1
|
Gogna A, Tan HK, Too CW, Chang Pik Eu J. IR management of portal hypertension complications. Clin Liver Dis (Hoboken) 2023; 22:75-79. [PMID: 37663554 PMCID: PMC10473336 DOI: 10.1097/cld.0000000000000077] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/05/2022] [Accepted: 07/17/2023] [Indexed: 09/05/2023] Open
Affiliation(s)
- Apoorva Gogna
- Department of Vascular and Interventional Radiology, Singapore General Hospital, Singapore
| | - Hiang Keat Tan
- Department of Gastroenterology & Hepatology, Singapore General Hospital, Singapore
| | - Chow Wei Too
- Department of Vascular and Interventional Radiology, Singapore General Hospital, Singapore
| | - Jason Chang Pik Eu
- Department of Gastroenterology & Hepatology, Singapore General Hospital, Singapore
| |
Collapse
|
2
|
Helzberg JH, Parish A, Niedzwiecki D, Kim CY, Patel YA, Wilder JM, Muir AJ. Racial disparities in transjugular intrahepatic portosystemic shunt procedure outcomes. BMJ Open Gastroenterol 2022; 9:bmjgast-2021-000747. [PMID: 35086849 PMCID: PMC8796249 DOI: 10.1136/bmjgast-2021-000747] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/17/2021] [Accepted: 12/29/2021] [Indexed: 12/24/2022] Open
Abstract
Objective The transjugular intrahepatic portosystemic shunt (TIPS) procedure is an important intervention for management of complications of portal hypertension. The objective of this study was to identify predictors of mortality from the TIPS procedure with a focus on race and ethnicity. Design TIPS procedures from 2012 to 2014 in the National Inpatient Sample were identified. Weighting was applied to generate nationally representative results. In-hospital mortality was the primary outcome of interest. χ2 and Student’s t-tests were performed for categorical and continuous variables, respectively. Predictors of mortality following TIPS were assessed by survey-weighted logistic regression. Results 17 175 (95% CI 16 254 to 18 096) TIPS cases were identified. Approximately 71% were non-Hispanic (NH) white, 6% were NH black, 16% were Hispanic and 7% were other. NH black patients undergoing TIPS had an in-hospital mortality rate of 20.1%, nearly double the in-hospital mortality of any other racial or ethnic group. NH black patients also had significantly longer median postprocedure and total lengths of stay (p=0.03 and p<0.001, respectively). The interaction of race by clinical indication was a significant predictor of in-hospital mortality (p<0.001). NH black patients had increased mortality compared with other racial/ethnic groups when presenting with bleeding oesophageal varices (OR 3.85, 95% CI 2.14 to 6.95). Conclusion This cohort study presents important findings in end-stage liver disease care, with clear racial disparities in in-hospital outcomes following the TIPS procedure. Specifically, black patients had significantly higher in-hospital mortality and longer lengths of stay. Further research is needed to understand how we can better care for black patients with liver disease.
Collapse
Affiliation(s)
- James H Helzberg
- Department of Medicine, Duke University School of Medicine, Durham, North Carolina, USA
| | - Alice Parish
- Department of Biostatistics and Bioinformatics, Duke University School of Medicine, Durham, North Carolina, USA
| | - Donna Niedzwiecki
- Department of Biostatistics and Bioinformatics, Duke University School of Medicine, Durham, North Carolina, USA
| | - Charles Y Kim
- Department of Radiology, Division of Interventional Radiology, Duke University School of Medicine, Durham, North Carolina, USA
| | - Yuval A Patel
- Department of Medicine, Division of Gastroenterology, Duke University School of Medicine, Durham, North Carolina, USA
| | - Julius M Wilder
- Department of Medicine, Division of Gastroenterology, Duke University School of Medicine, Durham, North Carolina, USA.,Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina, USA
| | - Andrew J Muir
- Department of Medicine, Division of Gastroenterology, Duke University School of Medicine, Durham, North Carolina, USA .,Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina, USA
| |
Collapse
|
3
|
Tong H, Gan C, Wei B, Wang ZD, Li XD, Qian SJ, Huan H, Zhang LH, Yang Z, Chen YL, Gu YH, Chen LX, Yang YH, Wu H, Tang CW. Risk factors for overt hepatic encephalopathy after transjugular intrahepatic portosystemic shunt creation in patients with liver cirrhosis. J Dig Dis 2021; 22:31-40. [PMID: 33128287 DOI: 10.1111/1751-2980.12957] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/16/2020] [Revised: 09/03/2020] [Accepted: 10/28/2020] [Indexed: 02/05/2023]
Abstract
OBJECTIVE This study aimed to determine the risk factors and establish a risk score for post-transjugular intrahepatic portosystemic shunt (TIPS) overt hepatic encephalopathy (OHE). METHODS Altogether 299 and 62 cirrhotic patients receiving TIPS from January 2015 to March 2018 were divided into the derivation and validation cohorts, respectively. The data of the derivation cohort were analyzed for risk factors of post-TIPS OHE. A risk score was established from the derivation cohort and verified by the validation cohort. RESULTS During a median follow-up of 112.6 weeks, 52 (17.4%) patients in the derivation cohort experienced post-TIPS OHE. Logistic regression showed that alcoholic cirrhosis (odds ratio [OR] 3.068, 95% confidence interval [CI] 1.423-6.613, P = 0.004), stent diameter of 10 mm (OR 12.046 [95% CI 2.308-62.862], P = 0.003), portal pressure gradient (PPG) decrement ≥60% (OR 3.548 [95% CI 1.741-7.230], P < 0.001), model for end-stage liver disease (MELD) score ≥10 (OR 2.695 [95% CI 1.203-6.035], P = 0.016), blood ammonia (OR 1.009 [95% CI 1.000-1.018], P = 0.043) and notable hydrothorax (OR 4.393 [95% CI 1.554-12.415], P = 0.005) were associated with an increased risk of post-TIPS OHE. The risk score reached a promising risk evaluation of post-TIPS OHE when verified by the validation cohort (sensitivity 71.4%, specificity 70.7%, accuracy 71.0%). CONCLUSIONS Alcoholic cirrhosis and notable hydrothorax are independent risk factors for post-TIPS OHE in liver cirrhosis, together with the stent diameter of 10 mm, PPG decrement ≥60%, MELD score ≥10 and blood ammonia. The established risk score is reliable to identify high-risk individuals of developing post-TIPS OHE.
Collapse
Affiliation(s)
- Huan Tong
- Department of Gastroenterology, West China Hospital, Sichuan University, Chengdu, Sichuan Province, China
| | - Can Gan
- West China School of Medicine, Sichuan University, Chengdu, Sichuan Province, China
| | - Bo Wei
- Department of Gastroenterology, West China Hospital, Sichuan University, Chengdu, Sichuan Province, China
| | - Zhi Dong Wang
- Department of Gastroenterology, West China Hospital, Sichuan University, Chengdu, Sichuan Province, China
| | - Xiao Dan Li
- Department of Gastroenterology, West China Hospital, Sichuan University, Chengdu, Sichuan Province, China
| | - Shuai Jie Qian
- West China School of Medicine, Sichuan University, Chengdu, Sichuan Province, China
| | - Hui Huan
- West China School of Medicine, Sichuan University, Chengdu, Sichuan Province, China
| | - Lin Hao Zhang
- Department of Gastroenterology, West China Hospital, Sichuan University, Chengdu, Sichuan Province, China
| | - Zhu Yang
- West China School of Medicine, Sichuan University, Chengdu, Sichuan Province, China
| | - Yi Long Chen
- West China Biomedical Big Data Center, West China School of Medicine, Sichuan University, Chengdu, Sichuan Province, China.,Medical Big Data Center, Sichuan University, Chengdu, Sichuan Province, China
| | - Yong Hong Gu
- West China Biomedical Big Data Center, West China School of Medicine, Sichuan University, Chengdu, Sichuan Province, China.,Medical Big Data Center, Sichuan University, Chengdu, Sichuan Province, China
| | - Liu Xiang Chen
- West China School of Medicine, Sichuan University, Chengdu, Sichuan Province, China
| | - Yu Hang Yang
- West China School of Medicine, Sichuan University, Chengdu, Sichuan Province, China
| | - Hao Wu
- Department of Gastroenterology, West China Hospital, Sichuan University, Chengdu, Sichuan Province, China
| | - Cheng Wei Tang
- Department of Gastroenterology, West China Hospital, Sichuan University, Chengdu, Sichuan Province, China
| |
Collapse
|
4
|
El-Shazly H, Abdel-Samiee M, Tharwa ES, Zaghla H, Abass S, El-Warraky M, Ibrahim ES. The association between character of portal blood flow and post-TIPS incidence of hepatic encephalopathy. EGYPTIAN LIVER JOURNAL 2020. [DOI: 10.1186/s43066-020-00038-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
Abstract
Background
Hepatic encephalopathy (HE) is one of the serious complications observed post-TIPS operations in patients with different complications of portal hypertension such as refractory ascites, refractory hydrothorax, bleeding varices, and hepato-renal syndrome. Herein, we aimed to clarify predisposing factors for post-TIPS incidence of HE according to pre-TIPS hemodynamics.
Results
Fifty patients were enrolled in this study with different complications of portal hypertension; most of them have Child A and B scores. Patients were evaluated by ultrasound Doppler for the flow inside the portal vein and clinically recorded into two groups: group 1, 31 patients with hepatopetal flow; and group 2, 19 patients with hepatofugal flow. Then, TIPS was performed and patients were reassessed 1 month later to detect HE. Multiple variables such as age, gender, etiology of liver disease, and indication for TIPS had no significant differences. The incidence of HE post-TIPS was observed more at group 1 more than at group 2 (P = 0.02).
Conclusions
Post-TIPS incidence of HE was interestingly related to pre-TIPS flow in the portal vein (hepatopetal group more than hepatofugal group). Patients with hepatofugal flow in the portal vein are perfect candidate for TIPS than patients with hepatopetal flow in the portal vein. Patients with previous history of HE are contraindicated for TIPS except as a bridge for liver transplantation.
Collapse
|
5
|
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.
Collapse
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
| |
Collapse
|
6
|
Yanny B, Winters A, Boutros S, Saab S. Hepatic Encephalopathy Challenges, Burden, and Diagnostic and Therapeutic Approach. Clin Liver Dis 2019; 23:607-623. [PMID: 31563214 DOI: 10.1016/j.cld.2019.07.001] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
Hepatic encephalopathy (HE) is an important cause of morbidity and mortality in patients with cirrhosis. The impact of HE on the health care system is similarly profound. The number of hospital admissions for HE has increased in the last 10-year period. HE is a huge burden to the patients, care givers, and the health care system. HE represents a "revolving door" with readmission, severely affects care givers, and has effects on cognition that can persists after liver transplant. This article reviews the current literature to discuss the challenges and diagnostic and therapeutic approaches to HE.
Collapse
Affiliation(s)
- Beshoy Yanny
- Department of Medicine, University of California at Los Angeles, 1223 16th street, suite 3100, Santa Monica, CA 90404, USA.
| | - Adam Winters
- Department of Medicine, University of California at Los Angeles, 1223 16th street, suite 3100, Santa Monica, CA 90404, USA
| | - Sandra Boutros
- Department of Surgery, University of California at Los Angeles, 200 medical plaza, 3rd floor, Los Angeles, CA 90095, USA
| | - Sammy Saab
- Department of Medicine, University of California at Los Angeles, 1223 16th street, suite 3100, Santa Monica, CA 90404, USA; Department of Surgery, University of California at Los Angeles, 200 medical plaza, 3rd floor, Los Angeles, CA 90095, USA; Department of Nursing, University of California at Los Angeles, 200 medical plaza, 3rd floor, Los Angeles, CA 90095, USA
| |
Collapse
|
7
|
Rowley MW, Choi M, Chen S, Hirsch K, Seetharam AB. Race and Gradient Difference Are Associated with Increased Risk of Hepatic Encephalopathy Hospital Admission After Transjugular Intrahepatic Portosystemic Shunt Placement. J Clin Exp Hepatol 2018; 8:256-261. [PMID: 30302042 PMCID: PMC6175770 DOI: 10.1016/j.jceh.2017.12.003] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/12/2017] [Accepted: 12/23/2017] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND/AIMS Hepatic encephalopathy (HE) is a well-recognized complication of transjugular intrahepatic portosystemic shunt (TIPS) placement. The aim of this investigation was to evaluate incidence and predictors of post-TIPS HE necessitating hospital admission in a non-clinical trial setting. METHODS We performed a retrospective cohort study identifying 273 consecutive patients undergoing TIPS from 2010 to 2015 for any indication; 210 met inclusion/exclusion criteria. The primary endpoint was incidence of post-TIPS HE defined as encephalopathy with no other identifiable cause requiring hospitalization within 90 days of TIPS. Clinical demographics and procedural variables were collected and analyzed to determine predictors of readmission for post-TIPS HE. Categorical variables were analyzed using Fisher's exact test; continuous variables were compared using Levene's t-test and student's t-test; P < 0.05, significant. RESULTS Forty-two of 210 patients (20%) developed post-TIPS HE requiring hospitalization within 90 days. On analysis of cohorts (post-TIPS HE vs. no post-TIPS HE): non-white race (31.0% vs. 17.5%, P = 0.022) and increased hepatic venous pressure gradient (HVPG) difference during TIPS (10.5 vs. 8.9 mmHg, P = 0.030) were associated with an increased incidence of HE requiring readmission within 90 days. CONCLUSIONS HE remains a common complication of TIPS. Non-Caucasian race is a significant clinical demographic associated with increased risk for readmission. Independent of initial or final HVPG, HVPG difference appears to be a significant modifiable technical risk factor. In the absence of clear preventative strategies for post-TIPS encephalopathy, non-Caucasians with HVPG reductions >9 mmHg may require targeted follow up evaluation to prevent hospital readmission.
Collapse
Affiliation(s)
- Michael W. Rowley
- Department of Internal Medicine, Banner University Medical Center, Phoenix, AZ, USA,University of Arizona College of Medicine – Phoenix, Phoenix, AZ, USA
| | - Myunghan Choi
- Nursing and Healthcare Innovation, Arizona State University, Tempe, AZ, USA
| | - Steve Chen
- Department of Interventional Radiology, Banner University Medical Center, Phoenix, AZ, USA,University of Arizona College of Medicine – Phoenix, Phoenix, AZ, USA
| | - Kevin Hirsch
- Department of Interventional Radiology, Banner University Medical Center, Phoenix, AZ, USA,University of Arizona College of Medicine – Phoenix, Phoenix, AZ, USA
| | - Anil B. Seetharam
- Transplant and Advanced Liver Disease Center, Banner University Medical Center, Phoenix, AZ, USA,University of Arizona College of Medicine – Phoenix, Phoenix, AZ, USA,Address for correspondence: Anil B. Seetharam, University of Arizona College of Medicine Phoenix, Transplant and Advanced Liver Disease, 1300 N 12th Street, Suite 404, Phoenix, AZ 85006, USA. Tel.: +1 602 521 5900.
| |
Collapse
|
8
|
Suraweera D, Sundaram V, Saab S. Evaluation and Management of Hepatic Encephalopathy: Current Status and Future Directions. Gut Liver 2017; 10:509-19. [PMID: 27377741 PMCID: PMC4933409 DOI: 10.5009/gnl15419] [Citation(s) in RCA: 42] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/27/2015] [Accepted: 08/31/2015] [Indexed: 12/18/2022] Open
Abstract
Hepatic encephalopathy is a spectrum of neurocognitive manifestations often seen in patients with liver injury or rarely in patients with portosystemic shunting without liver injury. It can be divided into minimal (covert) hepatic encephalopathy and overt hepatic encephalopathy, depending on the severity. Patients with hepatic encephalopathy have compromised clinical outcomes, decreased quality of life, and increased healthcare utilization, often resulting in a heavy financial and personal burden on caregivers. The diagnosis remains largely clinical, with the exclusion of possible other causes for the altered mental status. Current treatment strategies include nonabsorbable disaccharides and antibiotics. This review will focus on the diagnosis, management and clinical impact of hepatic encephalopathy.
Collapse
Affiliation(s)
| | - Vinay Sundaram
- Department of Medicine, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Sammy Saab
- Department of Medicine, University of California at Los Angeles, Los Angeles, CA, USA.,Department of Surgery, University of California at Los Angeles, Los Angeles, CA, USA
| |
Collapse
|
9
|
Incidence of hepatic encephalopathy after transjugular intrahepatic portosystemic shunt (TIPS) according to its severity and temporal grading classification. Radiol Med 2017; 122:713-721. [PMID: 28510807 DOI: 10.1007/s11547-017-0770-6] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2017] [Accepted: 04/19/2017] [Indexed: 02/07/2023]
Abstract
OBJECTIVES To evaluate hepatic encephalopathy (HE) incidence after transjugular intrahepatic portosystemic shunt (TIPS) and classify by gravity and frequency. METHODS This is a retrospective study of 75 patients with no previous episodes of HE who underwent TIPS between 2008 and 2014 with clinical follow-up after 6 and 12 months. Patient risk factors evaluated include age, INR (international normalized ratio), creatinine, bilirubin, and MELD score (Model for End-of-stage Liver Disease). HE was reported using two classifications: (1) gravity divided in moderate (West-Haven grades I-II) and severe (III-IV); (2) frequency divided in episodic and recurrent/persistent. RESULTS Overall HE incidence was 36% at 6 months, with 12 month incidence significantly decreased to 27% (p = 0.02). 13/75 (17%) patients had one episode of moderate HE, while 3/75 (4%) patients had severe recurrent/persistent HE. Age was the only pre-TIPS risk predictor. Post-TIPS bilirubin and INR showed variations from basal values only in the presence of diagnosed HE. Bilirubin significantly increased (p = 0.03) in correlation to HE severity, whereas INR changes correlated with temporal frequency (p = 0.04). HE distribution classified for severity is similar at 6 and 12 months, whereas when classified for frequency shows significant differences (p = 0.04). CONCLUSIONS A classification by gravity and frequency attests post-TIPS HE as a manageable risk. Monitoring of bilirubin and INR may help on clinical management risk stratification.
Collapse
|
10
|
Routhu M, Safka V, Routhu SK, Fejfar T, Jirkovsky V, Krajina A, Cermakova E, Hosak L, Hulek P. Observational cohort study of hepatic encephalopathy after transjugular intrahepatic portosystemic shunt (TIPS). Ann Hepatol 2017; 16:140-148. [PMID: 28051803 DOI: 10.5604/16652681.1226932] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
UNLABELLED Introduction and Aim: Hepatic encephalopathy (HE) is a common complication of transjugular intrahepatic portosystemic shunting (TIPS). It is associated with a reduced quality of life and poor prognosis. The aim of this study was to compare two groups of patients who did and did not develop overt HE after TIPS. We looked for differences between these groups before TIPS. MATERIALS AND METHODS A study of 895 patients was conducted based on a retrospective analysis of clinical data. Data was analyzed using Fisher's exact test, Chi-square, Mann Whitney test, unpaired t-test and logistic regression. After the initial analyses, we have looked at a regression models for the factors associated with development of HE after TIPS. RESULTS 257 (37.9%) patients developed HE after TIPS. Patients' age, pre-TIPS portal venous pressure, serum creatinine, aspartate transaminase, albumin, presence of diabetes mellitus and etiology of portal hypertension were statistically significantly associated with the occurrence of HE after TIPS (p < 0.01). However, only the age, pre-TIPS portal venous pressure, serum creatinine, presence of diabetes mellitus and etiology of portal hypertension contributed to the regression model. Patients age, serum creatinine, presence of diabetes mellitus and portal vein pressure formed the model describing development of HE after TIPS for a subgroup of patients with refractory ascites. CONCLUSION we have identified, using a substantial sample, several factors associated with the development of HE after TIPS. This could be helpful in further research.
Collapse
Affiliation(s)
- Michaela Routhu
- School of Psychiatry, Health Education Wessex, United Kingdom
| | - Vaclav Safka
- Department of Physiology, Faculty of Medicine in Hradec Kralove, Charles University in Prague, Czech Republic
| | | | - Tomas Fejfar
- Department of Internal Medicine, University Hospital in Hradec Kralove, Czech Republic
| | - Vaclav Jirkovsky
- Department of Internal Medicine, University Hospital in Hradec Kralove, Czech Republic
| | - Antonin Krajina
- Department of Radiology, University Hospital in Hradec Kralove, Czech Republic
| | - Eva Cermakova
- Computer Technology Center, Faculty of Medicine in Hradec Kralove, Charles University in Prague, Czech Republic
| | - Ladislav Hosak
- Department of Psychiatry, University Hospital in Hradec Kralove, Czech Republic
| | - Petr Hulek
- Department of Psychiatry, University Hospital in Hradec Kralove, Czech Republic.,Department of Psychiatry, Faculty of Medicine in Hradec Kralove, Charles University in Prague, Czech Republic
| |
Collapse
|
11
|
Riggio O, Nardelli S, Pasquale C, Pentassuglio I, Gioia S, Onori E, Frieri C, Salvatori FM, Merli M. No effect of albumin infusion on the prevention of hepatic encephalopathy after transjugular intrahepatic portosystemic shunt. Metab Brain Dis 2016; 31:1275-1281. [PMID: 26290375 DOI: 10.1007/s11011-015-9713-x] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/16/2015] [Accepted: 07/16/2015] [Indexed: 12/14/2022]
Abstract
Hepatic encephalopathy (HE) is a major problem in patients submitted to TIPS. Previous studies identified low albumin as a factor associated to post-TIPS HE. In cirrhotics with diuretic-induced HE and hypovolemia, albumin infusion reduced plasma ammonia and improved HE. Our aim was to evaluate if the incidence of overt HE (grade II or more according to WH) and the modifications of venous blood ammonia and psychometric tests during the first month after TIPS can be prevented by albumin infusion. Twenty-three patients consecutively submitted to TIPS were enrolled and treated with 1 g/Kg BW of albumin for the first 2 days after TIPS followed by 0,5 g/Kg BW at day 4th and 7th and then once a week for 3 weeks. Forty-five patients included in a previous RCT (Riggio et al. 2010) followed with the same protocol and submitted to no pharmacological treatment for the prevention of HE, were used as historical controls. No differences in the incidence of overt HE were observed between the group of patients treated with albumin and historical controls during the first month (34 vs 31 %) or during the follow-up (39 vs 48 %). Two patients in the albumin group and three in historical controls needed the reduction of the stent diameter for persistent HE. Venous blood ammonia levels and psychometric tests were also similarly modified in the two groups. Survival was also similar. Albumin infusion has not a role in the prevention of post-TIPS HE.
Collapse
Affiliation(s)
- Oliviero Riggio
- Department of Clinical Medicine, Center for the Diagnosis and Treatment of Portal Hypertension "Sapienza" University of Rome, Rome, Italy.
- Centro di Riferimento per l'Ipertensione Portale, II Gastroenterologia, Dipartimento di Medicina Clinica, "Sapienza" Università di Roma, Viale dell'Università 37, 00185, Roma, Italy.
| | - Silvia Nardelli
- Department of Clinical Medicine, Center for the Diagnosis and Treatment of Portal Hypertension "Sapienza" University of Rome, Rome, Italy
| | - Chiara Pasquale
- Department of Clinical Medicine, Center for the Diagnosis and Treatment of Portal Hypertension "Sapienza" University of Rome, Rome, Italy
| | - Ilaria Pentassuglio
- Department of Clinical Medicine, Center for the Diagnosis and Treatment of Portal Hypertension "Sapienza" University of Rome, Rome, Italy
| | - Stefania Gioia
- Department of Clinical Medicine, Center for the Diagnosis and Treatment of Portal Hypertension "Sapienza" University of Rome, Rome, Italy
| | - Eugenia Onori
- Department of Clinical Medicine, Center for the Diagnosis and Treatment of Portal Hypertension "Sapienza" University of Rome, Rome, Italy
| | - Camilla Frieri
- Department of Clinical Medicine, Center for the Diagnosis and Treatment of Portal Hypertension "Sapienza" University of Rome, Rome, Italy
| | - Filippo Maria Salvatori
- Department of Clinical Medicine, Center for the Diagnosis and Treatment of Portal Hypertension "Sapienza" University of Rome, Rome, Italy
| | - Manuela Merli
- Department of Clinical Medicine, Center for the Diagnosis and Treatment of Portal Hypertension "Sapienza" University of Rome, Rome, Italy
| |
Collapse
|
12
|
Kok HK, Asadi H, Ryan E, Given MF, McGrath FP, Lee MJ. Balloon-Assisted Reduction of Transjugular Intrahepatic Portosystemic Shunt (BART) Using Polytetrafluoroethylene Stent-Grafts. Cardiovasc Intervent Radiol 2016; 39:1533-6. [PMID: 27224986 DOI: 10.1007/s00270-016-1371-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/09/2016] [Accepted: 05/16/2016] [Indexed: 10/21/2022]
Affiliation(s)
- Hong Kuan Kok
- Department of Interventional Radiology, Beaumont Hospital and Royal College of Surgeons in Ireland, Dublin 9, Ireland
| | - Hamed Asadi
- Department of Interventional Radiology, Beaumont Hospital and Royal College of Surgeons in Ireland, Dublin 9, Ireland.,Faculty of Health, School of Medicine, Deakin University, Geelong, VIC, Australia
| | - Elizabeth Ryan
- Department of Interventional Radiology, Beaumont Hospital and Royal College of Surgeons in Ireland, Dublin 9, Ireland
| | - Mark F Given
- Department of Interventional Radiology, Beaumont Hospital and Royal College of Surgeons in Ireland, Dublin 9, Ireland
| | - Frank P McGrath
- Department of Interventional Radiology, Beaumont Hospital and Royal College of Surgeons in Ireland, Dublin 9, Ireland
| | - Michael J Lee
- Department of Interventional Radiology, Beaumont Hospital and Royal College of Surgeons in Ireland, Dublin 9, Ireland.
| |
Collapse
|
13
|
Pereira K, Carrion AF, Martin P, Vaheesan K, Salsamendi J, Doshi M, Yrizarry JM. Current diagnosis and management of post-transjugular intrahepatic portosystemic shunt refractory hepatic encephalopathy. Liver Int 2015; 35:2487-94. [PMID: 26332169 DOI: 10.1111/liv.12956] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/23/2015] [Accepted: 08/24/2015] [Indexed: 02/07/2023]
Abstract
Transjugular intrahepatic portosystemic shunt has evolved into an important option for management of complications of portal hypertension. The use of polytetrafluoroethylene covered stents enhances shunt patency. Hepatic encephalopathy (HE) remains a significant problem after TIPS placement. The approach to management of patients with refractory hepatic encephalopathy typically requires collaboration between different specialties. Patient selection for TIPS requires careful evaluation of risk factors for HE. TIPS procedure-related technical factors like stent size, attention to portosystemic pressure gradient reduction and use of adjunctive variceal embolization maybe important. Conservative medical therapy in combination with endovascular therapies often results in resolution or substantial reduction of symptoms. Liver transplantation is, however, the ultimate treatment.
Collapse
Affiliation(s)
- Keith Pereira
- Department of Interventional Radiology, Jackson Memorial Hospital, University of Miami Hospital, Miami, FL, USA
| | - Andres F Carrion
- Division of Hepatology, Jackson Memorial Hospital, University of Miami Hospital, Miami, FL, USA
| | - Paul Martin
- Division of Hepatology, Jackson Memorial Hospital, University of Miami Hospital, Miami, FL, USA
| | - Kirubahara Vaheesan
- Department of Interventional Radiology, Saint Louis University School of medicine, St Louis, MO, USA
| | - Jason Salsamendi
- Department of Interventional Radiology, Jackson Memorial Hospital, University of Miami Hospital, Miami, FL, USA
| | - Mehul Doshi
- Department of Interventional Radiology, Jackson Memorial Hospital, University of Miami Hospital, Miami, FL, USA
| | - Jose M Yrizarry
- Department of Interventional Radiology, Jackson Memorial Hospital, University of Miami Hospital, Miami, FL, USA
| |
Collapse
|
14
|
Quality Improvement Guidelines for Transjugular Intrahepatic Portosystemic Shunts. J Vasc Interv Radiol 2015; 27:1-7. [PMID: 26614596 DOI: 10.1016/j.jvir.2015.09.018] [Citation(s) in RCA: 111] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2015] [Revised: 09/25/2015] [Accepted: 09/25/2015] [Indexed: 12/12/2022] Open
|
15
|
Pillai AK, Andring B, Patel A, Trimmer C, Kalva SP. Portal hypertension: a review of portosystemic collateral pathways and endovascular interventions. Clin Radiol 2015; 70:1047-59. [PMID: 26188844 DOI: 10.1016/j.crad.2015.06.077] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2014] [Revised: 05/24/2015] [Accepted: 06/01/2015] [Indexed: 12/12/2022]
Abstract
The portal vein is formed at the confluence of the splenic and superior mesenteric vein behind the head of the pancreas. Normal blood pressure within the portal system varies between 5 and 10 mmHg. Portal hypertension is defined when the gradient between the portal and systemic venous blood pressure exceeds 5 mmHg. The most common cause of portal hypertension is cirrhosis. In cirrhosis, portal hypertension develops due to extensive fibrosis within the liver parenchyma causing increased vascular resistance. In addition, the inability of the liver to metabolise certain vasodilators leads to hyperdynamic splanchnic circulation resulting in increased portal blood flow. Decompression of the portal pressure is achieved by formation of portosystemic collaterals. In this review, we will discuss the pathophysiology, anatomy, and imaging findings of spontaneous portosystemic collaterals and clinical manifestations of portal hypertension with emphasis on the role of interventional radiology in the management of complications related to portal hypertension.
Collapse
Affiliation(s)
- A K Pillai
- Department of Radiology, University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd, Dallas, TX 75390, USA.
| | - B Andring
- Department of Radiology, University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd, Dallas, TX 75390, USA
| | - A Patel
- Department of Radiology, University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd, Dallas, TX 75390, USA
| | - C Trimmer
- Department of Radiology, University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd, Dallas, TX 75390, USA
| | - S P Kalva
- Department of Radiology, University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd, Dallas, TX 75390, USA
| |
Collapse
|
16
|
Parvinian A, Bui JT, Knuttinen MG, Minocha J, Gaba RC. Transjugular intrahepatic portosystemic shunt for the treatment of medically refractory ascites. Diagn Interv Radiol 2015; 20:58-64. [PMID: 24004975 DOI: 10.5152/dir.2013.13131] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
PURPOSE This study was performed to assess the safety, efficacy, and clinical outcomes of transjugular intrahepatic portosystemic shunt (TIPS) creation for treatment of medically refractory ascites and to identify prognostic factors for clinical response, morbidity, and mortality. MATERIALS AND METHODS In this retrospective study, 80 patients (male:female, 52:28; mean age, 56 years; mean Model for End-Stage Liver Disease [MELD] score, 15.1) who underwent elective TIPS creation for refractory ascites between 1999-2012 were studied. A medical record review was performed to identify data on demographics, liver disease, procedures, and outcome. The influence of these parameters on 30-day, 90-day, and one-year mortality was assessed using binary logistic regression. Overall survival was analyzed with Kaplan-Meier statistics. RESULTS TIPS was successfully created using covered (n=70) or bare metal (n=10) stents. Hemodynamic success was achieved in all cases. The mean final portosystemic pressure gradient (PSG) was 6.8 mmHg. Thirty-day complications included mild encephalopathy in 35% of patients. Clinical improvement in ascites occurred in 78% of patients, with complete resolution or a ≥50% decrease in 66% of patients. No predictors of response or optimal PSG threshold were identified. The 30-day, 90-day, and one-year mortality rates were 14%, 23%, and 33%, respectively. Patient age (P = 0.026) was associated with 30-day mortality, while final PSG was associated with 90-day (P = 0.020) and one year (P = 0.032) mortality. No predictors of overall survival were identified. CONCLUSION TIPS creation effectively treats medically refractory ascites with nearly 80% efficacy. The incidence of mild encephalopathy is nontrivial. Older age and final PSG are associated with mortality, and these factors should be considered in patient selection and procedure performance.
Collapse
Affiliation(s)
- Ahmad Parvinian
- From the Department of Radiology (R.C.G. e-mail: ), Interventional Radiology Section, University of Illinois Hospital and Health Sciences System, Chicago, Illinois, USA
| | | | | | | | | |
Collapse
|
17
|
Merola J, Chaudhary N, Qian M, Jow A, Barboza K, Charles H, Teperman L, Sigal S. Hyponatremia: A Risk Factor for Early Overt Encephalopathy after Transjugular Intrahepatic Portosystemic Shunt Creation. J Clin Med 2014; 3:359-72. [PMID: 26237379 PMCID: PMC4449686 DOI: 10.3390/jcm3020359] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2014] [Revised: 03/04/2014] [Accepted: 03/07/2014] [Indexed: 02/07/2023] Open
Abstract
Hepatic encephalopathy (HE) is a frequent complication in cirrhotic patients undergoing transjugular intrahepatic portosystemic shunt (TIPS). Hyponatremia (HN) is a known contributing risk factor for the development of HE. Predictive factors, especially the effect of HN, for the development of overt HE within one week of TIPS placement were assessed. A single-center, retrospective chart review of 71 patients with cirrhosis who underwent TIPS creation from 2006–2011 for non-variceal bleeding indications was conducted. Baseline clinical and laboratory characteristics were collected. Factors associated with overt HE within one week were identified, and a multivariate model was constructed. Seventy one patients who underwent 81 TIPS procedures were evaluated. Fifteen patients developed overt HE within one week. Factors predictive of overt HE within one week included pre-TIPS Na, total bilirubin and Model for End-stage Liver Disease (MELD)-Na. The odds ratio for developing HE with pre-TIPS Na <135 mEq/L was 8.6. Among patients with pre-TIPS Na <125 mEq/L, 125–129.9 mEq/L, 130–134.9 mEq/L and ≥135 mEq/L, the incidence of HE within one week was 37.5%, 25%, 25% and 3.4%, respectively. Lower pre-TIPS Na, higher total bilirubin and higher MELD-Na values were associated with the development of overt HE post-TIPS within one week. TIPS in hyponatremic patients should be undertaken with caution.
Collapse
Affiliation(s)
- Jonathan Merola
- Department of Medicine, New York University School of Medicine, New York, NY, 10016, USA.
| | - Noami Chaudhary
- Department of Medicine, New York University School of Medicine, New York, NY, 10016, USA.
| | - Meng Qian
- Department of Biostatistics, New York University School of Medicine, New York, NY 10016, USA.
| | - Alexander Jow
- Department of Medicine, New York University School of Medicine, New York, NY, 10016, USA.
| | - Katherine Barboza
- Department of Medicine, New York University School of Medicine, New York, NY, 10016, USA.
| | - Hearns Charles
- Department of Radiology, New York University School of Medicine, New York, NY 10016, USA.
| | - Lewis Teperman
- Department of Surgery, New York University School of Medicine, New York, NY 10016, USA.
| | - Samuel Sigal
- Department of Medicine, New York University School of Medicine, New York, NY, 10016, USA.
| |
Collapse
|
18
|
Bai M, Qi XS, Yang ZP, Yang M, Fan DM, Han GH. TIPS improves liver transplantation-free survival in cirrhotic patients with refractory ascites: An updated meta-analysis. World J Gastroenterol 2014; 20:2704-2714. [PMID: 24627607 PMCID: PMC3949280 DOI: 10.3748/wjg.v20.i10.2704] [Citation(s) in RCA: 101] [Impact Index Per Article: 10.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/03/2013] [Revised: 09/28/2013] [Accepted: 11/05/2013] [Indexed: 02/06/2023] Open
Abstract
AIM: To compare the liver transplantation-free (LTF) survival rates between patients who underwent transjugular intrahepatic portosystemic shunts (TIPS) and those who underwent paracentesis by an updated meta-analysis that pools the effects of both number of deaths and time to death.
METHODS: MEDLINE, EMBASE, and the Cochrane Library were searched from the inception to October 2012. LTF survival, liver transplantation, liver disease-related death, non-liver disease-related death, recurrent ascites, hepatic encephalopathy (HE) and severe HE, and hepatorenal syndrome were assessed as outcomes. LTF survival was estimated using a HR with a 95%CI. Other outcomes were estimated using OR with 95%CIs. Sensitivity analyses were performed to assess the effects of potential outliers in the studies according to the risk of bias and the study characteristics.
RESULTS: Six randomized controlled trials with 390 patients were included. In comparison to paracentesis, TIPS significantly improved LTF survival (HR = 0.61, 95%CI: 0.46-0.82, P < 0.001). TIPS also significantly decreased liver disease-related death (OR = 0.62, 95%CI: 0.39-0.98, P = 0.04), recurrent ascites (OR = 0.15, 95%CI: 0.09-0.24, P < 0.001) and hepatorenal syndrome (OR = 0.32, 95%CI: 0.12-0.86, P = 0.02). However, TIPS increased the risk of HE (OR = 2.95, 95%CI: 1.87-4.66, P = 0.02) and severe HE (OR = 2.18, 95%CI: 1.27-3.76, P = 0.005).
CONCLUSION: TIPS significantly improved the LTF survival of cirrhotic patients with refractory ascites and decreased the risk of recurrent ascites and hepatorenal syndrome with the cost of increased risk of HE compared with paracentesis. Further studies are warranted to validate the survival benefit of TIPS in clinical practice settings.
Collapse
|
19
|
Riggio O, Nardelli S, Moscucci F, Pasquale C, Ridola L, Merli M. Hepatic encephalopathy after transjugular intrahepatic portosystemic shunt. Clin Liver Dis 2012; 16:133-46. [PMID: 22321469 DOI: 10.1016/j.cld.2011.12.008] [Citation(s) in RCA: 105] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
Transjugular intrahepatic portosystemic shunt (TIPS) has been used for more than 20 years to treat some of the complications of portal hypertension. When TIPS was initially proposed, it was claimed that the optimal calibration of the shunt could allow an adequate reduction of portal hypertension, avoiding, at the same time, the occurrence of hepatic encephalopathy (HE), a neurologic syndrome. However, several clinical observations have shown that HE occurred rather frequently after TIPS, and HE has become an important issue to be taken into consideration in TIPS candidates and a problem to be faced after the procedure.
Collapse
Affiliation(s)
- Oliviero Riggio
- Department of Clinical Medicine, Centre for the Diagnosis and Treatment of Portal Hypertension, Sapienza University of Rome, Viale dell'Università 37, 00185 Rome, Italy
| | | | | | | | | | | |
Collapse
|
20
|
Madoff DC, Wallace MJ. Reduced stents and stent-grafts for the management of hepatic encephalopathy after transjugular intrahepatic portosystemic shunt creation. Semin Intervent Radiol 2011; 22:316-28. [PMID: 21326710 DOI: 10.1055/s-2005-925558] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Hepatic encephalopathy (HE) is a common complication encountered by patients after transjugular intrahepatic portosystemic shunt (TIPS) creation. Although most patients respond well to conservative medical therapy, up to 7% of patients do not and require more invasive therapeutic approaches. One option is emergent liver transplantation; however, most patients are not suitable candidates. During the past decade, various percutaneous techniques have been described that alter the hemodynamics through the TIPS by occluding it with coils or balloons or by reducing its diameter using constrained stents or stent-grafts. These endovascular techniques have produced symptomatic improvement in many patients with refractory HE, with either complete resolution or substantial reduction of HE symptoms that can be controlled with additional medical therapy. Unfortunately, despite all attempts, some patients remain incapacitated and ultimately die. Further research is necessary to improve our understanding of HE after TIPS creation so that less invasive and safer procedures can be developed to treat this difficult clinical problem.
Collapse
Affiliation(s)
- David C Madoff
- Department of Diagnostic Radiology, Section of Interventional Radiology, The University of Texas M.D. Anderson Cancer Center, Houston, Texas
| | | |
Collapse
|
21
|
Wallace MJ, Madoff DC. Transjugular intrahepatic portosystemic shunts in patients with hepatic malignancy. Semin Intervent Radiol 2011; 22:309-15. [PMID: 21326709 DOI: 10.1055/s-2005-925557] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Since its first clinical application in 1988, the transjugular intrahepatic portosystemic shunt (TIPS) has emerged as a safe and effective means of managing patients with morbid portal hypertension. Despite the considerable body of literature on TIPS, portal decompression in patients with malignancy has not been sufficiently examined. These patients typically experience sequelae of portal hypertension that requires palliation. The purpose of this article is to review the reported experience with TIPS in patients with malignancy.
Collapse
Affiliation(s)
- Michael J Wallace
- Department of Diagnostic Radiology, Section of Interventional Radiology, The University of Texas M.D. Anderson Cancer Center, Houston, Texas
| | | |
Collapse
|
22
|
Bai M, Qi X, Yang Z, Yin Z, Nie Y, Yuan S, Wu K, Han G, Fan D. Predictors of hepatic encephalopathy after transjugular intrahepatic portosystemic shunt in cirrhotic patients: a systematic review. J Gastroenterol Hepatol 2011; 26:943-51. [PMID: 21251067 DOI: 10.1111/j.1440-1746.2011.06663.x] [Citation(s) in RCA: 118] [Impact Index Per Article: 9.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND AND AIM Hepatic encephalopathy (HE) is a very common complication in patients after transjugular intrahepatic portosystemic shunt (TIPS). The purpose of this study is to determine the most robust predictors of post-TIPS HE by performing a systematic review of studies that identified the risk factors for patients with post-TIPS HE. METHODS A PUBMED search was performed using the predefined rule. Studies were selected for analysis based on certain inclusion and exclusion criteria. Data were extracted from each study on the basis of predefined items. Meta-analyses were executed to verify the relevant risk factors. RESULTS Thirty studies were included in this systematic review. In the 30 studies, the numbers of variables evaluated by univariate and multivariate analyses were 60 and 32, respectively. The numbers of variables found to be significant in univariate and multivariate analyses were 18 and 14, respectively. According to the accumulated number of studies that identified these variables as significant, the three most vigorous predictors of post-TIPS HE were age, prior HE and Child-Pugh class/score in both univariate analysis and multivariate analysis. Our meta-analysis showed that patients with HE before TIPS or higher Child-Pugh class/score had increased risk of post-TIPS HE. CONCLUSIONS Increased age, prior HE and higher Child-Pugh class/score were the most robust predictors for post-TIPS HE.
Collapse
Affiliation(s)
- Ming Bai
- Department of Digestive Interventional Radiology, Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an, China
| | | | | | | | | | | | | | | | | |
Collapse
|
23
|
Punamiya SJ, Amarapurkar DN. Role of TIPS in Improving Survival of Patients with Decompensated Liver Disease. Int J Hepatol 2011; 2011:398291. [PMID: 21994854 PMCID: PMC3170767 DOI: 10.4061/2011/398291] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/26/2011] [Accepted: 04/13/2011] [Indexed: 12/11/2022] Open
Abstract
Liver cirrhosis is associated with higher morbidity and reduced survival with appearance of portal hypertension and resultant decompensation. Portal decompression plays a key role in improving survival in these patients. Transjugular intrahepatic portosystemic shunts are known to be efficacious in reducing portal venous pressure and control of complications such as variceal bleeding and ascites. However, they have been associated with significant problems such as poor shunt durability, increased encephalopathy, and unchanged survival when compared with conservative treatment options. The last decade has seen a significant improvement in these complications, with introduction of covered stents, better selection of patients, and clearer understanding of procedural end-points. Use of TIPS early in the period of decompensation also appears promising in further improvement of survival of cirrhotic patients.
Collapse
Affiliation(s)
- Sundeep J. Punamiya
- Department of Radiology, Tan Tock Seng Hospital, 11 Jalan Tan Tock Seng, Singapore 308433,*Sundeep J. Punamiya:
| | - Deepak N. Amarapurkar
- Department of Gastroenterology, Bombay Hospital, 12 Marine Lines, Mumbai 400020, India
| |
Collapse
|
24
|
Cookson DT, Zaman Z, Gordon-Smith J, Ireland HM, Hayes PC. Management of Transjugular Intrahepatic Portosystemic Shunt (TIPS)-associated Refractory Hepatic Encephalopathy by Shunt Reduction Using the Parallel Technique: Outcomes of a Retrospective Case Series. Cardiovasc Intervent Radiol 2010; 34:92-9. [DOI: 10.1007/s00270-010-0016-7] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/21/2010] [Accepted: 09/09/2010] [Indexed: 12/14/2022]
|
25
|
Riggio O, Ridola L, Angeloni S, Cerini F, Pasquale C, Attili AF, Fanelli F, Merli M, Salvatori FM. Clinical efficacy of transjugular intrahepatic portosystemic shunt created with covered stents with different diameters: results of a randomized controlled trial. J Hepatol 2010; 53:267-72. [PMID: 20537753 DOI: 10.1016/j.jhep.2010.02.033] [Citation(s) in RCA: 100] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/01/2009] [Revised: 02/25/2010] [Accepted: 02/25/2010] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS The incidence of post-TIPS hepatic encephalopathy (HE) could be reduced by using stents with a small diameter. The aim of this study was to compare the incidence of HE and the clinical efficacy of TIPS created with 8- or 10-mm PTFE-covered stents. METHODS Consecutive cirrhotics submitted to TIPS for variceal bleeding or refractory ascites were randomized to receive a 8- or 10-mm covered stent. As recommended by our Ethical Committee, the trial was stopped after the inclusion of 45 patients. RESULTS The two groups were comparable for age, sex, etiology, and psychometric performance. After TIPS, the portosystemic pressure gradient was significantly higher in the 8-mm stent group (8.9+/-2.7 versus 6.5+/-2.7 mmHg; p=0.007). Consequently, the probability of remaining free of complications due to portal hypertension was significantly higher in the 10-mm than in the 8-mm stent group: 82.9% versus 41.9% at one year; log-rank test, p=0.002. In particular, the persistence of ascites with the need for repeated paracentesis was significantly more frequent in the patients treated with 8-mm stent diameter for refractory ascites (log-rank test, p=0.008). The probability of remaining free of HE was similar in both groups. Cumulative survival rate was similar in both groups. CONCLUSIONS The use of 8-mm diameter stents for TIPS leads to a significantly less efficient control of complications of portal hypertension. HE remains an unsolved major problem after TIPS.
Collapse
Affiliation(s)
- Oliviero Riggio
- II Gastroenterologia, Dipartimento di Medicina Clinica, La Sapienza Università di Roma, Italy.
| | | | | | | | | | | | | | | | | |
Collapse
|
26
|
Monnin-Bares V, Thony F, Sengel C, Bricault I, Leroy V, Ferretti G. Stent-graft Narrowed with a Lasso Catheter: An Adjustable TIPS Reduction Technique. J Vasc Interv Radiol 2010; 21:275-80. [DOI: 10.1016/j.jvir.2009.10.019] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2009] [Revised: 09/16/2009] [Accepted: 10/28/2009] [Indexed: 01/22/2023] Open
|
27
|
Cura M. Refractory hepatic encephalopathy due to concomitant transjugular intrahepatic portosystemic shunt and spontaneous mesocaval shunt controlled by embolization of the competitive portosystemic shunt. Clin Imaging 2009; 33:231-3. [DOI: 10.1016/j.clinimag.2009.01.004] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2008] [Accepted: 01/08/2009] [Indexed: 12/24/2022]
|
28
|
Riggio O, Angeloni S, Salvatori FM, De Santis A, Cerini F, Farcomeni A, Attili AF, Merli M. Incidence, natural history, and risk factors of hepatic encephalopathy after transjugular intrahepatic portosystemic shunt with polytetrafluoroethylene-covered stent grafts. Am J Gastroenterol 2008; 103:2738-46. [PMID: 18775022 DOI: 10.1111/j.1572-0241.2008.02102.x] [Citation(s) in RCA: 184] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
BACKGROUND AND AIMS The aim of this study was to assess the incidence, natural history, and risk factors of hepatic encephalopathy (HE) after transjugular intrahepatic portosystemic shunt (TIPS) with the new polytetrafluoroethylene (PTFE)-covered stent grafts in cirrhotic patients. PATIENTS AND METHODS Seventy-eight cirrhotic patients treated by TIPS with PTFE-covered stent grafts and followed by the same medical team--according to a prospective protocol for diagnostic workup and surveillance strategy--were reviewed. The follow-up was 19.9 +/- 20.6 months. RESULTS At least one episode of HE occurred in 35 of 78 (44.8%) patients. The probability of remaining free of HE was 53.8% (95% confidence interval [CI] 41.4-66.2] at 1 yr and 50.9% at 2 yr (95% CI 38.2-63.8%). The total number of HE episodes was 89. Fifty-five percent of the episodes were grades III-IV. The occurrence of HE tended to be constant during the follow-up, probably because of the very low incidence of shunt dysfunction (13.6% at 2 yr). Moreover, in six patients, a refractory HE required the reduction of the shunt diameter. One patient died due to variceal bleeding after this procedure. At a multivariate analysis, an older age, high creatinine levels, and low serum sodium and low albumin values were shown to be independent factors for the occurrence of HE. Serum creatinine level was the only variable related to the development of refractory HE at the logistic multivariate analysis. CONCLUSIONS HE after TIPS with PTFE-covered stent grafts is frequent; its incidence is not confined to the first post-TIPS period, but it has the tendency to be frequent over time. Refractory HE occurred in 8% of patients and may be successfully managed by reducing the stent diameter. The selection of patients undergoing TIPS placement should be very accurate, especially for those subjects with abnormal creatinine level.
Collapse
Affiliation(s)
- Oliviero Riggio
- II Gastroenterologia, Dipartimento di Medicina Clinica, Sapienza Università di Roma, Rome, Italy
| | | | | | | | | | | | | | | |
Collapse
|
29
|
Lyon S. How I do it: flow-limiting stent for intractable encephalopathy following transjugular intrahepatic portosystemic shunt. ACTA ACUST UNITED AC 2008; 51:564-6. [PMID: 17958693 DOI: 10.1111/j.1440-1673.2007.01894.x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Affiliation(s)
- S Lyon
- Department of Interventional Radiology, The Alfred Hospital, Melbourne, Victoria, Australia.
| |
Collapse
|
30
|
Weitzman G, Schamberg NJ, Lake-Bakaar G. Synergism between hepatocellular injury and shunting in portosystemic encephalopathy (PSE): case report of acute brittle TIPS-induced PSE. Dig Dis Sci 2007; 52:3270-4. [PMID: 17638078 DOI: 10.1007/s10620-006-9371-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/02/2006] [Accepted: 04/01/2006] [Indexed: 12/09/2022]
Affiliation(s)
- Gil Weitzman
- Division of Gastroenterology and Hepatology, New York Presbyterian Hospital-Weill Medical College of Cornell University, New York, New York 10021, USA
| | | | | |
Collapse
|
31
|
Weintraub JL, Mobley DG, Weiss ME, Swanson E, Kothary N. A novel endovascular adjustable polytetrafluoroethylene-covered stent for the management of hepatic encephalopathy after transjugular intrahepatic portosystemic shunt. J Vasc Interv Radiol 2007; 18:563-6. [PMID: 17446548 DOI: 10.1016/j.jvir.2007.02.004] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
Transjugular intrahepatic portosystemic shunt (TIPS) is frequently complicated by hepatic encephalopathy. When medical therapy fails, TIPS narrowing and resultant increase in the portosystemic pressure gradient and blood flow to the liver is performed in order to reverse the encephalopathy. We present a method for reducing the TIPS using a polytetrafluoroethylene-covered balloon expandable stent placed over a self-expanding stent. This results in a narrowed TIPS that not only rapidly increases the portosystemic gradient but also can be adjusted by dilating the balloon expandable stent. This method was successful in narrowing the patient's TIPS, acutely increasing the portosystemic gradient and reversing the hepatic encephalopathy.
Collapse
Affiliation(s)
- Joshua L Weintraub
- Mount Sinai School of Medicine, One Gustave L. Levy Place, New York, NY 10029, USA.
| | | | | | | | | |
Collapse
|
32
|
Holden A, Ng R, Gane E, Hill A, McCall J. A technique for controlled partial closure of a transjugular intrahepatic portosystemic shunt tract in a patient with hepatic encephalopathy. J Vasc Interv Radiol 2007; 17:1957-61. [PMID: 17185693 DOI: 10.1097/01.rvi.0000244850.39439.34] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
A novel endovascular technique to reduce flow through a transjugular intrahepatic portosystemic shunt (TIPS) is described in a patient with severe hepatic encephalopathy. This technique allows controlled and potentially adjustable partial closure of the TIPS without thromboembolic risk. The patient experienced a dramatic clinical improvement after the procedure.
Collapse
Affiliation(s)
- Andrew Holden
- Department of Radiology, Auckland City Hospital, Park Road, Grafton, Auckland 9, New Zealand.
| | | | | | | | | |
Collapse
|
33
|
Jacquier A, Vidal V, Monnet O, Varoquaux A, Gaubert JY, Champsaur P, Gerolami R, Bartoli JM, Moulin G. A modified procedure for transjugular intrahepatic portosystemic shunt flow reduction. J Vasc Interv Radiol 2006; 17:1359-63. [PMID: 16923985 DOI: 10.1097/01.rvi.0000231950.34734.79] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
The authors present a modified transjugular intrahepatic portosystemic shunt (TIPS) flow reduction procedure to treat TIPS-related refractory hepatic encephalopathy, giving the results and follow-up on six patients. A 6-mm-diameter Uni Wallstent was introduced over a guide wire and deployed beyond the angulated portion of the TIPS. A Wallgraft was then introduced over the same guide wire, pushed through the Uni Wallstent coaxially, and deployed in the TIPS. All cases were technically and clinically successful. There were no deaths in the first month after the procedure. In this study, three patients had more than 1 year's patency.
Collapse
Affiliation(s)
- Alexis Jacquier
- Department of Radiology Pr Bartoli-Pr Moulin, La Timone University Hospital, 264 rue St Pierre, 3385 Marseille 5, France.
| | | | | | | | | | | | | | | | | |
Collapse
|
34
|
Wróblewski T, Rowiński O, Ziarkiewicz-Wróblewska B, Górnicka B, Albrecht J, Jones EA, Krawczyk M. Two-stage transjugular intrahepatic porta-systemic shunt for patients with cirrhosis and a high risk of portal-systemic encephalopathy patients as a bridge to orthotopic liver transplantation: a preliminary report. Transplant Proc 2006; 38:204-8. [PMID: 16504703 DOI: 10.1016/j.transproceed.2005.12.019] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
AIM Placement of a transjugular intrahepatic porta-systemic shunt (TIPS) is a therapeutic option for the management of bleeding esophageal varices. However, the procedure is associated with an increased risk of portal-systemic encephalopathy (PSE). In this study, a two-stage modification of the standard TIPS technique was introduced for the management of variceal bleeding in cirrhotic patients with a high risk of PSE before liver transplantation. METHODS The modified procedure was applied to four patients with cirrhosis, portal hypertension, and ascites. Two had a history of encephalopathy after variceal bleeding; the other two were encephalopathic at the time of the first stage of the modified procedure. In the first stage, a 6-mm diameter intrahepatic shunt was created using a Palmaz-Schatz stent. One month later, in the second stage, the lumen of the shunt was expanded to a diameter of 10 mm. RESULTS Both stages of this TIPS procedure were undertaken without any associated adverse events. In particular, neither stage was followed by a deterioration of neurologic status. From completion of the second stage to undertaking orthotopic liver transplantation (a period of 2 to 6 months), no rebleeding from esophageal varices occurred. CONCLUSIONS A two-stage TIPS procedure to reduce portal hypertension enables a more gradual adaptation to post-TIPS hemodynamic and metabolic changes than occurs after creation of a conventional TIPS. A two-stage TIPS procedure may be the method of choice for treating bleeding from esophageal varices in patients who have a high risk of developing PSE and give them a chance for liver transplantation.
Collapse
Affiliation(s)
- T Wróblewski
- Department of General, Transplant and Liver Surgery, the Warsaw Medical University, ul. Banacha 1a, 02-097 Warsaw, Poland.
| | | | | | | | | | | | | |
Collapse
|
35
|
Riggio O, Masini A, Efrati C, Nicolao F, Angeloni S, Salvatori FM, Bezzi M, Attili AF, Merli M. Pharmacological prophylaxis of hepatic encephalopathy after transjugular intrahepatic portosystemic shunt: a randomized controlled study. J Hepatol 2005; 42:674-9. [PMID: 15826716 DOI: 10.1016/j.jhep.2004.12.028] [Citation(s) in RCA: 147] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/01/2004] [Revised: 12/17/2004] [Accepted: 12/20/2004] [Indexed: 02/06/2023]
Abstract
BACKGROUND/AIMS Hepatic encephalopathy is a frequent event after transjugular-intrahepatic-portosystemic-shunt (TIPS), especially during the first months. Aim of this study was to compare two different treatments (lactitol 60 g/day, rifaximin 1200 mg/day) with no-treatment in the prevention of post-TIPS hepatic encephalopathy. METHODS Seventy-five consecutive cirrhotics submitted to TIPS were randomized to receive either one of the above treatments or no-treatment. The main end-point was the occurrence of an episode of overt hepatic encephalopathy during the first month post-TIPS. Before the procedure and weekly thereafter the patients were evaluated by examining their mental status, asterixis, ammonia and trail-making-test Part-A (TMT-A). RESULTS The three groups were comparable for age, sex, etiology, Child-Pugh-score, post-TIPS porto-systemic gradient, previous hepatic encephalopathy, basal values of ammonia and psychometric performance. Twenty-five patients developed hepatic encephalopathy (33%, CI 95%=22-45%). One-month incidence was similar in the three groups (P=0.97). Previous hepatic encephalopathy (Relative Hazard=3.79;1.27-11.31) and basal-TMT-A Z-score>1.5 (RH=3.55;1.24-10.2) were predictors of post-TIPS encephalopathy at multivariate analysis. A <5 mmHg porto-systemic gradient was also significantly related to the occurrence of encephalopathy. CONCLUSIONS Our data show that treatment with lactitol or rifaximin is not effective in the prophylaxis of hepatic encephalopathy during the first month after a TIPS.
Collapse
Affiliation(s)
- O Riggio
- Department of Clinical Medicine, University of Rome "La Sapienza", Rome, Italy.
| | | | | | | | | | | | | | | | | |
Collapse
|
36
|
Wallace MJ, Madoff DC, Ahrar K, Warneke CL. Transjugular intrahepatic portosystemic shunts: experience in the oncology setting. Cancer 2004; 101:337-45. [PMID: 15241832 DOI: 10.1002/cncr.20367] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
BACKGROUND Transjugular intrahepatic portosystemic shunt (TIPS) placement has emerged as an effective and minimally invasive method of treating portal hypertension and its associated complications. To the authors' knowledge there is limited documentation of its use for percutaneous shunting in patients with hepatic and extrahepatic malignancies. The current study reports the authors' experience with TIPS in the oncology setting. METHODS Thirty-eight patients with cancer underwent TIPS procedures. Nineteen patients had a history of hepatic malignancy. All medical records and imaging studies were reviewed retrospectively. The indication for TIPS, the presence of malignancy, procedural details, complications, survival, and treatment success were assessed. RESULTS Primary technical success was accomplished in 37 of 38 patients (97%) without technical procedure-related complications. Hepatic encephalopathy occurred in 15 of 34 patients (44%), with 3 patients requiring shunt reduction. Premature shunt occlusion (< 30 days) occurred in 3 patients (8%). Recurrent hemorrhage occurred in 1 of 19 patients (5%), and ascites and hepatic hydrothorax resolved or improved subjectively in 9 of 12 patients (75%). Shunts traversed malignancy in 9 patients, and varying degrees of portal compromise were encountered in 12 patients (32%). The overall 30-day and 90-day survival rates were 84% and 60%, respectively. There was a statistically significant difference in 90-day survival rates for patients who had ascites and hepatic hydrothorax indications (27%) compared with patients who had variceal and portal gastropathy indications (84%; P = 0.0075). In addition, the 90-day survival rate was significantly lower in patients who had primary hepatic malignancies (36%) compared with the remainder of the study population (74%; P = 0.0077), and it was significantly lower in patients who had model for end-stage liver disease (MELD) scores > or = 12 (P = 0.0020). CONCLUSIONS TIPS was performed safely for patients with cancer without increasing rates of procedure-related complications. However, some patients subgroups, such at those with malignancy and ascites, primary hepatic malignancy, or MELD scores > or = 12, had the lowest 90-day survival rates.
Collapse
Affiliation(s)
- Michael J Wallace
- Section of Vascular and Interventional Radiology, Department of Diagnostic Radiology, The University of Texas M. D. Anderson Cancer Center, Houston, Texas 77030, USA.
| | | | | | | |
Collapse
|
37
|
Madoff DC, Wallace MJ, Ahrar K, Saxon RR. TIPS-related hepatic encephalopathy: management options with novel endovascular techniques. Radiographics 2004; 24:21-36; discussion 36-7. [PMID: 14730033 DOI: 10.1148/rg.241035028] [Citation(s) in RCA: 62] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Hepatic encephalopathy is a common complication that develops after creation of a transjugular intrahepatic portosystemic shunt (TIPS). Although most patients respond well to conservative medical therapy (ie, protein-restricted diet, nonabsorbable disaccharides, nonabsorbable antibiotics), a small percentage of patients (3%-7%) do not benefit from these methods and require more invasive therapeutic approaches. One option is emergent liver transplantation, but the majority of patients are not suitable candidates. Recently, various percutaneous techniques have been described that alter the hemodynamics through the shunt by occluding it with coils or balloons or by reducing its diameter by inserting constrained stents or stent-grafts. Other techniques have been used for patients with TIPS-related hepatic encephalopathy in whom spontaneous splenorenal shunts are present. In many patients with refractory hepatic encephalopathy, these percutaneous techniques have produced symptomatic improvement, with either a complete resolution or a substantial reduction in hepatic encephalopathy symptoms that can be controlled with medical therapy. Unfortunately, despite all attempts, some patients remain incapacitated and ultimately die. Further research is necessary to improve our understanding of TIPS-related hepatic encephalopathy so that newer, less invasive and safer procedures can be developed to treat this difficult clinical problem.
Collapse
Affiliation(s)
- David C Madoff
- Division of Diagnostic Imaging, Section of Vascular and Interventional Radiology, University of Texas M. D. Anderson Cancer Center, 1515 Holcombe Blvd, Unit 325, Houston, TX 77030-4009, USA.
| | | | | | | |
Collapse
|
38
|
Jiang ZB, Shan H, Shen XY, Huang MS, Li ZR, Zhu KS, Guan SH. Transjugular intrahepatic portosystemic shunt for palliative treatment of portal hypertension secondary to portal vein tumor thrombosis. World J Gastroenterol 2004; 10:1881-4. [PMID: 15222028 PMCID: PMC4572222 DOI: 10.3748/wjg.v10.i13.1881] [Citation(s) in RCA: 43] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
AIM: To evaluate the palliative therapeutic effects of transjugular intrahepatic portosystemic shunt (TIPS) in portal vein tumor thrombosis (PVTT) complicated by portal hypertension.
METHODS: We performed TIPS for 14 patients with PVTT due to hepatocellular carcinoma (HCC). Of the 14 patients, 8 patients had complete occlusion of the main portal vein, 6 patients had incomplete thrombosis, and 5 patients had portal vein cavernous transformation. Clinical characteristics and average survial time of 14 patients were analysed. Portal vein pressure, ascites, diarrohea, and variceal bleeding and circumference of abdomen were assessed before and after TIPS.
RESULTS: TIPS was successful in 10 cases, and the successful rate was about 71%. The mean portal vein pressure was reduced from 37.2 mmHg to 18.2 mmHg. After TIPS, the ascites decreased, hemorrhage stopped and the clinical symptoms disappeared in the 10 cases. The average survial time was 132.3 d. The procedure failed in 4 cases because of cavernous transformation in portal vein and severe cirrhosis.
CONCLUSION: TIPS is an effective palliative treatment to control hemorrhage and ascites due to HCC complicated by PVTT.
Collapse
Affiliation(s)
- Zai-Bo Jiang
- 3rd Affiliated Hospital of Sun Yat-Sen University, Guangzhou 510630, Guangdong Province, China.
| | | | | | | | | | | | | |
Collapse
|
39
|
ter Borg PCJ, Hollemans M, Van Buuren HR, Vleggaar FP, Groeneweg M, Hop WCJ, Laméris JS. Transjugular Intrahepatic Portosystemic Shunts: Long-term Patency and Clinical Results in a Patient Cohort Observed for 3–9 Years. Radiology 2004; 231:537-45. [PMID: 15044746 DOI: 10.1148/radiol.2312021797] [Citation(s) in RCA: 46] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
PURPOSE To retrospectively assess the outcome of transjugular intrahepatic portosystemic shunt (TIPS) placement in a nonselected group of consecutive patients. MATERIALS AND METHODS TIPS placement was attempted in 82 patients. Patients were followed up for at least 3 years according to a standard protocol that included repeated shunt evaluations. Fifty-four patients underwent TIPS placement for variceal bleeding, 24 for refractory ascites, and four for other indications. Recurrent bleeding, effect on ascites, long-term patency, development of encephalopathy, and survival and complication rates were evaluated with Kaplan-Meier survival analysis and Cox multivariate analysis. RESULTS TIPS placement was successful in 75 patients (91%). Mean follow-up lasted 29.4 months. Primary patency was 22% and 12%, primary-assisted patency was 67% and 46%, and secondary patency was 91% and 91% at 1- and 5-year follow-up, respectively. Nonalcoholic liver disease (P =.007) and increasing platelet counts (P =.006) independently predicted development of shunt insufficiency. The 1- and 5-year rates of recurrent variceal bleeding were 21% and 27%, respectively. In the majority of patients with refractory ascites, a beneficial effect of TIPS placement was observed. The risk for encephalopathy was 25% at 1-month follow-up and 52% at 3-year follow-up. The risk for chronic or severe intermittent encephalopathy was 15% at 1-year follow-up and 20% at 3-year follow-up. Serum creatinine levels (P =.001) and age (P =.02) were independent risk factors. Overall survival rate was 61%, 49%, and 42% at 1-, 3-, and 5-year follow-up, respectively. Age (P =.03), serum albumin level (P =.02), and serum creatinine level (P <.001) were independently related to mortality. CONCLUSION The risk for definitive loss of shunt function was 17% at 5-year follow-up, indicating that surveillance with shunt revision-when indicated-results in excellent long-term TIPS patency. TIPS placement effectively protects against recurrent bleeding.
Collapse
Affiliation(s)
- Pieter C J ter Borg
- Department of Gastroenterology and Hepatology, Erasmus MC, Dr. Molewaterplein 40, Room Ca 326, 3015 GD Rotterdam, The Netherlands.
| | | | | | | | | | | | | |
Collapse
|
40
|
Abstract
Transjugular intrahepatic portosystemic shunts (TIPS) were successfully placed through hepatic malignancy, without technical complication, in nine patients. A mean follow-up of 229 days (range, 53-391 days) was available in six patients. Ascites improved in three patients and variceal hemorrhage did not recur in another three patients. Hepatic encephalopathy occurred in three patients. Three acute shunt occlusions and two deaths occurred within 30 days of TIPS placement. Shunts that traverse malignancy can be created safely without increased technical complication. Although there is a high rate of acute shunt occlusion, hepatic neoplasm alone should not be a contraindication for TIPS placement.
Collapse
Affiliation(s)
- Michael Wallace
- Section of Vascular and Interventional Radiology, Department of Diagnostic Radiology, the University of Texas M.D. Anderson Cancer Center, 1515 Holcombe Boulevard, Unit 325, Houston, Texas 77030-4009, USA.
| | | |
Collapse
|
41
|
Madoff DC, Perez-Young IV, Wallace MJ, Skolkin MD, Toombs BD. Management of TIPS-related refractory hepatic encephalopathy with reduced Wallgraft endoprostheses. J Vasc Interv Radiol 2003; 14:369-74. [PMID: 12631643 DOI: 10.1097/01.rvi.0000058418.01661.48] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
The purpose of this study is to evaluate the feasibility of constrained endografts used for the treatment of transjugular intrahepatic portosystemic shunt (TIPS)-related refractory hepatic encephalopathy (HE). Because the clinical status of two patients worsened (return of intractable ascites requiring transplantation, n = 1; death, n = 1) after complete balloon occlusion, six patients were treated with constrained/modified Wallgraft endoprostheses placed within the preexisting TIPS. Shunt reductions were technically successful in all six patients, as shown by an immediate mean portosystemic gradient increase of 9.3 mm Hg. Clinical improvement was achieved in five patients within 72 hours of reduction. The remaining patient continued to decline and died 3 weeks later. Two endografts completely occluded within 8 months without HE recurrence. This technique offers an attractive alternative to previously described shunt reduction methods.
Collapse
Affiliation(s)
- David C Madoff
- Division of Diagnostic Imaging, Section of Vascular and Interventional Radiology, University of Texas M. D. Anderson Cancer Center, Houston, Texas 77030, USA.
| | | | | | | | | |
Collapse
|
42
|
Patel NH, Sasadeusz KJ, Seshadri R, Chalasani N, Shah H, Johnson MS, Namyslowski J, Moresco KP, Trerotola SO. Increase in hepatic arterial blood flow after transjugular intrahepatic portosystemic shunt creation and its potential predictive value of postprocedural encephalopathy and mortality. J Vasc Interv Radiol 2001; 12:1279-84. [PMID: 11698626 DOI: 10.1016/s1051-0443(07)61552-8] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023] Open
Abstract
PURPOSE To determine (i) whether there is a significant increase in hepatic artery blood flow (HABF) after transjugular intrahepatic portosystemic shunt (TIPS) creation and (ii) whether the extent of incremental increase in HABF is predictive of clinical outcome after TIPS creation. MATERIALS AND METHODS Prospective, nonrandomized, nonblinded duplex Doppler ultrasound (US) examinations were performed on 24 consecutive patients (19 men; Child Class A/B/C: 4/12/8, respectively) with a mean age of 52.8 years who were referred for TIPS creation for variceal bleeding. Peak hepatic artery velocity and vessel dimensions were used to calculate the hepatic arterial blood flow (HABF) before and after TIPS creation. Patients were clinically followed in the gastrohepatology clinic and TIPS US surveillance was performed at 1 and 3 months to assess shunt function. The extent of incremental increase in HABF was analyzed as a predictor of post-TIPS encephalopathy and/or death. RESULTS The technical success rate of TIPS creation was 100%. The shunt diameters were either 10 mm (n = 11) or 12 mm (n = 13). TIPS resulted in a significant reduction in the portosystemic gradient from 24.3 mm Hg +/- 5.7 to 9.3 mm Hg +/- 2.9 (P <.001). The hepatic artery peak systolic velocity and HABF increased significantly after TIPS creation, from 60.8 cm/sec +/- 26.7 to 121 cm/sec +/- 51.5 (P <.001) and from 254.2 mL/min +/- 142.2 to 507.8 mL/min +/- 261.3 (P <.001), respectively. The average incremental increase in HABF from pre-TIPS to post-TIPS was 253.6 mL/min +/- 174.2 and the average decremental decrease in portosystemic gradient was 15.0 mm Hg +/- 5.3, but there was no significant correlation (r = 0.04; P =.86) between the two. All shunts were patent at 30 and 90 days without sonographic evidence of shunt dysfunction. After TIPS creation, new or worsened encephalopathy developed in five patients at 30 days and in an additional three at 90 days. They were all successfully managed medically. Three patients (12.5%) died within 30 days of the TIPS procedure. The extent of incremental increase in HABF after TIPS was variable and did not correlate with the development of 30-day and 90-day encephalopathy (P =.41 and P =.83, respectively) or 30-day mortality (P =.2). CONCLUSIONS HABF increases significantly after TIPS but is not predictive of clinical outcome. The significance of the incremental increase is yet to be determined.
Collapse
Affiliation(s)
- N H Patel
- Department of Radiology, Indiana University School of Medicine, Indianapolis, Indiana 46202, USA.
| | | | | | | | | | | | | | | | | |
Collapse
|
43
|
Wang MQ, Dake MD, Cui ZP, Wang ZQ, Gao YA. Portal-systemic myelopathy after transjugular intrahepatic portosystemic shunt creation: report of four cases. J Vasc Interv Radiol 2001; 12:879-81. [PMID: 11435545 DOI: 10.1016/s1051-0443(07)61514-0] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
The authors attempted to describe the clinical manifestations of portal-systemic myelopathy (PSM) after transjugular intrahepatic portosystemic shunt (TIPS) creation. PSM was developed in four of 212 (1.89%) patients who underwent TIPS procedures in our hospital. Three men and one woman, ranging in age from 41 to 56 years, with a history of posthepatitis cirrhosis and recurrent bleeding from gastroesophageal varices had intrahepatic shunts created with 10-mm-diameter Wallstents. Shunt patency was confirmed by color Doppler ultrasonography (US) in each patient after TIPS creation. Progressive spastic paraparesis involving the lower extremities occurred between 5 weeks and 5 months after TIPS creation in the four patients. Neurologic examination showed evidence of spasticity in all cases, with ankle clonus, extensor plantar responses, and lower extremity hyperreflexia. All sensory modalities remained intact. Cytologic examination of cerebrospinal fluid from each patient was normal. There was no evidence of spinal cord compression on the imaging studies. PSM is a rare syndrome that includes spastic paraparesis with intact sensation. Initially noted in patients who have undergone surgical placement of a portacaval shunt, it also may occur after TIPS creation.
Collapse
Affiliation(s)
- M Q Wang
- Division of Cardiovascular and Interventional Radiology, Stanford University Medical Center, Stanford, California 94305, USA
| | | | | | | | | |
Collapse
|
44
|
Abstract
In the last decade, a significant amount of research has been devoted to the pathogenesis and treatment of hepatic encephalopathy (HE). Non-invasive neuroimaging techniques such as magnetic resonance imaging and spectroscopy have become important research tools. The search for a suitable animal model of HE associated with cirrhosis is still ongoing. Moreover, consensus terminology and diagnostic criteria for HE in humans are badly needed.
Collapse
Affiliation(s)
- J P Ong
- Department of Gastroenterology, Cleveland Clinic Foundation, Cleveland, OH, USA
| | | |
Collapse
|
45
|
Hassoun Z, Deschênes M, Lafortune M, Dufresne MP, Perreault P, Lepanto L, Gianfelice D, Bui B, Pomier-Layrargues G. Relationship between pre-TIPS liver perfusion by the portal vein and the incidence of post-TIPS chronic hepatic encephalopathy. Am J Gastroenterol 2001; 96:1205-9. [PMID: 11316171 DOI: 10.1111/j.1572-0241.2001.03704.x] [Citation(s) in RCA: 44] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
OBJECTIVE In the present study we evaluated the predictive value of pretransjugular intrahepatic portosystemic shunt (TIPS) portal perfusion as assessed by Doppler ultrasonography for the onset of chronic encephalopathy after TIPS. METHODS A total of 231 cirrhotic patients were followed-up prospectively after TIPS placement. The pattern of intrahepatic portal flow was assessed before TIPS. Patients were divided into two groups according to Doppler findings. Group 1 comprised patients with prograde portal flow (n = 200), whereas group 2 comprised those with loss of portal perfusion (hepatofugal or back-and-forth flow or portal vein thrombosis; n = 31). The presence of chronic encephalopathy during a median follow-up of 32 months was prospectively recorded. The prognostic value of the following parameters for the onset of chronic recurrent encephalopathy after TIPS was evaluated: age, presence of encephalopathy before TIPS, alcoholism, Pugh score, and loss of portal perfusion before TIPS. The independent prognostic value of each variable was tested with a multiple logistic regression analysis. RESULTS The two groups were comparable in terms of age, incidence of prior episodes of hepatic encephalopathy, and portacaval gradient before and after the procedure; however, liver failure was more severe in patients in group 2 (Pugh score: 9.2 +/- 1.9 vs 10.3 +/- 1.7). The 3-yr survival was identical for both groups; 25% of the 200 patients in group 1 developed chronic encephalopathy as compared to 6% of the 31 patients in group 2 (p = 0.03). Multiple logistic regression analysis demonstrated that loss of portal perfusion and age >65 yr were the only independent predictors of the onset of post-TIPS chronic encephalopathy (odds ratios 0.24 and 1.98, respectively). CONCLUSIONS Cirrhotic patients with loss of portal perfusion before TIPS were protected against post-TIPS chronic hepatic encephalopathy despite a more severe liver dysfunction at baseline. The only other independent predictive factor for the onset of this complication was age.
Collapse
Affiliation(s)
- Z Hassoun
- Radiology Department, Centre Hospitalier de l'Université de Montreal-H pital Saint-Luc and the University of Montréal, Québec, Canada
| | | | | | | | | | | | | | | | | |
Collapse
|
46
|
Abstract
Since the introduction of transjugular intrahepatic portosystemic shunt (TIPS) 10 years ago, it has been used increasingly in the management of portal hypertension and its complications. TIPS is now considered the procedure of choice for management of refractory variceal bleeding. Its role in the management of refractory ascites, hepatic hydrothorax, hepatorenal syndrome, and hepatopulmonary syndrome still awaits further prospective studies. The two main complications of TIPS are hepatic encephalopathy and shunt malfunction. Generally, TIPS stenosis or occlusion is a major drawback requiring routine surveillance of TIPS with doppler ultrasound. Venography with balloon dilation of the stent or placement of serial or parallel stents may be required in some cases. Promising modalities of preventing TIPS malfunction (e.g., brachy-therapy, covered stents, or anti-platelet derived growth factor) are currently being investigated.
Collapse
Affiliation(s)
- J P Ong
- Department of Gastroenterology, Cleveland Clinic Foundation, Ohio 44195, USA
| | | | | |
Collapse
|
47
|
|