Transjugular intrahepatic portosystemic shunt in refractory ascites: a meta-analysis.

Transjugular intrahepatic portosystemic shunt (TIPS) is a more effective treatment for refractory ascites than large volume paracentesis (LVP), but the magnitude of its effect in terms of control of ascites, encephalopathy and survival has not been established. AIM: This meta-analysis compare TIPS to LVP in terms of control of ascites at 4 and 12 months, encephalopathy and survival at 1 and 2 years. RESULTS: Five randomized controlled trials involving 330 patients were included. In the TIPS group, control of ascites was more frequently achieved at 4 months (66% vs 23.8%, mean difference: 41.4%, 95% confidence interval (CI): 29.5-53.2%, P < 0.001) and 12 months (54.8% vs 18.9%, mean difference: 35%, 95% CI: 24.9-45.1%, P < 0.001), whereas encephalopathy was higher (54.9% vs 38.1%, mean difference: 17%, 95% CI: 7.3-26.6%, P < 0.001). Survival at 1 year (61.7% vs 56.5%, mean difference: 3.2%, 95% CI: -14.7 to 21.9%) and 2 years (50% vs 42.8%, mean difference: 6.8%, 95% CI: -10 to 23.6%) were not significantly different. CONCLUSIONS: TIPS is a more effective treatment for refractory ascites than LVP. However, TIPS increase encephalopathy and does not improve survival.     

Transjugular intrahepatic portosystemic shunt for refractory ascites: a meta-analysis of individual patient data

BACKGROUND & AIMS: Several randomized controlled trials have compared a transjugular intrahepatic portosystemic shunt (TIPS) with large-volume paracentesis in cirrhotic patients with refractory ascites. Although all agree that TIPS reduces the recurrence rate of ascites, survival is controversial. The aim of this study was to compare the effects of TIPS and large-volume paracentesis in cirrhotic patients with refractory ascites by means of meta-analysis of individual patient data from 4 randomized controlled trials. METHODS: The study population consisted of 305 patients: 149 allocated to TIPS and 156 to paracentesis. Cumulative probabilities of transplant-free survival and of hepatic encephalopathy (HE) were estimated by the Kaplan-Meier method and differences assessed by log-rank test. The total number of HE episodes per patient was also compared between TIPS and paracentesis. RESULTS: Tense ascites recurred in 42% of patients allocated to TIPS and 89% allocated to paracentesis (P < .0001). Sixty-five patients in the TIPS group and 78 in the paracentesis group died. The actuarial probability of transplant-free survival was significantly better in the TIPS group (P = .035). Cox regression analysis performed in a subgroup of 235 patients (114 allocated to TIPS and 121 to paracentesis) showed that age, serum bilirubin level, plasma sodium level, and treatment allocation were independently associated with transplant-free survival. The average number of HE episodes was significantly higher in the TIPS group (1.13 +/- 1.93 vs 0.63 +/- 1.18; P = .006), although the cumulative probability of developing the first episode of HE was similar between the groups (P = .19). CONCLUSIONS: The present meta-analysis of individual patient data provides further evidence to the previous meta-analyses of literature data showing that TIPS significantly improves transplant-free survival of cirrhotic patients with refractory ascites.     

Differences in long-term survival after transjugular intrahepatic portosystemic shunt for refractory ascites and variceal bleed

OBJECTIVE: To compare the survival after transjugular intrahepatic portosystemic shunt (TIPS) for refractory ascites and variceal bleed, and to identify the factors predictive of survival. METHODS: Single tertiary center, retrospective-prospective study. Chart review was performed on all patients who underwent TIPS between 1993 and 2000 and prospective follow-up to determine survival. Pre- and post-TIPS clinical parameters were compared and Kaplan-Meier analysis was applied to compare the survival of both groups. Cox regression was used to identify predictors of survival after TIPS. RESULTS: A total of 163 patients were included, 62 with refractory ascites and 101 with variceal bleed. Both groups had similar age (48.2 vs 48.9 year; P = 0.65) and consisted of predominantly Caucasians (51%) and Mexican-Americans (39%). More than 75% had chronic hepatitis C, alcoholic liver disease or both. Overall, the median survival was significantly better for variceal bleed (2 years) compared with refractory ascites (6 months) (P < 0.001). This survival advantage persisted in patients with Mayo risk score greater than 1.17. Transjugular intrahepatic portosystemic shunt improved severe ascites in 45% of patients (P = 0.03). Mayo risk score was highly predictive of survival after TIPS with a hazard ratio of 2.3, followed by Child-Pugh score, creatinine, albumin and ethnicity, with better survival among Mexican-Americans. Shunt dysfunction (31%) and hepatic encephalopathy (27%) were the most common complications of TIPS. CONCLUSIONS: Patients who received TIPS for variceal bleed had significantly longer survival compared with those for refractory ascites. Mexican-Americans had an improved long-term survival compared with Caucasians. The reason for this ethnic difference in survival is unclear and warrants further prospective evaluation.     

经颈静脉肝内门体支架分流术治疗肝硬化顽固性腹腔积液患者疗效分析

目的分析经颈静脉肝内门体支架分流术(TIPS)治疗肝硬化顽固性腹腔积液的疗效。方法回顾性分析四川华西医院2012年1—12月31例因肝硬化合并顽固性腹腔积液行TIPS治疗的患者,评估腹腔积液缓解率、TIPS并发症和远期预后。应用Cox模型单因素分析筛选腹腔积液缓解的危险因素;Cox模型单因素分析提示有统计学意义的因素纳入Cox模型多因素分析。结果 31例患者均成功接受支架植入,操作成功率100%。平均随访(9.4±3.1)个月,术后1个月、6个月腹腔积液完全缓解率分别为19%(6/31)和71%(22/31)。多因素分析显示TIPS术前Child-pugh评分是腹腔积液完全缓解的独立预测因子(相对危险度0.275,95%CI 0.037～0.716,P=0.012)。结论 TIPS可有效缓解肝硬化顽固性腹腔积液,同时未明显增加手术并发症。     

Current diagnosis and management of post‐transjugular intrahepatic portosystemic shunt refractory hepatic encephalopathy

Transjugular intrahepatic portosystemic shunt has evolved into an important option for management of complications of portal hypertension. The use of polytetrafluoroethylene covered stents enhances shunt patency. Hepatic encephalopathy (HE) remains a significant problem after TIPS placement. The approach to management of patients with refractory hepatic encephalopathy typically requires collaboration between different specialties. Patient selection for TIPS requires careful evaluation of risk factors for HE. TIPS procedure‐related technical factors like stent size, attention to portosystemic pressure gradient reduction and use of adjunctive variceal embolization maybe important. Conservative medical therapy in combination with endovascular therapies often results in resolution or substantial reduction of symptoms. Liver transplantation is, however, the ultimate treatment.     

经颈内静脉肝内门体分流术治疗肝肾综合征临床研究

[目的]观察经颈内静脉肝内门体分流术(TIPS)治疗肝肾综合征(HRS)的临床疗效,探讨其可能的作用机制。[方法]10例确诊为HRS患者行TIPS,分别于术前及术后测门静脉压力、门静脉内径及血流速度、尿钠排泄、尿量、血肌酐(Cr)、尿素氮(BUN)及血Cr清除率;术前及术后7 d测定肾素(PRA)、血管紧张素Ⅱ(AT-Ⅱ)、醛固酮(ALD)水平。[结果]TIPS术后门静脉压力、门静脉内径及血流速度分别为(2.3±0.3)kPa、(1.26±0.04)cm、(44.2±14.5)cm/s,与术前比较均P<0.01。BUN、血Cr、尿钠排泄、血Cr清除率及尿量手术前后差异有统计学意义(均P<0.01)。术后PRA、AT-Ⅱ、ALD分别为(67.12±25.28)、(138.02±58.54)、(597.37±284.25)ng/L,与术前比较,P<0.01,<0.05,<0.05。[结论]TIPS治疗HRS近期疗效明显,其作用可能与血容量的增加和肾素-血管紧张素-醛固酮系统改变有关。     

经颈静脉肝内门体分流术的规范化问题

经颈静脉肝门体分流术(transjugular intrahepatic portosystemic shunt, TIPS)临床应用以来,避免了危险而复杂的外科开放手术以及由此带来的较大创伤和全身麻醉的危险,控制了病情的发展,挽救了患者的生命.     

Clinical events after transjugular intrahepatic portosystemic shunt: Correlation with hemodynamic findings

Background & Aims: Transjugular intrahepatic portosystemic shunt (TIPS) procedures are increasingly being used, but the relationship between the hemodynamic effects of TIPS and the clinical events on follow-up remains undefined. Hence, we have investigated the hemodynamic correlations of portal hypertension–related events after a TIPS procedure. Methods: Prospective follow-up of 122 cirrhotic patients who had a TIPS procedure performed because of variceal hemorrhage was conducted. Results: The portacaval pressure gradient (PPG) significantly decreased after the TIPS procedure (from 19.7 ± 4.6 to 8.6 ± 2.7 mm Hg; P > 0.001), but increased thereafter and at rebleeding (n = 25) was >12 mm Hg in all patients (18.4 ± 4.6 mm Hg). Twenty-six patients developed ascites; the PPG (measured in 19) was always >12 mm Hg. Increasing the PPG to >12 mm Hg occurred very frequently (83% at 1 year). Within 1 year, 77% of patients underwent balloon angioplasty or restenting. However, 80% had again a PPG of >12 mm Hg 1 year after reintervention. Hepatic encephalopathy developed in 31% of patients at 1 year; 21 of 23 patients had a PPG of <12 mm Hg. Conclusions: Total protection from the risk of recurrent complications of portal hypertension after a TIPS procedure requires that the PPG be decreased and maintained <12 mm Hg. However, reintervention will be required in most patients within 1 year and again the second year. On the other hand, such portal decompression is associated with an increased risk of hepatic encephalopathy.GASTROENTEROLOGY 1998;114:1296-1303     

Refractory hepatic hydrothorax treated with transjugular intrahepatic portosystemic shunt

A 66-year-old cirrhotic woman was referred to our hospital for evaluation of refractory pleural effusion and dyspnea. Massive right sided-pleural effusion but no ascites was detected. She had been treated with diuretics and albumin, repeated thoracenteses, and pleural drainage with an intercostal catheter, all of which had failed to relieve her symptoms. The diagnosis of hepatic hydrothorax without ascites was made by injection of technetium-99m-sulfur colloid into the peritoneal cavity. A transjugular intrahepatic portosystemic shunt was placed and successfully reduced the pleural effusion, resulting in complete relief of her symptoms. The patient has been free of symptoms for 18 months after the procedure. (Received Jan. 19, 1998; accepted June 24, 1998)     

The effects of transjugular intrahepatic portosystemic shunt on portal hypertensive gastropathy

In addition to variceal bleeding, haematemesis may occur due to haemorrhagic gastritis in patients with portal hypertension. This has been known as portal hypertensive gastropathy (PHG). We have evaluated the effects of the transjugular intrahepatic portosystemic shunt (TIPS) on portal venous pressure (PVP) and endoscopic gastric mucosal changes observed in patients with portal hypertension. We performed TIPS in 12 patients with complications due to portal hypertension as follows: variceal bleeding in nine patients (bleeding from oesophageal varices in seven and gastric varices in two), refractory ascites in three and haemorrhage from severe PHG in one. Endoscopic examinations were performed before and after TIPS for all patients. Changes of PVP and gastric mucosal findings on endoscopy were analysed. Before TIPS, PHG was seen in 10 patients. Portal venous pressure decreased from an average of 25.1 ± 8.8 to 17.1 ± 6.2 mmHg after TIPS ( P < 0.005). On endoscopy, PHG improved in nine of 10 patients. Oesophagogastric varices improved in eight of 11 patients. In one patient with massive haematemesis, haemorrhage from severe PHG completely stopped after TIPS. Because TIPS effectively reduced PVP, this procedure appeared to be effective for the treatment of uncontrollable PHG.     

Systemic and splanchnic endothelin‐1 plasma levels in liver cirrhosis before and after transjugular intrahepatic portosystemic shunt (TIPS)

Abstract: Aims/Background: Endothelin‐1 (ET‐1) may be a mediator for portal hypertension in liver cirrhosis. The aim of the present study was to determine the concentrations of ET‐1 in the systemic and splanchnic circulation before and after reduction of portal hypertension by transjugular intrahepatic portosystemic shunt implantation (TIPS). Methods: Plasma concentrations of immunoreactive ET‐1 were measured in peripheral venous blood samples from 25 patients with liver cirrhosis before and at 1, 3, 9 and 15 months after TIPS. Furthermore, acute effects of TIPS on ET‐1 were studied in plasma samples from the hepatic vein, the portal vein 30 minutes before and after TIPS and in the femoral artery (only after TIPS) in a subgroup of 15 patients. In addition, the portocaval pressure gradient was determined before and after TIPS. Results: Before TIPS peripheral venous plasma ET‐1 concentrations (n=25; median 4.2 pg/ml; range 1.9–14.7) were significantly increased in patients with refractory ascites (n=7; median 7.8, range 3.5–14.7) compared to patients with repetitive bleeding (n=18; median 3.4; range 1.9–7.1) (p=0.003). Furthermore, peripheral ET‐1 concentrations correlated with the degree of liver dysfunction according to the Child‐Pugh classification (Spearman's r=0.46; p=0.02). Following TIPS, peripheral ET‐1 concentrations remained unchanged during a follow‐up of 15 months. Before TIPS, a positive gradient of ET‐1 concentrations from portalvenous to hepatovenous and peripheral venous levels was found (p<0.03). Immediately after TIPS, arterial ET‐1 concentrations reached markedly increased levels in individual patients (88, 92 and 103 pg/ml). Severe systemic reactions to these high levels were not observed. Peripheral venous, hepatovenous and portalvenous ET‐1 concentrations did not correlate with portocaval pressure gradients. Conclusion: Cirrhotic patients demonstrated unchanged peripheral venous ET‐1 concentrations up to 15 months after TIPS. Portal congestion was associated with increased ET‐1 levels in the prehepatic splanchnic area. The effect of portal decompression on splanchnic and systemic ET‐1 levels deserves further investigation.     

Budd-Chiari syndrome: long-term effect on outcome with transjugular intrahepatic portosystemic shunt

BACKGROUND: The long-term outcome of Budd-Chiari syndrome (BCS) with transjugular intrahepatic portosystemic shunts (TIPS) is not well studied. To address this, the records of 47 consecutive patients with BCS evaluated in one center from January 1989 to April 2004, were analyzed. RESULTS: Seven patients with liver tumors were excluded from analyses. Eleven patients had Bechet's disease, 14 had thrombophiliac disorders, four had myeloproliferative diseases and 11 patients had other or unknown causes. The site of block was hepatic vein in 16 patients, in the suprhepatic inferior vena cava in 19 and not known in five. The majority of patients (21/40; 52.5%) presented with subacute disease with massive ascites and abdominal pain as the dominant manifestations. Eight patients with membranes or segemental block were treated with transluminal angiopalsty, and six were treated with clinical and biochemical recovery. The TIPS was placed through a transcaval puncture in eight patients with progressive liver disease who were on medical therapy and had thrombosis limited to hepatic veins. One patient bled from portal vein puncture, which was managed by placing stent across the punctured site. The TIPS was very effective in decreasing portal pressure gradient, improving synthetic functions, reducing transaminase levels and controlling ascites. Five patients had TIPS dysfunction needing revision. In two patients it was difficult to maintain TIPS patency due to repeated TIPS dysfunction. However, both these patients were asymptomatic with normal liver function tests. Long-term follow up revealed that patients with TIPS had significantly better survival than those treated with medical therapy alone (log-rank test, P = 0.04). In a multivariate Cox-model analysis four variables, namely, more florid presentation, male sex, no treatment with TIPS and increasing Child-Pugh-Turcotte score, adversely affected the survival. CONCLUSIONS: Budd-Chiari syndrome needs an individualized multidisciplinary approach and TIPS is indicated in a subgroup of patients with progressive liver disease. It is safe, feasible and improves survival.     

Endotipsitis‐persistent infection of transjugular intrahepatic portosystemic shunt: pathogenesis,clinical features and management

Transjugular intrahepatic portosystemic shunt (TIPS) is in widespread use for the decompression of portal pressure. The entity of persistent TIPS infection, also known as ‘endotipsitis’ is a rare but serious complication of TIPS insertion. The exact definition of ‘endotipsitis’ is still debated, but involves persistent bacteremia and fever together with either shunt occlusion, or vegetation, or bacteremia in the presence of a patent shunt, when other sources of bacteremia have been ruled out. To date, approximately 40 cases of ‘endotipsitis’ have been described, with predominance for male and alcoholic hepatitis patients. The clinical course is variable, but fever and chills are a constant feature. Bacteremia, can either occur early (<120 days) or late (>120 days) after stent insertion, with some cases occurring many years after the procedure. Although no predominant bacterial species have been described in ‘endotipsitis’, staphylococci and other Gram‐positive bacteria are more commonly seen in early infection. The diagnosis of ‘endotipsitis’ is difficult and requires a high index of suspicion. A rigorous imaging work‐up to rule out other sources of endovascular infection is usually required including ultrasonography, computed tomography and echocardiography. Because removal of the infected stent is impractical, treatment is empirical and based on a prolonged course of antibiotics. If eligible, some patients may be referred for liver transplantation. The use of prophylactic antibiotics during the initial TIPS procedure is controversial, and despite the lack of evidence, prophylaxis is the common practice. The aim of this review was to describe the definition, clinical course, diagnosis, pathogenesis, microbiology, treatment and outcome of endotipsitis.     

经颈静脉肝内门体分流术后腹腔出血4例救治经验及文献复习

<正>随着覆膜支架的广泛应用及操作技术的不断改进,基于越来越多的循证医学证据,经颈静脉肝内门体分流术(transjugular intrahepatic portosystemic shunt,TIPS)治疗门静脉高压症的作用已被广泛认识,其适应证在不断修正和更新。TIPS公认的主要适应证包括不能成功被药物或内镜下治疗控制的食管胃底静脉破裂出血(二级预防)、难治性腹水,也有研究将其作