The transjugular intrahepatic portosystemic shunt (original) (raw)
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World journal of gastroenterology : WJG, 2012
To compare early use of transjugular intrahepatic portosystemic shunt (TIPS) with endoscopic treatment (ET) for the prophylaxis of recurrent variceal bleeding. In-patient data were collected from 190 patients between January 2007 and June 2010 who suffured from variceal bleeding. Patients who were older than 75 years; previously received surgical treatment or endoscopic therapy for variceal bleeding; and complicated with hepatic encephalopathy or hepatic cancer, were excluded from this research. Thirty-five cases lost to follow-up were also excluded. Retrospective analysis was done in 126 eligible cases. Among them, 64 patients received TIPS (TIPS group) while 62 patients received endoscopic therapy (ET group). The relevant data were collected by patient review or telephone calls. The occurrence of rebleeding, hepatic encephalopathy or other complications, survival rate and cost of treatment were compared between the two groups. During the follow-up period (median, 20.7 and 18.7 mo ...
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
Hepatology, 2015
Gastroesophageal variceal bleeding in patients with cirrhosis is associated with significant morbidity and mortality, as well as a high rebleeding risk. Limited data are available on the role of transjugular intrahepatic portosystemic shunt (TIPS) with covered stents in patients receiving standard endoscopic, vasoactive, and antibiotic treatment. In this multicenter randomized trial, long-term endoscopic variceal ligation (EVL) or glue injection 1 b-blocker treatment was compared with TIPS placement in 72 patients with a first or second episode of gastric and/or esophageal variceal bleeding, after hemodynamic stabilization upon endoscopic, vasoactive, and antibiotic treatment. Randomization was stratified according to Child-Pugh score. Kaplan-Meier (event-free) survival estimates were used for the endpoints rebleeding, death, treatment failure, and hepatic encephalopathy. During a median follow-up of 23 months, 10 (29%) of 35 patients in the endoscopy 1 b-blocker group, as compared to 0 of 37 (0%) patients in the TIPS group, developed variceal rebleeding (P 5 0.001). Mortality (TIPS 32% vs. endoscopy 26%; P 5 0.418) and treatment failure (TIPS 38% vs. endoscopy 34%; P 5 0.685) did not differ between groups. Early hepatic encephalopathy (within 1 year) was significantly more frequent in the TIPS group (35% vs. 14%; P 5 0.035), but during longterm follow-up this difference diminished (38% vs. 23%; P 5 0.121). Conclusions: In unselected patients with cirrhosis, who underwent successful endoscopic hemostasis for variceal bleeding, covered TIPS was superior to EVL 1 b-blocker for reduction of variceal rebleeding, but did not improve survival. TIPS was associated with higher rates of early hepatic encephalopathy.
European Journal of Gastroenterology & Hepatology, 1999
Background. The presence of refractory ascites is a common indication for transjugular intrahepatic portosystemic shunt (TIPS). Different models have been proposed for the prediction of survival after TIPS. The aim of this study was to evaluate the predictive factors associated with patients' survival after TIPS placement for refractory ascites. Methods. Data from all consecutive patients undergoing TIPS placement in our center for refractory ascites between February 2003 and January 2008 were prospectively recorded. Results. Seventy-three patients (52M/21F; 57 ± 10 years) met the inclusion criteria; mean follow-up was 17 ± 2 months. Mean MELD value, before TIPS placement, was 15.7 ± 5.3. TIPS placement led to an effective resolution of refractory ascites in 54% of patients (n = 40) with no significant increase in severe portosystemic encephalopathy. The 1-year survival rate observed was 65.7%, while the overall mortality was 23.3% (n = 17) with a mean survival of 17 ± 14 months. MELD score (B = 0.161, p = 0.042), basal AST (B = 0.020, p = 0.090), and pre-TIPS HVPG (B = 0.016, p = 0.093) were independent predictors of overall mortality, while MELD (B = 0.419, p = 0.018) and HVPG (B = 0.223, p = 0.060) independently predicted 1-year survival. ROC curves identified MELD ‡ 19 and HVPG ‡ 25 mmHg as the best cut-off points for the prediction of 1-year mortality. Conclusions. TIPS is an effective treatment for refractory ascites in cirrhotic patients, leading to an effective ascites control in more than half patients. Improvement in patients' selection criteria could lead to better outcome and survival after this procedure. Liver function (MELD), presence of active necroinflammation (AST), and portal hypertension (HVPG) are independent predictors of patients' outcome after TIPS.
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.
Current use of transjugular intrahepatic portosystemic shunts
Current Gastroenterology Reports, 2003
The principal indication for transjugular intrahepatic portosystemic shunts (TIPS) continues to be rescue therapy for variceal hemorrhage that cannot be controlled by endoscopic or medical therapy. TIPS provide no survival advantage in prevention of rebleeding or refractory ascites. The indications for TIPS continue to expand, however, especially for Budd-Chiari syndrome and hydrothorax. Other more novel indications include bleeding portal hypertensive gastropathy or ectopic varices, Budd-Chiari syndrome, veno-occlusive disease, hepatorenal syndrome, hepatopulmonary syndrome, hepatocellular carcinoma, and polycystic liver disease. Great strides have been made recently in models to predict mortality and complications following TIPS placement. Graft stents hold promise based on early studies. Finally, complications are common and may be life threatening.
Hepatology, 1994
Despite the efficacy of shunt surgery in the treatment of variceal bleeding, less effective nonoperative therapies are being substituted because surgical shunt does not modify survival and increases hepatic encephalopathy. However, the real impact of shunt surgery on the natural history of ascites and its complications has not been established. The course of 204 Child-Pugh A and B cirrhotic patients with variceal bleeding included in three controlled trials of our units who survived first hospitalization was updated. Ninetyeight patients (group I) were treated by portacaval(56 patients) or distal splenorenal (42 patients) shunt, whereas 106 (group 11) were treated by nonshunt procedures (sclerotherapy in 89 patients and staple transection in 17 patients). As expected, the 5-yr probability of variceal rebleeding was lower (13% vs. 44%) and hepatic encephalopathy higher (50% vs. 28%) in group I than in group 11, and survival was similar (67% vs. 60%). Shunt surgery had a great impact on the natural history of ascites and its complications. The probability of occurrence of ascites (15% vs. 73%; p < O.OOOl), spontaneous bacterial peritonitis (2% vs. 21%; p < 0.0001) and hepatorenal syndrome (4% vs. 21%; p < 0.01) was greatly reduced. These beneficial effects accounted for the lower percentage patients requiring readmissions (51% vs. 70%; p = 0.02) and shorter total time spent in hospital (14 f 22 vs. 26 f 39 daydpatient; p = 0.01) in group 1. These data indicate that shunt surgery, in addition to reducing the probability of rebleeding, markedly decreases the probability of ascites, spontaneous bacterial peritonitis and hepatorenal syndrome development. Therefore, ascites and its complications should be considered in any therapeutic trial assessing the efficacy of surgical or percutaneous portacaval anastomosis on variceal bleeding. (HEPATOLOGY 1994;20:584-591.)
CardioVascular and Interventional Radiology, 2006
Purpose: To evaluate the safety and efficacy of transjugular intrahepatic portosystemic shunt (TIPS) in the control of bleeding from ectopic varices. Methods: From 1995 to 2004, 24 cirrhotic patients, bleeding from ectopic varices, mean age 54.5 years (range 15-76 years), were treated by TIPS. The etiology of cirrhosis was alcoholic in 13 patients and nonalcoholic in 11 patients. The location of the varices was duodenal (n = 5), stomal (n = 8), ileocolic (n = 6), anorectal (n = 3), umbilical (n = 1), and peritoneal (n = 1). Results: TIPS controlled the bleeding in all patients and induced a decrease in the portacaval gradient from 19.7 € 5.4 to 6.4 € 3.1 mmHg. Postoperative complications included self-limited intra-abdominal bleeding (n = 2), selflimited hemobilia (n = 1), acute thrombosis of the shunt (n = 1), and bile leak treated by a covered stent (n = 1). Median follow-up was 592 days (range 28-2482 days). Rebleeding occurred in 6 patients. In 2 cases rebleeding was observed despite a post-TIPS portacaval gradient lower than 12 mmHg and was controlled by variceal embolization; 1 patient underwent surgical portacaval shunt and never rebled; in 3 patients rebleeding was related to TIPS stenosis and treated with shunt dilatation with addition of a new stent. The cumulative rate of rebleeding was 23% and 31% at 1 and 2 years, respectively. One-and 2-year survival rates were 80% and 76%, respectively. Conclusion: The present series demonstrates that bleeding from ectopic varices, a challenging clinical problem, can be managed safely by TIPS placement with low rebleeding and good survival rates.