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Larrue H, Allaire M, Weil-Verhoeven D, Barge S, Thabut D, Payance A, Moga L, Jézéquel C, Artru F, Archambeaud I, Elkrief L, Oberti F, Roux C, Laleman W, Rudler M, Dharancy S, Laborde N, Minello A, Mouillot T, Desjonquères E, Wandji LCN, Bourlière M, Ganne-Carrié N, Bureau C. French guidelines on TIPS: Indications and modalities. Liver Int 2024. [PMID: 38758295 DOI: 10.1111/liv.15976] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/12/2024] [Revised: 04/19/2024] [Accepted: 05/05/2024] [Indexed: 05/18/2024]
Abstract
Transjugular intrahepatic portosystemic shunt (TIPS) has become essential in the treatment or prevention of portal hypertension-related complications. In the early 1990s, the primary indication was refractory bleeding. It is now proposed for the treatment of ascites for the prevention of bleeding and in patients with vascular diseases of the liver. Thus, there are a growing number of patients being treated with TIPS all over the world. The broadening of indications, the involvement of multiple stakeholders, the need for an accurate selection, the positioning in relation to transplantation and the lack of standardization in pre-therapeutic assessment, in the procedure itself and in the follow-up have led the board of the French Association for the Study of the Liver to establish recommendations.
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Affiliation(s)
- Hélène Larrue
- Service d'Hépatologie Hopital Rangueil CHU Toulouse et Université Paul Sabatier, Toulouse, France
| | - Manon Allaire
- Service d'Hépato-gastroentérologie, Hôpital Universitaire Pitié-Salpêtrière, AP-HP Sorbonne Université, Paris, France
| | - Delphine Weil-Verhoeven
- Service d'Hépatologie et Soins intensifs digestifs, CHU Jean Minjoz, Besançon, France
- Université de Franche-Comté, CHU Besançon, EFS, INSERM, UMR RIGHT, Besançon, France
| | - Sandrine Barge
- Service d'Hépato-gastro-entérologie, Centre Hospitalier Intercommunal de Créteil, Creteil, France
| | - Dominique Thabut
- Service d'Hépato-gastroentérologie, Hôpital Universitaire Pitié-Salpêtrière, AP-HP Sorbonne Université, Paris, France
| | - Audrey Payance
- AP-HP, Hôpital Beaujon, Service d'Hépatologie, DMU DIGEST, Centre de Référence des Maladies Vasculaires du Foie, FILFOIE, ERN RARE-LIVER, Centre de recherche sur l'inflammation, Inserm, UMR 1149, Université de Paris, Paris, France
| | - Lucile Moga
- AP-HP, Hôpital Beaujon, Service d'Hépatologie, DMU DIGEST, Centre de Référence des Maladies Vasculaires du Foie, FILFOIE, ERN RARE-LIVER, Centre de recherche sur l'inflammation, Inserm, UMR 1149, Université de Paris, Paris, France
| | | | - Florent Artru
- Service des Maladies du Foie, CHU Rennes, Rennes, France
| | - Isabelle Archambeaud
- Hépato-Gastro-Entérologie et Assistance Nutritionnelle-Institut des Maladies de l'Appareil Digestif (IMAD), CHU Nantes-Inserm CIC 1413, Nantes, France
| | - Laure Elkrief
- Service d'Hépato-Gastroentérologie, Hôpital Trousseau, CHRU de Tours et Faculté de Médecine de Tours, Tours, France
| | - Frédéric Oberti
- Service d'Hépato-Gastroentérologie, CHU Angers, Angers, France
| | - Charles Roux
- Service de Radiologie Intervent.ionnelle, AP-HP Sorbonne Université, Hôpital Universitaire Pitié-Salpêtrière, Paris, France
| | - Wim Laleman
- Service de Gastroentérologie et Hépatologie, Hôpital Universitaire Gasthuisberg, KU Leuven, Louvain, Belgium
| | - Marika Rudler
- Service d'Hépato-gastroentérologie, Hôpital Universitaire Pitié-Salpêtrière, AP-HP Sorbonne Université, Paris, France
| | - Sébastien Dharancy
- CHU Lille, Hôpital Huriez, Maladies de l'Appareil Digestif, 2 Rue Michel Polonovski, Lille, France
| | - Nolwenn Laborde
- Gastro-Entérologie, Hépatologie, Nutrition, Maladies Héréditaires du Métabolisme Pédiatriques, Centre de Compétence Maladies Rares du Foie, Hôpital des Enfants, CHU, Toulouse, France
| | - Anne Minello
- Service D'hépato-Gastroentérologie et Oncologie Médicale, CHU F. Mitterrand, Dijon, France
| | - Thomas Mouillot
- Service D'hépato-Gastroentérologie et Oncologie Médicale, CHU F. Mitterrand, Dijon, France
| | - Elvire Desjonquères
- AP-HP Sorbonne Paris Nord, Hôpitaux Universitaire Paris Seine Saint-Denis, Service d'Hépatologie, Bobigny, France
| | - Line Caroll Ntandja Wandji
- Inserm, CHU Lille, U1286-INFINITE-Institute for Translational Research in Inflammation, University of Lille, Lille, France
| | - Marc Bourlière
- Département d'Hépatologie et Gastroentérologie, Hôpital Saint Joseph, Marseille, France
| | - Nathalie Ganne-Carrié
- AP-HP Sorbonne Paris Nord, Hôpitaux Universitaire Paris Seine Saint-Denis, Service d'Hépatologie, Bobigny, France Centre de Recherche des Cordeliers, Sorbonne Université, INSERM, Université de Paris, Paris, France
| | - Christophe Bureau
- Service d'Hépatologie Hopital Rangueil CHU Toulouse et Université Paul Sabatier, Toulouse, France
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Boike JR, Thornburg BG, Asrani SK, Fallon MB, Fortune BE, Izzy MJ, Verna EC, Abraldes JG, Allegretti AS, Bajaj JS, Biggins SW, Darcy MD, Farr MA, Farsad K, Garcia-Tsao G, Hall SA, Jadlowiec CC, Krowka MJ, Laberge J, Lee EW, Mulligan DC, Nadim MK, Northup PG, Salem R, Shatzel JJ, Shaw CJ, Simonetto DA, Susman J, Kolli KP, VanWagner LB. North American Practice-Based Recommendations for Transjugular Intrahepatic Portosystemic Shunts in Portal Hypertension. Clin Gastroenterol Hepatol 2022; 20:1636-1662.e36. [PMID: 34274511 PMCID: PMC8760361 DOI: 10.1016/j.cgh.2021.07.018] [Citation(s) in RCA: 81] [Impact Index Per Article: 40.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/30/2021] [Revised: 07/01/2021] [Accepted: 07/13/2021] [Indexed: 02/07/2023]
Abstract
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.
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Affiliation(s)
- Justin R. Boike
- Department of Medicine, Division of Gastroenterology & Hepatology, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Bartley G. Thornburg
- Department of Radiology, Division of Vascular and Interventional Radiology, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | | | - Michael B. Fallon
- Department of Medicine, Division of Gastroenterology and Hepatology, Banner - University Medical Center Phoenix, Phoenix, AZ, USA
| | - Brett E. Fortune
- Department of Medicine, Division of Gastroenterology and Hepatology, Weill Cornell Medical College, New York, NY, USA
| | - Manhal J. Izzy
- Department of Medicine, Division of Gastroenterology, Hepatology, and Nutrition, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Elizabeth C. Verna
- Department of Medicine, Division of Digestive and Liver Diseases, Columbia University College of Physicians & Surgeons, New York, NY, USA
| | - Juan G. Abraldes
- Division of Gastroenterology (Liver Unit), University of Alberta, Edmonton, AB, Canada
| | - Andrew S. Allegretti
- Department of Medicine, Division of Nephrology, Massachusetts General Hospital, Boston, MA, USA
| | - Jasmohan S. Bajaj
- Department of Internal Medicine, Division of Gastroenterology, Hepatology, and Nutrition, Virginia Commonwealth University and Central Virginia Veterans Healthcare System, Richmond, VA, USA
| | - Scott W. Biggins
- Department of Medicine, Division of Gastroenterology & Hepatology, University of Washington Medical Center, Seattle, WA, USA
| | - Michael D. Darcy
- Department of Radiology, Division of Interventional Radiology, Washington University School of Medicine, St. Louis, MO, USA
| | - Maryjane A. Farr
- Department of Medicine, Division of Cardiology, Columbia University College of Physicians & Surgeons, New York, NY, USA
| | - Khashayar Farsad
- Dotter Department of Interventional Radiology, Oregon Health and Science University, Portland, OR, USA
| | - Guadalupe Garcia-Tsao
- Department of Digestive Diseases, Yale University, Yale University School of Medicine, and VA-CT Healthcare System, CT, USA
| | - Shelley A. Hall
- Department of Internal Medicine, Division of Cardiology, Baylor University Medical Center, Dallas, TX, USA
| | - Caroline C. Jadlowiec
- Department of Surgery, Division of Transplant Surgery, Mayo Clinic, Phoenix, AZ, USA
| | - Michael J. Krowka
- Department of Pulmonary and Critical Care Medicine, Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN, USA
| | - Jeanne Laberge
- Department of Radiology and Biomedical Imaging, Division of Interventional Radiology, University of California San Francisco, San Francisco, CA, USA
| | - Edward W. Lee
- Department of Radiology, Division of Interventional Radiology, University of California-Los Angeles David Geffen School of Medicine, Los Angeles, CA, USA
| | - David C. Mulligan
- Department of Surgery, Division of Transplantation, Yale University School of Medicine, New Haven, CT, USA
| | - Mitra K. Nadim
- Department of Medicine, Division of Nephrology and Hypertension, University of Southern California, Los Angeles, California, USA
| | - Patrick G. Northup
- Department of Medicine, Division of Gastroenterology and Hepatology, University of Virginia, Charlottesville, VA, USA
| | - Riad Salem
- Department of Radiology, Division of Vascular and Interventional Radiology, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Joseph J. Shatzel
- Division of Hematology and Medical Oncology, Oregon Health and Science University, Portland, OR, USA
| | - Cathryn J. Shaw
- Department of Radiology, Division of Interventional Radiology, Baylor University Medical Center, Dallas, TX, USA
| | - Douglas A. Simonetto
- Department of Physiology, Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN, USA
| | - Jonathan Susman
- Department of Radiology, Division of Interventional Radiology, Columbia University Irving Medical Center, New York, NY, USA
| | - K. Pallav Kolli
- Department of Radiology and Biomedical Imaging, Division of Interventional Radiology, University of California San Francisco, San Francisco, CA, USA
| | - Lisa B. VanWagner
- Department of Medicine, Division of Gastroenterology & Hepatology, Northwestern University Feinberg School of Medicine, Chicago, IL, USA,Department of Preventive Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL, USA,Address for correspondence: Lisa B. VanWagner MD MSc FAST FAHA, Assistant Professor of Medicine and Preventive Medicine, Divisions of Gastroenterology & Hepatology and Epidemiology, Northwestern University Feinberg School of Medicine, 676 N. St Clair St - Suite 1400, Chicago, Illinois 60611 USA, Phone: 312 695 1632, Fax: 312 695 0036,
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Duong N, Healey M, Patel K, Strife BJ, Sterling RK. Use of doppler ultrasound to predict need for transjugular intrahepatic portosystemic shunt revision. World J Hepatol 2022; 14:1200-1209. [PMID: 35978660 PMCID: PMC9258261 DOI: 10.4254/wjh.v14.i6.1200] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/30/2022] [Revised: 03/28/2022] [Accepted: 05/23/2022] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Transjugular intrahepatic portosystemic shunt (TIPS) is used to treat complications of portal hypertension, such as ascites and variceal bleeding (VB). While liver doppler ultrasound (DUS) is used to assess TIPS patency, trans-shunt venography (TSV) is the gold standard.
AIM To determine the accuracy of DUS to assess TIPS dysfunction and for need for revision.
METHODS Retrospective review of patients referred for TIPS revision from 2008-2021. Demographics, DUS parameters at baseline and at the DUS preceding TIPS revision, TSV data were collected. Receiver operating characteristics curves, sensitivity, specificity, performance for doppler to predict need for revision were performed. Univariate and multivariate analyses were used to predict clinical factors associated with need for TIPS revision.
RESULTS The cohort consisted of 89 patients with cirrhosis (64% men, 76% white, 31% alcohol as etiology); median age 59 years. Indication for initial TIPS were VB (41%), refractory ascites (51%), and other (8%). TIPS was revised in 44%. On univariate analysis, factors associated with need for TIPS revision were male (P = 0.03), initial indication for TIPS (P = 0.05) and indication for revision (P = 0.01). Revision of TIPS was associated with lower mortality (26% vs 46%) and significantly lower rates of transplant (13% vs 24%; P = 0.1). In predicting need for TIPS revision, DUS has a 40% sensitivity, 45% specificity, PPV 78%, and NPV 14%. The most accurate location for shunt velocity measure was distal velocity (Area under the curve: 0.79; P = 0.0007).
CONCLUSION DUS has poor overall sensitivity and specificity in predicting need for TIPS revision. Non-invasive methods of predicting TIPS dysfunction are needed since those needing TIPS revision had better survival.
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Affiliation(s)
- Nikki Duong
- Division of Gastroenterology, Hepatology, and Nutrition, Virginia Commonwealth University Medical Center, Richmond, VA 23219, United States
| | - Marcus Healey
- Department of Internal Medicine, Virginia Commonwealth University Medical Center, Richmond, VA 23219, United States
| | - Kunal Patel
- Division of Interventional Radiology, Virginia Commonwealth University Medical Center, Richmond, VA 23219, United States
| | - Brian J Strife
- Division of Interventional Radiology, Virginia Commonwealth University Medical Center, Richmond, VA 23219, United States
| | - Richard K Sterling
- Division of Gastroenterology, Hepatology, and Nutrition, Virginia Commonwealth University Medical Center, Richmond, VA 23219, United States
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Han H, Yang J, Jin WK, Li X, Zhang F, Zhuge YZ, Wu M, Yang B. Diagnostic value of conventional ultrasound and shear wave elastography in detecting transjugular intrahepatic portosystemic shunt dysfunction. Acta Radiol 2021; 62:1575-1582. [PMID: 33251812 DOI: 10.1177/0284185120975183] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND Transjugular intrahepatic portosystemic shunt (TIPS) dysfunction can cause recurrent portal hypertension (PH)-related complications such as ascites and gastroesophageal variceal bleeding. Portography is invasive and costly limits its use as a screening modality. PURPOSE To assess the clinical value of conventional ultrasound in combination with point shear wave elastography (pSWE) to predict TIPS dysfunction. MATERIAL AND METHODS A total of 184 patients with cirrhosis scheduled for TIPS implantation were enrolled in this study and evaluated retrospectively. The splenoportal venous blood flow parameter, liver stiffness (LS), and spleen stiffness (SPS) were measured. Outcome measures included differences in portal vein velocity (PVV), splenic vein velocity (SPVV), LS, and SPS. The accuracy of change in PVV (ΔPVV), SPVV (ΔSPVV), and SPS (ΔSPS) to diagnose TIPS dysfunction was investigated. RESULTS TIPS dysfunction occurred in 28 of 184 patients (15.2%). Eighteen (64.3%) patients had shunt stenoses and 10 (35.7%) had shunt occlusion. Portal vein diameter (PVD), PVV, splenic vein diameter (SPVD), SPVV, LS, and SPS were not significantly different between the TIPS normal and TIPS dysfunction groups. Compared with the TIPS normal group, PVV and SPVV of the TIPS dysfunction group decreased significantly, whereas SPS increased significantly (P < 0.001). The values of areas under the receiver operating characteristic curves of ΔPVV, ΔSPVV, and ΔSPS for the diagnosis of TIPS dysfunction were 0.97, 0.96, and 0.87, respectively. CONCLUSION pSWE showed a diagnostic efficacy comparable to conventional ultrasound for diagnosing TIPS dysfunction and can be used routinely after TIPS procedures.
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Affiliation(s)
- Hao Han
- Department of Ultrasound, Nanjing Drum Tower Hospital Clinical College of Nanjing Medical University, Nanjing, PR China
| | - Jian Yang
- Department of Ultrasound, Nanjing Drum Tower Hospital, The Affiliated Hospital of Nanjing University Medical School, Nanjing, PR China
| | - Wei-kui Jin
- Department of Ultrasound, Nanjing Drum Tower Hospital, The Affiliated Hospital of Nanjing University Medical School, Nanjing, PR China
| | - Xia Li
- Department of Ultrasound, Nanjing Drum Tower Hospital, The Affiliated Hospital of Nanjing University Medical School, Nanjing, PR China
| | - Feng Zhang
- Department of Gastroenterology, Nanjing Drum Tower Hospital, The Affiliated Hospital of Nanjing University Medical School, Nanjing, PR China
| | - Yu-zheng Zhuge
- Department of Gastroenterology, Nanjing Drum Tower Hospital, The Affiliated Hospital of Nanjing University Medical School, Nanjing, PR China
| | - Min Wu
- Department of Ultrasound, Nanjing Drum Tower Hospital, The Affiliated Hospital of Nanjing University Medical School, Nanjing, PR China
| | - Bin Yang
- Department of Ultrasound, Jinling Hospital, Nanjing Medical University, Nanjing, PR China
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Brants L, Leiderman M, Veitsman E, Ofer A, Beck-Razi N. Role of Doppler Ultrasound Combined With Clinical Features in the Diagnosis of Transjugular Intrahepatic Portosystemic Shunt Dysfunction in the Era of Covered Stents. JOURNAL OF ULTRASOUND IN MEDICINE : OFFICIAL JOURNAL OF THE AMERICAN INSTITUTE OF ULTRASOUND IN MEDICINE 2020; 39:2373-2377. [PMID: 32468705 DOI: 10.1002/jum.15346] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/21/2020] [Revised: 04/29/2020] [Accepted: 05/03/2020] [Indexed: 06/11/2023]
Abstract
OBJECTIVES Our goal was to discuss the role of Doppler ultrasound (US), combined with clinical features, in the diagnosis of transjugular intrahepatic portosystemic shunt (TIPS) dysfunction in the era of covered stents. In light of the lack of research regarding the accuracy of Doppler US in TIPS dysfunction evaluations when using covered stents and a recent major meta-analysis, which primarily reviewed studies with bare metal stents but few with covered stents, we aimed to provide our single-center case study for further investigation. METHODS All patients from 2010 to 2019 who underwent angiography for a covered stent preceded by a Doppler US examination in our institution were retrospectively reviewed. RESULTS All of the Doppler US and angiographic examination results showed complete agreement, and 11 of 12 were positive for TIPS dysfunction. CONCLUSIONS Combining the presence of positive clinical signs for TIPS dysfunction with Doppler US may increase its accuracy. Considering our results, there may be a need to reinvestigate Doppler US as a noninvasive, inexpensive, and available tool for the diagnosis of TIPS dysfunction in the era of covered stents, despite recent publications depicting Doppler US as inadequate for evaluating a TIPS.
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Affiliation(s)
| | | | | | - Amos Ofer
- Department of Medical Imaging, Haifa, Israel
| | - Nira Beck-Razi
- Department of Medical Imaging, Haifa, Israel
- Rambam Health Care Campus, and the Ruth and Bruce Rappaport Faculty of Medicine, Technion, Israel Institute of Technology, Haifa, Israel
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Rajesh S, George T, Philips CA, Ahamed R, Kumbar S, Mohan N, Mohanan M, Augustine P. Transjugular intrahepatic portosystemic shunt in cirrhosis: An exhaustive critical update. World J Gastroenterol 2020; 26:5561-5596. [PMID: 33088154 PMCID: PMC7545393 DOI: 10.3748/wjg.v26.i37.5561] [Citation(s) in RCA: 47] [Impact Index Per Article: 11.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/05/2020] [Revised: 07/31/2020] [Accepted: 08/29/2020] [Indexed: 02/06/2023] Open
Abstract
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.
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Affiliation(s)
- Sasidharan Rajesh
- Division of Hepatobiliary Interventional Radiology, Cochin Gastroenterology Group, Ernakulam Medical Center, Kochi 682028, Kerala, India
| | - Tom George
- Division of Hepatobiliary Interventional Radiology, Cochin Gastroenterology Group, Ernakulam Medical Center, Kochi 682028, Kerala, India
| | - Cyriac Abby Philips
- The Liver Unit and Monarch Liver Lab, Cochin Gastroenterology Group, Ernakulam Medical Center, Kochi 682028, Kerala, India
| | - Rizwan Ahamed
- Gastroenterology and Advanced GI Endoscopy, Cochin Gastroenterology Group, Ernakulam Medical Center, Kochi 682028, Kerala, India
| | - Sandeep Kumbar
- Gastroenterology and Advanced GI Endoscopy, Cochin Gastroenterology Group, Ernakulam Medical Center, Kochi 682028, Kerala, India
| | - Narain Mohan
- The Liver Unit and Monarch Liver Lab, Cochin Gastroenterology Group, Ernakulam Medical Center, Kochi 682028, Kerala, India
| | - Meera Mohanan
- Anesthesia and Critical Care, Cochin Gastroenterology Group, Ernakulam Medical Center, Kochi 682028, Kerala, India
| | - Philip Augustine
- Gastroenterology and Advanced GI Endoscopy, Cochin Gastroenterology Group, Ernakulam Medical Center, Kochi 682028, Kerala, India
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An Update on Hepatobiliary Ultrasound. CURRENT RADIOLOGY REPORTS 2020. [DOI: 10.1007/s40134-020-00357-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Long-term Outcome of Transjugular Intrahepatic Portosystemic Shunt in Children With Portal Hypertension. J Pediatr Gastroenterol Nutr 2020; 70:615-622. [PMID: 31880663 DOI: 10.1097/mpg.0000000000002597] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
OBJECTIVES A proportion of children with chronic liver disease have severe portal hypertension (PH) and a preserved synthetic and biliary function. In our institution these children have been managed with transjugular intrahepatic portosystemic shunts (TIPS). We aimed to evaluate the long-term patency of TIPS placed in pediatric patients with PH. METHODS Retrospective study of children who underwent TIPS in the last 15 years. We compared patients with cirrhotic PH to those with noncirrhotic PH, and all with an historical cohort of children who underwent a surgical portosystemic shunt. Kaplan-Meier analysis measured long-term shunt patency. RESULTS Twenty-nine patients were recorded (cirrhotic PH = 11, noncirrhotic PH = 18, mean age 10.3 years[±4.3], mean weight 36.7 kg [±20.1], mean pediatric end-stage liver disease score 4.1 [±7.1]); in 5 TIPS was placed after split liver transplantation. Indication for TIPS was variceal bleeding in 18, refractory ascites in 11. Primary patency rates at 6 months and at 1, 2, and 4 years were 91%, 83%, 60%, and 46%, respectively. At last follow-up (mean of 2.8 years [±2.4, range 0.1-8.1 years]) secondary patency (after radiological revision) was 100%. The patency rate of the historical cohort of patients who underwent a surgical portosystemic shunt was 26 of 31 (82%) at a median follow-up of 12.5 years (1.6-25.8). CONCLUSION TIPS appears to have a high mid-term patency rate, especially if monitored and revised. Its high clinical success rate, along with a minimally invasive approach, suggests that in this setting TIPS should not be regarded only as a bridge to liver transplantation.
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The Pull-Through Technique for Recanalization of Transjugular Intrahepatic Portosystemic Shunt Dysfunction. Gastroenterol Res Pract 2020; 2020:9150173. [PMID: 32411208 PMCID: PMC7201481 DOI: 10.1155/2020/9150173] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/05/2019] [Accepted: 03/09/2020] [Indexed: 02/07/2023] Open
Abstract
Purpose To evaluate the technical efficacy and safety of the pull-through technique in recanalization of transjugular intrahepatic portosystemic shunt (TIPS) when standard transjugular approach is inaccessible. Materials and Methods A retrospective review of patients underwent TIPS revision via the pull-through technique was performed. Transhepatic directly punctured stent was conducted if the portal vein could not be accessed via standard transjugular approach. Technical success was defined by recanalization of shunt. Clinical success was defined as bleeding interruption and ascites regression without pharmacological support. All patients were followed up by clinical evaluation and Doppler ultrasound. Results Between January 2010 and December 2016, a total of 63 patients underwent TIPS revision, and 14 of them could not be accessed via standard transjugular approaches owing to stenosis or occlusion of the hepatic vein. The pull-through technique was successful in 13 patients, and one patient underwent parallel TIPS. No procedure-related complication was observed. One patient died of liver failure one week after the procedure. During the follow-up, three patients developed hepatic encephalopathy, and one patient developed TIPS dysfunction again and experienced variceal bleeding. The primary patency rate after TIPS revision was 92% (11/12) at 12 months. Conclusion The pull-through technique was effective and safe for recanalization of TIPS inaccessible via standard transjugular approach.
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Manatsathit W, Samant H, Panjawatanan P, Braseth A, Suh J, Esmadi M, Wiedel N, Ingviya T. Performance of ultrasound for detection of transjugular intrahepatic portosystemic shunt dysfunction: a meta-analysis. Abdom Radiol (NY) 2019; 44:2392-2402. [PMID: 30905044 DOI: 10.1007/s00261-019-01981-w] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
PURPOSE Although ultrasound has been widely used to evaluate transjugular intrahepatic portosystemic shunts (TIPS) patency, several studies have reported conflicting data regarding its performance. Therefore, we aimed to evaluate performance of ultrasound for detection of TIPS dysfunction by performing a meta-analysis. METHODS Literature search was performed for studies evaluating ultrasound for TIPS dysfunction, stenosis, and occlusion using PubMed, EMBASE, Scopus, and Cochrane Library through February 2019. Pooled sensitivity, specificity, log diagnostic odds ratio (LDOR), and area under curve (AUC) of summary receiver-operating characteristic were calculated. Subgroup analyses were performed according to ultrasonographic criteria and type of stent. RESULTS In total, 21 studies were evaluated. Pooled sensitivity, specificity, and LDOR of ultrasound for detection of TIPS dysfunction were 0.82 (0.67, 0.93), 0.58 (0.46, 0.70), and 1.77 (1.20, 2.35). Pooled sensitivity, specificity, and LDOR for TIPS stenosis were 0.80 (0.69, 0.90), 0.80 (0.69, 0.91), and 2.83 (1.88, 3.78). Pooled sensitivity, specificity, and LDOR for TIPS occlusion were 0.96 (0.92, 0.99), 1 (0.99, 1.00), and 6.28 (4.96, 7.60). AUCs of ultrasound for TIPS dysfunction, stenosis, and occlusion were 0.77, 0.86, and 0.95, respectively. CONCLUSIONS Although ultrasound had excellent performance for TIPS occlusion and acceptable performance for TIP stenosis, most studies utilized bare metal stent, and therefore, application to current practice is limited. Ultrasound for TIPS dysfunction in the setting of covered metal stent appeared to have acceptable sensitivity of 0.82, but limited specificity of 0.58 and low LDOR of 1.77. A new noninvasive tool is needed for detection of TIPS dysfunction in the era of covered metal stent.
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Affiliation(s)
- Wuttiporn Manatsathit
- Division of Gastroenterology and Hepatology, University of Nebraska Medical Center, 982000 Nebraska Medical Center, Omaha, NE, 68198-2000, USA.
| | - Hrishikesh Samant
- Division of Gastroenterology, Louisiana State University Health Science Center, Shreveport, LA, USA
| | | | - Annie Braseth
- Department of Internal Medicine, University of Nebraska Medical Center, Omaha, NE, USA
| | - Jane Suh
- Division of Gastroenterology and Hepatology, University of Nebraska Medical Center, 982000 Nebraska Medical Center, Omaha, NE, 68198-2000, USA
| | - Mohammad Esmadi
- Department of Internal Medicine, Methodist Physicians Clinic, Council Bluffs, IA, USA
| | - Noah Wiedel
- Department of Internal Medicine, University of Nebraska Medical Center, Omaha, NE, USA
| | - Thammasin Ingviya
- Department of Family Medicine and Preventive Medicine, Prince of Songkhla University, Songkhla, Thailand
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11
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Predictive Value of Abnormal Findings on Covered Transjugular Intrahepatic Portosystemic Shunt Baseline Doppler Sonography. Ultrasound Q 2019; 36:74-78. [PMID: 31136539 DOI: 10.1097/ruq.0000000000000456] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Doppler ultrasound (DUS) is frequently performed as a screening and diagnostic modality to evaluate the transjugular intrahepatic portosystemic shunt (TIPS) for short- and intermediate-term complications of the procedure. However, the clinical significance of initial frequently observed abnormalities in flow velocities, gradient, and direction in patients with covered TIPS is less studied. A retrospective study was performed between January 2005 and December 2014, and all patients undergoing covered TIPS procedure for the management of portal hypertension were included. Abnormal DUS findings were defined as intrashunt peak systolic velocities (PSVs) less than 90 or greater than 190 cm/s, intrashunt gradient greater than 50 cm/s, and abnormal flow direction in the main, right, and/or left portal veins. A total of 283 patients with adequate clinical follow-up and baseline TIPS DUS were included in the study. Median follow-up was 18.2 months. During the follow-up period, portal hypertension symptoms recurred in 83 patients who underwent TIPS angiography and/or revision. Of the 83, 57 had an elevated portosystemic gradient (>12 mm Hg) requiring angioplasty/stenting. With regard to baseline ultrasound, low PSVs were present in 88 patients (31.1%), high PSVs in 44 patients (15.5%), and elevated gradient in 98 patients (34.6%). The rate of developing TIPS stenosis in the future was not higher in patients with abnormal DUS parameters. For example, 26 (19.7%) of 132 patients with abnormal TIPS velocities developed stenosis compared with 31 (20.5%) of 151 patients with normal velocities (P = 0.9). Based on these results, abnormal DUS findings observed on baseline TIPS ultrasound examination have low predictive value for future covered TIPS dysfunction and failure.
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12
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Buechter M, Manka P, Gerken G, Canbay A, Blomeyer S, Wetter A, Altenbernd J, Kahraman A, Theysohn JM. Transjugular Intrahepatic Portosystemic Shunt in Patients with Portal Hypertension: Patency Depends on Coverage and Interventionalist's Experience. Dig Dis 2018; 36:218-227. [PMID: 29316565 DOI: 10.1159/000486030] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/13/2017] [Accepted: 11/29/2017] [Indexed: 02/02/2023]
Abstract
BACKGROUND AND AIMS Transjugular intrahepatic portosystemic shunt (TIPS) is the treatment of choice in decompensated portal hypertension. TIPS revision due to thrombosis or stenosis increases morbidity and mortality. Our aim was to investigate patient- and procedure-associated risk factors for TIPS-revision. PATIENTS AND METHODS We retrospectively evaluated 189 patients who underwent the TIPS procedure. Only patients who required TIPS revision within 1 year (Group I, 34 patients) and patients who did not require re-intervention within the first year (Group II [control group], 54 patients) were included. RESULTS Out of 88 patients, the majority were male (69.3%) and mean age was 56 ± 11 years. Indications for TIPS were refractory ascites (68%), bleeding (24%), and Budd-Chiari syndrome (8%). The most frequent liver disease was alcohol-induced cirrhosis (60%). Forty-three patients (49%) received bare and 45 patients (51%) covered stents, thus resulting in reduction of hepatic venous pressure gradient (HVPG) from 19.0 to 9.0 mm Hg. When comparing patient- and procedure-related factors, the type of stent (p < 0.01) and interventionalist's experience (number of performed TIPS implantations per year; p < 0.05) were the only factors affecting the risk of re-intervention due to stent dysfunction, while age, gender, indication, Child-Pugh, and model of end-stage liver disease score, platelet count, pre- and post-HVPG, additional variceal embolization, stent diameter, and number of stents did not significantly differ. CONCLUSION Patients undergoing TIPS procedure should be surveilled closely for shunt dysfunction while covered stents and high-level experience are associated with increased -patency.
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Affiliation(s)
- Matthias Buechter
- Department of Gastroenterology and Hepatology, University Hospital Essen, Essen, Germany
| | - Paul Manka
- Department of Gastroenterology and Hepatology, University Hospital Essen, Essen, Germany.,Regeneration and Repair, Institute of Hepatology, Division of Transplantation Immunology and Mucosal Biology, Faculty of Life Sciences and Medicine, King's College London, London, United Kingdom
| | - Guido Gerken
- Department of Gastroenterology and Hepatology, University Hospital Essen, Essen, Germany
| | - Ali Canbay
- Department of Gastroenterology, Hepatology and Infectious Diseases, Otto-von-Guericke University, Magdeburg, Germany
| | - Sandra Blomeyer
- Department of Gastroenterology and Hepatology, University Hospital Essen, Essen, Germany
| | - Axel Wetter
- Department of Diagnostic and Interventional Radiology and Neuroradiology, University Hospital Essen, Essen, Germany
| | - Jens Altenbernd
- Department of Radiology and Neuroradiology, Klinikum Vest Knappschaftskrankenhaus Recklinghausen, Recklinghausen, Germany
| | - Alisan Kahraman
- Department of Gastroenterology and Hepatology, University Hospital Essen, Essen, Germany
| | - Jens M Theysohn
- Department of Diagnostic and Interventional Radiology and Neuroradiology, University Hospital Essen, Essen, Germany
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13
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Buechter M, Manka P, Theysohn JM, Reinboldt M, Canbay A, Kahraman A. Spleen stiffness is positively correlated with HVPG and decreases significantly after TIPS implantation. Dig Liver Dis 2018; 50:54-60. [PMID: 29102174 DOI: 10.1016/j.dld.2017.09.138] [Citation(s) in RCA: 41] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/29/2017] [Revised: 09/11/2017] [Accepted: 09/28/2017] [Indexed: 02/08/2023]
Abstract
BACKGROUND Transjugular intrahepatic portosystemic shunt (TIPS) is indicated in patients with decompensated portal hypertension (PH). Hepatic venous pressure gradient (HVPG) is considered gold standard for assessment of PH. Because HVPG measurement is invasive, non-invasive methods for evaluating severity of PH are warranted. PATIENTS AND METHODS We retrospectively correlated spleen stiffness as measured by FibroScan with HVPG in patients who underwent TIPS. Twenty-four patients with spleen stiffness measurement (SSM) one day before (D-1), one day after (D+1) and 28 days after TIPS (D+28) were included. RESULTS SSM was positively correlated with pre-TIPS HVPG (HVPG <13mmHg, median SSM: 19.7±8.6kPa; HVPG 13-24mmHg, median SSM: 45.0±15.7kPa; HVPG >24mmHg, median SSM: 75.0±6.2kPa; p<0.05]; r2=0.72; p<0.001) and decreased significantly after TIPS implantation (D-1, median SSM: 67.1±17.3kPa; D+1, median SSM: 44.7±18.5kPa; D+28, median SSM: 35.6±17.0kPa; p<0.05), while liver stiffness measurement decrease was not statistically significant. CONCLUSIONS Our study highlights the utility of SSM as non-invasive tool in patients with chronic liver disease in evaluating degree of PH potentially offering a confirmable additional parameter in surveillance of patients undergoing TIPS procedure.
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Affiliation(s)
- Matthias Buechter
- Department of Gastroenterology and Hepatology, University Hospital Essen, Germany
| | - Paul Manka
- Department of Gastroenterology and Hepatology, University Hospital Essen, Germany; Regeneration and Repair, Institute of Hepatology, Division of Transplantation Immunology and Mucosal Biology, Faculty of Life Sciences and Medicine, King's College London, London, UK
| | - Jens M Theysohn
- Department of Diagnostic and Interventional Radiology and Neuroradiology, University Hospital Essen, Germany
| | - Marcus Reinboldt
- Department of Diagnostic and Interventional Radiology and Neuroradiology, University Hospital Essen, Germany
| | - Ali Canbay
- Department of Gastroenterology, Hepatology and Infectious Diseases, Otto-von-Guericke University, Magdeburg, Germany
| | - Alisan Kahraman
- Department of Gastroenterology and Hepatology, University Hospital Essen, Germany.
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Duplex Ultrasound Versus Clinical Surveillance in the Prediction of TIPS Malfunction Placed for Refractory Ascites: Is Ultrasound Surveillance Useful? Cardiovasc Intervent Radiol 2017; 40:1861-1865. [DOI: 10.1007/s00270-017-1706-1] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/23/2017] [Accepted: 05/19/2017] [Indexed: 12/23/2022]
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15
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An Algorithm for Management After Transjugular Intrahepatic Portosystemic Shunt Placement According to Clinical Manifestations. Dig Dis Sci 2017; 62:305-318. [PMID: 28058594 DOI: 10.1007/s10620-016-4399-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/08/2015] [Accepted: 11/29/2016] [Indexed: 12/16/2022]
Abstract
We propose an algorithm for management after transjugular intrahepatic portosystemic shunt (TIPS) placement according to clinical manifestations. For patients with an initial good clinical response, surveillance Doppler ultrasound is recommended to detect stenosis or occlusion. A TIPS revision can be performed using basic or advanced techniques to treat stenosis or occlusion. In patients with an initial poor clinical response, a TIPS venogram with pressure measurements should be performed to assess shunt patency. The creation of a parallel TIPS may also be required if the patient is symptomatic and the portal pressure remains high after TIPS revision. Additional procedures may also be necessary, such as peritoneovenous shunt (Denver shunt) placement for refractory ascites, tunneled pleural catheter for hepatic hydrothorax, and balloon-occluded retrograde transvenous obliteration procedure for gastric variceal bleeding. A TIPS reduction procedure can also be performed in patients with uncontrolled hepatic encephalopathy or hepatic failure.
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16
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Pathological Predictors of Shunt Stenosis and Hepatic Encephalopathy after Transjugular Intrahepatic Portosystemic Shunt. BIOMED RESEARCH INTERNATIONAL 2016; 2016:3681731. [PMID: 27975051 PMCID: PMC5126395 DOI: 10.1155/2016/3681731] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/14/2016] [Revised: 08/22/2016] [Accepted: 08/31/2016] [Indexed: 12/23/2022]
Abstract
Background. Transjugular intrahepatic portosystemic shunt (TIPS) is an artificial channel from the portal vein to the hepatic vein or vena cava for controlling portal vein hypertension. The major drawbacks of TIPS are shunt stenosis and hepatic encephalopathy (HE); previous studies showed that post-TIPS shunt stenosis and HE might be correlated with the pathological features of the liver tissues. Therefore, we analyzed the pathological predictors for clinical outcome, to determine the risk factors for shunt stenosis and HE after TIPS. Methods. We recruited 361 patients who suffered from portal hypertension symptoms and were treated with TIPS from January 2009 to December 2012. Results. Multivariate logistic regression analysis showed that the risk of shunt stenosis was increased with more severe inflammation in the liver tissue (OR, 2.864; 95% CI: 1.466–5.592; P = 0.002), HE comorbidity (OR, 6.266; 95% CI, 3.141–12.501; P < 0.001), or higher MELD score (95% CI, 1.298–1.731; P < 0.001). Higher risk of HE was associated with shunt stenosis comorbidity (OR, 6.266; 95% CI, 3.141–12.501; P < 0.001), higher stage of the liver fibrosis (OR, 2.431; 95% CI, 1.355–4.359; P = 0.003), and higher MELD score (95% CI, 1.711–2.406; P < 0.001). Conclusion. The pathological features can predict individual susceptibility to shunt stenosis and HE.
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17
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Owen JM, Gaba RC. Transjugular Intrahepatic Portosystemic Shunt Dysfunction: Concordance of Clinical Findings, Doppler Ultrasound Examination, and Shunt Venography. J Clin Imaging Sci 2016; 6:29. [PMID: 27563495 PMCID: PMC4977976 DOI: 10.4103/2156-7514.186510] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2016] [Accepted: 06/15/2016] [Indexed: 12/23/2022] Open
Abstract
Objectives: The objective of this study was to evaluate the concordance between clinical symptoms, Doppler ultrasound (US), and shunt venography for the detection of stent-graft transjugular intrahepatic portosystemic shunt (TIPS) dysfunction. Materials and Methods: Forty-one patients (M:F 30:11, median age 55 years) who underwent contemporaneous clinical exam, Doppler US, and TIPS venography between 2003 and 2014 were retrospectively studied. Clinical symptoms (recurrent ascites or variceal bleeding) were dichotomously classified as present/absent, and US and TIPS venograms were categorized in a binary fashion as normal/abnormal. US abnormalities included high/low (>190 or <90 cm/s) TIPS velocity, significant velocity rise/fall (>50 cm/s), absent flow, and return of antegrade intra-hepatic portal flow. Venographic abnormalities included shunt stenosis/occlusion and/or pressure gradient elevation. Clinical and imaging concordance rates were calculated. Results: Fifty-two corresponding US examinations and venograms were assessed. The median time between studies was 3 days. Forty of 52 (77%) patients were symptomatic, 33/52 (64%) US examinations were abnormal, and 20/52 (38%) TIPS venograms were abnormal. Concordance between clinical symptoms and TIPS venography was 48% (25/52), while the agreement between US and shunt venography was 65% (34/52). Clinical symptoms and the US concurred in 60% (31/52) of the patients. The sensitivity of clinical symptoms and US for the detection of venographically abnormal shunts was 80% (16/20) and 85% (17/20), respectively. Both clinical symptoms and the US had low specificity (25%, 8/32 and 50%, 16/32) for venographically abnormal shunts. Conclusion: Clinical findings and the US had low concordance rates with TIPS venography, with acceptable sensitivity but poor specificity. These findings suggest the need for improved noninvasive imaging methods for stent-graft TIPS surveillance.
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Affiliation(s)
- Joshua M Owen
- University of Illinois College of Medicine, Chicago, IL, USA
| | - Ron Charles Gaba
- Department of Radiology, Division of Interventional Radiology, University of Illinois Hospital and Health Sciences System, Chicago, IL, USA
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18
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Gao J, Zheng X, Zheng YY, Zuo GQ, Ran HT, Auh YH, Waldron L, Chan T, Wang ZG. Shear Wave Elastography of the Spleen for Monitoring Transjugular Intrahepatic Portosystemic Shunt Function: A Pilot Study. JOURNAL OF ULTRASOUND IN MEDICINE : OFFICIAL JOURNAL OF THE AMERICAN INSTITUTE OF ULTRASOUND IN MEDICINE 2016; 35:951-958. [PMID: 27036168 DOI: 10.7863/ultra.15.07009] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/06/2015] [Accepted: 08/21/2015] [Indexed: 06/05/2023]
Abstract
OBJECTIVES To assess the feasibility of splenic shear wave elastography in monitoring transjugular intrahepatic portosystemic shunt (TIPS) function. METHODS We measured splenic shear wave velocity (SWV), main portal vein velocity (PVV), and splenic vein velocity (SVV) in 33 patients 1 day before and 3 days to 12 months after TIPS placement. We also measured PVV, SVV, and SWV in 10 of 33 patients with TIPS dysfunction 1 day before and 3 to 6 days after TIPS revision. Analyses included differences in portosystemic pressure gradient (PPG), PVV, SVV, and mean SWV before and after TIPS procedures; comparison of median SWV before and after TIPS procedures; differences in PVV, SVV, and SWV before and at different times up to 12 months after TIPS placement; accuracy of PVV, SVV, and SWV in determining TIPS dysfunction; and correlation between PPG and SWV. RESULTS During 12 months of follow-up, 23 of 33 patients had functioning TIPS, and 10 had TIPS dysfunction. The median SWV was significantly different before and after primary TIPS placement (3.60 versus 3.05 m/s; P = .005), as well as before and after revision (3.73 versus 3.06 m/s; P = .003). The PPG, PVV, and SVV were also significantly different before and after TIPS placement and revision (P < .001). The PPG and SWV decreased, whereas PVV and SVV increased, after successful TIPS procedures. A positive correlation was observed between PPG and SWV (r = 0.70; P < .001), and a negative correlation was observed between PPG and PVV and SVV (r = -0.65; P < .001). The areas under the receiver operating characteristic curve for PVV, SVV, and SWV in determining TIPS dysfunction were 0.82, 0.84, and 0.81, respectively. CONCLUSIONS Splenic SWV is compatible with splenoportal venous velocity in quantitatively monitoring TIPS function and determining TIPS dysfunction.
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Affiliation(s)
- Jing Gao
- Department of Radiology, Well Cornel Medical College, New York, New York USA
| | - Xiao Zheng
- Institute of Ultrasound Imaging, Second Affiliated Hospital, Chongqing Medical University, Chongqing, China
| | - Yuan-Yi Zheng
- Institute of Ultrasound Imaging, Second Affiliated Hospital, Chongqing Medical University, Chongqing, China
| | - Guo-Qing Zuo
- Institute of Ultrasound Imaging, Second Affiliated Hospital, Chongqing Medical University, Chongqing, China
| | - Hai-Tao Ran
- Institute of Ultrasound Imaging, Second Affiliated Hospital, Chongqing Medical University, Chongqing, China
| | - Yong Ho Auh
- Department of Radiology, Well Cornel Medical College, New York, New York USA
| | - Levi Waldron
- City University of New York, School of Public Health, Hunter College, New York, New York USA
| | - Tiffany Chan
- City University of New York, School of Public Health, Hunter College, New York, New York USA
| | - Zhi-Gang Wang
- Institute of Ultrasound Imaging, Second Affiliated Hospital, Chongqing Medical University, Chongqing, China
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Ferral H, Gomez-Reyes E, Fimmel CJ. Post-Transjugular Intrahepatic Portosystemic Shunt Follow-Up and Management in the VIATORR Era. Tech Vasc Interv Radiol 2016; 19:82-8. [PMID: 26997092 DOI: 10.1053/j.tvir.2016.01.009] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
The transjugular intrahepatic portosystemic shunt (TIPS) is a non-selective portosystemic shunt created using endovascular techniques. The first TIPS was performed in Germany in 1988. The VIATORR self-expandable PTFE covered stent-graft (WL Gore, Flagstaff AZ) was approved by the FDA for a TIPS application in December of 2004. This stent-graft offers excellent shunt patency rates and it is possible that it has a beneficial effect on patient survival. Patient surveillance and post-procedural management have changed after the introduction of this stent-graft. This article presents the current management strategies that are followed at our Institution for patients who have undergone a TIPS procedure with a VIATORR stent graft including imaging follow-up, management of encephalopathy, medical management and nutritional aspects.
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Affiliation(s)
- Hector Ferral
- The Department of Radiology, Section of Interventional Radiology, NorthShore University HealthSystem, Evanston, IL.
| | - Elisa Gomez-Reyes
- Departamento de Gastroenterologia, Instituto Nacional de la Nutricion Salvador Zubiran, Tlalpan, Mexico City, Mexico
| | - Claus J Fimmel
- University of Chicago Pritzker School of Medicine, Section Chief of Hepatology, Division of Gastroenterology, NorthShore University HealthSystem, Evanston, IL
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Parker R. Role of transjugular intrahepatic portosystemic shunt in the management of portal hypertension. Clin Liver Dis 2014; 18:319-34. [PMID: 24679497 DOI: 10.1016/j.cld.2013.12.004] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
A transjugular intrahepatic portosystemic shunt (TIPS) is an expandable metal stent inserted via the jugular vein that creates a shunt from the portal vein to the systemic circulation via an artificial communication through the liver. It is used to treat complications of portal hypertension. In addition to rescue treatment in variceal bleeding, TIPS can play an important role in prevention of rebleeding. TIPS can improve symptoms if medical treatment of ascites or hepatic hydrothrorax has failed, but may not improve survival. Selected cases of Budd-Chiari syndrome improve with TIPS. This article discusses the indications, evidence, and complications of TIPS.
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Affiliation(s)
- Richard Parker
- NIHR Centre for Liver Research, University of Birmingham, Birmingham B15 2TT, UK.
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