|
1
|
Wang ZB, Zhu B, Meng MM, Wu YF, Zhang Y, Li DZ, Tian H, Wang FC, Lv YF, Ye QX, Liu FQ. Nomogram for predicting survival after transjugular intrahepatic portosystemic shunt in portal hypertension patients with bleeding. World J Gastrointest Surg 2025; 17:104884. [DOI: 10.4240/wjgs.v17.i4.104884] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/04/2025] [Revised: 02/17/2025] [Accepted: 03/10/2025] [Indexed: 03/29/2025] Open
Abstract
BACKGROUND Portal hypertension (PHT) is a life-threatening complication of cirrhosis, often resulting in gastrointestinal bleeding that requires transjugular intrahepatic portosystemic shunt (TIPS). While TIPS effectively reduces portal pressure, predicting long-term survival remains challenging due to the multifactorial nature of patient outcomes. Accurate survival prediction tools are lacking, and existing models often omit critical factors such as portal vein diameter. This study aimed to develop and validate a nomogram incorporating key clinical and biochemical variables to predict 1-year and 2-year survival following TIPS in PHT patients. We hypothesized that this model would provide improved risk stratification and guide clinical decisions.
AIM To develop and validate a nomogram for predicting 1-year and 2-year survival in PHT patients post-TIPS.
METHODS This retrospective cohort study included 848 TIPS-treated PHT patients with gastrointestinal bleeding from two tertiary hospitals (2013-2021). Mortality was the primary endpoint. Predictive variables were selected using least absolute shrinkage and selection operator regression, and a nomogram was developed with Cox regression to predict 1-year and 2-year survival. Model performance was evaluated through receiver operating characteristic curves, calibration plots, and decision curve analysis.
RESULTS The mean age of the included (848) patients was 53.00 years ± 12.51, where 69.58% were men. Results showed that portal vein diameter, serum creatinine, potassium, and alpha-fetoprotein were the independent predictors of post-TIPS survival. Besides, the model showed strong discriminatory ability (C-index, 0.816 in the training set; 0.827 in the validation set) and good calibration. The area under the curve for 1-year and 2-year survival in the training set were 0.890 [95% confidence interval (CI): 0.802-0.948] and 0.838 (95%CI: 0.803-0.869), respectively. The area under the curve for 1-year and 2-year survival in the validation set were 0.934 (95%CI: 0.815-0.987) and 0.864 (95%CI: 0.811-0.907), respectively.
CONCLUSION The developed nomogram could reliably predict 1-year and 2-year survival in patients undergoing TIPS for PHT-induced gastrointestinal bleeding.
Collapse
Affiliation(s)
- Zhi-Bin Wang
- Center for Minimally Invasive Treatment of Liver Diseases, Beijing Shijitan Hospital, Capital Medical University, Beijing 100080, China
| | - Bing Zhu
- Center for Diagnosis and Treatment of Hepatic Vascular Diseases, Fifth Medical Center of Chinese PLA General Hospital, Beijing 100071, China
| | - Ming-Ming Meng
- Center for Minimally Invasive Treatment of Liver Diseases, Beijing Shijitan Hospital, Capital Medical University, Beijing 100080, China
| | - Yi-Fan Wu
- Center for Minimally Invasive Treatment of Liver Diseases, Beijing Shijitan Hospital, Capital Medical University, Beijing 100080, China
| | - Yu Zhang
- Center for Minimally Invasive Treatment of Liver Diseases, Beijing Shijitan Hospital, Capital Medical University, Beijing 100080, China
| | - Dong-Ze Li
- Center for Diagnosis and Treatment of Hepatic Vascular Diseases, Fifth Medical Center of Chinese PLA General Hospital, Beijing 100071, China
| | - Hua Tian
- Center for Diagnosis and Treatment of Hepatic Vascular Diseases, Fifth Medical Center of Chinese PLA General Hospital, Beijing 100071, China
| | - Fu-Chuan Wang
- Center for Diagnosis and Treatment of Hepatic Vascular Diseases, Fifth Medical Center of Chinese PLA General Hospital, Beijing 100071, China
| | - Yi-Fan Lv
- Center for Minimally Invasive Treatment of Liver Diseases, Beijing Shijitan Hospital, Capital Medical University, Beijing 100080, China
| | - Qiu-Xia Ye
- Center for Minimally Invasive Treatment of Liver Diseases, Beijing Shijitan Hospital, Capital Medical University, Beijing 100080, China
| | - Fu-Quan Liu
- Center for Minimally Invasive Treatment of Liver Diseases, Beijing Shijitan Hospital, Capital Medical University, Beijing 100080, China
- Center for Diagnosis and Treatment of Hepatic Vascular Diseases, Fifth Medical Center of Chinese PLA General Hospital, Beijing 100071, China
| |
Collapse
|
|
2
|
Wang ZB, Zhu B, Meng MM, Wu YF, Zhang Y, Li DZ, Tian H, Wang FC, Lv YF, Ye QX, Liu FQ. Effect of portal pressure gradient reduction on outcomes after transjugular intrahepatic portosystemic shunt in portal hypertension patients. World J Hepatol 2025; 17:103261. [PMID: 40177196 PMCID: PMC11959671 DOI: 10.4254/wjh.v17.i3.103261] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/14/2024] [Revised: 02/01/2025] [Accepted: 03/04/2025] [Indexed: 03/26/2025] Open
Abstract
BACKGROUND Portal hypertension (PHT), a complication of liver cirrhosis, is sometimes managed with transjugular intrahepatic portosystemic shunt (TIPS) to reduce portal pressure. Although effective, TIPS poses risks, including hepatic encephalopathy (HE). This study investigates whether a significant reduction in the portal pressure gradient (PPG) after TIPS improves outcomes in PHT patients. AIM To evaluate the impact of post-TIPS PPG reduction on clinical outcomes and explore the relationship between PPG reduction and portal vein diameter. METHODS This retrospective cohort study included 815 patients with PHT who underwent TIPS at two tertiary hospitals between 2014 and 2022. Patients were categorized based on whether they achieved a 50% reduction in PPG. Propensity score matching was applied to balance baseline characteristics. Kaplan-Meier analysis assessed clinical outcomes, including rebleeding, HE, liver failure, and hepatocellular carcinoma. Cox regression identified risk factors, and Spearman correlation analyzed the relationship between PPG reduction and portal vein diameter. RESULTS Patients with a PPG reduction > 50% had significantly lower risks of rebleeding (P = 0.004), shunt dysfunction (P = 0.002), and mortality (P = 0.024) compared to those with a PPG reduction ≤ 50%. However, these patients faced higher risks of HE (P < 0.001) and liver failure (P = 0.003). A significant negative correlation was observed between the percentage of PPG reduction and portal vein diameter (ρ = -0.632, P < 0.001), suggesting that patients with smaller portal vein diameters may achieve greater PPG reductions. CONCLUSION A significant PPG reduction following TIPS is associated with improved clinical outcomes, including reduced risks of rebleeding, shunt dysfunction, hepatocellular carcinoma, and mortality, though it increases HE and liver failure risks. The observed correlation between portal vein diameter and PPG reduction highlights the potential role of portal vein anatomy in predicting TIPS efficacy, warranting further investigation.
Collapse
Affiliation(s)
- Zhi-Bin Wang
- Center for Minimally Invasive Treatment of Liver Diseases, Beijing Shijitan Hospital, Capital Medical University, Beijing 100080, China
| | - Bing Zhu
- Center for Diagnosis and Treatment of Hepatic Vascular Diseases, The Fifth Medical Center of Chinese People's Liberation Army General Hospital, Beijing 100071, China
| | - Ming-Ming Meng
- Center for Minimally Invasive Treatment of Liver Diseases, Beijing Shijitan Hospital, Capital Medical University, Beijing 100080, China
| | - Yi-Fan Wu
- Center for Minimally Invasive Treatment of Liver Diseases, Beijing Shijitan Hospital, Capital Medical University, Beijing 100080, China
| | - Yu Zhang
- Center for Minimally Invasive Treatment of Liver Diseases, Beijing Shijitan Hospital, Capital Medical University, Beijing 100080, China
| | - Dong-Ze Li
- Center for Diagnosis and Treatment of Hepatic Vascular Diseases, The Fifth Medical Center of Chinese People's Liberation Army General Hospital, Beijing 100071, China
| | - Hua Tian
- Center for Diagnosis and Treatment of Hepatic Vascular Diseases, The Fifth Medical Center of Chinese People's Liberation Army General Hospital, Beijing 100071, China
| | - Fu-Chuan Wang
- Center for Diagnosis and Treatment of Hepatic Vascular Diseases, The Fifth Medical Center of Chinese People's Liberation Army General Hospital, Beijing 100071, China
| | - Yi-Fan Lv
- Center for Minimally Invasive Treatment of Liver Diseases, Beijing Shijitan Hospital, Capital Medical University, Beijing 100080, China
| | - Qiu-Xia Ye
- Center for Minimally Invasive Treatment of Liver Diseases, Beijing Shijitan Hospital, Capital Medical University, Beijing 100080, China
| | - Fu-Quan Liu
- Center for Minimally Invasive Treatment of Liver Diseases, Beijing Shijitan Hospital, Capital Medical University, Beijing 100080, China
- Center for Diagnosis and Treatment of Hepatic Vascular Diseases, The Fifth Medical Center of Chinese People's Liberation Army General Hospital, Beijing 100071, China.
| |
Collapse
|
|
3
|
Xiong X, Li L, Feng YX, Liu S, Zhao C, Gao L, Li JY, Feng DP. High stent shunt flow increases the incidence of overt-hepatic encephalopathy in cirrhotic patients after transjugular intrahepatic portosystemic shunt. Eur J Gastroenterol Hepatol 2025; 37:00042737-990000000-00501. [PMID: 40106699 PMCID: PMC11949224 DOI: 10.1097/meg.0000000000002942] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/12/2024] [Accepted: 01/13/2025] [Indexed: 03/22/2025]
Abstract
BACKGROUND The incidence of hepatic encephalopathy (HE) was higher within 1 year after transjugular intrahepatic portosystemic shunt (TIPS) in cirrhosis. While some findings showed that the shunt flow correlates with HE, it remains unknown whether the stent shunt flow (SSF) is associated with overt-hepatic encephalopathy (OHE). This study, therefore, investigated the association between SSF and OHE after a TIPS. METHODS A digital color ultrasonic diagnostic device was used to measure stent flow velocity (SFV). The association between SSF and OHE was then examined using logistic regression and restricted cubic spline models. The predictive value of SSF for OHE was also assessed using receiver operating characteristic curve analysis. RESULTS Of the 91 patients, 24 (26.4%) developed OHE after TIPS within 1 year. Patients with OHE post-TIPS had higher SSF than those without [2459 (2203-2490) ml/min vs. 2190 (1968-2363) ml/min; P = 0.001]. Multiple logistic regression showed interquartile range of SSF was associated positively with the risk of OHE after TIPS [odds ratio, 2.483; 95% confidence interval (CI), 1.407-4.383; P = 0.002]. The Andersen-Gill model indicated SSF [hazard ratio (HR), 1.002; 95% CI, 1.001-1.004; P < 0.05] and age (HR, 1.042; 95% CI, 1.012-1.072; P < 0.01) were independent predictors of OHE after TIPS. SSF had higher predictive power for OHE than age, ammonia levels, Child-Pugh score, and model for end-stage liver disease score. CONCLUSION This study suggests high SSF may be associated closely with an increased risk of OHE in patients with cirrhosis following TIPS.
Collapse
Affiliation(s)
- Xin Xiong
- Academy of Medical Sciences, Shanxi Medical University
| | - Lei Li
- Department of Oncological and Vascular Intervention, First Hospital of Shanxi Medical University
- Shanxi Provincial Clinical Research Center for Interventional Medicine, First Hospital of Shanxi Medical University, Taiyuan, Shanxi Province, China
| | - Yu-Xing Feng
- Academy of Medical Sciences, Shanxi Medical University
| | - Shuai Liu
- Department of Oncological and Vascular Intervention, First Hospital of Shanxi Medical University
- Shanxi Provincial Clinical Research Center for Interventional Medicine, First Hospital of Shanxi Medical University, Taiyuan, Shanxi Province, China
| | - Chao Zhao
- Department of Oncological and Vascular Intervention, First Hospital of Shanxi Medical University
- Shanxi Provincial Clinical Research Center for Interventional Medicine, First Hospital of Shanxi Medical University, Taiyuan, Shanxi Province, China
| | - Long Gao
- Department of Oncological and Vascular Intervention, First Hospital of Shanxi Medical University
- Shanxi Provincial Clinical Research Center for Interventional Medicine, First Hospital of Shanxi Medical University, Taiyuan, Shanxi Province, China
| | - Jin-Yu Li
- Department of Oncological and Vascular Intervention, First Hospital of Shanxi Medical University
- Shanxi Provincial Clinical Research Center for Interventional Medicine, First Hospital of Shanxi Medical University, Taiyuan, Shanxi Province, China
| | - Dui-Ping Feng
- Department of Oncological and Vascular Intervention, First Hospital of Shanxi Medical University
- Shanxi Provincial Clinical Research Center for Interventional Medicine, First Hospital of Shanxi Medical University, Taiyuan, Shanxi Province, China
| |
Collapse
|
|
4
|
Praktiknjo M, Shawcross D, Laleman W. The clinical relevance of acute-on-chronic liver failure in medical procedures: Endoscopy, interventions and surgery. Liver Int 2025; 45:e15749. [PMID: 37753553 DOI: 10.1111/liv.15749] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/30/2023] [Revised: 08/30/2023] [Accepted: 09/13/2023] [Indexed: 09/28/2023]
Abstract
Acute-on-chronic liver failure (ACLF) is a specific, but complex and multifactorial form of acute decompensation (AD) of cirrhosis and is characterized by an extraordinary dynamic natural course, rapidly evolving organ failure and high short-term mortality. In daily clinical practice, patients with liver cirrhosis and decompensation have indications for different medical procedures such as endoscopies, interventional treatments like transjugular intrahepatic portosystemic shunt (TIPS) or even surgical procedures. In these situations, clinicians often need to balance the expected benefits of such procedures with the risks of causing acute decompensation or ACLF. This review summarizes the evidence of medical procedures and their role in precipitating or preventing ACLF and highlights the aspects to consider during patient selection.
Collapse
Affiliation(s)
- Michael Praktiknjo
- Department of Medicine B, Gastroenterology, Hepatology, Endocrinology, Infectious Diseases, Universitätsklinikum Münster, Münster, Germany
| | - Debbie Shawcross
- Institute of Liver Studies, Department of Inflammation Biology, School of Immunology and Microbial Sciences, Faculty of Life Sciences and Medicine, King's College London, London, UK
| | - Wim Laleman
- Department of Medicine B, Gastroenterology, Hepatology, Endocrinology, Infectious Diseases, Universitätsklinikum Münster, Münster, Germany
- Department of Gastroenterology & Hepatology, University Hospitals Leuven, Leuven, Belgium
- Department of Chronic Diseases, Metabolism and Aging (CHROMETA), Catholic University of Leuven, Leuven, Belgium
| |
Collapse
|
|
5
|
de Mattos AA, de Mattos AZ, Manica M, Tovo CV. Which patients benefit the most? An update on transjugular intrahepatic portosystemic shunt. World J Hepatol 2025; 17:99809. [PMID: 40027554 PMCID: PMC11866145 DOI: 10.4254/wjh.v17.i2.99809] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/31/2024] [Revised: 12/23/2024] [Accepted: 01/09/2025] [Indexed: 02/20/2025] Open
Abstract
This is a narrative review in which the advances in technical aspects, the main indications, limitations and clinical results of the transjugular intrahepatic portosystemic shunt (TIPS) in portal hypertension (PH) are addressed. With the emergence of the coated prosthesis, a better shunt patency, a lower incidence of hepatic encephalopathy (HE) and better survival when compared to TIPS with the conventional prosthesis are demonstrated. The main indications for TIPS are refractory ascites, acute variceal bleeding unresponsive to pharmacological/endoscopic therapy and, lastly, patients considered at high risk for rebleeding preemptive TIPS (pTIPS). Absolute contraindications to the use of TIPS are severe uncontrolled HE, systemic infection or sepsis, congestive heart failure, severe pulmonary arterial hypertension, and biliary obstruction. The control of hemorrhage due to variceal rupture can reach up to 90%-100% of cases, and 55% in refractory ascites. Despite evidences regarding pTIPS in patients at high risk for rebleeding, less than 20% of eligible patients are treated. TIPS may also decrease the incidence of future decompensation in cirrhosis and increase survival in selected patients. In conclusion, TIPS is an essential treatment for patients with PH, but is often neglected. It is important for the hepatologist to form a multidisciplinary team, in which the role of the radiologist with experience in interventional procedures is prominent.
Collapse
Affiliation(s)
- Angelo Alves de Mattos
- Postgraduation Program in Medicine: Hepatology, Universidade Federal de Ciências da Saúde de Porto Alegre (UFCSPA), Porto Alegre 90050-170, Rio Grande do Sul, Brazil
| | - Angelo Zambam de Mattos
- Postgraduation Program in Medicine: Hepatology, Universidade Federal de Ciências da Saúde de Porto Alegre (UFCSPA), Porto Alegre 90050-170, Rio Grande do Sul, Brazil
| | - Muriel Manica
- Postgraduation Program in Medicine: Hepatology, Universidade Federal de Ciências da Saúde de Porto Alegre (UFCSPA), Porto Alegre 90050-170, Rio Grande do Sul, Brazil
| | - Cristiane Valle Tovo
- Postgraduation Program in Medicine: Hepatology, Universidade Federal de Ciências da Saúde de Porto Alegre (UFCSPA), Porto Alegre 90050-170, Rio Grande do Sul, Brazil.
| |
Collapse
|
|
6
|
Wang Z, Xu XY, Liu CY, Huang JT, Li WC, Zhang S, Shen J, Zhong BY, Zhu XL. Evaluation of the Efficacy and Safety of Transjugular Intrahepatic Portosystemic Shunt Combined With Concurrent Antegrade Embolization of Large Spontaneous Portosystemic Shunts. J Med Imaging Radiat Oncol 2025. [PMID: 39981811 DOI: 10.1111/1754-9485.13832] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2024] [Revised: 12/11/2024] [Accepted: 12/29/2024] [Indexed: 02/22/2025]
Abstract
OBJECTIVES To compare the long-term efficacy and safety of transjugular intrahepatic portosystemic shunt (TIPS) combined with concurrent antegrade embolization in treating portal hypertension with oesophagogastric variceal bleeding in patients with and without large spontaneous portosystemic shunts (L-SPSSs). MATERIALS AND METHODS We retrospectively analysed data from patients with portal hypertension who underwent TIPS from November 2015 to April 2022. The patients were screened according to the inclusion criteria and were divided into L-SPSSs group (L-S group) and Non L-SPSSs group (Non L-S group). The primary outcome was the 2-year liver transplantation-free survival (TFS) rate. Secondary outcomes contained the incidence of overt hepatic encephalopathy (OHE), ectopic embolization and the 2-year rebleeding rate. RESULTS A total of 259 patients were enrolled (64 patients in L-S group and 195 patients in Non L-S group). The average age was 57.2 years, and the success rate of procedure was 100%. Baseline data showed no significant differences between two groups. There was a statistically significant difference in the 2-year liver transplantation-free rate between two groups (L-S vs. Non L-S, 84.38% vs. 71.28%; p = 0.045). OHE occurred in 19 (29.69%) patients with L-SPSSs and 104 (53.33%) patients without L-SPSSs, with a statistically significant difference (p = 0.001). And no statistically significant difference was found in ectopic embolism incidence rate and the 2-year rebleeding rate between two groups. Multivariate Cox regression analysis identified male gender, portal vein thrombosis and preoperative high blood ammonia levels as independent risk factors for long-term survival. CONCLUSION Compared to Non L-S group, the patients in L-S group achieve longer liver transplantation-free survival and lower incidence rate of OHE without increasing the risk of 2-year rebleeding and ectopic embolization.
Collapse
Affiliation(s)
- Ze Wang
- Department of Interventional Radiology, The First Affiliated Hospital of Soochow University, Suzhou, People's Republic of China
| | - Xiao-Yang Xu
- Department of Interventional Radiology, The First Affiliated Hospital of Soochow University, Suzhou, People's Republic of China
| | - Chen-You Liu
- Department of Interventional Radiology, The First Affiliated Hospital of Soochow University, Suzhou, People's Republic of China
| | - Jin-Tao Huang
- Department of Interventional Radiology, The First Affiliated Hospital of Soochow University, Suzhou, People's Republic of China
| | - Wan-Ci Li
- Department of Interventional Radiology, The First Affiliated Hospital of Soochow University, Suzhou, People's Republic of China
| | - Shuai Zhang
- Department of Interventional Radiology, The First Affiliated Hospital of Soochow University, Suzhou, People's Republic of China
| | - Jian Shen
- Department of Interventional Radiology, The First Affiliated Hospital of Soochow University, Suzhou, People's Republic of China
| | - Bin-Yan Zhong
- Department of Interventional Radiology, The First Affiliated Hospital of Soochow University, Suzhou, People's Republic of China
| | - Xiao-Li Zhu
- Department of Interventional Radiology, The First Affiliated Hospital of Soochow University, Suzhou, People's Republic of China
| |
Collapse
|
|
7
|
Bozon-Rivière P, Rudler M, Weiss N, Thabut D. TIPS and hepatic encephalopathy in patients with cirrhosis. Metab Brain Dis 2025; 40:117. [PMID: 39903376 DOI: 10.1007/s11011-025-01541-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/06/2024] [Accepted: 01/17/2025] [Indexed: 02/06/2025]
Abstract
Despite a better understanding in its prognosis and pathogenesis, hepatic encephalopathy (HE) remains one of the major complications of Transjugular Intrahepatic Portosystemic Shunt (TIPS) with a prevalence ranging from 35 to 50%. Its epidemiology differs according to the indication for TIPS (salvage/rescue TIPS, preemptive (pTIPS) or elective TIPS). In salvage/rescue TIPS, the prognosis is linked to that of bleeding, and HE should not be a contraindication to TIPS, especially as bleeding is a common precipitating factor of HE. In pTIPS, i.e. TIPS performed within the 72 h after stabilization of acute variceal bleeding in high-risk patients, the risk rebleeding and HE is reduced, when compared to endoscopic and drugs treatment. As a consequence, the Baveno VII recommendations state that HE at admission should not be considered as a contraindication to pTIPS placement. In elective situations, such as refractory (intractable ascites (intolerance to diuretics) or resistant ascites (i.e. despite optimal diuretic treatment (spironolactone 400 mg/d and Furosemide 160 mg/d combined with low-salt treatment (< 5.2 g/day) or recurrent ascites (the need for at least 3 paracenteses per year) and secondary prophylaxis of variceal bleeding, it is recommended to systematically look for risk factors for HE, and chronic or refractory HE remain not recommended to TIPS in most centers. Chronic HE involves persistent neurological symptoms with fluctuating acute episodes. Recurrent HE refers to repeated episodes occurring within 6 months, while refractory HE is resistant to standard treatments, often requiring more aggressive management (Vilstrup et al. 2014). A careful selection of patients is mandatory before elective TIPS decision. Risk factors must be identified and corrected if possible before any TIPS decision is made. Management of HE after TIPS is based on identification of precipitating factors, curative treatment with lactulose as first-line therapy and rifaximin as second-line therapy, and nutritional management. In elective TIPS, prophylactic administration of rifaximin is recommended in order to decrease the risk of further HE development in selected patients (not in everyone, at least according to Baveno VII). Liver transplantation (LT) should be discussed with a multidisciplinary team as an alternative option to TIPS in case of high-risk of post-TIPS HE, and in case of refractory HE after TIPS.
Collapse
Affiliation(s)
- Pauline Bozon-Rivière
- Liver Intensive Care Unit, Hepatogastroenterology Department, AP-HP, Sorbonne Université, Pitié-Salpêtrière Hospital, 47-83 Boulevard de l'Hôpital, Paris, 75013, France
| | - Marika Rudler
- Brain-Liver Pitié-Salpêtrière Study Group (BLIPS), Hôpital de la Pitié Salpétrière, INSERM UMR_S 938, CDR Saint-Antoine, Assistance Publique-Hôpitaux de Paris, Paris, France.
- Liver Intensive Care Unit, Hepatogastroenterology Department, AP-HP, Sorbonne Université, Pitié-Salpêtrière Hospital, 47-83 Boulevard de l'Hôpital, Paris, 75013, France.
| | - Nicolas Weiss
- Brain-Liver Pitié-Salpêtrière Study Group (BLIPS), Hôpital de la Pitié Salpétrière, INSERM UMR_S 938, CDR Saint-Antoine, Assistance Publique-Hôpitaux de Paris, Paris, France.
- Neurology Intensive Care Unit, Neurology Department, AP-HP, Sorbonne Université, La Pitié-Salpêtrière Hospital, 47-83 Boulevard de l'Hôpital, Paris, 75013, France.
| | - Dominique Thabut
- Brain-Liver Pitié-Salpêtrière Study Group (BLIPS), Hôpital de la Pitié Salpétrière, INSERM UMR_S 938, CDR Saint-Antoine, Assistance Publique-Hôpitaux de Paris, Paris, France.
- Liver Intensive Care Unit, Hepatogastroenterology Department, AP-HP, Sorbonne Université, Pitié-Salpêtrière Hospital, 47-83 Boulevard de l'Hôpital, Paris, 75013, France.
| |
Collapse
|
|
8
|
Lv Y, Wang Q, Luo B, Bai W, Li M, Li K, Wang Z, Xia D, Guo W, Li X, Yuan J, Zhang N, Wang X, Xie H, Pan Y, Nie Y, Yin Z, Fan D, Han G. Identifying the optimal measurement timing and hemodynamic targets of portal pressure gradient after TIPS in patients with cirrhosis and variceal bleeding. J Hepatol 2025; 82:245-257. [PMID: 39181214 DOI: 10.1016/j.jhep.2024.08.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/17/2024] [Revised: 07/28/2024] [Accepted: 08/06/2024] [Indexed: 08/27/2024]
Abstract
BACKGROUND & AIMS The optimal timing of measurement and hemodynamic targets of portacaval pressure gradient (PPG) after transjugular intrahepatic portosystemic shunt (TIPS) placement remain unclear. This study aimed to identify the ideal moment for hemodynamic measurements and the optimal target of PPG in patients undergoing covered TIPS for variceal bleeding. METHODS Between May 2018 and December 2021, 466 consecutive patients with recurrent variceal bleeding treated with covered TIPS were prospectively included. Post-TIPS PPG was measured immediately (immediate PPG), 24-72 hours (early PPG), and again 1 month (late PPG) after TIPS placement. The agreement among PPGs measured at different time points was assessed by intra-class correlation coefficient (ICC) and Bland-Altman method. The unadjusted and confounder-adjusted effects of PPGs on clinical outcomes (portal hypertensive complications [PHCs], overt hepatic encephalopathy [OHE], further decompensation, and death) were assessed using Fine and Gray competing risk regression models. RESULTS The agreement between early PPG and late PPG (ICC: 0.34) was better than that between immediate PPG and late PPG (ICC: 0.23, p <0.001). Early PPG revealed an excellent predictive value for PHCs (early PPG≥ vs. <12 mmHg: adjusted hazard ratio 2.17, 95% CI 1.33-3.55, p = 0.002) and OHE (0.40, 95% CI 0.17-0.91, p = 0.030), while immediate PPG did not. Late PPG showed a predictive value for PHC risk but not OHE. By targeting the lowest risk of further decompensation, we identified an optimal hemodynamic target with early PPG ranging from 11 to 14 mmHg that was associated with a decreased risk of OHE and effective prevention of PHCs. CONCLUSIONS PPG measured 24 to 72 hours after TIPS correlates with long-term PPG and clinical outcomes, and a hemodynamic target PPG of 11-14 mmHg is associated with reduced encephalopathy but not compromised clinical efficacy. IMPACT AND IMPLICATIONS The optimal timing of measurement and hemodynamic targets of portacaval pressure gradient (PPG) after transjugular intrahepatic portosystemic shunt (TIPS) remain unclear. Here we show that post-TIPS PPG measured at least 24 hours but not immediately after the procedure correlated with long-term PPG and clinical events. Thus, PPG measurements taken at least 24 hours after TIPS should be used to guide decision making in order to improve clinical outcomes. Targeting a post-TIPS PPG of 11-14 mmHg or a 20%-50% relative reduction from pre-TIPS baseline measured 24-72 hours after the procedure was associated with reduced encephalopathy but not compromised clinical efficacy. Thus, these criteria could be used to guide TIPS creation and revision in patients with cirrhosis and variceal bleeding undergoing covered TIPS. CLINICAL TRIAL REGISTRATION NUMBER ClinicalTrials.gov, ID: NCT03590288.
Collapse
Affiliation(s)
- Yong Lv
- National Clinical Research Center for Digestive Diseases and State Key Laboratory of Holistic Integrative Management of Gastrointestinal Cancers, Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an 710032, China; Department of Liver Diseases and Digestive Interventional Radiology, National Clinical Research Centre for Digestive Diseases, Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an 710032, China
| | - Qiuhe Wang
- Department of Liver Diseases and Digestive Interventional Radiology, National Clinical Research Centre for Digestive Diseases, Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an 710032, China
| | - Bohan Luo
- Department of Liver Diseases and Digestive Interventional Radiology, National Clinical Research Centre for Digestive Diseases, Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an 710032, China; Department of Liver Diseases and Digestive Interventional Radiology, Digestive Diseases Hospital, Xi'an International Medical Center Hospital, Northwest University, Xi'an 710032, China
| | - Wei Bai
- Department of Liver Diseases and Digestive Interventional Radiology, National Clinical Research Centre for Digestive Diseases, Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an 710032, China; Department of Liver Diseases and Digestive Interventional Radiology, Digestive Diseases Hospital, Xi'an International Medical Center Hospital, Northwest University, Xi'an 710032, China
| | - Menghao Li
- National Clinical Research Center for Digestive Diseases and State Key Laboratory of Holistic Integrative Management of Gastrointestinal Cancers, Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an 710032, China; Department of Liver Diseases and Digestive Interventional Radiology, National Clinical Research Centre for Digestive Diseases, Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an 710032, China
| | - Kai Li
- National Clinical Research Center for Digestive Diseases and State Key Laboratory of Holistic Integrative Management of Gastrointestinal Cancers, Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an 710032, China; Department of Liver Diseases and Digestive Interventional Radiology, National Clinical Research Centre for Digestive Diseases, Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an 710032, China
| | - Zhengyu Wang
- Department of Liver Diseases and Digestive Interventional Radiology, National Clinical Research Centre for Digestive Diseases, Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an 710032, China; Department of Liver Diseases and Digestive Interventional Radiology, Digestive Diseases Hospital, Xi'an International Medical Center Hospital, Northwest University, Xi'an 710032, China
| | - Dongdong Xia
- National Clinical Research Center for Digestive Diseases and State Key Laboratory of Holistic Integrative Management of Gastrointestinal Cancers, Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an 710032, China; Department of Liver Diseases and Digestive Interventional Radiology, National Clinical Research Centre for Digestive Diseases, Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an 710032, China
| | - Wengang Guo
- Department of Liver Diseases and Digestive Interventional Radiology, National Clinical Research Centre for Digestive Diseases, Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an 710032, China; Department of Liver Diseases and Digestive Interventional Radiology, Digestive Diseases Hospital, Xi'an International Medical Center Hospital, Northwest University, Xi'an 710032, China
| | - Xiaomei Li
- Department of Liver Diseases and Digestive Interventional Radiology, National Clinical Research Centre for Digestive Diseases, Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an 710032, China; Department of Liver Diseases and Digestive Interventional Radiology, Digestive Diseases Hospital, Xi'an International Medical Center Hospital, Northwest University, Xi'an 710032, China
| | - Jie Yuan
- Department of Liver Diseases and Digestive Interventional Radiology, National Clinical Research Centre for Digestive Diseases, Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an 710032, China; Department of Liver Diseases and Digestive Interventional Radiology, Digestive Diseases Hospital, Xi'an International Medical Center Hospital, Northwest University, Xi'an 710032, China
| | - Na Zhang
- Department of Liver Diseases and Digestive Interventional Radiology, Digestive Diseases Hospital, Xi'an International Medical Center Hospital, Northwest University, Xi'an 710032, China
| | - Xing Wang
- Department of Liver Diseases and Digestive Interventional Radiology, Digestive Diseases Hospital, Xi'an International Medical Center Hospital, Northwest University, Xi'an 710032, China
| | - Huahong Xie
- National Clinical Research Center for Digestive Diseases and State Key Laboratory of Holistic Integrative Management of Gastrointestinal Cancers, Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an 710032, China
| | - Yanglin Pan
- National Clinical Research Center for Digestive Diseases and State Key Laboratory of Holistic Integrative Management of Gastrointestinal Cancers, Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an 710032, China
| | - Yongzhan Nie
- National Clinical Research Center for Digestive Diseases and State Key Laboratory of Holistic Integrative Management of Gastrointestinal Cancers, Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an 710032, China
| | - Zhanxin Yin
- Department of Liver Diseases and Digestive Interventional Radiology, National Clinical Research Centre for Digestive Diseases, Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an 710032, China; Department of Liver Diseases and Digestive Interventional Radiology, Digestive Diseases Hospital, Xi'an International Medical Center Hospital, Northwest University, Xi'an 710032, China
| | - Daiming Fan
- National Clinical Research Center for Digestive Diseases and State Key Laboratory of Holistic Integrative Management of Gastrointestinal Cancers, Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an 710032, China
| | - Guohong Han
- Department of Liver Diseases and Digestive Interventional Radiology, National Clinical Research Centre for Digestive Diseases, Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an 710032, China; Department of Liver Diseases and Digestive Interventional Radiology, Digestive Diseases Hospital, Xi'an International Medical Center Hospital, Northwest University, Xi'an 710032, China.
| |
Collapse
|
|
9
|
Liu Z, Lyu T, Yang J, Xie Y, Fan S, Song L, Zou Y, Wang J. Fully Covered Stent-TIPS for Advanced HCC Patients with Portal Vein Tumor Thrombus-Related Severe Symptomatic Portal Hypertension. J Hepatocell Carcinoma 2025; 12:29-41. [PMID: 39830160 PMCID: PMC11742244 DOI: 10.2147/jhc.s491153] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2024] [Accepted: 01/07/2025] [Indexed: 01/22/2025] Open
Abstract
Purpose Portal vein tumor thrombus (PVTT)-related severe symptomatic portal hypertension (SPH) leads to a poor prognosis in patients with advanced hepatocellular carcinoma (HCC). Traditional transjugular intrahepatic portosystemic shunt (TIPS) using covered plus bare stent can effectively relieve SPH, however, the bare segment is susceptible to obstruction due to PVTT invasion. This study aimed to evaluate the safety and efficacy of fully covered stent-TIPS (FCS-TIPS) for treatment of PVTT-related SPH in advanced HCC patients. Patients and Methods This retrospective study enrolled 25 patients with advanced HCC who underwent FCS-TIPS for PVTT-related severe SPH from June 2018 to January 2024. The evaluated outcomes included overall survival (OS), technical success rate, reduction in portal venous pressure gradient (PPG), stent patency rate, SPH control rate, liver function and complications. Results The technical success rate was 100% without perioperative deaths or severe procedure-related adverse events. The average PPG decreased by 13.4±4.6 mmHg. The overall symptom control rate of SPH was 96.0%. Variceal bleeding, ascites/hydrothorax, and enteropathy control rates were 100%, 95.0%, and 100%, respectively. Liver function showed mild improvement one month after TIPS. One patient (4.0%) experienced overt hepatic encephalopathy (OHE) and three (12.0%) patients developed shunt dysfunction during the follow-up period. None of the patients experienced shunt-induced extrahepatic metastasis. The median OS was 6.0 months and the cumulative survival rates at 3, 6, 12 months were 80.0%, 52.0% and 21.3%. Conclusion FCS-TIPS is safe and effective for treating PVTT-related severe SPH and can serve as a bridging therapy for advanced HCC.
Collapse
Affiliation(s)
- Zechuan Liu
- Department of Interventional and Vascular Surgery, Peking University First Hospital, Beijing, People’s Republic of China
| | - Tianshi Lyu
- Department of Interventional and Vascular Surgery, Peking University First Hospital, Beijing, People’s Republic of China
| | - Jinming Yang
- Department of Vascular Interventional, Aerospace Central Hospital, Beijing, People’s Republic of China
| | - Yong Xie
- Department of Interventional and Vascular Surgery, Peking University First Hospital, Beijing, People’s Republic of China
| | - Siyuan Fan
- Department of Interventional and Vascular Surgery, Peking University First Hospital, Beijing, People’s Republic of China
| | - Li Song
- Department of Interventional and Vascular Surgery, Peking University First Hospital, Beijing, People’s Republic of China
| | - Yinghua Zou
- Department of Interventional and Vascular Surgery, Peking University First Hospital, Beijing, People’s Republic of China
| | - Jian Wang
- Department of Interventional and Vascular Surgery, Peking University First Hospital, Beijing, People’s Republic of China
| |
Collapse
|
|
10
|
Kabelitz MA, Hartl L, Schaub G, Tiede A, Rieland H, Kornfehl A, Hübener P, Jachs M, Hinrichs J, Schütte SL, Riedel C, Mauz JB, Tergast TL, Meyer BC, Bannas P, Kappel J, Wedemeyer H, Kluwe J, Piecha F, Reiberger T, Sandmann L, Maasoumy B. Identification of optimal portal pressure decrease to control ascites while minimizing HE after TIPS: A multicenter study. Hepatology 2025:01515467-990000000-01132. [PMID: 39773850 DOI: 10.1097/hep.0000000000001219] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/27/2024] [Accepted: 12/11/2024] [Indexed: 01/11/2025]
Abstract
BACKGROUND AND AIMS Clinically significant portal hypertension in patients with liver cirrhosis can lead to refractory ascites. A TIPS treats clinically significant portal hypertension but may cause overt hepatic encephalopathy (oHE). Our aim was to determine the optimal reduction of the portal pressure gradient (PPG) through TIPS to control ascites without raising oHE risk. APPROACH AND RESULTS This multicenter study screened 1509 patients from 3 European centers (Hannover, Vienna, and Hamburg) undergoing TIPS implantation between 2000 and 2023. Patients with TIPS indications other than refractory ascites/hepatic hydrothorax, vascular liver disease, HCC, or insufficient PPG data were excluded. PPG was measured before and after TIPS insertion. Outcome data were assessed up to 1 year after TIPS insertion. Analyses were conducted utilizing a modern machine learning model, namely a competing-risk random survival forest, partial dependence plots, and competing risk analyses with liver transplantation/death as competitors. The cohort was divided into a 60% derivation and 40% validation cohort. Overall, 729 patients (median MELD: 13 [IQR 10-16], 66% male, 23% oHE before TIPS) were analyzed. The derivation cohort comprised 438 patients, and the validation cohort comprised 291 patients. The optimal PPG reduction, determined by maximally selected Gray statistic and PDP of the random survival forest, was 60%-80%. In this range, patients showed significantly fewer hepatic decompensations due to ascites (HDA) (subdistribution hazard ratio [sHR]: 0.7 [0.52-0.96]) with similar oHE incidences (sHR: 0.92 [0.67-1.27]). The PPG range was confirmed in the validation cohort (HDA: sHR: 0.66 [0.46-0.96]; oHE: sHR: 0.89 [0.61-1.32]). CONCLUSIONS A targeted PPG reduction of 60%-80% showed significantly reduced HDA without increased oHE risk. Therefore, PPG reduction within this range could be a valid reduction target.
Collapse
Affiliation(s)
- Martin A Kabelitz
- Department for Gastroenterology, Hepatology, Infectious Diseases and Endocrinology, Hannover Medical School, Hannover, Germany
| | - Lukas Hartl
- Department of Internal Medicine III, Division of Gastroenterology and Hepatology, Medical University of Vienna, Vienna, Austria
- Vienna Hepatic Hemodynamic Lab, Department of Internal Medicine III, Division of Gastroenterology and Hepatology, Medical University of Vienna, Vienna, Austria
| | - Golda Schaub
- I. Department of Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Anja Tiede
- Department for Gastroenterology, Hepatology, Infectious Diseases and Endocrinology, Hannover Medical School, Hannover, Germany
- German Center for Infection Research (DZIF), Hannover/Braunschweig, Germany
| | - Hannah Rieland
- Department for Gastroenterology, Hepatology, Infectious Diseases and Endocrinology, Hannover Medical School, Hannover, Germany
| | - Andrea Kornfehl
- Department of Internal Medicine III, Division of Gastroenterology and Hepatology, Medical University of Vienna, Vienna, Austria
- Vienna Hepatic Hemodynamic Lab, Department of Internal Medicine III, Division of Gastroenterology and Hepatology, Medical University of Vienna, Vienna, Austria
| | - Peter Hübener
- I. Department of Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Mathias Jachs
- Department of Internal Medicine III, Division of Gastroenterology and Hepatology, Medical University of Vienna, Vienna, Austria
- Vienna Hepatic Hemodynamic Lab, Department of Internal Medicine III, Division of Gastroenterology and Hepatology, Medical University of Vienna, Vienna, Austria
| | - Jan Hinrichs
- Department of Diagnostic and Interventional Radiology, Hannover Medical School, Hannover, Germany
| | - Sarah L Schütte
- Department for Gastroenterology, Hepatology, Infectious Diseases and Endocrinology, Hannover Medical School, Hannover, Germany
| | - Christoph Riedel
- Department of Diagnostic and Interventional Radiology and Nuclear Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Jim B Mauz
- Department for Gastroenterology, Hepatology, Infectious Diseases and Endocrinology, Hannover Medical School, Hannover, Germany
| | - Tammo L Tergast
- Department for Gastroenterology, Hepatology, Infectious Diseases and Endocrinology, Hannover Medical School, Hannover, Germany
| | - Bernhard C Meyer
- Department of Diagnostic and Interventional Radiology, Hannover Medical School, Hannover, Germany
| | - Peter Bannas
- Department of Diagnostic and Interventional Radiology and Nuclear Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Julia Kappel
- Department of Internal Medicine III, Division of Gastroenterology and Hepatology, Medical University of Vienna, Vienna, Austria
- Vienna Hepatic Hemodynamic Lab, Department of Internal Medicine III, Division of Gastroenterology and Hepatology, Medical University of Vienna, Vienna, Austria
| | - Heiner Wedemeyer
- Department for Gastroenterology, Hepatology, Infectious Diseases and Endocrinology, Hannover Medical School, Hannover, Germany
- German Center for Infection Research (DZIF), Hannover/Braunschweig, Germany
- Excellence Cluster RESIST, Excellence Initiative Hannover Medical School, Hannover, Germany
| | - Johannes Kluwe
- I. Department of Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
- Department of Internal Medicine and Gastroenterology, Amalie Sieveking Hospital, Hamburg, Germany
| | - Felix Piecha
- I. Department of Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Thomas Reiberger
- Department of Internal Medicine III, Division of Gastroenterology and Hepatology, Medical University of Vienna, Vienna, Austria
- Vienna Hepatic Hemodynamic Lab, Department of Internal Medicine III, Division of Gastroenterology and Hepatology, Medical University of Vienna, Vienna, Austria
| | - Lisa Sandmann
- Department for Gastroenterology, Hepatology, Infectious Diseases and Endocrinology, Hannover Medical School, Hannover, Germany
- German Center for Infection Research (DZIF), Hannover/Braunschweig, Germany
| | - Benjamin Maasoumy
- Department for Gastroenterology, Hepatology, Infectious Diseases and Endocrinology, Hannover Medical School, Hannover, Germany
- German Center for Infection Research (DZIF), Hannover/Braunschweig, Germany
| |
Collapse
|
|
11
|
Lucatelli P, Krajina A, Loffroy R, Miraglia R, Pieper CC, Franchi-Abella S, Rocco B. CIRSE Standards of Practice on Transjugular Intrahepatic Portosystemic Shunts. Cardiovasc Intervent Radiol 2024; 47:1710-1726. [PMID: 39550753 DOI: 10.1007/s00270-024-03866-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/18/2023] [Accepted: 09/10/2024] [Indexed: 11/18/2024]
Abstract
BACKGROUND Proposed in the early 1980s as a solution for managing complications of portal hypertension, the percutaneous creation of transjugular intrahepatic portosystemic shunt has consistently gained a central role. Increasingly lower complication rates have been observed thanks to improvements in both technologies and the skills of interventional radiologists. PURPOSE This document is aimed at interventional radiologists and provides best practice recommendations for transjugular intrahepatic portosystemic shunt creation, describing patient selection, intraprocedural management and follow-up, in addition to recommendations in paediatric settings. METHODS The CIRSE Standards of Practice Committee established a writing group consisting of seven European clinicians with recognised expertise in the creation of transjugular intrahepatic portosystemic shunt. The writing group reviewed the existing literature performing a pragmatic evidence search using PubMed to select relevant publications in the English language and involving human subjects, preferably published from 2009 to 2024. The final recommendations were developed by consensus. RESULTS TIPS creation has an established role in the successful management of portal hypertension and its complications. This Standards of Practice document provides up-to-date recommendations for patient selection, materials, its safe performance, and follow-up with complications management.
Collapse
Affiliation(s)
- Pierleone Lucatelli
- Department of Diagnostic Medicine and Radiology, Interventional Radiology Unit, Azienda Policlinico Universitario Policlinico Umberto I, Rome, Italy
| | - Antonín Krajina
- Department of Radiology, University Hospital, Charles University, Faculty of Medicine, Hradec Kralove, Czech Republic
| | - Romaric Loffroy
- Department of Vascular and Interventional Radiology, François-Mitterrand University Hospital, Dijon, France
| | | | - Claus Christian Pieper
- Department of Diagnostic and Interventional Radiology, University Hospital Bonn, Bonn, Germany
| | - Stéphanie Franchi-Abella
- Paris-Saclay University, Faculty of Medicine - AP-HP, Pediatric Radiology Department, Bicêtre Hospital, Reference Center for Vascular Diseases of the Liver, FSMR Filfoie, ERN Rare Liver, FHU Hepatinov - Biomaps UMR 9011, CNRS-INSERM-CEA, Le Kremlin-Bicêtre, France
| | - Bianca Rocco
- Department of Diagnostic Medicine and Radiology, Interventional Radiology Unit, Sapienza University of Rome, Rome, Italy.
| |
Collapse
|
|
12
|
Yamamoto M, Yamada K, Kinoshita M, Kondo H, Oba H. Transjugular Intrahepatic Portosystemic Shunt: An Update. INTERVENTIONAL RADIOLOGY (HIGASHIMATSUYAMA-SHI (JAPAN) 2024; 9:142-148. [PMID: 39559808 PMCID: PMC11570155 DOI: 10.22575/interventionalradiology.2022-0011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/22/2022] [Accepted: 08/03/2022] [Indexed: 11/20/2024]
Abstract
It is more than 50 years since the concept of transjugular intrahepatic portosystemic shunt (TIPS) was first introduced as a percutaneous procedure for patients with refractory variceal bleeding and ascites. TIPS has become widely accepted in the management of complications of portal hypertension because it is less invasive than surgery. In the early days of TIPS, complications included the poor long-term patency of the stent and a high incidence of hepatic encephalopathy. In addition, an excessive shunt diameter after TIPS often resulted in severe hepatic encephalopathy. Although recent covered stents have significantly reduced shunt dysfunction, the development of hepatic encephalopathy and early liver failure remain to be crucial post-TIPS complications. This study reviews the current literature on the status of TIPS in the treatment of cirrhosis.
Collapse
Affiliation(s)
| | - Kentaro Yamada
- Department of Radiology, Teikyo University School of Medicine, Japan
| | | | - Hiroshi Kondo
- Department of Radiology, Teikyo University School of Medicine, Japan
| | - Hiroshi Oba
- Department of Radiology, Teikyo University School of Medicine, Japan
| |
Collapse
|
|
13
|
Larrue H, Allaire M, Weil-Verhoeven D, Barge S, Thabut D, Payance A, Moga L, Jézéquel C, Artru F, Archambeaud I, Elkrief L, Oberti F, Roux C, Laleman W, Rudler M, Dharancy S, Laborde N, Minello A, Mouillot T, Desjonquères E, Wandji LCN, Bourlière M, Ganne-Carrié N, Bureau C. French guidelines on TIPS: Indications and modalities. Liver Int 2024; 44:2125-2143. [PMID: 38758295 DOI: 10.1111/liv.15976] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/12/2024] [Revised: 04/19/2024] [Accepted: 05/05/2024] [Indexed: 05/18/2024]
Abstract
Transjugular intrahepatic portosystemic shunt (TIPS) has become essential in the treatment or prevention of portal hypertension-related complications. In the early 1990s, the primary indication was refractory bleeding. It is now proposed for the treatment of ascites for the prevention of bleeding and in patients with vascular diseases of the liver. Thus, there are a growing number of patients being treated with TIPS all over the world. The broadening of indications, the involvement of multiple stakeholders, the need for an accurate selection, the positioning in relation to transplantation and the lack of standardization in pre-therapeutic assessment, in the procedure itself and in the follow-up have led the board of the French Association for the Study of the Liver to establish recommendations.
Collapse
Affiliation(s)
- Hélène Larrue
- Service d'Hépatologie Hopital Rangueil CHU Toulouse et Université Paul Sabatier, Toulouse, France
| | - Manon Allaire
- Service d'Hépato-gastroentérologie, Hôpital Universitaire Pitié-Salpêtrière, AP-HP Sorbonne Université, Paris, France
| | - Delphine Weil-Verhoeven
- Service d'Hépatologie et Soins intensifs digestifs, CHU Jean Minjoz, Besançon, France
- Université de Franche-Comté, CHU Besançon, EFS, INSERM, UMR RIGHT, Besançon, France
| | - Sandrine Barge
- Service d'Hépato-gastro-entérologie, Centre Hospitalier Intercommunal de Créteil, Creteil, France
| | - Dominique Thabut
- Service d'Hépato-gastroentérologie, Hôpital Universitaire Pitié-Salpêtrière, AP-HP Sorbonne Université, Paris, France
| | - Audrey Payance
- AP-HP, Hôpital Beaujon, Service d'Hépatologie, DMU DIGEST, Centre de Référence des Maladies Vasculaires du Foie, FILFOIE, ERN RARE-LIVER, Centre de recherche sur l'inflammation, Inserm, UMR 1149, Université de Paris, Paris, France
| | - Lucile Moga
- AP-HP, Hôpital Beaujon, Service d'Hépatologie, DMU DIGEST, Centre de Référence des Maladies Vasculaires du Foie, FILFOIE, ERN RARE-LIVER, Centre de recherche sur l'inflammation, Inserm, UMR 1149, Université de Paris, Paris, France
| | | | - Florent Artru
- Service des Maladies du Foie, CHU Rennes, Rennes, France
| | - Isabelle Archambeaud
- Hépato-Gastro-Entérologie et Assistance Nutritionnelle-Institut des Maladies de l'Appareil Digestif (IMAD), CHU Nantes-Inserm CIC 1413, Nantes, France
| | - Laure Elkrief
- Service d'Hépato-Gastroentérologie, Hôpital Trousseau, CHRU de Tours et Faculté de Médecine de Tours, Tours, France
| | - Frédéric Oberti
- Service d'Hépato-Gastroentérologie, CHU Angers, Angers, France
| | - Charles Roux
- Service de Radiologie Intervent.ionnelle, AP-HP Sorbonne Université, Hôpital Universitaire Pitié-Salpêtrière, Paris, France
| | - Wim Laleman
- Service de Gastroentérologie et Hépatologie, Hôpital Universitaire Gasthuisberg, KU Leuven, Louvain, Belgium
| | - Marika Rudler
- Service d'Hépato-gastroentérologie, Hôpital Universitaire Pitié-Salpêtrière, AP-HP Sorbonne Université, Paris, France
| | - Sébastien Dharancy
- CHU Lille, Hôpital Huriez, Maladies de l'Appareil Digestif, 2 Rue Michel Polonovski, Lille, France
| | - Nolwenn Laborde
- Gastro-Entérologie, Hépatologie, Nutrition, Maladies Héréditaires du Métabolisme Pédiatriques, Centre de Compétence Maladies Rares du Foie, Hôpital des Enfants, CHU, Toulouse, France
| | - Anne Minello
- Service D'hépato-Gastroentérologie et Oncologie Médicale, CHU F. Mitterrand, Dijon, France
| | - Thomas Mouillot
- Service D'hépato-Gastroentérologie et Oncologie Médicale, CHU F. Mitterrand, Dijon, France
| | - Elvire Desjonquères
- AP-HP Sorbonne Paris Nord, Hôpitaux Universitaire Paris Seine Saint-Denis, Service d'Hépatologie, Bobigny, France
| | - Line Caroll Ntandja Wandji
- Inserm, CHU Lille, U1286-INFINITE-Institute for Translational Research in Inflammation, University of Lille, Lille, France
| | - Marc Bourlière
- Département d'Hépatologie et Gastroentérologie, Hôpital Saint Joseph, Marseille, France
| | - Nathalie Ganne-Carrié
- AP-HP Sorbonne Paris Nord, Hôpitaux Universitaire Paris Seine Saint-Denis, Service d'Hépatologie, Bobigny, France Centre de Recherche des Cordeliers, Sorbonne Université, INSERM, Université de Paris, Paris, France
| | - Christophe Bureau
- Service d'Hépatologie Hopital Rangueil CHU Toulouse et Université Paul Sabatier, Toulouse, France
| |
Collapse
|
|
14
|
Garbuzenko DV. Milestones to optimize of transjugular intrahepatic portosystemic shunt technique as a method for the treatment of portal hypertension complications. World J Hepatol 2024; 16:891-899. [PMID: 38948432 PMCID: PMC11212652 DOI: 10.4254/wjh.v16.i6.891] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/07/2024] [Revised: 05/10/2024] [Accepted: 05/20/2024] [Indexed: 06/20/2024] Open
Abstract
This editorial describes the milestones to optimize of transjugular intrahepatic portosystemic shunt (TIPS) technique, which have made it one of the main methods for the treatment of portal hypertension complications worldwide. Innovative ideas, subsequent experimental studies and preliminary experience of use in cirrhotic patients contributed to the introduction of TIPS into clinical practice. At the moment, the main achievement in optimize of TIPS technique is progress in the qualitative characteristics of stents. The transition from bare metal stents to extended polytetrafluoroethylene-covered stent grafts made it possible to significantly prevent shunt dysfunction. However, the question of its preferred diameter, which contributes to an optimal reduction of portal pressure without the risk of developing post-TIPS hepatic encephalopathy, remains relevant. Currently, hepatic encephalopathy is one of the most common complications of TIPS, significantly affecting its effectiveness and prognosis. Careful selection of patients based on cognitive indicators, nutritional status, assessment of liver function, etc., will reduce the incidence of post-TIPS hepatic encephalopathy and improve treatment results. Optimize of TIPS technique has significantly expanded the indications for its use and made it one of the main methods for the treatment of portal hypertension complications. At the same time, there are a number of limitations and unresolved issues that require further randomized controlled trials involving a large cohort of patients.
Collapse
|
|
15
|
Bai Y, Liu J, Wang C, Yao W, Ju S, Wang Y, Zhou C, Dong X, Zheng C. Comparison of specialized stent versus generic stent and bare stent combination for transjugular intrahepatic portosystemic shunt creation. Sci Rep 2024; 14:14439. [PMID: 38910214 PMCID: PMC11194257 DOI: 10.1038/s41598-024-64358-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2024] [Accepted: 06/07/2024] [Indexed: 06/25/2024] Open
Abstract
Transjugular intrahepatic portosystemic shunt (TIPS) creation using the Viatorr stent remains relatively uncommon in underdeveloped and high-burden disease regions in Asia-Pacific, and there is a lack of comparative studies regarding its prognostic effects compared with the generic stent-graft/bare stent combination. The purpose of this retrospective study is to compare the prognostic endpoints of these two treatments in patients who underwent TIPS creation. Clinical data from 145 patients were collected, including 82 in the combination group and 63 in the Viatorr group. Differences in prognostic endpoints (shunt dysfunction, death, overt hepatic encephalopathy [OHE], rebleeding) between the two groups were analyzed using Kaplan-Meier curves. The Cox proportional hazards model was used to identify independent risk factors for post-TIPS shunt dysfunction. The TIPS procedure was successful in all patients. After TIPS creation, both groups showed a significant decrease in porto-caval pressure gradient compared to that before TIPS creation. The stent patency rates at 6, 12, and 18 months were high in both the combination and Viatorr groups (93.7%, 88.5%, and 88.5% vs. 96.7%, 93.4%, and 93.4%, respectively). The stent patency rates was higher in the combination group than in the Viatorr group, although not statistically significant (HR = 2.105, 95% CI 0.640-6.922, Log-rank P = 0.259). There were no significant differences in other prognostic endpoints (death, OHE, rebleeding) between the two groups. The Cox model identified portal vein diameter (HR = 0.807, 95% CI 0.658-0.990, P = 0.040) and portal vein thrombosis (HR = 13.617, 95% CI 1.475-125.678, P = 0.021) as independent risk factors for post-TIPS shunt dysfunction. The shunt patency rates between the Viatorr stent and the generic stent-graft/bare stent combination showed no significant difference and the generic stent-graft/bare stent combination may be a viable alternative in areas where the Viatorr stent is not yet available.
Collapse
Affiliation(s)
- Yaowei Bai
- Department of Radiology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Jiefang Avenue #1277, Wuhan, 430022, China
- Hubei Province Key Laboratory of Molecular Imaging, Wuhan, 430022, China
| | - Jiacheng Liu
- Department of Radiology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Jiefang Avenue #1277, Wuhan, 430022, China
- Hubei Province Key Laboratory of Molecular Imaging, Wuhan, 430022, China
| | - Chaoyang Wang
- Department of Radiology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Jiefang Avenue #1277, Wuhan, 430022, China
- Hubei Province Key Laboratory of Molecular Imaging, Wuhan, 430022, China
| | - Wei Yao
- Department of Radiology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Jiefang Avenue #1277, Wuhan, 430022, China
- Hubei Province Key Laboratory of Molecular Imaging, Wuhan, 430022, China
| | - Shuguang Ju
- Department of Radiology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Jiefang Avenue #1277, Wuhan, 430022, China
- Hubei Province Key Laboratory of Molecular Imaging, Wuhan, 430022, China
| | - Yingliang Wang
- Department of Radiology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Jiefang Avenue #1277, Wuhan, 430022, China
- Hubei Province Key Laboratory of Molecular Imaging, Wuhan, 430022, China
| | - Chen Zhou
- Department of Radiology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Jiefang Avenue #1277, Wuhan, 430022, China
- Hubei Province Key Laboratory of Molecular Imaging, Wuhan, 430022, China
| | - Xiangjun Dong
- Department of Radiology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Jiefang Avenue #1277, Wuhan, 430022, China.
- Hubei Province Key Laboratory of Molecular Imaging, Wuhan, 430022, China.
| | - Chuansheng Zheng
- Department of Radiology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Jiefang Avenue #1277, Wuhan, 430022, China.
- Hubei Province Key Laboratory of Molecular Imaging, Wuhan, 430022, China.
| |
Collapse
|
|
16
|
Adebayo D, Wong F. Review article: Recent advances in ascites and acute kidney injury management in cirrhosis. Aliment Pharmacol Ther 2024; 59:1196-1211. [PMID: 38526023 DOI: 10.1111/apt.17972] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/07/2023] [Revised: 09/08/2024] [Accepted: 03/14/2024] [Indexed: 03/26/2024]
Abstract
BACKGROUND Better understanding of disease pathophysiology has led to advances in managing ascites and its associated complications including hepatorenal syndrome-acute kidney Injury (HRS-AKI), especially medicinal and interventional advances. AIM To review the latest changes in the management of ascites and HRS-AKI. METHODS A literature search was conducted in Pubmed, using the keywords cirrhosis, ascites, renal dysfunction, acute kidney injury, hepatorenal syndrome, beta-blockers, albumin, TIPS and vasoconstrictors, including only publications in English. RESULTS The medicinal advances include earlier treatment of clinically significant portal hypertension to delay the onset of ascites and the use of human albumin solution to attenuate systemic inflammation thus improving the haemodynamic changes associated with cirrhosis. Furthermore, new classes of drugs such as sodium glucose co-transporter 2 are being investigated for use in patients with cirrhosis and ascites. For HRS-AKI management, newer pharmacological agents such as vasopressin partial agonists and relaxin are being studied. Interventional advances include the refinement of TIPS technique and patient selection to improve outcomes in patients with refractory ascites. The development of the alfa pump system and the study of outcomes associated with the use of long-term palliative abdominal drain will also serve to improve the quality of life in patients with refractory ascites. CONCLUSIONS New treatment strategies emerged from better understanding of the pathophysiology of ascites and HRS-AKI have shown improved prognosis in these patients. The future will see many of these approaches confirmed in large multi-centre clinical trials with the aim to benefit the patients with ascites and HRS-AKI.
Collapse
Affiliation(s)
- Danielle Adebayo
- Department of Gastroenterology, Royal Berkshire NHS Foundation Trust, Reading, UK
| | - Florence Wong
- Division of Gastroenterology and Hepatology, Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| |
Collapse
|
|
17
|
Meram E, Russell E, Ozkan O, Kleedehn M. Variceal and Nonvariceal Upper Gastrointestinal Bleeding Refractory to Endoscopic Management: Indications and Role of Interventional Radiology. Gastrointest Endosc Clin N Am 2024; 34:275-299. [PMID: 38395484 DOI: 10.1016/j.giec.2023.09.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/25/2024]
Abstract
For over 60 years, diagnostic and interventional radiology have been heavily involved in the evaluation and treatment of patients presenting with gastrointestinal bleeding. For patients who present with upper GI bleeding and have a contraindication to endoscopy or have an unsuccessful attempt at endoscopy for identifying or controlling the bleeding, interventional radiology is often consulted for evaluation and consideration of catheter-based intervention.
Collapse
Affiliation(s)
- Ece Meram
- University of Wisconsin School of Medicine and Public Health, University of Wisconsin Hospitals and Clinics, 600 Highland Avenue, Madison, WI 53792, USA
| | - Elliott Russell
- University of Wisconsin School of Medicine and Public Health, University of Wisconsin Hospitals and Clinics, 600 Highland Avenue, Madison, WI 53792, USA
| | - Orhan Ozkan
- University of Wisconsin School of Medicine and Public Health, University of Wisconsin Hospitals and Clinics, 600 Highland Avenue, Madison, WI 53792, USA
| | - Mark Kleedehn
- University of Wisconsin School of Medicine and Public Health, University of Wisconsin Hospitals and Clinics, 600 Highland Avenue, Madison, WI 53792, USA.
| |
Collapse
|
|
18
|
Iannone G, Pompili E, De Venuto C, Pratelli D, Tedesco G, Baldassarre M, Caraceni P, Zaccherini G. The Role of Transjugular Intrahepatic Portosystemic Shunt for the Management of Ascites in Patients with Decompensated Cirrhosis. J Clin Med 2024; 13:1349. [PMID: 38592162 PMCID: PMC10932158 DOI: 10.3390/jcm13051349] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2024] [Revised: 02/09/2024] [Accepted: 02/18/2024] [Indexed: 04/10/2024] Open
Abstract
The development and progression of ascites represent a crucial event in the natural history of patients with cirrhosis, predisposing them to other complications and carrying a heavy impact on prognosis. The current standard of care for the management of ascites relies on various combinations of diuretics and large-volume paracenteses. Periodic long-term albumin infusions on top of diuretics have been recently shown to greatly facilitate the management of ascites. The insertion of a transjugular intrahepatic portosystemic shunt (TIPS), an artificial connection between the portal and caval systems, is indicated to treat patients with refractory ascites. TIPS acts to decrease portal hypertension, thus targeting an upstream event in the pathophysiological cascade of cirrhosis decompensation. Available evidence shows a significant benefit on ascites control/resolution, with less clear results on patient survival. Patient selection plays a crucial role in obtaining better clinical responses and avoiding TIPS-related adverse events, the most important of which are hepatic encephalopathy, cardiac overload and failure, and liver failure. At the same time, some recent technical evolutions of available stents appear promising but deserve further investigations. Future challenges and perspectives include (i) identifying the features for selecting the ideal candidate to TIPS; (ii) recognizing the better timing for TIPS placement; and (iii) understanding the most appropriate role of TIPS within the framework of all other available treatments for the management of patients with decompensated cirrhosis.
Collapse
Affiliation(s)
- Giulia Iannone
- Department of Medical and Surgical Sciences, University of Bologna, 40138 Bologna, Italy; (G.I.); (E.P.); (C.D.V.); (D.P.); (G.T.); (P.C.)
- Unit of Semeiotics, Liver and Alcohol-Related Diseases, IRCCS Azienda Ospedaliero-Universitaria di Bologna, 40138 Bologna, Italy;
| | - Enrico Pompili
- Department of Medical and Surgical Sciences, University of Bologna, 40138 Bologna, Italy; (G.I.); (E.P.); (C.D.V.); (D.P.); (G.T.); (P.C.)
- Unit of Semeiotics, Liver and Alcohol-Related Diseases, IRCCS Azienda Ospedaliero-Universitaria di Bologna, 40138 Bologna, Italy;
| | - Clara De Venuto
- Department of Medical and Surgical Sciences, University of Bologna, 40138 Bologna, Italy; (G.I.); (E.P.); (C.D.V.); (D.P.); (G.T.); (P.C.)
- Unit of Semeiotics, Liver and Alcohol-Related Diseases, IRCCS Azienda Ospedaliero-Universitaria di Bologna, 40138 Bologna, Italy;
| | - Dario Pratelli
- Department of Medical and Surgical Sciences, University of Bologna, 40138 Bologna, Italy; (G.I.); (E.P.); (C.D.V.); (D.P.); (G.T.); (P.C.)
- Unit of Semeiotics, Liver and Alcohol-Related Diseases, IRCCS Azienda Ospedaliero-Universitaria di Bologna, 40138 Bologna, Italy;
| | - Greta Tedesco
- Department of Medical and Surgical Sciences, University of Bologna, 40138 Bologna, Italy; (G.I.); (E.P.); (C.D.V.); (D.P.); (G.T.); (P.C.)
| | - Maurizio Baldassarre
- Unit of Semeiotics, Liver and Alcohol-Related Diseases, IRCCS Azienda Ospedaliero-Universitaria di Bologna, 40138 Bologna, Italy;
| | - Paolo Caraceni
- Department of Medical and Surgical Sciences, University of Bologna, 40138 Bologna, Italy; (G.I.); (E.P.); (C.D.V.); (D.P.); (G.T.); (P.C.)
- Unit of Semeiotics, Liver and Alcohol-Related Diseases, IRCCS Azienda Ospedaliero-Universitaria di Bologna, 40138 Bologna, Italy;
| | - Giacomo Zaccherini
- Department of Medical and Surgical Sciences, University of Bologna, 40138 Bologna, Italy; (G.I.); (E.P.); (C.D.V.); (D.P.); (G.T.); (P.C.)
- Unit of Semeiotics, Liver and Alcohol-Related Diseases, IRCCS Azienda Ospedaliero-Universitaria di Bologna, 40138 Bologna, Italy;
| |
Collapse
|
|
19
|
Rajan A, Boike J. TIPS for Refractory Ascites and Hepatic Hydrothorax. CURRENT HEPATOLOGY REPORTS 2024; 23:45-53. [DOI: 10.1007/s11901-023-00625-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 12/09/2023] [Indexed: 01/04/2025]
|
|
20
|
Lee EW, Eghtesad B, Garcia-Tsao G, Haskal ZJ, Hernandez-Gea V, Jalaeian H, Kalva SP, Mohanty A, Thabut D, Abraldes JG. AASLD Practice Guidance on the use of TIPS, variceal embolization, and retrograde transvenous obliteration in the management of variceal hemorrhage. Hepatology 2024; 79:224-250. [PMID: 37390489 DOI: 10.1097/hep.0000000000000530] [Citation(s) in RCA: 33] [Impact Index Per Article: 33.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/21/2023] [Accepted: 06/22/2023] [Indexed: 07/02/2023]
Affiliation(s)
- Edward Wolfgang Lee
- Department of Radiology and Surgery, Ronald Reagan UCLA Medical Center, Los Angeles, California, USA
| | - Bijan Eghtesad
- Department of General Surgery, Digestive Disease and Surgery Institute Cleveland Clinic, Cleveland, Ohio, USA
| | - Guadalupe Garcia-Tsao
- Yale University School of Medicine, Department of Internal Medicine, Section of Digestive Diseases, New Haven, Connecticut, USA
- VA Connecticut Healthcare System, West Haven, Connecticut, USA
| | - Ziv J Haskal
- Department of Radiology and Medical Imaging/Interventional Radiology, University of Virginia School of Medicine, Charlottesville, Virginia, USA
| | - Virginia Hernandez-Gea
- Barcelona Hepatic Hemodynamic Laboratory, Liver Unit, Hospital Clínic, Institut D'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS). Universitat de Barcelona (UB). CIBEREHD (Centro de Investigación Biomédica en Red Enfermedades Hepáticas y Digestivas). Health Care Provider of the European Reference Network on Rare Liver Disorders (ERN-Liver), Barcelona, Spain
| | - Hamed Jalaeian
- Department of Interventional Radiology, Miller School of Medicine, University of Miami, Miami, Florida, USA
| | | | - Arpan Mohanty
- Boston University Chobanian and Avedisian School of Medicine, Boston, Massachusetts, USA
| | - Dominique Thabut
- AP-HP Sorbonne Université, Hôpital Universitaire Pitié-Salpêtrière, Service d'Hépato-gastroentérologie, Paris, France
| | - Juan G Abraldes
- Division of Gastroenterology (Liver Unit), University of Alberta, Edmonton, Canada
| |
Collapse
|
|
21
|
Saltini D, Indulti F, Guasconi T, Bianchini M, Cuffari B, Caporali C, Casari F, Prampolini F, Senzolo M, Colecchia A, Schepis F. Transjugular Intrahepatic Portosystemic Shunt: Devices Evolution, Technical Tips and Future Perspectives. J Clin Med 2023; 12:6758. [PMID: 37959225 PMCID: PMC10650044 DOI: 10.3390/jcm12216758] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2023] [Revised: 10/18/2023] [Accepted: 10/20/2023] [Indexed: 11/15/2023] Open
Abstract
Portal hypertension (PH) constitutes a pivotal factor in the progression of cirrhosis, giving rise to severe complications and a diminished survival rate. The transjugular intrahepatic portosystemic shunt (TIPS) procedure has undergone significant evolution, with advancements in stent technology assuming a central role in managing PH-related complications. This review aims to outline the progression of TIPS and emphasizes the significant influence of stent advancement on its effectiveness. Initially, the use of bare metal stents (BMSs) was limited due to frequent dysfunction. However, the advent of expanding polytetrafluoroethylene-covered stent grafts (ePTFE-SGs) heralded a transformative era, greatly enhancing patency rates. Further innovation culminated in the creation of ePTFE-SGs with controlled expansion, enabling precise adjustment of TIPS diameters. Comparative analyses demonstrated the superiority of ePTFE-SGs over BMSs, resulting in improved patency, fewer complications, and higher survival rates. Additional technical findings highlight the importance of central stent placement and adequate stent length, as well as the use of smaller calibers to reduce the risk of shunt-related complications. However, improving TIPS through technical means alone is inadequate for optimizing patient outcomes. An extensive understanding of hemodynamic, cardiac, and systemic factors is required to predict outcomes and tailor a personalized approach. Looking forward, the ongoing progress in SG technology, paired with the control of clinical factors that can impact outcomes, holds the promise of reshaping the management of PH-related complications in cirrhosis.
Collapse
Affiliation(s)
- Dario Saltini
- Division of Gastroenterology, Azienda Ospedaliero-Universitaria di Modena, and University of Modena and Reggio Emilia, 41121 Modena, Italy (F.I.); (T.G.); (M.B.); (B.C.); (A.C.)
| | - Federica Indulti
- Division of Gastroenterology, Azienda Ospedaliero-Universitaria di Modena, and University of Modena and Reggio Emilia, 41121 Modena, Italy (F.I.); (T.G.); (M.B.); (B.C.); (A.C.)
| | - Tomas Guasconi
- Division of Gastroenterology, Azienda Ospedaliero-Universitaria di Modena, and University of Modena and Reggio Emilia, 41121 Modena, Italy (F.I.); (T.G.); (M.B.); (B.C.); (A.C.)
| | - Marcello Bianchini
- Division of Gastroenterology, Azienda Ospedaliero-Universitaria di Modena, and University of Modena and Reggio Emilia, 41121 Modena, Italy (F.I.); (T.G.); (M.B.); (B.C.); (A.C.)
| | - Biagio Cuffari
- Division of Gastroenterology, Azienda Ospedaliero-Universitaria di Modena, and University of Modena and Reggio Emilia, 41121 Modena, Italy (F.I.); (T.G.); (M.B.); (B.C.); (A.C.)
| | - Cristian Caporali
- Division of Radiology, Azienda Ospedaliero-Universitaria di Modena, and University of Modena and Reggio Emilia, 41121 Modena, Italy; (C.C.)
| | - Federico Casari
- Division of Radiology, Azienda Ospedaliero-Universitaria di Modena, and University of Modena and Reggio Emilia, 41121 Modena, Italy; (C.C.)
| | - Francesco Prampolini
- Division of Radiology, Azienda Ospedaliero-Universitaria di Modena, and University of Modena and Reggio Emilia, 41121 Modena, Italy; (C.C.)
| | - Marco Senzolo
- Multivisceral Transplant Unit-Gastroenterology, Department of Surgery, Oncology and Gastroenterology, Padua University Hospital, 35128 Padua, Italy;
| | - Antonio Colecchia
- Division of Gastroenterology, Azienda Ospedaliero-Universitaria di Modena, and University of Modena and Reggio Emilia, 41121 Modena, Italy (F.I.); (T.G.); (M.B.); (B.C.); (A.C.)
| | - Filippo Schepis
- Division of Gastroenterology, Azienda Ospedaliero-Universitaria di Modena, and University of Modena and Reggio Emilia, 41121 Modena, Italy (F.I.); (T.G.); (M.B.); (B.C.); (A.C.)
| |
Collapse
|
|
22
|
Gu W, Zeleke Y, Hortlik H, Schaaf L, Uschner FE, Schulz M, Tischendorf M, Peiffer KH, Brol MJ, Kimmann M, Vogl T, Köhler M, Meyer C, Gerbes A, Rössle M, Laleman W, Zipprich A, Steib C, Praktiknjo M, Trebicka J. Use and outcome of TIPS in hospitalized patients in Germany: A Nationwide study (2007-2018). Hepatol Commun 2023; 7:e0237. [PMID: 37708430 PMCID: PMC10503680 DOI: 10.1097/hc9.0000000000000237] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/21/2023] [Accepted: 06/14/2023] [Indexed: 09/16/2023] Open
Abstract
BACKGROUND The number of complications in patients admitted for cirrhosis has increased over time. Portal hypertension is the driver of many complications of cirrhosis. TIPS placement is the most effective treatment of portal hypertension. The aim of this study was to analyze the use and impact of TIPS placement in the last decade in a nationwide study in Germany. METHODS We analyzed 14,598 admissions of patients for TIPS insertions in Germany from 2007 to 2018 using the DRG system, 12,877 out of 2,000,765 total admissions of patients with cirrhosis. All diagnoses and procedures were coded according to ICD-10-CM and OPS codes. The data were analyzed, focusing on the number of admissions and in-hospital mortality. RESULTS The number of TIPS placements increased over the last decade. In-hospital mortality of cirrhotic patients with TIPS decreased when it was placed for severe bleeding (15.2% [TIPS] vs. 19.5% [endoscopy treatment]), ascites (8.7% [TIPS] vs. 14.4% [paracentesis]), and hepatorenal syndrome (HRS) (17.1% [TIPS] vs. 43.3% [no-TIPS]). In the case of bleeding, TIPS significantly decreased in-hospital mortality and also in ascites and HRS. During hospitalization, 22.6% admissions of patients with TIPS insertion showed HE. However, in-hospital mortality in patients admitted with HE grades 1 or 2 and TIPS was lower than in patients without TIPS. In the logistic regression, a higher HE grade(3 and 4), infection, and circulatory disease were found to be independently associated with in-hospital mortality in patients with TIPS insertion. CONCLUSION Our nationwide study demonstrates that TIPS insertion is increasingly used in Germany. TIPS improves outcomes, especially in patients with ascites and HRS, regardless of lower HE grades, while higher HE grades, infection, and circulatory diseases seem to be associated with risk of in-hospital mortality.
Collapse
Affiliation(s)
- Wenyi Gu
- Department of Internal Medicine B, University Hospital Muenster, Muenster, Germany
- Department of Internal Medicine I, University Hospital Frankfurt, Goethe University Frankfurt, Frankfurt am Main, Germany
| | - Yasmin Zeleke
- Department of Internal Medicine I, University Hospital Frankfurt, Goethe University Frankfurt, Frankfurt am Main, Germany
| | - Hannah Hortlik
- Department of Internal Medicine I, University Hospital Frankfurt, Goethe University Frankfurt, Frankfurt am Main, Germany
| | - Louisa Schaaf
- Department of Internal Medicine I, University Hospital Frankfurt, Goethe University Frankfurt, Frankfurt am Main, Germany
| | - Frank E. Uschner
- Department of Internal Medicine B, University Hospital Muenster, Muenster, Germany
| | - Martin Schulz
- Department of Internal Medicine B, University Hospital Muenster, Muenster, Germany
| | - Michael Tischendorf
- Department of Internal Medicine B, University Hospital Muenster, Muenster, Germany
| | - Kai-Henrik Peiffer
- Department of Internal Medicine B, University Hospital Muenster, Muenster, Germany
| | | | - Markus Kimmann
- Department of Internal Medicine B, University Hospital Muenster, Muenster, Germany
| | - Thomas Vogl
- Institute of Diagnostic and Interventional Radiology, University Hospital Frankfurt, Frankfurt am Main, Germany
| | - Michael Köhler
- Clinic for Radiology, University Hospital Muenster, Muenster, Germany
| | - Carsten Meyer
- Clinic for Radiology, University Hospital Bonn, Bonn, Germany
| | - Alexander Gerbes
- Department of Medicine II, University Clinic Munich LMU, Munich, Germany
| | - Martin Rössle
- Department of Internal Medicine II, Faculty of Medicine, Medical Centre University of Freiburg, University of Freiburg, Freiburg, Germany
| | - Wim Laleman
- Department of Internal Medicine B, University Hospital Muenster, Muenster, Germany
- Department of Gastroenterology and Hepatology, University Hospitals Leuven, KU Leuven, Leuven, Belgium
| | - Alexander Zipprich
- Department of Internal Medicine IV (Gastroenterology, Hepatology and Infectious Diseases), Jena University Hospital, Friedrich-Schiller-University Jena, Jena, Germany
| | - Christian Steib
- Department of Medicine II, University Clinic Munich LMU, Munich, Germany
| | - Michael Praktiknjo
- Department of Internal Medicine B, University Hospital Muenster, Muenster, Germany
| | - Jonel Trebicka
- Department of Internal Medicine B, University Hospital Muenster, Muenster, Germany
- European Foundation for Study of Chronic Liver Failure, Barcelona, Spain
- Department of Gastroenterology and Hepatology, Odense University Hospital, Odense, Denmark
| |
Collapse
|
|
23
|
Carroll A, Boike JR. TIPS: indications, Contraindications, and Evaluation. Curr Gastroenterol Rep 2023; 25:232-241. [PMID: 37603109 DOI: 10.1007/s11894-023-00884-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/09/2023] [Indexed: 08/22/2023]
Abstract
PURPOSE OF REVIEW This review summarizes the current and emerging indications, contraindications, and evaluation for TIPS. In the last three decades of use, there have been substantial changes and progress in this field, including the use of controlled-expansion, covered stents, which has broadened the clinical uses of TIPS. RECENT FINDINGS Recent findings have rapidly expanded the indications for TIPS, including emerging uses in hepatorenal syndrome, hepatopulmonary syndrome and before abdominal surgery. The widespread use of controlled-expansion, covered stents has decreased rates of post-TIPS hepatic encephalopathy, opening TIPS to a larger patient population. Overall, with newer stent technology and more research in this area, the clinical utility and potential of TIPS has rapidly expanded. Going forward, a renewed focus on randomized-control trials and long-term outcomes will be a crucial element to selecting appropriate TIPS recipients and recommending emerging indications for this procedure.
Collapse
Affiliation(s)
- Allison Carroll
- Department of Medicine, Division of Gastroenterology & Hepatology, Northwestern University Feinberg School of Medicine, 676 N. St. Clair, Suite 1900, Chicago, IL, 60611, USA
- Feinberg School of Medicine, Northwestern University, Chicago, USA
| | - Justin R Boike
- Department of Medicine, Division of Gastroenterology & Hepatology, Northwestern University Feinberg School of Medicine, 676 N. St. Clair, Suite 1900, Chicago, IL, 60611, USA.
| |
Collapse
|
|
24
|
Chang J, Hoffstall S, Gödiker J, Lehmann J, Schwind L, Lingohr P, Manekeller S, Wehner S, Strassburg CP, Chang P, Praktiknjo M. Surgical site infections are independently associated with the development of postoperative acute-on-chronic liver failure in liver cirrhosis. Liver Transpl 2023; 29:928-939. [PMID: 36950832 DOI: 10.1097/lvt.0000000000000135] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/04/2022] [Accepted: 03/03/2023] [Indexed: 03/24/2023]
Abstract
Acute-on-chronic liver failure (ACLF) is associated with organ failure and high short-term mortality. Bacterial infections and surgery have been reported as major precipitants for ACLF. However, detailed characterization of postoperative infections after elective surgery in patients with liver cirrhosis and their impact on the development of ACLF have not been investigated yet. A total of 235 patients with cirrhosis without ACLF and proven bacterial infections undergoing elective surgery were included. The primary end point was the development of ACLF within 28 days after surgery, and secondary end points were infection development within 28 days and 3-month ACLF-related mortality. Cox regression analysis was used for identification of risk factors associated with ACLF development, infection development, and mortality. A total of 86 patients (37%) developed ACLF within 28 days after surgery. Patients with new postoperative infections had significantly higher rates of associated ACLF episodes within 28 days (51% vs. 24%, p < 0.001) and higher 3-month mortality ( p < 0.05) than patients without postoperative infections. New infections after surgery [HR: 2.43 (1.59-3.71), p < 0.001] and organ/space surgical site infections [HR: 2.46 (1.26-4.80), p = 0.01] in particular were independent risk factors associated with ACLF development 28 days after surgery. Extensive procedures were associated with the development of new postoperative infection episodes within 28 days. Infections treated with initial appropriate empirical antibiotic strategies showed significantly improved survival. This study characterizes and identifies bacterial infections in general and organ/space surgical site infection in particular as precipitating events for the development of ACLF after elective surgery in patients with cirrhosis. Postoperative ACLF combined with infections leads to higher postoperative short-term mortality than each condition separately, especially in extensive procedures. Interdisciplinary care, early identification of postoperative ACLF and infections, and adequate, broad, and early treatment strategies are needed to improve postoperative outcome.
Collapse
Affiliation(s)
- Johannes Chang
- Department of Internal Medicine I, University Hospital Bonn, Bonn, Germany
- Center for Cirrhosis and Portal Hypertension Bonn (CCB), University Hospital Bonn, Bonn, Germany
| | - Schwiedhard Hoffstall
- Department of Internal Medicine I, University Hospital Bonn, Bonn, Germany
- Center for Cirrhosis and Portal Hypertension Bonn (CCB), University Hospital Bonn, Bonn, Germany
| | - Juliana Gödiker
- Department of Internal Medicine B, Münster University Hospital, Münster, Germany
| | - Jennifer Lehmann
- Department of Internal Medicine I, University Hospital Bonn, Bonn, Germany
- Center for Cirrhosis and Portal Hypertension Bonn (CCB), University Hospital Bonn, Bonn, Germany
| | - Lea Schwind
- Department of Internal Medicine I, University Hospital Bonn, Bonn, Germany
- Center for Cirrhosis and Portal Hypertension Bonn (CCB), University Hospital Bonn, Bonn, Germany
| | - Philipp Lingohr
- Department of Visceral Surgery, University Hospital Bonn, Bonn, Germany
| | | | - Sven Wehner
- Department of Visceral Surgery, University Hospital Bonn, Bonn, Germany
| | - Christian P Strassburg
- Department of Internal Medicine I, University Hospital Bonn, Bonn, Germany
- Center for Cirrhosis and Portal Hypertension Bonn (CCB), University Hospital Bonn, Bonn, Germany
| | - Petrus Chang
- Center for Cirrhosis and Portal Hypertension Bonn (CCB), University Hospital Bonn, Bonn, Germany
- Department of Ophthalmology, University Hospital Bonn, Bonn, Germany
| | - Michael Praktiknjo
- Department of Internal Medicine I, University Hospital Bonn, Bonn, Germany
- Center for Cirrhosis and Portal Hypertension Bonn (CCB), University Hospital Bonn, Bonn, Germany
- Department of Internal Medicine B, Münster University Hospital, Münster, Germany
| |
Collapse
|
|
25
|
Mandorfer M, Aigner E, Cejna M, Ferlitsch A, Datz C, Gräter T, Graziadei I, Gschwantler M, Hametner-Schreil S, Hofer H, Jachs M, Loizides A, Maieron A, Peck-Radosavljevic M, Rainer F, Scheiner B, Semmler G, Reider L, Reiter S, Schoder M, Schöfl R, Schwabl P, Stadlbauer V, Stauber R, Tatscher E, Trauner M, Ziachehabi A, Zoller H, Fickert P, Reiberger T. Austrian consensus on the diagnosis and management of portal hypertension in advanced chronic liver disease (Billroth IV). Wien Klin Wochenschr 2023:10.1007/s00508-023-02229-w. [PMID: 37358642 DOI: 10.1007/s00508-023-02229-w] [Citation(s) in RCA: 20] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2023] [Accepted: 05/15/2023] [Indexed: 06/27/2023]
Abstract
The Billroth IV consensus was developed during a consensus meeting of the Austrian Society of Gastroenterology and Hepatology (ÖGGH) and the Austrian Society of Interventional Radiology (ÖGIR) held on the 26th of November 2022 in Vienna.Based on international recommendations and considering recent landmark studies, the Billroth IV consensus provides guidance regarding the diagnosis and management of portal hypertension in advanced chronic liver disease.
Collapse
Affiliation(s)
- Mattias Mandorfer
- Division of Gastroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, Währinger Gürtel 18-20, 1090, Vienna, Austria.
- Vienna Hepatic Hemodynamic Laboratory, Division of Gastroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria.
| | - Elmar Aigner
- First Department of Medicine, Paracelsus Medical University, Salzburg, Austria
| | - Manfred Cejna
- Department of Radiology, LKH Feldkirch, Feldkirch, Austria
| | - Arnulf Ferlitsch
- Department of Internal Medicine I, KH Barmherzige Brüder Wien, Vienna, Austria
| | - Christian Datz
- Department of Internal Medicine, General Hospital Oberndorf, Teaching Hospital of the Paracelsus Medical University Salzburg, Salzburg, Austria
| | - Tilmann Gräter
- Department of Radiology, Medical University of Graz, Graz, Austria
| | - Ivo Graziadei
- Department of Internal Medicine, KH Hall in Tirol, Hall, Austria
| | - Michael Gschwantler
- Division of Gastroenterology and Hepatology, Department of Medicine IV, Klinik Ottakring, Vienna, Austria
| | - Stephanie Hametner-Schreil
- Department of Gastroenterology and Hepatology, Ordensklinikum Linz Barmherzige Schwestern, Linz, Austria
| | - Harald Hofer
- Department of Internal Medicine I, Klinikum Wels-Grieskirchen, Wels, Austria
| | - Mathias Jachs
- Division of Gastroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, Währinger Gürtel 18-20, 1090, Vienna, Austria
- Vienna Hepatic Hemodynamic Laboratory, Division of Gastroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria
| | - Alexander Loizides
- Department of Radiology, Medical University of Innbsruck, Innsbruck, Austria
| | - Andreas Maieron
- Department of Internal Medicine II, University Hospital St. Pölten, St. Pölten, Austria
| | - Markus Peck-Radosavljevic
- Department of Internal Medicine and Gastroenterology, Hepatology, Endocrinology, Rheumatology and Nephrology, Klinikum Klagenfurt am Wörthersee, Klagenfurt, Austria
| | - Florian Rainer
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Medical University of Graz, Graz, Austria
| | - Bernhard Scheiner
- Division of Gastroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, Währinger Gürtel 18-20, 1090, Vienna, Austria
- Vienna Hepatic Hemodynamic Laboratory, Division of Gastroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria
| | - Georg Semmler
- Division of Gastroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, Währinger Gürtel 18-20, 1090, Vienna, Austria
- Vienna Hepatic Hemodynamic Laboratory, Division of Gastroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria
| | - Lukas Reider
- Department of Interventional Radiology, Medical University of Vienna, Vienna, Austria
| | - Silvia Reiter
- Department of Internal Medicine and Gastroenterology and Hepatology, Kepler Universitätsklinikum, Linz, Austria
| | - Maria Schoder
- Department of Interventional Radiology, Medical University of Vienna, Vienna, Austria
| | - Rainer Schöfl
- Department of Gastroenterology and Hepatology, Ordensklinikum Linz Barmherzige Schwestern, Linz, Austria
| | - Philipp Schwabl
- Division of Gastroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, Währinger Gürtel 18-20, 1090, Vienna, Austria
- Vienna Hepatic Hemodynamic Laboratory, Division of Gastroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria
| | - Vanessa Stadlbauer
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Medical University of Graz, Graz, Austria
| | - Rudolf Stauber
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Medical University of Graz, Graz, Austria
| | - Elisabeth Tatscher
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Medical University of Graz, Graz, Austria
| | - Michael Trauner
- Division of Gastroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, Währinger Gürtel 18-20, 1090, Vienna, Austria
| | - Alexander Ziachehabi
- Department of Internal Medicine and Gastroenterology and Hepatology, Kepler Universitätsklinikum, Linz, Austria
| | - Heinz Zoller
- Department of Internal Medicine I, Medical University of Innsbruck, Innsbruck, Austria
| | - Peter Fickert
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Medical University of Graz, Graz, Austria
| | - Thomas Reiberger
- Division of Gastroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, Währinger Gürtel 18-20, 1090, Vienna, Austria.
- Vienna Hepatic Hemodynamic Laboratory, Division of Gastroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria.
| |
Collapse
|
|
26
|
Ahmed O, Yu Q. Transjugular Intrahepatic Portosystemic Shunt Placement: Entering the Era of Controlled Expansion. Cardiovasc Intervent Radiol 2023:10.1007/s00270-023-03450-w. [PMID: 37138106 DOI: 10.1007/s00270-023-03450-w] [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: 04/11/2023] [Accepted: 04/12/2023] [Indexed: 05/05/2023]
Affiliation(s)
- Osman Ahmed
- Department of Radiology, Section of Vascular and Interventional Radiology, University of Chicago Medicine, Chicago, IL, USA.
| | - Qian Yu
- Department of Radiology, Section of Vascular and Interventional Radiology, University of Chicago Medicine, Chicago, IL, USA
| |
Collapse
|
|
27
|
Gu W, Kimmann M, Laleman W, Praktiknjo M, Trebicka J. To TIPS or Not to TIPS in High Risk of Variceal Rebleeding and Acute-on-Chronic Liver Failure. Semin Liver Dis 2023; 43:189-205. [PMID: 37286178 DOI: 10.1055/a-2107-0576] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/09/2023]
Abstract
Variceal bleeding is a consequence of severe portal hypertension in patients with liver cirrhosis. Although the rate of bleeding has decreased over time, variceal bleeding in the presence of acute-on-chronic liver failure (ACLF) carries a high risk of treatment failure and short-term mortality. Treatment and/or removal of precipitating events (mainly bacterial infection and alcoholic hepatitis) and decrease of portal pressure may improve outcome of patients with acute decompensation or ACLF. Transjugular intrahepatic portosystemic shunts (TIPSs), especially in the preemptive situation, have been found to efficiently control bleeding, prevent rebleeding, and reduce short-term mortality. Therefore, TIPS placement should be considered as an option in the management of ACLF patients with variceal bleeding.
Collapse
Affiliation(s)
- Wenyi Gu
- Department of Medical Clinic B, University Hospital Muenster, Muenster, Germany
- Medical Department I, Frankfurt University Hospital, Frankfurt am Main, Germany
| | - Markus Kimmann
- Department of Medical Clinic B, University Hospital Muenster, Muenster, Germany
| | - Wim Laleman
- Department of Medical Clinic B, University Hospital Muenster, Muenster, Germany
- Department of Gastroenterology and Hepatology, Section of Liver and Biliopancreatic Disorders, University Hospitals Leuven, KU Leuven, Leuven, Belgium
| | - Michael Praktiknjo
- Department of Medical Clinic B, University Hospital Muenster, Muenster, Germany
| | - Jonel Trebicka
- Department of Medical Clinic B, University Hospital Muenster, Muenster, Germany
- European Foundation for Study of Chronic Liver Failure, Barcelona, Spain
- Department of Gastroenterology and Hepatology, Odense University Hospital, Odense, Denmark
| |
Collapse
|
|
28
|
Right vs left portal branch puncture in TIPS creation with controlled expansion covered stent: comparison of hemodynamic and clinical outcomes. Eur Radiol 2023; 33:2647-2654. [PMID: 36454260 DOI: 10.1007/s00330-022-09280-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2022] [Revised: 11/03/2022] [Accepted: 11/04/2022] [Indexed: 12/03/2022]
Abstract
PURPOSE To retrospectively compare outcomes of TIPS performed by puncturing left portal vein (LPV) vs right portal vein (RPV) to access the portal system. MATERIALS AND METHODS One hundred ninety-three consecutive patients underwent TIPS with controlled expansion covered stent by using the LPV (37 patients) or the RPV (156 patients). Patients were followed until the last clinical evaluation, liver transplantation, or death. RESULTS Demographics and clinical characteristics of the two groups were comparable. The median follow-up was 9.6 months (range 0.1-50.6). Portosystemic pressure gradient (PSG) before TIPS 15.7 mmHg ± 4.7 in RPV group (RPVG) vs 15.4 mmHg ± 4.5 in LPV group (LPVG) (p = 0.725). After TIPS, PSG 6.3 mmHg ± 2.8 in RPVG vs 6.2 mmHg ± 2.2 (p = 0.839). In LPVG, the stent was dilated to 8-mm in 95% of patients vs 77% of RPVG (p = 0.015). Two (5.4%) and 22 (14%) patients underwent TIPS revision in LPVG and RPVG (p = 0.15). The incidence of overt HE was 13% in LPVG and 24% in RPVG (p = 0.177). Rebleeding occurred in 3 of 49 patients (6%) with variceal bleeding as an indication: 2/41 patients (4.9%) in RPVG vs 1/8 patients (12.5%) in LPVG (p = 0.417). Among 126 patients with refractory ascites 20 patients (15.9%) needed paracentesis 3 months after the procedure: 18/101 patients (17.8%) in RPVG vs 2/25 patients (8%) in LPVG (p = 0.231). Thirty-seven patients (19%) died: 32 (21%) in RPVG and 5 (14%) in LPVG (p = 0.337). CONCLUSION Compared with RPV puncture, in TIPS created through the LPV, the targeted PSG was reached with a smaller stent diameter. However, no significant difference in clinical outcomes was observed. KEY POINTS • A LPV approach for TIPS creation does not lead to better control of complications of portal hypertension as compared to a RPV approach.
Collapse
|
|
29
|
Queck A, Schwierz L, Gu W, Ferstl PG, Jansen C, Uschner FE, Praktiknjo M, Chang J, Brol MJ, Schepis F, Merli M, Strassburg CP, Lehmann J, Meyer C, Trebicka J. Targeted decrease of portal hepatic pressure gradient improves ascites control after TIPS. Hepatology 2023; 77:466-475. [PMID: 35869810 DOI: 10.1002/hep.32676] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/02/2022] [Revised: 06/13/2022] [Accepted: 07/05/2022] [Indexed: 02/01/2023]
Abstract
BACKGROUND Ascites is a definitive sign of decompensated liver cirrhosis driven by portal hypertension. Although transjugular intrahepatic portosystemic shunt insertion (TIPS) is indicated for therapy of recurrent and refractory ascites, there is no evidence-based recommendation for a specific target of portal hepatic pressure gradient (PPG) decrease. METHODS In this single-center, retrospective trial, we investigated the decrease of PPG in 341 patients undergoing TIPS insertion for therapy of refractory or recurrent ascites until 2015. During each procedure, portal and inferior vena cava pressures were invasively measured and correlated with patients' outcome and ascites progression over time, according to the prespecified Noninvasive Evaluation Program for TIPS and Follow-Up Network protocol (NCT03628807). RESULTS Patients without ascites at 6 weeks after TIPS had significantly greater PPG reduction immediately after TIPS, compared to the patients with refractory ascites (median reduction 65% vs. 55% of pre-TIPS PPG; p = 0.001). Survival was significantly better if ascites was controlled, compared to patients with need for paracentesis 6 weeks after TIPS (median survival: 185 vs. 41 weeks; HR 2.0 [1.3-2.9]; p < 0.001). Therefore, higher PPG reduction by TIPS ( p = 0.005) and lower PPG after TIPS ( p = 0.02) correlated with resolution of severe ascites 6 weeks after TIPS. Multivariable analyses demonstrated that higher Child-Pugh score before TIPS (OR 1.3 [1.0-1.7]; p = 0.03) and lower serum sodium levels (OR 0.9 [0.9-1.0]; p = 0.004) were independently associated with ascites persistence 6 weeks after TIPS, whereas PPG reduction (OR 0.98 [0.97-1.00]; p = 0.02) was associated with resolution of ascites 6 weeks after TIPS. CONCLUSION Extent of PPG reduction and/or lowering of target PPG immediately after TIPS placement is associated with improved ascites control in the short term and with survival in the long term. A structured follow-up visit for patients should assess persistence of ascites at 6 weeks after TIPS.
Collapse
Affiliation(s)
- Alexander Queck
- Department of Internal Medicine 1 , University Hospital Frankfurt, Johann Wolfgang Goethe-University , Frankfurt am Main , Germany
| | - Louise Schwierz
- Department of Internal Medicine I , University Hospital Bonn , Bonn , Germany
| | - Wenyi Gu
- Department of Internal Medicine 1 , University Hospital Frankfurt, Johann Wolfgang Goethe-University , Frankfurt am Main , Germany.,Department of Internal Medicine B , University of Münster , Münster , Germany
| | - Philip G Ferstl
- Department of Internal Medicine 1 , University Hospital Frankfurt, Johann Wolfgang Goethe-University , Frankfurt am Main , Germany
| | - Christian Jansen
- Department of Internal Medicine I , University Hospital Bonn , Bonn , Germany
| | - Frank E Uschner
- Department of Internal Medicine 1 , University Hospital Frankfurt, Johann Wolfgang Goethe-University , Frankfurt am Main , Germany.,Department of Internal Medicine B , University of Münster , Münster , Germany
| | - Michael Praktiknjo
- Department of Internal Medicine I , University Hospital Bonn , Bonn , Germany.,Department of Internal Medicine B , University of Münster , Münster , Germany
| | - Johannes Chang
- Department of Internal Medicine I , University Hospital Bonn , Bonn , Germany
| | - Maximilian J Brol
- Department of Internal Medicine 1 , University Hospital Frankfurt, Johann Wolfgang Goethe-University , Frankfurt am Main , Germany.,Department of Internal Medicine B , University of Münster , Münster , Germany
| | - Filippo Schepis
- Division of Gastroenterology , Azienda Ospedaliero-Universitaria di Modena and University of Modena and Reggio Emilia , Modena , Italy
| | - Manuela Merli
- Gastroenterology, Department of Translational and Precision Medicine , Sapienza University of Rome , Rome , Italy
| | | | - Jennifer Lehmann
- Department of Internal Medicine I , University Hospital Bonn , Bonn , Germany
| | - Carsten Meyer
- Department of Radiology , University Hospital, University Bonn , Bonn , Germany
| | - Jonel Trebicka
- Department of Internal Medicine 1 , University Hospital Frankfurt, Johann Wolfgang Goethe-University , Frankfurt am Main , Germany.,Department of Internal Medicine B , University of Münster , Münster , Germany.,European Foundation for the Study of Chronic Liver Failure , Barcelona , Spain
| |
Collapse
|
|
30
|
Gupta AN, Sze DY, Rigas DA. Smaller Diameter and Adjustable Diameter Transjugular Intrahepatic Portosystemic Shunts. Semin Intervent Radiol 2023; 40:21-26. [PMID: 37152799 PMCID: PMC10159728 DOI: 10.1055/s-0043-1764285] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/09/2023]
Abstract
Complications of overshunting, including hepatic encephalopathy and hepatic insufficiency, remain prevalent following transjugular intrahepatic portosystemic shunt (TIPS) creation. Smaller diameter TIPS may reduce the risk of overshunting, but the use of smaller stents must be weighed against the risk of undershunting and persistent or recurrent hemorrhage, ascites, and other complications of portal hypertension. This article explores the question of optimal shunt diameter by examining outcomes for smaller diameter TIPS stent-grafts (<10 mm), underdilated stent-grafts, and variable diameter stent-grafts.
Collapse
Affiliation(s)
- Aakash N. Gupta
- Division of Interventional Radiology, Department of Radiology, Stanford University School of Medicine, Stanford, California
| | - Daniel Y. Sze
- Division of Interventional Radiology, Department of Radiology, Stanford University School of Medicine, Stanford, California
| | - Diamanto Amanda Rigas
- Division of Interventional Radiology, Department of Radiology, Stanford University School of Medicine, Stanford, California
- Division of Interventional Radiology, Department of Radiology, Veteran Administration Palo Alto Health Care System, Palo Alto, California
| |
Collapse
|
|
31
|
Deltenre P, Zanetto A, Saltini D, Moreno C, Schepis F. The role of transjugular intrahepatic portosystemic shunt in patients with cirrhosis and ascites: Recent evolution and open questions. Hepatology 2023; 77:640-658. [PMID: 35665949 DOI: 10.1002/hep.32596] [Citation(s) in RCA: 32] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/15/2022] [Revised: 05/14/2022] [Accepted: 05/16/2022] [Indexed: 01/28/2023]
Abstract
In selected patients with cirrhosis and ascites, transjugular intrahepatic portosystemic shunt (TIPS) placement improves control of ascites and may reduce mortality. In this review, we summarize the current knowledge concerning the use of TIPS for the treatment of ascites in patients with cirrhosis, from pathophysiology of ascites formation to hemodynamic consequences, patient selection, and technical issues of TIPS insertion. The combination of these factors is important to guide clinical decision-making and identify the best strategy for each individual patient. There is still a need to identify the best timing for TIPS placement in the natural history of ascites (recurrent vs. refractory) as well as which type and level of renal dysfunction is acceptable when TIPS is proposed for the treatment of ascites in cirrhosis. Future studies are needed to define the optimal stent diameter according to patient characteristics and individual risk of shunt-related side effects, particularly hepatic encephalopathy and insufficient cardiac response to hemodynamic consequences of TIPS insertion.
Collapse
Affiliation(s)
- Pierre Deltenre
- Department of Gastroenterology, Hepatopancreatology, and Digestive Oncology , CUB Hôpital Erasme, Université Libre de Bruxelles , Brussels , Belgium.,Department of Gastroenterology and Hepatology , CHU UCL Namur, Université Catholique de Louvain , Yvoir , Belgium.,Department of Gastroenterology and Hepatology , Clinique St Luc , Bouge , Belgium
| | - Alberto Zanetto
- Division of Gastroenterology, Hepatic Hemodynamic Laboratory , Azienda Ospedaliero-Universitaria di Modena, and University of Modena and Reggio Emilia , Modena , Italy.,Gastroenterology and Multivisceral Transplant Unit, Department of Surgery, Oncology, and Gastroenterology , Padova University Hospital , Padova , Italy
| | - Dario Saltini
- Division of Gastroenterology, Hepatic Hemodynamic Laboratory , Azienda Ospedaliero-Universitaria di Modena, and University of Modena and Reggio Emilia , Modena , Italy
| | - Christophe Moreno
- Department of Gastroenterology, Hepatopancreatology, and Digestive Oncology , CUB Hôpital Erasme, Université Libre de Bruxelles , Brussels , Belgium.,Laboratory of Experimental Gastroenterology , Université Libre de Bruxelles , Brussels , Belgium
| | - Filippo Schepis
- Division of Gastroenterology, Hepatic Hemodynamic Laboratory , Azienda Ospedaliero-Universitaria di Modena, and University of Modena and Reggio Emilia , Modena , Italy
| |
Collapse
|
|
32
|
Calmet F, Mohan P, Jalaeian H, Martin P. Management of Patients With Gastric Varices. Gastroenterol Hepatol (N Y) 2022; 18:574-585. [PMID: 36397927 PMCID: PMC9666800] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/16/2023]
Abstract
Management of patients with gastric varices represents a unique challenge for clinicians. The broad range of endoscopic and endovascular techniques currently available is in stark contrast with the limited evidence available to inform the optimal management of these patients. This article describes the classification, pathophysiology, and natural history of gastric varices; summarizes the available evidence regarding medical, endoscopic, and endovascular management of gastric varices; and provides recommendations on how to integrate these options. Management of these patients ultimately requires a multidisciplinary approach involving hepatologists, therapeutic endoscopists, and interventional radiologists, with consideration given to patient characteristics and local expertise.
Collapse
Affiliation(s)
- Fernando Calmet
- Department of Medicine, Division of Gastroenterology, Newton-Wellesley Hospital, Newton, Massachusetts
- Department of Medicine, Division of Gastroenterology, Tufts University School of Medicine, Boston, Massachusetts
| | - Prasoon Mohan
- Department of Interventional Radiology, Miller School of Medicine, University of Miami, Miami, Florida
| | - Hamed Jalaeian
- Department of Interventional Radiology, Miller School of Medicine, University of Miami, Miami, Florida
| | - Paul Martin
- Department of Medicine, Division of Hepatology, Miller School of Medicine, University of Miami, Miami, Florida
| |
Collapse
|
|
33
|
Altenbernd J, Zimmer S, Andrae L, Labonte B, Gruber J, Beier H, Abdulgader M, Buechter M, Forsting M, Theysohn J. High volume retrograde portography for better discrimination of the portal vein during TIPS procedure. Acta Radiol Open 2022; 11:20584601221128405. [PMID: 36157917 PMCID: PMC9493682 DOI: 10.1177/20584601221128405] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2022] [Accepted: 09/06/2022] [Indexed: 11/15/2022] Open
Abstract
Background: Imaging of the portal vein prior to puncture for TIPS is essential. Purpose: With this study, we examined a modified retrograde portography with regard to the reliable representation of the portal vein. Material and Methods: Prospective evaluation of 65 TIPS interventions with regard to the delimitation of the portal vein and the exact parameters of retrograde portography such as catheter diameter and contrast medium volume per injection. Results: Retrograde portographies with a large-lumen catheter (10 F) and a large contrast medium volume (40 mL) were performed in 35/63 patients with significantly better delineation of the portal vein than when using 5 F catheters with 10 mL contrast medium. Conclusion: The so-called high volume retrograde portography leads to better delimitation of the portal vein during TIPS application.
Collapse
Affiliation(s)
- J Altenbernd
- Institute of Diagnostic and Interventional
Radiology and Neuroradiology, University Hospital Essen, Germany
- Institute of Radiology and Neuroradiology, Gemeinschaftskrankenhaus Herdecke, Germany
- J Altenbernd, Institute of Diagnostic and
Interventional Radiology and Neuroradiology, University Hospital Essen, Essen 45147,
Germany; Institute of Radiology and Neuroradiology, Gemeinschaftskrankenhaus Herdecke,
Herdecke 58313, Germany.
| | - S Zimmer
- Institute of Radiology and Neuroradiology,
St Marien-Hospital Hamm, Gemeinschaftskrankenhaus Herdecke, Germany
| | - L Andrae
- Internal Medicine and Gastroenterology, Gemeinschaftskrankenhaus Herdecke, Germany
| | - B Labonte
- Internal Medicine and Gastroenterology, Gemeinschaftskrankenhaus Herdecke, Germany
| | - J Gruber
- Internal Medicine and Gastroenterology, Gemeinschaftskrankenhaus Herdecke, Germany
| | - H Beier
- Internal Medicine and Gastroenterology, Allgemeines Krankenhaus Hagen, Germany
| | - M Abdulgader
- Internal Medicine and Gastroenterology, Allgemeines Krankenhaus Hagen, Germany
| | - M Buechter
- Internal Medicine and Gastroenterology, St Elisabeth Hospital Iserlohn, Germany
| | - M Forsting
- Institute of Diagnostic and Interventional
Radiology and Neuroradiology, University Hospital Essen, Germany
| | - J Theysohn
- Institute of Diagnostic and Interventional
Radiology and Neuroradiology, University Hospital Essen, Germany
| |
Collapse
|
|
34
|
Lv Y, Chen H, Luo B, Bai W, Li K, Wang Z, Xia D, Guo W, Wang Q, Li X, Yuan J, Cai H, Xia J, Yin Z, Fan D, Han G. Concurrent large spontaneous portosystemic shunt embolization for the prevention of overt hepatic encephalopathy after TIPS: A randomized controlled trial. Hepatology 2022; 76:676-688. [PMID: 35266571 DOI: 10.1002/hep.32453] [Citation(s) in RCA: 51] [Impact Index Per Article: 17.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/05/2022] [Revised: 03/02/2022] [Accepted: 03/07/2022] [Indexed: 12/21/2022]
Abstract
BACKGROUND AND AIMS Large spontaneous portosystemic shunt (SPSS) is associated with increased risk of HE in patients undergoing transjugular intrahepatic portosystemic shunt (TIPS). This study aimed to evaluate whether prophylactic embolization of large SPSS at the time of TIPS creation could reduce the incidence of post-TIPS HE in patients with cirrhosis and variceal bleeding. APPROACH AND RESULTS From June 2014 to August 2017, 56 patients with cirrhosis and large SPSS planning to undergo TIPS for the prevention of variceal bleeding were randomly assigned (1:1) to receive TIPS alone (TIPS group, n = 29) or TIPS plus simultaneous SPSS embolization (TIPS+E group, n = 27). The primary endpoint was overt HE. TIPS placement and SPSS embolization was successful in all patients. During a median follow-up of 24 months, the primary endpoint was met in 15 patients (51.7%) in the TIPS group and six patients (22.2%) in the TIPS+E group (p = 0.045). The 2-year cumulative incidence of overt HE was significantly lower in the TIPS+E group compared with the TIPS group (21.2% vs. 48.3%; HR, 0.38; 95% CI, 0.15-0.97; p = 0.043). The 2-year incidence of recurrent bleeding (TIPS+E vs. TIPS, 15.4% vs. 25.1%; p = 0.522), shunt dysfunction (12.3% vs. 18.6%, p = 0.593), death (15.0% vs. 6.9%, p = 0.352), and other adverse events was not significantly different between the two groups. CONCLUSIONS In patients with cirrhosis treated with TIPS for variceal bleeding, concurrent large SPSS embolization reduced the risk for overt HE without increasing other complications. Concurrent large SPSS embolization should therefore be considered for prophylaxis of post-TIPS HE.
Collapse
Affiliation(s)
- Yong Lv
- Department of Liver Diseases and Digestive Interventional Radiology, National Clinical Research Centre for Digestive Diseases and Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an, China
- Military Medical Innovation Center, Fourth Military Medical University, Xi'an, China
| | - Hui Chen
- Department of Liver Diseases and Digestive Interventional Radiology, National Clinical Research Centre for Digestive Diseases and Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an, China
| | - Bohan Luo
- Department of Liver Diseases and Digestive Interventional Radiology, National Clinical Research Centre for Digestive Diseases and Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an, China
- Department of Liver Diseases and Interventional Radiology, Digestive Diseases Hospital, Xi'an International Medical Center Hospital, Northwestern University, Xi'an, China
| | - Wei Bai
- Department of Liver Diseases and Digestive Interventional Radiology, National Clinical Research Centre for Digestive Diseases and Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an, China
- Department of Liver Diseases and Interventional Radiology, Digestive Diseases Hospital, Xi'an International Medical Center Hospital, Northwestern University, Xi'an, China
| | - Kai Li
- Department of Liver Diseases and Digestive Interventional Radiology, National Clinical Research Centre for Digestive Diseases and Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an, China
| | - Zhengyu Wang
- Department of Liver Diseases and Digestive Interventional Radiology, National Clinical Research Centre for Digestive Diseases and Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an, China
- Department of Liver Diseases and Interventional Radiology, Digestive Diseases Hospital, Xi'an International Medical Center Hospital, Northwestern University, Xi'an, China
| | - Dongdong Xia
- Department of Liver Diseases and Digestive Interventional Radiology, National Clinical Research Centre for Digestive Diseases and Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an, China
- Department of Liver Diseases and Interventional Radiology, Digestive Diseases Hospital, Xi'an International Medical Center Hospital, Northwestern University, Xi'an, China
| | - Wengang Guo
- Department of Liver Diseases and Digestive Interventional Radiology, National Clinical Research Centre for Digestive Diseases and Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an, China
- Department of Liver Diseases and Interventional Radiology, Digestive Diseases Hospital, Xi'an International Medical Center Hospital, Northwestern University, Xi'an, China
| | - Qiuhe Wang
- Department of Liver Diseases and Digestive Interventional Radiology, National Clinical Research Centre for Digestive Diseases and Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an, China
| | - Xiaomei Li
- Department of Liver Diseases and Digestive Interventional Radiology, National Clinical Research Centre for Digestive Diseases and Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an, China
- Department of Liver Diseases and Interventional Radiology, Digestive Diseases Hospital, Xi'an International Medical Center Hospital, Northwestern University, Xi'an, China
| | - Jie Yuan
- Department of Liver Diseases and Digestive Interventional Radiology, National Clinical Research Centre for Digestive Diseases and Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an, China
- Department of Liver Diseases and Interventional Radiology, Digestive Diseases Hospital, Xi'an International Medical Center Hospital, Northwestern University, Xi'an, China
| | - Hongwei Cai
- Department of Technology, First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, China
| | - Jielai Xia
- Department of Medical Statistics, School of Preventive Medicine, Fourth Military Medical University, Xi'an, China
| | - Zhanxin Yin
- Department of Liver Diseases and Digestive Interventional Radiology, National Clinical Research Centre for Digestive Diseases and Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an, China
- Department of Liver Diseases and Interventional Radiology, Digestive Diseases Hospital, Xi'an International Medical Center Hospital, Northwestern University, Xi'an, China
| | - Daiming Fan
- State Key Laboratory of Cancer Biology, National Clinical Research Centre for Digestive Diseases and Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an, China
| | - Guohong Han
- Department of Liver Diseases and Digestive Interventional Radiology, National Clinical Research Centre for Digestive Diseases and Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an, China
- Department of Liver Diseases and Interventional Radiology, Digestive Diseases Hospital, Xi'an International Medical Center Hospital, Northwestern University, Xi'an, China
| |
Collapse
|
|
35
|
Gairing SJ, Müller L, Kloeckner R, Galle PR, Labenz C. Review article: post-TIPSS hepatic encephalopathy-current knowledge and future perspectives. Aliment Pharmacol Ther 2022; 55:1265-1276. [PMID: 35181894 DOI: 10.1111/apt.16825] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/27/2021] [Revised: 01/23/2022] [Accepted: 02/02/2022] [Indexed: 12/13/2022]
Abstract
BACKGROUND In light of the global rise in the burden of chronic liver diseases and liver cirrhosis, the number of patients suffering from decompensation events is expected to increase. Transjugular intrahepatic portosystemic shunts (TIPSS) provide effective long-term symptom control and may prolong transplant-free survival in portal hypertension-driven recurrent ascites and variceal bleeding. New-onset or recurrent hepatic encephalopathy (HE) after TIPSS insertion (post-TIPSS HE) represents the most severe post-interventional complication. AIMS To provide insight into the epidemiology and risk factors for post-TIPSS HE and scrutinize the current state of the art in treatment and drug therapy options. METHODS We conducted a literature search on post-TIPSS HE in patients with liver cirrhosis. RESULTS Post-TIPSS HE occurs in up to 54.5% of cases and particularly early recurrent HE is associated with a dismal prognosis. In recent years, several risk factors for the development of post-TIPSS HE have been identified. These include not only parameters reflecting liver function (model for end-stage liver disease score/Child-Pugh score) as well as cognitive dysfunction caused by minimal HE but also extrahepatic factors such as sarcopenia and common medications such as proton pump inhibitors. In addition, new data on the benefit of rifaximin and of smaller stent grafts emerged and may improve the prevention of post-TIPSS HE. CONCLUSIONS Careful selection of TIPSS candidates is of utmost importance to reduce the risk of post-TIPSS HE. In this narrative review, we provide a concise overview of the current epidemiology and risk factors of the treatment options for post-TIPSS HE.
Collapse
Affiliation(s)
- Simon Johannes Gairing
- Department of Internal Medicine I, University Medical Center of the Johannes Gutenberg-University, Mainz, Germany.,Cirrhosis Center Mainz (CCM), University Medical Center of the Johannes Gutenberg-University, Mainz, Germany
| | - Lukas Müller
- Department of Radiology, University Medical Center of the Johannes Gutenberg-University, Mainz, Germany
| | - Roman Kloeckner
- Department of Radiology, University Medical Center of the Johannes Gutenberg-University, Mainz, Germany
| | - Peter R Galle
- Department of Internal Medicine I, University Medical Center of the Johannes Gutenberg-University, Mainz, Germany.,Cirrhosis Center Mainz (CCM), University Medical Center of the Johannes Gutenberg-University, Mainz, Germany
| | - Christian Labenz
- Department of Internal Medicine I, University Medical Center of the Johannes Gutenberg-University, Mainz, Germany.,Cirrhosis Center Mainz (CCM), University Medical Center of the Johannes Gutenberg-University, Mainz, Germany
| |
Collapse
|
|
36
|
Cannella R, Tselikas L, Douane F, Cauchy F, Rautou PE, Duran R, Ronot M. Imaging-guided interventions modulating portal venous flow: evidence and controversies. JHEP REPORTS : INNOVATION IN HEPATOLOGY 2022; 4:100484. [PMID: 35677591 PMCID: PMC9168703 DOI: 10.1016/j.jhepr.2022.100484] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/30/2021] [Revised: 03/23/2022] [Accepted: 03/25/2022] [Indexed: 12/07/2022]
Abstract
Portal hypertension is defined by an increase in the portosystemic venous gradient. In most cases, increased resistance to portal blood flow is the initial cause of elevated portal pressure. More than 90% of cases of portal hypertension are estimated to be due to advanced chronic liver disease or cirrhosis. Transjugular intrahepatic portosystemic shunts, a non-pharmacological treatment for portal hypertension, involve the placement of a stent between the portal vein and the hepatic vein or inferior vena cava which helps bypass hepatic resistance. Portal hypertension may also be a result of extrahepatic portal vein thrombosis or compression. In these cases, percutaneous portal vein recanalisation restores portal trunk patency, thus preventing portal hypertension-related complications. Any portal blood flow impairment leads to progressive parenchymal atrophy and triggers hepatic regeneration in preserved areas. This provides the rationale for using portal vein embolisation to modulate hepatic volume in preparation for extended hepatic resection. The aim of this paper is to provide a comprehensive evidence-based review of the rationale for, and outcomes associated with, the main imaging-guided interventions targeting the portal vein, as well as to discuss the main controversies around such approaches.
Collapse
|
|
37
|
Wu HM, Huang SQ, Wan YM, Li YH, Xu Y. Clinical Outcomes of Transjugular Intrahepatic Portosystemic Shunt (Tips) Creation Using Fluency Versus Viatorr Stent-Grafts: A Single-Centre Retrospective Study. Cardiovasc Intervent Radiol 2022; 45:552-562. [PMID: 35274174 DOI: 10.1007/s00270-022-03102-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/12/2021] [Accepted: 02/13/2022] [Indexed: 11/02/2022]
Abstract
PURPOSE To investigate the effects of transjugular intrahepatic portosystemic shunt (TIPS) creation using Fluency versus Viatorr stent-grafts on the long-term clinical outcomes. MATERIALS AND METHODS This was a single-center retrospective study from January 2010 to October 2021 in 213 patients receiving TIPS with Fluency (Fluency group, n = 154) versus Viatorr (Viatorr group, n = 59) stent-grafts. Inclusion criteria were: age > 18 years old and TIPS creation for variceal hemorrhage. Exclusion criteria were: age > 80 years old, concomitant chronic heart or lung disease, active tuberculosis or human immunodeficiency virus infection, extrahepatic malignancy, alcohol dependence, TIPS created outside of our hospital, without any follow-up data, or decline to participate. The primary outcome was primary patency rate and its associated risk factors. RESULTS The 5-year cumulative primary patency rate was significantly higher in Viatorr group than in Fluency group (89.0% vs. 19.6%, p < 0.001), whereas the 5-year cumulative transplant-free survival rate (62.3% vs. 62.2%, p = 0.636) was comparable between two groups. Cox-regression models revealed that group (hazard ratio [HR]4.029, 95% confidence interval [CI] 1.486-10.927, p = 0.006), use of bare stents (HR 3.307, 95% CI 1.903-5.747, p < 0.001), and baseline portal vein thrombosis (HR 0.248, 95% CI 0.149-0.412, p < 0.001) were significantly associated with shunt patency. Incidences of adverse events were not significantly different between two groups (p > 0.05). CONCLUSIONS TIPS creation using Viatorr stent-grafts is superior to using Fluency stent-grafts in terms of higher long-term primary patency rate but similar transplant-free survival rate.
Collapse
Affiliation(s)
- Hua-Mei Wu
- Gastroenterology Department II, The Second Affiliated Hospital of Kunming Medical University, Kunming, 650101, Yunnan, China
| | - Song-Quan Huang
- Department of Hepatobiliary and Pancreatic Surgery, The Second Affiliated Hospital of Kunming Medical University, Kunming, 650101, Yunnan, China
| | - Yue-Meng Wan
- Gastroenterology Department II, The Second Affiliated Hospital of Kunming Medical University, Kunming, 650101, Yunnan, China.
| | - Yu-Hua Li
- Gastroenterology Department II, The Second Affiliated Hospital of Kunming Medical University, Kunming, 650101, Yunnan, China
| | - Ying Xu
- Gastroenterology Department II, The Second Affiliated Hospital of Kunming Medical University, Kunming, 650101, Yunnan, China
| |
Collapse
|
|
38
|
Meyer C, Paar Pérez AM, Chang J, Sprinkart AM, Böhling N, Luu AM, Kütting D, Jansen C, Luetkens J, Bischoff LM, Attenberger U, Strassburg CP, Trebicka J, Wolter K, Praktiknjo M. Cranial stent position is independently associated with the development of TIPS dysfunction. Sci Rep 2022; 12:3559. [PMID: 35241785 PMCID: PMC8894460 DOI: 10.1038/s41598-022-07595-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2021] [Accepted: 02/17/2022] [Indexed: 11/16/2022] Open
Abstract
Complications of portal hypertension can be treated with transjugular intrahepatic portosystemic shunt (TIPS) in selected patients. TIPS dysfunction is a relevant clinical problem. This study investigated the prognostic value of two-dimensional (2D) TIPS geometry for the development of TIPS dysfunction. Three hundred and seven patients undergoing TIPS procedure between 2014 and 2019 were analyzed in this monocentric retrospective study. 2D angiograms from the patients with and without TIPS dysfunction were reviewed to determine geometric characteristics including insertion and curve angles and the location of the stent. Primary outcome was the development of TIPS dysfunction. A total of 70 patients developed TIPS dysfunction and were compared to the dysfunction-free (n = 237) patients. The position of the cranial stent end in the hepatic vein and the persistence of spontaneous portosystemic shunts were significantly associated with the development of TIPS dysfunction. Among significant parameters in univariable regression analysis (portal vein-pressure after TIPS, Child-Pugh Score before TIPS, MELD before TIPS and white blood cell count before TIPS), multivariable models showed cranial stent position (p = 0.027, HR 2.300, 95% CI 1.101-4.806) and SPSS embolization (p = 0.006, HR 0.319, 95% CI 0.140-0.725) as the only predictors of TIPS dysfunction. This monocentric study demonstrates that the position of the cranial stent end is independently associated with the development of TIPS dysfunction. The distance of the cranial stent end to the IVC at the time of TIPS placement should be less than 1 cm in 2D angiography.
Collapse
Affiliation(s)
- Carsten Meyer
- Department of Radiology, University Hospital Bonn, Bonn, Germany
| | - Alba Maria Paar Pérez
- Department of Internal Medicine I, University Hospital Bonn, Venusberg-Campus 1, 53127, Bonn, Germany
| | - Johannes Chang
- Department of Internal Medicine I, University Hospital Bonn, Venusberg-Campus 1, 53127, Bonn, Germany
| | | | - Nina Böhling
- Department of Internal Medicine I, University Hospital Bonn, Venusberg-Campus 1, 53127, Bonn, Germany
| | - Andreas Minh Luu
- Department of General and Visceral Surgery, St. Josef Hospital, University of Bochum, Bochum, Germany
| | - Daniel Kütting
- Department of Radiology, University Hospital Bonn, Bonn, Germany
| | - Christian Jansen
- Department of Internal Medicine I, University Hospital Bonn, Venusberg-Campus 1, 53127, Bonn, Germany
| | - Julian Luetkens
- Department of Radiology, University Hospital Bonn, Bonn, Germany
| | | | | | - Christian P Strassburg
- Department of Internal Medicine I, University Hospital Bonn, Venusberg-Campus 1, 53127, Bonn, Germany
| | - Jonel Trebicka
- Department of Internal Medicine 1, University of Frankfurt, Frankfurt, Germany
- European Foundation for the Study of Chronic Liver Failure - EF CLIF, Barcelona, Spain
| | - Karsten Wolter
- Department of Radiology, University Hospital Bonn, Bonn, Germany
| | - Michael Praktiknjo
- Department of Internal Medicine I, University Hospital Bonn, Venusberg-Campus 1, 53127, Bonn, Germany.
| |
Collapse
|
|
39
|
Li X, Partovi S, Coronado WM, Gadani S, Martin C, Thompson D, Levitin A, Kapoor B. Hepatic Encephalopathy After TIPS Placement: Predictive Factors, Prevention Strategies, and Management. Cardiovasc Intervent Radiol 2022; 45:570-577. [PMID: 34981195 DOI: 10.1007/s00270-021-03045-3] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/10/2021] [Accepted: 12/08/2021] [Indexed: 12/19/2022]
Abstract
Hepatic encephalopathy (HE) is a challenging complication after transjugular intrahepatic portosystemic shunt (TIPS) placement. Despite recent advances, much is still uncertain regarding risk factors, preventative measures, and the management of HE after TIPS placement. Appropriate patient selection and pre-procedural risk stratification remain areas of focus. In this manuscript, we discuss the current state of research related to HE after TIPS placement, including information regarding risk stratification, complication prevention, and treatment options.
Collapse
Affiliation(s)
- Xin Li
- Department of Radiology, Hospital of The University of Pennsylvania, Philadelphia, PA, USA
| | - Sasan Partovi
- Section of Interventional Radiology, Imaging Institute, Cleveland Clinic Main Campus, Cleveland, OH, USA.
| | | | - Sameer Gadani
- Section of Interventional Radiology, Imaging Institute, Cleveland Clinic Main Campus, Cleveland, OH, USA
| | - Charles Martin
- Section of Interventional Radiology, Imaging Institute, Cleveland Clinic Main Campus, Cleveland, OH, USA
| | - Dustin Thompson
- Section of Interventional Radiology, Imaging Institute, Cleveland Clinic Main Campus, Cleveland, OH, USA
| | - Abraham Levitin
- Section of Interventional Radiology, Imaging Institute, Cleveland Clinic Main Campus, Cleveland, OH, USA
| | - Baljendra Kapoor
- Section of Interventional Radiology, Imaging Institute, Cleveland Clinic Main Campus, Cleveland, OH, USA
| |
Collapse
|
|
40
|
Chang J, Höfer P, Böhling N, Lingohr P, Manekeller S, Kalff JC, Dohmen J, Kaczmarek DJ, Jansen C, Meyer C, Strassburg CP, Trebicka J, Praktiknjo M. Pre-operative TIPS may reduce post-operative ACLF occurrence. JHEP REPORTS : INNOVATION IN HEPATOLOGY 2022; 4:100442. [PMID: 35198929 PMCID: PMC8844300 DOI: 10.1016/j.jhepr.2022.100442] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/01/2021] [Revised: 12/10/2021] [Accepted: 12/28/2021] [Indexed: 11/25/2022]
Abstract
Background & Aims Acute-on-chronic liver failure (ACLF) is a syndrome associated with organ failure and high short-term mortality. Recently, the role of surgery as a precipitating event for ACLF has been characterised. However, the impact of preoperative transjugular intrahepatic portosystemic shunt (TIPS) placement on ACLF development in patients with cirrhosis undergoing surgery has not been investigated yet. Methods A total of 926 patients (363 with cirrhosis undergoing surgery and 563 patients with TIPS) were screened. Forty-five patients with preoperative TIPS (TIPS group) were 1:1 propensity matched to patients without preoperative TIPS (no-TIPS group). The primary endpoint was the development of ACLF within 28 and 90 days after surgery. The secondary endpoint was 1-year mortality. Results were confirmed by a differently 1:2 matched cohort (n = 176). Results Patients in the no-TIPS group had significantly higher rates of ACLF within 28 days (29 vs. 9%; p = 0.016) and 90 days (33 vs. 13%; p = 0.020) after surgery as well as significantly higher 1-year mortality (38 vs. 18%; p = 0.023) compared with those in the TIPS group. Surgery without preoperative TIPS and Chronic Liver Failure Consortium–Acute Decompensation (CLIF-C AD) score were independent predictors for 28- and 90-day ACLF development and 1-year mortality after surgery, especially in patients undergoing visceral surgery. In the no-TIPS group, a CLIF-C AD score of >45 could be identified as cut-off for patients at risk for postoperative ACLF development benefiting from TIPS. Conclusions This study suggests that preoperative TIPS may result in lower rates of postoperative ACLF development especially in patients undergoing visceral surgery and with a CLIF-C AD score above 45. Lay summary Acute-on-chronic liver failure (ACLF) is a syndrome that is associated with high short-term mortality. Surgical procedures are a known precipitating event for ACLF. This study investigates the role of preoperative insertion of a transjugular intrahepatic portosystemic shunt (TIPS) on postoperative mortality and ACLF development. Patients with TIPS insertion before a surgical procedure exhibit improved postoperative survival and lower rates of postoperative ACLF, especially in patients undergoing visceral surgery and with a high CLIF-C AD prognostic score. Thus, this study suggests preoperative TIPS insertion in those high-risk patients.
This study investigates the impact of preoperative TIPS on postsurgical ACLF. Patients with preoperative TIPS, especially before visceral surgery, develop significantly lower rates of ACLF. Preoperative TIPS is associated with improved postsurgical survival. CLIF-C AD score >45 can be used as cut-off for patients at risk for postsurgical ACLF. Selected patients might benefit from preoperative TIPS insertion.
Collapse
|
|
41
|
Wang HL, Lu WJ, Zhang YL, Nie CH, Zhou TY, Zhou GH, Zhu TY, Wang BQ, Chen SQ, Yu ZN, Jing L, Sun JH. Comparison of Transjugular Intrahepatic Portosystemic Shunt in the Treatment of Cirrhosis With or Without Portal Vein Thrombosis: A Retrospective Study. Front Med (Lausanne) 2021; 8:737984. [PMID: 34671621 PMCID: PMC8523019 DOI: 10.3389/fmed.2021.737984] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2021] [Accepted: 09/06/2021] [Indexed: 12/27/2022] Open
Abstract
Aim: The purpose of our study was to conduct a retrospective analysis to compare the effectiveness of transjugular intrahepatic portosystemic shunts (TIPS) in the treatment of patients with cirrhosis with or without portal vein thrombosis (PVT). Methods: We included a total of 203 cirrhosis patients successfully treated with TIPS between January 2015 and January 2018, including 72 cirrhosis patients with PVT (35.5%) and 131 without PVT (64.5%). Our subjects were followed for at least 1 year after treatment with TIPS. Data were collected to estimate the mortality, shunt dysfunction, and complication rates after TIPS creation. Results: During the mean follow-up time of 19.5 ± 12.8 months, 21 (10.3%) patients died, 15 (7.4%) developed shunt dysfunction, and 44 (21.6%) experienced overt hepatic encephalopathy (OHE). No significant differences in mortality (P = 0.134), shunt dysfunction (P = 0.214), or OHE (P = 0.632) were noted between the groups. Age, model for end-stage liver disease (MELD) score, and refractory ascites requiring TIPS were risk factors for mortality. A history of diabetes, percutaneous transhepatic variceal embolization (PTVE), 8-mm diameter stent, and platelet (PLT) increased the risk of shunt dysfunction. The prevalence of variceal bleeding and recurrent ascites was comparable between the two groups (16.7 vs. 16.7% P = 0.998 and 2.7 vs. 3.8% P = 0.678, respectively). Conclusions: Transjugular intrahepatic portosystemic shunts are feasible in the management of cirrhosis with PVT. No significant differences in survival or shunt dysfunction were noted between the PVT and no-PVT groups. The risk of recurrent variceal bleeding, recurrent ascites, and OHE in the PVT group was generally similar to that in the no-PVT group. TIPS represents a potentially feasible treatment option in cirrhosis patients with PVT.
Collapse
Affiliation(s)
- Hong-Liang Wang
- Hepatobiliary and Pancreatic Interventional Treatment Center, Division of Hepatobiliary and Pancreatic Surgery, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China.,Zhejiang Provincial Research Center for Diagnosis and Treatment of Hepatobiliary Diseases, Hangzhou, China
| | - Wei-Jie Lu
- Hepatobiliary and Pancreatic Interventional Treatment Center, Division of Hepatobiliary and Pancreatic Surgery, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Yue-Lin Zhang
- Hepatobiliary and Pancreatic Interventional Treatment Center, Division of Hepatobiliary and Pancreatic Surgery, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China.,Zhejiang Clinical Research Center of Hepatobiliary and Pancreatic Diseases, Hangzhou, China
| | - Chun-Hui Nie
- Hepatobiliary and Pancreatic Interventional Treatment Center, Division of Hepatobiliary and Pancreatic Surgery, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China.,Zhejiang Clinical Research Center of Hepatobiliary and Pancreatic Diseases, Hangzhou, China
| | - Tan-Yang Zhou
- Hepatobiliary and Pancreatic Interventional Treatment Center, Division of Hepatobiliary and Pancreatic Surgery, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China.,Zhejiang Provincial Research Center for Diagnosis and Treatment of Hepatobiliary Diseases, Hangzhou, China
| | - Guan-Hui Zhou
- Hepatobiliary and Pancreatic Interventional Treatment Center, Division of Hepatobiliary and Pancreatic Surgery, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China.,Zhejiang Provincial Research Center for Diagnosis and Treatment of Hepatobiliary Diseases, Hangzhou, China
| | - Tong-Yin Zhu
- Hepatobiliary and Pancreatic Interventional Treatment Center, Division of Hepatobiliary and Pancreatic Surgery, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China.,Zhejiang Provincial Research Center for Diagnosis and Treatment of Hepatobiliary Diseases, Hangzhou, China
| | - Bao-Quan Wang
- Hepatobiliary and Pancreatic Interventional Treatment Center, Division of Hepatobiliary and Pancreatic Surgery, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China.,Zhejiang Provincial Research Center for Diagnosis and Treatment of Hepatobiliary Diseases, Hangzhou, China
| | - Sheng-Qun Chen
- Hepatobiliary and Pancreatic Interventional Treatment Center, Division of Hepatobiliary and Pancreatic Surgery, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China.,Zhejiang Provincial Research Center for Diagnosis and Treatment of Hepatobiliary Diseases, Hangzhou, China
| | - Zi-Niu Yu
- Hepatobiliary and Pancreatic Interventional Treatment Center, Division of Hepatobiliary and Pancreatic Surgery, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China.,Zhejiang Provincial Research Center for Diagnosis and Treatment of Hepatobiliary Diseases, Hangzhou, China
| | - Li Jing
- Hepatobiliary and Pancreatic Interventional Treatment Center, Division of Hepatobiliary and Pancreatic Surgery, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China.,Zhejiang Provincial Research Center for Diagnosis and Treatment of Hepatobiliary Diseases, Hangzhou, China
| | - Jun-Hui Sun
- Hepatobiliary and Pancreatic Interventional Treatment Center, Division of Hepatobiliary and Pancreatic Surgery, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China.,Zhejiang Provincial Research Center for Diagnosis and Treatment of Hepatobiliary Diseases, Hangzhou, China.,Zhejiang Clinical Research Center of Hepatobiliary and Pancreatic Diseases, Hangzhou, China
| |
Collapse
|
|
42
|
Mansour S, Lemmers A, Trépo E, Moreno C, Deltenre P. The clinical advantage of fixed 8-mm diameter VCX stents over underdilated VTS stents is not established in refractory ascites. JHEP Rep 2021; 3:100319. [PMID: 34505034 PMCID: PMC8411241 DOI: 10.1016/j.jhepr.2021.100319] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/25/2021] [Accepted: 05/28/2021] [Indexed: 12/27/2022] Open
Affiliation(s)
- Sohaïb Mansour
- Department of Gastroenterology, Hepatopancreatology and Digestive Oncology, CUB Hôpital Erasme, Université Libre de Bruxelles, Brussels, Belgium
| | - Arnaud Lemmers
- Department of Gastroenterology, Hepatopancreatology and Digestive Oncology, CUB Hôpital Erasme, Université Libre de Bruxelles, Brussels, Belgium
| | - Eric Trépo
- Department of Gastroenterology, Hepatopancreatology and Digestive Oncology, CUB Hôpital Erasme, Université Libre de Bruxelles, Brussels, Belgium.,Laboratory of Experimental Gastroenterology, Université Libre de Bruxelles, Brussels, Belgium
| | - Christophe Moreno
- Department of Gastroenterology, Hepatopancreatology and Digestive Oncology, CUB Hôpital Erasme, Université Libre de Bruxelles, Brussels, Belgium.,Laboratory of Experimental Gastroenterology, Université Libre de Bruxelles, Brussels, Belgium
| | - Pierre Deltenre
- Department of Gastroenterology, Hepatopancreatology and Digestive Oncology, CUB Hôpital Erasme, Université Libre de Bruxelles, Brussels, Belgium.,Department of Gastroenterology and Hepatology, Clinique St Luc, Bouge, Belgium
| |
Collapse
|
|
43
|
Praktiknjo M, Witt A, Schepis F, Garcia-Pagan JC, Merli M, Trebicka J. Reply to: "The clinical advantage of fixed 8-mm diameter VCX stents over underdilated VTS stents is not established in refractory ascites". JHEP Rep 2021; 3:100349. [PMID: 34505036 PMCID: PMC8411234 DOI: 10.1016/j.jhepr.2021.100349] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/20/2021] [Accepted: 07/29/2021] [Indexed: 11/29/2022] Open
Affiliation(s)
- Michael Praktiknjo
- Department of Internal Medicine I, University Hospital Bonn, Bonn, Germany
| | - Antonia Witt
- Department of Internal Medicine I, University Hospital Bonn, Bonn, Germany
| | - Filippo Schepis
- Division of Gastroenterology, Azienda Ospedaliero-Universitaria di Modena and University of Modena and Reggio Emilia, Modena, Italy
| | | | - Manuela Merli
- Department of Translational and Precision Medicine, Sapienza University of Rome, Rome, Italy
| | - Jonel Trebicka
- Department of Internal Medicine I, J.W.Goethe University Hospital, Frankfurt, Germany
- European Foundation for Study of Chronic Liver Failure, Barcelona, Spain
| |
Collapse
|
|
44
|
Mattock R, Tripathi D, O'Neill F, Craig J, Tanner J, Patch D, Aithal G. Economic evaluation of covered stents for transjugular intrahepatic portosystemic stent shunt in patients with variceal bleeding and refractory ascites secondary to cirrhosis. BMJ Open Gastroenterol 2021; 8:bmjgast-2021-000641. [PMID: 34429322 PMCID: PMC8386212 DOI: 10.1136/bmjgast-2021-000641] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/09/2021] [Accepted: 07/18/2021] [Indexed: 12/20/2022] Open
Abstract
Objectives Transjugular intrahepatic portosystemic stent shunt (TIPSS) is clinically effective in variceal bleeding and refractory ascites; however, the cost-effectiveness of TIPSS has yet to be evaluated in the UK. This study aimed to establish the cost-effectiveness of (i) pre-emptive TIPSS versus endoscopic band ligation (EBL) in populations with variceal bleeding and (ii) TIPSS versus large volume paracentesis (LVP) in refractory ascites. Methods A cost-utility analysis was conducted with the perspective including healthcare costs and quality-adjusted life years (QALYs). A Markov model was constructed with a 2-year time horizon, health states for mortality and survival and probabilities for the development of variceal bleeding, ascites and hepatic encephalopathy. A survival analysis was conducted to extrapolate 12-month to 24-month mortality for the refractory ascites indication. Uncertainty was analysed in deterministic and probabilistic sensitivity analyses. Results TIPSS was cost-effective (dominant) and cost saving for both indications. For variceal bleeding, pre-emptive TIPSS resulted in 0.209 additional QALYs, and saved £600 per patient compared with EBL. TIPSS had a very high probability of being cost-effective (95%) but was not cost saving in scenario analyses driven by rates of variceal rebleeding. For refractory ascites, TIPSS resulted in 0.526 additional QALYs and saved £17 983 per patient and had a 100% probability of being cost-effective and cost saving when compared with LVP. Conclusions TIPSS is a cost-effective intervention for variceal bleeding and refractory ascites. TIPSS is highly cost-saving for refractory ascites. Robust randomised trial data are required to confirm whether pre-emptive TIPSS is cost saving for variceal bleeding.
Collapse
Affiliation(s)
- Richard Mattock
- York Health Economics Consortium, University of York, York, UK
| | - Dhiraj Tripathi
- Liver Unit, Queen Elizabeth Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | | | - Joyce Craig
- York Health Economics Consortium, University of York, York, UK
| | | | - David Patch
- Hepatology and Liver Transplantation, Royal Free London NHS Foundation Trust, London, UK
| | - Guruprasad Aithal
- Faculty of Medicine & Health Sciences, The University of Nottingham, Nottingham, UK
| |
Collapse
|
|
45
|
Simbrunner B, Trauner M, Reiberger T, Mandorfer M. Recent advances in the understanding and management of hepatorenal syndrome. Fac Rev 2021; 10:48. [PMID: 34131658 PMCID: PMC8170686 DOI: 10.12703/r/10-48] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
Renal dysfunction occurs frequently in hospitalized patients with advanced chronic liver disease (ACLD)/cirrhosis and has profound prognostic implications. In ACLD patients with ascites, hepatorenal syndrome (HRS) may result from circulatory dysfunction that leads to reduced kidney perfusion and glomerular filtration rate (in the absence of structural kidney damage). The traditional subclassification of HRS has recently been replaced by acute kidney injury (AKI) type of HRS (HRS-AKI) and non-AKI type of HRS (HRS-NAKI), replacing the terms “HRS type 1” and “HRS type 2”, respectively. Importantly, the concept of absolute serum creatinine (sCr) cutoffs for diagnosing HRS was partly abandoned and short term sCr dynamics now may suffice for AKI diagnosis, which facilitates early treatment initiation that may prevent the progression to HRS-AKI or increase the chances of AKI/HRS-AKI reversal. Recent randomized controlled trials have established (a) the efficacy of (long-term) albumin in the prevention of complications of ascites (including HRS-AKI), (b) the benefits of transjugular intrahepatic portosystemic shunt placement in patients with recurrent ascites, and (c) the superiority of terlipressin over noradrenaline for the treatment of HRS-AKI in the context of acute-on-chronic liver failure. This review article aims to summarize recent advances in the understanding and management of HRS.
Collapse
Affiliation(s)
- Benedikt Simbrunner
- Division of Gastroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, Waehringer Guertel 18-20, 1090 Vienna, Austria
- Vienna Hepatic Hemodynamic Lab, Medical University of Vienna, Waehringer Guertel 18-20, 1090 Vienna, Austria
| | - Michael Trauner
- Division of Gastroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, Waehringer Guertel 18-20, 1090 Vienna, Austria
| | - Thomas Reiberger
- Division of Gastroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, Waehringer Guertel 18-20, 1090 Vienna, Austria
- Vienna Hepatic Hemodynamic Lab, Medical University of Vienna, Waehringer Guertel 18-20, 1090 Vienna, Austria
| | - Mattias Mandorfer
- Division of Gastroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, Waehringer Guertel 18-20, 1090 Vienna, Austria
- Vienna Hepatic Hemodynamic Lab, Medical University of Vienna, Waehringer Guertel 18-20, 1090 Vienna, Austria
| |
Collapse
|