Long-Term Follow-Up of TIPS Created with Expanded Poly-Tetrafluoroethylene Covered Stents

Background

Transjugular intrahepatic portosystemic shunts (TIPS) created with expanded poly-tetrafluoroethylene-covered stents have largely replaced bare metal stents. Short-term shunt patency is typically assessed with protocol Doppler ultrasound (US), while little information exists with regard to long-term patency.

Aim

We investigated the value of Doppler US in assessing TIPS patency as well as long-term clinical outcomes.

Methods

A retrospective analysis of 59 patients with covered stents used for TIPS between January 2001 and December 2011 was performed.

Results

Fifty-four patients had early (median 9 days) Doppler US follow-up. Seven of eight patients with an abnormal baseline US required stent revisions. None of the 46 patients with normal baseline Doppler US required revisions within the first 6 months; six of these patients subsequently had a portogram because of symptoms, but all TIPS were patent. Fifty-two patients survived for long-term (>6 months) follow-up, averaging 654 days and three Doppler US exams. Five of six patients with abnormal follow-up Doppler US required revisions, whereas none of the 46 patients with normal follow-up US had revisions. The recurrence of symptoms of portal hypertension and/or hepatic encephalopathy (HE) was low (4/52 patients). No significant predictors of long-term stenosis were identified. Post-TIPS HE was independent of pre-TIPS HE or Child-Pugh score.

Conclusions

Short-term patency and that at approximately 2 years after TIPS placement was 87 and 77 %, respectively. We conclude that Doppler US at least 1 week after TIPS is warranted, but repeated Doppler US follow-up is probably not necessary in the absence of clinical symptoms.     

Efficacy of Transjugular Intrahepatic Portosystemic Shunt with Adjunctive Embolotherapy with Cyanoacrylate for Esophageal Variceal Bleeding

Background

Transjugular intrahepatic portosystemic shunt (TIPS) with adjunctive embolotherapy has recently been reported to be effective in the prevention of variceal hemorrhage of cirrhotic patients. However, further investigation of its long-term efficacy is still needed.

Aim

To examine the rebleeding, survival, and hepatic encephalopathy (HE) after treatment with TIPS alone and TIPS with adjunctive embolotherapy using cyanoacrylate for esophageal variceal bleeding.

Methods

Patients with refractory to endoscopic therapy for esophageal variceal bleeding were enrolled. TIPS was performed in 101 patients with adjunctive embolotherapy (n = 53) or alone (n = 48) between January 2006 and December 2011. Chart reviews were performed to determine rebleeding, survival rates, and the incidence of HE.

Results

Recurrent hemorrhage occurred in 12 (11.9 %) patients during the mean follow-up periods of 35.8 months. Rebleeding was observed in 9/48 (18.8 %) patients in TIPS alone group and 3/53 (5.7 %) patients in TIPS with adjunctive embolotherapy group (p = 0.042). Death occurred in 30 patients during follow-up (TIPS alone: n = 16, TIPS with adjunctive embolotherapy: n = 14, p = 0.447). Twenty-six episodes of HE occurred in 18 patients in TIPS alone group and 16 episodes occurred in 10 patients in TIPS with embolotherapy group. The probability of HE was significantly higher in TIPS alone group than in TIPS with embolotherapy group (p = 0.019).

Conclusions

TIPS with adjunctive embolotherapy with cyanoacrylate is relatively safe and effective, with a lower rebleeding and HE incidence in comparison of TIPS alone.     

Effects of transjugular intrahepatic portosystemic shunt on changes in the small bowel mucosa of cirrhotic patients with portal hypertension

Background

The introduction of capsule endoscopy (CE) has facilitated the detection of mucosal changes in the small bowel, and such mucosal changes have been noted in cirrhotic patients with portal hypertension; these changes are described as portal hypertensive enteropathy. The aim of this study was to assess the effects of transjugular intrahepatic portosystemic shunt (TIPS) on the small bowel mucosal changes detected by CE in cirrhotic patients with portal hypertension.

Methods

TIPS was performed in fifteen cirrhotic patients with portal hypertension. All patients underwent CE before and 2 weeks after TIPS. The small bowel mucosal changes were defined as edema, angiodysplasia-like lesions, red spots, and small bowel varices. Changes in the portosystemic pressure gradient (PSG) and CE findings were evaluated.

Results

Before TIPS, small bowel edema was detected in all 15 patients, angiodysplasia-like lesions in 7, and red spots in 14 patients. The PSG decreased significantly, from 21.2 ± 2.6 before TIPS to 8.9 ± 3.3 mmHg (p < 0.001) after the procedure. After TIPS, the small bowel edema was attenuated in 8 of the 15 patients. In two patients with angiodysplasia-like lesions and 4 with red spots, these lesions were attenuated after TIPS. The average score for small bowel edema and the grade of red spots were reduced significantly after TIPS (2.3 ± 0.7–1.8 ± 0.6, p < 0.005 and 1.6 ± 0.9–1.3 ± 0.7, p < 0.05, respectively). Small bowel varices were seen in 4 patients before TIPS and all these varices disappeared after TIPS.

Conclusions

In cirrhotic patients with portal hypertension, small bowel edema, red spots, and small bowel varices were attenuated after TIPS. Portal hypertension may be an important factor in the development of small bowel mucosal changes.     

Combined TIPS with portal-azygous disconnection improved the long term clinical outcome in portal hypertension patients

Objective

The results of TIPS and the combined TIPS and portal-azygous disconnection for portal hypertension and variceal bleeding were evaluated.

Methods

358 patients with portal hypertension were admitted to our clinical ward because of variceal bleeding. 263 patients underwent TIPS and 95 patients with combined TIPS and portal-azygous disconnection. Portal hemodynamics was evaluated by pressure measurements, venography and Doppler ultrasound before and 2 weeks after the procedure. The rates of shunt patency, rebleeding, encephalopathy and survival were observed during the follow-up period from 1 to 10 years.

Results

The portal pressure and HVPG were decreased significantly after TIPS. TIPS procedure was successfully performed in 97.50% patients. During 1 month after treatment, acute shunt occlusion occurred in 3.42% patients with TIPS and there were no occluded shunts in patients with combined TIPS and portal-azygous disconnection. Encephalopathy was observed in 36.50% patients with TIPS and 18.95% with combined TIPS and portal-azygous disconnection. Recurrent variceal bleeding was documented in 6.46% patients with TIPS and none of patients with combined TIPS and azygous portal disconnection. Thirty-three patients with TIPS and two patients with combined TIPS and portal-azygous disconnection died. During follow-up periods, the patency of shunts in patients with TIPS and patients combined TIPS and azygous portal disconnection was 68.47, 43.84 and 87.06, 57.65% in 12 and 24 months after operation, respectively. The rates of rebleeding, and encephalopathy in patients with TIPS and patients with combined TIPS and azygous portal disconnection were 17.95, 31.79 and 7.04, 16.47%, respectively. The survival rate in 1, 5, 10 years in patients with TIPS and patients combined TIPS and azygous portal disconnection was 87.68, 51.23, 39.90 and 94.12, 81.18, 76.47%.

Conclusion

Combined TIPS and portal-azygous disconnection can improve the effect of TIPS for portal hypertension.     

Percutaneous transhepatic variceal embolization with cyanoacrylate vs. transjugular intrahepatic portal systematic shunt for esophageal variceal bleeding

Purpose

To compare the long-term results of modified percutaneous transhepatic variceal embolization with cyanoacrylate (PTVE) and the transjugular intrahepatic portal systemic shunt (TIPS) for treating esophageal variceal bleeding.

Methods

Patients with cirrhosis and variceal bleeding who underwent TIPS and PTVE with cyanoacrylate between January 2006 and December 2010 were selected. We performed chart reviews to determine the rebleeding rate, survival and the rate of encephalopathy.

Results

This retrospective study included 96 PTVE patients and 43 TIPS patients, with a median follow-up of 30.4 and 31.6 months in the two groups, respectively. Rebleeding occurred in 13 patients (30.2 %) in the TIPS group and in 20 patients (20.8 %) in the PTVE group (p = 0.229). For patients with model for end-stage liver disease (MELD) scores >18 at 1, 3 and 5 years, the survival rates were 84.2, 39.9 and 16.0 %, respectively, in the TIPS group, and they were 96.7, 72.0 and 36.0 %, respectively, in the PTVE group (p = 0.037). Sixteen (16.7 %) PTVE patients and 25 (58.1 %) TIPS patients developed encephalopathy (p = 0.000). Mean MELD and Child–Pugh scores improved significantly in modified PTVE patients. However, no such changes were observed in TIPS patients.

Conclusions

PTVE and TIPS were comparable in terms of variceal rebleeding prevention. However, in >18-MELD-score patients, PTVE offered better survival than TIPS. In addition, PTVE offered lower incidence of encephalopathy than TIPS.     

Effects of modified splenocaval shunt plus devascularization on esophagogastric variceal bleeding: a comparative study of this treatment and devascularization only in cirrhotic portal hypertension

Background

Pericardial devascularization (PCDV) and portosystemic shunt were reported to have favorable results for the management of portal hypertension in cirrhotic patients in China and the West, respectively. This study was undertaken to investigate the effects of a modified proximal splenocaval shunt plus PCDV on variceal bleeding in patients with portal hypertension.

Methods

From January 1997 to December 2007, 168 patients with portal hypertension of cirrhotic origin received an operation for gastroesophageal variceal bleeding. Of these, 90 patients received a splenocaval shunt plus a PCDV procedure (Combined Group) and the other 78 patients received a PCDV procedure only (PCDV Group). The procedure-related morbidity and mortality, rebleeding, encephalopathy, and survival rates were analyzed.

Results

Postoperative mortality was 3.3% in the combined group and 5.1% in the PCDV group (P > 0.05). Overall morbidity was 13.3% in the combined group and 15.4% in the PCDV group (P > 0.05). The rate for rebleeding, including variceal bleeding and gastropathy, was 5.1% in the combined group, which was significantly lower than that in the PCDV group, at 16.7% (P < 0.05). The incidence of encephalopathy was 6.63% in the combined group and 6.67% in the PCDV group (P > 0.05). The 1-, 3-, 5- and 10-year survival rates were 97.4, 91.7, 80.0, and 60.0% in the combined group and 96.7, 83.3, 73.3, and 53.3% in the PCDV group (P > 0.05).

Conclusions

The modified splenocaval shunt plus PCDV is a safe and effective procedure for the long-term control of variceal bleeding; the procedure may not only maintain the portal flow to the liver, but may also protect the liver function in cirrhotic patients. The better clinical outcome means that the procedure may be one of the best choices for treating portal hypertension of cirrhotic origin.     

Stent-grafts for the treatment of TIPS dysfunction:Fluency stent vs Wallgraft stent

AIM:To evaluate the clinical efficacy of an expanded polytetrafluoro-ethylene-covered Fluency stent compared with that of a polyethylene terephthalate-covered Wallgraft stent for the management of transjugular intrahepatic portosystemic shunt(TIPS)dysfunction.METHODS:A retrospective review of patients who underwent TIPS revision with stent-grafts between May 2007 and June 2011 was conducted.The patients were divided into two groups according to the stentgrafts implanted:the Fluency stent(Bard Incorporated,Karlsruhe,Germany)and the Wallgraft stent(Boston Scientific,Galway,Ireland).The primary patency rates were calculated and compared using the Kaplan-Meier method.RESULTS:A total of 73 patients were evaluated in this study:33 with Fluency stents and 40 with Wallgraft stents.The primary patency rates at 12 and 24 mo were 91% and 85%,respectively,in the Fluency stent group and 78% and 63%,respectively,in the Wallgraft stent group.The primary shunt patency rates after TIPS revision were significantly better with the Fluency stent than with the Wallgraft stent(P = 0.033).CONCLUSION:TIPS revision with the Fluency stent has higher medium-term patency rates than that with the Wallgraft stent.     

Risk factors for the exacerbation of esophageal varices or portosystemic encephalopathy after sustained virological response with IFN therapy for HCV-related compensated cirrhosis

Background

We aimed to identify risk factors contributing to the exacerbation of esophageal varices (EV) or portosystemic encephalopathy after hepatitis C virus (HCV) eradication with interferon (IFN) therapy in patients with compensated cirrhosis. Also, the prognosis after HCV eradication was analyzed.

Methods

Fifty-two patients with sustained virological response to IFN treatment for HCV-related compensated cirrhosis were enrolled in this retrospective cohort study.

Results

At the achievement of HCV eradication, in 31 of the 52 patients (60 %), feeding vessels for EVs (left gastric vein, posterior gastric vein, short gastric vein) were shown, and in 18 patients (35 %) there were extrahepatic portosystemic shunts (paraesophageal vein, paraumbilical vein, and splenorenal shunt). Although the HCV eradication was successful, significant improvements were not observed in portosystemic collateral vessels 1 year after HCV eradication, and EVs were exacerbated in 19 (36 %) patients. The cumulative 1- and 3-year rates of EV exacerbation were 13 % and 49 %, respectively. By multivariate analysis, the existence of feeding vessels for EVs at HCV eradication was an independent predictive factor for the exacerbation of EVs (P = 0.009). Seven patients who had an extrahepatic portosystemic shunt at HCV eradication developed portosystemic encephalopathy during follow up. The 1-, 3-, and 5-year incidences of portosystemic encephalopathy were 6, 21, and 34 %, respectively. The cumulative 5-year survival rate of the cohort was 81 %. Two patients died of hepatocellular carcinoma (HCC).

Conclusions

Our findings suggest that the existence of radical portosystemic collateral vessels at successful HCV eradication increases the risk of the exacerbation of EVs and the incidence of portosystemic encephalopathy in patients with HCV-related cirrhosis.     

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.     

Small intestinal bacterial overgrowth and delayed orocecal transit time in patients with cirrhosis and low-grade hepatic encephalopathy

Background

Hepatic encephalopathy (HE) is associated with poor prognosis in cirrhosis. Gut-derived nitrogenous substances play a role in pathogenesis of HE. The present study was conducted to assess small intestinal bacterial overgrowth (SIBO) and prolonged orocecal transit time (OCTT) in cirrhosis and low-grade HE.

Methods

In cross-sectional prospective study, 75 patients were divided into 3 groups: group 1 (no HE, n = 31), group 2 (minimal HE, n = 29), and group 3 (early/grade 1 HE, n = 15). Minimal HE (MHE) was diagnosed when psychometric hepatic encephalopathy score (PHES) was ≤5. Early HE was diagnosed, according to West Haven criteria. All patients underwent glucose hydrogen breath test (GHBT) for SIBO and lactulose hydrogen breath test (LHBT) for OCTT.

Results

A total of 29 patients (38.67 %) had MHE and 15 (20 %) had early HE. Prevalence of MHE in Child–Turcotte–Pugh (CTP) class A, B, and C was 33.3, 38.71, and 45 %, respectively, while SIBO was detected in 26 (34.67 %). Prevalence of SIBO was 12.5 % in CTP class A, 41.94 % in CTP class B, and 50 % in CTP class C. Five (16.13 %) patients in no HE group had SIBO as compared to 14 (48.28 %) in MHE group and 7 (46.67 %) in early HE group (p = 0.018). OCTT was 111.13 ± 13.95 min in patients with no HE as compared to 137.59 ± 14.80 min in patients with MHE and 150 ± 15.12 min in patients with early HE (p < 0.001). OCTT was significantly prolonged in patients with SIBO (145 ± 17.49 min) than in those without SIBO (120.71 ± 18.3 min) (p < 0.001).

Conclusion

SIBO and delayed OCTT are more common with MHE and early HE in patients with cirrhosis.     

Influence of different portal vein branches on hepatic encephalopathy during intrahepatic portal shunt via jugular vein

This letter is regarding the study titled ‘Targeted puncture of left branch of intrahepatic portal vein in transjugular intrahepatic portosystemic shunt (TIPS) to reduce hepatic encephalopathy’. Prior to the approval of TIPS dedicated stents (Viatorr stents) in China in October 2015, Fluency covered stents were typically used. As Fluency covered stents have a strong support force and axial elastic tension, a ‘cap’ may form if the stent is located too low at the end of the hepatic vein or too short at the end of the portal vein during surgery, leading to stent dysfunction. Since the blood shunted by the stent is from the main trunk of the portal vein, the correlation between the incidence of postoperative hepatic encephalopathy and the location of the puncture target (left or right portal vein branch) is worth discussion. Notably, no studies in China or foreign countries have proven the occurrence of left and right blood stratification after the accumulation of splenic vein and mesenteric blood flow in the main trunk of the portal vein in patients with cirrhotic portal hypertension.     

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.     

Short- and long-term clinical outcome after balloon-occluded retrograde transvenous obliteration: is pretreatment portal flow direction a predictive factor?

Purpose

To determine whether pretreatment portal flow direction can predict different clinical manifestations or prognosis after balloon-occluded retrograde transvenous obliteration (B-RTO) for gastric varices.

Methods

The subjects were 103 cirrhotic patients with medium- or large-grade gastric varices treated by B-RTO. Short- and long-term clinical outcomes were compared among patients with forward portal flow (F group) and those with reversed or to-and-fro portal flow (R group) on color Doppler sonography before B-RTO.

Results

Deterioration of liver function reserve 1 year after B-RTO was more frequent in the R group (34.7 %) than in the F group (11.1 %, p = 0.0251). Thrombotic disorders within 1 year after B-RTO were also more frequent in the R group (20.7 %) than in the F group (2.7 %, p = 0.0079). There was no significant difference in cumulative survival rate of Child class A patients between the two groups. In Child class B or class C patients, however, the cumulative survival rate was poorer in the R group (68.7, 30.5, and 30.5 % at 1, 5, and 9 years, respectively) than in the F group (94.9, 58.8, and 37.8 % and 1, 5, and 9 years, respectively; p = 0.0097).

Conclusions

Hemodynamic assessment of portal flow direction is important before B-RTO, and care should be taken to manage thrombotic disorders in the perioperative period in patients with reversed portal flow after B-RTO. Another treatment option might be preferred for gastric varices in Child classes B and C patients with reversed portal flow instead of B-RTO, which may have a poor prognosis.     

The Portosystemic Shunt Syndrome and Role of Shunt Embolization in the Management of Hepatic Encephalopathy

Purpose of Review

Portosystemic shunting (PSS) is a result of changes in hepatic hemodynamics where portal flow diverts away from the liver due to increased intrahepatic resistance from cirrhosis and is associated with hepatic encephalopathy (HE). Over time, increased PSS may directly lead to worsening liver failure because of severely decreased loss of effective portal inflow towards the liver and result in recurrent or persistent HE. This clinical scenario has been recently defined as “portosystemic shunt syndrome” and has been associated with poor clinical outcomes.

Recent Findings

The presence of PSS is common in patients with cirrhosis and increased PSS size appears to correlate with recurrent or persistent HE. Recent studies have shown that patients with Model for End-Stage Liver Disease (MELD) score <?11 have demonstrated high clinical benefit in recurrent or persistent HE when treated with shunt embolization.

Summary

There is a growing literature that demonstrates potential clinical benefit using PSS embolization for selected patients, particularly with MELD under 11, with recurrent or persistent HE. Further investigation into improved risk stratification in order to determine effective treatments is necessary as well as heightened detection of the portosystemic shunt syndrome in its earlier and possibly reversible stages.

     

Transjugular intrahepatic portosystemic shunt versus paracentesis plus albumin in patients with refractory ascites who have good hepatic and renal function: a prospective randomized trial

Background

Transjugular intrahepatic portosystemic shunt (TIPS) has recently been reported to be effective in the treatment of cirrhotic patients with refractory ascites. However, the clinical utility of TIPS in the subset of refractory ascitic patients with good hepatic and renal function is uncertain. The aim of this study was to compare the efficacy of TIPS to that of large-volume paracentesis in cirrhotic patients with refractory ascites who have good hepatic and renal function.

Methods

Sixty cirrhotic patients with refractory ascites who presented with a Child?CPugh score of <11, serum bilirubin of <3?mg/dl and creatinine of <1.9?mg/dl were assigned randomly to TIPS (n?=?30) or large-volume paracentesis plus albumin (n?=?30). The primary endpoint was survival. The secondary endpoints were response to treatment and development of hepatic encephalopathy.

Results

The baseline characteristics were similar in the two groups. Seventeen patients treated with TIPS and 21 treated with paracentesis died during the study period. The cumulative probabilities of survival at 1 and 2?years were 80 and 64% in the TIPS group and 49 and 35% in the paracentesis group (p?<?0.005). TIPS was significantly superior to paracentesis in the control of ascites (p?<?0.005). Treatment failure was more frequent in the paracentesis group, whereas the frequency of hepatic encephalopathy was greater in the TIPS group.

Conclusions

In cirrhotic patients with refractory ascites who have good hepatic and renal function, TIPS improves survival and provides better control of ascites than large-volume paracentesis.     

Transjugular intrahepatic portosystemic shunt--role in treating intractable variceal bleeding, ascites, and hepatic hydrothorax

Transjugular intrahepatic portosystemic shunt (TIPS) patency can be improved by the use of covered stents. Although this technical advance may lower the costs associated with TIPS, the overall role of TIPS in the management of portal hypertension may not change. Currently, bare metal TIPS is indicated in the treatment of acute refractory variceal hemorrhage, in the secondary prevention of variceal hemorrhage, for the management of ascites refractory to both medical management and large-volume paracentesis, and in the control of hepatic hydrothorax refractory to medical management.     

PTFE-covered stents improve TIPS patency in Budd-Chiari syndrome

Transjugular intrahepatic portosystemic shunt (TIPS) have been shown to be an efficient portal-systemic derivative treatment for Budd-Chiari syndrome (BCS) patients uncontrolled by medical therapy. However, the main drawback of TIPS for this condition is a very high rate of shunt dysfunction. Recently, polytetrafluoroethylene (PTFE)-covered stents have been shown to reduce the incidence of TIPS dysfunction in patients with cirrhosis. The aim of the study was to assess the incidence of TIPS dysfunction in 2 cohorts of BCS patients treated with bare or PTFE-covered stents. The study included 25 TIPS procedures (16 bare stents and 9 covered stents) with a median follow-up period of 20.4 months (range, 3.9-124.8). Fourteen of 16 patients (87%) receiving bare stents had TIPS dysfunction compared to 3 of the 9 patients (33%) receiving PTFE-covered stents (P = .005). The actuarial rates of primary patency in the bare-stent group were 19% at 1 year compared with 67% in the PTFE-covered stent group (P = .02; log-rank test). The number of additional interventional procedures to maintain TIPS patency was significantly greater in the bare-stent than in the PTFE-covered stent group (1.9 +/- 1.2 vs. 0.6 +/- 0.9; P = .007). The number of patients with clinical relapses was greater in the bare-stent group compared to the PTFE-covered stent group (13 vs. 5 episodes in 9 and 3 patients, respectively). In conclusion, PTFE-covered stents have a considerable advantage over bare stents for the TIPS treatment of BCS patients, with a lower dysfunction rate, a lower number of reinterventions, and fewer prosthesis requirements. PTFE-covered stents are preferable in patients with Budd-Chiari Syndrome.     

Transcatheter local thrombolysis in patients with extensive TIPS thrombosis

Background

Transcatheter local thrombolytic therapy in patients with portosplanchnic venous thrombosis has been used in few cases.

Case reports

Here, we present our single-center experience with transcatheter thrombolytic therapy in three patients with extensive refractory portal and transjugular intrahepatic portosystemic shunt (TIPS) thrombosis. Thrombolytic therapy was successful for all three patients. Two patients developed minor procedure-related bleeding.

Conclusion

Local thrombolysis could be proposed in case of TIPS thrombosis for patients in whom the venous flow cannot be restored by using conventional anticoagulant therapy and stent mechanical revision.     

Self Expandable Metal Stents for Anastomotic Stricture Following Liver Transplant

Background

Endoscopic treatment for biliary strictures with plastic stent placement has been used widely. The use of covered self-expandable metal stents (CSEMS) has been reported in anastomotic strictures post liver transplant. The aim of this study was to evaluate the efficacy of different CSEMS in these subjects.

Methods

A total of 55 patients with anastomotic stricture received CSEMS, which were removed after 3–4 months. There were 19 patients in group A (partially covered SEMS), 21 patients in group B (fully covered SEMS with fins) and 15 patients in group C (fully covered SEMS with flared ends). Technical success, stricture resolution, follows up, and complications were documented.

Results

CSEMS were successfully deployed in all 55 cases. There was no evidence of significant difference with regards to stricture resolution (14 [74 %] vs. 15 [71 %] vs. 9 [60 %] p = 0.6630, df = 2) or complications between groups. Stent-related complications were as follows: three in group A (2 migration, 1 occlusion), five in group B (4 occlusions, 1 migration), and one proximal migration in group C (p = 0.3894, df = 2). Three cases required surgery (hepatico-jejunostomy) due to refractory strictures.

Conclusions

The observed clinical success rate of CSEMS (70.4 %) proved to be below the reported one for multiple plastic stents, while no significant differences between CSEMS types were observed.     

Occlusion of portosystemic shunts improves hyperinsulinemia due to insulin resistance in cirrhotic patients with portal hypertension

Background

Liver cirrhosis (LC) is often complicated by hyperinsulinemia due to insulin resistance (IR), which is considered to be closely related to shunt formation and impaired liver function. This study evaluates whether balloon-occluded retrograde transvenous obliteration (B-RTO) can affect glucose and insulin metabolism in patients with LC.

Methods

Twenty-five cirrhotic patients (mean age = 69.6 years; female/male = 12/13; hepatitis C virus/alcohol/nonalcoholic steatohepatitis = 14/6/5; Child-Pugh’s class A/B = 10/15) with gastric varices and/or hepatic encephalopathy caused by portosystemic shunts (PSS) due to portal hypertension (PH) underwent B-RTO at our hospital. Testing was performed before and at 1 month after the procedure.

Results

Shunt occlusion resulted in a decrease in extrahepatic collateral blood flow and an increase in portal venous flow, as well as a dramatic improvement in hepatic function markers. In addition, B-RTO significantly decreased homeostasis model assessment (HOMA) of IR without a statistical decline of HOMA of β-cell function. The 75-g oral glucose tolerance test (75-OGTT) revealed that occlusion of PSS reduced both fasting immunoreactive insulin (IRI) levels and the area under the curve for IRI. However, no significant change in preprandial or postprandial plasma glucose levels was observed. Furthermore, according to the criteria of the American Diabetes Association, B-RTO led to an improved 75-OGTT profile in 58.3 % of patients who had impaired glucose tolerance or diabetes mellitus before the procedure.

Conclusions

Shunt occlusion improves IR-related hyperinsulinemia through increased portal venous flow, ameliorated liver function, and consequent augmented hepatic insulin clearance in cirrhotic patients with PH.