Impact of transjugular intrahepatic portosystemic shunt on orthotopic liver transplantation

Transjugular intrahepatic portosystemic shunt (TIPS) is being increasingly utilized prior to liver transplantation for portal hypertensive bleeding refractory to sclerotherapy or as initial management of variceal bleeding. The impact of TIPS on subsequent orthotopic liver transplantation (OLT) is uncertain. The purpose of this study was to analyze the effect of TIPS on OLT in terms of operative transfusion requirements, operative time, length of hospital stay, and graft and patient survival. The results in 17 patients undergoing TIPS for control of initial or recurrent variceal bleeding prior to OLT between June 1991 and December 1992 were compared to two other groups undergoing transplantation: 32 control patients with a history of variceal bleeding not treated by TIPS and 11 patients with a previous surgical portosystemic shunt. Compared with control and surgical shunt patients, patients who underwent TIPS had less transfusion requirement for packed red blood cells and fresh frozen plasma during OLT. The operative time and hospital stay of the TIPS patients were slightly, but not significantly, less. In contrast to patients having TIPS, the patients with a history of a previous surgical shunt had an increased requirement for packed red blood cells, longer operative time, and longer stay in the intensive care unit and hospital. Two patients had recurrent variceal bleeding after TIPS; one patient was found to have an occluded stent, and the other patient (with a patent stent) responded to sclerotherapy. Of the 14 patients with ascites, 8 patients improved and 6 patients had complete resolution after TIPS. There were no major complications related to TIPS, although 3 patients had new or recurrent hepatic encephalopathy that was easily manageable. Thus the preoperative performance of TIPS is associated with less operative transfusion requirement during OLT, presumably secondary to a reduction in portal hypertension. TIPS is preferred to surgical shunt for pretransplant refractory variceal bleeding, as the latter is associated not only with significant morbidity and mortality but also increased transfusion requirements and prolonged operative time and hospital stay.

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Resumen El shunt portosistémico intrahepático transyugular (TIPS) es de utilización creciente con anterioridad al trasplante hepático en pacientes con sangrado por hipertensión portal refractario a la escleroterapia, o como modalidad inicial de manejo en la hemorragia varicosa. El impacto del TIPS sobre un subsiguiente trasplante ortotópico de hígado (TOH) es todavía incierto. El propósito del presente estudio fue analizar el efecto del TIPS sobre el TOH en términos de los requerimientos operatorios de transfusión, el tiempo operatorio, la duración de la hospitalización y la sobrevida tanto del trasplante como del paciente. Los resultados en 17 pacientes sometidos a TIPS para el control de sangrado varicoso inicial o recurrente antes de TOH en el período junio 1991 a diciembre 1992 fueron comparados con otros dos Grupos sometidos a trasplante: 32 pacientes control con historia de hemorragia varicosa no tratada por medio de TIPS y 11 pacientes que habían recibido previamente un shunt portosistémico. En comparación con los pacientes del Grupo control y del Grupo quirúrgico, los pacientes sometidos a TIPS exhibieron menores requerimientos operatorios de transfusión de glóbulos rojos y plasma fresco congelado en el curso del TOH. El tiempo operatorio y la duración de la hospitalización en los pacientes con TIPS fueron ligeramente más cortos, aunque no en forma significativa. En contraste con los pacientes sometidos a TIPS, aquellos con historia de shunt quirúrgico previo, exhibieron un requerimiento mayor de glóbulos rojos y un timepo operatorio más prolongado, así como una más prolongada estancia tanto en la unidad de cuidado intensivo como en el hospital. Dos pacientes presentaron hemorragia varicosa recurrente luego de TIPS: un paciente desarrolló trombosis de la prótesis y el otro, con la prótesis permeable, respondió a la escleroterapia. De los 14 pacientes con ascitis, 8 mejoraron y 6 presentaron resolución completa luego del TIPS. No se registraron complicaciones mayores relacionadas con el TIPS, aunque 3 pacientes exhibieron encefalopatía hepática nueva o recurrente que fue facilmente manejable. En RESUMEN, la realización preoperatoria de TIPS se asocia con menos requerimientos transfusionales en el curso del TOH, presumiblemente como resultado de la reducción de la hipertensión portal. El TIPS es preferible al shunt quirúrgico en el tratamiento de la hemorragia varicosa refractaria pretrasplante, puesto que el shunt se asocia con significativas morbilidad y mortalidad y también con mayores requerimientos transfusionales y más prolongados tiempo operatorio y estancia hospitalaria.

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Résumé Le shunt portocave (PC) intrahépatique par voie transjugulaire (TIPS) est utilisé de plus en plus souvent, avant la transplantation hépatique, en cas d'hémorragie par rupture de varices oesophagiennes n'étant pas contrôlée par la sclérothérapie ou parfois comme traitement initial. L'influence du TIPS sur la transplantation hépatique orthotopique (THO) ultérieure n'est pas connue. Nous avons analysé l'effet du TIPS sur la THO en termes de nécessité et de quantité de transfusion sanguine, la durée d'intervention, la durée de séjour hospitalier, la survie du patient et du greffon. Entre Juin 1991 et Décembre 1992, 17 patients ayant eu un TIPS ont été comparés à deux autres groupes de patients ayant eu une transplantation: 32 patient sans avoir un TIPS au préalable, et 11 patients ayant eu un shunt PC chirurgical. Comparés aux patients contrôles et aux patients ayant eu un shunt PC chirurgical, les patients ayant eu un TIPS ont eu moins besoin de culots globulaires et de plasma frais pendant la THO. Les durées d'opération et d'hospitalisation des patients ayant eu un TIPS étaient moindres mais pas de façon significative. Comparés aux patients ayant eu un TIPS, les patients ayant eu un shunt PC chirurgical ont eu besoin de plus de transfusions (culots globulaires), et leur durée d'intervention et de séjour en soins intensifs et à l'hôpital étaient plus longues. Deux patients ont eu une récidive hémorragique après TIPS: l'un avait une occlusion du shunt, l'autre a répondu de façon satisfaisante par sclérothérapie. Des 14 patients ayant une ascite, huit se sont améliorés et six ont eu une résolution complète après TIPS. Il n'y avait eu aucune complication majeure en rapport avec la pose du TIPS. Trois patients ont eu une encéphalopathie nouvelle ou récidivante facilement contrôlable. En résumé, la pose du TIPS préopératoire est associé avec moins de transfusion pendant la THO, peut-être par réduction de l'hypertension portale. Le TIPS doit être préféré aux shunts chirurgicaux pour les candidats à la THO ayant saigné de varices oesophagiennes non contrôlés par sclérothérapie car cette dernièrc modalité est associée avec une plus grand mortalité, morbidité et des besoins de transfusions, une durée d'opération et d'hospitalisation plus élevées.

     

Liver transplantation and transjugular intrahepatic portosystemic shunt

OBJECTIVE: Describe the results of liver transplantation after installing Transjugular Intrahepatic Portosystemic Shunt (TIPS) and compare them with those of a control group in a comparative, longitudinal, retrospective study. MATERIALS AND METHODS: Between April 1986 and October 2002, we performed 875 liver transplantations. Between January 1996 and October 2002, 26 transplantations were performed on TIPS carriers. This group was compared with a control cohort of 50 randomly selected patients who underwent transplantation in this period (non-TIPS carriers). Both groups were homogeneous with no significant differences between age, sex United Network for Organ Sharing (UNOS) score, Child stage, or etiology. RESULTS: Actuarial survival rates at 1 and 3 years: TIPS group 96.15% and 89.29% versus control cohort 87.8% and 81%, respectively. In 73.9%, the TIPS was clearly effective; in 88.9%, a postoperative Doppler revealed normal flow. There were no statistically significant differences compared with time on the waiting list for transplant, duration of the operation, ischemia times, intraoperative consumption of hemoderivates, vascular or nonvascular postoperative complications, duration of stay in the intensive care unit, hospital stay, or retransplantation rate. CONCLUSIONS: In our experience, TIPS insertion does not affect either the intraoperative or postoperative evolution and is not associated with an increased time on the liver transplant waiting list.     

Severe venoocclusive disease after liver transplantation treated with transjugular intrahepatic portosystemic shunt

Venoocclusive disease (VOD) is due to hepatic sinusoidal lining injury leading to portal hypertension; its incidence after liver transplantation is about 2%. When severe, it does not respond to medical therapy and has a high mortality; retransplantation is the only therapeutic option. However, there are no detailed data regarding the use of transjugular intrahepatic portosystemic shunt for VOD after liver transplantation. We describe two patients who developed severe VOD after liver transplantation, failed defibrotide therapy, and were treated by transjugular intrahepatic portosystemic shunt (TIPS). The portal hypertension resolved completely and one had full histological recovery. We believe that TIPS should be attempted as it may resolve progressive portal hypertension and the hepatic congestion, while allowing the clinician time for listing for further liver transplantation if the patient fails to respond.     

Transjugular intrahepatic portosystemic shunt migration in patients undergoing liver transplantation

Transjugular intrahepatic portosystemic shunt (TIPS) is a useful procedure for patients with variceal bleeding and refractory ascites. Migration of TIPS can potentially complicate the subsequent transplant procedure. The aim of this study was to compare survival, operating time, and blood transfusion requirements in patients with migrated and nonmigrated TIPS undergoing liver transplantation. Of 152 patients, 21 received TIPS; stent migration was noted in seven patients-six distally and one proximally. Mean age of the patients was 54 +/- 11 years (range, 27-65 years), and there were 12 men and 9 women. The etiology of liver disease included the following: hepatitis C virus, six patients; cryptogenic cirrhosis, seven patients; alcoholic cirrhosis, four patients; primary biliary cirrhosis, three patients; and autoimmune hepatitis, one patient. The mean Child-Pugh-Turcotte score was 10 +/- 2. Mean length of hospital stay for patients with migrated TIPS was 22.2 days and for nonmigrated TIPS was 23.5 days. Patient and graft survival (actual) was 81% in both groups with a mean follow-up of 27.9 months. Migration of TIPS is not rare, and in our study it did not affect survival, length of surgery, or blood transfusion requirements compared with patients in whom TIPS had not migrated.     

经颈静脉肝内门-体分流术后5年肝功能变化

目的评估经颈静脉肝内门-体分流(TIPS)术后患者5年肝功能变化。方法收集因门静脉高压伴食管胃底静脉曲张破裂出血或顽固性腹腔积液、临床随访时间5年以上的76例患者资料,均行TIPS进行治疗,随访患者术后1、6、12、24、36、48、60个月的肝功能指标变化,并按照Child-Pugh分数、支架门静脉位置、支架直径进行分层分析。结果手术成功率为100%。随访时间为62~132个月,平均(72.3±16.4)个月。术后患者门静脉压力由术前平均(37.12±7.61)cmH2O降至术后(22.23±6.95)cmH2O(t=12.72,P0.05)。与术前相比,术后1、6、12个月Child-Pugh A级患者Child-Pugh评分增高(P均0.05),而Child-Pugh B级患者评分下降(P均0.05)。Child-Pugh C级患者术后第6个月评分下降(P0.05)。与支架位于门静脉右支者相比,位于左支者术后1、6、12、24个月Child-Pugh评分较低(P均0.05);与支架直径≥8mm者相比,直径8mm者术后1、6个月Child-Pugh评分较低(P均0.05)。结论 TIPS对远期肝功能无明显影响。TIPS对Child-Pugh B级和C级患者前期肝功能有益处,但无法改善Child-Pugh A级患者肝功能。支架直径及支架位置是影响术后前期肝功能的重要因素。     

经颈静脉肝内门体分流术(TIPSS)与肝移植

目的 经颈静脉肝内门体分流术（TIPSS）正逐渐成为控制食管曲张静脉破裂出血和肝移植之间的桥梁。目前国内没有有关TIPSS对原位肝移植手术影响的报道。方法 回顾性研究接受术前TIPSS治疗的肝移植病人，即评价TIPSS作为肝移植桥梁的有效性和是否影响移植手术。结果 匹兹堡移植中心5例术前接受TIPSS的肝移植病人。行TIPSS与肝移植间隔时间为9．6（0．2－24．7）个月，3例病人在肝移植前能有效地控制出血。4例病人的支架位于肝实质内，并不影响手术；1例部分突出于肝外门静脉，术中需要移去支架。术后随访时间平均4.2(2-7)个月，无门静脉血栓形成。手术时间和术中输血量无显著性差异。结论 TIPSS是一种有效的桥梁，并没有增加移植术后并发症发生率和死亡率；鉴于有潜在的手术风险，支架最好放置在肝实质内，但肝外支架并不构成移植手术的反指征。     

Transjugular intrahepatic portosystemic shunt and liver transplantation

Transjugular intrahepatic portosystemic stent shunting (TIPSS) appears to be an attractive, nonsurgical procedure to overcome complications of end-stage liver disease. During the period August 1992 to February 1995, 23 adults who had previously undergone TIPSS received liver transplants. These patients were compared to 36 cirrhotic patients, grafted during the same time period, in relation to the implantation technique, the intraoperative use of blood products, and the length of their hospital stay. These groups were comparable for previous right upper quadrant surgery, splanchnic vein modifications, and Child-Pugh classification. Liver transplantation was performed electively in all TIPSS patients. Ten patients (43.4%) presented with a significant shunt stenosis at a median follow-up time of 4.5 months (range 2.5 to 30 months). At transplantation 8 of the 23 TIPSS patients (34.8%) had specific TIPSS-related modifications i.e., extrahepatic portal vein aneurysm formation (n=2), dislocation of the distal end of the stent into the inferior vena cava (n=4) or into the main portal vein trunk (n=1), bilioportal fistula (n=1), and pronounced phlebitis of the inferior vena cava and hepatic veins due to redilation of shunt stenosis (n=4). The intraoperative blood product requirement at transplantation was similar in the 23 TIPSS-patients and in the 36 cirrhotic patients who received transplants without the TIPSS procedure during the same time period [median 800 ml (range 0–20300 ml) vs median 620 ml (range 0–7600 ml), respectively]. There was also no difference between the two groups in length of hospital stay [median 18 days (range 0–34 days) vs median 19 days (range 0–66 days), respectively]. We conclude that TIPSS plays an important role in the management of life-threatening complications of end-stage liver disease arising in potential liver transplant candidates. TIPSS should be considered as a temporary, effective bridge to elective transplantation and not as a means to lower the blood product requirement at transplantation. Specific TIPSS-related modifications should be recognized early by the transplant surgeon in order to adapt the technique of graft implantation.     

Hemodynamic and metabolic effects of transjugular intrahepatic portosystemic shunt (TIPS) during anesthesia for orthotopic liver transplantation

Recently, the tranjugular intrahepatic portosystemic shunt (TIPS) has been advocated as a safe bridge to orthotopic liver transplantation (OLT). We retrospectively studied 53 consecutive cirrhotic patients who underwent OLT: 27 patients with TIPS were compared to 26 controls. Hemodynamic and oxyphoretic data (Fick method) were collected during six phases of OLT. There were no significant differences in demographic data and Child-Pugh class, nor in surgical time and blood product requirements before the anhepatic phase between TIPS patients and controls. In the TIPS group, we observed a marked hyperdynamic profile with a lower systemic vascular resistance index, higher cardiac index, and depressed oxygen consumption before native liver removal. During the same period, the TIPS group developed a greater acidosis and was treated with a larger amount of Na-HCO₃. Following the anhepatic phase, no differences between the two groups were detected. All transplantations were successful, and no complications related to TIPS were observed. These results seem to be the consequence of a reduced liver function reserve with a direct hemodynamic effect due to the TIPS.     

Open cardiotomy for removal of migrating transjugular intrahepatic portosystemic shunt stent combined with liver transplantation

BACKGROUND: Transjugular intrahepatic shunts are widely used for the management of variceal bleeding. Complications such as stent misplacement or migration may occur. METHODS: We describe the management of a transjugular intrahepatic shunts stent that migrated across the tricuspid valve in a patient with Child-Pugh category C cirrhosis. RESULTS: An attempt at percutaneous retrieval of the stent was unsuccessful. Due to the unacceptably high risk for mortality from open heart surgery with cardiopulmonary bypass in the setting of cirrhosis, stent removal was deferred until the time of orthotopic liver transplantation. The procedures were performed successfully, and the patient made a good recovery. CONCLUSION: Surgical stent extraction and valve repair can be performed safely along with orthotopic liver transplantation in carefully selected patients with end-stage liver disease.     

Small-for-size syndrome after living donor liver transplantation: Successful treatment with a transjugular intrahepatic portosystemic shunt

Small-for-size syndrome (SFSS) is a serious complication after living donor liver transplantation (LDLT) that can disrupt liver regeneration and result in hepatic dysfunction. Until now, the treatment options for SFSS after LDLT have been very limited. Here we describe a patient with SFSS after LDLT who was successfully treated with a transjugular intrahepatic portosystemic shunt (TIPS). A 56-year-old man who had undergone adult-to-adult LDLT because of decompensated liver cirrhosis started displaying signs of acute jaundice and ascites within 72 hours of the operation. The patient was diagnosed with SFSS, and because he had already undergone splenectomy before the transplant, partial splenic embolization was not feasible. Consequently, the TIPS procedure was chosen in an attempt to reduce portal hyperperfusion. After the procedure, the patient's symptoms were gradually ameliorated and were eventually resolved. In conclusion, when partial splenic embolization is not feasible, TIPS placement may be a feasible option for the treatment of SFSS after LDLT. Liver Transpl, 2012. ? 2012 AASLD.     

Atrial natriuretic factor after transjugular intrahepatic portosystemic shunt in liver cirrhosis and ascites

Summary Background: The detailed mechanisms of ascites resolution after transjugular intrahepatic portosystemic shunt (TIPS) still remain unknown. Aim of the study was to investigate the influence of TIPS on endocrine factors regulating sodium and fluid homeostasis. Methods: Plasma levels of atrial natriuretic factor (ANF), antidiuretic hormone (ADH) and aldosterone were studied in 14 patients with liver cirrhosis and ascites. Results: After TIPS, ascites completely disappeared in 57% (responders), was partially reduced in 3 patients and remained unchanged in 3 patients. 5 out of the latter 6 non/partial responders (83%) had peripheral edema but none of the responders. In the responders baseline ANF was normal (60.5 [32–86] ng/L; median [range]) and increased after TIPS (102.5 [55–250] ng/L; p<0.05). In contrast, in the non/partial responders baseline ANF was elevated (121 [87–305] ng/L; p<0.05) without significant increase 1 week after TIPS. Baseline ADH levels (responders: 2.5 [0.8–4.7] ng/L; non/partial responders: 4.0 [2.1–7.2] ng/L) increased after TIPS (7.3 [1.2–9.0] vs. 7.1 [5.3–9.0] ng/L; p<0.05) and decreased a week thereafter (1.4 [0.8–4.6] ng/L vs. 3.9 [1.3–5.1] ng/L; p<0.05). Pretreatment aldosterone levels were elevated in both groups and decreased only insignificantly after TIPS. Conclusions: A favourable response to TIPS was associated with low baseline levels of ANF and with early increased ANF levels following TIPS. Improved hemodynamics after TIPS, release of ANF and renal response to it may be involved in the successful elimination of the volume load following TIPS in responders. Existing overstimulation of the ANF system together with possibly reduced renal sensitivity to ANF before TIPS could explain the blunted response to TIPS in non/partial responders. Low pre-TIPS ANF levels appear to be predictive for an early beneficial effect of TIPS on ascites resolution in cirrhotics.      

经颈静脉肝内门体分流术与肝细胞癌的相关性

经颈静脉肝内门体分流术（TIPS）可有效治疗肝硬化患者门静脉高压,但可能影响患者血流动力学和肝功能。TIPS与肝硬化及肝癌具有潜在相关性,可能与肝脏血流动力学改变和肠道群菌失调等有关,目前对于其间关系仍不明确。本文就TIPS与肝细胞癌相关性研究进展进行综述。     

经颈静脉肝内门体分流术后抗凝治疗现状

经颈静脉肝内门体分流术(TIPS)可治疗门静脉高压,但术后常发生分流道狭窄或闭塞。TIPS术后抗凝治疗可预防支架内血栓形成,但同时增加出血风险,且目前尚缺乏统一标准。本文就TIPS术后抗凝治疗现状进行综述。     

经颈静脉肝内门体分流术后肝性脑病研究进展

肝性脑病(HE)可引起不同程度的神经精神异常。经颈静脉肝内门体分流术(TIPS)术后高发HE,严重制约其在门静脉高压症治疗中的应用。本文主要对TIPS术后HE的发病机制、危险因素和治疗方面的研究进展进行综述。     

Complications following transjugular intrahepatic portosystemic shunt: a retrospective analysis

Transjugular intrahepatic portosystemic shunt (TIPS) has been the therapeutic option for severe decompensation of chronic liver disease and as a bridge to liver transplantation. The aim of this study was to analyze the complications of this procedure. The records of 47 patients (39 men) of mean age 48 years underwent TIPS procedures from 1998 to 2003 were reviewed. Forty-one patients received 45 successful TIPS; it failed in six patients. Improvement was observed in 20 of 28 patients with upper gastrointestinal bleeding (71%); 9 of 11 with ascites (82%); and 5 of 8 with impaired renal function (62%). The Child-Pugh scores improved in 6 of the 47 patients (13%). Transplantation was performed in 11 patients (23%). The complications were: encephalopathy (49%); infection (19%); renal failure (17%); TIPS migration to the portal vein (4%) and to the right atrium (4%). Mortality was 32% (15/47) over 3 months. Eight patients developed active bleeding during TIPS installation requiring mechanical ventilation and intensive care, and died within the first week. Other causes of death were sepsis (n = 2), liver failure (n = 1), accidental puncture of the Glisson's capsule leading to intra-abdominal bleeding (n = 1) and refractory upper gastrointestinal bleeding (n = 3). The latter four patients had TIPS placement failure. In conclusion, TIPS produced clinical improvement among 51% of patients with complications in 49%. The main complications were encephalopathy (49%), infection (19%), and renal failure (17%). The 3-month mortality rate after TIPS placement was 32%.     

Predictors of mortality and stenosis after transjugular intrahepatic portosystemic shunt

Transjugular intrahepatic portosystemic shunts (TIPSs) are used to treat variceal hemorrhage and refractory ascites. We sought to determine factors associated with stenosis and mortality after TIPS placement in patients with end-stage liver disease. This is a retrospective review of 90 TIPSs placed over a 3-year period. Demographic, clinical, and biochemical parameters were analyzed in univariate analyses to determine their association with stenosis and death. Multivariate analyses were conducted using logistic regression and Cox proportional hazard modeling. Thirty-five TIPSs were placed for recurrent variceal bleeding; 14 TIPSs, for uncontrolled variceal bleeding; 34 TIPSs, for refractory ascites; and 7 TIPSs, for other causes. The overall mortality rate was 33%, and 18 patients died within 30 days of TIPS placement. The 1-year stenosis rate was 49%. Fourteen patients underwent liver transplantation a mean of 116 [plusmn] 143 days after TIPS placement. Prothrombin time greater than 17 seconds, serum creatinine level greater than 1.7 mg/dL, total bilirubin level greater than 3 mg/dL, and uncontrolled variceal bleeding as an indication for TIPS placement were significant predictors of 30-day mortality. Serum creatinine level was a predictor of 30-day mortality in individuals with recurrent variceal hemorrhage or ascites. Multivariate analyses showed that creatinine level greater than 1.7 mg/dL and uncontrolled variceal bleeding as an indication for TIPS placement were independently associated with 30-day mortality. Individuals with both coagulopathy and renal insufficiency had a 30-day mortality rate of 78%. Urgent placement of TIPS was associated with an increased risk for stenosis (hazard ratio = 4.5; 95% confidence interval, 1.9 to 10.1; P [lt ] .001), but no other clinical variables were associated with stenosis. Uncontrolled variceal bleeding as an indication for TIPS placement, coagulopathy, hyperbilirubinemia, and renal insufficiency were associated with increased mortality in patients with TIPSs. Individuals with both coagulopathy and renal insufficiency had high mortality. Urgent TIPS placement for uncontrolled variceal bleeding was associated with stenosis. (Liver Transpl 2002;8:271-277.)