Does Transjugular Intrahepatic Portosystemic Shunt Stent Differentially Improve Survival in a Subset of Cirrhotic Patients?

2018 ◽  
Vol 38 (01) ◽  
pp. 087-096 ◽  
Author(s):  
Jonel Trebicka
Keyword(s):  
Transjugular Intrahepatic Portosystemic Shunt ◽  
Venous Pressure ◽  
Portal Pressure ◽  
Portosystemic Shunt ◽  
Refractory Ascites ◽  
Variceal Hemorrhage ◽  
Early Evaluation ◽  
Vein Thrombosis ◽  
Intrahepatic Portosystemic Shunt

AbstractDoes transjugular intrahepatic portosystemic shunt stent (TIPS) improve survival in a subgroup of patients? Yes. TIPS nearly halves portal pressure and increases the effective blood volume. In cases of acute variceal hemorrhage and with a high risk of treatment failure, defined as either hepatic venous pressure gradient higher than 20 mm Hg, Child B with active bleeding at the endoscopy, or Child C with less than 14 points, early or preemptive placement of TIPS (within 72 hours) improves survival. Also, in suitable patients with intractable or refractory ascites, TIPS improves survival if placed early in the course of treatment. While TIPS does not improve survival in other situations, it improves disease management, especially in patients without TIPS contraindications but with refractory bleeding, early rebleeding, portal vein thrombosis, and hepatorenal syndrome. Experience gained at the centers and follow-up of TIPS patients are key features that improve outcome. Important factors for selection and follow-up include cardiac function, inflammation, sarcopenia, age, and early evaluation for liver transplantation.

scholarly journals Rapid change of liver stiffness after variceal ligation and TIPS implantation

2018 ◽  
Vol 314 (2) ◽  
pp. G179-G187 ◽  
Author(s):  
Felix Piecha ◽  
Daniel Paech ◽  
Janina Sollors ◽  
Helmut-Karl Seitz ◽  
Martin Rössle ◽  
...  
Keyword(s):  
Transjugular Intrahepatic Portosystemic Shunt ◽  
Esophageal Varices ◽  
Wistar Rats ◽  
Venous Pressure ◽  
Portal Pressure ◽  
Liver Stiffness ◽  
Portosystemic Shunt ◽  
Central Venous ◽  
Intrahepatic Portosystemic Shunt ◽  
Pressure Changes

Liver stiffness (LS) as measured by transient elastography is widely used to screen for liver fibrosis. However, LS also increases in response to pressure changes like congestion but no data on portal pressure are available. We study here the effect of rapid portal pressure changes on LS. Therefore, LS was assessed directly prior and after ligation of esophageal varices ( n = 11) as well as transjugular intrahepatic portosystemic shunt (TIPS) implantation in patients with established cirrhosis ( n = 14). Additionally, we retrospectively analyzed changes in LS and variceal size in patients with sequential gastroscopic monitoring and LS measurements ( n = 14). To study LS and portal pressure in healthy livers, LS (µFibroscan; Echosens, Paris, France) and invasive pressures (Powerlab, AD Instruments, New Zealand) were assessed in male Wistar rats after ligation of single liver lobes. Ligation of esophageal varices caused an immediate and significant increase of LS from 40.3 ± 19.0 to 56.1 ± 21.5 kPa. Likewise, LS decreased significantly from 53.1 ± 16.6 to 43.8 ± 17.3 kPa after TIPS placement, which correlated significantly with portal pressure ( r = 0.558). In the retrospective cohort, the significant LS decrease from 54.9 ± 23.5 to 47.9 ± 23.8 kPa over a mean observation interval of 4.3 ± 3 mo was significantly correlated with a concomitant increase of variceal size ( r = −0.605). In the animal model, LS and portal pressure increased significantly after single lobe ligation without changes of arterial or central venous pressure. In conclusion, rapid changes of portal pressure are a strong modulator of LS in healthy and cirrhotic organs. In patients with stable cirrhosis according to the model for end-stage liver disease (MELD), a decrease of LS may be indicative for enlarging varices. NEW & NOTEWORTHY Liver stiffness (LS) immediately increases after variceal ligation while it decreases after transjugular intrahepatic portosystemic shunt (TIPS) implantation due to portal pressure changes. LS and portal pressure rapidly increase after single lobe ligation in Wistar rats without changes of arterial or central venous pressure. Collateral formation may be one cause for a transient decrease in LS in the absence of other confounders. Such pressure changes should be considered when interpreting LS in clinical practice.

scholarly journals Transjugular Intrahepatic Portosystemic Shunt: A Literature Review

2017 ◽  
Vol 34 (2) ◽  
pp. 114-122 ◽  
Author(s):  
Vicki R. Franklin ◽  
Layla Q. Simmons ◽  
Anthony L. Baker
Keyword(s):  
Portal Hypertension ◽  
Transjugular Intrahepatic Portosystemic Shunt ◽  
Venous Pressure ◽  
Portosystemic Shunt ◽  
Portal System ◽  
Refractory Ascites ◽  
Hepatic Veins ◽  
Technological Advances ◽  
Intrahepatic Portosystemic Shunt ◽  
Diseased Liver

Transjugular intrahepatic portosystemic shunt, or TIPS, is a procedure used to decompress the portal system resulting from portal hypertension. The technique was inadvertently discovered during a transjugular cholangiography procedure around 1969. Technological advances in the 1980s and 1990s have resulted in more positive outcomes for the TIPS procedure since its inception. There are several indications for performing the procedure, including refractory ascites, variceal bleeding, and portal hypertension. Liver disease can lead to portal hypertension, and few treatments are available; however, with TIPS, many patients obtain favorable results. The goal of placing an intrahepatic portosystemic shunt is to bypass the vascular resistance in the cirrhotic liver by creating a channel between the portal and hepatic veins, thereby reducing portal venous pressure and portal hypertension. Normal and diseased liver function is explained as well as the TIPS procedure process, materials, complications, and long-term outcomes.

scholarly journals Transjugular Intrahepatic Portosystemic Shunt (TIPS): Pathophysiologic Basics, Actual Indications and Results with Review of the Literature

2018 ◽  
Vol 190 (08) ◽  
pp. 701-711 ◽  
Author(s):  
Holger Strunk ◽  
Milka Marinova
Keyword(s):  
Transjugular Intrahepatic Portosystemic Shunt ◽  
Endoscopic Therapy ◽  
Secondary Prophylaxis ◽  
Portosystemic Shunt ◽  
Refractory Ascites ◽  
Variceal Hemorrhage ◽  
Line Therapy ◽  
Intrahepatic Portosystemic Shunt ◽  
Pugh Class ◽  
Early Tips

Background Transjugular intrahepatic portosystemic shunt (TIPS) is a non-selective portosystemic shunt created using endovascular techniques. During recent years technical improvements and new insights into pathophysiology have modified indications for TIPS placement. In this article we therefore want to discuss current knowledge. Method A literature review was performed to review and discuss the pathophysiology, indications and results of the TIPS procedure. Results Established TIPS indications are persistent bleeding despite combined pharmacological and endoscopic therapy and rebleeding during the first five days. A new indication in the European recommendations is early TIPS placement within 72 hours, ideally within 24 hours, in patients bleeding from esophageal or gastroesophageal varices at high risk for treatment failure (e. g. Child-Pugh class C < 14 points or Child-Pugh class B with active bleeding) after initial pharmacological and endoscopic therapy. For prevention of recurrent variceal hemorrhage in the recommendations, covered TIPS placement is the treatment of choice only after failed first-line therapy, although numerous TIPS studies show a prolonged time to rebleeding and a reduction of mortality. Similarly for secondary prophylaxis in patients with refractory ascites, covered TIPS placement may be considered only if the patient continues to be intolerant to NSBBs and is an appropriate TIPS candidate even though studies show that the TIPS procedure controls ascites, improves survival and renal function better than paracentesis. Potential indications for TIPS implantation are Budd-Chiari syndrome, acute portal vein thromboses, hydrothorax, hepatopulmonary and hepatorenal syndrome (Typ 2), portal hypertensive gastropathy (PHG) and prophylaxis of complications of abdominal surgery, very rarely bleeding in ectopic varices or in patients with chylothorax or chylous ascites. Conclusion TIPS placement is an established procedure with a new indication as “early TIPS”. In the European recommendations it is only the second-line therapy for prevention of recurrent variceal hemorrhage and for secondary prophylaxis in patients with refractory ascites although several studies showed a clear benefit of the TIPS procedure compared to ligation and NSBBs. Key Points  Citation Format

Transjugular Intrahepatic Portosystemic Shunt in Patients with Portal Hypertension: Patency Depends on Coverage and Interventionalist’s Experience

2018 ◽  
Vol 36 (3) ◽  
pp. 218-227 ◽  
Author(s):  
Matthias Buechter ◽  
Paul Manka ◽  
Guido Gerken ◽  
Ali Canbay ◽  
Sandra Blomeyer ◽  
...  
Keyword(s):  
Portal Hypertension ◽  
Liver Disease ◽  
Transjugular Intrahepatic Portosystemic Shunt ◽  
Venous Pressure ◽  
Portosystemic Shunt ◽  
Refractory Ascites ◽  
Control Group ◽  
Covered Stents ◽  
Group I ◽  
Intrahepatic Portosystemic Shunt

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.

scholarly journals Transjugular Intrahepatic Portosystemic Shunt for the Treatment of Portal Hypertension in Noncirrhotic Patients with Portal Cavernoma

2014 ◽  
Vol 2014 ◽  
pp. 1-8 ◽  
Author(s):  
Xuefeng Luo ◽  
Ling Nie ◽  
Biao Zhou ◽  
Denghua Yao ◽  
Huaiyuan Ma ◽  
...  
Keyword(s):  
Portal Hypertension ◽  
Transjugular Intrahepatic Portosystemic Shunt ◽  
Portal Pressure ◽  
Portosystemic Shunt ◽  
Single Instance ◽  
Massive Gastrointestinal Bleeding ◽  
Portal Cavernoma ◽  
Intrahepatic Portosystemic Shunt ◽  
Procedural Complications

Background. The purpose of this study was to evaluate the safety and efficacy of transjugular intrahepatic portosystemic shunt (TIPS) placement in the management of portal hypertension in noncirrhotic patients with portal cavernoma.Methods. We conducted a single institution retrospective analysis of 15 noncirrhotic patients with portal cavernoma treated with TIPS placement. 15 patients (4 women and 11 men) were evaluated via the technical success of TIPS placement, procedural complications, and follow-up shunt patency.Results. TIPS placement was technically successful in 11 out of 15 patients (73.3%). Procedure-related complications were limited to a single instance of hepatic encephalopathy in one patient. In patients with successful shunt placement, the portal pressure gradient decreased from25.8±5.7to9.5±4.2 mmHg (P<0.001). TIPS dysfunction occurred in two patients during a median follow-up time of 45.2 months. Revision was not performed in one patient due to inadequate inflow. The other patient died of massive gastrointestinal bleeding in a local hospital. The remaining nine patients maintained functioning shunts through their last evaluation.Conclusions. TIPS is a safe and effective therapeutic treatment for noncirrhotic patients with symptomatic portal hypertension secondary to portal cavernoma.

scholarly journals Retrospective Study of Transjugular Intrahepatic Portosystemic Shunt Placement for Cirrhotic Portal Hypertension

2020 ◽  
Vol 28 (1) ◽  
pp. 5-12
Author(s):  
Sara Santos ◽  
Eduardo Dantas ◽  
Filipe Veloso Gomes ◽  
José Hugo Luz ◽  
Nuno Vasco Costa ◽  
...  
Keyword(s):  
Portal Hypertension ◽  
Adverse Events ◽  
Liver Failure ◽  
Transjugular Intrahepatic Portosystemic Shunt ◽  
Variceal Bleeding ◽  
Portosystemic Shunt ◽  
Refractory Ascites ◽  
Lower Baseline ◽  
Intrahepatic Portosystemic Shunt

<b><i>Background and Aims:</i></b> Transjugular intrahepatic portosystemic shunt (TIPS) is used for decompressing clinically significant portal hypertension. The aims of this study were to evaluate clinical outcomes and adverse events associated with this procedure. <b><i>Methods:</i></b> Retrospective single-center study including 78 patients submitted to TIPS placement between January 2015 and November 2018. Follow-up data were missing in 27 patients, and finally 51 patients were included in the study sample. Data collected from individual registries included demographics, comorbidities, laboratory results, complications, and clinical results according to the indication. <b><i>Results:</i></b> Average<b><i></i></b>pre-TIPS portosystemic pressure gradient decreased from 18.1 ± 5 to 6 ± 3 mm Hg after TIPS placement. Indications for TIPS were refractory ascites (63%, <i>n</i> = 49), recurrent or uncontrolled variceal bleeding (36%, <i>n</i> = 28), and Budd-Chiari syndrome (1.3%, <i>n</i> = 1). TIPS-related adverse events occurred in 29/51 (56.8%) patients, with hepatic encephalopathy (HE) in 21 (41%) patients, sepsis in 3, liver failure in 2, hemolytic anemia in 1, acute pulmonary edema in 1, and capsular perforation in 1 patient. Mean follow-up was 15.7 ± 15 months. First-month mortality was 11.7% (<i>n</i> = 6) (sepsis, <i>n</i> = 3; acute liver failure, <i>n</i> = 2; and recurrence of variceal bleeding, <i>n</i> = 1) and was significantly higher for patients with Child-Pugh &#x3e;9 points (<i>p</i> = 0.01), model of end-stage liver disease (MELD) scores &#x3e;19 (<i>p</i> = 0.02), and for patients with a history of HE before the procedure (<i>p</i> = 0.001). Older age (<i>p</i> = 0.006) and higher levels of creatinine (<i>p</i> = 0.008) were significantly higher in patients developing HE after TIPS. Ascites persisted in 21.2% (7/33 patients) and was more frequent in patients with lower baseline albumin levels (<i>p</i> = 0.003). Recurrent variceal bleeding occurred in 22% (<i>n</i> = 4/18 patients) and was more frequent in patients with lower baseline hemoglobin levels (<i>p</i> = 0.03). <b><i>Conclusion:</i></b> TIPS is effective in up to 80% of patients presenting with variceal bleeding or refractory ascites. Careful patient selection based on age and HE history may reduce adverse events after TIPS.

Transjugular portal vein recanalization with creation of intrahepatic portosystemic shunt (PVR-TIPS) in patients with chronic non-cirrhotic, non-malignant portal vein thrombosis

2017 ◽  
Vol 56 (03) ◽  
pp. 221-237 ◽  
Author(s):  
Christoph Klinger ◽  
Bettina Riecken ◽  
Arthur Schmidt ◽  
Andrea De Gottardi ◽  
Benjamin Meier ◽  
...  
Keyword(s):  
Portal Vein ◽  
Portal Vein Thrombosis ◽  
Portosystemic Shunt ◽  
Refractory Ascites ◽  
Bleeding Complications ◽  
Vein Thrombosis ◽  
Cavernous Transformation ◽  
Intrahepatic Portosystemic Shunt ◽  
Intraperitoneal Bleeding

Abstract Purpose To determine safety and efficacy of transjugular portal vein recanalization with creation of intrahepatic portosystemic shunt (PVR-TIPS) in patients with chronic non-cirrhotic, non-malignant portal vein thrombosis (PVT). Methods This retrospective study includes 17 consecutive patients with chronic non-cirrhotic PVT (cavernous transformation n = 15). PVR-TIPS was indicated because of variceal bleeding (n = 13), refractory ascites (n = 2), portal biliopathy with recurrent cholangitis (n = 1), or abdominal pain (n = 1). Treatment consisted of a combination of transjugular balloon angioplasty, mechanical thrombectomy, and—depending on extent of residual thrombosis—transjugular intrahepatic portosystemic shunt and additional stenting of the portal venous system. Results Recanalization was successful in 76.5 % of patients despite cavernous transformation in 88.2 %. Both 1- and 2-year secondary PV and TIPS patency rates were 69.5 %. Procedure-related bleeding complications occurred in 2 patients (intraperitoneal bleeding due to capsule perforation, n = 1; liver hematoma, n = 1) and resolved spontaneously. However, 1 patient died due to subsequent nosocomial pneumonia. During follow-up, 3 patients with TIPS occlusion and PVT recurrence experienced portal hypertensive complications. Conclusions PVR-TIPS is safe and effective in selected patients with chronic non-cirrhotic PVT. Due to technical complexity and possible complications, it should be performed only in specialized centers with high experience in TIPS procedures.

scholarly journals Transjugular Intrahepatic Portosystemic Shunt Using the Trans-splenic Approach and a Snare Technique

2017 ◽  
Vol 01 (03) ◽  
pp. 175-178
Author(s):  
Juil Park ◽  
Hyo-Cheol Kim
Keyword(s):  
Secondary Prevention ◽  
Portal Vein ◽  
Transjugular Intrahepatic Portosystemic Shunt ◽  
Variceal Bleeding ◽  
Technical Difficulty ◽  
Portosystemic Shunt ◽  
Refractory Ascites ◽  
Fluoroscopic Guidance ◽  
Vein Thrombosis ◽  
Intrahepatic Portosystemic Shunt

AbstractTransjugular intrahepatic portosystemic shunt (TIPS) is an established procedure for the secondary prevention of variceal bleeding and management of refractory ascites. Portal vein thrombosis presents technical difficulty during TIPS due to nonvisualization of portal vein. In such patients, trans-splenic approach can be utilized to navigate thrombosed portal vein and use a snare as a fluoroscopic guidance for the intraparenchymal pass. We present the case of a 63-year old man who received the successful TIPS procedure via trans-splenic access without any complication.

Clinical Outcome Using the Fluency Stent Graft for Transjugular Intrahepatic Portosystemic Shunt in Patients with Portal Hypertension

2013 ◽  
Vol 79 (3) ◽  
pp. 305-312 ◽  
Author(s):  
Xingjiang Wu ◽  
Weiwei Ding ◽  
Jianmin Cao ◽  
Xinxin Fan ◽  
Jieshou Li
Keyword(s):  
Portal Hypertension ◽  
Hepatic Encephalopathy ◽  
Stent Graft ◽  
Transjugular Intrahepatic Portosystemic Shunt ◽  
Variceal Bleeding ◽  
Portal Pressure ◽  
Portosystemic Shunt ◽  
Refractory Ascites ◽  
Shunt Occlusion ◽  
Intrahepatic Portosystemic Shunt

The objective of this study was to evaluate the clinical outcomes using the Fluency stent graft for transjugular intrahepatic portosystemic shunt (TIPS) in patients with portal hypertension. From January 2008 to December 2011, 150 patients (110 male and 40 female with a mean age of 51 years) with portal hypertension underwent TIPS creation with the Fluency stent graft. Indications for TIPS treatment were variceal bleeding in 134 cases and refractory ascites in 16 cases. The clinical results pre- and postprocedure were evaluated. All 150 patients underwent a successful TIPS procedure without any technical complications. The portal pressure decreased from 24.3 ± 3.2 mmHg preoperatively to 15.1 ± 2.7 mmHg postoperatively ( P < 0.001), and the portal flow velocity increased from 18.3 ± 4.6 cm/s to 55.6 ± 15.8 cm/s ( P < 0.001). Emergency TIPS was performed in 18 patients with uncontrolled variceal bleeding. During hospitalization, the rates of shunt occlusion, hepatic encephalopathy, variceal rebleeding, and death were 1.3, 0.0, 1.3, and 2.0 per cent, respectively. At a mean follow-up of 24.1 ± 8.8 months, the rates of shunt occlusion, hepatic encephalopathy, variceal rebleeding, and death were 10.0, 15.3, 11.3, and 10.0 per cent, respectively. The main causes of death were hepatic failure, hepatic carcinoma, and recurrent variceal bleeding. The Fluency stent graft is effective in TIPS creation with high patency rates and improves the results of TIPS for portal hypertension.

scholarly journals Technical and Medium-Term Clinical Outcomes of Transjugular Intrahepatic Portosystemic Shunt with Fluoroscopy and Additional Trans-abdominal Ultrasound Guidance

2021 ◽  
Author(s):  
Shyamkumar N. Keshava ◽  
Vinu Moses ◽  
Anand Sharma ◽  
Munawwar Ahmed ◽  
Sathya Narayanan ◽  
...  
Keyword(s):  
Clinical Outcomes ◽  
Transjugular Intrahepatic Portosystemic Shunt ◽  
Ultrasound Guidance ◽  
Vena Cava ◽  
Portosystemic Shunt ◽  
Refractory Ascites ◽  
Transabdominal Ultrasound ◽  
Technical Success ◽  
Intrahepatic Portosystemic Shunt

Abstract Background and Objective The aim of the study is to evaluate the technical and clinical outcomes of transjugular intrahepatic portosystemic shunt (TIPS) performed with additional transabdominal ultrasound guidance. Material and Methods Patients who underwent TIPS between January 2004 to January 2020 in our center were studied. Technical, hemodynamic, angiographic, and clinical outcome were recorded up to 1 year of follow-up. Results TIPS was attempted in 162 patients (median [range] age 37[3–69] years; 105 were males and 57 were females; Etiology: Budd-Chiari syndrome [BCS] 91, cirrhosis 65, symptomatic acute portal venous thrombosis [PVT] 3, veno-occlusive disease [VOD] 2, congenital portosystemic shunt [CPSS] 1) during the study period. Indication for TIPS was refractory ascites in 135 patients (BCS 86, cirrhosis 49) and variceal bleed in 21 patients (BCS 5, cirrhosis 16). Technical success was seen in 161 of the 162 (99.4%) patients. The tract was created from hepatic vein in 55 patients and inferior vena cava (IVC) in 106 patients. Complications within 1 week post TIPS were seen in 29 of the 162 (18%) patients, of whom one developed unexplained arrhythmia and hypotension and died. Of the patients with available follow-up, clinical success was noted in 120 (81%), while 14 (9%) patients had partial nonresponse and six (4%) had complete nonresponse. Eight (5%) patients died during the follow-up period. Conclusion The technical success of TIPS creation with additional transabdominal ultrasound guidance is very high with low peri-procedural complication rate. It has enabled the inclusion of a wider spectrum of cases like acute PVT and obliterated hepatic veins which were otherwise considered contraindications.

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