Transjugular Intrahepatic Portosystemic Shunts in Patients with Cirrhosis with Refractory Ascites: Comparison of Clinical Outcomes by Using 8- and 10-mm PTFE-covered Stents

6-mm shunt transjugular intrahepatic portosystemic shunt in patients with severe liver atrophy and variceal bleeding

OBJECTIVES

We proposed a strategy for the creation of a 6-mm transjugular intrahepatic portosystemic shunt (TIPS) and to assess its effectiveness compared to a conventional 8-mm shunt for TIPS-induced hepatic encephalopathy (HE).

METHODS

Patients were reviewed retrospectively using propensity score matching (1:1) and divided into 6-mm and 8-mm shunt groups based on shunt diameter. The stent patency, HE incidence, and rebleeding rate between the two groups were then compared.

RESULTS

From January 2018 to June 2021, both 6-mm shunt group and 8-mm shunt group included 58 patients. The 6-mm shunt group had significantly smaller liver volumes (879.3 ± 237.1 vs. 1008.8 ± 293.0; p = 0.010), and the median stent patency times were 30.7 and 33.8 months in the 6-mm and 8-mm groups, respectively (p = 0.124). No statistically significant difference was found between the two groups in the 1-year (8.6% vs. 3.4%; p = 0.242) and 2-year (17.2% vs. 12.1%; p = 0.242) rebleeding rates. The 1-year cumulative incidences of overt HE were 12.1% and 27.6% in the 6-mm and 8-mm groups, respectively (p = 0.040), and the 2-year cumulative overt HE incidences in these groups were 19.0% and 36.2%, respectively (p = 0.038). Notably, patients with a 6-mm shunt also experienced less hepatic impairment.

CONCLUSIONS

For patients with variceal bleeding and a small liver volume, the 6-mm shunt significantly reduced the incidence of overt HE, protected perioperative liver function, and did not affect stent patency or rebleeding rate.

CLINICAL RELEVANCE STATEMENT

For patients with variceal bleeding with small liver volume, the 6-mm transjugular intrahepatic portosystemic shunt (TIPS) significantly reduced the incidence of overt hepatic encephalopathy after TIPS, protected perioperative liver function, and did not affect stent patency and rebleeding rate.

KEY POINTS

• A strategy for the creation of a 6-mm transjugular intrahepatic portosystemic shunt for patients with variceal bleeding and a small liver volume was proposed. • The 6-mm transjugular intrahepatic portosystemic shunt significantly reduced the incidence of overt hepatic encephalopathy. • The 6-mm transjugular intrahepatic portosystemic shunt did not affect stent patency or rebleeding rate.

Effectiveness and prognosis of covered stents with different diameters in transjugular intrahepatic portosystemic shunt: a meta-analysis

PURPOSE

This meta-analysis was designed to evaluate the clinical outcomes of transjugular intrahepatic portosystemic shunt (TIPS) conducted utilizing stents of different diameters, thus providing recommendations for more logical selections of covered stents for patients with portal hypertension, in particular for the Asian population.

MATERIALS AND METHODS

Web of Science, PubMed, Embase, Cochrane Library, Chinese National Knowledge Infrastructure and Wan Fang were searched for randomized controlled trials and cohort studies from inception until February 2023. The meta-analysis was carried out using Revman 5.4 Software. Heterogeneity between researches was assessed by the χ2 test and I2 index. The outcomes evaluated were the incidence of post-TIPS hepatic encephalopathy (HE), variceal rebleeding, shunt dysfunction, 1-year overall survival and decrease in portal pressure gradient (PPG).

RESULTS

Eight appropriate clinical trials with 1246 patients were selected (638 and 608 patients in the experimental and control groups, respectively). In regards to preoperative PPG reduction, there was no discernible difference between the two groups [mean difference = 1.15, 95% confidence interval (CI) = -0.29-2.58, P = 0.12]. The rate of post-TIPS HE was significantly higher in patients in the 8 mm stent group than in the 6-7 mm stent group [odds ratio (OR) = 0.54, 95% CI = 0.42-0.70, P < 0.00001, I2 = 46%]. There were no significant differences in the rates of variceal rebleeding (OR = 1.05, 95% CI = 0.67-1.65, P = 0.84, I2 = 0%), shunt dysfunction (OR = 0.88, 95% CI = 0.53-1.47, P = 0.64, I2 = 0%) and 1-year overall survival (OR = 0.86, 95% CI = 0.50-1.50, P = 0.61, I2 = 0%).

CONCLUSION

Asian populations with portal hypertension may benefit more from TIPS with 6-7 mm covered stents because they can reduce the risk of postoperative HE while offering similar efficacy when compared to 8 mm covered stents.

Analysis of transjugular intrahepatic portosystemic shunt by hemodynamic simulation

BACKGROUND

Transjugular intrahepatic portosystemic shunt (TIPS), which artificially creates a portocaval shunt to reduce portal venous pressure, has gradually become the primary treatment for portal hypertension (PH). However, there is no prefect shunting scheme in TIPS to balance the occurrence of postoperative complications and effective haemostasis.

OBJECTIVE

To construct cirrhotic PH models and compare different shunting schemes in TIPS.

METHODS

Three cases of cirrhotic PH with different liver volumes were selected for enhanced computed tomography scanning. The models for different shunting schemes were created using Mimics software, and following FLUENT calculation, all the models were imported into the software computational fluid dynamic-post for processing. In each shunting scheme, the differences in portal vein pressure, hepatic blood perfusion and blood flow from the superior mesenteric vein in the shunt tract were compared. The coefficient G was adapted to evaluate the advantages and disadvantages.

RESULTS

(1) Concerning the precise location of the shunt tract, the wider the diameter of the shunt tract, the lower the pressure of the portal vein and the lesser the hepatic blood perfusion. Meanwhile, the pressure drop objective was not achieved with the 6 mm-diameter shunting scheme. (2) The 8 mm-diameter shunting scheme through the left portal vein (LPV) had the highest coefficient G.

CONCLUSION

The 8 mm-diameter shunting scheme through the LPV may demonstrate a superior effect and prognosis in TIPS procedures.

Transjugular Intrahepatic Portosystemic Shunt: Devices Evolution, Technical Tips and Future Perspectives

Portal hypertension (PH) constitutes a pivotal factor in the progression of cirrhosis, giving rise to severe complications and a diminished survival rate. The transjugular intrahepatic portosystemic shunt (TIPS) procedure has undergone significant evolution, with advancements in stent technology assuming a central role in managing PH-related complications. This review aims to outline the progression of TIPS and emphasizes the significant influence of stent advancement on its effectiveness. Initially, the use of bare metal stents (BMSs) was limited due to frequent dysfunction. However, the advent of expanding polytetrafluoroethylene-covered stent grafts (ePTFE-SGs) heralded a transformative era, greatly enhancing patency rates. Further innovation culminated in the creation of ePTFE-SGs with controlled expansion, enabling precise adjustment of TIPS diameters. Comparative analyses demonstrated the superiority of ePTFE-SGs over BMSs, resulting in improved patency, fewer complications, and higher survival rates. Additional technical findings highlight the importance of central stent placement and adequate stent length, as well as the use of smaller calibers to reduce the risk of shunt-related complications. However, improving TIPS through technical means alone is inadequate for optimizing patient outcomes. An extensive understanding of hemodynamic, cardiac, and systemic factors is required to predict outcomes and tailor a personalized approach. Looking forward, the ongoing progress in SG technology, paired with the control of clinical factors that can impact outcomes, holds the promise of reshaping the management of PH-related complications in cirrhosis.

Do the stent blind insertion into the main portal vein (MPV) and stent diameter influence the surgical outcome of the transjugular intrahepatic portosystemic shunt (TIPS)?

Transjugular intrahepatic portosystemic shunt (TIPS) surgery is a clinical intervention to treat portal hypertension (PH) by deploying a covered stent to establish a shunt path for the portal vein (PV) system, and proper surgical strategy is of great importance to balance the shunt effect and the risk of complications. To understand the clinical strategies of the stent blind insertion and stent selection in clinic, this study investigated the effects of varying stent insertion positions and diameters on the PV hemodynamics and the shunt effect by computational fluid dynamics (CFD) analysis of five post-TIPS subjects. The results showed that the successful TIPS surgeries of the five PH subjects were confirmed by quantifying their pressure drops. The stent insertion positions at the main portal vein (MPV) slightly affected the clinically concerned hemodynamic indexes (i.e., MPV pressure, stent-outlet velocity) and the shunt index (SI). This indicated that the position of the stent going into the MPV may not need to be deliberately selected. Moreover, the covered stents with 6 mm and 8 mm diameters slightly influenced the hemodynamics as well, but the large-diameter stent better improved the shunt effect compared to the small-diameter one. Despite this, the 6 mm stent was suggested thanks to the higher risk of the hepatic encephalopathy (HE) observed in clinic, which indicated the excessive shunt of the 8 mm stent. The current work revealed the effects of different TIPS strategies on the surgical outcome, and could be useful for potential clinical practices.

Right vs left portal branch puncture in TIPS creation with controlled expansion covered stent: comparison of hemodynamic and clinical outcomes

PURPOSE

To retrospectively compare outcomes of TIPS performed by puncturing left portal vein (LPV) vs right portal vein (RPV) to access the portal system.

MATERIALS AND METHODS

One hundred ninety-three consecutive patients underwent TIPS with controlled expansion covered stent by using the LPV (37 patients) or the RPV (156 patients). Patients were followed until the last clinical evaluation, liver transplantation, or death.

RESULTS

Demographics and clinical characteristics of the two groups were comparable. The median follow-up was 9.6 months (range 0.1-50.6). Portosystemic pressure gradient (PSG) before TIPS 15.7 mmHg ± 4.7 in RPV group (RPVG) vs 15.4 mmHg ± 4.5 in LPV group (LPVG) (p = 0.725). After TIPS, PSG 6.3 mmHg ± 2.8 in RPVG vs 6.2 mmHg ± 2.2 (p = 0.839). In LPVG, the stent was dilated to 8-mm in 95% of patients vs 77% of RPVG (p = 0.015). Two (5.4%) and 22 (14%) patients underwent TIPS revision in LPVG and RPVG (p = 0.15). The incidence of overt HE was 13% in LPVG and 24% in RPVG (p = 0.177). Rebleeding occurred in 3 of 49 patients (6%) with variceal bleeding as an indication: 2/41 patients (4.9%) in RPVG vs 1/8 patients (12.5%) in LPVG (p = 0.417). Among 126 patients with refractory ascites 20 patients (15.9%) needed paracentesis 3 months after the procedure: 18/101 patients (17.8%) in RPVG vs 2/25 patients (8%) in LPVG (p = 0.231). Thirty-seven patients (19%) died: 32 (21%) in RPVG and 5 (14%) in LPVG (p = 0.337).

CONCLUSION

Compared with RPV puncture, in TIPS created through the LPV, the targeted PSG was reached with a smaller stent diameter. However, no significant difference in clinical outcomes was observed.

KEY POINTS

• A LPV approach for TIPS creation does not lead to better control of complications of portal hypertension as compared to a RPV approach.

Clinical outcomes of transjugular intrahepatic portosystemic shunt with PTFE-covered stents after liver transplantation and technical results in split and whole liver graft recipients

OBJECTIVES

To assess the outcomes of transjugular intrahepatic portosystemic shunt (TIPS) creation using PTFE-covered stents in liver transplant (LT) recipients and to analyze the technical result of TIPS creation in split grafts (SG) compared with whole liver grafts (WG).

METHODS AND MATERIALS

Single-center, retrospective study, analyzing LT patients who underwent TIPS using PTFE-covered stents. Clinical and technical variables were analyzed.

RESULTS

Between 2005 and 2021, TIPS was created using PTFE-covered stents in 48 LT patients at a median of 43 months (range, 0.5-192) after LT. TIPS indications were refractory ascites (RA) in 33 patients (69%), variceal bleeding (VB) in 9 patients (19%), others in 6 (12%). Ten patients (21%) received a SG. Technical success rate was 100% in both groups: in two WG recipients, (5%) a second attempt was required. An unconventional approach (combined transhepatic or transplenic access) was needed in 2 WG (5%) and 2 SG recipients (20%). Two procedure-related death occurred in the WG group. After a median follow-up of 22 months (range, 0,1-144), 16 patients (48%) in the RA group did not require post-TIPS paracentesis, in the VB group rebleeding occurred in 3 patients (33%). Fifteen patients (31%) underwent TIPS revision. Overt hepatic encephalopathy occurred in 14 patients (29%). Patient survival at 6 months, 1 year, and 3 years was 77%, 66%, and 43%, respectively.

CONCLUSIONS

The feasibility and safety of TIPS creation in SG are comparable to that of WG. TIPS creation using PTFE-covered stents represents a viable option to treat portal hypertensive complications in LT recipients.

KEY POINTS

• TIPS creation using PTFE-covered stents represents a viable option to treat complications of PH in LT recipients. • TIPS creation in LT SG recipients appears to be safe and feasible as in WG. • Results from this study may help to refine the management of LT patients with recurrent portal hypertensive complications encouraging physicians to consider TIPS creation as a treatment option in both SG and WG recipients.

First reports of clinical effects of transjugular intrahepatic portosystemic shunt in four patients with cirrhotic ascites refractory to tolvaptan

OBJECTIVE

Ascites in patients with decompensated cirrhosis can lead to abdominal distention and decrease quality of life. Tolvaptan, a vasopressin V2 receptor antagonist, is an effective agent in the treatment of ascites, whereas some patients are refractory to tolvaptan. The efficacy of transjugular intrahepatic portosystemic shunt (TIPS) for these patients is not known. In this study, we performed TIPS for tolvaptan-refractory cirrhotic patients and analysed its efficacy and safety in these patients.

DESIGN

This retrospective analysis included patients with liver cirrhosis who received TIPS for ascites or hydrothorax refractory to tolvaptan therapy along with conventional diuretics between January 2015 and May 2018 at Tokai University Hospital. We evaluated the efficacy and safety of TIPS.

RESULTS

This study included four patients. All patients presented with Child-Pugh class B liver cirrhosis and model for end-stage liver disease-sodium scores were 10/12/14/16. TIPS was generated successfully without any major complications in all patients. The body weight decreased by a mean of 4.7 (SD=1.0) kg and estimated glomerular filtration rate improved from a mean of 38.2 (SD=10.3) to 59.5 (SD=25.0) mL/min/1.73 m² in a month after TIPS procedure.

CONCLUSION

TIPS is an effective potential treatment for ascites in patients with tolvaptan refractory condition. In appropriate patients who can tolerate TIPS, the treatment may lead towards renal function improvement.

Smaller Diameter and Adjustable Diameter Transjugular Intrahepatic Portosystemic Shunts

Complications of overshunting, including hepatic encephalopathy and hepatic insufficiency, remain prevalent following transjugular intrahepatic portosystemic shunt (TIPS) creation. Smaller diameter TIPS may reduce the risk of overshunting, but the use of smaller stents must be weighed against the risk of undershunting and persistent or recurrent hemorrhage, ascites, and other complications of portal hypertension. This article explores the question of optimal shunt diameter by examining outcomes for smaller diameter TIPS stent-grafts (<10 mm), underdilated stent-grafts, and variable diameter stent-grafts.

The role of transjugular intrahepatic portosystemic shunt in patients with cirrhosis and ascites: Recent evolution and open questions

In selected patients with cirrhosis and ascites, transjugular intrahepatic portosystemic shunt (TIPS) placement improves control of ascites and may reduce mortality. In this review, we summarize the current knowledge concerning the use of TIPS for the treatment of ascites in patients with cirrhosis, from pathophysiology of ascites formation to hemodynamic consequences, patient selection, and technical issues of TIPS insertion. The combination of these factors is important to guide clinical decision-making and identify the best strategy for each individual patient. There is still a need to identify the best timing for TIPS placement in the natural history of ascites (recurrent vs. refractory) as well as which type and level of renal dysfunction is acceptable when TIPS is proposed for the treatment of ascites in cirrhosis. Future studies are needed to define the optimal stent diameter according to patient characteristics and individual risk of shunt-related side effects, particularly hepatic encephalopathy and insufficient cardiac response to hemodynamic consequences of TIPS insertion.

Left gastric vein embolization during TIPS placement for acute variceal bleeding has no effect on bleeding recurrence: Results of a multicenter study

PURPOSE

The purpose of this study was to evaluate whether concomitant left gastric vein embolization (LGVE) during transjugular intrahepatic portosystemic shunt (TIPS) for acute variceal hemorrhage could reduce the risk of bleeding recurrence.

MATERIAL AND METHOD

A national multicenter observational study was conducted in 14 centers between January 2019 and December 2020. All cirrhotic patients who underwent TIPS placement for acute variceal bleeding were included. During TIPS procedure, size of left gastric vein (LGV), performance of LGVE, material used for LGVE and portosystemic pressure gradient (PPG) before and after TIPS placement were collected. A propensity score for the occurrence of LGVE was calculated to assess effect of LGVE on rebleeding recurrence at six weeks and one year.

RESULTS

A total of 356 patients were included (mean age 57.3 ± 10.8 [standard deviation] years; 283/356 [79%] men). Median follow-up was 11.2 months [interquartile range: 1.2, 13.3]. The main indication for TIPS was pre-emptive TIPS (162/356; 46%), rebleeding despite secondary prophylaxis (105/356; 29%), and salvage TIPS (89/356; 25%). Overall, 128/356 (36%) patients underwent LGVE during TIPS procedure. At six weeks and one year, rebleeding-free survival did not differ significantly between patients who underwent LGVE and those who did not (6/128 [5%] vs. 15/228 [7%] at six weeks, and 11/128 [5%] vs. 22/228 [7%] at one year, P = 0.622 and P = 0.889 respectively). A total of 55 pairs of patients were retained after propensity score matching. In patients without LGVE, the rebleeding rate was not different from those with LGVE (3/55 [5%] vs. 4/55 [7%], P > 0.99, and 5/55 [9%] vs. 6/55[11%], P > 0.99, at six weeks and one year respectively). Multivariable analysis identified PPG after TIPS placement as the only predictor of bleeding recurrence (hazard ratio = 1.09; 95% confidence interval: 1.02-1.18; P = 0.012).

CONCLUSION

In this multicenter national real-life study, we did not observe any benefit of concomitant LGVE during TIPS placement for acute variceal bleeding on bleeding recurrence rate.

Computational hemodynamic analysis for optimal stent position in the transjugular intrahepatic portosystemic shunt procedure

Transjugular intrahepatic portosystemic shunt (TIPS) is an effective treatment for portal hypertension (PH). The current study aimed to investigate the effect of stent position on post-TIPS hemodynamic performance using computational fluid dynamics. Patient-specific pre- and post-TIPS models were reconstructed from CT images of two patients, then virtual TIPS models were created by shifting the portal vein (PV) entry site of the stent. Although there were marginal differences the effects of left-sided and right-sided TIPS on post-TIPS portal pressure and shunting flow, right-sided TIPS resulted in a greater proportion of superior mesenteric vein (SMV) flow diverting to stents compared to that for left-sided TIPS. The results also demonstrated that the nearer the entry site of stent to the portal venous bifurcation, the greater and more stable the shunting blood flow. These results suggest that the entry site of the stent should be as close to the portal vein bifurcation as possible during TIPS. TIPS on the right branch of the portal vein may be more likely to result in post-TIPS hepatic encephalopathy than that on the left branch.

Effect of underdilated transjugular intrahepatic portosystemic shunt on prognosis in patients with prior splenectomy: a propensity score-matched case-control study

PURPOSE

This study aimed to investigate whether underdilated transjugular intrahepatic portosystemic shunt (TIPS) could reduce the risk of hepatic encephalopathy (HE) and ameliorate impaired hepatic function in patients with a history of splenectomy.

METHODS

A retrospective case-control study was conducted with 96 patients who had prior splenectomy and TIPS placement from August 2016 to May 2022. All patients were divided into two groups based on the diameter of expansion balloon catheters, the underdilated group (6-mm balloon catheter, n = 60) and a control group (8-mm balloon catheter, n = 36). Following the 1:1 propensity score matching (PSM), 33 patients in the underdilated group and 33 patients in the control group were included.

RESULTS

During a median follow-up of 36 months, a quicker recovery in liver function after TIPS placement was showed in the underdilated group. The mean TBIL content (16.562 ± 6.549 μmol/L vs 23.871 ± 11.609 μmol/L, P = 0.019) and the mean CLIF-C AD score (41.108 ± 5.223 vs 45.100 ± 4.429, P = 0.033) in the underdilated group were significantly lower than those in the control group during 6 to 12 months after the procedure. In line with the control group, the ability to reduce portal pressure gradient (PPG) and achieve a significantly clinical remission of PVT and ascites severity was showed in the underdilated group 3 months after TIPS creation (P < 0.001). The Kaplan-Meier analysis demonstrated that no statistically significant differences were found in the cumulative incidence of no overt HE (OHE) (log-rank P = 0.383), cumulative incidence without shunt dysfunction (log-rank P = 0.283), cumulative incidence of no variceal rebleeding (log-rank P = 0.696), and survival (log-rank P = 0.341) (log-rank P = 0.341) between the two groups during the follow-up period.

CONCLUSION

For patients with prior splenectomy, it is safe to employ underdilated TIPS, as the stents will eventually self-expand to 8 mm. The present study has shown some degree of liver function preservation in the underdilated group, which may be related to slower progressive changes in the portal hemodynamics.

North American Practice-Based Recommendations for Transjugular Intrahepatic Portosystemic Shunts in Portal Hypertension

Complications of portal hypertension, including ascites, gastrointestinal bleeding, hepatic hydrothorax, and hepatic encephalopathy, are associated with significant morbidity and mortality. Despite few high-quality randomized controlled trials to guide therapeutic decisions, transjugular intrahepatic portosystemic shunt (TIPS) creation has emerged as a crucial therapeutic option to treat complications of portal hypertension. In North America, the decision to perform TIPS involves gastroenterologists, hepatologists, and interventional radiologists, but TIPS creation is performed by interventional radiologists. This is in contrast to other parts of the world where TIPS creation is performed primarily by hepatologists. Thus, the successful use of TIPS in North America is dependent on a multidisciplinary approach and technical expertise, so as to optimize outcomes. Recently, new procedural techniques, TIPS stent technology, and indications for TIPS have emerged. As a result, practices and outcomes vary greatly across institutions and significant knowledge gaps exist. In this consensus statement, the Advancing Liver Therapeutic Approaches group critically reviews the application of TIPS in the management of portal hypertension. Advancing Liver Therapeutic Approaches convened a multidisciplinary group of North American experts from hepatology, interventional radiology, transplant surgery, nephrology, cardiology, pulmonology, and hematology to critically review existing literature and develop practice-based recommendations for the use of TIPS in patients with any cause of portal hypertension in terms of candidate selection, procedural best practices and, post-TIPS management; and to develop areas of consensus for TIPS indications and the prevention of complications. Finally, future research directions are identified related to TIPS for the management of portal hypertension.

Current treatment options of refractory ascites in liver cirrhosis - A systematic review and meta-analysis

BACKGROUND

Refractory ascites is a severe complication of liver cirrhosis and treatment options consist in large volume paracentesis, transjugular intrahepatic portosystemic shunt, alfapump®, peritoneovenous shunt and permanent indwelling peritoneal catheter.

AIM

Our aim was to assess the efficacy, mortality and complications of each treatment.

METHODS

We performed a systematic review using Pubmed and Embase. Frequencies were summarized with Comprehensive Meta-Analysis Software.

RESULTS

Seventy-seven studies were included. In patients with transjugular intrahepatic portosystemic shunt, 1-year mortality was 33% (95% CI 0.29-0.39, I²=82.1; τ² = 0.37; p<0.001) with lower mortality in newer studies (26% vs. 44%). At 6 months, mortality in patients with alfapump® was 24% (95% CI 0.16-0.33, I²=0.00; τ² = 0.00; p = 0.83), 31% developed acute kidney injury (95% CI 0.18-0.48, I²=44.0; τ² = 0.22; p = 0.15). Mortality at 12 months was 44% (95% CI 32%-58%, I²=76.7, τ² = 0.44, p<0.001) in peritoneovenous shunts and 45% (95% CI 38%-53%, I²=61.4, τ² = 0.18, p = 0.003) in large volume paracentesis, respectively. Overall mortality in patients with permanent indwelling catheters was 66% (95% CI 33%-89%, I²=82.5, τ² = 1.57, p = 0.001).

DISCUSSION

Mortality in patients with transjugular intrahepatic portosystemic shunt was lower in newer studies, probably due to a better patient selection. Acute kidney injury was frequent in patients with alfapump®. Permanent indwelling catheters seemed to be a good option in a palliative setting.

Imaging-guided interventions modulating portal venous flow: evidence and controversies

Portal hypertension is defined by an increase in the portosystemic venous gradient. In most cases, increased resistance to portal blood flow is the initial cause of elevated portal pressure. More than 90% of cases of portal hypertension are estimated to be due to advanced chronic liver disease or cirrhosis. Transjugular intrahepatic portosystemic shunts, a non-pharmacological treatment for portal hypertension, involve the placement of a stent between the portal vein and the hepatic vein or inferior vena cava which helps bypass hepatic resistance. Portal hypertension may also be a result of extrahepatic portal vein thrombosis or compression. In these cases, percutaneous portal vein recanalisation restores portal trunk patency, thus preventing portal hypertension-related complications. Any portal blood flow impairment leads to progressive parenchymal atrophy and triggers hepatic regeneration in preserved areas. This provides the rationale for using portal vein embolisation to modulate hepatic volume in preparation for extended hepatic resection. The aim of this paper is to provide a comprehensive evidence-based review of the rationale for, and outcomes associated with, the main imaging-guided interventions targeting the portal vein, as well as to discuss the main controversies around such approaches.

Hepatic Encephalopathy After TIPS Placement: Predictive Factors, Prevention Strategies, and Management

Hepatic encephalopathy (HE) is a challenging complication after transjugular intrahepatic portosystemic shunt (TIPS) placement. Despite recent advances, much is still uncertain regarding risk factors, preventative measures, and the management of HE after TIPS placement. Appropriate patient selection and pre-procedural risk stratification remain areas of focus. In this manuscript, we discuss the current state of research related to HE after TIPS placement, including information regarding risk stratification, complication prevention, and treatment options.

Transjugular intrahepatic portosystemic shunt: a meta-analysis of 8 mm versus 10 mm stents

Introduction

Transjugular intrahepatic portosystemic shunt (TIPS) is an approach that is used to alleviate portal hypertension-related symptoms. The optimal stent diameter for TIPS remains controversial.

Aim

To assess outcomes in patients who underwent TIPS using 8 mm and 10 mm stents.

Material and methods

The PubMed, Embase, and Cochrane Library databases were queried for all pertinent studies. The meta-analysis was conducted using RevMan v5.3. This meta-analysis was registered at the PROSPERO website (Number: CRD42020212392).

Results

Eighty-two potentially relevant articles were initially detected, with seven of these ultimately being included in this meta-analysis. Patients in the 10 mm stent group exhibited a significantly higher Δportosystemic pressure gradient (ΔPPG) relative to the 8 mm group (p = 0.04), whereas no differences between groups were observed with respect to postoperative hepatic encephalopathy (HE, p = 0.25), re-bleeding (p = 0.82), liver transplantation (p = 0.45), or mortality (p = 0.43) rates. The TIPS dysfunction rate was significant lower in the 10 mm group (p = 0.01). In Asian studies, the postoperative HE rate was found to be significantly lower in the 8 mm group relative to the 10 mm group (p = 0.02), whereas all other endpoints were comparable between these groups. In Western studies, ΔPPG values were significantly greater in the 10 mm group (p < 0.0001), whereas all other endpoint data were comparable between these groups.

Conclusions

TIPS with 10 mm stents provides a lower TIPS dysfunction rate. However, 8 mm stents may be recommended for Asian patients, as they can decrease the risk of postoperative HE.

Transjugular Portosystemic Stent Shunt: Impact of Right Atrial Pressure on Portal Venous Hemodynamics Within the First Week

Purpose

Porto-systemic pressure gradient is used to prognosticate rebleeding and resolution of ascites after TIPS. This study investigates the reliability of portal pressure characteristics as quantified immediately after TIPS placement and at short-term control.

Patients and Methods

Portal venous pressure (PVP) and right atrial pressure (RAP) were prospectively obtained before and after TIPS as well as ≥ 48 h after TIPS procedure. Porto-systemic pressure gradients (PSG) and pressure changes were calculated. A multivariate regression analysis was performed to predict portal hemodynamics at short-term control.

Results

The study included 124 consecutive patients. Indications for TIPS were refractory ascites, variceal bleeding or combinations of both. Pre- and post-interventional PSG yielded 16.4 ± 5.3 mmHg and 5.9 ± 2.7 mmHg, respectively. At that time, 105/124 patients (84.7%) met the target (PSG ≤ 8 mmHg). After 4 days (median), PSG was 8.5 ± 3.5 mmHg and only 66 patients (53%) met that target. In patients exceeding the target PSG at follow-up, PVP was significantly higher and RAP was lower resulting in the increased PSG. The highly variable changes of RAP were the main contributor to different pressure gradients. In the multivariate regression analysis, PVP and RAP immediately after TIPS were predictors for PSG at short-term control with moderately predictive capacity (AUC = 0.75).

Conclusion

Besides the reduction of portal vein pressure, the highly variable right atrial pressure was the main contributor to different pressure gradients. Thus, immediate post-TIPS measurements do not reliably predict portal hemodynamics during follow-up. These findings need to be further investigated with respect to the corresponding clinical course of the patients.

Supplementary Information

The online version contains supplementary material available at 10.1007/s00270-021-03003-z.

Management of Ascites in Patients with Cirrhosis: An Update

Ascites represents a critical event in the natural history of liver cirrhosis. From a prognostic perspective, its occurrence marks the transition from the compensated to the decompensated stage of the disease, leading to an abrupt worsening of patients' life expectancy. Moreover, ascites heralds a turbulent clinical course, characterized by acute events and further complications, frequent hospitalizations, and eventually death. The pathophysiology of ascites classically relies on hemodynamic mechanisms, with effective hypovolemia as the pivotal event. Recent discoveries, however, integrated this hypothesis, proposing systemic inflammation and immune system dysregulation as key mechanisms. The mainstays of ascites treatment are represented by anti-mineralocorticoids and loop diuretics, and large volume paracentesis. When ascites reaches the stage of refractoriness, however, diuretics administration should be cautious due to the high risk of adverse events, and patients should be treated with periodic execution of paracentesis or with the placement of a trans-jugular intra-hepatic portosystemic shunt (TIPS). TIPS reduces portal hypertension, eases ascites control, and potentially modify the clinical course of the disease. Further studies are required to expand its indications and improve the management of complications. Long-term human albumin administration has been studied in two RCTs, with contradictory results, and remains a debated issue worldwide, despite a potential effectiveness both in ascites control and long-term survival. Other treatments (vaptans, vasoconstrictors, or implantable drainage systems) present some promising aspects but cannot be currently recommended outside clinical protocols or a case-by-case evaluation.

Prevention of Cirrhosis Complications: Looking for Potential Disease Modifying Agents

The current therapeutic strategies for the management of patients with cirrhosis rely on the prevention or treatment of specific complications. The removal of the causative agents (i.e., viruses or alcohol) prevents decompensation in the vast majority of patients with compensated cirrhosis. In contrast, even when etiological treatment has been effective, a significant proportion of patients with decompensated cirrhosis remains at risk of further disease progression. Therefore, therapies targeting specific key points in the complex pathophysiological cascade of decompensated cirrhosis could represent a new approach for the management of these severely ill patients. Some of the interventions currently employed for treating or preventing specific complications of cirrhosis or used in other diseases (i.e., poorly absorbable oral antibiotics, statins, albumin) have been proposed as potential disease-modifying agents in cirrhosis (DMAC) since clinical studies have shown their capacity of improving survival. Additional multicenter, large randomized clinical trials are awaited to confirm these promising results. Finally, new drugs able to antagonize key pathophysiological mechanisms are under pre-clinical development or at the initial stages of clinical assessment.

Transjugular intrahepatic portosystemic shunt (TIPS) placement at index portal hypertensive decompensation (anticipant TIPS) in cirrhosis and the role of early intervention in variceal bleeding and ascites

BACKGROUND

Transjugular intrahepatic portosystemic shunt (TIPS) placement improves survival in patients with refractory/recurrent acute variceal bleeding (RAVB) and refractory ascites/hydrothorax. Recently, early TIPS was shown to reduce rebleeding and improve survival compared to the conventional TIPS. We aimed to study outcomes in patients with cirrhosis undergoing TIPS at first significant portal hypertensive (PHT) decompensation (termed anticipant TIPS) compared to those undergoing TIPS for recurrent or persistent PHT complications (conventional) and compared the former to matched controls on standard medical management (SMT).

METHODS

We retrospectively analyzed the clinical, biochemical, and liver disease severity parameters and survival at baseline and post-intervention in cirrhosis patients at two major hepatobiliary intervention centers undergoing anticipant (n = 27) or conventional TIPS (n = 30) and compared the former group to matched historical controls on SMT (n = 35).

RESULTS

Baseline parameters were comparable between both the groups, including the Child-Pugh class and model for end-stage liver disease (MELD) scores. Length of stay in the intensive care unit, post-procedure admission rates, and sepsis events were higher among patients undergoing conventional TIPS (p < 0.05). Post-TIPS, at 1 year, overall and sub-grouped survivals were   better in patients undergoing anticipant TIPS. On further sub-group analysis, based on the PHT events and stratified based on Child-Pugh and MELD scores, a higher proportion of patients survived after anticipant TIPS at 1 year. Compared to SMT, patients undergoing anticipant TIPS had significantly lesser hospitalizations, recurrence of varices, and ascites at 1 year, reducing hospital visits and financial burden.

CONCLUSIONS

Anticipant TIPS at the first significant PHT event could improve liver-related events and survival compared to   standard medical management and conventional TIPS, respectively.

Management of the major complications of cirrhosis: Beyond guidelines

Along with a growing understanding of the pathophysiology of cirrhosis and its complications, new therapies and management strategies have emerged in recent years. Many of these advances have helped inform the current EASL clinical practice guidelines¹ on the management of some of the key complications of cirrhosis, such as ascites, variceal bleeding and infection. However, there are still some aspects of management where the evidence base is less clear, and/or where opinions amongst practitioners remain divided. Some of these more controversial areas are explored in this section, wherein we present evidence culminating in a suggested management approach based on expert opinion and extending beyond the current guidelines.

Controlled underdilation using novel VIATORR® controlled expansion stents improves survival after transjugular intrahepatic portosystemic shunt implantation

Background & Aims

Smaller 8-mm diameter transjugular intrahepatic portosystemic shunts (TIPS) appear to be more beneficial than larger 10-mm TIPS stent-grafts, but lack the ability for secondary dilation in cases of clinical ineffectiveness. Underdilated VIATORR® TIPS stent grafts (VTS) expand passively, whereas novel VIATORR Controlled Expansion (VCX) stent grafts do not. This study evaluated the impact on survival of underdilated VCX compared with VTS in patients with decompensated cirrhosis.

Methods

This was a prospective case-control study including patients with cirrhosis receiving TIPS using 10-mm VCX underdilated to 8 mm. Patients with cirrhosis receiving 10-mm VTS underdilated to 8 mm were matched for age, sex, indication for TIPS, and liver function.

Results

A total of 114 patients (47 VCX, 47 VTS, and 20 fully dilated VCX/VTS) were included. After TIPS implantation, underdilated VCX diameter was 8.0 (7.8-9.2) mm at a median time of 359 (87-450) days, compared with VTS at 9.9 (9.7-10.0) mm (p <0.001). The portosystemic pressure gradient immediately after TIPS procedure and after 7 days did not change significantly in VCX [mean 9.4 (± 0.8) vs. 10.4 (± 0.7) mmHg, p = 0.115). Hospital readmission rates for hepatic encephalopathy were 23% (n = 11) vs 51% (n = 24) for VCX and VTS (p <0.001), respectively. Patients with VCX had significantly lower rates of large-volume paracentesis (n = 5 [11%] vs. n = 10 [21%], p = 0.017) and heart failure (n = 1 [2%] vs. n = 7 [15%], p = 0.015). One-year mortality for underdilated VCX and VTS was 15% (n = 7) and 30% (n = 14) and, for fully dilated VCX/VTS, was 45% (n = 9) (log-rank p = 0.008), respectively.

Conclusions

This study demonstrated that VCX stent grafts underdilated to 8 mm do not passively expand to nominal diameter and suggests reduced hospital readmissions because of hepatic encephalopathy, uncontrolled ascites, and heart failure, and improved 1-year survival compared with underdilated VTS.

Lay summary

Transjugular intrahepatic portosystemic shunt (TIPS) improves survival in selected patients with liver cirrhosis and acute variceal bleeding or refractory ascites. Smaller 8-mm diameter TIPS stent grafts appear to improve patient outcome compared with larger 10-mm diameter stent grafts. Novel VIATORR® Controlled Expansion (VCX) stent grafts facilitate safe and stable underdilation to 8 mm of large 10-mm diameter stent grafts with improved patient outcome (survival, hepatic encephalopathy, ascites and heart failure) compared with legacy VIATORR TIPS stent graft (VTS). Thus, the use of underdilated VCX could preserve heart function.

Clinical Trials Registration

The study is registered at Clinicaltrials.govNCT03628807.

Small-diameter TIPS combined with splenic artery embolization in the management of refractory ascites in cirrhotic patients

PURPOSE

Maximally decreasing portal pressures with transjugular intrahepatic portosystemic shunt (TIPS) is associated with improved ascites control but also increased encephalopathy incidence. Since splenic venous flow contributes to portal hypertension, we assessed if combining small-diameter TIPS with splenic artery embolization could improve ascites while minimizing encephalopathy.

METHODS

Fifty-five patients underwent TIPS creation for refractory ascites. Subjects underwent creation of 8 mm TIPS followed by proximal splenic artery embolization (group A, n=8), or of 8 mm (group B, n=6) or 10 mm TIPS (group C, n=41) without splenic embolization. Data were retrospectively reviewed.

RESULTS

In group A, median portosystemic gradient decreased from 19 mmHg to 9 mmHg after TIPS, and 8 mmHg after subsequent splenic artery embolization. In groups B and C, gradient decreased from 15 mmHg to 8 mmHg and 16 mmHg to 6 mmHg. All patients except for one in group A and two in C had greater than 50% reduction in the number of paracenteses in 3 months. Any postprocedural encephalopathy incidence was 62%, 50%, 83% in groups A, B, and C, respectively. Overall, 20% of subjects with 10 mm TIPS required TIPS reduction/closure compared to 7% of subjects with 8 mm TIPS.

CONCLUSION

We found that 8 mm diameter TIPS provided similar ascites control compared to 10 mm TIPS regardless of splenic embolization. While more patients with 10 mm TIPS required reduction/closure for severe encephalopathy, the study was underpowered for definitive assessment. Splenic embolization might have the potential to further decrease portosystemic gradient and ascites as an alternative to dilation of TIPS to 10 mm minimizing the risk of encephalopathy, but larger studies are warranted.

Management of Refractory Ascites Due to Portal Hypertension: Current Status

Refractory ascites is a costly and debilitating condition that occurs most frequently in the setting of substantial cirrhotic portal hypertension, where it portends a poor prognosis. Many treatment options are available, among them medical management, serial large volume paracenteses, transjugular intrahepatic portosystemic shunts, and implanted drainage devices. Although the availability of multiple therapies ensures that most patients will achieve satisfactory results, it can be challenging for the provider to select the appropriate treatment for each specific patient. This article reviews the available therapeutic options for refractory ascites and incorporates available data and clinical experience to suggest a linear stepwise management approach to enhance patient outcomes.

Guidelines on the management of ascites in cirrhosis

The British Society of Gastroenterology in collaboration with British Association for the Study of the Liver has prepared this document. The aim of this guideline is to review and summarise the evidence that guides clinical diagnosis and management of ascites in patients with cirrhosis. Substantial advances have been made in this area since the publication of the last guideline in 2007. These guidelines are based on a comprehensive literature search and comprise systematic reviews in the key areas, including the diagnostic tests, diuretic use, therapeutic paracentesis, use of albumin, transjugular intrahepatic portosystemic stent shunt, spontaneous bacterial peritonitis and beta-blockers in patients with ascites. Where recent systematic reviews and meta-analysis are available, these have been updated with additional studies. In addition, the results of prospective and retrospective studies, evidence obtained from expert committee reports and, in some instances, reports from case series have been included. Where possible, judgement has been made on the quality of information used to generate the guidelines and the specific recommendations have been made according to the 'Grading of Recommendations Assessment, Development and Evaluation (GRADE)' system. These guidelines are intended to inform practising clinicians, and it is expected that these guidelines will be revised in 3 years' time.

Efficacy and safety of transjugular intrahepatic portosystemic shunt (TIPS) created using covered stents of different diameters: A systematic review and meta-analysis

PURPOSE

The purpose of this study was to make a systematic review and meta-analysis to determine the stent diameter (8mm vs. 10mm) that conveys better safety and clinical efficacy for transjugular intrahepatic portosystemic shunt (TIPS).

MATERIALS AND METHODS

Four databases were used to identify clinical trials published from inception until March 2020. Data were extracted to estimate and compare one-year and three-year overall survivals, hepatic encephalopathy, variceal rebleeding, and shunt dysfunction rates between patients with 8mm covered stents and those with 10mm covered stents.

RESULTS

Five eligible studies were selected, which included 489 patients (316 men, 173 women). The 8mm covered stent group had higher efficacy regarding one-year or three-year overall survival (odds ratio [OR], 2.88; P=0.003) and (OR, 1.81; P=0.04) and lower hepatic encephalopathy (OR, 0.69; P=0.04) compared with 10mm covered stent group. There were no significant differences in variceal rebleeding rate (OR 0.80; P=0.67). However, shunt dysfunction was lower in 10mm covered stent group (OR, 2.26; P=0.003).

CONCLUSIONS

Our results suggest that the use of 8mm covered stents should be preferred to that of 10mm covered stents for TIPS placement when portal pressure is frequently monitored.

Long-term clinical outcome and survival predictors in patients with cirrhosis after 10-mm-covered transjugular intrahepatic portosystemic shunt

BACKGROUND AND AIMS

Transjugular intrahepatic portosystemic shunts (TIPS) are successfully used in the management of portal hypertension (PH)-related complications. Debate surrounds the diameter of the dilation. The aim was to analyse the outcomes of and complications deriving from TIPS in patients with cirrhosis and identify predictors of survival.

METHODS

This was a retrospective single-centre study, which included patients with cirrhosis who had a TIPS procedure for PH from 2009 to October 2018. Demographic, clinical and radiological data were collected. The Kaplan-Meier method was used to measure survival and predictors of survival were identified with the Cox regression model.

RESULTS

A total of 98 patients were included (78.6% male), mean age was 58.5 (SD±/-9.9) and the median MELD was 13.3 (IQR 9.5-16). The indications were refractory ascites (RA), variceal bleeding (VB) and hepatic hydrothorax (HH). Median survival was 72 months (RA 46.4, VB 68.5 and HH 64.7) and transplant-free survival was 26 months. Clinical and technical success rates were 70.5% and 92.9% respectively. Age (HR 1.05), clinical success (HR 0.33), sodium (HR 0.92), renal failure (HR 2.46) and albumin (HR 0.35) were predictors of survival. Hepatic encephalopathy occurred in 28.6% of patients and TIPS dysfunction occurred in 16.3%.

CONCLUSIONS

TIPS with 10-mm PTFE-covered stent is an effective and safe treatment for PH-related complications in patients with cirrhosis. Age, renal failure, sodium, albumin and clinical success are independent predictors of long-term survival.

Transjugular Intrahepatic Portosystemic Shunt Placement for Portal Hypertension: Meta-Analysis of Safety and Efficacy of 8 mm vs. 10 mm Stents

Introduction

Hepatic encephalopathy (HE) following transjugular intrahepatic portosystemic shunt (TIPS) placement remains a leading adverse event. Controversy remains regarding the optimal stent diameter given that smaller stents may decrease the amount of shunted blood and decrease the risk of HE, but stent patency and/or clinical adequacy of portal decompression may also be affected. We aim to provide meta-analysis-based evidence regarding the safety and efficacy of 8 mm vs. 10 mm stents during TIPS placement.

Methods

PubMed, Embase, Cochrane Library, and Web of Science were searched for studies comparing 8 mm and 10 mm stents during TIPS placement for portal hypertension decompression in cirrhotic patients. Randomized controlled trials and cohort studies were prioritized for inclusion. Overall evaluation of quality and bias for each study was performed. The outcomes assessed were the prevalence of HE, rebleeding or failure to control refractory ascites, and overall survival. Subgroup analysis based on TIPS indication was conducted.

Results

Five studies with a total number of 489 cirrhotic patients were identified. The pooled hazard ratio (HR) of post-TIPS HE was significantly lower in patients in the 8 mm stent group than in the 10 mm stent group (HR: 0.68, 95% CI: 0.51~0.92, p value < 0.0001). The combined HR of post-TIPS rebleeding/the need for paracentesis was significantly higher in patients in the 8 mm stent group than in the 10 mm stent group (HR: 1.76, 95% CI: 1.22~2.55, p value < 0.0001). There was no statistically significant difference in the overall survival between the 8 mm and 10 mm stent groups. The combined risk of HE in the variceal bleeding subgroup was statistically lower (HR: 0.52, CI: 0.34-0.80) with an 8 mm stent compared with a 10 mm stent. The combined risk of both rebleeding/paracentesis and survival was not statistically significant between 8 mm and 10 mm stent use in subgroup analysis.

Conclusion

8 mm stents during TIPS placement are associated with a significant lower risk of HE compared to 10 mm stents (32% decreased risk), as well as a 76% increased risk of rebleeding/paracentesis. Meta-analysis results suggest that there is not one superior stent choice for all clinical scenarios and that the TIPS indication of variceal bleeding or refractory ascites might have different appropriate selection of the shunt diameter.

Transjugular intrahepatic portosystemic shunt in cirrhosis: An exhaustive critical update

More than five decades after it was originally conceptualized as rescue therapy for patients with intractable variceal bleeding, the transjugular intrahepatic portosystemic shunt (TIPS) procedure continues to remain a focus of intense clinical and biomedical research. By the impressive reduction in portal pressure achieved by this intervention, coupled with its minimally invasive nature, TIPS has gained increasing acceptance in the treatment of complications of portal hypertension. The early years of TIPS were plagued by poor long-term patency of the stents and increased incidence of hepatic encephalopathy. Moreover, the diversion of portal flow after placement of TIPS often resulted in derangement of hepatic functions, which was occasionally severe. While the incidence of shunt dysfunction has markedly reduced with the advent of covered stents, hepatic encephalopathy and instances of early liver failure continue to remain a significant issue after TIPS. It has emerged over the years that careful selection of patients and diligent post-procedural care is of paramount importance to optimize the outcome after TIPS. The past twenty years have seen multiple studies redefining the role of TIPS in the management of variceal bleeding and refractory ascites while exploring its application in other complications of cirrhosis like hepatic hydrothorax, portal hypertensive gastropathy, ectopic varices, hepatorenal and hepatopulmonary syndromes, non-tumoral portal vein thrombosis and chylous ascites. It has also been utilized to good effect before extrahepatic abdominal surgery to reduce perioperative morbidity and mortality. The current article aims to review the updated literature on the status of TIPS in the management of patients with liver cirrhosis.

Transjugular intrahepatic portosystemic shunt for patients with liver cirrhosis: survey evaluating indications, standardization of procedures and anticoagulation in 43 German hospitals

OBJECTIVES

Transjugular intrahepatic portosystemic shunt (TIPS) insertion is an established treatment to lower portal pressure. There are no obligatory evidence-based recommendations addressing procedure and anticoagulation. Therefore, a survey was performed to establish current practice at different German hospitals.

METHODS

A three-page survey was sent out via postal mail to 76 different hospitals addressing the topics indication, contraindication, follow-up and anticoagulation.

RESULTS

Forty-three hospitals completed the survey: the median number of TIPS/year was 28.6 ± 23. Ascites and hydrothorax were announced as the main indications. Bilirubin levels above 5 mg/dl, hepatic encephalopathy and cardiac disease were considered as absolute contraindications in most hospitals, but age was not. The biggest variations were reported with regard to anticoagulation after TIPS procedure. Four hospitals never used any anticoagulation; most hospitals reported the use of low molecular weight heparins for a period of days up to 4 weeks. But also aspirin or clopidogrel was used after TIPS insertion in eight different hospitals. Additionally, the standards for follow-up after TIPS insertion were different in the hospitals.

CONCLUSIONS

There is no consensus how to handle indication, contraindications and anticoagulation after the TIPS procedure. A national and international consensus is warranted to improve the outcome of TIPS patients and reduce secondary complications. In addition to compare results and efficacy in the future standard operation procedures as proposed here need to be put in place.

Transjugular Intrahepatic Portosystemic Shunts: Advances and New Uses in Patients with Chronic Liver Disease

Transjugular intrahepatic portosystemic shunts is an established treatment for portal hypertensive complications. Advancements in technology and technique have led to novel indications, including treatment of chronic portal vein thrombosis and use before abdominal surgery to alleviate portal hypertensive complications. Use of TIPS can facilitate the embolization of large portal-systemic shunts to alleviate refractory hepatic encephalopathy owing to excessive portal shunting. Despite these advances, transjugular intrahepatic portosystemic shunts is an invasive procedure with risk for complications and should be performed at a center with expertise to ensure a successful patient outcome.

Where does TIPS fit in the management of patients with cirrhosis?

In this review, we summarise the current knowledge on the indications and contraindications of transjugular intrahepatic portosystemic shunt (TIPS) placement for the treatment of the complications of portal hypertension in cirrhosis, specifically variceal haemorrhage and ascites. Moreover, we discuss the role of TIPS for the treatment of portal vein thrombosis (PVT) and the prevention of complications after extrahepatic surgery ('preoperative TIPS') in patients with cirrhosis. The position of TIPS in the treatment hierarchy depends on the clinical setting and on patient characteristics. In acute variceal haemorrhage, preemptive TIPS is indicated in patients at a high risk of failing standard therapy, that is those with a Child-Pugh score of 10-13 points or Child-Pugh B with active bleeding at endoscopy, although the survival benefit in the latter group still remains to be established. Non-preemptive TIPS is a second-line therapy for the prevention of recurrent variceal haemorrhage and for the treatment of ascites. Of note, TIPS may also improve sarcopenia. Contraindications to TIPS placement, independent of clinical setting, include very advanced disease (Child-Pugh >13 points), episodes of recurrent overt hepatic encephalopathy without an identifiable precipitating factor, heart failure, and pulmonary hypertension. In patients with PVT, TIPS placement not only controls complications of portal hypertension, but also promotes portal vein recanalisation. Although the severity of portal hypertension correlates with poor outcomes after extrahepatic surgery, there is no evidence to recommend preoperative TIPS placement.

Transjugular intrahepatic portosystemic stent-shunt in the management of portal hypertension

These guidelines on transjugular intrahepatic portosystemic stent-shunt (TIPSS) in the management of portal hypertension have been commissioned by the Clinical Services and Standards Committee (CSSC) of the British Society of Gastroenterology (BSG) under the auspices of the Liver Section of the BSG. The guidelines are new and have been produced in collaboration with the British Society of Interventional Radiology (BSIR) and British Association of the Study of the Liver (BASL). The guidelines development group comprises elected members of the BSG Liver Section, representation from BASL, a nursing representative and two patient representatives. The quality of evidence and grading of recommendations was appraised using the GRADE system. These guidelines are aimed at healthcare professionals considering referring a patient for a TIPSS. They comprise the following subheadings: indications; patient selection; procedural details; complications; and research agenda. They are not designed to address: the management of the underlying liver disease; the role of TIPSS in children; or complex technical and procedural aspects of TIPSS.

ACR Appropriateness Criteria® Radiologic Management of Gastric Varices

Hemorrhage, resulting from gastric varies, can be challenging to treat, given the various precipitating etiologies. A wide variety of treatment options exist for managing the diverse range of the underlying disease processes. While cirrhosis is the most common cause for gastric variceal bleeding, occlusion of the portal or splenic vein in noncirrhotic states results in a markedly different treatment paradigm. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.

Use of fenestration to revise shunt dysfunction after transjugular intrahepatic portosystemic shunt

PURPOSE

To explore the feasibility of fenestration in the treatment of shunt dysfunction after transjugular intrahepatic portosystemic shunt (TIPS).

METHODS

Between February 2012 and December 2017, 12 TIPS patients with shunt dysfunction underwent fenestration to resolve recurrent portal hypertension with gastric variceal bleeding or ascites. The demographic data, operative data, postoperative recovery data, hemodynamic data, and complications were analyzed.

RESULTS

Twelve patients underwent TIPS revision by fenestration, with a technical success rate of 100%. After stent reconstruction, the portal vein diameters decreased gradually with time (before the procedure: at 5 days/1 month/3 months/6 months; after procedure: 1.45 ± 0.11 cm/1.38 ± 0.06 cm/1.36 ± 0.05 cm/1.34 ± 0.05 cm/1.32 ± 0.06 cm, respectively, P = 0.057). Additionally, the blood flow velocity and blood flow rapidly increased in the portal veins and shunts after TIPS revision (P < 0.001). Surprisingly, after 3 months of stent reconstruction, the portal blood flow was 4607.99 ± 1304.10 mL/min which was even lower than the shunt flow at 4651.18 ± 612.74 mL/min. The mean pressure gradient (PSG) prior to TIPS revision was 36.71 ± 3.36 mmHg which decreased to 17.42 ± 3.37 mmHg after the procedure (P < 0.001). Clinical improvement was observed in all patients after the shunt reconstruction. Three patients (25%) had mild intra-abdominal hemorrhage at 1 week after the operation. After a mean 11.0 ± 1.24 months follow-up, ascites and bleeding were well controlled, and no stenosis of the stents was found.

CONCLUSIONS

For patients with failed TIPS revision, fenestration to reconstruct the shunt provides an excellent alternative procedure, which is effective, safe, and has a certain clinical value, for continuing the treatment of portal hypertension.

Transjugular Portosystemic Shunt Reductions: A Retrospective Single-Center Experience

PURPOSE

To report the results of transjugular intrahepatic portosystemic shunt (TIPS) reductions for hepatic encephalopathy (HE), acute liver failure (ALF), and pulmonary hypertension (PH).

MATERIALS AND METHODS

A single-institution retrospective review analysis was performed between 2007 and 2017 on patients undergoing TIPS reduction at single tertiary liver transplant center. A total of 27 patients (14 males and 13 females) underwent TIPS reduction for refractory HE (n = 18), ALF (n = 7), and PH (n = 2). The average age at time of reduction was 59 years (range, 23-73; standard deviation [SD], 8). Mean prereduction Model of End-State Liver Disease-Na and portosystemic pressure gradient were 19 (range, 11-29; SD, 6) and 9.4 mm Hg (range, -2 to 19; SD, 4.8), respectively. Comparison between responders and nonresponders was performed for multiple variables using a 2-tailed t test. Methods of reduction were compared in cases of HE.

RESULTS

Technical success, defined as a decrease of at least 50% of the caliber of the shunt, was 100%. Clinical success rates in improving HE, ALF, and PH were calculated at 89%, 71%, and 100%, respectively. Eight patients had major and 10 had minor complications after the reductions. There were 3 shunt thrombosis. Pre- and postreduction Model of End-State Liver Disease-Na, portosystemic pressure gradient change, duration of indwelling TIPS, and reduction method were not significantly different between responders and nonresponders. Six-month survival rates were 80%, 20%, and 100% for HE, ALF, and PH, respectively.

CONCLUSIONS

TIPS reduction is effective in reversing refractory HE, ALF, and PH after TIPS creation. TIPS reduction is associated with a high rate of complications and should be reserved for severe refractory overshunting complications.

Hospital readmission following transjugular intrahepatic portosystemic shunt: a 14-year single-center experience

Background

Placement of a transjugular intrahepatic portosystemic shunt (TIPS) is a relatively common procedure used to treat complications of portal hypertension. However, only limited data exist regarding the hospital-readmission rate after TIPS placement and no studies have addressed the causes of hospital readmission. We therefore sought to identify the 30-day hospital-readmission rate after TIPS placement at our institution and to determine potential causes and predictors of readmission.

Methods

We reviewed our electronic medical-records system at our institution between 2004 and 2017 to identify patients who had undergone primary TIPS placement with polytetrafluoroethylene-covered stents and to determine the 30-day readmission rate among these patients. A series of univariable logistic-regression models were fit to assess potential predictors of 30-day readmission.

Results

A total of 566 patients were included in the analysis. The 30-day readmission rate after TIPS placement was 36%. The most common causes for readmission were confusion (48%), infection (15%), bleeding (11%), and fluid overload (7%). A higher Model for End-Stage Liver Disease (MELD) score corresponded with a higher rate of readmission (odds ratio associated with each 1-unit increase in MELD score: 1.06; 95% confidence interval: 1.02–1.09; P = 0.001). Other potential predictors, including indication for TIPS placement, were not significantly associated with a higher readmission rate.

Conclusions

The 30-day readmission rate after TIPS placement with covered stents is high, with nearly half of these readmissions due to hepatic encephalopathy—a known complication of TIPS placement. Novel interventions to help reduce the TIPS readmission rate should be prioritized in future research.

Incidence of portal vein thrombosis after splenectomy and its influence on transjugular intrahepatic portosystemic shunt stent patency

BACKGROUND

Transjugular intrahepatic portosystemic shunt (TIPS) is widely accepted as an alternative to surgery for management of complications of portal hypertension. TIPS has been used to treat portal vein thrombosis (PVT) in many centers since the 1990s. Although TIPS has good therapeutic effects on the formation of PVT, the effect of PVT on TIPS stenting has rarely been reported. Patients with splenectomy and pericardial devascu-larization have a high incidence of PVT, which can markedly affect TIPS stent patency and increase the risk of recurrent symptoms associated with shunt stenosis or occlusion.

AIM

To investigate the incidence of PVT after splenectomy and its influence on the patency rate of TIPS in patients with cirrhosis and portal hypertension.

METHODS

Four hundred and eighty-six patients with portal hypertension for refractory ascites and/or variceal bleeding who required TIPS placement between January 2010 and January 2016 were included in this retrospective analysis. Patients without prior splenectomy were defined as group A (n = 289) and those with prior splenectomy as group B (n = 197). The incidence of PVT before TIPS was compared between the two groups. After TIPS placement, primary patency rate was compared using Kaplan–Meier analysis at 3, 6, 9 and 12 mo, and 2 and 3 years. The clinical outcomes were analyzed.

RESULTS

Before TIPS procedure, the incidence of PVT in group A was lower than in group B (P = 0.003), and TIPS technical success rate in group A was higher than in group B (P = 0.016). The primary patency rate in group A tended to be higher than in group B at 3, 6, 9 and 12 mo, 2 years and 3 years (P = 0.006, P = 0.011, P = 0.023, P = 0.032, P = 0.037 and P = 0.028, respectively). Recurrence of bleeding and ascites rate in group A was lower than in group B at 3 mo (P ≤ 0.001 and P = 0.001), 6 mo (P = 0.003 and P = 0.005), 9 mo (P = 0.005 and P = 0.012), 12 mo (P = 0.008 and P = 0.024), 2 years (P = 0.011 and P = 0.018) and 3 years (P = 0.016 and P = 0.017), respectively. During 3-years follow-up, the 1-, 2- and 3-year survival rate in group A were higher than in group B (P = 0.008, P = 0.021, P = 0.018, respectively), but there was no difference of the incidence of hepatic encephalopathy (P = 0.527).

CONCLUSION

Patients with prior splenectomy have a high incidence of PVT, which potentially increases the risk of recurrent symptoms associated with shunt stenosis or occlusion.

Current approaches to the management of patients with cirrhotic ascites

This review describes current approaches to the management of patients with cirrhotic ascites in relation to the severity of its clinical manifestations. The PubMed database, the Google Scholar retrieval system, the Cochrane Database of Systematic Reviews, and the reference lists from related articles were used to search for relevant publications. Articles corresponding to the aim of the review were selected for 1991-2018 using the keywords: “liver cirrhosis,” “portal hypertension,” “ascites,” “pathogenesis,” “diagnostics,” and “treatment.” Uncomplicated and refractory ascites in patients with cirrhosis were the inclusion criteria. The literature analysis has shown that despite the achievements of modern hepatology, the presence of ascites is associated with poor prognosis and high mortality. The key to successful management of patients with ascites may be the stratification of the risk of an adverse outcome and personalized therapy. Pathogenetically based approach to the choice of pharmacotherapy and optimization of minimally invasive methods of treatment may improve the quality of life and increase the survival rate of this category of patients.

Unsolved Questions in Salvage TIPSS: Practical Modalities for Placement, Alternative Therapeutics, and Long-Term Outcomes

Salvage transjugular intrahepatic portosystemic shunt (TIPSS) has proven its efficacy to treat refractory variceal bleeding for patients with cirrhosis. However, this procedure is associated with very poor outcomes. As it is used as a last resort to treat a severe complication of cirrhosis, it seems essential to improve our practice, with the aim of optimizing management of those patients. Somehow, many questions are still unsolved: which stents should be used? Should a concomitant embolization be systematically considered? Is there any alternative therapeutic in case of recurrent bleeding despite TIPSS? What are the long-term outcomes on survival, liver transplantation, and hepatic encephalopathy after salvage TIPSS? Is this procedure futile in some patients? Is prognosis with salvage TIPSS nowadays as bad as earlier, despite the improvement of prophylaxis for variceal bleeding? The aim of this review is to summarize those data and to identify the lacking ones to guide further research on salvage TIPSS.

Targeted puncture of left branch of intrahepatic portal vein in transjugular intrahepatic portosystemic shunt to reduce hepatic encephalopathy

BACKGROUND

Transjugular intrahepatic portosystemic shunt (TIPS) is currently used for the treatment of complications of portal hypertension. The incidence of hepatic encephalopathy (HE) remains a problem in TIPS placement. It has been reported that the right branch mainly receives superior mesenteric venous blood while the left branch mainly receives blood from the splenic vein. We hypothesized that targeted puncture of the left portal vein would divert the non-nutritive blood from the splenic vein into the TIPS shunt; therefore, targeted puncture of the left branch of the intrahepatic portal vein during TIPS may reduce the risk of HE.

AIM

To evaluate the influence of targeted puncture of left branch of portal vein in TIPS on HE.

METHODS

A retrospective analysis of 1244 patients with portal-hypertension-related complications of refractory ascites or variceal bleeding who underwent TIPS from January 2000 to January 2013 was performed. Patients were divided into group A (targeting left branch of portal vein, n = 937) and group B (targeting right branch of portal vein, n = 307). TIPS-related HE and clinical outcomes were analyzed.

RESULTS

The symptoms of ascites and variceal bleeding disappeared within a short time. By the endpoint of follow-up, recurrent bleeding and ascites did not differ significantly between groups A and B (P = 0.278, P = 0.561, respectively). Incidence of HE differed significantly between groups A and B at 1 mo (14.94% vs 36.80%, χ² = 4.839, P = 0.028), 3 mo (12.48% vs 34.20%, χ² = 5.054, P = 0.025), 6 mo (10.03% vs 32.24%, χ² = 6.560, P = 0.010), 9 mo (9.17% vs 31.27%, χ² = 5.357, P = 0.021), and 12 mo (8.21% vs 28.01, χ² = 3.848, P = 0.051). There were no significant differences between groups A and B at 3 years (6.61% vs 7.16%, χ² = 1.204, P = 0.272) and 5 years (5.01% vs 6.18%, χ² = 0.072, P = 0.562). The total survival rate did not differ between groups A and B (χ² = 0.226, P = 0.634, log-rank test).

CONCLUSION

Targeted puncture of the left branch of the intrahepatic portal vein during TIPS may reduce the risk of HE but has no direct influence on prognosis of portal-hypertension-related complications.

Transjugular Intrahepatic Portosystemic Shunt:The Impact of Portal Venous Pressure Declines on Shunt Patency and Clinical Efficacy

RATIONALE AND OBJECTIVES

Transjugular intrahepatic portosystemic shunt (TIPS) placement using the same-diameter covered stents can lead to differed declines of portal venous pressure declines (PVDs). This study aimed to compare the long-term shunt patency and clinical efficacy of TIPS placement that caused low PVDs (≤9 mmHg) and high PVDs (>9 mmHg).

MATERIALS AND METHODS

A total of 129 patients treated by TIPS placement with 8 mm-diameter polytetrafluoroethylene covered stents were included and analyzed retrospectively. They were stratified into group A with low PVDs (n = 69) and group B with high PVDs (n = 60).

RESULTS

The 6-year actuarial probabilities of remaining free of shunt dysfunction (47.2% vs 64.6%; p = 0.007) and variceal rebleeding (48.3% vs 63.9%; p = 0.038) were significantly lower in group A than in group B. The 6-year actuarial probability of remaining free of hepatic encephalopathy was significantly higher in group A than in group B (44.5% vs 32.5%; p = 0.010), though the 6-year cumulative survival rate was similar in both groups (A vs B: 65.5% vs 56.0%; p = 0.240). The baseline portal vein thrombosis (hazard ratio [HR]: 6.045, 95% confidence interval [CI]: 2.762-13.233; p = 0.000) and stent type (HR: 4.447, 95%CI: 1.711-11.559, p = 0.002) were associated with shunt dysfunction, whereas only ascites was associated with mortality (HR: 1.373, 95%CI: 1.114-3.215; p = 0.024).

CONCLUSION

High PVDs (>9 mmHg) were associated with higher shunt patency, lower incidence of variceal rebleeding, but higher frequency of hepatic encephalopathy and similar survival rate than low PVDs (≤9 mmHg) after TIPS placement.

Transjugular intrahepatic portosystemic shunt (TIPS) dysfunction: quantitative assessment of flow and perfusion changes using 2D-perfusion angiography following shunt revision

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 (TTP_parenchyma/TTP_inflow, PD_parenchyma/PD_inflow, AUC_parenchyma/AUC_inflow, TTP_TIPS/TTP_inflow, PD_TIPS/PD_inflow, AUC_TIPS/AUC_inflow, TTP_atrium/TTP_inflow, PD_atrium/PD_inflow, and AUC_atrium/AUC_inflow). 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). PD_TIPS/PD_inflow (0.22 vs. 0.35; p = 0.0014) and AUC_TIPS/AUC_inflow (0.24 vs. 0.39; p = 0.0012) increased significantly. Likewise, PD_atrium/PD_inflow (0.32 vs. 0.78; p = 0.0004) and AUC_atrium/AUC_inflow (0.3 vs. 0.79; p < 0.0001) increased, whereas PD_parenchyma/PD_inflow decreased significantly (0.14 vs. 0.1; p = 0.0084). Pressure gradient changes correlated significantly with the increase in PD_atrium/PD_inflow (r = - 0.77, p = 0.0012) and AUC_atrium/AUC_inflow (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.

Management of refractory cirrhotic ascites: challenges and solutions

Among the various risky complications of liver cirrhosis, refractory ascites is associated with poor survival of cirrhotics and persistently worsens their quality of life (QOL). Major clinical guidelines worldwide define refractory ascites as ascites that cannot be managed by medical therapy either because of a lack of response to maximum doses of diuretics or because patients develop complications related to diuretic therapy that preclude the use of an effective dose of diuretics. Due to the difficulty in receiving a liver transplantation (LT), the ultimate solution for refractory ascites, most cirrhotic patients have selected the palliative therapy such as repeated serial paracentesis, transjugular intrahepatic portosystemic shunt, or peritoneovenous shunt to improve their QOL. During the past several decades, new interventions and methodologies, such as indwelling peritoneal catheter, peritoneal-urinary drainage, and cell-free and concentrated ascites reinfusion therapy, have been introduced. In addition, new medical treatments with vasoconstrictors or vasopressin V2 receptor antagonists have been proposed. Both the benefits and risks of these old and new modalities have been extensively studied in relation to the pathophysiological changes in ascites formation. Although the best solution for refractory ascites is to eliminate hepatic failure either by LT or by causal treatment, the selection of the best palliative therapy for individual patients is of utmost importance, aiming at achieving the longest possible, comfortable life. This review briefly summarizes the changing landscape of variable treatment modalities for cirrhotic patients with refractory ascites, aiming at clarifying their possibilities and limitations. Evolving issues with regard to the impact of gut-derived systemic and local infection on the clinical course of cirrhotic patients have paved the way for the development of a new gut microbiome-based therapeutics. Thus, it should be further investigated whether the early therapeutic approach to gut dysbiosis provides a better solution for the management of cirrhotic ascites.