观察改良TIPS在治疗门静脉高压消化道出血中的应用

目的观察改良TIPS在胃食管出血应用中的技术可行性及临床效果。 方法收集接受改良TIPS治疗的肝硬化门静脉消化道出血的患者56例。操作技术改良是在线阵血管探头引导下穿刺右颈内静脉,引入导丝并将Rups-100穿刺系统送至肝右静脉,自肝静脉向门静脉穿刺成功后,引入加强硬度导丝至肠系膜上静脉,撤出Rups-100穿刺系统,直接将8 mm×40 mm球囊经12F鞘沿加硬导丝快速通过肝静脉-肝实质-门静脉,扩张球囊并保留球囊上肝静脉和门静脉切迹图像。支架技术改良是先释放1枚8 mm×60 mm的裸支架,根据球囊切迹,再释放1枚8 mm×40 mm的覆膜支架,覆膜部分覆盖实质全程而不阻挡同侧门静脉入肝血流,其余部分伸入肝静脉内,常规用弹簧栓子和明胶海绵栓塞胃冠状静脉。测量分流前后门静脉压力变化。 结果56例均获得技术性成功,成功率为100%。分流道建立前后门静脉压力分别为（31.20±3.98）mmHg和（17.36±3.48）mmHg,平均下降幅度为（13.839±2.585）mmHg（t=40.062,P<0.001）。随访1～3年。1、2、3年分流道通畅率分别为89.3%、75.0%、67.8%;再出血率分别为7.1%、12.5%、16.1%;肝性脑病发生率为12.5%。有1例术后第2天出现腹腔感染,抗感染治疗7天后好转;有7例于术后1～3年内因分流道完全闭塞而复发再出血,分别给予了介入开通和覆膜支架植入。所有病例均未出现其他严重并发症。5例在随访期间分别死于肝衰竭、肝癌和多器官衰竭。 结论通过对支架的改良,采用模拟Viatorr支架方法能够提高TIPS分流道的中远期通畅率,降低再出血率;简化TIPS操作步骤可减少与技术操作相关的并发症。     

Short-Term Rebleeding Rates for Isolated Gastric Varices Managed by Transjugular Intrahepatic Portosystemic Shunt versus Balloon-Occluded Retrograde Transvenous Obliteration

PurposeTo assess the short-term rebleeding rate associated with the use of a transjugular intrahepatic portosystemic shunt (TIPS) compared with balloon-occluded retrograde transvenous obliteration (BRTO) for management of gastric varices (GV).Materials and MethodsA single-center retrospective comparison of 50 patients with bleeding from GV treated with a TIPS or BRTO was performed. Of 50 patients, 27 (17 men and 10 women; median age, 55 y; range, 31–79 y) received a TIPS with covered stents, and 23 (12 men and 11 women; median age, 52 y; range, 23–83 y) underwent a BRTO procedure with a foam sclerosant. All study subjects had clinical and endoscopic evidence of isolated bleeding GV and were hemodynamically stable at the time of the procedure. Clinical and endoscopic follow-up was performed. Kaplan-Meier analysis was used to evaluate rebleeding rates from the GV.ResultsThe technical success rate was 100% in the TIPS group and 91% in the BRTO group (P = .21). Major complications occurred in 4% of the patients receiving TIPS and 9% of patients the undergoing BRTO (P = .344). Encephalopathy was reported in 4 of 27 (15%) patients in the TIPS group and in none of the patients in the BRTO group (0%; P = .12). At 12 months, the incidence of rebleeding from a GV source was 11% in the TIPS group and 0% in the BRTO group (P = .25).ConclusionsBRTO appears to be equivalent to TIPS in the short-term for management of bleeding GV. Further comparative studies are warranted to determine optimal management strategies in individual patients.     

Ectopic Varices in the Gastrointestinal Tract: Short- and Long-Term Outcomes of Percutaneous Therapy

To evaluate the results of percutaneous management of ectopic varices, a retrospective review was carried out of 14 patients (9 men, 5 women; mean age 58 years) who between 1992 and 2001 underwent interventional radiological techniques for management of bleeding ectopic varices. A history of prior abdominal surgery was present in 12 of 14 patients. The interval between the surgery and percutaneous intervention ranged from 2 to 38 years. Transhepatic portal venography confirmed ectopic varices to be the source of portal hypertension-related gastrointestinal bleeding. Embolization of the ectopic varices was performed by a transhepatic approach with coil embolization of the veins draining into the ectopic varices. Transjugular intrahepatic portosystemic shunt (TIPS) was performed in the standard fashion. Eighteen procedures (12 primary coil embolizations, 1 primary TIPS, 2 re-embolizations, 3 secondary TIPS) were performed in 13 patients. One patient was not a candidate for percutaneous treatment. All interventions but one (re-embolization) were technically successful. In 2 of 18 interventions, re-bleeding occurred within 72 hr (both embolization patients). Recurrent bleeding (23 days to 27 months after initial intervention) was identified in 9 procedures (8 coil embolizations, 1 TIPS due to biliary fistula). One patient had TIPS revision because of ultrasound surveillance findings. New encephalopathy developed in 2 of 4 TIPS patients. Percutaneous coil embolization is a simple and safe treatment for bleeding ectopic varices; however, recurrent bleeding is frequent and reintervention often required. TIPS can offer good control of bleeding at the expense of a more complex procedure and associated risk of encephalopathy.     

Early and long-term clinical and radiological follow-up results of expanded-polytetrafluoroethylene-covered stent-grafts for transjugular intrahepatic portosystemic shunt procedures

The purpose of this study was to assess the therapeutic efficacy and immediate and long-term safety of expanded-tetrafluoroethylene covered stent-grafts for transjugular intrahepatic portosystemic shunts in patients with portal hypertension-related complications. A cohort of 56 patients suffering from severe portal hypertension-related complications underwent implantation of an expanded-polytetrafluoroethylene-covered stent-graft. All patients suffered from severe liver cirrhosis graded Child-Pugh A (n=8; 16%), B (n=13; 21%) or C (n=35; 63%). In 44 patients, the stent-graft was placed during the initial TIPS procedure (de novo TIPS); in the other 12 patients, the stent-graft was placed to repermeabilize the previously placed bare stent (TIPS revision). Follow-up was performed with clinical assessment, duplex ultrasound and, if abnormal or inconclusive, with invasive venography and pressure measurements. Per- en immediate post-procedural complications occurred in four patients (4/56, 7%). None of them was lethal. During follow-up, stent occlusion appeared in one patient and stenosis in two; no recurrence of bleeding was noted in all patients treated for variceal bleeding (n=28), and 24 of the 28 patients (86%) suffering from refractory ascites and/or hepatic hydrothorax were free of regular paracenteses and/or drainage of pleural effusion after shunt creation. The 30-day and global mortality for the total study population (n=56) was, respectively, 7% (n=4) and 28.5% (n=16). In the patient subgroup with variceal bleeding (n=28), 30-day mortality was 3.5% (n=1) and global mortality 14.2% (n=4). In the ascites and/or hydrothorax subgroup (n=28), 8.1% (n=3) mortality at 30 days was found and global mortality was 32.4% (n=12). In 10 patients of the 56 studied patients (18%), isolated hepatic encephalopathy occurred, which was lethal in 4 (Child C) patients (7%). Three of these four patients died within the 1st month after TIPS placement. A very high primary patency rate of TIPS can be obtained long-term after implantation of an e-PTFE-covered stent-graft, leading to a definitive resolution of portal hypertension-related complications. The incidence of TIPS-induced hepatic encephalopathy is acceptable.     

经皮经肝门腔静脉分流术血流动力学与支架构型关系的临床研究

目的介绍一种全新肝内分流预应力支架的结构和在经皮经肝肝内门腔静脉分流术（PTPS）中应用的临床结果。分析应用该支架建立的门腔静脉分流道与经典TIPS所用支架血流动力学之间的区别,探讨其潜在的临床意义。方法38例门静脉高压患者采用预应力支架行经皮经肝途径门腔静脉分流术（PTPS）。静脉曲张出血36例,难治性腹水1例及肝肺综合征1例;Child＇s B级27例、C级11例。经皮经肝穿刺进入门静脉右支,再经门静脉左支矢状部穿刺肝段下腔静脉,经皮经肝植入预应力支架于门静脉左支与肝段下腔静脉之间。结果38例采用预应力支架行PTPS均获成功,技术成功率100％,未出现术中与技术相关并发症,术后门腔压力梯度平均下降14cmH2O,平均随访493d,所有患者未发生再出血,难治性腹水得到有效地控制。初步开通率98．9%,明显高于经典直管形裸支架TIPS。结论采用预应力支架经皮经肝途径建立门腔静脉分流是安全可行的,其血流动力学结果提示：预应力支架形状及与相关血管壁间“吻合”严密,符合正常肝内门静脉血流动力学分布,既起到门静脉部分性降压作用,亦保障了门静脉右支血流的肝内灌注,对预防术后分流道再狭窄及降低肝性脑病发生率具有明显的临床意义。     

Transjugular intrahepatic portosystemic shunt in the treatment of portal hypertension using memotherm stents: a prospective multicenter study

Purpose: In a prospective multicenter study, efficacy and safety of transjugular intrahepatic portosystemic shunts (TIPS) were evaluated in the treatment of the complications of portal hypertension using a new self-expanding mesh-wire stent (Memotherm). Methods: One hundred and eighty-one patients suffering from variceal bleeding (either acute or recurrent) or refractory ascites were enrolled. Postinterventional follow-up lasted for 8.4 months on average. Differences were analyzed by the log-rank test (chi-square) or Wilcoxon test. Results: Shunt insertion was completed successfully in all patients (n = 181 patients, 100%). During follow-up, shunt occlusion was evident in 23 patients, and shunt stenosis was found in 33 patients (12.7% and 18.2%, respectively). Variceal rebleeding occurred in 20 of 139 patients (14.4%), with at least one episode of bleeding before TIPS treatment. The overall mortality rate of the patients treated by TIPS was 39.8%. In 51.4% of these cases (37 of 72 patients), however, the patients died within 30 days after TIPS placement. Analysis of subgroups showed that patients who underwent emergency TIPS for acute variceal bleeding had a significantly higher early mortality compared with other patient groups (p = 0.0014). Conclusion: In the present prospective multicenter study, we were able to show that insertion of Memotherm stents is an effective tool for TIPS. The occlusion rates seem to be comparable to those reported for the Palmaz stent. It could be shown that in particular, those patients who were treated for acute bleeding were at high risk of early mortality. Consequently, in such a critical condition, the indication for TIPS has to be set carefully.     

Elective Transjugular Intrahepatic Portosystemic Shunt Using Viatorr Stent-Grafts: A Single-Center Experience from China

Background and Aims:Transjugular intrahepatic portosystemic shunt (TIPS) is a well-established approach for the management of variceal bleeding, refractory ascites, hepatic hydrothorax, and preoperative treatment of portal hypertension prior to major abdominal surgery in patients with compensated cirrhosis, and so on. This study aimed to investigate the safety and long-term efficacy of TIPS implantation using Viatorr TIPS stent-grafts.Material and Methods:A cohort of 59 patients undergoing TIPS placement using Viatorr TIPS stent-grafts were included, and the periprocedural events, and long-term mortality, shunt dysfunction, variceal rebleeding and incidence of hepatic encephalopathy (HE) were analyzed.Results:The technical success rate was 100%. The median portosystemic pressure gradient was reduced from 21 mmHg (interquatile range: 19–25) to 13 mmHg (interquatile range: 10–16) before and after TIPS, leading to a hemodynamic success rate of 72.9%. The cumulative rate of overall mortality was 34.2% at five years, and direct bilirubin (hazard ratio [HR] = 1.336, 95% confidence interval [CI]: 1.050–1.700, P = 0.018) and post-TIPS right atrial pressure (HR = 1.238, 95% CI: 1.015–1.510, P = 0.035) were independent predictors for mortality. The cumulative rates of shunt dysfunction and variceal rebleeding were 11.0% and 28.3% at five years, respectively, and portal venous pressure gradient (HR = 2.572, 95% CI: 1.094–6.047, P = 0.030) was the only independent predictor for shunt dysfunction. The cumulative four-year HE-free rate was 48.6%. No severe adverse event was noted during TIPS procedures.Conclusion:Elective TIPS implantation using Viatorr TIPS stent-grafts is generally safe, and the long-term efficacy is favorable for the treatment of cirrhotic patients with recurrent variceal bleeding or refractory ascites.     

TIPS recubierto en niños. Estudio preliminar sobre su seguridad y permeabilidad

Objective

To retrospectively analyze the safety and efficacy of transjugular intrahepatic portosystemic shunting (TIPS) using covered stents in children.

Material and methods

We present 6 children (mean age, 10.6 years; mean weight, 33.5 kg) who underwent TIPS with 8 mm diameter Viatorr^® covered stents for acute (n=4) or recurrent (n=2) upper digestive bleeding that could not be controlled by endoscopic measures. Five of the children had cirrhosis and the other had portal vein thrombosis with cavernous transformation. We analyzed the relapse of upper digestive bleeding, the complications that appeared, and the patency of the TIPS shunt on sequential Doppler ultrasonography or until transplantation.

Results

A single stent was implanted in a single session in each child; none of the children died. The mean transhepatic gradient decreased from 16 mmHg (range: 12-21 mmHg) before the procedure to 9 mmHg (range: 1-15 mmHg) after TIPS.One patient developed mild encephalopathy, and the girl who had portal vein thrombosis with cavernous transformation developed an acute occlusion of the TIPS that resolved after the implantation of a coaxial stent.Three children received transplants (7, 9, and 10 months after the procedure, respectively), and the patency of the TIPS was confirmed at transplantation. In the three remaining children, patency was confirmed with Doppler ultrasonography 1, 3, and 5 months after implantation. None of the children had new episodes of upper digestive bleeding during follow-up after implantation (mean: 8.1 months).

Conclusion

Our results indicate that TIPS with 8 mm diameter Viatorr^® covered stents can be safe and efficacious for the treatment of upper digestive bleeding due to gastroesophageal varices in cirrhotic children; our findings need to be corroborated in larger series.     

Transjugular Intrahepatic Portosystemic Shunt Creation for the Prevention of Gastric Variceal Rebleeding in Patients with Hepatocellular Carcinoma: A Multicenter Retrospective Study

PurposeTo evaluate the effectiveness and safety of transjugular intrahepatic portosystemic shunt (TIPS) creation for the prevention of gastric variceal rebleeding in patients with hepatocellular carcinoma (HCC).Materials and MethodsThis multicenter retrospective study included 126 cirrhotic patients (mean age, 54.1 ± 10.2 years; 110 men) with HCC who underwent TIPS creation for the prevention of gastric variceal rebleeding. Of these, 110 (87.3%) patients had gastroesophageal varices and 16 (12.7%) patients had isolated gastric varices. Thirty-five (27.8%) patients had portal vein tumor thrombus.ResultsTIPS creation was technically successful in 124 (98.4%) patients. Rebleeding occurred in 26 (20.6%) patients during the follow-up period. The 6-week and 1-year actuarial probabilities of patients remaining free of rebleeding were 98.3% ± 1.2% and 81.2% ± 3.9%, respectively. Forty-nine (38.8%) patients died during the follow-up period. The 6-week and 1-year actuarial probabilities of survival were 98.4 ± 1.1% and 65.6 ± 4.4%, respectively. Two (1.6%) patients had major procedure-related complications, including acute liver failure (n = 1) and intra-abdominal bleeding (n = 1). Thirty-three (26.2%) patients had at least 1 episode of overt hepatic encephalopathy during the follow-up period. Shunt dysfunction occurred in 15 (11.9%) patients after a median follow-up time of 11.4 months (range, 1.4–41.3 months). Lung metastasis occurred in 3 (2.4%) patients, 3.9–32.9 months after TIPS creation.ConclusionsTIPS creation may be effective and safe for the prevention of gastric variceal rebleeding in patients with HCC.     

Transjugular intrahepatic portosystemic shunts using the Wallstent prosthesis: A follow-up study

Purpose: The aim of the present study was to assess the efficacy of transjugular intrahepatic portosystemic shunts (TIPS) in 45 patients with cirrhosis during a mean follow-up of 7 months. Methods: Forty-five consecutive patients treated by TIPS and who had been followed for at least 6 months after TIPS or until death, were included. Mean follow-up was 7.2±5.0 months. Shunt patency was assessed at 1 week and 1 month, then every 3 months after the procedure by Doppler US and angiography whenever needed. Results: Thirty-six patients had been stented for refractory bleeding from ruptured esophagogastric varices. Of these, 8 patients (22%) rebled, 7 of whom were treated by a second shunt. Nine patients were treated for refractory ascites. Three patients had recurrent ascites due to shunt obstruction. All were treated by a second shunt which occluded in 2 patients. As a whole, 14 (31.1%) patients developed shunt obstruction within a mean of 120±136 days, 4 of whom remained asymptomatic. Other complications were septicemia by Staphylococcus aureus in 1 patient, transient encephalopathy in 9 patients, and disseminated intravascular coagulation in 1 patient. Conclusion: TIPS appears to be a relatively safe and effective technique in treating complications of portal hypertension in patients with cirrhosis. Shunt obstruction in 31% of our patients probably represents the most important limitation of this technique.     

A new nitinol monofilament stent: early experience with use for transjugular intrahepatic portosystemic shunts

The purpose of this study was to investigate the suitability of a new nitinol monofilament stent (Niti-S) for transjugular intrahepatic portosystemic shunt (TIPS) creation. TIPS was performed with a Niti-S stent in 22 patients for variceal bleeding (n = 20) or intractable ascites (n = 2). The efficacy, complication, and patency rates during the follow-up period (up to 27 months, mean 13.9 months) were evaluated. TIPS was successfully performed in all patients. The mean portosystemic pressure gradient decreased from 23.8 ± 7.2 mmHg to 10.2 ± 3.1 mmHg. No mortality or significant morbidity was encountered at 1 month. Variceal bleeding and/or ascites were controlled in all patients. Primary patency rates were 77.3% at 6 months and 71.8% at 1 year. Secondary patency rates were 95.4% up to 26 months. TIPS with the Niti-S stent produced short-term technical and clinical results comparable to the other commercially available stents. A prospective randomized comparison study is indicated.     

Combined transjugular intrahepatic portosystemic shunt and segmentai lipiodol hepatic artery embolization for the treatment of esophagogastric varices and hepatocellular carcinoma in patients with cirrhosis: Preliminary report

Purpose To evaluate the feasibility of combining placement of a transjugular intrahepatic portosystemic shunt (TIPS) and transcatheter hepatic segmental artery chemoembolization with Lipiodol (Seg-Lp-TAE) in patients with cirrhosis, esophagogastric varices, and hepatocellular carcinoma (HCC). Methods Five patients with bleeding or large, highflow esophagogastric varices and HCC were treated by TIPS and Seg-Lp-TAE. Results The mean portosystemic pressure gradient decreased from 20.8 cm H₂O to 7.8 cm H₂O after TIPS. The direct portogram and endoscopic examination revealed reduction of varices. At 6 months, one shunt had functionally occluded and could not be reopened; the other TIPS remained functional Follow-up CT and the changes of alpha fetoprotein indicated effective therapy of Seg-Lp-TAE for HCC. Four patients are in stabile clinical condition at 9, 6, 1, and 1 months after the combined therapy; one died after 14 months due to decompensated liver cirrhosis. Conclusion The combined therapy of TIPS and SegLp-TAE will become a new interventional approach for patients with HCC and esophagogastric varices.     

Combined Transjugular Intrahepatic Portosystemic Shunt Plus Variceal Obliteration versus Transjugular Intrahepatic Portosystemic Shunt Alone for the Management of Gastric Varices: Comparative Single-Center Clinical Outcomes

PurposeTo compare the safety and clinical outcomes of combined transjugular intrahepatic portosystemic shunt (TIPS) plus variceal obliteration to those of TIPS alone for the treatment of gastric varices (GVs).Materials and MethodsA single-center, retrospective study of 40 patients with bleeding or high-risk GVs between 2008 and 2019 was performed. The patients were treated with combined therapy (n = 18) or TIPS alone (n = 22). There were no significant differences in age, sex, model for end-stage liver disease score, or GV type between the groups. The primary outcomes were the rates of GV eradication and rebleeding. The secondary outcomes included portal hypertensive complications and hepatic encephalopathy.ResultsThe mean follow-up period was 15.4 months for the combined therapy group and 22.9 months for the TIPS group (P = .32). After combined therapy, there was a higher rate of GV eradication (92% vs 47%, P = .01) and a trend toward a lower rate of GV rebleeding (0% vs 23%, P = .056). The estimated rebleeding rates were 0% versus 5% at 3 months, 0% versus 11% at 6 months, 0% versus 18% at 1 year, and 0% versus 38% at 2 years after combined therapy and TIPS, respectively (P = .077). There was no difference in ascites (13% vs 11%, P = .63), hepatic encephalopathy (47% vs 55%, P = .44), or esophageal variceal bleeding (0% vs 0%, P > .999) after the procedure between the groups.ConclusionsThe GV eradication rate is significantly higher after combined therapy, with no associated increase in portal hypertensive complications. This translates to a clinically meaningful trend toward a reduction in GV rebleeding. The value of a combined treatment strategy should be prospectively studied in a larger cohort to determine the optimal management of GVs.     

Budd-Chiari syndrome due to prothrombotic disorder: mid-term patency and efficacy of endovascular stents

Our objective was to evaluate efficacy and patency of metallic stent placement for symptomatic Budd-Chiari syndrome (BCS) due to prothrombotic disorders. Eleven patients with proved BCS due to prothrombotic disorders were referred for endovascular treatment because of refractory ascites (n=9), abdominal pain (n=8), jaundice (n=6), and/or gastrointestinal bleeding (n=4). Stents were inserted for stenosed hepatic vein (n=7), inferior vena cava (n=2), or mesenterico-caval shunt (n=2). Clinical efficacy and stent patency was evaluated by clinical and Doppler follow-up. After a mean follow-up of 21 months, 6 patients had fully patent stents without reintervention (primary stent patency: 55%). Two patients with hepatic vein stenosis had stent thrombosis and died 4 months after procedure. Restenosis occurred in 3 cases (2 hepatic vein and 1 mesenterico-caval shunt stenosis) and were successfully treated by balloon angioplasty (n=2) and addition of new stents (n=1) leading to a 82% secondary stent patency. Of 9 patients with patent stent, 7 were asymptomatic (77%) at the end of the study. Stent placement is a safe and effective procedure to control of symptomatic BCS. Prothrombotic disorder does not seem to jeopardize patency in anticoagulated patients. Electronic Publication     

Embolization with the Amplatzer Vascular Plug in TIPS Patients

Vessel embolization can be a valuable adjunct procedure in transjugular intrahepatic portosystemic shunt (TIPS). During the creation of a TIPS, embolization of portal vein collaterals supplying esophageal varices may lower the risk of secondary rebleeding. And after creation of a TIPS, closure of the TIPS itself may be indicated if the resulting hepatic encephalopathy severely impairs mental functioning. The Amplatzer Vascular Plug (AVP; AGA Medical, Golden Valley, MN) is well suited for embolization of large-diameter vessels and has been employed in a variety of vascular lesions including congenital arteriovenous shunts. Here we describe the use of the AVP in the context of TIPS to embolize portal vein collaterals (n = 8) or to occlude the TIPS (n = 2).     

Interventional Radiological Management of Prehepatic Obstruction the Splanchnic Venous System

Purpose The purpose of this study was to retrospectively evaluate interventional radiological management of patients with symptomatic portal hypertension secondary to obstruction of splanchnic veins. Material and Methods Twenty-four patients, 15 males and 9 females, 0.75 to 79 years old (mean, 36.4 years), with symptomatic portal hypertension, secondary to splanchnic venous obstruction, were treated by percutaneous methods. Causes and extent of splanchnic venous obstruction and methods are summarized following a retrospective evaluation. Results Obstructions were localized to the main portal vein (n = 22), intrahepatic portal veins (n = 8), splenic vein (n = 4), and/or mesenteric veins (n = 4). Interventional treatment of 22 (92%) patients included recanalization (n = 19), pharmacological thrombolysis (n = 1), and mechanical thrombectomy (n = 5). Partial embolization of the spleen was done in five patients, in two of them as the only possible treatment. TIPS placement was necessary in 10 patients, while an existing occluded TIPS was revised in two patients. Transhepatic embolization of varices was performed in one patient, and transfemoral embolization of splenorenal shunt was performed in another. Thirty-day mortality was 13.6% (n=3). During the follow-up, ranging between 2 days and 58 months, revision was necessary in five patients. An immediate improvement of presenting symptoms was achieved in 20 patients (83%). Conclusion We conclude that interventional procedures can be successfully performed in the majority of patients with obstruction of splanchnic veins, with subsequent improvement of symptoms. Treatment should be customized according to the site and nature of obstruction. An erratum to this article can be found at     

Balloon-Occluded Retrograde Transvenous Obliteration for Gastric Variceal Bleeding: Its Feasibility Compared with Transjugular Intrahepatic Portosystemic Shunt

Objective

To assess the feasibility of balloon-occluded retrograde transvenous obliteration (BRTO) in active gastric variceal bleeding, and to compare the findings with those of transjugular intrahepatic portosystemic shunt (TIPS).

Materials and Methods

Twenty-one patients with active gastric variceal bleeding due to liver cirrhosis were referred for radiological intervention. In 15 patients, contrast-enhanced CT scans demonstrated gastrorenal shunt, and the remaining six (Group 1) underwent TIPS. Seven of the 15 with gastrorenal shunt (Group 2) were also treated with TIPS, and the other eight (Group 3) underwent BRTO. All patients were followed up for 6 to 21 (mean, 14.4) months. For statistical inter-group comparison of immediate hemostasis, rebleeding and encephalopathy, Fisher''s exact test was used. Changes in the Child-Pugh score before and after each procedure in each group were statistically analyzed by means of Wilcoxon''s signed rank test.

Results

One patient in Group 1 died of sepsis, acute respiratory distress syndrome, and persistent bleeding three days after TIPS, while the remaining 20 survived the procedure with immediate hemostasis. Hepatic encephalopathy developed in four patients (one in Group 1, three in Group 2, and none in Group 3); one, in Group 2, died while in an hepatic coma 19 months after TIPS. Rebleeding occurred in one patient, also in Group 2. Except for transient fever in two Group-3 patients, no procedure-related complication occurred. In terms of immediate hemostasis, rebleeding and encephalopathy, there were no statistically significant differences between the groups (p > 0.05). In Group 3, the Child-Pugh score showed a significant decrease after the procedure (p = 0.02).

Conclusion

BRTO can effectively control active gastric variceal bleeding, and because of immediate hemostasis, the absence of rebleeding, and improved liver function, is a good alternative to TIPS in patients in whom such bleeding, accompanied by gastrorenal shunt, occurs.     

Transjugular intrahepatic portosystemic shunting (TIPS) with balloon-expandable and self-expanding stents: Technical and clinical aspects after 3 1/2 years’ experience

Purpose To evaluate prospectively our experience with transjugular intrahepatic portosystemic shunt (TIPS) using four different metallic stents. Methods Between November 1991 and April 1995, 57 patients (41 men and 16 women; age 35–72 years, mean 54 years) underwent the TIPS procedure. Techniques for portal vein localization before and during TIPS were fluoroscopy, computed tomography (CT) studies, wedged hepatic venography, arterial portography, and ultrasound. After predilation we deployed balloon-expandable (n=48) and self-expanding (n=45) metallic stents. Fifteen patients underwent variceal embolization. Initial follow-up angiograms (mean 6.9 months, range 3–24 months) were obtained in 39 of these patients. Results Fifty-three patients (93%) had successful TIPS placement. The mean decrease in portal pressure was 42.7%. Besides fluoroscopy, the most helpful techniques for portal vein localization were venography and CT. Residual stenosis (n=1) and late shortening (n=4) of Wallstents resulted in shunt dysfunction. The technical problems encountered with the Palmaz stent resulted from its lack of flexibility. We combined balloon-expandable and self-expanding stents in 12 patients. The 30-day and late follow-up (mean 11.9 months) percutaneous reintervention rates were 11.3% and 64.2%, respectively. There were no clinically significant complications related to the TIPS insertions. Conclusion An ideal stent does not exist for TIPS, and the authors recommend combining a Palmaz stent with a flexible self-expanding stent.     

Viatorr支架行TIPS术治疗门静脉高压性静脉曲张消化道出血效果评估

目的评价应用Viatorr支架行经颈静脉肝内门体分流术(TIPS)术治疗门静脉高压性静脉曲张消化道出血的可行性、安全性和临床效果。方法回顾性分析2015年10月至2018年11月收治的42例肝硬化门静脉高压性静脉曲张消化道出血患者临床资料,所有患者符合TIPS治疗指征,均接受Viatorr支架行TIPS术治疗。术中检测门静脉压力梯度(PPG)。术后1、3、6、12个月,之后每年随访超声或增强CT检查,评价分流道通畅情况,并通过电子病历、临床或电话随访患者肝功能、凝血4项、再出血、肝性脑病发生和生存时间。配对t检验分析术前、术后PPG、总胆红素、血清白蛋白和凝血酶原时间变化,Kaplan-Meier法分析分流道通畅率和生存率。结果 42例均成功施行TIPS术,技术成功率为100%。共植入直径8 mm Viatorr支架42枚。PPG均值由术前(26.85±6.00) mmHg(1 mmHg=0.133 kPa)降低为(11.62±4.54) mmHg(t=11.359,P<0.05),平均降低(55.63±16.77)%。与术前相比,术后3 d总胆红素浓度升高(P<0.05),血清白蛋白降低(P<0.05),凝血酶原时间延长(P<0.05)。术后1个月总胆红素、血清白蛋白和凝血酶原时间与术前水平差异均无统计学意义(P>0.05)。术后中位随访14.5(2~39)个月,再出血发生率为9.5%(4/42),其中1例接受分流道再通;肝性脑病发生率为19.1%(8/42)。术后1、2、3年分流道通畅率分别为91.9%、83.9%、77.4%,生存率分别为94.7%、89.4%、82.0%。肝硬化相关死亡率为9.5%(4/42),均于术后2~30个月死于终末期肝病伴多脏器功能衰竭。结论 Viatorr支架行TIPS术治疗肝硬化门静脉高压性静脉曲张消化道出血具有较高的技术成功率,术后分流道通畅率高,肝性脑病发生率低。     

Emergent Transjugular Intrahepatic Portosystemic Shunt as a First-Line Therapy in Patients with Cirrhosis with Acute Gastroesophageal Variceal Hemorrhage

PurposeTo investigate the safety and effectiveness of emergent transjugular intrahepatic portosystemic shunt (TIPS) as first-line therapy in patients with advanced cirrhosis with acute variceal hemorrhage.Materials and MethodsFrom July 2016 to June 2019, 76 patients with advanced cirrhosis and acute variceal hemorrhage were included in this retrospective study. All patients underwent emergent TIPS as first-line therapy within 24 hours. Gastroesophageal varices in patients with cirrhosis were diagnosed with contrast-enhanced computed tomography because emergent endoscopy has not been routinely performed in this center. The primary outcomes were the control rate of bleeding and the rate of rebleeding. Secondary outcomes were the technical success rate of procedure, transplantation-free survival, the mean hospitalization time, the time of stay in the intensive care unit, and adverse events.ResultsAll patients underwent TIPS creation successfully and were transferred to general wards. The median follow-up time was 21.7 months (interquartile range, 12.6–28.1 months). The control rate of bleeding (≤5 days) was 100%. The rates of early (>5 days to 6 weeks) and late (>6 weeks to 2 years) rebleeding were 6.6% and 1.3%, respectively. The 6-week, 1-year, and 2-year transplantation-free survival rates were 94.7%, 93.4%, and 84.6%, respectively. The incidences of acute liver failure, hepatic encephalopathy, and shunt dysfunction were 5.3%, 25%, and 5.3%, respectively.ConclusionsEmergent TIPS as a first-line therapy in patients with advanced cirrhosis with acute variceal hemorrhage is safe and effective. This study provides an alternative approach for medical centers without emergent endoscopy facility to manage the condition.