Reduction in Portal Venous Pressure by Transjugular Intrahepatic Portosystemic Shunt for Treatment of Hemorrhagic Stomal Varices

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.

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Transjugular Intrahepatic Portosystemic Shunt: A Literature Review

Journal of Diagnostic Medical Sonography ◽

10.1177/8756479317746338 ◽

2017 ◽

Vol 34 (2) ◽

pp. 114-122 ◽

Cited By ~ 1

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.

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

Digestive Diseases ◽

10.1159/000486030 ◽

2018 ◽

Vol 36 (3) ◽

pp. 218-227 ◽

Cited By ~ 4

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.

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Transjugular intrahepatic portosystemic shunt for bleeding stomal varices associated with chronic portal vein occlusion: long-term angiographic, hemodynamic, and clinical follow-up

The American Journal of Gastroenterology ◽

10.1111/j.1572-0241.2000.03211.x ◽

2000 ◽

Vol 95 (10) ◽

pp. 2966-2968 ◽

Cited By ~ 21

Author(s):

Christopher S. Morris ◽

Kenneth E. Najarian

Keyword(s):

Portal Vein ◽

Transjugular Intrahepatic Portosystemic Shunt ◽

Portosystemic Shunt ◽

Portal Vein Occlusion ◽

Vein Occlusion ◽

Stomal Varices ◽

Intrahepatic Portosystemic Shunt

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Endovascular management of bleeding peristomal varices

International Surgery Journal ◽

10.18203/2349-2902.isj20171158 ◽

2017 ◽

Vol 4 (4) ◽

pp. 1458

Author(s):

Krantikumar Rathod ◽

H. L. Deshmukh ◽

Bhavesh Popat ◽

Shamsh Tabrez Alam

Keyword(s):

Variceal Bleeding ◽

Venous Pressure ◽

High Rate ◽

Portal Venous Pressure ◽

Endovascular Management ◽

Stoma Creation ◽

Stomal Varices ◽

Intrahepatic Portosystemic Shunt ◽

Inflammatory Bowel ◽

Collateral Formation

Bleeding from the peristomal varices is a rare recognised complication of stoma creation following proctocolectomy in a case of inflammatory bowel disease and associated sclerosing cholangitis. Peri-stomal varices are uncommon site of porto-systemic collateral formation in cases of pre-exiting portal hypertension and eventually a potential site of variceal bleeding. The management of peristomal variceal bleeding includes local compression, ligation, sclerotherapy and percutaneous variceal embolization; however these procedures are associated with high rate of recurrence because of the persistent raised portal venous pressure. Transjugular intrahepatic portosystemic shunt (TIPSS) is an artificial shunt created to reduce the raised portal venous pressure and can be used for the immediate relief of bleeding from peristomal varices. We are reporting a case of peristomal varices managed by transjugular intrahepatic porto-systemic shunt creation followed by coil embolization of peristomal varices and subsequently review the literature related to its management.

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