Transjugular intrahepatic porto-systemic shunt in the elderly: Palliation for complications of portal hypertension

Table 1 Patient characteristics and clinical results

Patient	Sex, age (yr)	Underlying condition	Indication for TIPS	Previous treatment	Child pugh score	MELD score	Survival post shunt	Complications and follow-up
1	F (76)	Hepatitis B	Hydrothorax, refractory ascites	Numerous thoracenteses, furosemide	B (9)	9	25 mo, expired	transient encephalopathy (grade 1 to 2) 1 episode < 30 d, 6 episodes over 24 mo, pulm, edema x 1
2	M (78)	Celiac sprue	Refractory ascites	Numerous paracenteses, spironolactone	C (10)	7	41 mo, expired	Encephalopathy (grade 1 to 2) > 30 d 6 episodes over 40 mo
3	M (71)	Cryptogenic cirrhosis	Refractory ascites	Numerous paracenteses, spironolactone	B (8)	16	8 mo, expired	None
4	F (80)	Cryptogenic cirrhosis	Hepatic hydrothorax	Numerous thoracenteses, spironolactone	C (11)	11	3.5 mo, expired	Encephalopathy transient grade 1 (2 episodes at 30 d and 3 mo)
5	M (69)	Sclerosing cholangitis	Refractory ascites	Numerous paracenteses, spironolactone	C (12)	17	3 mo, expired post attempted shunt	None
6	M (65)	Alcoholic cirrhosis	Hepatic hydrothorax	Numerous thoracenteses, spironolactone, lasix	B (9)	15	19 mo liver transplant, still alive	Encephalopathy transient grade 1 (1 episode > 30 d and < 3 mo)
7	M (71)	Alcoholic cirrhosis	Refractory ascites	Numerous paracenteses, spironolactone, lasix	C (10)	13	3 mo, expired	Encephalopathy transient grade 1 (3 episodes > 30 d)
8	F (70)	Hepatitis C	Refractory ascites, skin breakdown	Numerous paracenteses, spironolactone, lasix	B (8)	9	2nd TIPS placed at 21 mo due to occlusion of 1st TIPS expired 47 mo post initial TIPS	None
9	F (66)	Hepatitis C	Acute bleeding		B (7)	9	Lost to fu pt in Spain	None
10	F (72)	Cryptogenic	Acute bleeding, refractory ascites	Paracentesis, propanolol, lactulose, protonix	B (9)	12	10 mo lost to fu	None
11	F (72)	Hepatitis C	Acute bleeding	Sclerotherapy, spleno-renal shunt × 2, numerous paracentesis, lasix, spironolactone	B (8)	9	Liver transplant 18 mo after TIPS, still alive	None
12	F (67)	Hepatitis B portal vein thrombois	Acute bleeding	Octreotide, protonix	C (10)	10	Liver transplant 16 mo after TIPS, still alive	None
13	M (74)	Hepatitis C (end stage liver disease)	Refractory ascites	Aldactone, lasix, lactulose, protonix	B (8)	15	2 wk, expired	Transient encephalopathy grade 1 (< 2 wk)
14	F (68)	Hepatitis C	Acute bleeding	Midodrine	B (7)	24	2 mo, expired	Recurrent GI bleed 3 wk required revision
15	M (69)	Cryptogenic	Acute bleeding	4 unsuccessful banding, lasix, spironolactone, lactulose, paracentesis	C (10)	21	Revision required 48 h after liver transplant 11 mo after revision, still alive	Continued bleed after 1st TIPS, stopped after revision
16	F (73)	NASH cirrhosis	Acute bleeding	Octreotide, protonix, spironolactone, lasix	B (9)	11	25 mo, still alive	Minimal ascites
17	M (71)	Cryptogenic	Acute bleeding	Band ligation-not successful	B (8)	16	Lost to fu	None
18	M (82)	Cryptogenic	Refractory ascites, acute bleeding	Numerous paracentesis, lasix, amiloride	B (9)	16	2 wk expired (AV block-DNR/DNI )	None
19	M (73)	Hepatitis C	Refractory ascites	Numerous paracenteses, Spironolactone, lasix s/p kidney and liver tx	B (9)	14	1 mo lost to fu	None
20	F (78)	Hepatitis C	Acute bleeding, refractory ascites		B (8)	18	5 d, expired	Post-procedural bleeding, encephalopathy (< 30 d), ascites
21	M (71)	Cirrhosis	Acute bleeding		B (8)	11	Status unknown, discharged to rehabilitation hospital	None
22	M (66)	Alcoholic cirrhosis, s/p liver transplant, portal vein thrombosis	Refractory ascites	Lasix	B (9)	8	Unknown	Failed attempted TIPS
23	M (76)	Alcoholic cirrhosis	Refractory ascites	Numerous paracenteses (once a week)	B(8)	12	15 mo, still alive	None

Table 2 Technical details and results

Patient	Procedure time (min)	Success	No. of stents	Stent type (mm)	Balloon size (mm)	Portosystemic gradient (mmHg)	Revision dates
1	195	No	N/A	N/A	N/A	N/A
1	150	Yes	2	10 × 68	10	6-9
2	160	Yes	2	10 × 68	8	8
Revision 2	165	Yes	1	12 × 90	10	5	Revision 3 wk
Revision 2	105	Yes	1	12 × 90	10	10-12	Revision 8 mo
Revision 2	90	Yes	1	12 × 90	10	6-8	Revision 32 mo
3	140	Yes	1	12 × 90	10	3-4
4	65	Yes	1	10 × 94	8	3-5
5	127	No	N/A	N/A	N/A	N/A
6	165	Yes	1	10 × 601	8	12
7	235	Yes	1	10 × 701	8	13
8	135	Yes	2	8 × 601	8	12
Revision 8	120	Yes	2	8 × 61	8	10	New Parallel TIPS 21 mo
9	15	Yes	1	8 × 701	8	5
10	Unavailable	Yes	1	10 × 801	10	7
Revision 10	50	Yes	1	Unavailable	Unavailable	Unavailable	Revision 10 mo
11	50	Yes	2	10 × 801	10	10
12	70	Yes	1	10 × 801	10	4
13	150	Yes	1	10 × 801	10	3
14	35	Yes	1	10 × 601	10	6
Revision 14	Unavailable	Yes	1	Unavailable	Unavailable	Unavailable	Revision 3 wk
15	35	Yes	1	10 × 701	10	13
Revision 15	18	Yes	1	Unavailable	Unavailable	Unavailable	Revision 48 h
16	55	Yes	1	10 × 801	10	2
17	65	Yes	1	10 × 801	10	8
18	30	Yes	1	10 × 801	10	4
19	85	Yes	2	10 × 601	10	4
Revision 19	Unavailable	Yes	1	12 × 601	10	Unavailable	Unavailable
20	Unavailable	Yes	1	10 × 801	8	4
21	Unavailable	Yes	1	8 × 801	8	2
22	Unavailable	No	N/A	N/A	N/A	N/A
23	135	Yes	1	10 × 701	8	8

¹Denotes Viatorr (W.L Gore, Elkton, MD) covered stent use.

Table 3 Comorbidites

Patient
1	Hypothyroidism, diabetes mellitus, hypertension, chronic GI bleed, hypoxemia on home oxygen
2	Celiac sprue, recurrent chronic bleeding from esophageal varices
3	Congestive heart failure, s/p CABG, s/p mitral valve replacement, chronic atrial fibrillation, hypertension
4	Aortic stenosis
5	Noninsulin dependent diabetes mellitus, chronic renal failure, cholecystectomy, bilateral hernia repair
6	None
7	None
8	None
9	None
10	Status post lumpectomy, diabetes type 2, basal cell carcinoma of the skin, some masculinizing tumor of the ovary for which the patient has had a bilateral salpingo-oopherectomy, hypertension
11	Cholecystectomy, diabetes mellitus
12	Breast cancer in 1996 status post modified radical mastectomy, history of portal vein thrombosis in 2002 secondary to tamoxifen
13	Aortic stenosis; coronary artery disease, status post 3-vessel CABG; diabetes mellitus; and bilateral lower extremity cellulitis.
14	End-stage renal, diabetes, GERD, diverticulitis
15	Hypertension
16	Coronary artery disease (CAD), hyperlipidemia, Anemia
17	Peptic ulcer disease, obstructive sleep apnea, gastroesophageal reflux disease, myeloproliferative disorder, diabetes, aortic stenosis, status post aortic valve replacement in 1996, coronary artery disease
18	Severe aortic stenosis, chronic renal insufficiency, BPH, sinus bradycardia with mobitz type I AV block
19	Renal failure, status post transplant, cryoglobulinemia, BPH, hypothyroidism
20	Hypothyroid, coagulopathy
21	Prostate cancer, CHF, AFib, COPD, hypertension, CVA, respiratory failure, history of MRSA and VRE
22	Spontaneous bacterial peritonitis, status post liver transplant, hypertension, diabetes, portal vein thrombosis
23	CAD, hiatal hernia