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Zhu J, Xia Y, Liu X, Zhang C. Preventing variceal rebleeding in cirrhotic patients with portal vein thrombosis: A systematic review and meta-analysis. J Gastroenterol Hepatol 2024; 39:642-648. [PMID: 38233086 DOI: 10.1111/jgh.16489] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/11/2023] [Revised: 12/28/2023] [Accepted: 01/02/2024] [Indexed: 01/19/2024]
Abstract
BACKGROUND AND AIM Preventing rebleeding is crucial, but the best prevention technique for patients with cirrhosis and portal vein thrombosis (PVT) remains debatable. Therefore, this systematic review and meta-analysis compared a transjugular intrahepatic portosystemic shunt (TIPS) with endoscopic therapy (ET) plus nonselective beta-blockers (NSBBs) for preventing variceal rebleeding in this patient population. METHODS The PubMed, Embase, Cochrane Library, and Web of Science databases were searched from their inception until May 18, 2023. The studies were screened using predetermined criteria, relevant data were extracted, and pooled analyses were performed using the Reviewer Manager 5.4.1 software. RESULTS We retrieved 1032 studies, of which 5 studies comprising a total of 272 patients were included. The postoperative variceal rebleeding rate was significantly lower in the TIPS group than in the ET + NSBBs group (odds ratio [OR] = 0.19, 95% confidence interval [CI] = 0.11-0.35, P < 0.05, I2 = 0%), but the portal vein recanalization rate was higher (OR = 7.92, 95% CI = 3.04-20.67, P < 0.05, I2 = 0%). The rates of hepatic encephalopathy (HE) and mortality did not differ between the groups. CONCLUSIONS Our results suggest that TIPS prevents variceal rebleeding without increasing the hepatic encephalopathy risk more effectively than ET plus NSBBs, but this benefit did not translate into improved survival. Thus, it may be preferable to ET plus NSBBs for preventing variceal rebleeding in patients with cirrhosis and PVT. However, more large-scale and multicenter randomized controlled trials involving other patient populations are required to verify the clinical efficacy of both these treatments and ensure generalizability.
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Affiliation(s)
- Junyuan Zhu
- Department of Gastroenterology, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, China
| | - Yifu Xia
- Department of Gastroenterology, Shandong Provincial Hospital, Shandong University, Jinan, China
| | - Xiao Liu
- Department of Gastroenterology, Shandong Provincial Hospital, Shandong University, Jinan, China
| | - Chunqing Zhang
- Department of Gastroenterology, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, China
- Department of Gastroenterology, Shandong Provincial Hospital, Shandong University, Jinan, China
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Berengy MS, Abd El-Hamid Hassan EM, Ibrahim AH, Mohamed EF. Safety and efficacy of transjugular intrahepatic portosystemic shunts vs endoscopic band ligation plus propranolol in patients with cirrhosis with portal vein thrombosis: a systematic review and meta-analysis. J Gastrointest Surg 2024; 28:316-326. [PMID: 38445926 DOI: 10.1016/j.gassur.2023.12.031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/21/2023] [Revised: 12/20/2023] [Accepted: 12/30/2023] [Indexed: 03/07/2024]
Abstract
BACKGROUND This systematic review and meta-analysis aimed to assess the efficacy and safety of transjugular intrahepatic portosystemic shunts (TIPS) against the combined treatment of endoscopic band ligation (EBL) and propranolol in managing patients with cirrhosis diagnosed with portal vein thrombosis (PVT). METHODS A literature search from inception to September 2023 was performed using MEDLINE, the Cochrane Library, Web of Science, and Scopus. Independent screening, data extraction, and quality assessment were performed. The main measured outcomes were the incidence and recurrence of variceal bleeding (VB), hepatic encephalopathy, and overall survival. RESULTS A total of 5 studies were included. For variceal eradication, there was initially no significant difference between the groups; however, after sensitivity analysis, a significant effect emerged (risk ratio [RR], 1.55; P < .0001). TIPS was associated with a significant decrease in the incidence of VB (RR, 0.34; P < .0001) and a higher probability of remaining free of VB in the first 2 years after the procedure (first year: RR, 1.41; P < .0001; second year: RR, 1.58; P < .0001). TIPS significantly reduced the incidence of death due to acute GI bleeding compared with EBL + propranolol (RR, 0.37; P = .05). CONCLUSION TIPS offers a comprehensive therapeutic advantage over the combined EBL and propranolol regimen, especially for patients with cirrhosis with PVT. Its efficacy in variceal eradication, reducing rebleeding, and mitigating death risks due to acute GI bleeding is evident.
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Affiliation(s)
- Mahmoud Saad Berengy
- Department of Internal Medicine, Damietta Faculty of Medicine, Al-Azhar University, Damietta, Egypt.
| | | | - Amal H Ibrahim
- Department of Internal Medicine, Faculty of Medicine for Girls, Al-Azhar University, Cairo, Egypt
| | - Eman F Mohamed
- Department of Internal Medicine, Faculty of Medicine for Girls, Al-Azhar University, Cairo, Egypt
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Friis KH, Thomsen KL, Laleman W, Montagnese S, Vilstrup H, Lauridsen MM. Post-Transjugular Intrahepatic Portosystemic Shunt (TIPS) Hepatic Encephalopathy-A Review of the Past Decade's Literature Focusing on Incidence, Risk Factors, and Prophylaxis. J Clin Med 2023; 13:14. [PMID: 38202028 PMCID: PMC10779844 DOI: 10.3390/jcm13010014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2023] [Revised: 12/11/2023] [Accepted: 12/14/2023] [Indexed: 01/12/2024] Open
Abstract
Transjugular intrahepatic portosystemic shunt (TIPS) is an established treatment for portal hypertension and its' complications in liver cirrhosis, yet the development of hepatic encephalopathy (HE) remains a significant concern. This review covers the reported incidence, risk factors, and management strategies for post-TIPS HE over the past decade. Incidence varies widely (7-61%), with factors like age, liver function, hyponatremia, and spontaneous portosystemic shunts influencing risk. Procedural aspects, including TIPS timing, indication, and stent characteristics, also contribute. Pharmacological prophylaxis with lactulose and rifaximin shows promise, but current evidence is inconclusive. Procedural preventive measures, such as shunt embolization and monitoring portal pressure gradients, are explored. Treatment involves pharmacological options like lactulose and rifaximin, and procedural interventions like stent diameter reduction. Ongoing studies on novel predictive markers and emerging treatments, such as faecal microbiota transplant, reflect the evolving landscape in post-TIPS HE management. This concise review provides clinicians with insights into the multifaceted nature of post-TIPS HE, aiding in improved risk assessment, prophylaxis, and management for patients undergoing TIPS procedures.
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Affiliation(s)
- Karina Holm Friis
- Department of Gastroenterology and Hepatology, University Hospital of Southern Denmark, Finsensgade 35, 6700 Esbjerg, Denmark
| | - Karen Louise Thomsen
- Department of Hepatology and Gastroenterology, Aarhus University Hospital, 8200 Aarhus, Denmark
| | - Wim Laleman
- Department of Gastroenterology and Hepatology, University Hospitals Leuven, KU Leuven, 3000 Leuven, Belgium
| | - Sara Montagnese
- Department of Medicine, University of Padova, 35122 Padova, Italy
| | - Hendrik Vilstrup
- Department of Hepatology and Gastroenterology, Aarhus University Hospital, 8200 Aarhus, Denmark
| | - Mette Munk Lauridsen
- Department of Gastroenterology and Hepatology, University Hospital of Southern Denmark, Finsensgade 35, 6700 Esbjerg, Denmark
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Low adipose tissue index as an indicator of hepatic encephalopathy in cirrhotic patients following transjugular intrahepatic portosystemic shunt. ABDOMINAL RADIOLOGY (NEW YORK) 2023; 48:1454-1467. [PMID: 36735033 DOI: 10.1007/s00261-023-03813-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/19/2022] [Revised: 01/10/2023] [Accepted: 01/10/2023] [Indexed: 02/04/2023]
Abstract
PURPOSE We aimed to investigate the predictive value of body compositions measured by CT, including skeletal muscle and adipose tissue, for hepatic encephalopathy (HE) in cirrhotic patients following transjugular intrahepatic portosystemic shunt (TIPS). METHODS Patients who underwent TIPS between November 2015 and April 2021 were included in this retrospective study. CT images taken at L3 were quantified for three body composition indexes (cm2/m2), visceral fat area index (VFAI), subcutaneous fat area index (SFAI), and skeletal muscle index (SMI) at baseline. Multivariable logistic regression models were conducted to assess associations between post-TIPS HE and body compositions. Nomograms based on the multivariable logistic regression models were developed and were evaluated from Calibration curves. RESULTS Male patients had greater SMI, whereas SFAI and VFAI were higher in females (p < 0.001 for each). In sex stratified multivariate analyses after adjustment for other confounding variables, VFAI in males (p = 0.033) and SFAI in females (p = 0.003) were significant predictors of post-TIPS HE. Male patients with low VFAI (< 53.52 cm2/m2) (OR 6.44; 95% CI 1.72-23.59; p = 0.006) and female patients with low SFAI (< 70.05 cm2/m2) (OR 10.55; 95% CI 2.36-46.23; p = 0.002) had a higher risk of post-TIPS HE. Risk factors in the nomogram contributing to the male model included age, height, Child-Pugh score, and low VFAI; pre-albumin and low SFAI were contributed to female model. CONCLUSION Body compositions could not only be noninvasively used for nutritional assessment, but also be utilized to predict HE risk of cirrhotic patients after TIPS.
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Colaneri M, Lombardi A, Maffezzoni M, Sambo M, Fabbiani M, Quaretti P, Asperges E, Moramarco L, Sacchi P, Bruno R. The infection risk after transjugular intrahepatic portosystemic shunt: A multiple competing risk analysis from a tertiary care center. Dig Liver Dis 2022; 54:1686-1690. [PMID: 35697589 DOI: 10.1016/j.dld.2022.05.005] [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: 01/09/2022] [Revised: 05/07/2022] [Accepted: 05/13/2022] [Indexed: 12/30/2022]
Abstract
BACKGROUND Infections following transjugular intrahepatic portosystemic shunt (TIPS) placement have been poorly described. We aim to investigate the rate and the potential predictors of infections occurring after TIPS placement. METHODS Single center, retrospective, observational study. All patients who had undergone TIPS placement in the last 10 years with a minimum 1-year FU, were considered. Multiple competing risk analyses were performed to identify infection risk factors and a multivariable Cox proportional-hazard regression model to evaluate the predictors of death. RESULTS Forty-nine patients were considered. Among these, 23 (46%) developed at least 1 infection during the FU, at a median time of 237.7 days (IQR 151.5) from the TIPS placement. We did not find any predictor of infection, while MELD score and cancer were associated with death (p = .04; HR 1.14; CI 1.00- 1.30). CONCLUSION We found a high rate of all-type infections during the FU times. However, most of these infections occurred as late-onset infections and were caused by Gram-positive microorganisms. Thus, TIPS procedure itself does not seem to be burdened with high infectious perioperative risk.
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Affiliation(s)
- Marta Colaneri
- Infectious Diseases I Unit, IRCCS San Matteo, Pavia, Italy and Department of Medical, Surgical, Diagnostic and Paediatric Science, University of Pavia, V.le Golgi, 19, PV, 27100, Padiglione n. 42, Pavia, Italy.
| | - Andrea Lombardi
- Department of Pathophysiology and Transplantation, University of Milano, Milano, Italy; Infectious Diseases Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milano, Italy
| | - Marcello Maffezzoni
- Infectious Diseases I Unit, IRCCS San Matteo, Pavia, Italy and Department of Medical, Surgical, Diagnostic and Paediatric Science, University of Pavia, V.le Golgi, 19, PV, 27100, Padiglione n. 42, Pavia, Italy
| | - Margherita Sambo
- Infectious Diseases I Unit, IRCCS San Matteo, Pavia, Italy and Department of Medical, Surgical, Diagnostic and Paediatric Science, University of Pavia, V.le Golgi, 19, PV, 27100, Padiglione n. 42, Pavia, Italy
| | - Massimiliano Fabbiani
- Infectious and Tropical Diseases Unit, Azienda Ospedaliero-Universitaria Senese, Siena, Italy
| | - Pietro Quaretti
- Diagnostic Radiology and General Interventional Radiology, IRCCS San Matteo, Pavia, Italy
| | - Erika Asperges
- Infectious Diseases I Unit, IRCCS San Matteo, Pavia, Italy and Department of Medical, Surgical, Diagnostic and Paediatric Science, University of Pavia, V.le Golgi, 19, PV, 27100, Padiglione n. 42, Pavia, Italy
| | - Lorenzo Moramarco
- Diagnostic Radiology and General Interventional Radiology, IRCCS San Matteo, Pavia, Italy
| | - Paolo Sacchi
- Infectious Diseases I Unit, IRCCS San Matteo, Pavia, Italy and Department of Medical, Surgical, Diagnostic and Paediatric Science, University of Pavia, V.le Golgi, 19, PV, 27100, Padiglione n. 42, Pavia, Italy
| | - Raffaele Bruno
- Infectious Diseases I Unit, IRCCS San Matteo, Pavia, Italy and Department of Medical, Surgical, Diagnostic and Paediatric Science, University of Pavia, V.le Golgi, 19, PV, 27100, Padiglione n. 42, Pavia, Italy; Department of Medical, Surgical, Diagnostic and Paediatric Science, University of Pavia, Italy
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Yang C, Liu J, Shi Q, Huang S, Zhou C, Wang Y, Li T, Chen Y, Xiong B. Effect of splenectomy on the outcomes in patients with cirrhosis receiving transjugular intrahepatic portosystemic shunt. J Gastroenterol Hepatol 2021; 36:2893-2902. [PMID: 33973270 PMCID: PMC8518516 DOI: 10.1111/jgh.15543] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/10/2021] [Revised: 04/28/2021] [Accepted: 05/08/2021] [Indexed: 12/14/2022]
Abstract
BACKGROUND AND AIM Patients indicated to transjugular intrahepatic portosystemic shunt (TIPS) placement may have splenectomy history due to thrombocytopenia. This study aimed to evaluate the effect of prior splenectomy on TIPS procedure and post-TIPS outcomes. METHODS We conducted a longitudinal analysis based on a cohort of 284 patients with cirrhosis submitted to TIPS; 74 patients had splenectomy history (splenectomy group) and 210 did not (non-splenectomy group). Cox proportional hazards models were used to evaluate the association between splenectomy and outcomes after TIPS. The primary outcome was shunt dysfunction. Secondary outcomes included all-cause mortality, clinical recurrence of bleeding or ascites, and overt hepatic encephalopathy (OHE). RESULTS During a median follow-up of 16.2 months, the splenectomy group had significantly lower rates of postoperative shunt patency (85.5% vs 95.6% at 1 year and 75.2% vs 86.5% at 2 years; adjusted hazard ratio [HR] 2.53; 95% confidence interval [CI] 1.21-5.12; P = 0.01) and higher risk of OHE (adjusted HR 1.82; 95% CI 1.03-3.54; P = 0.04). But the risk of mortality (adjusted HR 0.87; 95% CI 0.41-1.87; P = 0.73) and recurrent bleeding or ascites (adjusted HR 1.17; 95% CI 0.53-2.35; P = 0.77) showed no statistical difference. Multivariate analysis confirmed splenectomy history and endoscopic therapy as independent predictors of shunt dysfunction. Besides, pre-TIPS splenectomy increased the difficulty of TIPS procedure by complicating portal vein puncture. CONCLUSIONS For patients with cirrhosis submitted to TIPS, prior splenectomy complicated TIPS procedure and increased the risk of shunt dysfunction and OHE after TIPS, but was not significantly associated with the occurrence of mortality and recurrent bleeding or ascites.
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Affiliation(s)
- Chongtu Yang
- Department of Radiology, Union Hospital, Tongji Medical CollegeHuazhong University of Science and TechnologyWuhanChina,Hubei Province Key Laboratory of Molecular ImagingWuhanChina
| | - Jiacheng Liu
- Department of Radiology, Union Hospital, Tongji Medical CollegeHuazhong University of Science and TechnologyWuhanChina,Hubei Province Key Laboratory of Molecular ImagingWuhanChina
| | - Qin Shi
- Department of Radiology, Union Hospital, Tongji Medical CollegeHuazhong University of Science and TechnologyWuhanChina,Hubei Province Key Laboratory of Molecular ImagingWuhanChina
| | - Songjiang Huang
- Department of Radiology, Union Hospital, Tongji Medical CollegeHuazhong University of Science and TechnologyWuhanChina,Hubei Province Key Laboratory of Molecular ImagingWuhanChina
| | - Chen Zhou
- Department of Radiology, Union Hospital, Tongji Medical CollegeHuazhong University of Science and TechnologyWuhanChina,Hubei Province Key Laboratory of Molecular ImagingWuhanChina
| | - Yingliang Wang
- Department of Radiology, Union Hospital, Tongji Medical CollegeHuazhong University of Science and TechnologyWuhanChina,Hubei Province Key Laboratory of Molecular ImagingWuhanChina
| | - Tongqiang Li
- Department of Radiology, Union Hospital, Tongji Medical CollegeHuazhong University of Science and TechnologyWuhanChina,Hubei Province Key Laboratory of Molecular ImagingWuhanChina
| | - Yang Chen
- Department of Radiology, Union Hospital, Tongji Medical CollegeHuazhong University of Science and TechnologyWuhanChina,Hubei Province Key Laboratory of Molecular ImagingWuhanChina
| | - Bin Xiong
- Department of Radiology, Union Hospital, Tongji Medical CollegeHuazhong University of Science and TechnologyWuhanChina,Hubei Province Key Laboratory of Molecular ImagingWuhanChina
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Single-Centre Retrospective Training Cohort Using Artificial Intelligence for Prognostic Prediction of Encephalopathy, Mortality, and Liver Dysfunction after Early TIPS Creation. Cardiovasc Intervent Radiol 2021; 44:1597-1608. [PMID: 34240232 DOI: 10.1007/s00270-021-02907-0] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/28/2021] [Accepted: 06/22/2021] [Indexed: 12/24/2022]
Abstract
OBJECTIVES Based on an artificial intelligence approach, this study attempted to establish prognostic models to predict 3-month overt hepatic encephalopathy (OHE) occurrence, 1-year mortality, and liver dysfunction for cirrhotic patients with acute variceal bleeding (AVB) treated with early transjugular intrahepatic portosystemic shunt (TIPS) creation. MATERIALS AND METHODS This retrospective study included patients treated with early TIPS between January 2016 and November 2019. Independent risk factors associated with occurrence of OHE within 3 months, 1-year mortality, and liver dysfunction after early TIPS were identified using univariate and multivariate logistic analyses. Artificial neural network (ANN) models and prognostic nomograms based on the independent risk factors were established and validated internally. RESULTS A total of 207 patients were included, with 33 (15.9%) experienced OHE within 3 months after TIPS creation. The albumin-bilirubin grade (P = 0.015), age (≤ 65, > 65 years) (P < 0.001), gender (P = 0.002), and alcoholic cirrhosis (P = 0.013) was identified as independent risk factors associated with 3-month OHE. Presence of portal vein thrombosis (P = 0.034) and model for end-stage liver disease score (P = 0.063) were identified as independent risk factors associated with 1-year mortality. The platelet-albumin-bilirubin grade (P = 0.041) and a history of hepatic encephalopathy (P = 0.018) were identified as independent risk factors associated with liver dysfunction after TIPS creation. Three ANN models and three nomograms were then established and validated with high accuracy. CONCLUSIONS The ANN and nomogram models have potential to accurately predict early occurrence of OHE, mortality, and liver dysfunction after early TIPS creation for cirrhotic patients with AVB.
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Prevention of variceal rebleeding in cirrhotic patients with spontaneous portosystemic shunts: transjugular intrahepatic portosystemic shunt versus endoscopic treatment. Eur J Gastroenterol Hepatol 2021; 33:752-761. [PMID: 33731589 DOI: 10.1097/meg.0000000000002079] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
BACKGROUND Spontaneous portosystemic shunts(SPSSs) in cirrhotic patients indicate higher incidence of gastric varices, which increases the risk for bleeding and death. However, few studies compared endoscopic therapy with transjugular intrahepatic portosystemic shunt (TIPS) in preventing variceal rebleeding in cirrhotic patients with SPSSs. This research aims to evaluate the effectiveness of the two methods in this group of patients. METHODS We reviewed consecutive cirrhotic patients with SPSSs who underwent either TIPS or endoscopic treatment to prevent variceal rebleeding between January 2015 and December 2018 in our institution. Outcomes including rebleeding, overt hepatic encephalopathy (OHE), complications and survival were compared. Meanwhile, subgroup analyses were conducted to screen relevant factors affecting the results. RESULTS A total of 97 patients were included in the study. The TIPS arm contained 50 patients and the endoscopy arm contained 47 patients. Rebleeding rate in TIPS group was statistically lower than endoscopic group [16.0 vs 38.3%, hazard ratio (HR) = 0.37, 95% confidence interval (CI): 0.16-0.84, P = 0.01], while OHE was more frequent (16.0 vs 2.1%, HR = 7.59, 95% CI: 0.94-61.2, P = 0.025), the survival rate (92 vs 89.4%, HR = 0.88, 95% CI: 0.22-3.60, P = 0.87) and frequency of complications were comparable between two groups. In the subgroups of GOV2/IGV1 and splenorenal shunt/gastrorenal shunt, compared with endoscopic treatments, TIPS reduced the rate of rebleeding without significantly increasing overt hepatic encephalopathy; however, it did not improve survival rate. CONCLUSIONS For cirrhotic patients with SPSSs, TIPS brought a lower rebleeding rate but a higher incidence of OHE. However, in the subgroups of GOV2/IGV1 and splenorenal shunt/gastrorenal shunt, TIPS was considered more reasonable due to the lower rebleeding rate and comparable OHE incidence.
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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.
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Coronado WM, Ju C, Bullen J, Kapoor B. Predictors of Occurrence and Risk of Hepatic Encephalopathy After TIPS Creation: A 15-Year Experience. Cardiovasc Intervent Radiol 2020; 43:1156-1164. [PMID: 32435836 DOI: 10.1007/s00270-020-02512-7] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/08/2019] [Accepted: 04/29/2020] [Indexed: 02/08/2023]
Abstract
PURPOSE To identify clinical variables, including use of newer Viatorr TIPS endoprosthesis with controlled expansion (VCX) that may affect the occurrence and risk of hepatic encephalopathy after transjugular intrahepatic portosystemic shunt (TIPS) creation. METHODS A total of 376 patients who underwent TIPS creation at our institution between 2003 and 2018 were retrospectively identified. Of these patients, 71 received a Viatorr controlled expansion endoprosthesis and 305 received a Viatorr TIPS endoprosthesis (older version without controlled expansion). Multivariate regression analysis was used to identify factors predicting the occurrence of hepatic encephalopathy after TIPS creation; a Cox proportional hazard model was used to assess risk of HE through time to HE onset RESULTS: A total of 194 patients (52%) developed hepatic encephalopathy after TIPS creation, including 28 of 71 patients (39%) who received a VCX endoprosthesis. Older patient age and the use of Viatorr endoprosthesis without controlled expansion were significantly associated with the development of hepatic encephalopathy overall. Pre-TIPS pressure variables, patient age, plasma international normalized ratio, and model for end-stage liver disease score were risk factors for time to hepatic encephalopathy. CONCLUSION Several variables are mild predictors of early hepatic encephalopathy development after TIPS creation, and the use of VCX endoprosthesis in TIPS creation is associated with a modest lower risk of hepatic encephalopathy. These preliminary findings should be considered in regard to patient selection, endoprosthesis selection, and post-transjugular intrahepatic portosystemic shunt creation monitoring for the development of hepatic encephalopathy.
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Affiliation(s)
| | - Connie Ju
- Case Western Reserve University School of Medicine, Cleveland, OH, USA
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Li S, Zhang C, Lin LL, Wang Q, Zuo HX, Zhan AL, Luo J, Niu YM, Zhong GQ. Early-TIPS Versus Current Standard Therapy for Acute Variceal Bleeding in Cirrhosis Patients: A Systemic Review With Meta-analysis. Front Pharmacol 2020; 11:603. [PMID: 32581776 PMCID: PMC7282546 DOI: 10.3389/fphar.2020.00603] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2019] [Accepted: 04/17/2020] [Indexed: 12/14/2022] Open
Abstract
Background The survival of early placement (within 72h after admission) of transjugular intrahepatic portosystemic shunts (early-TIPS) in patients with cirrhosis and acute variceal bleeding (AVB) is controversial. Objectives We performed a systemic review and meta-analysis to assess whether early-TIPS could improve survival in patients with cirrhosis and acute variceal bleeding. Methods A systematic search of the literature was conducted in PubMed, EMBASE, and Cochrane Library published before 25 June 2019 for eligible studies that compared early-TIPS with a combination of endoscopic variceal ligation (EVL) and pharmacotherapy in the therapeutic effect in AVB patients. Results A total of five studies with 1,754 participants were enrolled. The early-TIPS demonstrated a significant improvement in prevention of treatment failure (OR=0.11,95%CI=0.05-0.23), 6-weeks mortality (OR=0.24,95%CI=0.13-0.46), rebleeding within 6 weeks (OR=0.21,95%CI=0.12-0.36), rebleeding within 1 year (OR=0.16,95%CI=0.07-0.36), new or worsening ascites (OR=0.33,95%CI=0.21-0.53), except in encephalopathy (OR=1.29,95%CI=0.996-1.67). For 1-year mortality, a significant prior effect was also observed in early-TIPS (OR=0.64,95%CI=0.46-0.90), and the beneficial effect in Child-Pugh C patients (OR=0.35,95%CI=0.18-0.68) was equal to Child-Pugh B patients (OR=0.34,95%CI=0.25-0.58). No difference in liver transplantation and mortality caused by liver failure was observed. Conclusions Early covered-TIPS could be recommended for the management of AVB patients in cirrhosis demonstrating a significant improvement in treatment failure, both short- and long-term mortality, rebleeding risk, and new or worsening ascites compared to standard therapy, especially for high-risk AVB patients. It will also apply to patients with Child-Pugh A until solutions to prevent hepatic encephalopathy in future research are found.
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Affiliation(s)
- Shuang Li
- Center for Evidence-Based Medicine and Clinical Research, Taihe Hospital, Hubei University of Medicine, Shiyan, China
| | - Chao Zhang
- Center for Evidence-Based Medicine and Clinical Research, Taihe Hospital, Hubei University of Medicine, Shiyan, China
| | - Lu-Lu Lin
- Center for Evidence-Based Medicine and Clinical Research, Taihe Hospital, Hubei University of Medicine, Shiyan, China
| | - Qi Wang
- Center for Evidence-Based Medicine and Clinical Research, Taihe Hospital, Hubei University of Medicine, Shiyan, China
| | - Hong-Xia Zuo
- Center for Evidence-Based Medicine and Clinical Research, Taihe Hospital, Hubei University of Medicine, Shiyan, China
| | - Ai-Ling Zhan
- Department of Anesthesiology, Central Hospital of Shanghai Songjiang District, Shanghai, China
| | - Jie Luo
- Center for Evidence-Based Medicine and Clinical Research, Taihe Hospital, Hubei University of Medicine, Shiyan, China
| | - Yu-Ming Niu
- Center for Evidence-Based Medicine and Clinical Research, Taihe Hospital, Hubei University of Medicine, Shiyan, China
| | - Guo-Qing Zhong
- Department of Obstetrical, Jining No.1 People's Hospital, Jining, China
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12
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Li Y, He X, Pang H. A model to predict early hepatic encephalopathy in patients undergoing transjugular intrahepatic portosystemic shunt. TURKISH JOURNAL OF GASTROENTEROLOGY 2020; 30:702-707. [PMID: 31418414 DOI: 10.5152/tjg.2019.18485] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
BACKGROUND/AIMS Early hepatic encephalopathy (HE) is one of the most common complications developed after undergoing transjugular intrahepatic portosystemic shunt (TIPS). Hence, its early prevention and treatment are important. This study aimed at establishing a model to predict early post-TIPS HE. MATERIALS AND METHODS Clinical data of 262 patients who underwent TIPS procedure was analyzed retrospectively. Patients were divided into early post-TIPS HE and non-early post-TIPS HE groups, based on the presence of HE within 3 months after TIPS. About 70% of the patients were randomly selected as the model group to establish a prediction model, and the remaining 30% were used as the validation group to test the model. The independent risk factors for early HE post-TIPS were identified and selected using single factor analysis and multi-factor logistic regression analysis. Subsequently the prediction model was established and validated. RESULTS Age, Child-Pugh classification, and fibrinogen were found to be the independent risk factors for early post-TIPS HE., The logistic regression model was established based on these factors and their regression coefficients: p=1/{1+exp[4.829-1.975*age-1.110*(Child-Pugh classification)+1.724*loge (fibrinogen in g/L)]}. Finally, the model was validated among a set of 79 patients from the validation group. CONCLUSION The logistic regression model based on age, Child-Pugh classification, and fibrinogen for early post-TIPS HE can effectively predict the risk of early HE after TIPS.
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Affiliation(s)
- Yinglong Li
- Department of Interventional Radiology, Nanfang Hospital, Southern Medical University, Guangzhou, Guangdong, China;Department of Interventional Radiology, Guizhou Provincial People's Hospital, Guiyang, Guizhou, China
| | - Xiaofeng He
- Department of Interventional Radiology, Nanfang Hospital, Southern Medical University, Guangzhou, Guangdong, China
| | - Huajin Pang
- Department of Interventional Radiology, Nanfang Hospital, Southern Medical University, Guangzhou, Guangdong, China
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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.
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14
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Lv Y, Qi X, He C, Wang Z, Yin Z, Niu J, Guo W, Bai W, Zhang H, Xie H, Yao L, Wang J, Li T, Wang Q, Chen H, Liu H, Wang E, Xia D, Luo B, Li X, Yuan J, Han N, Zhu Y, Xia J, Cai H, Yang Z, Wu K, Fan D, Han G. Covered TIPS versus endoscopic band ligation plus propranolol for the prevention of variceal rebleeding in cirrhotic patients with portal vein thrombosis: a randomised controlled trial. Gut 2018; 67:2156-2168. [PMID: 28970291 DOI: 10.1136/gutjnl-2017-314634] [Citation(s) in RCA: 108] [Impact Index Per Article: 18.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/07/2017] [Revised: 08/18/2017] [Accepted: 08/21/2017] [Indexed: 02/07/2023]
Abstract
OBJECTIVE Limited data are available on the prevention of variceal rebleeding in cirrhotic patients with portal vein thrombosis (PVT). This study aimed to compare transjugular intrahepatic portosystemic shunt (TIPS) with covered stents versus endoscopic band ligation (EBL) plus propranolol for the prevention of variceal rebleeding among patients with cirrhosis and PVT. DESIGN Consecutive cirrhotic patients (94% Child-Pugh class A or B) with PVT who had variceal bleeding in the past 6 weeks were randomly assigned to TIPS group (n=24) or EBL plus propranolol group (EBL+drug, n=25), respectively. Primary endpoint was variceal rebleeding. Secondary endpoints included survival, overt hepatic encephalopathy (OHE), portal vein recanalisation and rethrombosis, other complications of portal hypertension and adverse events. RESULTS During a median follow-up of 30 months in both groups, variceal rebleeding was significantly less frequent in the TIPS group (15% vs 45% at 1 year and 25% vs 50% at 2 years, respectively; HR=0.28, 95% CI 0.10 to 0.76, p=0.008), with a significantly higher portal vein recanalisation rate (95% vs 70%; p=0.03) and a relatively lower rethrombosis rate (5% vs 33%; p=0.06) compared with the EBL+drug group. There were no statistically significant differences in survival (67% vs 84%; p=0.152), OHE (25% vs 16%; p=0.440), other complications of portal hypertension and adverse events between groups. CONCLUSION Covered TIPS placement in patients with PVT and moderately decompensated cirrhosis was more effective than EBL combined with propranolol for the prevention of rebleeding, with a higher probability of PVT resolution without increasing the risk of OHE and adverse effects, but this benefit did not translate into improved survival. TRIAL REGISTRATION NUMBER ClinicalTrials.gov: NCT01326949.
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Affiliation(s)
- Yong Lv
- Department of Liver Diseases and Digestive Interventional Radiology, National Clinical Research Center for Digestive Diseases and Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an, China
| | - Xingshun Qi
- Department of Liver Diseases and Digestive Interventional Radiology, National Clinical Research Center for Digestive Diseases and Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an, China
| | - Chuangye He
- Department of Liver Diseases and Digestive Interventional Radiology, National Clinical Research Center for Digestive Diseases and Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an, China
| | - Zhengyu Wang
- Department of Liver Diseases and Digestive Interventional Radiology, National Clinical Research Center for Digestive Diseases and Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an, China
| | - Zhanxin Yin
- Department of Liver Diseases and Digestive Interventional Radiology, National Clinical Research Center for Digestive Diseases and Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an, China
| | | | - Wengang Guo
- Department of Liver Diseases and Digestive Interventional Radiology, National Clinical Research Center for Digestive Diseases and Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an, China
| | - Wei Bai
- Department of Liver Diseases and Digestive Interventional Radiology, National Clinical Research Center for Digestive Diseases and Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an, China
| | - Hongbo Zhang
- Department of Digestive Endoscopy, National Clinical Research Center for Digestive Diseases and Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an, China
| | - Huahong Xie
- Department of Digestive Endoscopy, National Clinical Research Center for Digestive Diseases and Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an, China
| | - Liping Yao
- Department of Digestive Endoscopy, National Clinical Research Center for Digestive Diseases and Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an, China
| | - Jianhong Wang
- Department of Ultrasound, National Clinical Research Center for Digestive Diseases and Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an, China
| | - Tao Li
- Department of Ultrasound, National Clinical Research Center for Digestive Diseases and Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an, China
| | - Qiuhe Wang
- Department of Liver Diseases and Digestive Interventional Radiology, National Clinical Research Center for Digestive Diseases and Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an, China
| | - Hui Chen
- Department of Liver Diseases and Digestive Interventional Radiology, National Clinical Research Center for Digestive Diseases and Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an, China
| | - Haibo Liu
- Department of Liver Diseases and Digestive Interventional Radiology, National Clinical Research Center for Digestive Diseases and Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an, China
| | - Enxing Wang
- Department of Liver Diseases and Digestive Interventional Radiology, National Clinical Research Center for Digestive Diseases and Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an, China
| | - Dongdong Xia
- Department of Liver Diseases and Digestive Interventional Radiology, National Clinical Research Center for Digestive Diseases and Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an, China
| | - Bohan Luo
- Department of Liver Diseases and Digestive Interventional Radiology, National Clinical Research Center for Digestive Diseases and Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an, China
| | - Xiaomei Li
- Department of Liver Diseases and Digestive Interventional Radiology, National Clinical Research Center for Digestive Diseases and Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an, China
| | - Jie Yuan
- Department of Liver Diseases and Digestive Interventional Radiology, National Clinical Research Center for Digestive Diseases and Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an, China
| | - Na Han
- Department of Liver Diseases and Digestive Interventional Radiology, National Clinical Research Center for Digestive Diseases and Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an, China
| | - Ying Zhu
- Department of Liver Diseases and Digestive Interventional Radiology, National Clinical Research Center for Digestive Diseases and Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an, China
| | - Jielai Xia
- Department of Medical Statistics, Fourth Military Medical University, Xi'an, China
| | - Hongwei Cai
- Department of Medical Statistics, Fourth Military Medical University, Xi'an, China
| | - Zhiping Yang
- State Key Laboratory of Cancer Biology, National Clinical Research Center for Digestive Diseases and Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an, China
| | - Kaichun Wu
- State Key Laboratory of Cancer Biology, National Clinical Research Center for Digestive Diseases and Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an, China
| | - Daiming Fan
- State Key Laboratory of Cancer Biology, National Clinical Research Center for Digestive Diseases and Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an, China
| | - Guohong Han
- Department of Liver Diseases and Digestive Interventional Radiology, National Clinical Research Center for Digestive Diseases and Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an, China
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Maschke SK, Werncke T, Renne J, Kloeckner R, Marquardt S, Kirstein MM, Potthoff A, Wacker FK, Meyer BC, Hinrichs JB. Transjugular intrahepatic portosystemic shunt (TIPS) dysfunction: quantitative assessment of flow and perfusion changes using 2D-perfusion angiography following shunt revision. Abdom Radiol (NY) 2018; 43:2868-2875. [PMID: 29500653 DOI: 10.1007/s00261-018-1547-7] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
PURPOSE To analyze the feasibility of 2D-perfusion angiography (2D-PA) to quantify flow and perfusion changes pre- and post-transjugular intrahepatic portosystemic shunt (TIPS) revision. MATERIALS AND METHODS Fifteen consecutive patients (54 ± 14 years, seven men and eight women) scheduled for TIPS revision were included in this study. To quantify flow and perfusion changes caused by TIPS revision, digital subtraction angiography (DSA) series acquired during the revision were post-processed using a dedicated software. Reference region-of-interest (ROI) in the main portal vein (input function) and target ROIs in the TIPS lumen, the liver parenchyma and in the right atrium were placed in corresponding areas on DSA pre- and post-TIPS revision. 2D-PA evaluation included time to peak (TTP), peak density (PD), and the area under the curve (AUC) assessment. The ratios of reference ROI to target ROIs pre- and post-TIPS revision were calculated (TTPparenchyma/TTPinflow, PDparenchyma/PDinflow, AUCparenchyma/AUCinflow, TTPTIPS/TTPinflow, PDTIPS/PDinflow, AUCTIPS/AUCinflow, TTPatrium/TTPinflow, PDatrium/PDinflow, and AUCatrium/AUCinflow). Pressure measurements pre- and post-TIPS revision were performed and correlated to the 2D-PA parameters. Reproducibility of 2D-PA was assessed by the intra-class correlation coefficient (ICC). RESULTS The portosystemic pressure gradient was significantly reduced following TIPS revision (17.1 ± 6.3 vs. 8.9 ± 4.3 mmHg; p < 0.0001). PDTIPS/PDinflow (0.22 vs. 0.35; p = 0.0014) and AUCTIPS/AUCinflow (0.24 vs. 0.39; p = 0.0012) increased significantly. Likewise, PDatrium/PDinflow (0.32 vs. 0.78; p = 0.0004) and AUCatrium/AUCinflow (0.3 vs. 0.79; p < 0.0001) increased, whereas PDparenchyma/PDinflow decreased significantly (0.14 vs. 0.1; p = 0.0084). Pressure gradient changes correlated significantly with the increase in PDatrium/PDinflow (r = - 0.77, p = 0.0012) and AUCatrium/AUCinflow (r = - 0.76, p = 0.0018). ICC of the 2D-PA parameters was in the range of 0.88-0.99. CONCLUSION 2D-PA offers a feasible approach to quantify flow and perfusion changes during TIPS revision. Therefore, 2D-PA may be a valuable amendment to mere pressure measurements.
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Affiliation(s)
- Sabine K Maschke
- Department of Diagnostic and Interventional Radiology, Hannover Medical School, Carl-Neuberg-Str. 1, 30625, Hannover, Germany
| | - Thomas Werncke
- Department of Diagnostic and Interventional Radiology, Hannover Medical School, Carl-Neuberg-Str. 1, 30625, Hannover, Germany
| | - Julius Renne
- Department of Diagnostic and Interventional Radiology, Hannover Medical School, Carl-Neuberg-Str. 1, 30625, Hannover, Germany
| | - Roman Kloeckner
- Department of Diagnostic and Interventional Radiology, Johannes Gutenberg-University Medical Centre, Mainz, Germany
| | - Steffen Marquardt
- Department of Diagnostic and Interventional Radiology, Hannover Medical School, Carl-Neuberg-Str. 1, 30625, Hannover, Germany
| | - Martha M Kirstein
- Department of Gastroenterology, Hepatology and Endocrinology, Hannover Medical School, Hannover, Germany
| | - Andrej Potthoff
- Department of Gastroenterology, Hepatology and Endocrinology, Hannover Medical School, Hannover, Germany
| | - Frank K Wacker
- Department of Diagnostic and Interventional Radiology, Hannover Medical School, Carl-Neuberg-Str. 1, 30625, Hannover, Germany
| | - Bernhard C Meyer
- Department of Diagnostic and Interventional Radiology, Hannover Medical School, Carl-Neuberg-Str. 1, 30625, Hannover, Germany
| | - Jan B Hinrichs
- Department of Diagnostic and Interventional Radiology, Hannover Medical School, Carl-Neuberg-Str. 1, 30625, Hannover, Germany.
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16
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Sturm L, Bettinger D, Giesler M, Boettler T, Schmidt A, Buettner N, Thimme R, Schultheiss M. Treatment with proton pump inhibitors increases the risk for development of hepatic encephalopathy after implantation of transjugular intrahepatic portosystemic shunt (TIPS). United European Gastroenterol J 2018; 6:1380-1390. [PMID: 30386611 DOI: 10.1177/2050640618795928] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/18/2018] [Accepted: 07/23/2018] [Indexed: 12/18/2022] Open
Abstract
Background and objective Treatment with proton pump inhibitors (PPIs) has been associated with development of hepatic encephalopathy (HE). As development of HE is a major complication after implantation of a transjugular intrahepatic portosystemic shunt (TIPS), we hypothesized that PPI treatment may be associated with a higher risk of post-TIPS HE. Methods We analyzed data of 397 patients with liver cirrhosis who received de novo TIPS implantation at the University Medical Center Freiburg, Germany. We assessed whether PPI medication and other patient characteristics are predictive factors for the development of post-TIPS HE. Results Patients with PPI treatment at the time of TIPS implantation showed significantly higher rates of post-TIPS HE than those without PPI medication (30.4% vs 11.7%, p < 0.001). The rate of post-TIPS HE increased in a dose-dependent manner. However, PPI medication did not directly affect transplant-free survival. Remarkably, in 59.1% of patients who received PPIs there was no clear indication. Conclusions PPI treatment may be an independent risk factor for the development of post-TIPS HE and the risk increases with PPI dose. Indication for PPI treatment should be assessed carefully prior to TIPS implantation in patients with liver cirrhosis.
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Affiliation(s)
- Lukas Sturm
- Department of Medicine II, Medical Center University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Dominik Bettinger
- Department of Medicine II, Medical Center University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany.,Berta-Ottenstein-Programme, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Max Giesler
- Department of Medicine II, Medical Center University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Tobias Boettler
- Department of Medicine II, Medical Center University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Arthur Schmidt
- Department of Medicine II, Medical Center University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Nico Buettner
- Department of Medicine II, Medical Center University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Robert Thimme
- Department of Medicine II, Medical Center University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Michael Schultheiss
- Department of Medicine II, Medical Center University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
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17
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Wang Q, Lv Y, Chen H, Shao J, Han G. Use of 8-mm Covered TIPS: Is "Losses without Gains" the End of the Story? Radiology 2017; 284:604. [PMID: 28723295 DOI: 10.1148/radiol.2017170468] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Affiliation(s)
- Qiuhe Wang
- Department of Digestive Interventional Radiology, Xijing Hospital of Digestive Diseases, Fourth Military Medical University, 15 West Changle Rd, Xi'an 710032, China
| | - Yong Lv
- Department of Digestive Interventional Radiology, Xijing Hospital of Digestive Diseases, Fourth Military Medical University, 15 West Changle Rd, Xi'an 710032, China
| | - Hui Chen
- Department of Digestive Interventional Radiology, Xijing Hospital of Digestive Diseases, Fourth Military Medical University, 15 West Changle Rd, Xi'an 710032, China
| | - Jing Shao
- Department of Digestive Interventional Radiology, Xijing Hospital of Digestive Diseases, Fourth Military Medical University, 15 West Changle Rd, Xi'an 710032, China
| | - Guohong Han
- Department of Digestive Interventional Radiology, Xijing Hospital of Digestive Diseases, Fourth Military Medical University, 15 West Changle Rd, Xi'an 710032, China
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18
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Lv Y, He C, Wang Z, Guo W, Wang J, Bai W, Zhang L, Wang Q, Liu H, Luo B, Niu J, Li K, Tie J, Yin Z, Fan D, Han G. Association of Nonmalignant Portal Vein Thrombosis and Outcomes after Transjugular Intrahepatic Portosystemic Shunt in Patients with Cirrhosis. Radiology 2017; 285:999-1010. [PMID: 28682164 DOI: 10.1148/radiol.2017162266] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Purpose To assess the effects of preexisting nonmalignant portal vein thrombosis (PVT) on mortality, clinical relapse, shunt dysfunction, and overt hepatic encephalopathy (HE) after transjugular intrahepatic portosystemic shunt (TIPS) placement. Materials and Methods This retrospective study was approved by the institutional ethics committee, and written informed consent was obtained from all patients. From March 2001 to December 2014, 1171 consecutive patients with cirrhosis (762 men, 409 women; mean age, 50.0 years ± 12.8) and PVT (n = 212; 18%) or without PVT (n = 959; 82%) who underwent TIPS placement were included. The association between PVT and outcomes after TIPS placement was measured by using Fine and Gray competing risk regression model after adjusting for important baseline characteristics or by using propensity score. The Wald test was used to assess the homogeneity of the effects of PVT across different strata (stratified PVT according to the stages, degrees, and extents) and major subgroups. Results During a median follow-up period of 28.4 months, 507 (43%) patients died, 373 (32%) experienced clinical relapse, 217 (19%) developed shunt dysfunction, and 475 (41%) experienced overt HE. Compared with patients without PVT, patients with PVT had a similar risk of mortality (adjusted hazard ratio, 0.82; 95% confidence interval [CI]: 0.63, 1.09; P = .17), clinical relapse (adjusted hazard ratio, 1.24; 95% CI: 0.92, 1.69; P = .15), shunt dysfunction (adjusted hazard ratio, 1.03; 95% CI: 0.70, 1.51; P = .43), and overt HE (adjusted hazard ratio, 0.88; 95% CI: 0.70, 1.11; P = .29). Furthermore, the effects of PVT were consistent across the relevant strata and subgroups. Conclusion There was no evidence that preexisting PVT was associated with an improved or worsened outcome after TIPS. © RSNA, 2017 Online supplemental material is available for this article.
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Affiliation(s)
- Yong Lv
- From the Department of Liver Diseases and Digestive Interventional Radiology (Y.L., C.H., Z.W., W.G., W.B., L.Z., Q.W., H.L., B.L., J.N., K.L., J.T., Z.Y., G.H.), Department of Ultrasound (J.W.), and State Key Laboratory of Cancer Biology (D.F.), National Clinical Research Center for Digestive Diseases and Xijing Hospital of Digestive Diseases, Fourth Military Medical University, No. 127 Changle West Road, Xi'an 710032, China
| | - Chuangye He
- From the Department of Liver Diseases and Digestive Interventional Radiology (Y.L., C.H., Z.W., W.G., W.B., L.Z., Q.W., H.L., B.L., J.N., K.L., J.T., Z.Y., G.H.), Department of Ultrasound (J.W.), and State Key Laboratory of Cancer Biology (D.F.), National Clinical Research Center for Digestive Diseases and Xijing Hospital of Digestive Diseases, Fourth Military Medical University, No. 127 Changle West Road, Xi'an 710032, China
| | - Zhengyu Wang
- From the Department of Liver Diseases and Digestive Interventional Radiology (Y.L., C.H., Z.W., W.G., W.B., L.Z., Q.W., H.L., B.L., J.N., K.L., J.T., Z.Y., G.H.), Department of Ultrasound (J.W.), and State Key Laboratory of Cancer Biology (D.F.), National Clinical Research Center for Digestive Diseases and Xijing Hospital of Digestive Diseases, Fourth Military Medical University, No. 127 Changle West Road, Xi'an 710032, China
| | - Wengang Guo
- From the Department of Liver Diseases and Digestive Interventional Radiology (Y.L., C.H., Z.W., W.G., W.B., L.Z., Q.W., H.L., B.L., J.N., K.L., J.T., Z.Y., G.H.), Department of Ultrasound (J.W.), and State Key Laboratory of Cancer Biology (D.F.), National Clinical Research Center for Digestive Diseases and Xijing Hospital of Digestive Diseases, Fourth Military Medical University, No. 127 Changle West Road, Xi'an 710032, China
| | - Jianhong Wang
- From the Department of Liver Diseases and Digestive Interventional Radiology (Y.L., C.H., Z.W., W.G., W.B., L.Z., Q.W., H.L., B.L., J.N., K.L., J.T., Z.Y., G.H.), Department of Ultrasound (J.W.), and State Key Laboratory of Cancer Biology (D.F.), National Clinical Research Center for Digestive Diseases and Xijing Hospital of Digestive Diseases, Fourth Military Medical University, No. 127 Changle West Road, Xi'an 710032, China
| | - Wei Bai
- From the Department of Liver Diseases and Digestive Interventional Radiology (Y.L., C.H., Z.W., W.G., W.B., L.Z., Q.W., H.L., B.L., J.N., K.L., J.T., Z.Y., G.H.), Department of Ultrasound (J.W.), and State Key Laboratory of Cancer Biology (D.F.), National Clinical Research Center for Digestive Diseases and Xijing Hospital of Digestive Diseases, Fourth Military Medical University, No. 127 Changle West Road, Xi'an 710032, China
| | - Lei Zhang
- From the Department of Liver Diseases and Digestive Interventional Radiology (Y.L., C.H., Z.W., W.G., W.B., L.Z., Q.W., H.L., B.L., J.N., K.L., J.T., Z.Y., G.H.), Department of Ultrasound (J.W.), and State Key Laboratory of Cancer Biology (D.F.), National Clinical Research Center for Digestive Diseases and Xijing Hospital of Digestive Diseases, Fourth Military Medical University, No. 127 Changle West Road, Xi'an 710032, China
| | - Qiuhe Wang
- From the Department of Liver Diseases and Digestive Interventional Radiology (Y.L., C.H., Z.W., W.G., W.B., L.Z., Q.W., H.L., B.L., J.N., K.L., J.T., Z.Y., G.H.), Department of Ultrasound (J.W.), and State Key Laboratory of Cancer Biology (D.F.), National Clinical Research Center for Digestive Diseases and Xijing Hospital of Digestive Diseases, Fourth Military Medical University, No. 127 Changle West Road, Xi'an 710032, China
| | - Haibo Liu
- From the Department of Liver Diseases and Digestive Interventional Radiology (Y.L., C.H., Z.W., W.G., W.B., L.Z., Q.W., H.L., B.L., J.N., K.L., J.T., Z.Y., G.H.), Department of Ultrasound (J.W.), and State Key Laboratory of Cancer Biology (D.F.), National Clinical Research Center for Digestive Diseases and Xijing Hospital of Digestive Diseases, Fourth Military Medical University, No. 127 Changle West Road, Xi'an 710032, China
| | - Bohan Luo
- From the Department of Liver Diseases and Digestive Interventional Radiology (Y.L., C.H., Z.W., W.G., W.B., L.Z., Q.W., H.L., B.L., J.N., K.L., J.T., Z.Y., G.H.), Department of Ultrasound (J.W.), and State Key Laboratory of Cancer Biology (D.F.), National Clinical Research Center for Digestive Diseases and Xijing Hospital of Digestive Diseases, Fourth Military Medical University, No. 127 Changle West Road, Xi'an 710032, China
| | - Jing Niu
- From the Department of Liver Diseases and Digestive Interventional Radiology (Y.L., C.H., Z.W., W.G., W.B., L.Z., Q.W., H.L., B.L., J.N., K.L., J.T., Z.Y., G.H.), Department of Ultrasound (J.W.), and State Key Laboratory of Cancer Biology (D.F.), National Clinical Research Center for Digestive Diseases and Xijing Hospital of Digestive Diseases, Fourth Military Medical University, No. 127 Changle West Road, Xi'an 710032, China
| | - Kai Li
- From the Department of Liver Diseases and Digestive Interventional Radiology (Y.L., C.H., Z.W., W.G., W.B., L.Z., Q.W., H.L., B.L., J.N., K.L., J.T., Z.Y., G.H.), Department of Ultrasound (J.W.), and State Key Laboratory of Cancer Biology (D.F.), National Clinical Research Center for Digestive Diseases and Xijing Hospital of Digestive Diseases, Fourth Military Medical University, No. 127 Changle West Road, Xi'an 710032, China
| | - Jun Tie
- From the Department of Liver Diseases and Digestive Interventional Radiology (Y.L., C.H., Z.W., W.G., W.B., L.Z., Q.W., H.L., B.L., J.N., K.L., J.T., Z.Y., G.H.), Department of Ultrasound (J.W.), and State Key Laboratory of Cancer Biology (D.F.), National Clinical Research Center for Digestive Diseases and Xijing Hospital of Digestive Diseases, Fourth Military Medical University, No. 127 Changle West Road, Xi'an 710032, China
| | - Zhanxin Yin
- From the Department of Liver Diseases and Digestive Interventional Radiology (Y.L., C.H., Z.W., W.G., W.B., L.Z., Q.W., H.L., B.L., J.N., K.L., J.T., Z.Y., G.H.), Department of Ultrasound (J.W.), and State Key Laboratory of Cancer Biology (D.F.), National Clinical Research Center for Digestive Diseases and Xijing Hospital of Digestive Diseases, Fourth Military Medical University, No. 127 Changle West Road, Xi'an 710032, China
| | - Daiming Fan
- From the Department of Liver Diseases and Digestive Interventional Radiology (Y.L., C.H., Z.W., W.G., W.B., L.Z., Q.W., H.L., B.L., J.N., K.L., J.T., Z.Y., G.H.), Department of Ultrasound (J.W.), and State Key Laboratory of Cancer Biology (D.F.), National Clinical Research Center for Digestive Diseases and Xijing Hospital of Digestive Diseases, Fourth Military Medical University, No. 127 Changle West Road, Xi'an 710032, China
| | - Guohong Han
- From the Department of Liver Diseases and Digestive Interventional Radiology (Y.L., C.H., Z.W., W.G., W.B., L.Z., Q.W., H.L., B.L., J.N., K.L., J.T., Z.Y., G.H.), Department of Ultrasound (J.W.), and State Key Laboratory of Cancer Biology (D.F.), National Clinical Research Center for Digestive Diseases and Xijing Hospital of Digestive Diseases, Fourth Military Medical University, No. 127 Changle West Road, Xi'an 710032, China
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Incidence of hepatic encephalopathy after transjugular intrahepatic portosystemic shunt (TIPS) according to its severity and temporal grading classification. Radiol Med 2017; 122:713-721. [PMID: 28510807 DOI: 10.1007/s11547-017-0770-6] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2017] [Accepted: 04/19/2017] [Indexed: 02/07/2023]
Abstract
OBJECTIVES To evaluate hepatic encephalopathy (HE) incidence after transjugular intrahepatic portosystemic shunt (TIPS) and classify by gravity and frequency. METHODS This is a retrospective study of 75 patients with no previous episodes of HE who underwent TIPS between 2008 and 2014 with clinical follow-up after 6 and 12 months. Patient risk factors evaluated include age, INR (international normalized ratio), creatinine, bilirubin, and MELD score (Model for End-of-stage Liver Disease). HE was reported using two classifications: (1) gravity divided in moderate (West-Haven grades I-II) and severe (III-IV); (2) frequency divided in episodic and recurrent/persistent. RESULTS Overall HE incidence was 36% at 6 months, with 12 month incidence significantly decreased to 27% (p = 0.02). 13/75 (17%) patients had one episode of moderate HE, while 3/75 (4%) patients had severe recurrent/persistent HE. Age was the only pre-TIPS risk predictor. Post-TIPS bilirubin and INR showed variations from basal values only in the presence of diagnosed HE. Bilirubin significantly increased (p = 0.03) in correlation to HE severity, whereas INR changes correlated with temporal frequency (p = 0.04). HE distribution classified for severity is similar at 6 and 12 months, whereas when classified for frequency shows significant differences (p = 0.04). CONCLUSIONS A classification by gravity and frequency attests post-TIPS HE as a manageable risk. Monitoring of bilirubin and INR may help on clinical management risk stratification.
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20
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Routhu M, Safka V, Routhu SK, Fejfar T, Jirkovsky V, Krajina A, Cermakova E, Hosak L, Hulek P. Observational cohort study of hepatic encephalopathy after transjugular intrahepatic portosystemic shunt (TIPS). Ann Hepatol 2017; 16:140-148. [PMID: 28051803 DOI: 10.5604/16652681.1226932] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
UNLABELLED Introduction and Aim: Hepatic encephalopathy (HE) is a common complication of transjugular intrahepatic portosystemic shunting (TIPS). It is associated with a reduced quality of life and poor prognosis. The aim of this study was to compare two groups of patients who did and did not develop overt HE after TIPS. We looked for differences between these groups before TIPS. MATERIALS AND METHODS A study of 895 patients was conducted based on a retrospective analysis of clinical data. Data was analyzed using Fisher's exact test, Chi-square, Mann Whitney test, unpaired t-test and logistic regression. After the initial analyses, we have looked at a regression models for the factors associated with development of HE after TIPS. RESULTS 257 (37.9%) patients developed HE after TIPS. Patients' age, pre-TIPS portal venous pressure, serum creatinine, aspartate transaminase, albumin, presence of diabetes mellitus and etiology of portal hypertension were statistically significantly associated with the occurrence of HE after TIPS (p < 0.01). However, only the age, pre-TIPS portal venous pressure, serum creatinine, presence of diabetes mellitus and etiology of portal hypertension contributed to the regression model. Patients age, serum creatinine, presence of diabetes mellitus and portal vein pressure formed the model describing development of HE after TIPS for a subgroup of patients with refractory ascites. CONCLUSION we have identified, using a substantial sample, several factors associated with the development of HE after TIPS. This could be helpful in further research.
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Affiliation(s)
- Michaela Routhu
- School of Psychiatry, Health Education Wessex, United Kingdom
| | - Vaclav Safka
- Department of Physiology, Faculty of Medicine in Hradec Kralove, Charles University in Prague, Czech Republic
| | | | - Tomas Fejfar
- Department of Internal Medicine, University Hospital in Hradec Kralove, Czech Republic
| | - Vaclav Jirkovsky
- Department of Internal Medicine, University Hospital in Hradec Kralove, Czech Republic
| | - Antonin Krajina
- Department of Radiology, University Hospital in Hradec Kralove, Czech Republic
| | - Eva Cermakova
- Computer Technology Center, Faculty of Medicine in Hradec Kralove, Charles University in Prague, Czech Republic
| | - Ladislav Hosak
- Department of Psychiatry, University Hospital in Hradec Kralove, Czech Republic
| | - Petr Hulek
- Department of Psychiatry, University Hospital in Hradec Kralove, Czech Republic.,Department of Psychiatry, Faculty of Medicine in Hradec Kralove, Charles University in Prague, Czech Republic
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21
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Esophageal Stent for Refractory Variceal Bleeding: A Systemic Review and Meta-Analysis. BIOMED RESEARCH INTERNATIONAL 2016; 2016:4054513. [PMID: 27517043 PMCID: PMC4969514 DOI: 10.1155/2016/4054513] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/18/2016] [Revised: 06/15/2016] [Accepted: 06/20/2016] [Indexed: 12/14/2022]
Abstract
Background. Preliminary studies suggest that covered self-expandable metal stents may be helpful in controlling esophageal variceal bleeding. Aims. To evaluate the effectiveness and safety of esophageal stent in refractory variceal bleeding in a systematic review and meta-analysis. Methods. A comprehensive literature search was conducted on PubMed, EMBASE, and Cochrane Library covering the period from January 1970 to December 2015. Data were selected and abstracted from eligible studies and were pooled using a random-effects model. Heterogeneity was assessed using I2 test. Results. Five studies involving 80 patients were included in the analysis. The age of patients ranged from 18 to 91 years. The mean duration of follow-up was 46.8 d (range, 30–60 d). The success rate of stent deployment was 96.7% (95% CI: 91.6%–99.5%) and complete response to esophageal stenting was in 93.9% (95% CI: 82.2%–99.6%). The incidence of rebleeding was 13.2% (95% CI: 1.8%–32.8%) and the overall mortality was 34.5% (95% CI: 24.8%–44.8%). Most of patients (87.4%) died from hepatic or multiple organ failure, and only 12.6% of patients died from uncontrolled bleeding. There was no stent-related complication reported and the incidence of stent migration was 21.6% (95% CI: 4.7%–46.1%). Conclusion. Esophageal stent may be considered in patients with variceal bleeding refractory to conventional therapy.
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22
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Bissonnette J, Garcia-Pagán JC, Albillos A, Turon F, Ferreira C, Tellez L, Nault JC, Carbonell N, Cervoni JP, Abdel Rehim M, Sibert A, Bouchard L, Perreault P, Trebicka J, Trottier-Tellier F, Rautou PE, Valla DC, Plessier A. Role of the transjugular intrahepatic portosystemic shunt in the management of severe complications of portal hypertension in idiopathic noncirrhotic portal hypertension. Hepatology 2016; 64:224-31. [PMID: 26990687 DOI: 10.1002/hep.28547] [Citation(s) in RCA: 59] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/12/2015] [Revised: 02/02/2016] [Accepted: 03/06/2016] [Indexed: 12/13/2022]
Abstract
UNLABELLED Idiopathic noncirrhotic portal hypertension is a heterogeneous group of diseases characterized by portal hypertension in the absence of cirrhosis. The efficacy and safety of transjugular intrahepatic portosystemic shunt (TIPS) in this population are unknown. The charts of patients with idiopathic noncirrhotic portal hypertension undergoing TIPS in seven centers between 2000 and 2014 were retrospectively reviewed. Forty-one patients were included. Indications for TIPS were recurrent variceal bleeding (n = 25) and refractory ascites (n = 16). Patients were categorized according to the presence (n = 27) or absence (n = 14) of significant extrahepatic comorbidities. Associated conditions were hematologic, prothrombotic, neoplastic, immune, and exposure to toxins. During follow-up (mean 27 ± 29 months), variceal rebleeding occurred in 7/25 (28%), including three with early thrombosis of the stent. Post-TIPS overt hepatic encephalopathy was present in 14 patients (34%). Eleven patients died, five due the liver disease or complications of the procedure and six because of the associated comorbidities. The procedure was complicated by hemoperitoneum in four patients (10%), which was fatal in one case. Serum creatinine (P = 0.005), ascites as indication for TIPS (P = 0.04), and the presence of significant comorbidities (P = 0.01) at the time of the procedure were associated with death. Mortality was higher in patients with significant comorbidities and creatinine ≥100 μmol/L (P < 0.001). CONCLUSION In patients with idiopathic noncirrhotic portal hypertension who have normal kidney function or do not have severe extrahepatic conditions, TIPS is an excellent option to treat severe complications of portal hypertension. (Hepatology 2016;64:224-231).
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Affiliation(s)
- Julien Bissonnette
- Service d'Hépatologie, Hôpital Beaujon, APHP, Clichy, France.,DHU Unity, Hôpital Beaujon, APHP, Clichy, France.,Université Paris Diderot, Sorbonne Paris Cité, Paris, France.,Département Epidémiologie et Recherche Clinique, Hôpital Beaujon, APHP, Clichy, France.,Service d'hépatologie, Hôpital Saint-Luc, Montréal, Canada
| | - Juan Carlos Garcia-Pagán
- Barcelona Hepatic Hemodynamic Lab and Liver Unit, Hospital Clinic-IDIBAPS and CIBERehd, University of Barcelona, Spain
| | - Agustín Albillos
- Department of Gastroenterology and Hepatology, Hospital Universitario Ramón y Cajal, IRYCIS, CIBERehd, University of Alcalá, Madrid, Spain
| | - Fanny Turon
- Barcelona Hepatic Hemodynamic Lab and Liver Unit, Hospital Clinic-IDIBAPS and CIBERehd, University of Barcelona, Spain
| | - Carlos Ferreira
- Barcelona Hepatic Hemodynamic Lab and Liver Unit, Hospital Clinic-IDIBAPS and CIBERehd, University of Barcelona, Spain
| | - Luis Tellez
- Department of Gastroenterology and Hepatology, Hospital Universitario Ramón y Cajal, IRYCIS, CIBERehd, University of Alcalá, Madrid, Spain
| | - Jean-Charles Nault
- APHP, Hôpitaux Universitaires Paris-Seine Saint-Denis, Site Jean Verdier, Pôle d'Activité Cancérologique Spécialisée, Service d'Hépatologie, Bondy, Inserm, UMR-1162, Génomique fonctionnelle des Tumeurs solides, Equipe Labellisée Ligue Contre le Cancer, Paris, France
| | | | - Jean-Paul Cervoni
- Service d'hépatologie, Centre Hospitalier Régional et Universitaire de Besançon, Besançon, France
| | | | - Annie Sibert
- Service de radiologie, Hôpital Beaujon, Clichy, France
| | - Louis Bouchard
- Service de radiologie, Hôpital Saint-Luc, Montréal, Canada
| | | | - Jonel Trebicka
- Department of Internal Medicine I, University of Bonn, Bonn, Germany
| | | | - Pierre-Emmanuel Rautou
- Service d'Hépatologie, Hôpital Beaujon, APHP, Clichy, France.,DHU Unity, Hôpital Beaujon, APHP, Clichy, France.,Université Paris Diderot, Sorbonne Paris Cité, Paris, France.,Département Epidémiologie et Recherche Clinique, Hôpital Beaujon, APHP, Clichy, France
| | - Dominique-Charles Valla
- Service d'Hépatologie, Hôpital Beaujon, APHP, Clichy, France.,DHU Unity, Hôpital Beaujon, APHP, Clichy, France.,Université Paris Diderot, Sorbonne Paris Cité, Paris, France.,Département Epidémiologie et Recherche Clinique, Hôpital Beaujon, APHP, Clichy, France
| | - Aurélie Plessier
- Service d'Hépatologie, Hôpital Beaujon, APHP, Clichy, France.,DHU Unity, Hôpital Beaujon, APHP, Clichy, France.,Université Paris Diderot, Sorbonne Paris Cité, Paris, France.,Département Epidémiologie et Recherche Clinique, Hôpital Beaujon, APHP, Clichy, France
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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.
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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.
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24
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Rössle M, Bausch B, Klinger C. Therapy Algorithm for Portal Vein Thrombosis in Liver Cirrhosis: The Internist's Point of View. VISZERALMEDIZIN 2015; 30:401-8. [PMID: 26288607 PMCID: PMC4513837 DOI: 10.1159/000370053] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
BACKGROUND Treatment of non-malignant portal vein thrombosis (PVT) in patients with cirrhosis has been neglected in the past because of the fear of bleeding complications when using anticoagulation and due to the technical difficulties associated with the implantation of the transjugular intrahepatic portosystemic shunt (TIPS). However, PVT has a negative impact on outcome and compromises liver transplantation, warranting treatment by using anticoagulation and TIPS. METHODS This review considers studies on the treatment of PVT in cirrhosis published in the last 10 years. Unfortunately, many of these studies are limited by their retrospective design and a small sample size. RESULTS Anticoagulation using low-molecular-weight heparin (LMWH) or vitamin K antagonists is effective in the treatment of patients with limited and recent PVT, resulting in a recanalization in up to 50% of the patients. TIPS (plus local measures) results in a recanalization of up to 100% and reduces the rebleeding rate considerably in patients with recent or chronic PVT. CONCLUSION Based on the presently limited knowledge, a therapy algorithm is suggested favouring the TIPS as a first-line treatment for PVT in patients with symptomatic portal hypertension. Patients with thus far asymptomatic portal hypertension may first receive anticoagulation, preferably using LMWH. If these patients have a condition where anticoagulation is not promising (complete, extended, chronic PVT) or ineffective, or if they are candidates for liver transplantation, the TIPS may be implanted without delay.
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Affiliation(s)
- Martin Rössle
- 'PraxisZentrum für Gastroenterologie und Endokrinologie' and University Hospital Freiburg, Freiburg i.Br., Germany
| | - Birke Bausch
- Department of Gastroenterology, Hepatology, Endocrinology and Infectious Diseases, University Hospital Freiburg, Freiburg i.Br., Germany
| | - Christoph Klinger
- Department of Gastroenterology, Klinikum Ludwigsburg, Ludwigsburg, Germany
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25
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Copelan A, Kapoor B, Sands M. Transjugular intrahepatic portosystemic shunt: indications, contraindications, and patient work-up. Semin Intervent Radiol 2014; 31:235-42. [PMID: 25177083 DOI: 10.1055/s-0034-1382790] [Citation(s) in RCA: 70] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
The transjugular intrahepatic portosystemic shunt (TIPS) procedure is effective in achieving portal decompression and in managing some of the major complications of portal hypertension. While many clinicians are familiar with the two most common indications for TIPS placement, secondary prophylaxis of esophageal variceal hemorrhage and treatment of refractory ascites, evidence for its usefulness is growing in other entities, where it has been less extensively studied but demonstrates promising results. Newer indications include early utilization in the treatment of esophageal variceal hemorrhage, Budd-Chiari syndrome, ectopic varices, and portal vein thrombosis. The referring clinician and interventionist must remain cognizant of the contraindications to the procedure to avoid complications and potential harm to the patient. This review is designed to provide an in-depth analysis of the most common as well as less typical indications for TIPS placement, and to discuss the contraindications and appropriate patient evaluation for this procedure.
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Affiliation(s)
- Alexander Copelan
- Diagnostic Radiology Department, William Beaumont Hospital, Royal Oak, Michigan
| | | | - Mark Sands
- Imaging Institute, Cleveland Clinic, Cleveland, Ohio
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26
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Choe WH. Do cirrhotic patients with a high MELD score benefit from TIPS? Clin Mol Hepatol 2014; 20:15-7. [PMID: 24757654 PMCID: PMC3992325 DOI: 10.3350/cmh.2014.20.1.15] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/06/2014] [Accepted: 03/11/2014] [Indexed: 12/16/2022] Open
Affiliation(s)
- Won Hyeok Choe
- Department of Internal Medicine, Konkuk University Hospital, Konkuk University School of Medicine, Seoul, Korea
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27
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Syed MI, Karsan H, Ferral H, Shaikh A, Waheed U, Akhter T, Gabbard A, Morar K, Tyrrell R. Transjugular intrahepatic porto-systemic shunt in the elderly: Palliation for complications of portal hypertension. World J Hepatol 2012; 4:35-42. [PMID: 22400084 PMCID: PMC3295850 DOI: 10.4254/wjh.v4.i2.35] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/17/2011] [Revised: 01/08/2012] [Accepted: 02/24/2012] [Indexed: 02/06/2023] Open
Abstract
AIM To present a dedicated series of transjugular intrahepatic porto-systemic shunts (TIPS) in the elderly since data is sparse on this population group. METHODS A retrospective review was performed of patients at least 65 years of age who underwent TIPS at our institutions between 1997 and 2010. Twenty-five patients were referred for TIPS. We deemed that 2 patients were not considered appropriate candidates due to their markedly advanced liver disease. Of the 23 patients suitable for TIPS, the indications for TIPS placement was portal hypertension complicated by refractory ascites alone (n = 9), hepatic hydrothorax alone (n = 2), refractory ascites and hydrothorax (n = 1), gastrointestinal bleeding alone (n = 8), gastrointestinal bleeding and ascites (n = 3). RESULTS Of these 23 attempted TIPS procedure patients, 21 patients had technically successful TIPS procedures. A total of 29 out of 32 TIPS procedures including revisions were successful in 21 patients with a mean age of 72.1 years (range 65-82 years). Three of the procedures were unsuccessful attempts at TIPS and 8 procedures were successful revisions of our existing TIPS. Sixteen of 21 patients who underwent successful TIPS (excluding 5 patients lost to follow-up) were followed for a mean of 14.7 mo. Ascites and/or hydrothorax was controlled following technically successful procedures in 12 of 13 patients. Bleeding was controlled following technically successful procedures in 10 out of 11 patients. CONCLUSION We have demonstrated that TIPS is an effective procedure to control refractory complications of portal hypertension in elderly patients.
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Affiliation(s)
- Mubin I Syed
- Mubin I Syed, Azim Shaikh, Uzma Waheed, Kamal Morar, Robert Tyrrell, Dayton Interventional Radiology, Dayton, OH 45409, United States
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28
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The transjugular intrahepatic portosystemic shunt in the treatment of portal hypertension: current status. Int J Hepatol 2012; 2012:167868. [PMID: 22888442 PMCID: PMC3408669 DOI: 10.1155/2012/167868] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/17/2012] [Accepted: 05/18/2012] [Indexed: 02/06/2023] Open
Abstract
The transjugular intrahepatic portosystemic shunt (TIPS) represents a major advance in the treatment of complications of portal hypertension. Technical improvements and increased experience over the past 24 years led to improved clinical results and a better definition of the indications for TIPS. Randomized clinical trials indicate that the TIPS procedure is not a first-line therapy for variceal bleeding, but can be used when medical treatment fails, both in the acute situation or to prevent variceal rebleeding. The role of TIPS to treat refractory ascites is probably more justified to improve the quality of life rather than to improve survival, except for patients with preserved liver function. It can be helpful for hepatic hydrothorax and can reverse hepatorenal syndrome in selected cases. It is a good treatment for Budd Chiari syndrome uncontrollable by medical treatment. Careful selection of patients is mandatory before TIPS, and clinical followup is essential to detect and treat complications that may result from TIPS stenosis (which can be prevented by using covered stents) and chronic encephalopathy (which may in severe cases justify reduction or occlusion of the shunt). A multidisciplinary approach, including the resources for liver transplantation, is always required to treat these patients.
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29
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Martínez Moreno B, Bellot P, de España F, Palazón JM, Such J, Pérez-Mateo M. [Treatment of refractory hepatic encephalopathy associated with insertion of a transjugular intrahepatic portosystemic shunt through new endovascular techniques: a case report]. GASTROENTEROLOGIA Y HEPATOLOGIA 2011; 34:468-73. [PMID: 21652116 DOI: 10.1016/j.gastrohep.2011.03.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/20/2011] [Revised: 03/15/2011] [Accepted: 03/17/2011] [Indexed: 11/17/2022]
Abstract
Insertion of a transjugular intrahepatic portosystemic shunt (TIPS) is an increasingly used treatment in the management of the complications of portal hypertension. However, one of the complications of this technique is refractory or recurrent hepatic encephalopathy, which poses a difficult clinical problem. We report the case of a patient who underwent TIPS insertion to control bleeding due to esophageal varices. The patient subsequently developed refractory hepatic encephalopathy, requiring reduction of the caliber of the shunt.
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30
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Bai M, Qi X, Yang Z, Yin Z, Nie Y, Yuan S, Wu K, Han G, Fan D. Predictors of hepatic encephalopathy after transjugular intrahepatic portosystemic shunt in cirrhotic patients: a systematic review. J Gastroenterol Hepatol 2011; 26:943-51. [PMID: 21251067 DOI: 10.1111/j.1440-1746.2011.06663.x] [Citation(s) in RCA: 118] [Impact Index Per Article: 9.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND AND AIM Hepatic encephalopathy (HE) is a very common complication in patients after transjugular intrahepatic portosystemic shunt (TIPS). The purpose of this study is to determine the most robust predictors of post-TIPS HE by performing a systematic review of studies that identified the risk factors for patients with post-TIPS HE. METHODS A PUBMED search was performed using the predefined rule. Studies were selected for analysis based on certain inclusion and exclusion criteria. Data were extracted from each study on the basis of predefined items. Meta-analyses were executed to verify the relevant risk factors. RESULTS Thirty studies were included in this systematic review. In the 30 studies, the numbers of variables evaluated by univariate and multivariate analyses were 60 and 32, respectively. The numbers of variables found to be significant in univariate and multivariate analyses were 18 and 14, respectively. According to the accumulated number of studies that identified these variables as significant, the three most vigorous predictors of post-TIPS HE were age, prior HE and Child-Pugh class/score in both univariate analysis and multivariate analysis. Our meta-analysis showed that patients with HE before TIPS or higher Child-Pugh class/score had increased risk of post-TIPS HE. CONCLUSIONS Increased age, prior HE and higher Child-Pugh class/score were the most robust predictors for post-TIPS HE.
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Affiliation(s)
- Ming Bai
- Department of Digestive Interventional Radiology, Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an, China
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Córdoba J. New assessment of hepatic encephalopathy. J Hepatol 2011; 54:1030-40. [PMID: 21145874 DOI: 10.1016/j.jhep.2010.11.015] [Citation(s) in RCA: 160] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/25/2010] [Revised: 11/22/2010] [Accepted: 11/23/2010] [Indexed: 12/12/2022]
Abstract
Hepatic encephalopathy (HE) is a common complication of cirrhosis that requires careful appraisal of the clinical manifestations, evaluation of the underlying neurological disorders, and assessment of liver function and the portal-systemic circulation. This article reviews recent developments in the assessment of HE and discusses the controversy regarding the use of a categorical or a continuous approach in measuring the severity of this condition. New scales facilitate effective monitoring and assessment of episodic HE. Neuropsychological test batteries and neurophysiological tests are of value for evaluating cognitive function in outpatients and can establish the diagnosis of minimal HE, and the severity of low-grade HE. These tools allow better evaluation of the origin of cognitive complaints and help in estimating the risk of accidents. It is now possible to complete the evaluation with measurement of the effects of cognitive impairment on daily living. In difficult cases, imaging of the brain and portal-systemic circulation with magnetic resonance imaging is especially helpful. Based on these studies, neurological signs and symptoms can be attributed to HE in patients with mild liver disease and in those with complex neurological manifestations. The new methods presented are also valuable for investigating the neurological manifestations occurring after liver transplantation.
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Affiliation(s)
- Juan Córdoba
- Servei de Medicina Interna-Hepatologia, Hospital Vall d'Hebron, Universitat Autònoma de Barcelona and Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBEREHD), Paseo Vall d'Hebron 119, Barcelona 08035, Spain.
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Abstract
AIM Many researchers consider portal thrombosis (PT) as a contraindication to transjugular intrahepatic portosystemic shunt (TIPS). The aim of this retrospective study was to compare the feasibility and long-term prognosis of TIPS in cirrhotic patients, with and without, complete PT. PATIENTS AND METHODS Four hundred and thirty-six consecutive cirrhotic patients with portal hypertension were referred for TIPS, between 1990 and 2004. These patients were divided into two groups according to their portal patency. PT+: 34 patients with complete PT with cavernoma (19) or without (15) cavernoma versus PT-: 402 patients with normal portal patency (308) and partial PT (94). Epidemiological data were compared using the chi and Student's t-tests, and comparative evolution was made from actuarial data using the log-rank test. RESULTS PT+ patients were more frequently women with viral hepatitis, and TIPS was performed more often for bleeding indications. The TIPS success rate was significantly lower in the PT+ group (79%) than in the PT- group (99.5%) (P<10). Presence of a cavernoma decreased the success rate to 63%. TIPS was always feasible in cases of recent PT and portal cavernoma with an accessible intrahepatic patent portal branch. Early and late outcome and complications were not significantly different between the two groups. CONCLUSION Complete PT does not modify TIPS' long-term outcome. Rather than a contraindication, PT should be considered as an indication for TIPS in cirrhotic patients with accessible intrahepatic portal vein. Further randomized studies should be planned in cirrhotic patients with recent PT to better qualify TIPS and anticoagulation indications, respectively.
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Arulraj R, Mangat KS, Tripathi D. Embolization of bleeding stomal varices by direct percutaneous approach. Cardiovasc Intervent Radiol 2010; 34 Suppl 2:S210-3. [PMID: 20467869 DOI: 10.1007/s00270-010-9886-y] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/31/2010] [Accepted: 04/15/2010] [Indexed: 12/11/2022]
Abstract
Stomal varices can occur in patients with stoma in the presence of portal hypertension. Suture ligation, sclerotherapy, angiographic embolization, stoma revision, beta blockade, portosystemic shunt, and liver transplantation have been described as therapeutic options for bleeding stomal varices. We report the case of a 21-year-old patient with primary sclerosing cholangitis and colectomy with ileostomy for ulcerative colitis, where stomal variceal bleeding was successfully treated by direct percutaneous embolization. We consider percutaneous embolization to be an effective way of treating acute stomal bleeding in decompensated patients while awaiting decisions regarding shunt procedures or liver transplantation.
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Diagnostic and prognostic values of critical flicker frequency determination as new diagnostic tool for objective HE evaluation in patients undergoing TIPS implantation. Eur J Gastroenterol Hepatol 2009; 21:1383-94. [PMID: 19738480 DOI: 10.1097/meg.0b013e328310e0c3] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Abstract
OBJECTIVES The diagnostic and prognostic value of critical flicker frequency (CFF) analysis for assessment of severity and dynamics of hepatic encephalopathy (HE) was studied before and after implantation of a transjugular intrahepatic portosystemic shunt (TIPS). BASIC METHODS Sixty-three cirrhotic patients were retrospectively analyzed for the consequences of TIPS implantation. Thirty-one cirrhotic patients without TIPS implantation served as age-matched, sex-matched, Child-Pugh-matched controls. CFF and computer psychometric tests as objective test parameters of HE-severity were evaluated for analysis of visual discrimination ability, general arousal and cognitive function. Kaplan-Meier method and Cox proportional hazards regression model were used for analysis of prognostic significances. MAIN RESULTS In the control group, HE-severity was stable during the observation period (442+/-428 days) with minimal changes in CFF (-0.1+/-1.9 Hz). In the intervention group, TIPS implantation had no effect on HE-severity in 44% of the patients and CFF shifted by only 0.01+/-1.5 Hz. Thirty-five and 21% of the patients experienced an aggravation or improvement of HE after TIPS implantation, respectively. In HE improvers CFF increased by 3.3+/-2.3 Hz and decreased by 3.5+/-1.5 Hz in those experiencing an aggravation of HE-severity. Univariate analysis showed that overall survival in the study population inversely correlated with HE-severity and serum alkaline phosphatase activity and positively correlated with serum sodium, albumin and CFF. Serum albumin, alkaline phosphatase levels and CFF were independent predictors of survival in a multivariate Cox regression analysis. CONCLUSION The data show that pre-TIPS HE does not predict post-TIPS encephalopathy. Otherwise, CFF can reliably pick up the evolution of HE-severity after TIPS implantation. Low pre-TIPS CFF is indicative for a poor prognosis and may help to identify transplant candidates without delay.
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Chen L, Xiao T, Chen W, Long Q, Li R, Fang D, Wang R. Outcomes of transjugular intrahepatic portosystemic shunt through the left branch vs. the right branch of the portal vein in advanced cirrhosis: a randomized trial. Liver Int 2009; 29:1101-9. [PMID: 19386025 DOI: 10.1111/j.1478-3231.2009.02016.x] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND/AIMS The transjugular intrahepatic portosystemic shunt (TIPS) is technically divided into TIPS through the left branch of the portal vein (TIPS-LBPV) and TIPS through the right branch of the portal vein (TIPS-RBPV). In order to compare their advantages and disadvantages, this randomized, controlled trial was designed to investigate their outcomes in advanced cirrhotic patients. METHODS Seventy-two patients were randomly placed into TIPS-LBPV (36 patients) and TIPS-RBPV (36 patients, with four failures) groups, and they were prospectively followed for 2 years after TIPS implantation. RESULTS Patients who underwent the two different kinds of TIPS were balanced during recruitment for this study. The incidences of overall encephalopathy and de novo encephalopathy in the TIPS-LBPV group were significantly lower than that of the TIPS-RBPV group during follow-up (P=0.036 and 0.012 respectively). The incidences of rebleeding or re-intervention and improvement of ascites were similar between groups (P>0.05). Patients undergoing TIPS-RBPV required more rehospitalization and incurred more costs than those who underwent TIPS-LBPV (P=0.030 and 0.039 respectively). There was no significant difference between the two groups in survival based on a survival curve constructed according to the Kaplan-Meier method (P>0.05). CONCLUSION Patients undergoing TIPS-LBPV had a lower incidence of encephalopathy, less rehospitalization and lower costs after TIPS implantation compared with patients undergoing TIPS-RBPV.
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Affiliation(s)
- Lei Chen
- Department of Gastroenterology, Southwest Hospital, Third Military Medical University, Chongqing, China
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Liu F, Zhang CQ. Pathogenesis of hepatic encephalopathy and its prevention after transjugular intrahepatic portosystemic shunt. Shijie Huaren Xiaohua Zazhi 2009; 17:798-804. [DOI: 10.11569/wcjd.v17.i8.798] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
With the increasing use of transjugular intrahepatic portosystemic shunt (TIPS), we have obtained a breakout progress in the therapy of acute esophageal and gastric-fundus variceal bleeding and refractory ascites. whereas the patency of stent and hepatic encephalopathy (or namely portal-systemic encephalopathy, PSE) after TIPS become two great problems for TIPS. The patency of stent has been improved greatly after the use of covered stent such as Viator stents or covered vascular stents. But the problem of hepatic encephalopathy has not been well solved. In this review, we try to explore the pathogenesis of hepatic encephalopathy and its prevention after TIPS.
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Riggio O, Angeloni S, Salvatori FM, De Santis A, Cerini F, Farcomeni A, Attili AF, Merli M. Incidence, natural history, and risk factors of hepatic encephalopathy after transjugular intrahepatic portosystemic shunt with polytetrafluoroethylene-covered stent grafts. Am J Gastroenterol 2008; 103:2738-46. [PMID: 18775022 DOI: 10.1111/j.1572-0241.2008.02102.x] [Citation(s) in RCA: 184] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
BACKGROUND AND AIMS The aim of this study was to assess the incidence, natural history, and risk factors of hepatic encephalopathy (HE) after transjugular intrahepatic portosystemic shunt (TIPS) with the new polytetrafluoroethylene (PTFE)-covered stent grafts in cirrhotic patients. PATIENTS AND METHODS Seventy-eight cirrhotic patients treated by TIPS with PTFE-covered stent grafts and followed by the same medical team--according to a prospective protocol for diagnostic workup and surveillance strategy--were reviewed. The follow-up was 19.9 +/- 20.6 months. RESULTS At least one episode of HE occurred in 35 of 78 (44.8%) patients. The probability of remaining free of HE was 53.8% (95% confidence interval [CI] 41.4-66.2] at 1 yr and 50.9% at 2 yr (95% CI 38.2-63.8%). The total number of HE episodes was 89. Fifty-five percent of the episodes were grades III-IV. The occurrence of HE tended to be constant during the follow-up, probably because of the very low incidence of shunt dysfunction (13.6% at 2 yr). Moreover, in six patients, a refractory HE required the reduction of the shunt diameter. One patient died due to variceal bleeding after this procedure. At a multivariate analysis, an older age, high creatinine levels, and low serum sodium and low albumin values were shown to be independent factors for the occurrence of HE. Serum creatinine level was the only variable related to the development of refractory HE at the logistic multivariate analysis. CONCLUSIONS HE after TIPS with PTFE-covered stent grafts is frequent; its incidence is not confined to the first post-TIPS period, but it has the tendency to be frequent over time. Refractory HE occurred in 8% of patients and may be successfully managed by reducing the stent diameter. The selection of patients undergoing TIPS placement should be very accurate, especially for those subjects with abnormal creatinine level.
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Affiliation(s)
- Oliviero Riggio
- II Gastroenterologia, Dipartimento di Medicina Clinica, Sapienza Università di Roma, Rome, Italy
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The role of transjugular intrahepatic portosystemic shunt (TIPS) in the management of portal hypertension. J Clin Gastroenterol 2007; 41 Suppl 3:S344-51. [PMID: 17975487 DOI: 10.1097/mcg.0b013e318157e500] [Citation(s) in RCA: 105] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Transjugular intrahepatic portosystemic shunt (TIPS) is an interventional radiology technique that has shown a 90% success rate to decompress the portal circulation. As a non-surgical intervention, without requirement for anesthesia and very low procedure-related mortality, TIPS is applicable to severe cirrhotic patients, who are otherwise untreatable, for example, nonsurgical candidates. TIPS constitutes the most frequently employed tool to achieve portosystemic shunting. TIPS acts by lowering portal pressure, which is the main underlying pathophysiologic determinant of the major complications of cirrhosis. Regarding esophagogastric variceal bleeding, TIPS has excellent hemostatic effect (95%) with low rebleeding rate (<20%). TIPS is an accepted rescue therapy for first line treatment failures in 2 settings (1) acute variceal bleeding and (2) secondary prophylaxis. In addition, TIPS offers 70% to 90% hemostasis to patients presenting with recurrent active variceal bleeding. TIPS is more effective than standard therapy for patients with hepatic venous pressure gradient >20mm Hg. TIPS is particularly useful to treat bleeding from varices inaccessible to endoscopy. TIPS should not be applied for primary prophylaxis of variceal bleeding. Portosystemic encephalopathy and stent dysfunction are TIPS major drawbacks. The weakness of the TIPS procedure is the frequent need for endovascular reintervention to ensure stent patency. The circulatory effects of TIPS are an attractive approach for the treatment of refractory ascites and hepatorenal syndrome, yet TIPS is not considered first line therapy for refractory ascites owing to unacceptable incidence of portosystemic encephalopathy. Pre-TIPS evaluation taking into account predictors of outcome is mandatory. The improved results achieved with covered-stents might expand the currently accepted recommendations for TIPS use.
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Salerno F, Cammà C, Enea M, Rössle M, Wong F. Transjugular intrahepatic portosystemic shunt for refractory ascites: a meta-analysis of individual patient data. Gastroenterology 2007; 133:825-34. [PMID: 17678653 DOI: 10.1053/j.gastro.2007.06.020] [Citation(s) in RCA: 340] [Impact Index Per Article: 20.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/29/2006] [Accepted: 05/31/2007] [Indexed: 02/06/2023]
Abstract
BACKGROUND & AIMS Several randomized controlled trials have compared a transjugular intrahepatic portosystemic shunt (TIPS) with large-volume paracentesis in cirrhotic patients with refractory ascites. Although all agree that TIPS reduces the recurrence rate of ascites, survival is controversial. The aim of this study was to compare the effects of TIPS and large-volume paracentesis in cirrhotic patients with refractory ascites by means of meta-analysis of individual patient data from 4 randomized controlled trials. METHODS The study population consisted of 305 patients: 149 allocated to TIPS and 156 to paracentesis. Cumulative probabilities of transplant-free survival and of hepatic encephalopathy (HE) were estimated by the Kaplan-Meier method and differences assessed by log-rank test. The total number of HE episodes per patient was also compared between TIPS and paracentesis. RESULTS Tense ascites recurred in 42% of patients allocated to TIPS and 89% allocated to paracentesis (P < .0001). Sixty-five patients in the TIPS group and 78 in the paracentesis group died. The actuarial probability of transplant-free survival was significantly better in the TIPS group (P = .035). Cox regression analysis performed in a subgroup of 235 patients (114 allocated to TIPS and 121 to paracentesis) showed that age, serum bilirubin level, plasma sodium level, and treatment allocation were independently associated with transplant-free survival. The average number of HE episodes was significantly higher in the TIPS group (1.13 +/- 1.93 vs 0.63 +/- 1.18; P = .006), although the cumulative probability of developing the first episode of HE was similar between the groups (P = .19). CONCLUSIONS The present meta-analysis of individual patient data provides further evidence to the previous meta-analyses of literature data showing that TIPS significantly improves transplant-free survival of cirrhotic patients with refractory ascites.
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Affiliation(s)
- Francesco Salerno
- Department of Internal Medicine, IRCCS Policlinico San Donato, University of Milan, Milan, Italy.
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Garcia-Tsao G. The transjugular intrahepatic portosystemic shunt for the management of cirrhotic refractory ascites. ACTA ACUST UNITED AC 2006; 3:380-9. [PMID: 16819501 DOI: 10.1038/ncpgasthep0523] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2005] [Accepted: 04/12/2006] [Indexed: 12/26/2022]
Abstract
Cirrhotic ascites results from sinusoidal hypertension and sodium retention, which is secondary to a decreased effective arterial blood volume. Transjugular intrahepatic portosystemic shunt (TIPS) placement is currently indicated in cirrhotic patients with refractory ascites who require large-volume paracentesis (LVP) more than two or three times per month. TIPS placement is associated with normalization of sinusoidal pressure and a significant improvement in urinary sodium excretion that correlates with suppression of plasma renin activity, which is, itself, indicative of an improvement in effective arterial blood volume. Compared with serial LVP, placement of an uncovered TIPS stent is more effective at preventing ascites from recurring; however, increased incidence of hepatic encephalopathy and shunt dysfunction rates after TIPS placement are important issues that increase its cost. Although evidence suggests that TIPS placement might result in better patient survival, this needs to be confirmed, particularly in light of the development of polytetrafluoroethylene-covered stents. Favorable results apply to centers experienced in placing the TIPS, with the aim being to decrease the portosystemic gradient to <12 mmHg but >5 mmHg. This article reviews the pathophysiologic basis for the use of a TIPS in patients with refractory ascites, the results of controlled trials comparing TIPS placement (using uncovered stents) versus LVP, and a systematic review of predictors of death after TIPS placement for refractory ascites.
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Wolf DC, Siddiqui S, Rayyan Y, Rozenblit G. Emergent stent occlusion for TIPS-induced liver failure. Dig Dis Sci 2005; 50:2356-8. [PMID: 16416189 DOI: 10.1007/s10620-005-3062-2] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/28/2004] [Accepted: 03/28/2005] [Indexed: 01/23/2023]
Affiliation(s)
- David C Wolf
- Division of Gastroenterology and Hepatobiliary Diseases, New York Medical College and Westchester Medical Center, Valhalla, New York 10595, USA.
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D'Amico G, Luca A, Morabito A, Miraglia R, D'Amico M. Uncovered transjugular intrahepatic portosystemic shunt for refractory ascites: a meta-analysis. Gastroenterology 2005; 129:1282-93. [PMID: 16230081 DOI: 10.1053/j.gastro.2005.07.031] [Citation(s) in RCA: 125] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/18/2005] [Accepted: 03/30/2005] [Indexed: 12/13/2022]
Abstract
BACKGROUND & AIMS Several trials showed that uncovered transjugular intrahepatic portosystemic shunt (TIPS) is superior to paracentesis for the control of refractory ascites. However, the results for encephalopathy and mortality were not consistent across trials. We performed a systematic review of randomized controlled trials of TIPS for refractory ascites to assess the overall treatment effects and to explore potential reasons of heterogeneity. METHODS Pertinent studies were retrieved trough MEDLINE (1968-2004), EMBASE (1986-2004), the Cochrane Library (2004;4), and reference lists of key articles. Outcome measures were recurrence of ascites, encephalopathy, and mortality. Metaregression analysis was used to explore heterogeneity. RESULTS Five trials were identified including 330 patients. Successful TIPS placement ranged from 77% to 100% and portosystemic pressure gradient reduction ranged from 6.0 to 14.0 mm Hg. Metaregression analysis showed that bilirubin levels and successful TIPS placement rates were associated significantly with log-odds ratio for death after TIPS, explained heterogeneity of trials for mortality, and suggested an outlier trial. After exclusion of the outlier trial, pooled odds ratios for recurrence of ascites with TIPS was .14 (confidence interval, .07-.27), for encephalopathy was 2.26 (confidence interval, 1.35-3.76), and for mortality was .74 (confidence interval, .40-1.37), without any significant heterogeneity. CONCLUSIONS Uncovered TIPS is significantly better than paracentesis for control of refractory ascites. Although it increases encephalopathy, it also is associated with a trend toward improvement of survival. Future TIPS trials should select patients on the basis of bilirubin levels and predictors of the risk for post-TIPS encephalopathy, and assess costs and quality of life.
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Affiliation(s)
- Gennaro D'Amico
- Unit of Gastroenterology, Ospedale V. Cervello, Palermo, Italy.
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Abstract
During the last 15 years the transjugular intrahepatic portosystemic shunt (TIPS) procedure has become a safe and effective treatment of portal hypertension. Its major obstacle, the high rate of shunt insufficiency, is going to be solved by the availability of covered stents showing a patency rate of up to 90%. The treatment of acute oesophageal and gastric variceal bleeding is an unsolved problem because variceal bleeding remains the major cause of death in patients with cirrhosis. TIPS has become the rescue treatment of choice because it combines high efficacy with low invasiveness. In this context, the timing of the rescue TIPS is of major importance for achieving definitive haemostasis before multi-organ failure develops. In the prevention of re-bleeding, TIPS is accepted as a second-line treatment, required in about 10-20% of patients. TIPS may be indicated when more than two significant re-bleedings occurred within a time frame of 12 months in spite of adequate first-line measures i.e. drugs or ligation. Refractory ascites is the third main indication for TIPS. Five randomized studies comparing TIPS with paracentesis show good response and comparable survival. Interpretations of authors and comments of reviewers are, however, controversial and do not permit a definitive recommendation.
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Affiliation(s)
- Martin Rössle
- Praxiszentrum für Gastroenterologie, University Hospital, Bertoldstrasse 48, 79098 Freiburg, Germany.
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Hassoun Z, Pomier-Layrargues G. The transjugular intrahepatic portosystemic shunt in the treatment of portal hypertension. Eur J Gastroenterol Hepatol 2004; 16:1-4. [PMID: 15095845 DOI: 10.1097/00042737-200401000-00001] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
The transjugular intrahepatic portosystemic shunt (TIPS) represents a major advance in the treatment of complications of portal hypertension. It is most commonly used in the management of refractory variceal bleeding, where it can be life-saving. Two other indications have been studied in randomized controlled trials: prevention of variceal rebleeding and refractory cirrhotic ascites. These trials have demonstrated that TIPS is superior to standard therapy but is associated with a higher rate of hepatic encephalopathy and with no improvement in survival. Consequently, TIPS is considered a second-line therapy in these situations. TIPS has also been used successfully in the treatment of hepatic hydrothorax, hepatorenal syndrome, severe portal hypertensive gastropathy, Budd-Chiari syndrome and veno-occlusive disease. Its use in these indications has only been reported in small uncontrolled series. TIPS usefulness is limited by two major problems: shunt dysfunction and hepatic encephalopathy. Shunt dysfunction is frequently responsible for the recurrence of complications of portal hypertension, and requires a surveillance program to monitor shunt patency. The use of polytetrafluoroethylene-covered stents may help prevent this complication.
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Affiliation(s)
- Ziad Hassoun
- Liver Unit, Hôpital Saint-Luc, Centre Hospitalier de l'Université de Montreal, Montréal, Québéc, Canada
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Abstract
The principal indication for transjugular intrahepatic portosystemic shunts (TIPS) continues to be rescue therapy for variceal hemorrhage that cannot be controlled by endoscopic or medical therapy. TIPS provide no survival advantage in prevention of rebleeding or refractory ascites. The indications for TIPS continue to expand, however, especially for Budd-Chiari syndrome and hydrothorax. Other more novel indications include bleeding portal hypertensive gastropathy or ectopic varices, Budd-Chiari syndrome, veno-occlusive disease, hepatorenal syndrome, hepatopulmonary syndrome, hepatocellular carcinoma, and polycystic liver disease. Great strides have been made recently in models to predict mortality and complications following TIPS placement. Graft stents hold promise based on early studies. Finally, complications are common and may be life threatening.
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Affiliation(s)
- Timothy M McCashland
- Division of Gastroenterology and Hepatology, University of Nebraska Medical Center, PO Box 983285, Omaha, NE 68198-3285, USA.
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