Transjugular Intrahepatic Portosystemic Shunt in Nonliver Transplant Candidates: Is it Indicated?

Background: Transjugular intrahepatic portosystemic shunt (TIPS) is an effective treatment of severe portal hypertension complications. Liver transplantation (LT) candidacy has not been a prerequisite to TIPS placement in some medical centers. Objectives: To investigate the outcome and survival of non-LT candidates after TIPS. Methods: From November 1991 to February 1994, all patients referred for TIPS placement were evaluated for LT candidacy. Exclusions for LT included: age (>70 yr), other significant medical conditions, or noncompliance. Indications for TIPS included refractory variceal bleeding during an acute bleed, recurrent bleeding after more than or equal to four sessions of sclerotherapy, or refractory ascites. Results: Sixty patients received TIPS. Nineteen were considered non-LT candidates. Over a 2-yr follow-up, 14 of these non-LT candidates did not survive. Their median age was 63.5 compared with 56.5 yr for LT candidate nonsurvivors ( p < 0.05). Among the 14 non-LT candidate nonsurvivors, 10 were Childs C class, and eight had emergent TIPS placement. The 2-year mortality rate was 84% for non-LT candidates versus 24% for LT candidates. Median survival time for non-LT candidates was 2.6 months compared with 20 months in the LT candidates ( p < 0.001). Only one death was due to a TIPS-related complication. Conclusions: TIPS is unquestionably an advancement in the management of patients with portal hypertension complications. Non-LT candidates, compared with LT candidates, tended to be older and of a Child-Pugh C class, and they had survival rates often less than 90 days post-TIPS. Given these high mortality rates, we need to address whether TIPS is indicated in these non-LT candidates.     

Transjugular intrahepatic portosystemic shunt in liver transplant recipients

AIM： To evaluate the efficacy of transjugular intrahepatic portosystemic shunts （TIPSs） after liver transplantation （LT）. METHODS： Between November 1996 and December 2005, 10 patients with severe recurrent hepatitis C virus infection （n = 4）, ductopenic rejection （n = 5） or portal vein thrombosis （n = 1） were included in this analysis. Eleven TIPSs （one patient underwent two TIPS procedures） were placed for management of therapy-refractory ascites （n = 7）, hydrothorax （n = 2） or bleeding from colonic varices （n = 1）. The median time interval between LT and TIPS placement was 15 （4-158） mo. RESULTS： TIPS placement was successful in all patients. The mean portosystemic pressure gradient was reduced from 12.5 to 8.7 mmHg. Complete and partial remission could be achieved in 43% and 29% of patients with ascites. Both patients with hydrothorax did not respond to TIPS. No recurrent bleeding was seen in the patient with colonic varices. Nine of 10 patients died during the study period. Only one of two patients, who underwent retransplantation after the TIPS procedure, survived. The median survival period after TIPS placement was 3.3 （range 0.4-20） too. The majority of patients died from sepsis with multiorgan failure. CONCLUSION： Indications for TIPS and technical performance in LT patients correspond to those in non-transplanted patients. At least partial control of therapy-refractory ascites and variceal bleeding could be achieved in most patients. Nevertheless, survival rates were disappointing, most probably because of the advanced stages of liver disease at the time of TIPS placement and the high risk of sepsis as a consequence of immunosuppression.     

Application of the model for end-stage liver disease score for transjugular intrahepatic portosystemic shunt in cirrhotic patients with refractory ascites and renal impairment

BACKGROUND AND AIMS: Transjugular intrahepatic portosystemic shunt (TIPS) can manage severe complications of portal hypertension. The Mayo Clinic group proposed a so-called model for end-stage liver disease (MELD) to predict survival in cirrhotic patients. High creatinine levels determine a decrease in calculated survival chances with MELD but functional renal disease can be reversed by TIPS. The aim of this study was to evaluate the efficacy of MELD in predicting survival after TIPS, particularly in patients with refractory ascites associated with functional renal failure. METHODS: This retrospective analysis examines 68 cirrhotic patients who underwent elective TIPS: 48 patients had refractory ascites and 20 patients had recurrent variceal bleeding. Multivariate analysis was used to establish predictive parameters of survival after TIPS. Kaplan-Meier and log-rank tests were used to compare survival rates observed in our patients with those evaluated with the MELD score. RESULTS: The age of patients was the only variable shown to have an independent value in predicting survival after TIPS. In patients undergoing shunting for refractory ascites, the survival rates at 6, 12 and 24 months after the procedure were significantly higher than expected with the MELD score. CONCLUSIONS: The MELD scale may underestimate the efficacy of TIPS in end-stage cirrhotic patients with refractory ascites and functional kidney dysfunction. Further studies are needed to confirm this finding and ultimately to assess a correction factor to better predict survival after TIPS in patients with functional renal impairment.     

Determinants of mortality in patients with advanced cirrhosis after transjugular intrahepatic portosystemic shunting

BACKGROUND & AIMS: Transjugular intrahepatic portosystemic shunt (TIPS) placement is effective in the treatment of complications of portal hypertension. This study evaluated the predictors of mortality in a group of cirrhotic patients with advanced liver disease after placement of TIPS. METHODS: A retrospective analysis of all patients undergoing TIPS placement over a 21/2-year period was undertaken. RESULTS: Fifty-six patients had TIPS placement for variceal hemorrhage, 49 for refractory ascites, and 24 for hepatic hydrothorax (total, 129). Of 21 variables available before TIPS placement, variceal hemorrhage requiring emergent TIPS placement (relative risk [RR], 37.5; 95% confidence interval [CI], 5.4-259) and bilirubin concentration > 3.0 mg/dL (RR, 5.4; 95% CI, 1.4-10.2) were independent predictors of 30-day mortality. Variceal hemorrhage requiring emergent TIPS placement (hazard ratio [HR], 5.1, 95% CI, 2. 2-9.1), alanine aminotransferase level > 100 IU/L (HR, 2.5; 95% CI, 1.2-5.5), bilirubin level > 3.0 mg/dL (HR, 2.6; 95% CI, 1.1-4.6), and pre-TIPS encephalopathy unrelated to bleeding (HR, 2.2; 95% CI, 1.2-4.8) independently predicted death during the follow-up period. A model was developed that separated the patients into 3 groups with significantly different survival rates. CONCLUSIONS: A clinical index consisting of 4 pre-TIPS variables can reliably predict outcome after TIPS.     

The transjugular intrahepatic portosystemic shunt for the management of cirrhotic refractory ascites

Cirrhotic ascites results from sinusoidal hypertension and sodium retention, which is secondary to a decreased effective arterial blood volume. Transjugular intrahepatic portosystemic shunt (TIPS) placement is currently indicated in cirrhotic patients with refractory ascites who require large-volume paracentesis (LVP) more than two or three times per month. TIPS placement is associated with normalization of sinusoidal pressure and a significant improvement in urinary sodium excretion that correlates with suppression of plasma renin activity, which is, itself, indicative of an improvement in effective arterial blood volume. Compared with serial LVP, placement of an uncovered TIPS stent is more effective at preventing ascites from recurring; however, increased incidence of hepatic encephalopathy and shunt dysfunction rates after TIPS placement are important issues that increase its cost. Although evidence suggests that TIPS placement might result in better patient survival, this needs to be confirmed, particularly in light of the development of polytetrafluoroethylene-covered stents. Favorable results apply to centers experienced in placing the TIPS, with the aim being to decrease the portosystemic gradient to <12 mmHg but >5 mmHg. This article reviews the pathophysiologic basis for the use of a TIPS in patients with refractory ascites, the results of controlled trials comparing TIPS placement (using uncovered stents) versus LVP, and a systematic review of predictors of death after TIPS placement for refractory ascites.     

Transjugular intrahepatic portosystemic shunt placement for refractory ascites: a single-centre experience

Abstract

Background. The presence of refractory ascites is a common indication for transjugular intrahepatic portosystemic shunt (TIPS). Different models have been proposed for the prediction of survival after TIPS. The aim of this study was to evaluate the predictive factors associated with patients' survival after TIPS placement for refractory ascites. Methods. Data from all consecutive patients undergoing TIPS placement in our center for refractory ascites between February 2003 and January 2008 were prospectively recorded. Results. Seventy-three patients (52M/21F; 57 ± 10 years) met the inclusion criteria; mean follow-up was 17 ± 2 months. Mean MELD value, before TIPS placement, was 15.7 ± 5.3. TIPS placement led to an effective resolution of refractory ascites in 54% of patients (n = 40) with no significant increase in severe portosystemic encephalopathy. The 1-year survival rate observed was 65.7%, while the overall mortality was 23.3% (n = 17) with a mean survival of 17 ± 14 months. MELD score (B = 0.161, p = 0.042), basal AST (B = 0.020, p = 0.090), and pre-TIPS HVPG (B = 0.016, p = 0.093) were independent predictors of overall mortality, while MELD (B = 0.419, p = 0.018) and HVPG (B = 0.223, p = 0.060) independently predicted 1-year survival. ROC curves identified MELD ≥ 19 and HVPG ≥ 25 mmHg as the best cut-off points for the prediction of 1-year mortality. Conclusions. TIPS is an effective treatment for refractory ascites in cirrhotic patients, leading to an effective ascites control in more than half patients. Improvement in patients' selection criteria could lead to better outcome and survival after this procedure. Liver function (MELD), presence of active necroinflammation (AST), and portal hypertension (HVPG) are independent predictors of patients' outcome after TIPS.     

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

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

Predictors of clinical response to transjugular intrahepatic portosystemic shunt (TIPS) in cirrhotic patients with refractory ascites

OBJECTIVE: Transjugular intrahepatic portosystemic shunt (TIPS) is used increasingly as a treatment for refractory ascites. The aim of the present study was to determine the prognostic value of different parameters in predicting a favorable evolution following TIPS in a cohort of 53 cirrhotic patients without organic renal disease and with refractory ascites. METHODS: Patients were classified as good responders if they survived more than 6 months, without severe chronic hepatic encephalopathy and with good control of ascites. The prognostic value for a good outcome was evaluated using age, creatinine clearance, plasma renin activity, plasma aldosterone, and Pugh score. RESULTS: Good control of ascites was obtained in 90%. The cumulative survival rate was 54% at 6 months, 48% at 1 yr, and 39% at 2 yr. The vast majority of patients died of complications of hepatic insufficiency. Severe chronic hepatic encephalopathy developed in 26%. Overall, a good clinical response was observed in 47%. Creatinine clearance was identified as the only pre-TIPS factor to be significantly and independently associated with a good clinical response to TIPS for refractory ascites. A good clinical response was observed in 57% of patients with a creatinine clearance >36 ml/min compared to 9% of those with a clearance <36 ml/min (p < 0.01). This cutoff point in creatinine clearance had a sensitivity of 96% and a specificity of 36%; positive predictive and negative predictive values were 57% and 90%, respectively. CONCLUSIONS: TIPS might be useful for the treatment of refractory ascites in cirrhotic patients without severe renal function impairment. However, the TIPS usefulness still has to be demonstrated compared to large volume paracentesis or Leveen shunt. In patients with poor renal function or with liver failure after TIPS, liver transplantation should be considered.     

Prognosis Assessment of Cirrhotic Patients with Refractory Ascites Treated with a Peritoneovenous Shunt

Objective: The role of peritoneovenous shunt in the management of refractory ascites has not been clearly established. The aim of this study was to determine readily accessible predictive survival factors in cirrhotic patients with refractory ascites treated with a peritoneovenous shunt.
Methods: We studied a cohort of 100 cirrhotic patients with refractory ascites who underwent peritoneovenous-shunt placement in a university-based reference hospital.
Results: The estimated median survival of patients after shunt placement was 11 months (95% CI, 7-14 months). Multivariate analysis based on the proportional hazards model disclosed four independent variables associated with poor survival: high Pugh score, nonalcoholic etiology, low ascitic fluid protein concentration, and history of spontaneous bacterial peritonitis.
Conclusions: Mortality of cirrhotic patients treated with a peritoneovenous shunt can be determined by a prognostic index using four easily available variables. Such a prognostic index, once prospectively validated, could be used as an adjunct in planning treatment of cirrhotic patients with refractory ascites.     

Effects of ascites resolution after successful TIPS on nutrition in cirrhotic patients with refractory ascites

OBJECTIVE: Malnutrition is common in patients with decompensated cirrhosis and refractory ascites. The use of transjugular intrahepatic portosystemic stent shunt (TIPS) is effective in eliminating ascites. The purpose of this study was to investigate the effect of TIPS and resolution of refractory ascites on the nutritional status of patients with decompensated cirrhosis. METHODS: Fourteen consecutive patients with refractory ascites and a Pugh score of 9.0+/-0.5 had a TIPS insertion. Biochemical data, resting energy expenditure (REE), total body nitrogen (TBN), body potassium (TBK), body fat (TBF), muscle force (MF), and food intake were recorded before TIPS, and at 3 and 12 months after the procedure. RESULTS: Ten patients completed the study. Baseline values for REE, TBN, TBF, MF, and energy intake were below normal at baseline. There was a significant increase in dry weight, TBN, and REE at 3 and 12 months compared with baseline. TBF improved significantly at 12 months. There was a trend toward an increase in energy intake (p = 0.072). There was no change in protein intake, TBK, MF, and Pugh score. CONCLUSION: In cirrhotic patients with refractory ascites, resolution of the ascites after TIPS placement resulted in improvement of several nutritional parameters, especially for body composition.     

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.     

The role of transjugular intrahepatic portosystemic shunt (TIPS) in the management of portal hypertension

Transjugular intrahepatic portosystemic shunt (TIPS) is an interventional radiology technique that has shown a 90% success rate to decompress the portal circulation. As a non-surgical intervention, without requirement for anesthesia and very low procedure-related mortality, TIPS is applicable to severe cirrhotic patients, who are otherwise untreatable, for example, nonsurgical candidates. TIPS constitutes the most frequently employed tool to achieve portosystemic shunting. TIPS acts by lowering portal pressure, which is the main underlying pathophysiologic determinant of the major complications of cirrhosis. Regarding esophagogastric variceal bleeding, TIPS has excellent hemostatic effect (95%) with low rebleeding rate (<20%). TIPS is an accepted rescue therapy for first line treatment failures in 2 settings (1) acute variceal bleeding and (2) secondary prophylaxis. In addition, TIPS offers 70% to 90% hemostasis to patients presenting with recurrent active variceal bleeding. TIPS is more effective than standard therapy for patients with hepatic venous pressure gradient >20mm Hg. TIPS is particularly useful to treat bleeding from varices inaccessible to endoscopy. TIPS should not be applied for primary prophylaxis of variceal bleeding. Portosystemic encephalopathy and stent dysfunction are TIPS major drawbacks. The weakness of the TIPS procedure is the frequent need for endovascular reintervention to ensure stent patency. The circulatory effects of TIPS are an attractive approach for the treatment of refractory ascites and hepatorenal syndrome, yet TIPS is not considered first line therapy for refractory ascites owing to unacceptable incidence of portosystemic encephalopathy. Pre-TIPS evaluation taking into account predictors of outcome is mandatory. The improved results achieved with covered-stents might expand the currently accepted recommendations for TIPS use.     

Prognosis of patients with ascites after PleurX insertion: an observational study

Objective: To evaluate the safety of PleurX in cirrhotic patients with refractory ascites.

Methods: We prospectively registered patients who received a PleurX catheter cirrhosis-associated refractory ascites at our department from July 2015 to November 2016. Our control group consisted of matched cirrhotic patients with refractory ascites treated with large volume paracentesis (LVP) and patients with malignant ascites treated with PleurX during the same period.

Results: We included 25 patients with cirrhosis-related ascites (7 in PleurX group) and 17 with malignant ascites (14 in PleurX group). Of these, six patients had hepatocellular carcinoma and cirrhosis (5 in PleurX group). None were eligible for insertion of a TIPS or liver transplantation. The maximum duration of follow-up was (480 days) in the PleurX group and 366 days in the LVP group (median 84 and 173 days, respectively). There was no difference in mortality when comparing PleurX with LVP treatment (hazard ratios: 3.0 and 1.0, p?=?.23 and .96, respectively). Mortality was higher in patients with malignant ascites (p=?.01). We found no significant differences in adverse events (incl. spontaneous bacterial peritonitis) or in P-albumin, P-creatinine and P-sodium between the groups.

Conclusion: PleurX insertion for the treatment of refractory ascites in cirrhotic patients appears to be safe. Prospective randomized trials are necessary in order to confirm these findings.     

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 in the management of complications of portal hypertension

Transjugular intrahepatic portosystemic shunt (TIPS) is a commonly used approach for managing many complications of portal hypertension. It is an attractive option due to its relative ease of creation (> 90% success rate) and the availability at most hospitals of an interventional radiologist capable of performing the procedure. TIPS is the preferred approach to control acutely bleeding esophageal or gastric varices that cannot be controlled with medical management. It is also now preferred to surgical shunts for preventing rebleeding in patients who rebleed despite adequate medical management. TIPS is more effective than large-volume paracentesis in controlling refractory cirrhotic ascites, with possibly a slight survival benefit but also increased encephalopathy. TIPS should be used to control refractory ascites in patients who cannot be managed with large-volume paracentesis. The role of TIPS in the treatment of hepatorenal syndrome is unclear; currently only patients with type 2 hepatorenal syndrome should be considered candidates for TIPS.     

Transjugular intrahepatic portosystemic shunt for cirrhosis and ascites: Effects in patients with organic or functional renal failure

BACKGROUND: A transjugular intrahepatic portosystemic shunt (TIPS) is increasingly being used for treatment of patients with refractory ascites and functional renal failure. In contrast, organic renal disease is commonly considered a relative contraindication for TIPS placement. The aim of this pilot study was to investigate the effects of TIPS in patients with refractory ascites and organic or functional renal impairment. METHODS: A TIPS was placed for refractory or intractable ascites in 10 consecutive patients with liver cirrhosis and impaired renal function (serum creatinine > 1.5 mg/100 ml). Four of them had organic kidney disorders. Of these patients, three had moderate renal impairment, and one had end-stage renal disease and needed hemodialysis every other day. The other six patients had functional renal impairment due to the underlying liver disease. RESULTS: TIPS was effective in reducing ascites in 8 of 10 patients, including all patients with organic renal disease. Furthermore, after TIPS the renal function improved in all patients. Serum creatinine and serum urea levels decreased significantly from 1.8 +/- 0.1 to 1.5 +/- 0.1 mg/100 ml (P < 0.05) and from 107 +/- 13 to 78 +/- 14 mg/100 ml (P < 0.05), respectively. The renal function of the three patients with organic renal failure improved similarly, as observed in the six patients with functional renal failure. In the patient on hemodialysis, TIPS was effective in reducing the frequency of paracenteses. CONCLUSION: TIPS may be useful in patients with functional and in patients with organic renal disease, resulting in improvement of ascites and renal function.     

Transjugular intrahepatic portosystemic shunt in five children with cystic fibrosis: long-term results

BACKGROUND/AIMS: The aim of this study was to report results of TIPS (transjugular intrahepatic portosystemic shunt) in 5 consecutive children with cystic fibrosis and monitor long-term follow-up results. METHODOLOGY: Five cystic fibrosis patients with multinodular cirrhosis of the liver and complications of portal hypertension (repeated variceal bleeding refractory to endoscopic treatment) underwent TIPS creation. There were 3 males and 2 females aged 8 to 18 years (median 14 yrs), their weight range was 27-51 (median 40) kg. A routine TIPS technique was used. The patients were followed by ultrasonography. RESULTS: The TIPS was successfully performed in all five patients. The mean portosystemic pressure gradient was reduced from 17 to 10 mmHg. There were no deaths related to the procedure. No clinical or laboratory signs of bleeding into the gastrointestinal tract were observed in any patient within the first 30 days following TIPS. There was recurrent bleeding 6 times and asymptomatic stenoses were revealed by ultrasonography 15 times during a follow-up period of 15-81 (median 70) months. All stenoses were successfully dilated. One patient had liver transplantation 15 months after TIPS. Two patients died 6.7 years and 4.5 years following the placement of TIPS due to respiratory insufficiency. CONCLUSIONS: Symptomatic portal hypertension was successfully managed with TIPS in long-term follow-up; multiple reinterventions were required for shunt stenoses. TIPS served as a bridge to liver transplantation in one case.     

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 Portal Systemic Shunt for the Management of Symptomatic Cirrhotic Hydrothorax

Objective: To investigate the safety and effectiveness of performing transjugular intrahepatic portal systemic shunt (TIPS) for the management of symptomatic cirrhotic hydrothorax in patients with advanced cirrhosis. Methods: TIPS was performed by standard technique after portal vein patency had been established by ultrasound. Portal-hepatic vein pressure gradient was determined before and after placement of the shunt. A portal-hepatic vein gradient of less than 12 mm Hg was the treatment goal. Results: Five patients underwent TIPS placement over an 11-month period. Despite use of diuretics, the patients had required a median of seven thoracenteses (range 2–11) for control of symptoms preceding placement of the shunt. A TIPS was placed without serious complications in all live patients. In two patients, insertion of the shunt was associated with no further need for thoracentesis. The other three patients had recurrent need for thoracentesis. These three patients were found to have occluded shunts which were rendered patent by angiopiasty and/or urokinase. Subsequently, two required no further thoracentesis, whereas, in the other patient, the need for thoracentesis was decreased dramatically. Conclusions: TIPS appears to be a safe and useful technique for the management of patients with symptomatic cirrhotic hydrothorax that is refractory to medical therapy. Recurrence of the pleural effusion after placement of TIPS may be an indication of shunt occlusion.