Abnormal portal venous flow at sonography predicts reduced survival after transjugular intrahepatic portosystemic shunt creation

PURPOSE: To determine if ultrasound (US) findings of abnormal portal venous flow (APVF) before transjugular intrahepatic portosystemic shunt (TIPS) creation are predictive of increased mortality risk after TIPS creation. MATERIALS AND METHODS: Retrospective review of 141 patients with US before TIPS creation was performed. APVF was defined by (i) bidirectional flow, (ii) thrombus, and/or (iii) reversed flow. Model for End-stage Liver Disease (MELD) scores were calculated. Kaplan-Meier survival curves and log-rank tests were used to detect survival differences based on the presence of APVF. Multivariate analysis included APVF, MELD, Child-Pugh class, International Normalized Ratio, creatinine level, total bilirubin level, ascites, hepatocellular carcinoma, low serum sodium level, congestive heart failure, and myocardial infarction. RESULTS: Twenty-six percent of patients (36 of 141) exhibited APVF on US before TIPS creation. Patients with APVF had lower survival rates at 3 and 6 months after TIPS procedures in comparison with patients with normal portal flow (P = .02 at 3 months and P = .04 at 6 months). In patients with MELD scores lower than 18, there was decreased survival based on APVF at 1, 3, and 6 months (P = .04, P = .02, and P = .04, respectively). In patients with MELD scores of 18 or greater, there was a trend for lower survival rates with APVF, but it did not reach statistical significance. Multivariate analysis of patients with MELD scores lower than 18 demonstrated only APVF and low serum sodium levels as independent predictors of outcome, with APVF resulting in a greater than six-fold increased likelihood of mortality. CONCLUSION: US findings of APVF before TIPS creation are associated with increased mortality risk and may be useful in identifying patients otherwise considered safe candidates based on MELD score alone.     

Portal-systemic myelopathy after transjugular intrahepatic portosystemic shunt creation: report of four cases.

The authors attempted to describe the clinical manifestations of portal-systemic myelopathy (PSM) after transjugular intrahepatic portosystemic shunt (TIPS) creation. PSM was developed in four of 212 (1.89%) patients who underwent TIPS procedures in our hospital. Three men and one woman, ranging in age from 41 to 56 years, with a history of posthepatitis cirrhosis and recurrent bleeding from gastroesophageal varices had intrahepatic shunts created with 10-mm-diameter Wallstents. Shunt patency was confirmed by color Doppler ultrasonography (US) in each patient after TIPS creation. Progressive spastic paraparesis involving the lower extremities occurred between 5 weeks and 5 months after TIPS creation in the four patients. Neurologic examination showed evidence of spasticity in all cases, with ankle clonus, extensor plantar responses, and lower extremity hyperreflexia. All sensory modalities remained intact. Cytologic examination of cerebrospinal fluid from each patient was normal. There was no evidence of spinal cord compression on the imaging studies. PSM is a rare syndrome that includes spastic paraparesis with intact sensation. Initially noted in patients who have undergone surgical placement of a portacaval shunt, it also may occur after TIPS creation.     

Detachable balloon-modified reducing stent to treat hepatic insufficiency after transjugular intrahepatic portosystemic shunt creation

A patient developed severe hepatic insufficiency after creation of a transjugular intrahepatic portosystemic shunt, which was treated unsuccessfully with a constrained Wallstent ("reducing stent"). After a failed attempt at occluding the shunt with an occlusion balloon, a detachable balloon was placed at the portal end of the constrained stent. This balloon-modified reducing stent reduced flow while maintaining shunt patency, and the patient's hepatic insufficiency improved. She went on to undergo successful liver transplantation several months later.     

A modified procedure for transjugular intrahepatic portosystemic shunt flow reduction

The authors present a modified transjugular intrahepatic portosystemic shunt (TIPS) flow reduction procedure to treat TIPS-related refractory hepatic encephalopathy, giving the results and follow-up on six patients. A 6-mm-diameter Uni Wallstent was introduced over a guide wire and deployed beyond the angulated portion of the TIPS. A Wallgraft was then introduced over the same guide wire, pushed through the Uni Wallstent coaxially, and deployed in the TIPS. All cases were technically and clinically successful. There were no deaths in the first month after the procedure. In this study, three patients had more than 1 year's patency.     

腔内超声辅助下经颈静脉肝内门体分流术1例

肝硬化合并反复上消化道出血、顽固性腹水已经成为经颈静脉肝内门体分流术(TIPS)的适应证.国外近年来逐渐开展了腔内超声(IVUS)辅助下TIPS,取得了良好效果.我们尝试使用IVUS辅助进行TIPS,现报道如下.临床资料患者女,58岁.因反复黑便1年余就诊.2015年5月及2016年1月患者分别解柏油样便,量共500～600ml,无呕血、腹痛、黄疸等症状,予内科对症治疗后症状均缓解.     

Polytetrafluoroethylene-covered nitinol stent-graft for transjugular intrahepatic portosystemic shunt creation: 3-year experience

PURPOSE: To prospectively evaluate the use of a recently developed expanded polytetrafluoroethylene (PTFE)-covered nitinol stent-graft in preventing the need for repeated intervention after transjugular intrahepatic portosystemic shunt (TIPS) creation. MATERIALS AND METHODS: Fifty-three consecutive patients underwent TIPS procedures between January 2000 and February 2002. Minimum patient follow-up was 9 months (mean, 16.3 months). Fifty-six stent-grafts were implanted in 53 patients; eight of the devices were 8 mm in diameter and 48 were 10 mm in diameter. The stent length varied from 4 to 7 cm. Indications for the procedure included recurrence of bleeding after sclerotherapy (28 patients with cirrhosis, one patient without), refractory ascites or hydrothorax (21 patients with cirrhosis, one patient without), and Budd-Chiari syndrome (two patients). RESULTS: A technical success rate of 100% was obtained, with an early clinical success rate of 96.2%. During the follow-up period, the recurrence rate was 3.4% (one of 29 patients) for bleeding and 9.0% (two of 22 patients) for ascites. Shunt malfunction occurred in nine of 53 patients (16.9%); in one of these nine patients, shunt occlusion was evident after revision, and a parallel shunt was created. The 1-year primary and secondary patency rates were 83.8% and 98.1%, respectively. In this series, the incidence of encephalopathy (included even as a single short-lived episode) was 47.1% (25 of 53 patients). The 30-day mortality rate was 3.8% (two of 53), and the late mortality rate was 17.3% (eight of 46), excluding seven patients who underwent transplantation. CONCLUSION: The new PTFE-covered nitinol stent-graft used appears to be excellent in preventing the need for repeated interventions. A primary patency rate of 83.8% and a secondary patency rate of 98.1% were achieved.     

Predictors of early mortality after transjugular intrahepatic portosystemic shunt creation for the treatment of refractory ascites

PURPOSE: Currently there is no consensus regarding a target portosystemic gradient (PSG) after transjugular intrahepatic portosystemic shunt (TIPS) creation for the treatment of refractory ascites. The goal of this study was to examine whether the PSG after TIPS creation is predictive of subsequent mortality risk. MATERIALS AND METHODS: Retrospective review of 99 patients who underwent successful TIPS creation for refractory ascites between January 1997 and December 2004 was performed. Follow-up consisted of clinic and emergency department visits, hospital admissions, and radiology studies (mean, 7 months). Comparison of baseline patient characteristics was performed between survivors and patients who died. Survival rates were calculated with use of the Kaplan-Meier method and compared with the log-rank test based on Model for End-stage Liver Disease (MELD) scores and PSGs before and after TIPS creation. Univariate and multivariate analysis of potential predictors of mortality was performed with Cox proportional-hazards analysis. RESULTS: Sixteen patients died during follow-up (mean, 1.9 months after TIPS creation). The patients who died had significantly higher MELD scores before TIPS creation than did survivors (P = .04) and significantly lower PSGs before and after TIPS creation (P = .02 and P = .03, respectively). Survival rates were significantly lower for patients with higher MELD scores (P = .01) and lower PSGs before TIPS creation (P = .01) and after TIPS creation (P = .01). Multivariate analysis demonstrated that Child class C cirrhosis, MELD score greater than 25, and PSG less than 8 mm Hg after TIPS creation were the most significant predictors of mortality (increased likelihood by factors of 4, 5, and 3, respectively). CONCLUSION: Excessive reduction of the PSG along with severe liver dysfunction is associated with an increased risk of mortality after TIPS creation in patients presenting with refractory ascites.     

Intraparenchymal anesthesia infiltration during transjugular intrahepatic portosystemic shunting.

The authors describe a technique for administration of anesthetic to the area of the transparenchymal tract during transjugular percutaneous transhepatic portosystemic shunting. Seven of the eight patients in whom the technique was used did not experience pain during balloon dilation of the tract, and one patient experienced only minimal pain. The technique allows good pain control in patients with severe liver failure and resultant inability of the liver to metabolize pharmaceuticals.     

TIPS中8mm直径覆膜支架直用的临床研究

目的评价在TIPS中应用8mm直径覆膜支架的临床效果。方法对19例伴有食管胃底静脉曲张破裂出血和(或)难治性腹水的门脉高压症患者行TIPS术,术中应用8mm直径的覆膜支架,术后观察临床症状改善程度,并进行定期影像学和实验室检查,以评价疗效。结果所有患者均成功完成TIPS术,技术成功率100%,术中未出现并发症。术后平均随访13.5个月(2.7～28个月),1例(1/19,5.3%)原有肝性脑病加重;2例(10.5%)再次出血;腹水改善及治愈率为66.7%(12/18);16例患者进行了6个月的随访,初次开通率100%,8例患者随访12个月,初次开通率87.5%。结论在TIPS术中应用8mm直径覆膜支架在保证有效分流量,提高术后分流道开通率的同时,可以降低肝性脑病的发生率。     

Survival after elective transjugular intrahepatic portosystemic shunt creation: prediction with model for end-stage liver disease score

PURPOSE: To evaluate the ability of a model of end-stage liver disease (MELD) score to predict survival in a diverse group of patients who underwent elective transjugular intrahepatic portosystemic shunt (TIPS) creation in two tertiary care institutions. MATERIALS AND METHODS: Patients who underwent elective TIPS creation in two institutions between May 1, 1999, and June 1, 2002, were selected. Patients who underwent emergency TIPS creation were excluded. One hundred sixty-six patients met the inclusion criteria. The MELD score was computed and compared with the survival rate. Survival curves were estimated with Kaplan-Meier product limit estimates and were compared with the log-rank test. Accuracy of the model was evaluated with the c statistic. RESULTS: The survival rate for all patients was 88.4% at 30 days, 78.1% at 3 months, and 71.8% at 6 months. Significantly lower survival rates were found in patients with MELD scores of 18 or more in comparison to those with MELD scores of 17 or less (P =.001). The c statistic for prediction of 3-month survival on the basis of the MELD score was 0.76. The early (30-day) death rate for this series was 11.4%. There was a significant difference in the 30-day mortality rate between patients with MELD scores of 17 or less and those with scores of 18 or more (P =.001). Patients who underwent TIPS creation for the management of refractory ascites had a significantly lower survival rate in comparison to that for the management of variceal bleeding (P =.001). CONCLUSION: Results confirm that after elective TIPS creation, patients with a MELD score of 18 or more have a significantly lower 3-month survival rate than do those with a MELD score of 17 or less.     

Intentional occlusion of a transjugular intrahepatic portosystemic shunt

The transjugular intrahepatic portosystemic shunt (TIPS) procedure is a well-described means of treating portal hypertension and its complications. Occasionally, the consequences of this shunt prompt the desire for its subsequent obliteration. We report one unsuccessful and one successful method of TIPS occlusion. Key words: TIPS, complications-Occlusion-Thrombosis-Balloon occlusion catheter-Amplatz spi-der-Embolization coil     

Indicators for longterm survival after the transjugular portosystemic intrahepatic shunt procedure

Introduction. Complications of portal hypertension can be treated effectively by the transjugular intrahepatic portosystemic shunt procedure (TIPS). Indicators for long time survival after TIPS implantation are presented. Patients and Methods. From September 1992 until May 1995 forty-two consecutive patients (26 male, 16 female) with liver cirrhosis complicated by variceal bleeding (n = 27) or refractory ascites (n = 15) were treated by TIPS implantation and followed up clinically in a prospective, open study. The follow up period range was 5–3278 days. Univariate and multivariate regression analyses were applied to determine the correlation between patient characteristics and long term survival after TIPS implantation. The indicators were dichotomized at the median. The outcome variable was dichotomized. Positive outcome was defined as survival longer than three years without liver transplantation, all other outcomes were regarded as negative. Survival rates were determined for all patients and for subgroups according to results of the regression analyses. Results. During follow-up liver transplantation was performed in 8 of the 42 patients. 29 patients died. Mean survival was 1440 (±1060) days. Survival after one, two, three and six years was 76% (n = 32), 69%(n = 29), 62% (n = 26) and 38% (n = 16), respectively. The multivariate regression analysis revealed a significant better survival related to a prothrombine time >70%, MEGX synthesis >30 μg/l, and ICG clearance <13 min. Patients with high ICG clearance (OR = 1.9), high MEGX synthesis (OR = 5.0) or high prothrombine time scores (OR = 5.2) had a significantly longer survival. This survival advantage increased with follow up time. Conclusion. Longterm survival after TIPS implantation is influenced by the initial liver function. This survival advantage increases during follow up and is most pronounced after 6 years.     

经颈静脉肝内门体分流术后肝性脑病研究进展

【摘要】 经颈静脉肝内门体分流术（TIPS）已在临床上大规模应用。TIPS治疗肝硬化门静脉高压所致并发症效果显著,但术后肝性脑病（HE）发生率高。该文就TIPS术后HE发生机制、分型和分级、危险因素及治疗作一综述。     

Safety and efficacy of transjugular intrahepatic portosystemic shunt creation for the treatment of hepatic hydrothorax

PURPOSE: To evaluate safety and efficacy of transjugular intrahepatic portosystemic shunt (TIPS) creation for hepatic hydrothorax (HHyd). MATERIALS AND METHODS: Twenty-one patients underwent TIPS creation for HHyd. A prospective TIPS database and medical records were reviewed. Clinical and radiographic outcomes were recorded as complete (symptom/effusion resolution), partial (improved symptoms/effusion), or none. Data patterns were examined with chi(2) tests and Kaplan-Meier analysis. RESULTS: Patients included 12 women and nine men, with a mean age of 56 years, all with Child class B (n = 7) or C (n = 14) disease. The technical success rate was 100%. Mean follow-up was 223 days. Twenty-nine percent (six of 21) died within 30 days of TIPS creation, 10% (two of 21) underwent transplantation within 30 days, and 62% (13 of 21) survived beyond 30 days. Data were incomplete in two patients. Clinical response was classified as complete in 63% (12 of 19), partial in 11% (two of 19), and none in 26% (five of 19). Radiographic response was classified as complete in 30% (six of 20), partial in 50% (10 of 20), and none in 20% (four of 20). Nonresponders had multisystem organ failure, and all but one died within 30 days. However, of the 13 patients surviving longer than 30 days, 10 (77%) had a complete clinical response. CONCLUSION: TIPS is a relatively safe and effective method of controlling HHyd. The majority of patients experienced improvement or resolution of clinical symptoms with a variable reduction in the quantity of pleural fluid. There was a tendency among nonresponders to die within 30 days.     

个体化经颈静脉肝内门体分流术血流动力学模拟研究

目的 建立个体化肝硬化门静脉高压模型,比较经颈静脉肝内门体分流术（TIPS）不同分流方案的差异。方法 选取1例肝硬化门静脉高压患者并测量数据。采用MIMIC软件建立9种分流方案模型,通过Fluent软件计算后导入计算流体力学（CFD）-Post软件行后处理。比较不同分流方案中门静脉压下降比、门静脉入肝血流比、分流道内来自肠系膜上静脉血流比,采用综合评价系数G进行优劣性评价。结果 分流道位置相同时,分流道直径越大,门静脉压下降越多、门静脉入肝血流越少,其中分流道直径为6 mm时不能充分降压。分流道直径相同时,分流道内来自肠系膜上静脉血流比为门静脉右支分流>主干分流>左支分流。G值在门静脉左支8 mm直径分流方案中最高。结论 TIPS术经门静脉左支构建直径为8 mm分流道方案的预期效果最佳。