Extrahepatic Portal Vein Puncture and Intra-abdominal Hemorrhage during Transjugular Intrahepatic Portosystemic Shunt Creation (original) (raw)
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Journal of Clinical Gastroenterology, 2004
Background: Pleural effusions(PE) complicate cirrhosis in ~5% of patients. Identification of cause and related complications is imperative. Unlike refractory ascites, large-scale studies on interventions for refractory PE are limited. Methods: Consecutive hospitalized cirrhotics having PE were retrospectively analyzed. None had liver transplantation (LT) within 6-month follow-up. We determined safety, efficacy and mortality predictors for PE managed with standard medical treatment(SMT), thoracentesis, catheter drainage and TIPS. Results: Of 1149 cirrhotics with PE(mean Child-Pugh 10.6 ±1.8 and MELD 21.2 ±7.4), 82.6% had hepatic hydrothorax(HH) and 12.3% were suspected tubercular PE(TBPE). Despite comparable HVPG and MELD scores, patients with HH developed more AKI, encephalopathy and septic shock (all P<0.01) on follow up. Among HH, 73.5% were symptomatic, 53.2% isolated right-sided PE and 21.3% had SBE. Presence of SBP[Odd's ratio,OR:4.5] and catheter drainage[OR:2.1] were independent predictors for SBE. In 70.3% of admissions, HH responded to SMT alone, 12.9% required thoracentesis and 11.5% underwent catheter drainage. 51 patients were selected for TIPS [lower mean CTP 9.9±1.6 and MELD score 18.7±5.4]. Despite reduction in pressure gradient from 23.1±3.8 mm Hg to 7.2±2.5 mm Hg, 25 patients had partial response, 10 had complete HH resolution. Major post-TIPS complications were portosystemic encephalopathy(8 patients, 6 resolved) and ischemic hepatitis(4 patients, 2 resolved). Overall, 35.9% patients with HH had 6-month mortality and independent predictors were MELD >25, SBP and septic shock. Conclusion: Refractory PE in cirrhosis requiring interventions including TIPS has poor outcome. Role of hemodynamics in predicting post-TIPS response and complications is limited. Early referral for LT is imperative.
Journal of the American College of Surgeons, 2002
BACKGROUND: This article discusses the largest and longest experience reported to date of the use of portalsystemic shunt (PSS) to treat recurrent bleeding from esophagogastric varices caused by extrahepatic portal hypertension associated with portal vein thrombosis (PVT). STUDY DESIGN: Two hundred consecutive children and adults with extrahepatic portal hypertension caused by PVT who were referred between 1958 and 1998 after recovering from at least two episodes of bleeding esophagogastric varices requiring blood transfusions were managed according to a well-defined and uniformly applied protocol. All but 14 of the 200 patients were eligible for and received 5 or more years of regular followup (93%); 166 were eligible for and received 10 or more years of regular followup (83%). RESULTS: The etiology of PVT was unknown in 65% of patients. Identifiable causes of PVT were neonatal omphalitis in 30 patients (15%), umbilical vein catheterization in 14 patients (7%), and peritonitis in 14 patients (7%). The mean number of bleeding episodes before PSS was 5.4 (range 2 to 18). Liver biopsies showed normal morphology in all patients. The site of PVT was the portal vein alone in 134 patients (76%), the portal vein and adjacent superior mesenteric vein in 10 patients (5%), and the portal and splenic veins in 56 patients (28%). Postoperative survival to leave the hospital was 100%. Actuarial 5-year, 10-year, and 15-year survival rates were 99%, 97%, and 95%, respectively. Five patients (2.5%), all with central end-to-side splenorenal shunts, developed thrombosis of the PSS, and these were the only patients who had recurrent variceal bleeding. During 10 or more years of followup, 97% of the eligible patients were shown to have a patent shunt and were free of bleeding. No patient developed portal-systemic encephalopathy, liver function tests remained normal, liver biopsies in 100 patients showed normal architecture, hypersplenism was corrected.
The transjugular intrahepatic portosystemic shunt
Journal of Hepatology - J HEPATOL, 1996
URMG TEE last 20 years improvement in endoscopic techniques have resulted in more than 90% success in the management of acute variceal bleeding. However, in the prevention of recurrence of variceal bleeding endoscopic treatment is of limited efficacy, with a l-year rebleeding rate' of more than 40% (1). In patients with insufficient response to endoscopic therapy, surgical shunts and devascularization operations have for many years been used as salvage treatments, but they have become less acceptable in recent years because of their high operative mortality and postoperative morbidity, especially in the many Child-class B and C patients. In 1988, the transjugular intrahepatic portosystemic stent-assisted shunt (TIPS) was introduced into clinical practice (2) and has since then enjoyed rapid acceptance around the world. This may in part be due to the fascinating technique of this novel intervention, but it may also be a consequence of the unfavorable results of the pre-existing therapies. The results presently available suggest that TIPS has a higher efficacy and a lower morbidity and mortality than endoscopic and surgical treatments, respectively. Its major limitations, namely shunt failure and hepatic encephalopathy, must be overcome by specific medication, improved stents and better selection of patients. This review concentrates on the two major indications, variceal bleeding and refractory ascites, and summarizes the results of major studies. TIPS for variceal rebleeding Uncontrolled studies Since its first description in 1988 (2) numerous papers have been published on TIPS for variceal
Surgery, 1999
Since the advent of liver transplantation and transjugular intrahepatic portosystemic shunts (TIPS), the role of surgical portosystemic shunts in the treatment of portal hypertension has changed. However, we have continued to use portosystemic shunts in patients with noncirrhotic portal hypertension and in patients with Child's A cirrhosis. We performed 48 surgical portosystemic shunt procedures between 1988 and 1998. The outcomes of these patients were evaluated to assess the efficacy of this treatment. Data from 39 of 48 patients were available for analysis. The average follow-up was 42 months. Liver function generally remained stable for the patients; only 2 patients had progressive liver failure and required transplant procedures. Gastrointestinal bleeding (3 patients), encephalopathy (3 patients), and shunt thrombosis (3 patients) were rare. Patient survival was 81% at 4 years, similar to survival with liver transplantation (P = .22). Surgical shunts remain the treatment of choice for prevention of recurrent variceal bleeding in patients with good liver function and portal hypertension.
The transjugular intrahepatic portosystemic shunt [Review]
Journal of Hepatology
URMG TEE last 20 years improvement in endoscopic techniques have resulted in more than 90% success in the management of acute variceal bleeding. However, in the prevention of recurrence of variceal bleeding endoscopic treatment is of limited efficacy, with a l-year rebleeding rate' of more than 40% (1). In patients with insufficient response to endoscopic therapy, surgical shunts and devascularization operations have for many years been used as salvage treatments, but they have become less acceptable in recent years because of their high operative mortality and postoperative morbidity, especially in the many Child-class B and C patients. In 1988, the transjugular intrahepatic portosystemic stent-assisted shunt (TIPS) was introduced into clinical practice (2) and has since then enjoyed rapid acceptance around the world. This may in part be due to the fascinating technique of this novel intervention, but it may also be a consequence of the unfavorable results of the pre-existing therapies. The results presently available suggest that TIPS has a higher efficacy and a lower morbidity and mortality than endoscopic and surgical treatments, respectively. Its major limitations, namely shunt failure and hepatic encephalopathy, must be overcome by specific medication, improved stents and better selection of patients. This review concentrates on the two major indications, variceal bleeding and refractory ascites, and summarizes the results of major studies. TIPS for variceal rebleeding Uncontrolled studies Since its first description in 1988 (2) numerous papers have been published on TIPS for variceal
Journal of Vascular and Interventional Radiology, 1993
MATERIALS AND METHODS: Twelve young swine were used. Acute portal hypertension was induced by means of selective injections of absolute alcohol, ethiodized oil, and polyvinyl alcohol sponge particles into Index terms: Hypertension, portal, intrahepatic portal branches. 959.711 Shunt, portosystemic, RESULTS: TIPS was successfully created in all swine by using spiral Z 959.453 Stents stents that were 6,8, and 10 mm in diameter; each size stent was deployed in four animals. Being sufficiently flexible, spiral Z stents accom-JVIR 1993; 4:85-90 modated for curved shunt tracts. An average of 48% portal pressure de-Abbreviations: PVA = polyvinyl alco-crease was achieved with 6-mm-diameter stents, 61% with 8-mmhol, TIPS = transjugular intrahepatic par-diameter stents, and 87% with 10-mm-diameter stents. tosystemic shunt CONCLUSION: These results are in agreement with our clinical experience with use of Gianturco-Rosch Z stents for TIPS formation. T n a N s l u o u v r n intrahepatic portosystemic shunt (TIPS) creation with MATERIALS AND METHODS connection between the portal and hepatic veins was first described by Twelve young swine weighing Rosch et a1 in experimental animals 17-21 kg were used. Following the (1,2). Colapinto et al were the first to guidelines established by the U.S. create TIPS clinically by using an Food and Drug administration, the angioplasty balloon catheter to keep animals were intubated and given the established shunt open (3). Intromethoxyflurane (Pitman-Moore, duction of expandable metallic stents Mundelein, Ill) inhalation anesthesia. to reinforce the hepatic parenchymal Percutaneous transhepatic cathetertract finally ensured consistent paization of the portal system was pertency (4-6). TIPS is now gaining formed first from the right midaxilwider acceptance in clinical practice lary line with use of a 5.5-F Torcon as an alternative to emergency shunt catheter (Cook, Bloomington, Ind). surgery in treatment of patients with Portal vein pressures were measured gastroesophageal variceal bleeding by using a Pharmaseal central ve-(7-1 1). Despite the obvious experinous pressure monitor (Baxter From the Dotter Institute for Interven-mental and clinical relevance of these Healthcare, Valencia, Calif) and contional Therapy, Oregon Health sciences observations, little is known about trol portography performed with use