Clinical outcome and predictors of survival after TIPS insertion in patients with liver cirrhosis

AIM:To determine the clinical outcome and predictors of survival after transjugular intrahepatic portosystemic stent shunt (TIPS) implantation in cirrhotic patients. METHODS:Eighty-one patients with liver cirrhosis and consequential portal hypertension had TIPS implantation (bare metal) for either refractory ascites (RA) (n= 27) or variceal bleeding (VB) (n = 54). Endpoints for the study were:technical success, stent occlusion and stent stenosis, rebleeding, RA and mortality. Clinical records of patients were collected and analysed. Baseline characteristics [e.g., age, sex, CHILD score and the model for end-stage liver disease score (MELD score), underlying disease] were retrieved. The Kaplan-Meier method was employed to calculate survival from the time of TIPS implantation and comparisons were made by log rank test. A multivariate analysis of factors influencing survival was carried out using the Cox proportional hazards regression model. Results were expressed as medians and ranges. Comparisons between groups were performed by using the Mann-Whitney Utest and the χ 2 test as appropriate. RESULTS:No difference could be seen in terms of age, sex, underlying disease or degree of portal pressure gradient (PPG) reduction between the ascites and the bleeding group. The PPG significantly decreased from 23.4 ± 5.3 mmHg (VB) vs 22.1 ± 5.5 mmHg (RA) before TIPS to 11.8 ± 4.0 vs 11.7 ± 4.2 after TIPS implantation (P = 0.001 within each group). There was a tendency towards more patients with stage CHILD A in the bleeding group compared to the ascites group (24 vs 6, P = 0.052). The median survival for the ascites group was 29 mo compared to 60 mo for the bleeding group (P = 0.009). The number of radiological controls for stent patency was 6.3 for bleeders and 3.8 for ascites patients (P = 0.029). Kaplan-Meier calculation indicated that stent occlusion at first control (P = 0.027), ascites prior to TIPS implantation (P = 0.009), CHILD stage (P = 0.013), MELD score (P = 0.001) and those patients not having undergone liver transplantation (P = 0.024) were significant predictors of survival. In the Cox regression model, stent occlusion (P = 0.022), RA (P = 0.043), CHILD stage (P = 0.015) and MELD score (P = 0.004) turned out to be independent prognostic factors of survival. The anticoagulation management (P = 0.097), the porto-systemic pressure gradient (P= 0.460) and rebleeding episodes (P = 0.765) had no significant effect on the overall survival. CONCLUSION:RA, stent occlusion, initial CHILD stage and MELD score are independent predictors of survival in patients with TIPS, speaking for a close follow-up in these circumstances.     

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。     

Transjugular intrahepatic portosystemic shunt (TIPS) for the treatment of refractory ascites

Background: The Transjugular Intrahepatic Portosystemic Shunt (TIPS) corrects portal hypertension and has proven to be effective in controlling variceal bleeding in patients with cirrhosis. Several reports have now appeared suggesting a possible role in patients with refractory ascites.
Aims: To examine the outcome of TIPS for the treatment of refractory ascites in patients with cirrhosis.
Methods: Fifteen patients underwent TIPS for ascites between April 1992 and December 1996. The clinical findings, response to treatment, complications, shunt patency and survival of these patients were analysed.
Results: TIPS was successfully placed in all patients. The mean period of follow-up was 375 days (range: 14–1165 days). In eight patients (53%) there was a reduction in the degree of ascites after shunt insertion, with six patients (40%) having complete resolution. Age, Child-Pugh class or portal pressure gradient, before or after the procedure, were not predictive of response. Of five patients with renal insufficiency (serum creatinine >130 umol/L), only one had improvement in ascites control. Six patients (40%) required shunt revision during follow-up, either for acute thrombotic occlusion (two) or stent stenosis (four). New or worsening encephalopathy developed in ten patients (67%). Two patients (13%) died of liver failure within 30 days. Cumulative survival was 46% at one year and 18% at two years. Treatment response was associated with increased survival (ρ=0.02), with median survival of 658 days as compared with 71 days for treatment failure.
Conclusions: TIPS can be effective in the treatment of refractory ascites in patients with cirrhosis. Our experience suggests the benefit may be less for patients with advanced liver disease and renal impairment. Controlled trials are needed to compare TIPS with other treatment modalities such as large volume paracentesis or peritoneovenous shunting.     

Transjugular intrahepatic portosystemic shunt (TIPS) augments hyperinsulinemia in patients with cirrhosis

BACKGROUND/AIMS: Cirrhosis of the liver is characterized by glucose intolerance and hyperinsulinemia. Both increased insulin secretion and decreased insulin clearance appear to contribute to hyperinsulinemia in cirrhotic patients. A decrease in hepatic insulin extraction rate may be due either to hepatocellular dysfunction or to portosystemic shunting with decreased first-pass insulin clearance. METHODS: To specifically address the contribution of portosystemic shunting to the pathogenesis of hyperinsulinemia in cirrhotic patients, we analyzed glycemic control and insulin levels in fasting serum in 23 cirrhotic patients before and after transjugular intrahepatic portosystemic shunt (TIPS). RESULTS: Compared to respective values in healthy controls, C-peptide, insulin and proinsulin concentrations at baseline were increased by 340%, 120% and by 100% in cirrhotic patients (all p<0.05). In cirrhotic patients insulin levels before TIPS averaged 104+/-73 pmol/l and increased by more than 50% to 163+/-118 pmol/l after TIPS (p<0.01), whereas levels of C-peptide and proinsulin showed no significant change. Glucose and fructosamin levels also remained unchanged after TIPS. CONCLUSION: Our data demonstrate that TIPS does not impair glycemic control in cirrhotic patients and that an increase in portosystemic shunting augments hyperinsulinemia, most likely by decreasing hepatic insulin clearance.     

Current approaches to the management of patients with cirrhotic ascites

This review describes current approaches to the management of patients with cirrhotic ascites in relation to the severity of its clinical manifestations. The PubMed database, the Google Scholar retrieval system, the Cochrane Database of Systematic Reviews, and the reference lists from related articles were used to search for relevant publications. Articles corresponding to the aim of the review were selected for 1991-2018 using the keywords:“liver cirrhosis,”“portal hypertension,”“ascites,”“pathogenesis,”“diagnostics,” and “treatment.” Uncomplicated and refractory ascites in patients with cirrhosis were the inclusion criteria. The literature analysis has shown that despite the achievements of modern hepatology, the presence of ascites is associated with poor prognosis and high mortality. The key to successful management of patients with ascites may be the stratification of the risk of an adverse outcome and personalized therapy. Pathogenetically based approach to the choice of pharmacotherapy and optimization of minimally invasive methods of treatment may improve the quality of life and increase the survival rate of this category of patients.     

EVS vs TIPS shunt for gastric variceal bleeding in patients with cirrhosis:A meta-analysis

AIM: To evaluate the clinical effects of transjugular intrahepatic portosystemic shunt (TIPS) vs endoscopic variceal sclerotherapy (EVS) in the management of gastric variceal (GV) bleeding in terms of variceal rebleeding, hepatic encephalopathy (HE), and survival by meta-analysis.METHODS: Medline, Embase, and CNKI were searched. Studies compared TIPS with EVS in treating GV bleeding were identified and included according to our predefined inclusion criteria. Data were extracted independently by two of our authors. Studies with prospective randomized design were considered to be of high quality. Hazard ratios (HRs) or odd ratios(ORs) were calculated using a fixed-effects model when there was no inter-trial heterogeneity. Oppositely, a random-effects model was employed.RESULTS: Three studies with 220 patients who had at least one episode of GV bleeding were included in the present meta-analysis. The proportions of patients with viral cirrhosis and alcoholic cirrhosis were 39% (range 0%-78%) and 36% (range 12% to 41%), respectively. The pooled incidence of variceal rebleeding in the TIPS group was significantly lower than that in the EVS group (HR = 0.3, 0.35, 95% CI: 0.17-0.71, P = 0.004). However, the risk of the development of any degree of HE was significantly increased in the TIPS group (OR = 15.97, 95% CI: 3.61-70.68). The pooled HR of survival was 1.26(95% CI: 0.76-2.09, P = 0.36). No inter-trial heterogeneity was observed among these analyses. CONCLUSION: The improved effect of TIPS in the prevention of GV rebleeding is associated with an increased risk of HE. There is no survival difference between the TIPS and EVS groups. Further studies are needed to evaluate the survival benefit of TIPS in cirrhotic patients with GV bleeding.     

Rebleeding rates following TIPS for variceal hemorrhage in the Viatorr era: TIPS alone versus TIPS with variceal embolization

Purpose  

To compare rebleeding rates following treatment of variceal hemorrhage with TIPS alone versus TIPS with variceal embolization in the covered stent-graft era.     

Transjugular intrahepatic portosystemic stent shunt for medically refractory hepatic hydrothorax: A systematic review and cumulative meta-analysis

AIM: To assess the effectiveness of transjugular intrahepatic portosystemic stent shunt (TIPSS) in refractory hepatic hydrothorax (RHH) in a systematic review and cumulative meta-analysis.METHODS: A comprehensive literature search was conducted on MEDLINE, EMBASE, and PubMed covering the period from January 1970 to August 2014. Two authors independently selected and abstracted data from eligible studies. Data were summarized using a random-effects model. Heterogeneity was assessed using the I² test.RESULTS: Six studies involving a total of 198 patients were included in the analysis. The mean (SD) age of patients was 56 (1.8) years. Most patients (56.9%) had Child-Turcott-Pugh class C disease. The mean duration of follow-up was 10 mo (range, 5.7-16 mo). Response to TIPSS was complete in 55.8% (95%CI: 44.7%-66.9%), partial in 17.6% (95%CI: 10.9%-24.2%), and absent in 21.2% (95%CI: 14.2%-28.3%). The mean change in hepatic venous pressure gradient post-TIPSS was 12.7 mmHg. The incidence of TIPSS-related encephalopathy was 11.7% (95%CI: 6.3%-17.2%), and the 45-d mortality was 17.7% (95%CI: 11.34%-24.13%).CONCLUSION: TIPSS is associated with a clinically relevant response in RHH. TIPSS should be considered early in these patients, given its poor prognosis.     

Diagnosis and therapy of ascites in liver cirrhosis

Ascites is one of the major complications of liver cirrhosis and is associated with a poor prognosis. It is important to distinguish noncirrhotic from cirrhotic causes of ascites to guide therapy in patients with noncirrhotic ascites. Mild to moderate ascites is treated by salt restriction and diuretic therapy. The diuretic of choice is spironolactone. A combination treatment with furosemide might be necessary in patients who do not respond to spironolactone alone. Tense ascites is treated by paracentesis, ...     

Parallel transjugular intrahepatic portosystemic shunt for controlling portal hypertension complications in cirrhotic patients

AIM: To evaluate the feasibility of a second parallel transjugular intrahepatic portosystemic shunt (TIPS) to reduce portal venous pressure and control complications of portal hypertension.METHODS: From January 2011 to December 2012, 10 cirrhotic patients were treated for complications of portal hypertension. The demographic data, operative data, postoperative recovery data, hemodynamic data, and complications were analyzed.RESULTS: Ten patients underwent a primary and parallel TIPS. Technical success rate was 100% with no technical complications. The mean duration of the first operation was 89.20 ± 29.46 min and the second operation was 57.0 ± 12.99 min. The mean portal system pressure decreased from 54.80 ± 4.16 mmHg to 39.0 ± 3.20 mmHg after the primary TIPS and from 44.40 ± 3.95 mmHg to 26.10 ± 4.07 mmHg after the parallel TIPS creation. The mean portosystemic pressure gradient decreased from 43.80 ± 6.18 mmHg to 31.90 ± 2.85 mmHg after the primary TIPS and from 35.60 ± 2.72 mmHg to 15.30 ± 3.27 mmHg after the parallel TIPS creation. Clinical improvement was seen in all patients after the parallel TIPS creation. One patient suffered from transient grade I hepatic encephalopathy (HE) after the primary TIPS and four patients experienced transient grade I-II after the parallel TIPS procedure. Mean hospital stay after the first and second operations were 15.0 ± 3.71 d and 16.90 ± 5.11 d (P = 0.014), respectively. After a mean 14.0 ± 3.13 mo follow-up, ascites and bleeding were well controlled and no stenosis of the stents was found.CONCLUSION: Parallel TIPS is an effective approach for controlling portal hypertension complications.     

Successful surgical management of ruptured umbilical hernias in cirrhotic patients

Acute umbilical hernia rupture in patients with hepatic cirrhosis and ascites is an unusual,but potentially lifethreatening complication,with postoperative morbidity about 70% and mortality between 60%-80% after supportive care and 6%-20% after urgent surgical repair.Management options include primary surgical repair with or without concomitant portal venous system decompression for the control of the ascites.We present a retrospective analysis of our centre’s experience over the last 6 years.Our cohort consisted of 11 consecutive patients(median age:53 years,range:36-63 years) with advanced hepatic cirrhosis and refractory ascites.Appropriate patient resuscitation and optimisation with intravenous fluids,prophylactic antibiotics and local measures was instituted.One failed attempt for conservative management was followed by a successful primary repair.In all cases,with one exception,a primary repair with non-absorbable Nylon,interrupted sutures,without mesh,was performed.The perioperative complication rate was 25% and the recurrence rate 8.3%.No mortality was recorded.Median length of hospital stay was 14 d(range:4-31 d).Based on our experience,the management of ruptured umbilical hernias in patients with advanced hepatic cirrhosis and refractory ascites is feasible without the use of transjugular intrahepatic portosystemic shunt routinely in the preoperative period,provided that meticulous patient optimisation is performed.     

Evaluation and management of patients with refractory ascites

Some patients with ascites due to liver cirrhosis become no longer responsive to diuretics. Once other causes of ascites such as portal vein thrombosis, malignancy or infection and non-compliance with medications and low sodium diet have been excluded, the diagnosis of refractory ascites can be made based on strict criteria. Patients with refractory ascites have very poor prognosis and therefore referral for consideration for liver transplantation should be initiated. Search for reversible components of the underlying liver pathology should be undertaken and targeted therapy, when available, should be considered. Currently, serial large volume paracentesis （LVP） and transjugular intrahepatic portasystemic stent-shunt （TIPS） are the two mainstay treatment options for refractory ascites. Other treatment options are available but not widely used either because they carry high morlJidity and mortality （most surgical options） rates, or are new interventions that have shown promise but still need further evaluation. In this comprehensive review, we describe the evaluation and management of patients with refractory ascites from the prospective of the practicing physician.     

Transjugular intrahepatic portosystemic shunt in refractory chylothorax due to liver cirrhosis

A pleural effusion containing chylomicrons is termed chylothorax and results from leakage of lymph fluid into the pleural cavity.We report on the case of a 59-year-old woman with severe dyspnea due to a large chylothorax.She was known to have liver cirrhosis but no ascites.There was no history of trauma,cardiac function was normal and thorough diagnostic work-up did not reveal any signs of malignancy.In summary,no other etiology of the chylothorax than portal hypertension could be found.Therapy with diuretics as well as parenteral feeding failed to relieve symptoms.After a transjugular intrahepatic portosystemic shunt(TIPS) had successfully been placed,pleural effusion decreased considerably.Eight months later,TIPS revision had to be performed because of stenosis,resulting in remission from chylothorax.This case shows that even in the absence of ascites,chylothorax might be caused by portal hypertension and that TIPS can be an effective treatment option.     

Selection of a TIPS stent for management of portal hypertension in liver cirrhosis: An evidence-based review

Nowadays,transjugular intrahepatic portosystemic shunt(TIPS)has become a mainstay treatment option for the management of portal hypertension-related complications in liver cirrhosis.Accumulated evidence has shown that its indications are being gradually expanded.Notwithstanding,less attention has been paid for the selection of an appropriate stent during a TIPS procedure.Herein,we attempt to review the current evidence regarding the diameter,type,brand,and position of TIPS stents.Several following recommendations may be considered in the clinical practice:(1)a 10-mm stent may be more effective than an 8-mm stent for the management of portal hypertension,and may be superior to a 12-mm stent for the improvement of survival and shunt patency;(2)covered stents are superior to bare stents for reducing the development of shunt dysfunction;(3)if available,Viatorr stent-grafts may be recommended due to a higher rate of shunt patency;and(4)the placement of a TIPS stent in the left portal vein branch may be more reasonable for decreasingthe development of hepatic encephalopathy.However,given relatively low quality of evidence,prospective well-designed studies should be warranted to further confirm these recommendations.     

Transjugular local thrombolysis with/without TIPS in patients with acute non-cirrhotic,non-malignant portal vein thrombosis

Background & aimsTherapeutic anticoagulation is the standard treatment in patients with acute non-cirrhotic portal vein thrombosis (PVT). In critically ill patients, anticoagulation only may not suffice to achive rapid and stable recanalization. This study evaluates efficacy and safety of transjugular interventional therapy in acute non-cirrhotic PVT.MethodsThis retrospective study includes 17 consecutive patients with acute noncirrhotic, non-malignant PVT. Main indication for interventional therapy was imminent intestinal infarction (n = 10). Treatment consisted of a combination of transjugular thrombectomy, local fibrinolysis and – depending on thrombus resolution – transjugular intrahepatic portosystemic shunt.ResultsRecanalization was successful in 94.1%. One- and two-year secondary PV patency rates were 88.2%. Major complications (n = 3) resolved spontaneously in all but one patient (heparin induced thrombocytopenia type 2 with intestinal infarction). Symptoms improved in all patients. However, segmental bowel resection had to be performed in two (11.8%). During a median follow-up of 28.6 months, no patient experienced portal hypertensive complications. Presence of JAK2 V617F mutation predicted both short-term and long-term technical success.ConclusionsTransjugular recanalization is safe and effective in patients with acute non-cirrhotic, non-malignant PVT. It should be considered especially in patients with imminent bowel infarction and low likelihood of recanalization following therapeutic anticoagulation. Patients with JAK2 mutation ought to be followed meticulously.     

TIPS for acute and chronic Budd-Chiari syndrome: a single-centre experience

BACKGROUND/AIMS: Transjugular intrahepatic portosystemic shunt (TIPS) is a technically challenging but feasible treatment for Budd-Chiari syndrome (BCS). However, information about the outcome, particularly in patients with liver failure, is scarce. We report our experience of TIPS for BCS. METHODS: Fifteen patients with BCS underwent TIPS. Eight had hepatic failure and seven underwent TIPS for BCS uncontrolled by medical treatment. RESULTS: Fourteen out of 15 had successful TIPS placement. Out of the eight hepatic failure patients, four died soon after TIPS: one liver rupture, one portal vein rupture, one liver failure and one pulmonary oedema. Another patient had a significant intrahepatic haematoma, which resolved with conservative management. TIPS was successfully placed in all of the seven patients with chronic BCS, in whom there was an average follow-up of 20 months. Ascites resolved and liver function improved in all. One patient died after 18 months from the original hepatic metastatic disease. Four patients have had evidence of TIPS dysfunction requiring three balloon dilatations and one restenting. No patient has required liver transplantation. CONCLUSIONS: TIPS should be the first line treatment for BCS uncontrolled by medical therapy. However, mortality in BCS with hepatic failure is high and liver transplantation could be a better option.     

早期抗凝干预用于经颈静脉肝内门体静脉支架分流术联合PSE治疗肝硬化患者价值探讨*

目的 研究在经颈静脉肝内门体静脉支架分流术(TIPS)联合部分脾栓塞(PSE)术治疗的肝硬化并发食管胃底静脉曲张患者早期抗凝干预对预防门静脉血栓形成的价值。方法 2016年9月～2018年9月我院收治的86例肝硬化并发门静脉高压症患者,均接受TIPS联合PSE治疗。术后,采用抽签法随机将患者分为对照组43例,给予肝素和阿司匹林抗凝治疗,和观察组43例,术后给予低分子肝素联合华法林治疗。随访3个月。结果 术后7 d,观察组PLT为(274.3±30.2)×10⁹/L,显著高于术前,对照组PLT为(257.6±29.7)×10⁹/L,也显著高于术前;观察组PLT、PT和APTT与对照组比较差异均无统计学意义(P＞0.05);门静脉直径为(12.2±2.2)mm,门静脉血流流速为(12.6±2.3)cm/s,门静脉血流量为(910.6±260.2)ml/min,与对照组的(12.1±2.0)mm、(13.0±4.1)cm/s和(889.4±192.6)ml/min比,差异无统计学意义(P>0.05);两组腹水、出血、肝性脑病、皮肤瘀斑和发热发生率比较差异均无统计学意义(P＞0.05),但观察组门静脉血栓形成发生率为2.3%,显著低于对照组的16.3%(P＜0.05)。结论 早期给予低分子肝素联合华法林抗凝处理能有效预防TIPS联合PSE术后门静脉系统血栓形成,临床应引起足够的重视。     

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.