1
|
Gómez-Centurión I, Gallardo Morillo AI, Pérez Martínez A, Cabrero Calvo M, Chinea A, González L, Pedraza A, Jiménez Lorenzo MJ, Robles MC, Bailén R, Cascón MJP, Cabero A, Piñana Sánchez JL, Luna A, Perera Alvarez M, Rovira M, Torrent Catarineu A, Sánchez-Pina J, Kwon M. Sinusoidal Obstruction Syndrome/Veno-Occlusive Disease after Unmanipulated Haploidentical Hematopoietic Stem Cell Transplantation with Post-Transplantation Cyclophosphamide: A Study on Behalf of the Spanish Hematopoietic Stem Cell Transplantation and Cellular Therapy Group (GETH). Transplant Cell Ther 2024; 30:914.e1-914.e8. [PMID: 38851323 DOI: 10.1016/j.jtct.2024.06.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/29/2024] [Revised: 05/13/2024] [Accepted: 06/03/2024] [Indexed: 06/10/2024]
Abstract
Sinusoidal obstruction syndrome/veno-occlusive disease (SOS/VOD) is a life-threatening complication after both autologous and allogeneic hematopoietic stem cell transplantation (HSCT). However, its characterization after haploidentical HSCT (haplo-HSCT) with post-transplantation cyclophosphamide (PT-Cy) is scarce. This study aimed to describe characteristics and outcomes of patients with SOS/VOD after haplo-HSCT with PT-Cy. We conducted a retrospective study of 797 patients undergoing a haplo-HSCT with PT-Cy between 2007 and 2019 in 9 centers in Spain. SOS/VOD was defined according to modified Seattle, Baltimore, or revised European Society for Blood and Marrow Transplantation (EBMT) criteria. Severity was graded retrospectively according to revised EBMT severity criteria into 4 categories: mild, moderate, severe, and very severe. From a total of 797 haplo-HSCTs performed, 46 patients (5.77%) were diagnosed with SOS/VOD at a median of 19 days (range, 4 to 84 days) after transplantation. Based on revised EBMT severity criteria, the SOS/VOD cases were classified as mild (n = 4; 8.7%), moderate (n = 10; 21.7%), severe (n = 12; 26.1%), and very severe (n = 20; 43.5%). Overall, 30 patients (65%) achieved SOS/VOD complete response, 25 (83%) of whom were treated with defibrotide. Twenty patients (43%) died before day +100 post-HSCT. Death was attributed to SOS/VOD in 11 patients, and 5 patients died of other causes without resolution of SOS/VOD. The incidence of SOS/VOD after haplo-HSCT with PT-Cy was comparable to those reported after HLA-identical HSCT series. Most of the patients developed very severe SOS/VOD according to revised EBMT severity criteria. Despite a promising SOS/VOD complete response (CR) rate (65%), 100-day mortality remained high (43%), indicating that further improvement in the management of this potentially fatal complication is needed.
Collapse
Affiliation(s)
- Ignacio Gómez-Centurión
- Department of Hematology, Hospital General Universitario Gregorio Marañón, Madrid, Spain; Department of Hematology, Instituto de Investigación Sanitaria Gregorio Marañón, Madrid, Spain.
| | | | | | - Mónica Cabrero Calvo
- Department of Hematology, Hospital Universitario de Salamanca, Salamanca, Spain; Department of Hematology, Instituto de Investigación Biomédica de Salamanca, Salamanca, Spain
| | - Anabelle Chinea
- Department of Hematology, Hospital Regional Universitario de Málaga, Málaga, Spain; Department of Hematology, Hospital Ramón y Cajal, Madrid, Spain
| | - Leslie González
- Department of Hematology, Hospital Regional Universitario de Málaga, Málaga, Spain; Department of Hematology, Hospital Universitario de Gran Canaria Doctor Negrín, Gran Canaria, Spain
| | - Alexandra Pedraza
- Department of Hematology, Hospital Regional Universitario de Málaga, Málaga, Spain; Department of Hematology, Hospital Clinic, Barcelona, Spain
| | - María Josefa Jiménez Lorenzo
- Department of Hematology, Hospital Regional Universitario de Málaga, Málaga, Spain; Department of Hematology, Institut Català d'Oncologia-Hospital Universitari Germans Trias i Pujol, Badalona, Spain
| | - María Calbacho Robles
- Department of Hematology, Hospital Regional Universitario de Málaga, Málaga, Spain; Department of Hematology, Hospital 12 de Octubre, Madrid, Spain
| | - Rebeca Bailén
- Department of Hematology, Hospital General Universitario Gregorio Marañón, Madrid, Spain; Department of Hematology, Instituto de Investigación Sanitaria Gregorio Marañón, Madrid, Spain
| | | | - Almudena Cabero
- Department of Hematology, Hospital Universitario de Salamanca, Salamanca, Spain; Department of Hematology, Instituto de Investigación Biomédica de Salamanca, Salamanca, Spain
| | | | - Alejandro Luna
- Department of Hematology, Hospital Ramón y Cajal, Madrid, Spain
| | - Mar Perera Alvarez
- Department of Hematology, Hospital Universitario de Gran Canaria Doctor Negrín, Gran Canaria, Spain
| | | | - Anna Torrent Catarineu
- Department of Hematology, Institut Català d'Oncologia-Hospital Universitari Germans Trias i Pujol, Badalona, Spain
| | | | - Mi Kwon
- Department of Hematology, Hospital General Universitario Gregorio Marañón, Madrid, Spain; Department of Hematology, Instituto de Investigación Sanitaria Gregorio Marañón, Madrid, Spain.
| |
Collapse
|
2
|
Delgado MG, Mertineit N, Bosch J, Baumgartner I, Berzigotti A. Combination of Model for End-Stage Liver Disease (MELD) and Sarcopenia predicts mortality after transjugular intrahepatic portosystemic shunt (TIPS). Dig Liver Dis 2024; 56:1544-1550. [PMID: 38555198 DOI: 10.1016/j.dld.2024.03.003] [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: 01/11/2024] [Revised: 02/21/2024] [Accepted: 03/01/2024] [Indexed: 04/02/2024]
Abstract
TIPS is the most effective treatment for portal hypertension. Patient selection remains important to achieving optimal post-TIPS outcomes. The study evaluates 1-year mortality factors in cirrhotic patients receiving TIPS. METHODS 87 cirrhotic patients received a TIPS between 2015 - 2021. Predictors of 1-year and overall mortality were assessed by estimating cumulative incidence functions and Grey's test to adjust for liver transplantation as a risk competing with mortality. Variables with p < 0.05 were checked for collinearity and included in the multivariate Cox proportional hazards model. Model discrimination was evaluated by calculating the area under the ROC curve. RESULTS 87 patients were included (68% men; 22% ≥70 years). ALD was the primary cirrhosis cause. Most patients were Child-Pugh class B, MELD-Na score was 13.6 ± 6.0 points. The most frequent indication for TIPS was bleeding (51.7%), followed by refractory ascites (42.5%). The variables positively associated with mortality in univariate analysis were ascites, clinically overt sarcopenia and MELD-Na score, while ongoing nutritional supplementation improved survival. In the multivariate analysis, only clinically overt sarcopenia and MELD-Na score remained independently associated with mortality. A MELD-Na/sarcopenia model demonstrated a good discrimination, AUROC: 0.86 (95% CI 0.77 - 0.95). CONCLUSION MELD-Na score, and sarcopenia were significantly associated with 1-year survival in cirrhotic patients who received TIPS.
Collapse
Affiliation(s)
- Maria Gabriela Delgado
- Department of Visceral Surgery and Medicine, Inselspital, Bern University Hospital, University of Bern, Switzerland; Center for Vascular Interventions (IZI), Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Nando Mertineit
- Center for Vascular Interventions (IZI), Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland; Department of Diagnostic, Interventional and Pediatric Radiology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland; Department of Medical Radiology, Buergerspital Solothurn, Solothurner Spitäler, Solothurn, Switzerland
| | - Jaime Bosch
- Department of Visceral Surgery and Medicine, Inselspital, Bern University Hospital, University of Bern, Switzerland
| | | | - Annalisa Berzigotti
- Department of Visceral Surgery and Medicine, Inselspital, Bern University Hospital, University of Bern, Switzerland; Center for Vascular Interventions (IZI), Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland.
| |
Collapse
|
3
|
Li R, Sarin S. Advanced chronic renal disease is an independent risk factor for inpatient mortality following transjugular intrahepatic portosystemic shunt procedure. Eur J Gastroenterol Hepatol 2024; 36:332-337. [PMID: 38179873 DOI: 10.1097/meg.0000000000002703] [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: 01/06/2024]
Abstract
BACKGROUND Transjugular intrahepatic portosystemic shunt (TIPS) is a procedure used to alleviate portal hypertension in patients with decompensated liver cirrhosis. However, the risks and outcomes associated with TIPS in patients with advanced chronic kidney disease (CKD) remain uncertain. This study aimed to investigate the perioperative outcomes of TIPS procedures in patients with advanced CKD using the National Inpatient Sample (NIS) database, a comprehensive all-payer inpatient database in the US. METHODS The study identified patients who underwent TIPS procedures in the NIS database from Q4 2015 to 2020. Patients with advanced CKD were identified using specific ICD-10-CM codes, and they were compared to patients without CKD. Preoperative variables, including demographics, indications for TIPS, comorbidities, APR-DRG subclass, primary payer status, and hospital characteristics, were noted. Perioperative outcomes were examined by multivariable logistic regression. RESULTS A total of 248 patients with advanced CKD and 5511 patients without CKD undergoing TIPS procedures were identified in the NIS database. Compared to non-CKD, patients with advanced CKD had higher mortality (13.70% vs. 8.60%, aOR = 1.56, P = 0.03), acute kidney injury (51.21% vs. 29.34, aOR = 1.46, P < 0.01), transfer out (25.00% vs. 12.84%, aOR = 1.88, P < 0.01), and length of stay over 7 days (64.11% vs. 38.97%, aOR = 2.34, P < 0.01). However, there was no difference in hepatic encephalopathy (31.85% vs. 27.19%, aOR = 1.12, P = 0.42). CONCLUSION Advanced CKD patients undergoing TIPS are at higher risk of mortality and AKI compared to patients without CKD; HE was mildly elevated but NS. Long-term prognosis of patients with advanced CKD who had TIPS is needed in future studies.
Collapse
Affiliation(s)
- Renxi Li
- The George Washington University School of Medicine and Health Sciences, Washington, DC
| | - Shawn Sarin
- The George Washington University Hospital, Department of Interventional Radiology, Washington, DC, USA
| |
Collapse
|
4
|
Hu XG, Dai JJ, Lu J, Li G, Wang JM, Deng Y, Feng R, Lu KP. Efficacy of transjugular intrahepatic portosystemic shunts in treating cirrhotic esophageal-gastric variceal bleeding. World J Gastrointest Surg 2024; 16:471-480. [PMID: 38463371 PMCID: PMC10921195 DOI: 10.4240/wjgs.v16.i2.471] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/22/2023] [Revised: 12/15/2023] [Accepted: 01/09/2024] [Indexed: 02/25/2024] Open
Abstract
BACKGROUND Esophageal-gastric variceal bleeding (EGVB) represents a severe complication among patients with cirrhosis and often culminates in fatal outcomes. Interventional therapy, a rapidly developing treatment modality over the past few years, has found widespread application in clinical practice due to its minimally invasive characteristics. However, whether transjugular intrahepatic portosystemic shunt (TIPS) treatment has an impact on patient prognosis remains controversial. AIM To probing the efficacy of TIPS for treating cirrhotic EGVB and its influence on the prognosis of patients afflicted by this disease. METHODS A retrospective study was conducted on ninety-two patients presenting with cirrhotic EGVB who were admitted to our hospital between September 2020 and September 2022. Based on the different modes of treatment, the patients were assigned to the study group (TIPS received, n = 50) or the control group (percutaneous transhepatic varices embolization received, n = 42). Comparative analyses were performed between the two groups preoperatively and one month postoperatively for the following parameters: Varicosity status; hemodynamic parameters [portal vein flow velocity (PVV) and portal vein diameter (PVD); platelet count (PLT); red blood cell count; white blood cell count (WBC); and hepatic function [albumin (ALB), total bilirubin (TBIL), and aspartate transaminase (AST)]. The Generic Quality of Life Inventory-74 was utilized to assess quality of life in the two groups, and the 1-year postoperative rebleeding and survival rates were compared. RESULTS Following surgical intervention, there was an improvement in the incidence of varicosity compared to the preoperative status in both cohorts. Notably, the study group exhibited more pronounced enhancements than did the control group (P < 0.05). PVV increased, and PVD decreased compared to the preoperative values, with the study cohort achieving better outcomes (P < 0.05). PLT and WBC counts were elevated postoperatively in the two groups, with the study cohort displaying higher PLT and WBC counts (P < 0.05). No differences were detected between the two groups in terms of serum ALB, TBIL, or AST levels either preoperatively or postoperatively (P < 0.05). Postoperative scores across all dimensions of life quality surpassed preoperative scores, with the study cohort achieving higher scores (P < 0.05). At 22.00%, the one-year postoperative rebleeding rate in the study cohort was significantly lower than that in the control group (42.86%; P < 0.05); conversely, no marked difference was observed in the 1-year postoperative survival rate between the two cohorts (P > 0.05). CONCLUSION TIPS, which has demonstrated robust efficacy in managing cirrhotic EGVB, remarkably alleviates varicosity and improves hemodynamics in patients. This intervention not only results in a safer profile but also contributes significantly to a more favorable prognosis.
Collapse
Affiliation(s)
- Xiao-Gang Hu
- Department of Interventional Radiology, The Affiliated Jinhua Hospital, Zhejiang University School of Medicine, Jinhua 321000, Zhejiang Province, China
| | - Jian-Ji Dai
- Department of Interventional Radiology, The Affiliated Jinhua Hospital, Zhejiang University School of Medicine, Jinhua 321000, Zhejiang Province, China
| | - Jun Lu
- Department of Interventional Radiology, The Affiliated Jinhua Hospital, Zhejiang University School of Medicine, Jinhua 321000, Zhejiang Province, China
| | - Gang Li
- Department of Interventional Radiology, The Affiliated Jinhua Hospital, Zhejiang University School of Medicine, Jinhua 321000, Zhejiang Province, China
| | - Jia-Min Wang
- Department of Interventional Radiology, The Affiliated Jinhua Hospital, Zhejiang University School of Medicine, Jinhua 321000, Zhejiang Province, China
| | - Yi Deng
- Department of Interventional Radiology, The Affiliated Jinhua Hospital, Zhejiang University School of Medicine, Jinhua 321000, Zhejiang Province, China
| | - Rui Feng
- Department of Interventional Medicine, Zhejiang Provincial People’s Hospital, People’s Hospital of Hangzhou Medical College, Hangzhou 310000, Zhejiang Province, China
| | - Kai-Ping Lu
- Department of Vascular Surgery, Zhejiang Provincial People’s Hospital, People’s Hospital of Hangzhou Medical College, Hangzhou 310000, Zhejiang Province, China
| |
Collapse
|
5
|
Terbah R, Testro A, Gow P, Majumdar A, Sinclair M. Portal Hypertension in Malnutrition and Sarcopenia in Decompensated Cirrhosis-Pathogenesis, Implications and Therapeutic Opportunities. Nutrients 2023; 16:35. [PMID: 38201864 PMCID: PMC10780673 DOI: 10.3390/nu16010035] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2023] [Revised: 12/18/2023] [Accepted: 12/19/2023] [Indexed: 01/12/2024] Open
Abstract
Malnutrition and sarcopenia are highly prevalent in patients with decompensated cirrhosis and are associated with poorer clinical outcomes. Their pathophysiology is complex and multifactorial, with protein-calorie malnutrition, systemic inflammation, reduced glycogen stores and hormonal imbalances all well reported. The direct contribution of portal hypertension to these driving factors is however not widely documented in the literature. This review details the specific mechanisms by which portal hypertension directly contributes to the development of malnutrition and sarcopenia in cirrhosis. We summarise the existing literature describing treatment strategies that specifically aim to reduce portal pressures and their impact on nutritional and muscle outcomes, which is particularly relevant to those with end-stage disease awaiting liver transplantation.
Collapse
Affiliation(s)
- Ryma Terbah
- Liver Transplant Unit, Austin Health, 145 Studley Road, Heidelberg, VIC 3084, Australia; (R.T.); (A.T.); (P.G.); (A.M.)
- Department of Medicine, The University of Melbourne, Parkville, VIC 3050, Australia
| | - Adam Testro
- Liver Transplant Unit, Austin Health, 145 Studley Road, Heidelberg, VIC 3084, Australia; (R.T.); (A.T.); (P.G.); (A.M.)
- Department of Medicine, The University of Melbourne, Parkville, VIC 3050, Australia
| | - Paul Gow
- Liver Transplant Unit, Austin Health, 145 Studley Road, Heidelberg, VIC 3084, Australia; (R.T.); (A.T.); (P.G.); (A.M.)
- Department of Medicine, The University of Melbourne, Parkville, VIC 3050, Australia
| | - Avik Majumdar
- Liver Transplant Unit, Austin Health, 145 Studley Road, Heidelberg, VIC 3084, Australia; (R.T.); (A.T.); (P.G.); (A.M.)
- Department of Medicine, The University of Melbourne, Parkville, VIC 3050, Australia
| | - Marie Sinclair
- Liver Transplant Unit, Austin Health, 145 Studley Road, Heidelberg, VIC 3084, Australia; (R.T.); (A.T.); (P.G.); (A.M.)
- Department of Medicine, The University of Melbourne, Parkville, VIC 3050, Australia
| |
Collapse
|
6
|
Khatri S, Villegas GE, Smith M. Management of inadvertent puncture of the hepatic capsule accompanied by post-TIPS hemoperitoneum secondary to bleeding diathesis. Radiol Case Rep 2023; 18:3798-3803. [PMID: 37663566 PMCID: PMC10474355 DOI: 10.1016/j.radcr.2023.08.024] [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: 05/23/2023] [Revised: 07/03/2023] [Accepted: 08/03/2023] [Indexed: 09/05/2023] Open
Abstract
Since its advent, the transjugular intrahepatic portosystemic shunt (TIPS) procedure has been accepted as an effective option to treat patients with complications of portal hypertension. While generally considered a safe procedure, TIPs can be associated with certain complications, including inadvertent puncture of the liver capsule with the needle/catheter combination during needle passes. In addition, the accompanying post-TIPS intraperitoneal hemorrhage has not been well reported and guidelines behind its management are not well described. We present a case of a 33-year-old male with refractory ascites who underwent TIPS, during which the hepatic capsule was inadvertently punctured, leading to the development of hemoperitoneum in the patient due to a bleeding diathesis.
Collapse
Affiliation(s)
| | | | - Matthew Smith
- Department of Radiology, NYC Health + Hospital/Queens, Queens, NY, USA
| |
Collapse
|
7
|
Zhu W, Wang X, Lv Y, Chen H, Chen X, Li X, Zhu S, Lin Z, Wang G. Comparison of long-term outcomes of splenectomy with periesophagogastric devascularization and transjugular intrahepatic portosystemic shunt in treating cirrhotic portal hypertension patients with recurrent variceal bleeding. Langenbecks Arch Surg 2023; 408:215. [PMID: 37247018 PMCID: PMC10227160 DOI: 10.1007/s00423-023-02933-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2022] [Accepted: 05/07/2023] [Indexed: 05/30/2023]
Abstract
PURPOSE Transjugular intrahepatic portosystemic shunt (TIPS) and splenectomy with periesophagogastric devascularization (SPD) are widely used to treat cirrhotic portal hypertension (PH) and prevent variceal rebleeding. However, direct comparisons between these two approaches are rare. This study was designed to compare the long-term outcomes of TIPS and SPD in patients with cirrhotic PH and variceal rebleeding. METHODS The study included cirrhotic PH patients with a history of gastroesophageal variceal bleeding between 18 and 80 years of age who were admitted to the Third Affiliated Hospital of Sun Yat-sen University from January 2012 to January 2022. Patients were enrolled into two groups according to TIPS or SPD was performed. Baseline characteristics were matched using propensity score matching (PSM). RESULTS A total of 230 patients underwent TIPS, while 184 underwent SPD. PSM was carried out to balance available covariates, resulting in a total of 83 patients in the TIPS group and 83 patients in the SPD group. Patients in SPD group had better liver function during 60 months follow-up. Five-year overall survival rates in SPD group and TIPS group were 72 and 27%, respectively, at 2 years were 88 and 86%, respectively. The 2- and 5-year freedom from variceal rebleeding rates were 95 and 80% in SPD group and 80 and 54% in TIPS group. CONCLUSIONS SPD is clearly superior to TIPS in terms of OS and freedom from variceal rebleeding in patients with cirrhotic PH. In addition, SPD improved liver function in patients with cirrhotic PH.
Collapse
Affiliation(s)
- Wenfeng Zhu
- Department of Hepatic Surgery, The Third Affiliated Hospital of Sun Yat-Sen University, Liver Transplantation, Guangzhou, 510630, China
- Guangdong Key Laboratory of Liver Disease Research, The Third Affiliated Hospital of Sun Yat-Sen University, Guangzhou, 510630, China
| | - Xiaowen Wang
- Department of Hepatic Surgery, The Third Affiliated Hospital of Sun Yat-Sen University, Liver Transplantation, Guangzhou, 510630, China
- Guangdong Key Laboratory of Liver Disease Research, The Third Affiliated Hospital of Sun Yat-Sen University, Guangzhou, 510630, China
| | - Yun Lv
- Department of Hepatic Surgery, The Third Affiliated Hospital of Sun Yat-Sen University, Liver Transplantation, Guangzhou, 510630, China
| | - Haoqi Chen
- Department of Hepatic Surgery, The Third Affiliated Hospital of Sun Yat-Sen University, Liver Transplantation, Guangzhou, 510630, China
- Guangdong Key Laboratory of Liver Disease Research, The Third Affiliated Hospital of Sun Yat-Sen University, Guangzhou, 510630, China
| | - Xiaolong Chen
- Department of Hepatic Surgery, The Third Affiliated Hospital of Sun Yat-Sen University, Liver Transplantation, Guangzhou, 510630, China
- Guangdong Key Laboratory of Liver Disease Research, The Third Affiliated Hospital of Sun Yat-Sen University, Guangzhou, 510630, China
| | - Xuejiao Li
- Guangdong Key Laboratory of Liver Disease Research, The Third Affiliated Hospital of Sun Yat-Sen University, Guangzhou, 510630, China
| | - Shuguang Zhu
- Department of Hepatic Surgery, The Third Affiliated Hospital of Sun Yat-Sen University, Liver Transplantation, Guangzhou, 510630, China
- Guangdong Key Laboratory of Liver Disease Research, The Third Affiliated Hospital of Sun Yat-Sen University, Guangzhou, 510630, China
| | - Zexin Lin
- Department of Hepatic Surgery, The Third Affiliated Hospital of Sun Yat-Sen University, Liver Transplantation, Guangzhou, 510630, China
| | - Genshu Wang
- Guangdong Provincial Hospital of Chinese Medicine, Guangzhou, 510630, China.
- The Second Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangdong, China.
| |
Collapse
|
8
|
Wang Z, Zhang Z, Guo X, Xu W, Wei N, Zhang Q, Zu M, Xu H. Efficacy, feasibility and safety of TIPS in the treatment of recurrent portal hypertension with variceal bleeding after open splenectomy and esophagogastric devascularization. Abdom Radiol (NY) 2023:10.1007/s00261-023-03945-7. [PMID: 37184569 DOI: 10.1007/s00261-023-03945-7] [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: 11/14/2022] [Revised: 04/27/2023] [Accepted: 05/01/2023] [Indexed: 05/16/2023]
Abstract
PURPOSE To investigate the efficacy, feasibility, and safety of transjugular intrahepatic portosystemic shunt (TIPS) as a treatment for patients with recurrent portal hypertension with variceal bleeding (RPHVB) who have previously undergone open splenectomy and esophagogastric devascularization (OSED). METHODS The data were retrospectively retrieved from 39 cirrhotic RPHVB patients who had undergone OSED from August 2015 to December 2020. All patients were treated with TIPS using the Viabahn stent. RESULTS Out of the 39 patients included in the study, TIPS was successfully performed in 38 patients with a success rate of 97.44%. One patient had a failed attempt due to cavernous transformation of the portal vein (CTPV). Among the 38 patients who underwent TIPS, 33 patients also underwent varicose vein embolization, while the remaining 5 patients only underwent TIPS procedure. A total of 39 Viabahn stents were implanted, with 5 patients receiving stents expanded to their nominal diameter of 8 mm and the remaining 33 patients having their shunt maintained at a diameter of 6 mm. The postoperative hemostasis rate was 97.37% (37/38). The portal vein pressure (PVP) and portal pressure gradient (PPG) decreased significantly from (31.28 ± 6.24) and (20.61 ± 5.14) mmHg to (19.58 ± 4.69) and (9.24 ± 3.07) mmHg, respectively (P < 0.001). During the follow-up period, the rebleeding rate was 6.09% (2/29), while the incidence of hepatic encephalopathy (HE) and shunt dysfunction was 13.79% (4/29) for each. CONCLUSION Transjugular intrahepatic portosystemic shunt is an effective, feasible and safe treatment for RPHVB patients who have previously undergone OSED. A satisfactory clinical outcome could be achieved with a 6 mm-diameter shunt in most patients.
Collapse
Affiliation(s)
- Zhongkai Wang
- Department of Interventional Radiology, The Affiliated Hospital of Xuzhou Medical University, 99 West Huaihai Road, Xuzhou, 221006, Jiangsu, China
- Center of Interventional Radiology and Vascular Surgery, Department of Radiology, Zhongda Hospital, Medical School, Southeast University, Nanjing, 210009, Jiangsu, China
| | - Zhiyuan Zhang
- Department of Interventional Oncology, The Second Affiliated Hospital of Xuzhou Medical University, 32 Meijian Road, Xuzhou, 221006, Jiangsu, China
| | - Xiao Guo
- Department of Interventional Radiology, The Affiliated Hospital of Xuzhou Medical University, 99 West Huaihai Road, Xuzhou, 221006, Jiangsu, China
- Department of Intervention, The Huai'an Hospital, 19 Shan-Yang Road, Huai'an, 223200, Jiangsu, China
| | - Wei Xu
- Department of Interventional Radiology, The Affiliated Hospital of Xuzhou Medical University, 99 West Huaihai Road, Xuzhou, 221006, Jiangsu, China
| | - Ning Wei
- Department of Interventional Radiology, The Affiliated Hospital of Xuzhou Medical University, 99 West Huaihai Road, Xuzhou, 221006, Jiangsu, China
| | - Qingqiao Zhang
- Department of Interventional Radiology, The Affiliated Hospital of Xuzhou Medical University, 99 West Huaihai Road, Xuzhou, 221006, Jiangsu, China
| | - Maoheng Zu
- Department of Interventional Radiology, The Affiliated Hospital of Xuzhou Medical University, 99 West Huaihai Road, Xuzhou, 221006, Jiangsu, China
| | - Hao Xu
- Department of Interventional Radiology, The Affiliated Hospital of Xuzhou Medical University, 99 West Huaihai Road, Xuzhou, 221006, Jiangsu, China.
| |
Collapse
|
9
|
Baliss M, Patel D, Madi MY, Bazarbashi AN. EUS-Guided Vascular Interventions. J Clin Med 2023; 12:jcm12062165. [PMID: 36983165 PMCID: PMC10052848 DOI: 10.3390/jcm12062165] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2023] [Revised: 02/18/2023] [Accepted: 02/21/2023] [Indexed: 03/14/2023] Open
Abstract
Endoscopic ultrasound (EUS) has numerous advanced applications as a diagnostic and therapeutic modality in contemporary medicine. Through intraluminal placement, EUS offers a real-time Doppler-guided endoscopic visualization and access to intra-abdominal vasculature, which were previously inaccessible using historical methods. We aim to provide a comprehensive review of key studies on both current and future EUS-guided vascular applications. This review details EUS-based vascular diagnostic techniques of portal pressure measurements in the prognostication of liver disease and portal venous sampling for obtaining circulating tumor cells in the diagnosis of cancer. From an interventional perspective, we describe effective EUS-guided treatments via coiling and cyanoacrylate injections of gastric varices and visceral artery pseudoaneurysms. Specific attention is given to clinical studies on efficacy and procedural techniques described by investigators for each EUS-based application. We explore novel and future emerging EUS-based interventions, such as liver tumor ablation and intrahepatic portosystemic shunt placement.
Collapse
Affiliation(s)
- Michelle Baliss
- Division of Gastroenterology, Saint Louis University Hospital, St. Louis, MO 63104, USA
| | - Devan Patel
- Division of Gastroenterology, Washington University in St. Louis, St. Louis, MO 63130, USA
| | - Mahmoud Y. Madi
- Division of Gastroenterology, Saint Louis University Hospital, St. Louis, MO 63104, USA
| | - Ahmad Najdat Bazarbashi
- Division of Gastroenterology, Washington University in St. Louis, St. Louis, MO 63130, USA
- Correspondence:
| |
Collapse
|
10
|
Chen ZX, Qiu ZK, Wang GB, Wang GS, Jiang WW, Gao F. Safety and effectiveness of transjugular intrahepatic portosystemic shunt in hepatocellular carcinoma patients with portal hypertension: a systematic review and meta-analysis. Clin Radiol 2022. [DOI: 10.1016/j.crad.2022.09.126] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
|
11
|
Transjugular extrahepatic portosystemic shunt (TEPS) creation in patients with complete occlusion of portal vein: Primary experience in a single medical center. Clin Res Hepatol Gastroenterol 2022; 46:101786. [PMID: 34384927 DOI: 10.1016/j.clinre.2021.101786] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/27/2021] [Accepted: 08/06/2021] [Indexed: 02/04/2023]
|
12
|
Mandal P, O'Donnell BP, Smith ER, Al-Bayati O, Khalil A, Jen S, Vela M, Lopera J. Portal and hepatic vein thrombosis after transjugular intrahepatic portosystemic shunt: Incidence in follow-up imaging and clinical implications. INTERNATIONAL JOURNAL OF GASTROINTESTINAL INTERVENTION 2022. [DOI: 10.18528/ijgii210028] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Affiliation(s)
- Partha Mandal
- Department of Radiology, Long School of Medicine, University of Texas Health Science Center at San Antonio, San Antonio, TX, USA
| | - Barrett P. O'Donnell
- Department of Radiology, Long School of Medicine, University of Texas Health Science Center at San Antonio, San Antonio, TX, USA
| | - Eric Reuben Smith
- Department of Radiology, Long School of Medicine, University of Texas Health Science Center at San Antonio, San Antonio, TX, USA
| | - Osamah Al-Bayati
- Department of Radiology, Long School of Medicine, University of Texas Health Science Center at San Antonio, San Antonio, TX, USA
| | - Adam Khalil
- Department of Radiology, Long School of Medicine, University of Texas Health Science Center at San Antonio, San Antonio, TX, USA
| | - Serena Jen
- Department of Radiology, Long School of Medicine, University of Texas Health Science Center at San Antonio, San Antonio, TX, USA
| | - Mario Vela
- Department of Radiology, Long School of Medicine, University of Texas Health Science Center at San Antonio, San Antonio, TX, USA
| | - Jorge Lopera
- Department of Radiology, Long School of Medicine, University of Texas Health Science Center at San Antonio, San Antonio, TX, USA
| |
Collapse
|
13
|
Li W, Duan Y, Liu Z, Lu X, She J, Qing J, Zhang C. Clinical value of hemodynamic changes in diagnosis of hepatic encephalopathy after transjugular intrahepatic portosystemic shunt. Scand J Gastroenterol 2022:1-6. [PMID: 35098853 DOI: 10.1080/00365521.2022.2029938] [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: 10/23/2021] [Revised: 01/02/2022] [Accepted: 01/11/2022] [Indexed: 02/04/2023]
Abstract
OBJECTIVE This paper aims to investigate clinical value of intrahepatic and intra-stent hemodynamic changes after transjugular intrahepatic portosystemic shunt (TIPS), by using color Doppler ultrasound during the diagnosis of hepatic encephalopathy (HE) in the patients with hepatitis B cirrhosis. METHODS A retrospective analysis of the patients with hepatitis B cirrhotic portal hypertension, who underwent TIPS in The First Affiliated Hospital of Anhui Medical University from January 2018 to January 2021, was conducted. 22 patients who developed HE within 3 months after TIPS comprised the observation group (HE group), and 51 patients who did not develop HE were randomly selected as the control group (non-HE group). The porto systemic gradient (PSG), as well as intrahepatic and intra-stent hemodynamic changes of patients in both the HE group and the non-HE group after TIPS were investigated. RESULTS The intra-stent blood flow, PSG difference, and PSG decrease percentage in the HE group were higher than those in the non-HE group, and the intra-stent flow had a weak positive correlation with PSG difference and with the PSG decrease percentage (r = 0.420, 0.258, respectively). The areas under the ROC curves of HE based on the PSG difference, the PSG decrease percentage, and the intra-stent flow were 0.762, 0.753, and 0.693, respectively. CONCLUSION The more obvious decrease in PSG, the larger the intra-stent blood flow, and the larger the possibility of HE occurrence were observed. Routine ultrasound measurement of hemodynamic changes has certain clinical significance for predicting HE occurrence.
Collapse
Affiliation(s)
- Wanyan Li
- Department of Ultrasound, The First Affiliated Hospital of Anhui Medical University, Hefei, China
| | - Yayang Duan
- Department of Ultrasound, The First Affiliated Hospital of Anhui Medical University, Hefei, China
| | - Zhike Liu
- Department of Radiology, The Linquan County People's Hospital, FuYang, China
| | - Xiaofeng Lu
- Department of Ultrasound, The First Affiliated Hospital of Anhui Medical University, Hefei, China
| | - Jingwen She
- Department of Ultrasound, The First Affiliated Hospital of Anhui Medical University, Hefei, China
| | - Jing Qing
- Department of Ultrasound, The First Affiliated Hospital of Anhui Medical University, Hefei, China
| | - Chaoxue Zhang
- Department of Ultrasound, The First Affiliated Hospital of Anhui Medical University, Hefei, China
| |
Collapse
|
14
|
Portal decompression with transjugular intrahepatic portosystemic shunt prior to nonhepatic surgery: a single-center case series. Eur J Gastroenterol Hepatol 2021; 33:e254-e259. [PMID: 33323758 DOI: 10.1097/meg.0000000000002026] [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 Cirrhosis increases perioperative and postoperative mortality in nonhepatic surgery. Transjugular intrahepatic portosystemic shunt (TIPSS), by reducing portal pressure, may reduce intraoperative bleeding and postoperative decompensation. We report our experience of prophylactic TIPSS in nonhepatic surgery. METHODS Patients who underwent prophylactic TIPSS before nonhepatic surgery were identified from database with retrospective data collection via an e-patient record system. Primary outcome was discharged without hepatic decompensation after a planned surgery. RESULTS Twenty-one patients [age (median, range): 55, 33-76 years, Child's score: 6, 5-9] who underwent prophylactic TIPSS before nonhepatic surgery over a period of 9 years were included. All patients underwent successful TIPSS with a reduction in portal pressure gradient from 21.5 (11-35) to 16 (7-25) mmHg (P < 0.001). Immediate post-TIPSS complications were seen in 7 (33%) patients including hepatic encephalopathy in four. Eighteen patients (86%) underwent planned surgical intervention. Significant postoperative complications included hepatic encephalopathy (3), sepsis (2) and bleed (1). Two patients died postoperatively with multi-organ failure. The primary outcome was achieved in 12 (57%) patients. Post-TIPSS portal pressure gradient was significantly higher in patients with the adverse primary outcome. Over a follow-up period of 11 (1-78) months; 1-, 6- and 12-months' survival was 90, 80 and 76%, respectively. CONCLUSION Prophylactic TIPSS is associated with complications in up to one-third of patients, with 57% achieving the primary outcome. Careful patient selection in a multidisciplinary team setting is essential. Multicentre studies are necessary before the universal recommendation of prophylactic TIPSS.
Collapse
|
15
|
Mann R, Goyal H, Perisetti A, Chandan S, Inamdar S, Tharian B. Endoscopic ultrasound-guided vascular interventions: Current insights and emerging techniques. World J Gastroenterol 2021; 27:6874-6887. [PMID: 34790012 PMCID: PMC8567466 DOI: 10.3748/wjg.v27.i40.6874] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/16/2021] [Revised: 05/03/2021] [Accepted: 09/14/2021] [Indexed: 02/06/2023] Open
Abstract
Endoscopic ultrasound (EUS) is one of the significant breakthroughs in the field of advanced endoscopy. In the last two decades, EUS has evolved from a diagnostic tool to a real-time therapeutic modality. The luminal gastrointestinal (GI) tract provides a unique opportunity to access multiple vascular structures, especially in the mediastinum and abdomen, thus permitting a variety of EUS-guided vascular interventions. The addition of the doppler and contrast-enhanced capability to EUS has further helped provide real-time visualization of blood flow in vessels through the GI tract. EUS-guided vascular interventions rely on standard endoscopic accessories and interventional tools such as fine-needle aspiration needles and fine-needle biopsy. EUS allows the visualization of various structures in real-time by differentiating tissue densities and vascularity, thus, avoiding radiation exposure. EUS-guided techniques also allow real-time microscopic examination after target biopsy. Furthermore, many necessary interventions can be done during the same procedure after diagnosis. This article provides an overview of EUS-guided vascular interventions such as variceal, non-variceal bleeding interventions, EUSguided portal vein (PV) access with the formation of an intrahepatic portosystemic shunt, and techniques related to diagnosis of GI malignancies. Furthermore, we discuss current insights and future outlook of therapeutic modalities like PV embolization, PV sampling, angiography, drug administration, and portal pressure measurement.
Collapse
Affiliation(s)
- Rupinder Mann
- Department of Internal Medicine, Saint Agnes Medical Center, Fresno, CA 93730, United States
| | - Hemant Goyal
- Department of Internal Medicine, The Wright Center for Graduate Medical Education, Scranton, PA 18503, United States
| | - Abhilash Perisetti
- Department of Gastroenterology and Hepatology, The University of Arkansas for Medical Sciences, Little Rock, AR 72205, United States
| | - Saurabh Chandan
- Department of Gastroenterology and Hepatology, CHI Creighton University Medical Center, Omaha, NE 68107, United States
| | - Sumant Inamdar
- Department of Internal Medicine, Gastroenterology and Hepatology Division, University of Arkansas for Medical Sciences, Little Rock, AR 72205, United States
| | - Benjamin Tharian
- Department of Internal Medicine, Gastroenterology and Hepatology Division, University of Arkansas for Medical Sciences, Little Rock, AR 72205, United States
| |
Collapse
|
16
|
Zheng D, Yu J, Li H, Gan H, Wang J, Jiang T, Ren H, Wu F. Effects of transjugular intrahepatic portosystemic shunt treatment of patients with liver cirrhosis and portal hypertension: Case series. Medicine (Baltimore) 2021; 100:e26610. [PMID: 34232216 PMCID: PMC8270572 DOI: 10.1097/md.0000000000026610] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/30/2020] [Accepted: 06/22/2021] [Indexed: 01/14/2023] Open
Abstract
RATIONALE Transjugular intrahepatic portosystemic shunt (TIPS) is well established as an effective treatment tool for portal hypertension. However, the effects of TIPS in patients with liver cirrhosis and portal hypertension have not been adequately verified in clinical trials. PATIENT CONCERNS To evaluate the effects of TIPS in patients with liver cirrhosis and portal hypertension with or without portal vein thrombosis (PVT). INTERVENTIONS A total of 55 patients with liver cirrhosis and portal hypertension received TIPS treatment from December 2014 to April 2018 were enrolled. Clinical data, including portal pressure, Child-Pugh score, and relevant complications were recorded. OUTCOMES TIPS was successfully performed in 54 patients. The overall technical success rate was 98.19% without serious technical complications. After TIPS treatment, portal pressure was significantly reduced from 38.13 ± 4.00 cmH2O to 24.14 ± 3.84 cmH2O (P < 0.05). In addition, symptoms including gastrointestinal bleeding and ascites were improved after TIPS treatment. During the 6 to 21-month follow up, hepatic encephalopathy in 15 patients (27.8%), shunt dysfunction in 5 patients (9.3%), rebleeding in 12 patients (22.2%) and deterioration of liver function in 2 patients (3.7%) were recorded. Moreover, there were no significant differences in the rates of rebleeding and hepatic encephalopathy between patients with PVT and the non-PVT group, whereas the occurrence rate of TIPS dysfunction was higher in the PVT group, but not statistically significant. LESSONS TIPS treatment could alleviate the symptoms of liver cirrhosis and portal hypertension in individuals with or without PVT. However, complications during follow-up should be appropriately noted and addressed with corresponding treatments.
Collapse
|
17
|
Nguyen C, Robinson T, Borgmann AJ, Baron C, Imani RA. A method for revision of a foreshortened transjugular intrahepatic portosystemic shunt (TIPS) stent using transhepatic trans-stent access. Radiol Case Rep 2021; 16:2376-2381. [PMID: 34306285 PMCID: PMC8258785 DOI: 10.1016/j.radcr.2021.06.019] [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: 06/02/2021] [Accepted: 06/07/2021] [Indexed: 11/28/2022] Open
Abstract
The high technical success rate of transjugular intrahepatic portosystemic shunt (TIPS) placement makes the procedure a popular treatment option for symptomatic portal hypertension. Among the major drawbacks of the procedure - hepatic encephalopathy, acute hepatic failure, hemorrhage, biliary injury - TIPS dysfunction is one of the most prevalent, often requiring endovascular reintervention. Conventional techniques for shunt revision rely on transjugular access to the stent; but in technically difficult cases of abnormal angulation or severe stenosis, transhepatic access may also be required. The pull-through method utilizes both transjugular and transhepatic access to achieve stable through-and-through access in order to advance a sheath into the stent and recannulate the shunt. In the case of TIPS foreshortening, however, the distal end of the stent may abut the wall of the hepatic vein, jailing it off and obviating the advancement of a wire out of that end. We present here a case of a modified pull-through method for TIPS revision whereby a transhepatic wire is passed through the interstices of the stent at the distal end to enter into the hepatic vein and IVC. Subsequent snaring of the wire at the transjugular end establishes through-and-through access, and balloon dilation through the interstices allows for insertion of a transjugular sheath into the TIPS stent for recanalization. Our case highlights how the modified pull-through method, using trans-stent access, can be safely performed in patients with a foreshortened TIPS that abuts against the hepatic and portal vessel walls.
Collapse
Affiliation(s)
- Christian Nguyen
- Vanderbilt University Medical Center, 1211 Medical Center Dr. Nashville, Tennessee 37232
| | - Taylor Robinson
- Vanderbilt University Medical Center, 1211 Medical Center Dr. Nashville, Tennessee 37232
| | - Anthony J Borgmann
- Vanderbilt University Medical Center, 1211 Medical Center Dr. Nashville, Tennessee 37232
| | - Christopher Baron
- Vanderbilt University Medical Center, 1211 Medical Center Dr. Nashville, Tennessee 37232
| | - Reza A Imani
- Vanderbilt University Medical Center, 1211 Medical Center Dr. Nashville, Tennessee 37232
| |
Collapse
|
18
|
Bochnakova T. Hepatic Venous Pressure Gradient. Clin Liver Dis (Hoboken) 2021; 17:144-148. [PMID: 33868655 PMCID: PMC8043695 DOI: 10.1002/cld.1031] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/21/2020] [Revised: 08/10/2020] [Accepted: 08/15/2020] [Indexed: 02/06/2023] Open
Affiliation(s)
- Teodora Bochnakova
- Dotter Institute of Interventional RadiologyOregon Health & Science UniversityPortlandOR
| |
Collapse
|
19
|
Alwarraky MS, Elzohary HA, Melegy MA, Mohamed A. Stent patency and outcome of TIPS through the left versus the right portal branches. THE EGYPTIAN JOURNAL OF RADIOLOGY AND NUCLEAR MEDICINE 2020. [DOI: 10.1186/s43055-020-00305-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
Abstract
Background
Our purpose is to compare the stent patency and clinical outcome of trans-jugular intra-hepatic porto-systemic shunt (TIPS) through the left branch portal vein (TIPS-LPV) to the standard TIPS through the right branch (TIPS-RPV). We retrospectively reviewed all patients (n = 54) with refractory portal hypertension who were subjected to TIPS-LPV at our institute (TIPS-LPV) between 2016 and 2018. These patients were matched with 56 control patients treated with the standard TIPS-RPV (TIPS-RPV). The 2 groups were compared regarding the stent patency rate, encephalopathy, and re-interventions for 1 year after the procedure.
Results
TIPS-LPV group showed 12 months higher patency rate (90.7% compared to 73.2%) (P < 0.005). The number of the encephalopathy attacks in the TIPS-LPV group was significantly lower than that of the TIPS-RPV group at 6 and 12 months of follow-up [P = 0.012 and 0.036, respectively]. Re-bleeding and improvement of ascites were the same in the two groups [P > 0.05]. Patients underwent TIPS-LPV needed less re-interventions and required less hospitalizations than those with TIPS-RPV [P = 0.039 and P = 0.03, respectively].
Conclusion
The new TIPS approach is to extend the stent to LPV. This new TIPS-LPV approach showed the same clinical efficiency as the standard TIPS-RPV in treating variceal bleeding and ascites. However, it proved a better stent patency with lower rates of re-interventions, encephalopathy, and hospital admissions than TIPS through the right branch.
Collapse
|
20
|
Gómez-Centurión I, Bailén R, Oarbeascoa G, Muñoz C, Luque AÁ, Boyra ME, Calleja E, Rincón D, Dorado N, Barzallo P, Anguita J, Díez-Martín JL, Kwon M. Transjugular Intrahepatic Portosystemic Shunt for Very Severe Veno-Occlusive Disease/Sinusoidal Obstruction Syndrome (VOD/SOS) after Unmanipulated Haploidentical Hematopoietic Stem Cell Transplantation with Post-transplantation Cyclophosphamide. Biol Blood Marrow Transplant 2020; 26:2089-2097. [PMID: 32791193 DOI: 10.1016/j.bbmt.2020.08.006] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2020] [Revised: 07/13/2020] [Accepted: 08/03/2020] [Indexed: 12/12/2022]
Abstract
Hepatic veno-occlusive disease or sinusoidal obstruction syndrome (VOD/SOS) is a threatening complication after both autologous and allogeneic hematopoietic stem cell transplantation (HSCT), with high mortality rates despite early medical treatment, including the use of defibrotide (DF). We retrospectively analyzed 185 unmanipulated haploidentical (haplo-) HSCT with post-transplantation cyclophosphamide as graft-versus-host disease prophylaxis performed consecutively between 2011 and June 2019 in a single center. Seventeen patients (9.2%) were diagnosed with VOD/SOS. Based on revised European Society for Blood and Marrow Transplantation severity criteria, the VOD/SOS cases were classified as mild in 2 patients (11.7%), moderate in 2 (11.7%), severe in 2 (11.7%), and very severe in 11 (64.9%). Thirteen patients (76%) were treated with DF, including all patients with severe or very severe VOD/SOS, except 1 patient with CNS hemorrhage. Sixteen patients (94%) were alive at day +100 after HSCT. Seven patients (41%) with very severe VOD/SOS were treated with transjugular intrahepatic portosystemic shunt (TIPS) owing to rapid clinical or analytical deterioration or refractory hepatorenal syndrome despite medical treatment, including DF. TIPS insertion was performed at a median time since VOD/SOS diagnosis of 4 days (range, 1 to 28 days) without technical complications in any case. The median hepatic venous pressure gradient before and after TIPS treatment was 24 mmHg (range, 14 to 29 mmHg) and 7 mmHg (range, 2 to 11 mmHg), respectively, with a median drop of 16 mmHg (range, 9 to 19 mmHg). Following TIPS insertion, all patients showed clinical improvement with hepatomegaly, ascites, and renal failure resolution, and all showed analytical improvement with reduced alanine aminotransferase (ALT), creatinine, and international normalized ratio values, except for patient 2, whose indication for TIPS was refractory hepatorenal syndrome with a normal ALT level. The 6 patients who had initiated DF before TIPS insertion completed 21 days of treatment. All patients met the criteria for complete remission (CR) at a median of 8 days after TIPS insertion (range, 2 to 82 days). The 100-day overall survival was 100%. For patients with rapid progressive VOD/SOS, early TIPS insertion allowed completion of DF therapy. The use of TIPS together with DF resulted in CR and no associated complications with no VOD/SOS-associated mortality despite high severity. In our experience, timely and individualized use of TIPS significantly improves outcomes of very severe VOD/SOS after haplo-HSCT. Therefore, TIPS should be promptly considered in rapidly progressive cases.
Collapse
Affiliation(s)
| | - Rebeca Bailén
- Department of Hematology, Hospital General Universitario Gregorio Marañón, Madrid, Spain; Gregorio Marañón Health Research Institute, Madrid, Spain
| | - Gillen Oarbeascoa
- Department of Hematology, Hospital General Universitario Gregorio Marañón, Madrid, Spain; Gregorio Marañón Health Research Institute, Madrid, Spain
| | - Cristina Muñoz
- Department of Hematology, Hospital General Universitario Gregorio Marañón, Madrid, Spain; Gregorio Marañón Health Research Institute, Madrid, Spain
| | - Arturo Álvarez Luque
- Department of Hematology, Hospital General Universitario Gregorio Marañón, Madrid, Spain; Gregorio Marañón Health Research Institute, Madrid, Spain
| | - Miguel Echenagusia Boyra
- Department of Hematology, Hospital General Universitario Gregorio Marañón, Madrid, Spain; Department of Interventional Radiology, Hospital General Universitario Gregorio Marañón, Madrid, Spain
| | - Enrique Calleja
- Department of Hematology, Hospital General Universitario Gregorio Marañón, Madrid, Spain; Department of Interventional Radiology, Hospital General Universitario Gregorio Marañón, Madrid, Spain
| | - Diego Rincón
- Department of Hematology, Hospital General Universitario Gregorio Marañón, Madrid, Spain; Department of Hepatology, Hospital General Universitario Gregorio Marañón, Madrid, Spain
| | - Nieves Dorado
- Department of Hematology, Hospital General Universitario Gregorio Marañón, Madrid, Spain; Gregorio Marañón Health Research Institute, Madrid, Spain
| | - Paola Barzallo
- Department of Hematology, Hospital General Universitario Gregorio Marañón, Madrid, Spain
| | - Javier Anguita
- Department of Hematology, Hospital General Universitario Gregorio Marañón, Madrid, Spain; Gregorio Marañón Health Research Institute, Madrid, Spain
| | - José Luis Díez-Martín
- Department of Hematology, Hospital General Universitario Gregorio Marañón, Madrid, Spain; Gregorio Marañón Health Research Institute, Madrid, Spain; Department of Hematology, Universidad Complutense de Madrid, Madrid, Spain
| | - Mi Kwon
- Department of Hematology, Hospital General Universitario Gregorio Marañón, Madrid, Spain; Gregorio Marañón Health Research Institute, Madrid, Spain
| |
Collapse
|
21
|
Charilaou P, Devani K, Petrosyan R, Reddy C, Pyrsopoulos N. Inpatient Mortality Benefit with Transjugular Intrahepatic Portosystemic Shunt for Hospitalized Hepatorenal Syndrome Patients. Dig Dis Sci 2020; 65:3378-3388. [PMID: 32062714 DOI: 10.1007/s10620-020-06136-2] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/28/2019] [Accepted: 02/04/2020] [Indexed: 02/07/2023]
Abstract
BACKGROUND It has been reported that transjugular intrahepatic portosystemic shunting (TIPS) might be utilized as a salvage option for hepatorenal syndrome (HRS), while randomized controlled trials are pending and real-world contemporary data on inpatient mortality is lacking. METHODS We conducted an observational retrospective cohort study from the National Inpatient Sample from 2005 to 2014. We included all adult patients admitted with HRS and cirrhosis, using ICD 9-CM codes. We excluded cases with variceal bleeding, Budd-Chiari, end-stage renal disease, liver transplant and transfers to acute-care facilities. TIPS' association with inpatient mortality was assessed using multivariable mixed-effects logistic regression, as well as exact-matching, thus mitigating for TIPS selection bias. The exact-matched analysis was repeated among TIPS-only versus dialysis-only patients. RESULTS A total of 79,354 patients were included. Nine hundred eighteen (1.2%) underwent TIPS. Between TIPS and non-TIPS groups, mean age (58 years) and gender (65% males) were similar. Overall mortality was 18% in TIPS and 48% in dialysis-only cases (n = 10,379; 13.1%). Ninety six (10.5%) TIPS patients underwent dialysis. In-hospital mortality in TIPS patients was twice less likely than in non-TIPS patients (adjusted odds ratio [aOR] = 0.43, 95% CI 0.30-0.62; p < 0.001), with similar results in matched analysis [exact-matched (em) OR = 0.39, 95% CI 0.17-0.89; p < 0.024; groups = 96; unweighted n = 463]. Head-to-head comparison showed that TIPS-only patients were 3.3 times less likely to succumb inpatient versus dialysis-only patients (contrast aOR = 0.31, 95% CI 0.20-0.46; p < 0.001), with similar findings post-matching (emOR = 0.22, 95% CI 0.15-0.33; p < 0.001; groups = 54, unweighted n = 1457). CONCLUSIONS Contemporary, real-world data reveal that TIPS on its own, and when compared to dialysis, is associated with decreased inpatient mortality when utilized in non-bleeders-HRS patients. Further randomized studies are needed to establish the long-term benefit of TIPS in these patients.
Collapse
Affiliation(s)
- Paris Charilaou
- Division of Gastroenterology & Hepatology, Saint Peter's University Hospital/Rutgers - RWJ Medical School, New Brunswick, NJ, USA.
| | - Kalpit Devani
- Division of Gastroenterology, East Tennessee State University, Johnson City, TN, USA
| | - Romela Petrosyan
- Department of Internal Medicine, Greenville Memorial Hospital, Greenville, SC, USA
| | - Chakradhar Reddy
- Division of Gastroenterology, East Tennessee State University, Johnson City, TN, USA
| | - Nikolaos Pyrsopoulos
- Division of Gastroenterology and Hepatology, Newark University Hospital/Rutgers - New Jersey Medical School, Newark, NJ, USA
| |
Collapse
|
22
|
Yoon U, Topper J, Goldhammer J. Preoperative Evaluation and Anesthetic Management of Patients With Liver Cirrhosis Undergoing Cardiac Surgery. J Cardiothorac Vasc Anesth 2020; 36:1429-1448. [PMID: 32891522 DOI: 10.1053/j.jvca.2020.08.022] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/28/2020] [Revised: 07/30/2020] [Accepted: 08/09/2020] [Indexed: 12/13/2022]
Abstract
Preoperative evaluation and anesthetic management of patients with liver cirrhosis undergoing cardiac surgery remain a clinical challenge because of its high risk for perioperative complications. This narrative review article summarizes the pathophysiology and anesthetic implication of liver cirrhosis on each organ system. It will help physicians to evaluate surgical candidates, to optimize intraoperative management, and to anticipate complications in liver cirrhosis patients undergoing cardiac surgery. Morbidity typically results from bleeding, sepsis, multisystem organ failure, or hepatic insufficiency. These complications occur as a result of the presence of coagulopathy, poor nutritional status, immune dysfunction, cirrhotic cardiomyopathy, and renal and pulmonary dysfunction that occur with liver cirrhosis. Therefore, liver cirrhosis should not be seen as a single disease, but one that manifests with multiorgan dysfunction. Cardiac surgery in patients with liver cirrhosis increases the risk of perioperative complications, and it presents a particular challenge to the anesthesiologist in that nearly every aspect of normally functioning physiology may be jeopardized in a unique way. Accurately classifying the extent of liver disease, preoperative optimization, and surgical risk communication with the patient are crucial. In addition, all teams involved in the surgery should communicate openly and coordinate in order to ensure optimal care. To reduce perioperative complications, consider using off-pump cardiopulmonary bypass techniques and optimal perfusion modalities to mimic current physiologic conditions.
Collapse
Affiliation(s)
- Uzung Yoon
- Department of Anesthesiology, Thomas Jefferson University Hospital, Philadelphia, PA.
| | - James Topper
- Department of Anesthesiology, Thomas Jefferson University Hospital, Philadelphia, PA
| | - Jordan Goldhammer
- Department of Anesthesiology, Thomas Jefferson University Hospital, Philadelphia, PA
| |
Collapse
|
23
|
Is There Still a Role for Surgical Shunts in the Treatment of Budd-Chiari Syndrome? A 25-Year Experience. J Gastrointest Surg 2020; 24:1359-1365. [PMID: 32016670 DOI: 10.1007/s11605-020-04524-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/30/2019] [Accepted: 01/22/2020] [Indexed: 01/31/2023]
Abstract
PURPOSE To investigate the long-term results of shunt surgery in the treatment of Budd-Chiari Syndrome. METHODS Medical records of patients treated with Budd-Chiari Syndrome between 1993 and 2006 were reviewed. RESULTS Thirty-seven patients (26 female, 11 male) were identified, with a median age of 30 years (range 14-51). Median duration of symptoms was 3 months (range 1 month to 10 years). Twenty-five patients, all in acute or subacute stages of disease, were treated surgically. Constructed shunts were mesoatrial in 17, portocaval in five (one was converted from a failed portorenal shunt) and mesocaval in three. Median portal pressure decreased from 44 cm H2O (range 31-55) to 20 cm H2O (range 5-27). Seven patients (28%) died in the perioperative period. Eighteen patients (72%) were followed up for a median of 186 months (24-241 months). Seven patients died during follow-up, five due to reasons related to the underlying cause and treatment. Remaining 11 patients (61%) were alive at a median of 18 years (13-25 years) with patent shunts. One-, 5-, and 10-year survival rates in patients undergoing shunt surgery were 78%, 72%, and 66%, respectively. CONCLUSION Portosystemic shunts may still be considered when expertise for transjugular intrahepatic portosystemic shunt or liver transplantation is not available.
Collapse
|
24
|
Stress-Induced Takotsubo Cardiomyopathy After Transjugular Intrahepatic Portosystemic Shunt. ACG Case Rep J 2020; 7:e00377. [PMID: 32607377 PMCID: PMC7289277 DOI: 10.14309/crj.0000000000000377] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/14/2019] [Accepted: 03/04/2020] [Indexed: 11/17/2022] Open
Abstract
This report presents the first known documented case of Takotsubo cardiomyopathy, characterized by transient left ventricular systolic dysfunction after a transjugular intrahepatic portosystemic shunt procedure. A 59-year-old woman with decompensated cirrhosis underwent transjugular intrahepatic portosystemic shunt procedure with subsequent new-onset heart failure without previous diagnostic evidence of underlying cardiovascular disease, including cirrhotic cardiomyopathy. After 2 weeks of medical management with β-blockade and diuretics, the patient had recovery of a left ventricular ejection fraction.
Collapse
|
25
|
KASL clinical practice guidelines for liver cirrhosis: Varices, hepatic encephalopathy, and related complications. Clin Mol Hepatol 2020; 26:83-127. [PMID: 31918536 PMCID: PMC7160350 DOI: 10.3350/cmh.2019.0010n] [Citation(s) in RCA: 69] [Impact Index Per Article: 17.3] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/22/2019] [Accepted: 10/23/2019] [Indexed: 02/06/2023] Open
|
26
|
The Effect of Puncture Sites of Portal Vein in TIPS with ePTFE-Covered Stents on Postoperative Long-Term Clinical Efficacy. Gastroenterol Res Pract 2019; 2019:2935498. [PMID: 30728835 PMCID: PMC6343182 DOI: 10.1155/2019/2935498] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/12/2018] [Revised: 08/26/2018] [Accepted: 10/18/2018] [Indexed: 12/15/2022] Open
Abstract
Purpose To evaluate the effect of puncture sites of the portal vein in transjugular intrahepatic portosystemic shunt (TIPS) on long-term clinical efficacy. Methods A retrospective review was performed, including consecutive 171 patients who underwent TIPS with ePTFE-covered stents. All patients were divided into 3 groups according to the puncture site of the portal vein: intrahepatic bifurcation of the portal vein (group A, n = 88), right branch of the portal vein (group B, n = 48), and left branch of the portal vein (group C, n = 35). The Kaplan-Meier analysis was performed to assess the effect of different puncture sites on primary patency, the incidence of hepatic encephalopathy (HE), and survival. Results The primary restenosis rate was 29.8% (51/171). The total HE rate was 31.6% (54/171). The cumulative death rate was 19.3% (33/171). The Kaplan-Meier analysis showed that group C versus group A, group C versus group B, and group A versus group B were significantly different on the primary restenosis rate, respectively (χ 2 = 11.49, P = 0.001; χ 2 = 4.54, P = 0.033; and χ 2 = 4.12, P = 0.046), and group C is better than the other two groups. What is more, group C versus group A and group C versus group B were significantly different on the incidence of HE, respectively (χ 2 = 8.07, P = 0.004; χ 2 = 9.44, P = 0.002), and group C is better than the other two groups. There was no significant difference on survival. Conclusion Choosing the left branch of the portal vein as the puncture site to create the shunt in TIPS with ePTFE-covered stents may decrease the incident of primary restenosis and HE significantly.
Collapse
|
27
|
Greco L, Chegai F, Pensabene MC, De Corato L, Pampana E, Lenci I, Garaci F, Floris R, Melis M. Early detection of hepatic encephalopathy after transjugular intrahepatic portsystemic shunt using multiparametric magnetic resonance with spectroscopy. Eur J Radiol Open 2019; 6:350-357. [PMID: 31886319 PMCID: PMC6909044 DOI: 10.1016/j.ejro.2019.09.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2019] [Revised: 09/04/2019] [Accepted: 09/05/2019] [Indexed: 12/01/2022] Open
Abstract
Background Hepatic encephalopathy (HE) is a complication of transjugular intrahepatic portosystemic shunt (TIPS). Aims Extend the knowledge about the early detection of multiple brain metabolic abnormalities following TIPS; these abnormalities can be detected and managed prior to the clinical manifestation of HE with use of Multiparametric Magnetic Resonance with Spectroscopy. Methods 12 cirrhotic Patients underwent TIPS; each Patient underwent a 3 T MRI evaluation before and after TIPS. The spectroscopic images were processed measuring the values of the metabolites N-acetylaspartate (NAA) - Glutamine / Glutamate (Glx) - Colina (Cho) - Myinositol (mI) at the level of the nuclei of the base. Results Spectroscopic examination performed before the TIPS procedure showed low values of Cho and Mi, instead following the procedure: an increase in the Glx value, a mean reduction in the values of Cho and mI, a statistically significant reduction in the Cho / Creatine ratio, in the mI / Creatine ratio and an increase of the Glx / Creatine ratio. Conclusions Our study demonstrated the efficacy of spectroscopy in Patient subjected to TIPS. MR 3 T with spectroscopy can become a valid tool for monitor the dynamics of changes in brain metabolism after TIPS and to provide an early diagnosis of HE allowing an early treatment.
Collapse
|
28
|
Abstract
Ascites, a common complication of liver cirrhosis, eventually becomes refractory to diuretic therapy and sodium restriction in ∼10% of patients. Multiple pathogenetic factors are involved in the development of refractory ascites, which ultimately lead to renal hypoperfusion and avid sodium retention. Therefore, renal dysfunction commonly accompanies refractory ascites. Management includes continuation of sodium restriction, which needs frequent reviews for adherence; and regular large volume paracentesis of 5 L or more with albumin infusions to prevent the development of paracentesis-induced circulatory dysfunction. In the appropriate patients with reasonable liver reserve, the insertion of a transjugular intrahepatic portosystemic stent shunt (TIPS) can be considered, especially if the patient is relatively young and has no previous hepatic encephalopathy or anatomical contraindications, and no past history of renal or cardiopulmonary disease. Response to TIPS with ascites clearance can lead to nutritional improvement. Devices such as an automated low-flow ascites pump may be available in the future for ascites treatment. Patients with refractory ascites and poor liver function and/or renal dysfunction, should be referred for liver transplant, as this will eliminate the portal hypertension and liver dysfunction. Renal dysfunction prior to liver transplant largely improves after transplant without affecting post-transplant survival.
Collapse
Affiliation(s)
- Danielle Adebayo
- Division of Gastroenterology, Department of Medicine, Toronto General Hospital, University of Toronto, Toronto, ON, Canada. These authors contributed equally: Danielle Adebayo, Shuet Fong Neong
| | - Shuet Fong Neong
- Division of Gastroenterology, Department of Medicine, Toronto General Hospital, University of Toronto, Toronto, ON, Canada. These authors contributed equally: Danielle Adebayo, Shuet Fong Neong
| | - Florence Wong
- Division of Gastroenterology, Department of Medicine, Toronto General Hospital, University of Toronto, Toronto, ON, Canada. These authors contributed equally: Danielle Adebayo, Shuet Fong Neong
| |
Collapse
|
29
|
Affiliation(s)
- Aluko A. Hope
- RS Morrison (corresponding author) Department of Geriatrics and Palliative Medicine, and Hertzberg Palliative Care Institute, Mount Sinai School of Medicine, 1 Gustave Levy Place, Box 1070, New York, New York, USA
| | - R. Sean Morrison
- Department of Medicine, Division of Pulmonary, Critical Care and Sleep Medicine, and Department of Geriatrics and Palliative Medicine, Mount Sinai School of Medicine, New York, New York, USA
| |
Collapse
|
30
|
Jiang J, Nambisan RM, Green S, Gianchandani YB. Encapsulation Approaches for In-Stent Wireless Magnetoelastic Sensors. IEEE Trans Biomed Eng 2018; 66:10.1109/TBME.2018.2882415. [PMID: 30475708 PMCID: PMC6667316 DOI: 10.1109/tbme.2018.2882415] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Wireless magnetoelastic sensors offer significant potential for measuring the accumulation of biomass within stents - enabling early detection prior to stent occlusion - but the encapsulation of these sensors remains a critical challenge. The encapsulation must allow the sensors to navigate the curvature and accommodate the contact forces imparted during and after the implantation procedure, while also leaving the sensor open to mechanical interaction with the biomass during the extended period of deployment. This paper is focused on the encapsulation of ribbon-like magnetoelastic sensors (12.5 mm x 1 mm x 60 μm) within plastic biliary stents (inner diameter of 2.54 mm). The compromise between two polymer-based package designs - one mechanically flexible (Type F) and one mechanically stiff (Type S) - is evaluated. The primary advantage of the Type F package is the flexibility during the delivery process while that of the Type S package is in maintaining a strong signal even when the stent is in a curved bile duct. The maximum thicknesses of the Type F and S packages are 0.53 mm and 0.74 mm, respectively. Mechanical tests show that both types protect the sensors from forces imparted by a standard introducer, and allow the encapsulated sensors to accommodate bending with a radius of curvature as small as 3 cm. The Type F package has also been tested in situ, in the bile duct of a porcine carcass. The signal is measurable with a wireless range of 10 cm, at a resonant frequency of 159 kHz and a quality factor of 397.
Collapse
|
31
|
Long-term clinical outcomes in patients with viral hepatitis related liver cirrhosis after transjugular intrahepatic portosystemic shunt treatment. Virol J 2018; 15:151. [PMID: 30285813 PMCID: PMC6167830 DOI: 10.1186/s12985-018-1067-7] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2018] [Accepted: 09/25/2018] [Indexed: 12/14/2022] Open
Abstract
Background Transjugular intrahepatic portosystemic shunt (TIPS) procedure has played a vital role in management of portal hypertension. Thus, we aimed to investigate the natural history, long-term clinical outcome, predictors of survival in viral hepatitis related cirrhotic patients post-TIPS. Method A total of 704 patients with complete followed-up data were enrolled, and clinical characteristics of patients were collected and analyzed. Kaplan-Meier method was used to calculate survival, and comparisons were made by log rank test. A multivariate analysis of factors influencing survival was carried out using the Cox proportional hazards regression model. Results TIPS implatantion significantly decreased portal vein pressure with 9.77 cmH2O reduction, without influencing long-term liver functions. The total incidence rate of major complication post-TIPS, including HE and re-bleeding/bleeding, was 37.9% and 15.5%, respectively. Patients in Child-Pugh C stage revealed higher overt hepatic encephalopathy (HE) occurrence (65.6%), while patients receiving covered, 6 mm in diameter stents indicated notably lower incidence of HE in comparison with other groups (6.4%). The median survival was > 60 months, 27.0 months, and 11.5 months in cirrhotic patients with variceal bleeding, refractory ascites, and both complications, respectively. The cumulative 5-year survival was significantly higher in patients with variceal bleeding (75.6%) in comparison with either that in patients with refractory ascites (12.5%) or that in patients with both complications (1.96%) (P < 0.0001). Covered stents usage, baseline model for end-stage liver disease (MELD) score, and baseline Child-Pugh classification were predictive of survival (P < 0.001). Other variables including age, male gender, and pre-TIPS PVP were not emerged as significant predictors (P > 0.05). Conclusion TIPS was an effective and safe therapeutic method for decompression of portal hypertension and for treatment of its complications. Careful selection of patients with minimal liver dysfunction for TIPS implantation was essential for better long-term outcomes.
Collapse
|
32
|
Philip M, Thornburg B. Preoperative Transjugular Intrahepatic Portosystemic Shunt Placement for Extrahepatic Abdominal Surgery. Semin Intervent Radiol 2018; 35:203-205. [PMID: 30087524 DOI: 10.1055/s-0038-1660799] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Extrahepatic abdominal surgery in patients with portal hypertension is associated with a high rate of perioperative complications and death due to the increased risk of liver failure, perioperative bleeding, and ascites. One proposed method to facilitate surgery in these patients is with preoperative placement of a transjugular intrahepatic portosystemic shunt (TIPS). By decompressing the portal circulation, this presurgical measure would theoretically decrease the potential for bleeding and improve the ability to control ascites in the perioperative and postoperative period. This article reviews the use of TIPS prior to abdominal surgery in patients with portal hypertension.
Collapse
Affiliation(s)
- Michelle Philip
- Section of Interventional Radiology, Department of Radiology, Northwestern Memorial Hospital, Chicago, Illinois
| | - Bartley Thornburg
- Section of Interventional Radiology, Department of Radiology, Northwestern Memorial Hospital, Chicago, Illinois
| |
Collapse
|
33
|
Affiliation(s)
- Idan Levy
- Paul May and Frank Stein Interventional Endoscopy Center, California Pacific Medical Center, San Francisco, California
| | - Kenneth F Binmoeller
- Paul May and Frank Stein Interventional Endoscopy Center, California Pacific Medical Center, San Francisco, California
| |
Collapse
|
34
|
Effects of transjugular intrahepatic portosystemic shunt (TIPS) on blood volume distribution in patients with cirrhosis. Dig Liver Dis 2017; 49:1353-1359. [PMID: 28729141 DOI: 10.1016/j.dld.2017.06.011] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/17/2017] [Revised: 06/10/2017] [Accepted: 06/19/2017] [Indexed: 02/08/2023]
Abstract
BACKGROUND Cirrhosis is accompanied by portal hypertension with splanchnic and systemic arterial vasodilation, and central hypovolaemia. A transjugular intrahepatic portosystemic shunt (TIPS) alleviates portal hypertension, but also causes major haemodynamic changes. AIMS To investigate effects of TIPS on regional blood volume distribution, and systemic haemodynamics. METHODS Thirteen cirrhotic patients had their regional blood volume distribution determined with gamma-camera technique before and after TIPS. Additionally, we measured systemic haemodynamics during liver vein and right heart catheterization. Central and arterial blood volume (CBV) and cardiac output (CO) were determined with indicator dilution technique. RESULTS After TIPS, the thoracic blood volume increased (+10.4% of total blood volume (TBV), p<0.01), whereas the splanchnic blood volume decreased (-11.9% of TBV, p<0.001). CO increased (+22%, p<0.0001), and systemic vascular resistance decreased (-26%, p<0.001), whereas CBV did not change. Finally, right atrial pressure and mean pulmonary artery pressure increased after TIPS (+50%, p<0.005; +40%, p<0.05, respectively). CONCLUSIONS TIPS restores central hypovolaemia by an increase in thoracic blood volume and alleviates splanchnic vascular congestion. In contrast, CBV seems unaltered. The improvement in central hypovolaemia is therefore based on an increase in thoracic blood volume that includes both the central venous and arterial blood volume. This is supported by an increase in preload, combined with a decrease in afterload.
Collapse
|
35
|
Li Y, Wang F, Chen X, Li B, Meng W, Qin C. Short outcome comparison of elderly patients versus nonelderly patients treated with transjugular intrahepatic portosystemic stent shunt: A propensity score matched cohort study. Medicine (Baltimore) 2017; 96:e7551. [PMID: 28723777 PMCID: PMC5521917 DOI: 10.1097/md.0000000000007551] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
A transjugular intrahepatic portosystemic stent shunt (TIPSS) has been widely used to treat portal hypertension and its complications. However, no established guidelines mentioned whether age was a risk factor for the treatment of TIPSS.The aim is to determine whether age is a risk factor for poor outcomes following TIPSS.The retrospective cohort study included 134 patients who received TIPSS treatment from 2003 to 2016. The adverse events after the TIPSS treatment were compared after propensity score matching to reduce the effect of selection bias. Multivariate logistic regression was conducted to confirm the potential confounders for rebleeding (RB) and ascites after TIPSS therapy.After excluding 10 patients, 124 patients were analyzed. Among them, 37 patients were included in the elderly group. In the propensity score matched cohort (32 pairs), there was no significant difference between the elderly group and the nonelderly group in terms of the event after TIPSS therapy (All P > .05). Multivariate logistic regression analysis revealed that hypertension (OR 13.246, 95% CI: [1.29, 136.073]; P = .03) was an independent risk factor for RB. In addition, smoking (OR 4.48, 95% CI: [1.43, 14.033]; P = .01) and preascites (OR 6.7, 95% CI: [2.04, 22.005]; P = .002) were independent risk factors for ascites after TIPSS treatment.Age is not an independent risk factor for poor outcomes following the treatment of TIPSS. Smoking and preascites are independent risk factors for patients' ascites, and hypertension is an independent risk factor for patients' RB after TIPSS therapy.
Collapse
Affiliation(s)
- Yang Li
- Department of Intensive Care Unit, Qilu Hospital Affiliated to Shandong University
| | - Fengyan Wang
- Department of Gastroenterology and Hepatology, Shandong provincial Qianfoshan Hospital
| | - Xiaomei Chen
- Department of Intensive Care Unit, Qilu Hospital Affiliated to Shandong University
| | - Bin Li
- Department of Gastroenterology and Hepatology, Shandong Province Hospital Affiliated to Shandong University
| | - Wei Meng
- Department of ECG, Qilu Hospital Affiliated to Shandong University, Shandong, China
| | - Chengyong Qin
- Department of Gastroenterology and Hepatology, Shandong Province Hospital Affiliated to Shandong University
| |
Collapse
|
36
|
Lin LL, Du SM, Fu Y, Gu HY, Wang L, Jian ZY, Shen XF, Luo J, Zhang C. Combination therapy versus pharmacotherapy, endoscopic variceal ligation, or the transjugular intrahepatic portosystemic shunt alone in the secondary prevention of esophageal variceal bleeding: a meta-analysis of randomized controlled trials. Oncotarget 2017; 8:57399-57408. [PMID: 28915680 PMCID: PMC5593651 DOI: 10.18632/oncotarget.18143] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2017] [Accepted: 04/25/2017] [Indexed: 12/27/2022] Open
Abstract
Patients with liver cirrhosis and variceal hemorrhage are at increased risk of rebleeding. We performed a meta-analysis toassess the clinical efficacy of combination therapy (pharmacotherapy and endoscopic variceal ligation (EVL)) compared with pharmacotherapy, EVL, or transjugular intrahepatic portosystemic shunt (TIPS) alone in the prevention of rebleeding and mortality. A literature search of MEDLINE, EMBASE, and the Cochrane Controlled Trials Register, up until November 2016, identified relevant randomized controlled trials. Data analysis was performed using Stata 12.0. Regarding overall mortality, combination therapy was as effective as EVL, pharmacotherapy, and TIPS (relative risk (RR) = 0.62, 95% confidence interval (CI): 0.36-1.08, RR=1.05, 95% CI: 0.68-1.63, and RR=1.39, 95% CI: 0.92-2.09, respectively). Combination therapy was as effective as EVL and pharmacotherapy alone in reducing blood-related mortality (RR=0.43, 95% CI: 0.15-1.25, and RR=0.42, 95% CI: 0.17-1.06), whereas TIPS was more effective than combination therapy (RR=5.66, 95% CI: 1.02-31.40). This was also the case for rebleeding; combination therapy was more effective than EVL and pharmacotherapy alone (RR=0.57, 95% CI: 0.41-0.79, and RR=0.65, 95% CI: 0.48-0.88), whereas TIPS was more effective than combination therapy (RR=9.42, 95% CI: 2.99-29.65). Finally, regarding rebleeding from esophageal varices, combination therapy was as effective as EVL alone (RR=0.59, 95% CI: 0.33-1.06) and was more effective than pharmacotherapy alone (RR=0.58, 95% CI: 0.40-0.85), although was less effective than TIPS (RR=2.20, 95% CI: 1.22-3.99). TIPS was recommended as the first choice of therapy in the secondary prevention of esophageal variceal bleeding.
Collapse
Affiliation(s)
- Lu-Lu Lin
- Center for Evidence-Based Medicine and Clinical Research, Taihe Hospital, Hubei University of Medicine, Shiyan 442000, China
| | - Shi-Ming Du
- Department of Pharmacy, Taihe Hospital, Hubei University of Medicine, Shiyan 442000, China
| | - Yan Fu
- Department of Hepatobiliary Surgery, Taihe Hospital, Hubei University of Medicine, Shiyan 442000, China
| | - Hui-Yun Gu
- Department of Gastroenterology, Taihe Hospital, Hubei University of Medicine, Shiyan 442000, China
| | - Lei Wang
- Administrative Offices, Taihe Hospital, Hubei University of Medicine, Shiyan 442000, China
| | - Zhi-Yuan Jian
- Hepatopancreatobiliary Surgery Treatment Center, Taihe Hospital, Hubei University of Medicine, Shiyan 442000, China
| | - Xian-Feng Shen
- Hepatopancreatobiliary Surgery Treatment Center, Taihe Hospital, Hubei University of Medicine, Shiyan 442000, China
| | - Jie Luo
- Center for Evidence-Based Medicine and Clinical Research, Taihe Hospital, Hubei University of Medicine, Shiyan 442000, China.,Administrative Offices, Taihe Hospital, Hubei University of Medicine, Shiyan 442000, China
| | - Chao Zhang
- Center for Evidence-Based Medicine and Clinical Research, Taihe Hospital, Hubei University of Medicine, Shiyan 442000, China
| |
Collapse
|
37
|
Qiu B, Li K, Dong X, Liu FQ. Transjugular Intrahepatic Portosystemic Shunt for Portal Hypertension in Hepatocellular Carcinoma with Portal Vein Tumor Thrombus. Cardiovasc Intervent Radiol 2017; 40:1372-1382. [PMID: 28488102 DOI: 10.1007/s00270-017-1655-8] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/10/2016] [Accepted: 04/18/2017] [Indexed: 12/13/2022]
Abstract
PURPOSE In patients with hepatocellular carcinoma (HCC), limited therapeutic options are available for portal hypertension resulted from portal vein tumor thrombus (PVTT). We aimed to determine safety and efficacy of TIPS for treatment of symptomatic portal hypertension in HCC with PVTT. METHODS We evaluated clinical characteristics of 95 patients with HCC and PVTT out of 992 patients who underwent TIPS. The primary endpoints included success rate, procedural mortality, serious complications, decrease in portosystemic pressure gradient, and symptom relief. The secondary endpoints included recurrence of portal hypertension, overall survival, adverse events related to treatments for HCC, and quality of life measured by Karnofsky Performance Status Scale (KPS). RESULTS Success rate of TIPS was 95.8% (91/95), with procedural mortality of 1.1%. Serious complications related to TIPS procedure occurred in 2.1% (2/95) of patients. The symptoms of portal hypertension were well relieved. Variceal bleeding was successfully controlled and terminated in 100% of patients, with a recurrence rate of 39.2% in 12 months. Refractory ascites/hydrothorax was controlled partially or completely in 92.9% of patients during 1 month after TIPS, with a recurrence rate of 17.9% in 12 months. Survival rate at 6, 12, 24, and 36 months was 75.8, 52.7, 26.4, and 3.3%, respectively. No unexpected adverse event related to treatments for HCC was observed. The KPS score was 49 ± 4.5 and 63 ± 4.7 before and 1 month after TIPS, respectively (p < 0.001). CONCLUSIONS TIPS is a safe and efficacious treatment for symptomatic portal hypertension in HCC with PVTT.
Collapse
Affiliation(s)
- Bin Qiu
- Department of Interventional Therapy, Beijing Shijitan Hospital, Capital Medical University, No. 10 Tieyi Rd., Yangfangdian, Haidian District, Beijing, 100038, China.,Department of Interventional Therapy, National Cancer Center/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, 100021, China
| | - Kai Li
- Department of General Surgery, Beijing Shijitan Hospital, Capital Medical University, Beijing, 100038, China
| | - Xiaoqun Dong
- Section of Gastroenterology, Section of Hematology/Oncology, Stephenson Cancer Center, Department of Internal Medicine, College of Medicine, The University of Oklahoma Health Sciences Center, Oklahoma City, OK, USA
| | - Fu-Quan Liu
- Department of Interventional Therapy, Beijing Shijitan Hospital, Capital Medical University, No. 10 Tieyi Rd., Yangfangdian, Haidian District, Beijing, 100038, China.
| |
Collapse
|
38
|
Weilert F, Binmoeller KF. Endoscopic management of gastric varices. TECHNIQUES IN GASTROINTESTINAL ENDOSCOPY 2017. [DOI: 10.1016/j.tgie.2017.03.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
|
39
|
Hernández-Jaras J, Espí-Reig J, Alis R, García-Martínez AM, Rodríguez-Ortega D, Roca-Argente L, Moll-Guillen JL. Immune Complex Membranoproliferative Glomerulonephritis Associated with Transjugular Intrahepatic Portosystemic Shunts in Alcoholic Cirrhosis: Two Case Reports. Med Princ Pract 2017; 26:286-288. [PMID: 28226323 PMCID: PMC5588412 DOI: 10.1159/000464365] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/23/2016] [Accepted: 02/20/2017] [Indexed: 11/19/2022] Open
Abstract
OBJECTIVE To report on 2 patients with alcoholic cirrhosis who were treated with transjugular intrahepatic portosystemic shunt (TIPS) placement. CLINICAL PRESENTATION AND INTERVENTION The 2 patients had a history of alcoholic cirrhosis, and TIPS surgery was performed on them. In both cases, 4 months after TIPS placement, proteinuria was observed along with histological alterations characteristic of immune complex membranoproliferative glomerulonephritis (MPGN). CONCLUSION The TIPS in one patient was successful without immediate complications, while the other patient was referred for a combined liver-kidney transplant. In both cases, immune complex MPGN might have developed after TIPS placement probably due to a reduced immune complex clearance.
Collapse
Affiliation(s)
- Julio Hernández-Jaras
- Servicio de Nefrología, Hospital Universitario y Politécnico La Fe, Valencia, Spain
- *Julio Hernández-Jaras, MD, PhD, Servicio de Nefrología, Hospital Universitario y Politécnico La Fe, Avda. de Fernando Abril Martorell 106, ES-46026 Valencia (Spain), E-Mail
| | - Jordi Espí-Reig
- Servicio de Nefrología, Hospital Universitario y Politécnico La Fe, Valencia, Spain
| | - Rafael Alis
- Servicio de Nefrología, Hospital Universitario y Politécnico La Fe, Valencia, Spain
| | | | | | - Lourdes Roca-Argente
- Servicio de Nefrología, Hospital Universitario y Politécnico La Fe, Valencia, Spain
| | | |
Collapse
|
40
|
Poincloux L, Chabrot P, Mulliez A, Genes J, Boyer L, Abergel A. Interventional endoscopic ultrasound: A new promising way for intrahepatic portosystemic shunt with portal pressure gradient. Endosc Ultrasound 2017; 6:394-401. [PMID: 29251274 PMCID: PMC5752762 DOI: 10.4103/eus.eus_42_17] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
Background and Objectives: Interventional endoscopic ultrasound (EUS) is a promising novel approach for intravascular interventions. The aim of this study was to assess the feasibility and safety of a EUS-guided intrahepatic portosystemic shunt (EGIPS) with portal pressure gradient measurement in a live porcine model. Methods: The left hepatic vein (LHV) or the inferior vena cava (IVC) was punctured with a needle that advanced into the portal vein (PV). A guidewire was then inserted into the PV, and a needle knife was used to create an intrahepatic fistula between LHV and PV. Portal pressure was recorded. The fistula was dilated with a balloon and a biliary metal stent was deployed between LHV and PV under sonographic and fluoroscopic observation. A portocavography validated the patency of the stent. Necropsies were realized after euthanasia. Results: Portosystemic stenting was achieved in 19/21 pigs. Final portocavography confirmed stent patency between PV and LHV or IVC in 17 pigs (efficacy of 81%): Four stents were dysfunctional as two were thrombosed and two were poor positioned. Portal pressure was documented before and after shunting in 20/21 pigs. Necropsies revealed that 19/21 procedures were transesophageal and two were transgastric. Hemoperitoneum and pneumothorax were found in one pig and hemothorax was found in two pigs. Morbidity was 14.2% (3/21 animals). Conclusion: EGIPS was feasible in 91% of cases, functional in 81%, with 14.2% per procedure morbidity. EGIPS still needs to be assessed in portal hypertension pig models with longer follow-up before being considered as an alternative when the transjugular intrahepatic portosystemic shunt fails.
Collapse
Affiliation(s)
- Laurent Poincloux
- Department of Digestive and Hepatobiliary Diseases, CHU Estaing; Auvergne University Department/CNRS 6284 Image Sciences for Innovations Techniques, France
| | - Pascal Chabrot
- Auvergne University Department/CNRS 6284 Image Sciences for Innovations Techniques; Department of Radiology, CHU Gabriel Montpied, France
| | - Aurélien Mulliez
- Department of Biostatistics, DRCI, CHU Gabriel Montpied, Clermont-Ferrand, France
| | - Julien Genes
- Department of Digestive and Hepatobiliary Diseases, CHU Estaing, France
| | - Louis Boyer
- Auvergne University Department/CNRS 6284 Image Sciences for Innovations Techniques; Department of Radiology, CHU Gabriel Montpied, France
| | - Armando Abergel
- Department of Digestive and Hepatobiliary Diseases, CHU Estaing; Auvergne University Department/CNRS 6284 Image Sciences for Innovations Techniques, France
| |
Collapse
|
41
|
Rosero EB, Joshi GP. Ambulatory Anesthesia in Remote Locations. CURRENT ANESTHESIOLOGY REPORTS 2016. [DOI: 10.1007/s40140-016-0181-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
|
42
|
Real-Time 3D CT Image Guidance for Transjugular Intrahepatic Portosystemic Shunt Creation Using Preoperative CT: A Prospective Feasibility Study of 20 Patients. AJR Am J Roentgenol 2016; 208:W11-W16. [PMID: 27786554 DOI: 10.2214/ajr.15.15210] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
OBJECTIVE The purpose of this study is to prospectively evaluate the feasibility and efficacy of real-time 3D CT image guidance during transjugular intrahepatic portosystemic shunt (TIPS) creation. SUBJECTS AND METHODS Between October 2013 and December 2013, a total of 20 patients were prospectively enrolled in the present study. Previously acquired portal venous phase CT datasets and intraoperative CT datasets were registered on a dedicated workstation. We accomplished semiautomatic registration for the datasets of 11 of 20 patients (55%), and we performed manual registration for the datasets of the remaining nine patients. The selected volume of interest of the CT image showing the portal vein vasculature was overlaid onto the fluoroscopic display to provide real-time 3D CT image guidance during the procedure. RESULTS For all 20 patients, TIPS procedures were successfully performed by the same operator. The mean (± SD) number of needle passes required for portal vein entry was 1.8 ± 1.1 passes (range, 1-5 passes). The mean duration of radiographic fluoroscopy was 3.5 ± 1.1 minutes for portal vein entry and 11.4 ± 2.1 minutes for the whole procedure. The mean radiation dose used for the whole TIPS procedure was 295.5 ± 66.6 Gy · cm2. No major technical complications were observed. CONCLUSION Real-time 3D guidance with the use of preoperative CT is feasible, safe, and effective for assisting in the creation of TIPS. This approach may result in a shorter procedural time and less radiation exposure. However, future studies are required to compare this method with other mapping techniques.
Collapse
|
43
|
Ansari-Gilani K, Seddigh Tonekaboni B, Nakamoto DA, Modaresi Esfeh J. Utility of Doppler ultrasonography for predicting improvement of platelet count after transjugular intrahepatic portosystemic shunt. Gastroenterol Rep (Oxf) 2016; 5:305-308. [PMID: 27694618 PMCID: PMC5691615 DOI: 10.1093/gastro/gow031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/14/2016] [Accepted: 08/16/2016] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVE Portal pressure gradient (PPG) after transjugular intrahepatic portosystemic shunt (TIPS) <12 mmHg has been reported as the only factor predictive of increase in platelet count. As flow velocities measured on Doppler ultrasound are related to pressure gradient based on the Bernoulli equation, we used this parameter to predict increased platelet count after TIPS placement. METHODS A total of 161 consecutive patients who underwent TIPS placement entered this retrospective study. The platelet count was measured before, one week after and one month after TIPS placement. Clinically significant thrombocytopenia was defined as platelet count ≤100 000. Pre- and post-TIPS PPGs were measured. The velocity of blood flow in the proximal, mid and distal TIPS stent was measured using Doppler ultrasound, and the difference in the highest and lowest measured velocity was entitled flow velocity gradient (FVG), which was considered normal when ≤100 cm/s. RESULTS In 121 patients with pre-TIPS thrombocytopenia, the mean platelet count one week and one month after TIPS placement increased 25.7 x 103 and 35.0 x 103 in 90 patients with PPG≤12 mmHg (P=0.028 and P=0.015), while there was no significant change in platelet count in patients with a PPG >12 mmHg (P=0.098 and P=0.075). Platelets increased significantly when FVG≤ 100 cm/s (n=95) vs FVG >100 cm/s (n=26) one week (37.0x103 vs 11.0x103; P = 0.005 vs 0.07) and one month after TIPS placement (17.0x103 vs 5.2x103; P = 0.01 vs 0.21). CONCLUSION FVG >100 cm/s is not associated with increase in post-TIPS platelet count. On the other hand, findings suggestive of proper TIPS function (FVG ≤100 cm/s and PPG≤ 12 mmHg) predict a significant increase in post-TIPS platelet count.
Collapse
Affiliation(s)
- Kianoush Ansari-Gilani
- Department of Diagnostic Radiology, University Hospitals Case Medical Center, Cleveland, OH, USA
| | | | - Dean A Nakamoto
- Department of Diagnostic Radiology, University Hospitals Case Medical Center, Cleveland, OH, USA
| | - Jamak Modaresi Esfeh
- Department of Gastroenterology and Hepatology, Cleveland Clinic, Cleveland, OH, USA
| |
Collapse
|
44
|
Isfort P, Penzkofer T, Wilkmann C, Na HS, Kotzlowski C, Ito N, Pfeffer JG, Bisplinghoff S, Osterhues S, Besting A, Gooding J, Schmitz-Rode T, Kuhl C, Mahnken AH, Bruners P. Feasibility of electromagnetically guided transjugular intrahepatic portosystemic shunt procedure. MINIM INVASIV THER 2016; 26:15-22. [PMID: 27686414 DOI: 10.1080/13645706.2016.1214155] [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: 10/21/2022]
Abstract
OBJECTIVES To develop an electromagnetic navigation technology for transjugular intrahepatic portosystemic shunt (TIPS) creation and translate it from phantom to an in-vivo large animal setting. MATERIAL AND METHODS A custom-designed device for TIPS creation consisting of a stylet within a 5 French catheter as well as a software prototype were developed that allow real-time tip tracking of both stylet and catheter using an electromagnetic tracking system. Feasibility of navigated TIPSS creation was tested in a phantom by two interventional radiologists (A/B) followed by in-vivo testing evaluation in eight domestic pigs. Procedure duration and number of attempts needed for puncture of the portal vein were recorded. RESULTS In the phantom setting, intervention time to gain access to the portal vein (PV) was 144 ± 67 s (A) and 122 ± 51 s (B), respectively. In the in-vivo trials, TIPS could be successfully completed in five out of eight animals. Mean time for the complete TIPS was 245 ± 205 minutes with a notable learning curve towards the last animal. CONCLUSIONS TIPS creation with the use of electromagnetic tracking technology proved to be feasible in-vitro as well as in-vivo. The system may be useful to facilitate challenging TIPSS procedures.
Collapse
Affiliation(s)
- Peter Isfort
- a Diagnostic and Interventional Radiology , RWTH Aachen University Hospital , Aachen , Germany
| | - Tobias Penzkofer
- a Diagnostic and Interventional Radiology , RWTH Aachen University Hospital , Aachen , Germany.,b Surgical Planning Laboratory , Brigham and Women's Hospital , Boston , MA , USA.,c Diagnostic and Interventional Radiology , Charité Universitätsmedizin Berlin , Berlin , Germany
| | - Christoph Wilkmann
- a Diagnostic and Interventional Radiology , RWTH Aachen University Hospital , Aachen , Germany
| | - Hong-Sik Na
- a Diagnostic and Interventional Radiology , RWTH Aachen University Hospital , Aachen , Germany
| | - Christian Kotzlowski
- a Diagnostic and Interventional Radiology , RWTH Aachen University Hospital , Aachen , Germany
| | - Nobutake Ito
- d Department of Radiology , Keio University , Tokyo , Japan.,e Applied Medical Engineering , RWTH Aachen University Hospital , Aachen , Germany
| | - Joachim Georg Pfeffer
- a Diagnostic and Interventional Radiology , RWTH Aachen University Hospital , Aachen , Germany
| | | | | | | | - Jorge Gooding
- e Applied Medical Engineering , RWTH Aachen University Hospital , Aachen , Germany
| | - Thomas Schmitz-Rode
- e Applied Medical Engineering , RWTH Aachen University Hospital , Aachen , Germany
| | - Christiane Kuhl
- a Diagnostic and Interventional Radiology , RWTH Aachen University Hospital , Aachen , Germany
| | - Andreas Horst Mahnken
- i Department of Diagnostic and Interventional Radiology , Philips University Hospital , Marburg , Germany
| | - Philipp Bruners
- a Diagnostic and Interventional Radiology , RWTH Aachen University Hospital , Aachen , Germany
| |
Collapse
|
45
|
Seif HMAH, Abu Rahma MZ, Zaky S, Swifee YM. Transjugular intrahepatic porto-systemic shunt in bleeding esophageal varices and refractory ascites. The first 4years experience in Assiut University Hospital. THE EGYPTIAN JOURNAL OF RADIOLOGY AND NUCLEAR MEDICINE 2016. [DOI: 10.1016/j.ejrnm.2016.05.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022] Open
|
46
|
Gao J, Zheng X, Zheng YY, Zuo GQ, Ran HT, Auh YH, Waldron L, Chan T, Wang ZG. Shear Wave Elastography of the Spleen for Monitoring Transjugular Intrahepatic Portosystemic Shunt Function: A Pilot Study. JOURNAL OF ULTRASOUND IN MEDICINE : OFFICIAL JOURNAL OF THE AMERICAN INSTITUTE OF ULTRASOUND IN MEDICINE 2016; 35:951-958. [PMID: 27036168 DOI: 10.7863/ultra.15.07009] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/06/2015] [Accepted: 08/21/2015] [Indexed: 06/05/2023]
Abstract
OBJECTIVES To assess the feasibility of splenic shear wave elastography in monitoring transjugular intrahepatic portosystemic shunt (TIPS) function. METHODS We measured splenic shear wave velocity (SWV), main portal vein velocity (PVV), and splenic vein velocity (SVV) in 33 patients 1 day before and 3 days to 12 months after TIPS placement. We also measured PVV, SVV, and SWV in 10 of 33 patients with TIPS dysfunction 1 day before and 3 to 6 days after TIPS revision. Analyses included differences in portosystemic pressure gradient (PPG), PVV, SVV, and mean SWV before and after TIPS procedures; comparison of median SWV before and after TIPS procedures; differences in PVV, SVV, and SWV before and at different times up to 12 months after TIPS placement; accuracy of PVV, SVV, and SWV in determining TIPS dysfunction; and correlation between PPG and SWV. RESULTS During 12 months of follow-up, 23 of 33 patients had functioning TIPS, and 10 had TIPS dysfunction. The median SWV was significantly different before and after primary TIPS placement (3.60 versus 3.05 m/s; P = .005), as well as before and after revision (3.73 versus 3.06 m/s; P = .003). The PPG, PVV, and SVV were also significantly different before and after TIPS placement and revision (P < .001). The PPG and SWV decreased, whereas PVV and SVV increased, after successful TIPS procedures. A positive correlation was observed between PPG and SWV (r = 0.70; P < .001), and a negative correlation was observed between PPG and PVV and SVV (r = -0.65; P < .001). The areas under the receiver operating characteristic curve for PVV, SVV, and SWV in determining TIPS dysfunction were 0.82, 0.84, and 0.81, respectively. CONCLUSIONS Splenic SWV is compatible with splenoportal venous velocity in quantitatively monitoring TIPS function and determining TIPS dysfunction.
Collapse
Affiliation(s)
- Jing Gao
- Department of Radiology, Well Cornel Medical College, New York, New York USA
| | - Xiao Zheng
- Institute of Ultrasound Imaging, Second Affiliated Hospital, Chongqing Medical University, Chongqing, China
| | - Yuan-Yi Zheng
- Institute of Ultrasound Imaging, Second Affiliated Hospital, Chongqing Medical University, Chongqing, China
| | - Guo-Qing Zuo
- Institute of Ultrasound Imaging, Second Affiliated Hospital, Chongqing Medical University, Chongqing, China
| | - Hai-Tao Ran
- Institute of Ultrasound Imaging, Second Affiliated Hospital, Chongqing Medical University, Chongqing, China
| | - Yong Ho Auh
- Department of Radiology, Well Cornel Medical College, New York, New York USA
| | - Levi Waldron
- City University of New York, School of Public Health, Hunter College, New York, New York USA
| | - Tiffany Chan
- City University of New York, School of Public Health, Hunter College, New York, New York USA
| | - Zhi-Gang Wang
- Institute of Ultrasound Imaging, Second Affiliated Hospital, Chongqing Medical University, Chongqing, China
| |
Collapse
|
47
|
Chen HJ, Zheng G, Wichmann JL, Schoepf UJ, Lu GM, Zhang LJ. The brain following transjugular intrahepatic portosystemic shunt: the perspective from neuroimaging. Metab Brain Dis 2015; 30:1331-41. [PMID: 26404041 DOI: 10.1007/s11011-015-9735-4] [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: 05/20/2015] [Accepted: 09/17/2015] [Indexed: 11/25/2022]
Abstract
Hepatic encephalopathy (HE) is a common complication after implantation of a transjugular intrahepatic portosystemic shunt (TIPS). Neuroimaging offers a variety of techniques for non-invasive evaluation of alterations in metabolism, as well as structural and functional changes of the brain in patients after TIPS implantation. In this article, we review the epidemiology and pathophysiology of post-TIPS HE. The potential of neuroimaging including positron emission tomography and multimodality magnetic resonance imaging to investigate the pathophysiology of post-TIPS HE is presented. We also give a perspective on the role of neuroimaging in this field.
Collapse
Affiliation(s)
- Hui Juan Chen
- Department of Medical Imaging, Jinling Hospital, Medical School of Nanjing University, No. 305 Zhongshan East Road, Nanjing, 210002, Jiangsu Province, China
| | - Gang Zheng
- Department of Medical Imaging, Jinling Hospital, Medical School of Nanjing University, No. 305 Zhongshan East Road, Nanjing, 210002, Jiangsu Province, China
- College of Civil Aviation, Nanjing University of Aeronautics and Astronautics, Nanjing, Jiangsu, 210016, China
| | - Julian L Wichmann
- Department of Radiology and Radiological Science, Medical University of South Carolina, Ashley River Tower, MSC 226, 25 Courtenay Dr, Charleston, SC, 29401, USA
- Department of Diagnostic and Interventional Radiology, University Hospital Frankfurt, Theodor-Stern-Kai 7, 60590, Frankfurt, Germany
| | - U Joseph Schoepf
- Department of Radiology and Radiological Science, Medical University of South Carolina, Ashley River Tower, MSC 226, 25 Courtenay Dr, Charleston, SC, 29401, USA
| | - Guang Ming Lu
- Department of Medical Imaging, Jinling Hospital, Medical School of Nanjing University, No. 305 Zhongshan East Road, Nanjing, 210002, Jiangsu Province, China
| | - Long Jiang Zhang
- Department of Medical Imaging, Jinling Hospital, Medical School of Nanjing University, No. 305 Zhongshan East Road, Nanjing, 210002, Jiangsu Province, China.
| |
Collapse
|
48
|
Srinivasan I, Tang SJ, Vilmann AS, Menachery J, Vilmann P. Hepatic applications of endoscopic ultrasound: Current status and future directions. World J Gastroenterol 2015; 21:12544-12557. [PMID: 26640331 PMCID: PMC4658609 DOI: 10.3748/wjg.v21.i44.12544] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/08/2015] [Revised: 09/28/2015] [Accepted: 10/13/2015] [Indexed: 02/06/2023] Open
Abstract
The diagnosis and staging of various gastrointestinal malignancies have been made possible with the use of endoscopic ultrasound, which is a relatively safe procedure. The field of endoscopic ultrasound is fast expanding due to advancements in therapeutic endoscopic ultrasound. Though various studies have established its role in gastrointestinal malignancies and pancreatic conditions, its potential in the field of hepatic lesions still remains vastly untapped. In this paper the authors attempt to review important and landmark trials, case series and case studies involving hepatic applications of endoscopic ultrasound, thus not only providing an overview of utilization of endoscopic ultrasound in various liver conditions but also speculating its future role.
Collapse
|
49
|
Wang Y, Zhang F, Zhang M, Zou XP, Zhu-Ge YZ. Efficacy of transjugular intrahepatic portosystemic stent-shunt in treatment of gynura segetum induced hepatic veno-occlusive disease with refractory ascites. Shijie Huaren Xiaohua Zazhi 2015; 23:4261-4265. [DOI: 10.11569/wcjd.v23.i26.4261] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
AIM: To investigate the efficacy of transjugular intrahepatic portosystemic stent-shunt (TIPS) in the treatment of gynura segetum induced hepatic veno-occlusive disease (HVOD) with refractory ascites.
METHODS: Seven patients with gynura segetum induced HVOD who received TIPS from May 2013 to March 2015 at the Affiliated Drum Tower Hospital of Nanjing University Medical School were included. The liver function and ascites were compared before and after TIPS treatment.
RESULTS: After TIPS treatment, serum albumin increased significantly (33.6 g/L ± 4.86 g/L vs 30 g/L ± 2.61 g/L, P < 0.05); serum creatinine decreased significantly (87.4 μmol/L ± 81.0 μmol/L vs 139.1 μmol/L ± 132.0 μmol/L, P < 0.05); the port vein pressure decreased quickly (27.0 cmH2O ± 7.0 cmH2O vs 37.7 cmH2O ± 6.1 cmH2O, P < 0.05); and port vein flow restored (57.1 cm/s ± 16.7 cm/s vs 18.2 cm/s ± 8.3 cm/s, P < 0.05). Only one patient died of multiple organ dysfunction and the others lived for a long time with ascites disappearing.
CONCLUSION: TIPS is safe and effective in the treatment of gynura segetum induced HVOD with refractory ascites.
Collapse
|
50
|
Abstract
The continued need to develop minimally invasive alternatives to surgical and radiologic interventions has driven the development of endoscopic ultrasound (EUS)-guided treatments. EUS has now stepped into the therapeutic arena. EUS provides the unique advantage of both real-time imaging and access to structures within and adjacent to the gastrointestinal (GI) tract. Hence, EUS-guided therapeutic techniques continue to evolve in several directions enabling a variety of minimally invasive therapies for pancreatic and biliary pathologies. Furthermore, the close proximity of the GI tract to vascular structures in the mediastinum and abdomen permits EUS-guided vascular access and therapy. Studies have demonstrated several EUS-guided vascular interventions by using standard endoscopic accessories and available tools from the interventional radiology armamentarium. This article provides an overview of the literature including clinical and nonclinical studies for the management of nonvariceal and variceal GI bleeding, formation of intrahepatic portosystemic shunts (IPSS), and EUS-guided cardiac access and therapy.
Collapse
Affiliation(s)
| | - Sundeep Lakhtakia
- Department of Gastroenterology, Asian Institute of Gastroenterology, Hyderabad, Telangana, India
| |
Collapse
|