Association of Hemostatic Blood Product Transfusion With Clinical Outcomes in Esophageal Variceal Bleeding.

Role of transjugular intrahepatic portosystemic shunt in the treatment of portal hypertension in pediatric patients.

PULMONARY HYPERTENSION FOLLOWING TRANSJUGULAR INTRAHEPATIC PORTOSYSTEMIC SHUNT (TIPS) PLACEMENT DUE TO NEUROHORMONAL VASOACTIVE CAUSES

Therapies for bleeding gastric varices: is the fog starting to clear?

Transjugular intrahepatic portosystemic shunt (TIPS) placement is a procedure that can effectively treat complications of portal hypertension, such as variceal bleeding and refractory ascites. However, there have been no specific studies on predicting long-term survival after TIPS placement. To establish a model to predict long-term survival in patients with hepatitis cirrhosis after TIPS. A retrospective analysis was conducted on a cohort of 224 patients who underwent TIPS implantation. Through univariate and multivariate Cox regression analyses, various factors were examined for their ability to predict survival at 6 years after TIPS. Consequently, a composite score was formulated, encompassing the indication, shunt reasonability, portal venous pressure gradient (PPG) after TIPS, percentage decrease in portal venous pressure (PVP), indocyanine green retention rate at 15 min (ICGR15) and total bilirubin (Tbil) level. Furthermore, the performance of the newly developed Cox (NDC) model was evaluated in an internal validation cohort and compared with that of a series of existing models. The indication (variceal bleeding or ascites), shunt reasonability (reasonable or unreasonable), ICGR15, postoperative PPG, percentage of PVP decrease and Tbil were found to be independent factors affecting long-term survival after TIPS placement. The NDC model incorporated these parameters and successfully identified patients at high risk, exhibiting a notably elevated mortality rate following the TIPS procedure, as observed in both the training and validation cohorts. Additionally, in terms of predicting the long-term survival rate, the performance of the NDC model was significantly better than that of the other four models [Child-Pugh, model for end-stage liver disease (MELD), MELD-sodium and the Freiburg index of post-TIPS survival]. The NDC model can accurately predict long-term survival after the TIPS procedure in patients with hepatitis cirrhosis, help identify high-risk patients and guide follow-up management after TIPS implantation.

IntroductionDecompensated cirrhosis is associated with poor outcomes and the incidence of advanced liver disease has increased in Wales over the last two decades. Transjugular intrahepatic portosystemic shunts (TIPSS) are an...

Early HVPG measurement and TIPS for acute variceal hemorrhage: Is sooner really better?

The effects of transjugular intrahepatic portosystemic shunt (TIPS) placement on esophageal motor function and gastroesophageal reflux were investigated in patients with esophageal varices. In six men with esophageal varices, esophageal manometry and upper gastrointestinal endoscopy were performed before and 15-20 days after TIPS placement. Intraesophageal pH monitoring was performed in the four patients with severe esophageal varices (defined as the largest sized varices) following TIPS placement. Findings were compared with those in six healthy men (controls) who underwent esophageal manometry and intraesophageal pH monitoring. The esophageal varices resolved or were reduced after TIPS placement. Resting lower esophageal sphincter (LES) pressures were similar in the study group before and after TIPS placement and in the control subjects. The incidence and progression of esophageal contractions were similar in the study group before and after TIPS placement and in the control subjects. At 3 cm above the LES, the amplitude of esophageal contraction after TIPS placement was significantly higher than that before TIPS placement. At 3 and 8 cm above the LES, the amplitude of esophageal contraction in the control subjects was significantly higher than that in the study group before and after TIPS placement. Esophageal acid exposure time after TIPS placement was similar to that in the controls. TIPS placement is a useful treatment that improves esophageal motor function without the occurrence of pathologic gastroesophageal reflux.

Transjugular intrahepatic portosystemic shunt (TIPS) is a non-selective portosystemic shunt created using endovascular techniques. During recent years technical improvements and new insights into pathophysiology have modified indications for TIPS placement. In this article we therefore want to discuss current knowledge. A literature review was performed to review and discuss the pathophysiology, indications and results of the TIPS procedure. Established TIPS indications are persistent bleeding despite combined pharmacological and endoscopic therapy and rebleeding during the first five days. A new indication in the European recommendations is early TIPS placement within 72 hours, ideally within 24 hours, in patients bleeding from esophageal or gastroesophageal varices at high risk for treatment failure (e. g. Child-Pugh class C < 14 points or Child-Pugh class B with active bleeding) after initial pharmacological and endoscopic therapy. For prevention of recurrent variceal hemorrhage in the recommendations, covered TIPS placement is the treatment of choice only after failed first-line therapy, although numerous TIPS studies show a prolonged time to rebleeding and a reduction of mortality. Similarly for secondary prophylaxis in patients with refractory ascites, covered TIPS placement may be considered only if the patient continues to be intolerant to NSBBs and is an appropriate TIPS candidate even though studies show that the TIPS procedure controls ascites, improves survival and renal function better than paracentesis. Potential indications for TIPS implantation are Budd-Chiari syndrome, acute portal vein thromboses, hydrothorax, hepatopulmonary and hepatorenal syndrome (Typ 2), portal hypertensive gastropathy (PHG) and prophylaxis of complications of abdominal surgery, very rarely bleeding in ectopic varices or in patients with chylothorax or chylous ascites. TIPS placement is an established procedure with a new indication as "early TIPS". In the European recommendations it is only the second-line therapy for prevention of recurrent variceal hemorrhage and for secondary prophylaxis in patients with refractory ascites although several studies showed a clear benefit of the TIPS procedure compared to ligation and NSBBs. · In addition to already established indications, new European recommendations suggest early TIPS placement in patients bleeding from esophageal or gastroesophageal varices at high risk for treatment failure.. · Strunk H, Marinova M, . Transjugular Intrahepatic Portosystemic Shunt (TIPS): Pathophysiologic Basics, Actual Indications and Results with Review of the Literature. Fortschr Röntgenstr 2018; 190: 701 - 711.

Fulminant hepatic failure from the Budd-Chiari syndrome. A bridge to transplantation with transjugular intrahepatic portosystemic shunt.

Embolization of spontaneous splenorenal shunt for after‐TIPS hepatic encephalopathy in a patient with cirrhosis and variceal bleeding

Clinical Characteristics and Outcomes of Transjugular Intrahepatic Portosystemic Shunt Procedure for Portal Hypertension Secondary to Myeloproliferative Neoplasms

Introduction: Transjugular intrahepatic portosystemic shunt (TIPS) procedures are used to treat complications of portal hypertension such as refractory ascites and variceal hemorrhage. Previous studies have shown that the model for end-stage liver disease (MELD) score is superior to other liver disease scoring systems to establish optimal candidates for TIPS procedure and liver transplantation. The purpose of our study was to analyze various prognostic indicators of 30- and 90-day mortality after TIPS creation. Methods: We conducted a retrospective chart review on cirrhotic patients who underwent TIPS procedure from June 2009 to September 2013. All TIPS revisions were excluded. Data on age, gender, underlying liver disease, indication for TIPS, blood pressure, hemoglobin, platelets, INR, serum albumin, ALT, AST, bilirubin, creatinine, glucose, and sodium upon admission prior to TIPS placement was collected. Pre- and post-TIPS, and absolute portosystemic reduction gradients were recorded. Physical examination ascertained the presence and severity of ascites and hepatic encephalopathy. Electronic medical records were reviewed to determine 30- and 90-day mortality rates. Continuous variables were compared by Student’s t-test and categorical variables by chi-square tests. In some cases, non-parametric tests were used. A logistic regression was performed to determine the effects of age, gender, presence of ascites or encephalopathy, BMI, and MELD-Na score on the likelihood of death within 90 days of TIPS procedure. Results: From June 2009 to September 2013, 69 patients underwent TIPS placement. We found MELD (p=0.026) and MELD-Na scores (p=0.014) to be significantly different between those who died within 30 days and those who did not following TIPS placement. MELD-Na score (p=0.01) was significantly different between the deceased and persons who survived the 90-day period. Our logistic regression model itself was statistically significant (p<0.05), explaining 29.6% (Nagelkerke R2) of the variance in 90-day mortality. It correctly classified 81.6% of cases. Sensitivity was 33.3%, specificity was 94.5%, positive predictive value was 62.5%, and negative predictive value was 83.6%. Of the six predictor variables, only MELD-Na score was statistically significant (p=0.028). For each point increase in MELD-Na score, chance of death increased by 1.15 times. Conclusion: Our single-center experience suggests that the MELD-Na score is the most effective predictor of survival after TIPS creation. In our study, an individual’s likelihood of death was 1.15 times greater for every 1-point increase in the MELD-Na score. The use of this data will help classify patients with endstage liver disease, establishing the best candidates for TIPS creation and liver transplantation.

INTRODUCTION: The simplest classification of portosystemic collateral veins classifies all non-esophagogastric varices as ectopic varices. Ileal varices are an example of ectopic varices formed from the ileal veins (tributaries of SMV) and draining into the mesenteric vessels. We present a case of an ileal conduit complicated by recurrent ectopic variceal bleeding amenable to a transjugular intrahepatic portosystemic shunt (TIPS) procedure. CASE DESCRIPTION/METHODS: A 45 year-old male with Hepatitis C and alcohol related cirrhosis complicated by portal hypertensive gastropathy and non-bleeding esophageal varices (EV) presented with a one month history of recurrent hematuria via his ileal conduit. He had a history of colon cancer stage IIB status post cystoprostatectomy and sigmoidectomy with ileal conduit in 2013. He had required three hospitalizations for his recurrent bleeding, needing multiple blood transfusions. Previous workup included a CT abdominal angiogram showing porto-systemic collaterals without active extravasation of contrast, an ileal conduit loopogram showing good functionality, and an ileal conduit endoscopy showing no visible ileal varices or active bleeding. On admission to our institution, he was hemodynamically stable and did not required additional blood transfusions. An abdominopelvic CT scan showed a normal ileal loop conduit and again small mesenteric portosystemic collaterals were evident. There was a high suspicion for ectopic varices in the ileal conduit, and a TIPS procedure was performed. A pre-TIPS portogram showed the presence of large ectopic ileal varices filled with contrast with resolution after TIPS placement. TIPS was successful with decrease of hepatic venous pressure gradient from 18 mmHg to 9 mmHg. He was discharged after TIPS procedure and has not required repeat hospitalization for hematuria. DISCUSSION: Ectopic varices account for up to 5% of variceal hemorrhage, and there is no consensus for therapeutic management. This patient had ileal conduit varices causing recurrent clinically significant hematuria. TIPS placement successfully controlled his recurrent ectopic variceal hemorrhage.

Combination of splanchnic vasoconstrictors and endoscopic band ligation is an effective treatment strategy for acute variceal hemorrhage; but how do we get those drugs approved by the FDA?

Transjugular intrahepatic portosystemic shunt in portal hypertension: How to go further while staying on track?