stratified into comparable risk groups.

MATERIALS AND METHODS

A retrospective review of patients with HCC who were treated with transarterial chemoembolization between January 2005 and December 2009 was performed. Of 158 patients with comparable model for end-stage liver disease (MELD) scores, 10 had a patent TIPS. Hepatobiliary severe adverse events (SAEs) occurring after transarterial chemoembolization were documented. In addition, 1-year survival and liver transplantation rate after transarterial chemoembolization were calculated in each group.

RESULTS

The incidence of hepatobiliary SAEs after transarterial chemoembolization was nearly two times higher in patients with a TIPS (70%) than in patients without a TIPS (36%; P=.046). The liver transplantation rate 1 year after transarterial chemoembolization was 2.5 times higher in patients with a TIPS (80%) than in patients without a TIPS (32%; P=.004). There was no significant difference in 1-year survival between the two groups after transarterial chemoembolization.

CONCLUSIONS

Patients with HCC and a patent TIPS are more likely to develop significant hepatotoxicity after transarterial chemoembolization than comparable patients without a TIPS in place.

Using transjugular intrahepatic portosystemic shunts for complications of cirrhosis

Transjugular intrahepatic portosystemic shunt (TIPS) decompresses the portal venous system. TIPS has been used to manage the complications of portal hypertension in cirrhosis, including variceal hemorrhage and refractory ascites. The uncoated TIPS stents are limited by stent stenosis; however, the introduction of coated stents has decreased this. With the introduction of coated stents, we must reevaluate the utility of TIPS in the management of complications of portal hypertension.

Advanced hemodynamic monitoring before and after transjugular intrahepatic portosystemic shunt: implications for selection of patients--a prospective study

PURPOSE

To investigate immediate and short-term effects of transjugular intrahepatic portosystemic shunt (TIPS) on cardiocirculatory, hepatic, and renal function and characterize predictors for TIPS outcome in terms of organ function after TIPS.

MATERIALS AND METHODS

This prospective study was approved by the ethics committee at a university hospital and was conducted in a medical intensive care unit. Informed consent was obtained. Twenty patients with indication for TIPS were enrolled. Monitoring of hemodynamic and hepatic function (transpulmonary thermodilution, indocyanine green plasma disappearance rate [ICG-PDR]) was performed. Biochemical markers of organ function were obtained. Statistical analysis (Wilcoxon test, Spearman correlation, multivariate linear regression analysis, receiver operating characteristic [ROC] analysis) was performed.

RESULTS

After TIPS, central venous pressure (median, 11 vs 15 cm H(2)O; P < .001), cardiac index (3.4 vs 3.8 L/min/m(2); P = .001), and global end-diastolic volume index (GEDVI) (726 vs 775 mL/m(2); P = .003) increased significantly. Portosystemic pressure gradient (28 vs 11 cm H(2)O; P < .001) and systemic vascular resistance index (1610 vs 1384 dyn · sec · cm(-5) · m(2); P = .015) decreased significantly. Creatinine (1.1 vs 1.1 mg/dL; P = .008) and blood urea nitrogen (BUN) (27 vs 21 mg/dL; P = .006) decreased significantly. Bilirubin (1.8 vs 2.2 mg/dL; P = .032) and international normalized ratio (1.4 vs 1.5; P = .022) increased significantly. ICG-PDR significantly deteriorated after TIPS (P = .006). Higher baseline creatinine was independently associated with a decrease in creatinine after TIPS (R = 0.816, P < .001). ROC analysis identified baseline BUN (P = .026, area under ROC curve [AUC] = 0.818), cystatin C (P = .033, AUC = 0.805), and creatinine (P = .052, AUC = 0.779) as predictors of a decrease in creatinine of 0.5 mg/dL or greater and/or 25% or greater. An increase in bilirubin of 1 mg/dL or greater 1 week after TIPS was significantly associated with high baseline BUN (P = .007, AUC = 0.893) and high central venous pressure (P = .040, AUC = 0.800). Lower baseline alanine aminotransferase (P = .002, AUC = 1.000) and cardiac power index · GEDVI (P = .005, AUC = 0.960) predicted favorable TIPS outcome (creatinine decrease of ≥ 0.2 mg/dL without model for end-stage liver disease score increase of more than one point).

CONCLUSION

Patients with renal insufficiency, compensated hepatocellular function, decreased cardiac preload, and decreased cardiac performance benefit most from TIPS.

A case-controlled study of the safety and efficacy of transjugular intrahepatic portosystemic shunts after liver transplantation

The role of transjugular intrahepatic portosystemic shunt (TIPS) insertion in managing the complications of portal hypertension is well established, but its utility in patients who have previously undergone liver transplantation is not well documented. Twenty-two orthotopic liver transplantation (OLT) patients and 44 nontransplant patients (matched controls) who underwent TIPS were analyzed. In the OLT patients, the TIPS procedure was performed at a median of 44.8 months (range = 0.3-143 months) after transplantation. Eight (36.4%) had variceal bleeding, and 14 (63.6%) had refractory ascites. The underlying liver disease was cholestatic in 10 (45.4%) and viral in 4 (18.2%). The mean pre-TIPS Model for End-Stage Liver Disease (MELD) score was 13.4 ± 5.1. There were no significant differences in age, sex, indication, etiology, or MELD score with respect to the control group. The mean initial portal pressure gradients (PPGs) were similar in the 2 groups (21.0 versus 22.4 mm Hg for the OLT patients and controls, respectively), but the final PPG was lower in the control group (9.9 versus 6.9 mm Hg, P < 0.05). The rates of both technical success and clinical success were higher in the control group versus the OLT group [95.5% versus 68.2% (P < 0.05) and 93.2% versus 77.2% (P < 0.05), respectively]. The rates of complications and post-TIPS encephalopathy were similar in the 2 groups, and there was a trend toward increased rates of shunt insufficiency in the OLT group. The mortality rate of the patients with a pre-TIPS MELD score > 15 was significantly higher in the OLT group [hazard ratio (HR) = 4.32, 95% confidence interval (CI) = 1.45-12.88, P < 0.05], but the mortality rates of the patients with a pre-TIPS MELD score < 15 were similar in the 2 groups. In the OLT group, the predictors of increased mortality were the pre-TIPS MELD score (HR = 1.161, 95% CI = 1.036-1.305, P < 0.05) and pre-TIPS MELD scores > 15 (HR = 5.846, 95% CI = 1.754-19.485, P < 0.05). In conclusion, TIPS insertion is feasible in transplant recipients, although its efficacy is lower in these patients versus control patients. Outcomes are poor for OLT recipients with a pre-TIPS MELD score > 15.

Stent-grafts for transjugular intrahepatic portosystemic shunt creation: specialized TIPS stent-graft versus generic stent-graft/bare stent combination

PURPOSE

To compare functional and anatomic outcomes of transjugular intrahepatic portosystemic shunts (TIPSs) created with the specialized Viatorr stent versus a Wallstent/Fluency stent combination.

MATERIALS AND METHODS

Retrospective review of patients who underwent TIPS creation with stent-grafts was conducted over a 54-month period ending in June 2008. Patients were divided into three groups: Viatorr only, Fluency only, and combined Viatorr/Fluency, the latter of which was included in the overall evaluation but excluded from the comparative analysis between the Viatorr and Fluency groups. Patient demographics, Child-Pugh scores, and portosystemic gradient (PSG) reduction were compared. Patencies were calculated using the Kaplan-Meier method and compared.

RESULTS

A total of 126 TIPSs created with stent-grafts were found: 28 with Fluency stents, 93 with Viatorr devices, and five combined. No significance in demographic factors or PSGs was found among groups (P > .05). Major encephalopathy rates were 3.6% and 4.3% in the Fluency and Viatorr groups, respectively (P = 1.000). Hemodynamic success rates were 93% and 98% in the Fluency and Viatorr groups, respectively (P = .099). The primary unassisted patency rates at 6, 9, and 12 months were 87%, 81%, and 81%, respectively, in the Fluency group and 95%, 93%, and 89%, respectively, in the Viatorr group (P = .03). Portal and hepatic end stenoses were the causes of TIPS narrowing in the Fluency and Viatorr groups, respectively.

CONCLUSIONS

The Wallstent/Fluency stent combination is associated with a 1-year patency rate greater than 80%, with no significant difference versus the Viatorr stent regarding technical and hemodynamic success and encephalopathy rate. However, the Viatorr stent is associated with improved patency (89%) versus this bare stent/stent-graft combination.

Influence of the secondary deployment of expanded polytetrafluoroethylene-covered stent grafts on maintenance of transjugular intrahepatic portosystemic shunt patency

PURPOSE

To evaluate the effects of secondary deployment of expanded polytetrafluoroethylene (ePTFE)-covered stent grafts in the treatment of dysfunctional transjugular intrahepatic portosystemic shunts (TIPSs) in comparison with other common approaches (conventional angioplasty or implantation of bare metal stents).

MATERIALS AND METHODS

A retrospective review of 121 dysfunctional bare metal TIPS presenting between 2000 and 2004 was conducted. The group was divided into four subgroups according to the type of intervention: conventional angioplasty (52 cases; 43%), bare metal stent deployment (35 cases; 28.9%), nondedicated ePTFE-covered stent-graft deployment (15 cases; 12.4%), and dedicated ePTFE-covered stent-graft deployment (19 cases; 15.7%). In all four groups, the primary patency after the specific intervention was calculated and mutually compared.

RESULTS

Primary patency rates after 12 and 24 months were 49.7% and 25.3%, respectively, in conventional angioplasty; 74.9% and 64.9%, respectively, with bare metal stents; 75.2% and 64.5%, respectively, with nondedicated ePTFE-covered stent grafts; and 88.1% and 80.8%, respectively, with dedicated ePTFE-covered stent grafts.

CONCLUSIONS

In the treatment of dysfunctional TIPS, better patency after the intervention was obtained by deploying dedicated ePTFE-covered stent grafts in comparison with conventional angioplasty, bare metal stents, and nondedicated ePTFE-covered stents.

Effect of transjugular intrahepatic portosystemic shunt placement on renal function: a 7-year, single-center experience

PURPOSE

Transjugular intrahepatic portosystemic shunt (TIPS) creation has been shown to improve renal function in small series of patients with hepatorenal syndrome. The present study examined the effect of TIPS creation on renal function in a large series of patients undergoing TIPS creation who had varying degrees of baseline renal function.

MATERIALS AND METHODS

All de novo TIPS creations during a 7-year period at a single institution were retrospectively reviewed regardless of indication. Pre- and postprocedural laboratory values were obtained and used to calculate Model for End-Stage Liver Disease (MELD) scores and glomerular filtration rates. Subanalysis was performed based on degree of renal insufficiency and indication for the procedure.

RESULTS

A total of 201 successful conventional TIPS procedures were identified. Of those, 72 patients were excluded for lack of follow-up, death during the same hospitalization, lack of TIPS function, or end-stage renal failure requiring dialysis before TIPS creation, leaving 129 procedures. Patients with preprocedural creatinine levels of 1.2-1.9 mg/dL (n = 45) showed an improvement in mean creatinine from 1.5 to 1.1 mg/dL (P < 10(-12)) and patients with preprocedure creatinine levels greater than 2.0 mg/dL (n = 21) showed an improvement from 2.8 to 1.5 mg/dL (P < 10(-5)). MELD scores decreased in patients with creatinine levels greater than 2.0 mg/dL from 22.1 to 19.2 (P < 0.005) but increased in all other patient groups. Amount of iodinated contrast medium administered did not affect creatinine level changes.

CONCLUSIONS

TIPS creation improves renal dysfunction in chronic liver disease. Patients with poorer renal function benefit the most from TIPS creation.

Evaluation of cardiac function in patients with liver cirrhosis

AIM OF THE STUDY

To study the cardiac function in patients with liver cirrhosis.

METHODS

Thirty patients with liver cirrhosis, referred to as group I (G 1), were selected. They were subdivided according to Child-Pugh classification into 3 groups: A, B, and C. Thirty healthy subjects, referred to as group II (G II), were selected as a control group. All persons were examined by resting ECG, abdominal ultrasound, laboratory tests, and echo-Doppler evaluation of systolic and diastolic functions of both ventricles using 2-D, M-mode, conventional Doppler, and tissue Doppler parameters.

RESULTS

Systolic and diastolic blood pressures were significantly reduced with increased resting HR and CO in G I (p<0.05). The QTc interval was prolonged in G I (0.45±0.03 ms; p<0.001) but EDV, ESV, EF%, and S´ velocity were not significantly different in both study groups for both ventricles. LAD, MPI, LVPWT, and, IVST were significantly increased in G I (p<0.05). E/A and E´/A´ ratios were reversed in G I with increased DT/E for both ventricles (p<0.001). No significant difference was found among Child A, B, C subgroups except for the LAD which was significantly increased in Child C (p<0.05). There was a significant inverse correlation between serum albumin and left ventricular MPI (r=-0.4, p<0.05).

CONCLUSION

Many cardiovascular abnormalities occur in patients with liver cirrhosis that mandate echocardiographic evaluation especially in cases who undergo any procedure which may affect the hemodynamics.

The transjugular intrahepatic portosystemic shunt (TIPS)

The creation of an intrahepatic portosystemic shunt via a transjugular approach (TIPS) is an interventional radiological procedure used to treat the complications of portal hypertension. TIPS insertion is principally indicated to prevent or arrest variceal bleeding when medical or endoscopic treatments fail, and in the management refractory ascites. This review discusses the development and execution of the technique, with focus on its clinical efficacy. Patient selection, imaging surveillance, revision techniques, and complications are also discussed.

Role of ultrasound surveillance of transjugular intrahepatic portosystemic shunts in the covered stent era

PURPOSE

To assess ultrasound (US) surveillance of expanded polytetrafluoroethylene (ePTFE)-covered stents in transjugular intrahepatic portosystemic shunts (TIPS).

MATERIALS AND METHODS

Procedural data, including stent size and portosystemic gradients (PSG) before and after creation of TIPS, were obtained retrospectively in 55 patients (33 men, 22 women). Chart review provided clinical information, including etiology of liver disease, indication for TIPS creation, and Child-Pugh class. Radiology reports provided US venography data and pathology reports confirmed shunt status in transplant recipients. Patients had baseline US examinations 3-7 days after TIPS creation with scheduled follow-up at 1, 3, 6, and 12 months after the procedure. Clinical and radiology reports were compared to evaluate US surveillance of Viatorr stents.

RESULTS

One hundred fifty-nine US examinations were performed on 52 patients, for an average 3.1 studies per patient (range, 1-7) over a mean follow-up duration of 173 days (range, 0-1,013 d). Sixty-four US studies (40%) were baseline studies, 88 studies (55%) were routine follow-up studies, and seven (4%) were interval studies. US predicted TIPS abnormalities in 30 of 159 studies (19%); venography followed 15 of 30 abnormal US findings (50%) and clinical examinations complemented 10 of 15 venograms (67%). Venography and US were concordant in eight of 15 paired studies (53%); clinical examinations, when conducted, accurately predicted shunt status in all but one case. US findings changed management in six of 159 studies (4%): five of six (83%) were baseline evaluations and the other one (17%) was a routine follow-up examination. A total of five baseline US examinations (8%) and one surveillance examination (1%) altered patient management.

CONCLUSIONS

A single US examination after a TIPS procedure to confirm immediate function may be valuable, but routine US is not effective for long-term surveillance of ePTFE-covered stents.

Dacron-covered stent-grafts in transjugular intrahepatic portosystemic shunts: initial experience

PURPOSE

To retrospectively review the authors' experience with use of a Dacron-covered stent-graft in transjugular intrahepatic postosystemic shunts (TIPS).

MATERIALS AND METHODS

The need for internal review board approval was waived. Informed consent was obtained from all patients. The study was compliant with the Health Insurance Portability and Accountability Act. A retrospective analysis was performed of 16 patients who received a Dacron-covered stent-graft during revision or de novo creation of TIPS. There were 13 men and three women aged 44-80 years (mean age, 61 years). Primary unassisted and assisted patency rates and secondary patency rates were estimated. The primary unassisted patency of patients who underwent de novo placement of stent-grafts (n = 10) was compared with that of patients with stent-grafts placed during shunt revision (n = 6); in all patients, stent-grafts were placed within stents. Primary unassisted patency was also compared between patients in whom the covered stent was confined to the parenchymal tract (n = 7) and those in whom the stent extended 1 cm or more into the portal vein (n = 9). Patency was estimated with the Kaplan-Meier method, and group comparisons were performed with the log-rank test.

RESULTS

Primary unassisted patency rates following stent-graft placement at 4, 12, and 24 months (+/- standard error) were 64% +/- 14, 54% +/- 15, and 40% +/- 16, respectively. The rates for primary assisted patency were 78% +/- 12, 67% +/- 14, and 67% +/- 14 and those for secondary patency were 91% +/- 9, 81% +/- 12, and 54% +/- 23. At 12 months, primary unassisted patency with de novo stent-graft placement was 90% +/- 9, whereas that with stent-grafts placed during TIPS revision was 17% +/- 15 (P = .005). At 12 months, the primary unassisted patency in patients with stent-grafts confined to the parenchymal tract was 75% +/- 22, and that of patients with stent-grafts extending at least 1 cm into the portal vein was 40% +/- 17 (P = .21).

CONCLUSION

In this small series, satisfactory long-term patency was observed among patients in whom Dacron-covered stent-grafts were placed during revision or de novo creation of TIPS. More favorable outcomes were observed when the stent-graft was placed during de novo TIPS creation and when the device was confined to the parenchymal tract.

Intravascular ultrasound-guided direct intrahepatic portacaval shunt: midterm follow-up

PURPOSE

To describe the midterm patency and clinical results of the intravascular ultrasound (US)-guided direct intrahepatic portacaval shunt (DIPS) procedure for the treatment of intractable ascites and variceal bleeding.

MATERIALS AND METHODS

From February 23, 1999, to December 18, 2002, inferior vena cava (IVC)-to-portal vein (PV) shunts were created in 40 patients for ascites (n = 35) and bleeding (n = 5). Intravascular US was used to guide direct puncture from the IVC to the PV. The shunts were completed with the use of single (n = 15) or overlapping (n = 25) polytetrafluoroethylene (PTFE)-covered Palmaz stents. These stent-grafts were deployed primarily at diameters of 8 mm. The diameter of the shunt was increased in three cases to achieve a target portosystemic gradient (PSG) of 15 mm Hg or lower. All patients were followed clinically and with portography with manometry.

RESULTS

All DIPSs were created successfully. Mean PSGs were reduced from 23 mm Hg before DIPS creation to 9 mm afterward. During the follow-up period of a maximum of 38 months, 22 of 40 patients died or underwent liver transplantation (mean follow-up, 9 months; median, 6 months). At the time of this report, 18 of 40 patients remain living after follow-up ranging in duration from 8 to 38 months (mean, 22 months; median, 16.5 months). During the follow-up period, there was one stent-graft occlusion and three stenoses. These four patients were successfully treated by additional stent-graft placement. In addition, two patients developed IVC stenosis cephalad to the DIPS, which required IVC stent placement. The primary patency rates by Kaplan-Meier analysis were 100% at 6 months and 75% (95% CI, 53%-97%) at 12 months.

CONCLUSION

Intravascular US-guided direct IVC-to-PV shunts may be created successfully with minimal complications. Primary patency of the shunt is greater than that with conventional TIPS with a bare wire stent and appears equal to that with TIPS with a PTFE-covered stent-graft.