Small-diameter TIPS combined with splenic artery embolization in the management of refractory ascites in cirrhotic patients.

Proximal splenic artery embolization for treatment of refractory ascites, a single-center experience.

Trial for treatment of refractory ascites TIPS the scales

Since the early 1970s several studies have reported distal splenic artery embolization, better known as partial spleen embolization (PSE), as an efficacious treatment of portal hypertensive variceal bleeding and hypersplenism in cirrhosis.(1, 2) However, the effect of PSE on portal pressure is secondary to the induction of splenic infarction. Depending on both the infarct volume and possible infection, PSE can induce serious complications including death.(2, 3) On the other hand, proximal splenic artery embolization (PSAE), which mimics surgical splenic artery ligation, prevents large infarction of the spleen, favoring collateral perfusion of its intact distal vasculature.(3) For this, PSAE has been extensively preferred over PSE for reducing portal hyperflow and treating refractory ascites (RA) after whole or partial liver transplantation (LT).(3, 4) We report here a case of PSAE used to treat RA in a patient with cirrhosis not eligible for transjugular intrahepatic portosystemic shunt (TIPS) and LT. A 72-year-old man under regular follow-up at our unit since 2009 (obesity as the main comorbidity, teetotaler, under 80 mg propranolol since 2013 for secondary prophylaxis of variceal bleeding, HCV eradicated in 2016) in October 2018 was admitted for his second acute decompensation (grade 3 ascites, grade 3 hepatic encephalopathy (HE), stage 2 acute kidney injury, no infections). After discharge, despite halving the dose of propranolol, administering 40 g/week of albumin, and tuning the diuretic dosage, grade 3 ascites kept recurring (20 L per month). In February 2019, diuretics were definitively withdrawn for induced complications (renal failure, severe hyponatremia, HE). The patient was judged not eligible for LT, mainly for exceeding the age limit. TIPS was considered not feasible because of the risk of complications related to the patient's age, history of recurrent episodes of HE, and creatinine levels often exceeding 3 mg/dL. At volumetric MRI, the spleen/liver volume ratio (SLVR) was 1.4.(4, 5) After obtaining the patient's consent, we decided to perform PSAE to treat RA following the hypothesis that it would primarily decrease portal pressure and ascites filtration and secondarily lessen the prerenal component of kidney failure. PSAE was performed as described.(3, 4) Pre-PSAE and post-PSAE imaging is shown in Fig. 1. Main clinical, laboratory, hemodynamic, and volumetric features recorded during the main follow-up time points are summarized in Fig. 2. No immediate or late complications related to PSAE were observed. Portal pressure significantly decreased, response/tolerance to diuretic was restored, and 3 weeks post-PSAE ascites disappeared. At the end of follow-up (15 months), estimated glomerular filtration rate improved by 104% and cardiac index and left ventricle stroke work index returned to predecompensation levels. MRI showed an expected reduction in the spleen volume and an unexpected increase in the total liver volume compared to pre-PSAE. Liver function tests, body mass index, and hemoglobin level returned to their predecompensation values. PSAE caused a decrease in portal pressure and ascites filtration. After this, renal response/tolerance to diuretics improved. Decrease in systemic inflammation, normalization of hemoglobin level, and nutritional status recovery may have contributed to renal and cardiac function improvement. The mechanism underlying liver enlargement remains unexplained. Future studies should clarify if it is due to liver regeneration triggered by changes in liver perfusion. Vascular plugs may present technical advantages compared with coils, allowing reliable deployment in a short proximal segment of the splenic artery.(4) The ideal SLVR as a predictor of significant portal pressure reduction after PSAE remains to be determined.(4, 5) In conclusion, the safety and long-term efficacy of PSAE as a therapeutic option in patients with cirrhosis and RA not eligible for TIPS or LT should be tested in larger case series. We thank the patient and his family for trusting us. We also thank the nurses who gracefully supported our work. All authors read and approved the final manuscript. C.C. was responsible for study concept and execution of the procedure. L.T. was responsible for acquisition of hemodynamic data, manuscript drafting, and technical and material support. F.P. was responsible for acquisition of volumetric data and technical and material support. P.Q. was responsible for study concept and critical revision of the manuscript for important intellectual content. M.B. was responsible for acquisition of hemodynamic data and technical and material support. D.S. was responsible for acquisition of clinical data and technical and material support. F.M. was responsible for technical and material support. F.C. and D.F. were responsible for execution of the procedure and technical and material support. J.C.G.-P., J.T., M.S., G.P.G., and F.D.B were responsible for interpretation of data and critical revision of the manuscript for important intellectual content. P.T. and E.V. were responsible for critical revision of the manuscript for important intellectual content. F.S. was responsible for study concept and design, execution of the procedure, acquisition of hemodynamic data, study supervision, analysis and interpretation of data, and critical revision of the manuscript for important intellectual content.

3:00 PM Abstract No. 282 Transjugular intrahepatic portosystemic shunting reduces paracentesis rates in patients with cirrhosis and ascites: a population-based analysis

Introduction: Refractory ascites after orthotopic liver transplantation is rare. While secondary precipitating causes can be identified in a sizable number, a small proportion of the patients with post-transplantation ascites have no identifiable cause. Splenic artery embolization has recently been reported as an effective method of treating refractory ascites in such cases. We present a case of successful treatment of refractory ascites after liver transplantation with partial splenic artery embolization. Case: A 52-year-old Caucasian male had received an orthotopic liver transplant in March, 2011 for hepatocellular carcinoma and chronic hepatitis C induced liver cirrhosis. The patient developed refractory ascites 2 months after transplantation requiring repetitive therapeutic paracenteses. Liver biopsy and echocardiography showed no evidence of rejection or recurrent hepatitis and congestive heart failure, respectively. Transjugular hepatic venogram and pressure evaluation showed a kink at the anastomosis of right hepatic vein and inferior vena cava which was successfully stented with resolution of pressure gradient post intervention. The patient continued to have refractory ascites despite these measures and underwent partial splenic artery embolization (SAE) to decrease the inflow of blood to the portal circulation. After SAE, the patient had significant reduction in ascites with decreased need for paracentesis, improved renal function and reduced diuretic requirement. Discussion: Refractory ascites (RA) is an uncommon complication of orthotopic liver transplantation which poses a serious challenge to the clinician. It is associated with increased risk of renal failure and peritoneal infections, increased hospital stay and shortened survival. In majority of patients with RA, treatment of secondary causes including right sided heart failure, acute or chronic graft rejection and hepatic inflow or outflow obstruction, leads to resolution of ascites. In the patients with no identifiable cause, treatment of ascites is challenging. Transjugular intrahepatic portosystemic shunting has shown mixed results as a treatment strategy. Splenic artery embolization leading to decreased splenic inflow and decreased portal hypertension has shown encouraging results in the recent years. Conclusion: Owing to its effectiveness in decreasing portal hypertension and low complication risk, splenic artery embolization appears to an attractive treatment option for the challenging problem of refractory ascites after liver transplantation.

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

Refractory ascites (RA) is a challenging complication after orthotopic liver transplantation. Its treatment consists of the removal of the precipitating factors. When the etiology is unknown, supportive treatment can be attempted. In severe cases, transjugular intrahepatic portosystemic shunts, portocaval shunts, and liver retransplantation have been used with marginal results. Recently, splenic artery embolization (SAE) has been described as an effective procedure for reducing portal hyperperfusion in patients undergoing partial or whole liver transplantation. Here we describe our experience with SAE for the treatment of RA. Between June 2004 and June 2010, 6 patients underwent proximal SAE for RA. Intraoperative flow measurements, graft characteristics, embolization portal vein (PV) velocities before and after SAE, and spleen/liver volume ratios were collected and analyzed. The response to treatment was assessed with imaging (ultrasound/computed tomography) and on the basis of clinical outcomes (weight changes, diuretic requirements, and the time to ascites resolution). The PV velocity decreased significantly for each patient after the embolization (median = 66.5 cm/second before SAE and median = 27.5 cm/second after SAE, P < 0.01). All patients experienced a significant postprocedural weight loss (mean = 88.1 ± 28.4 kg before SAE and mean = 75.8 ± 28.4 kg after SAE, P < 0.01) and a dramatic decrease in their diuretic requirements. All but 1 of the patients experienced a complete resolution of ascites after a median time of 49.5 days (range = 12-295 days). No patient presented with postembolization complications. In conclusion, SAE was effective in reducing the PV velocity immediately after the procedure. Clinically, this translated into a dramatic weight loss, a reduction of diuretic use, and a resolution of ascites. SAE appears to be a safe and effective treatment for RA.

Dietary sodium restriction and diuretic treatment have been shown to be effective in the treatment of ascites in the majority of cirrhotic patients. However, approximately 5 to 10% of patients develop refractory ascites, which is defined as ascites that does not respond to intensive diuretic therapy (diuretic-resistant) or ascites that cannot be controlled because the patient develops diuretic-induced complications that prevent the use of an effective diuretic dose (diuretic-intractable). Current therapeutic approaches for refractory ascites include repeated large-volume paracentesis and transjugular intrahepatic portosystemic shunting. In the present report, subcutaneous octreotide treatment improved renal function and hemodynamics and diuretic response in two patients with refractory ascites in line with a marked decrease in renin and aldosterone secretion. We consider that octreotide could be of value in the management of refractory ascites in cirrhotic patients.

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

P538 Aims: In patients awaiting liver transplantation (OLT), the transjugular intrahepatic portosystemic shunt (TIPS) has been fairly effective in the management of refractory ascites. After OLT, ascites can be present for various reasons and in rare situations may be refractory to medical management. In this report, we review our experience and outcomes with TIPS after OLT. Methods: Records of 309 primary adult OLT recipients, between January 1995 and December 2003, were retrospectively reviewed. Refractory ascites was noted when active intervention (paracentesis, TIPS) was needed beyond 30 days after OLT. Patients who required TIPS were the subject of this report. Demographics, indications for OLT, evidence of allograft dysfunction and outcomes after TIPS are described. Results: During the study period 8 TIPS were placed in 8 patients at a mean of 11.5 months after OLT (range 2-36). There were 5 males and 3 females, age 54±8.2years. Hepatitis C was the primary diagnosis in 7 patients and primary biliary cirrhosis in 1. Indications for TIPS included refractory ascites (8), associated variceal bleeding (2) and various degrees of hepatic vein outflow stenosis (3). Seven patients had resolution of ascites and associated findings of portal hypertension, and 1 patient with persistent ascites had severe hepatic vein outflow stenosis and associated hepatitis C in the allograft. Two patients required re-OLT for recurrent hepatitis C. There were 3 deaths: liver failure 1 month after TIPS done in the setting of allograft dysfunction, 3 months after TIPS with subsequent re-OLT and organ failure, and lung cancer 5 months after TIPS. One patient occluded his TIPS within 3 months after shunt placement but interestingly no longer has any ascites 2 months after TIPS occlusion. Bridging fibrosis was present in 3 patients, 2 needed re-OLT and 1 died from liver failure while waiting for OLT. Currently, 5 patients are alive without clinical evidence of ascites 2, 6, 8, 17 and 63 months after TIPS. Conclusions: 1- TIPS, used selectively, is effective and safe in the control of refractory ascites after OLT. 2- When performed in the setting of organ dysfunction, TIPS can be associated with a high mortality and may accelerate the urgency for re-OLT. 3- In setting of allograft fibrosis, refractory ascites should prompt more timely re-OLT. 4- TIPS has been successful in the setting of mild-moderate hepatic vein outflow stenosis and refractory ascites.

Portal hypertension significantly impacts the management and prognosis of patients with primary and secondary hepatic malignancies. Its presence may preclude curative surgical or locoregional therapies, increase perioperative risk, and worsen overall survival. Interventional radiology plays a central role in the management of portal hypertensive complications when medical and endoscopic therapies are insufficient. The mainstay intervention, transjugular intrahepatic portosystemic shunt (TIPS), is well-established for variceal bleeding, refractory ascites, and hepatic hydrothorax in cirrhotic patients, and emerging evidence supports its use in selected cancer patients, including those with hepatocellular carcinoma (HCC) and metastatic disease. Splenic artery embolization (SAE) serves as an alternative or adjunctive therapy in patients with contraindications to TIPS, in individuals who have persistent symptoms despite TIPS placement. This document outlines evidence-based management strategies for portal hypertension in cancer patients and discusses technical considerations in TIPS placement and splenic artery embolization.

See the Original "Clinical outcomes of transjugular intrahepatic portosystemic shunt for portal hypertension: Korean multicenter real-practice data" on page 18.

Transjugular Intrahepatic Portosystemic Shunt for Refractory Ascites: A Meta-analysis of Individual Patient Data

Transjugular intrahepatic portosystemic shunt (TIPS) is used in the management of refractory ascites (RA) and variceal bleeds. Little data exist on TIPS safety, efficacy, and survival after liver transplantation (LT). We conducted a retrospective analysis of patients who underwent TIPS placement after LT for RA. Clinical success was defined as a reduction of portosystemic gradient (PSG) and resolution of RA. Twenty-six patients underwent TIPS. The most common indication for LT was hepatitis C virus (88%). Median time from LT to TIPS was 17 months (1-89 months). Median pre-TIPS model for end-stage liver disease (MELD) score was 15 (7-33). The median pre-TIPS PSG was 18 mm Hg (7-38 mm Hg). Median change in the PSG after TIPS was 11 mm Hg (1-27 mm Hg). Fifty-eight percent (15/26) of TIPS were considered clinically successful. Median post-TIPS patient survival was 15 months (1-109 months). Cumulative 1-year post-TIPS patient survival was 50%. On multivariate analysis, pre-TIPS MELD was a significant and independent predictor of patient survival (P<0.01). The 3- and 6-month patient mortality and graft loss for patients with a pre-TIPS MELD of more than or equal to 15 were significantly higher than those with a pre-TIPS MELD score of less than 15 (P<0.01). The overall median survival for patients with a pre-TIPS MELD score of more than or equal to 15 was 3 months (1-59 months) compared with 45 months (2-109 months) for patients with pre-TIPS MELD score of less than 15. TIPS after LT can be clinically effective in patients with RA with a MELD score less than 15. This suggests that TIPS could be used as a means to extend posttransplant survival but should be carefully individualized in patients with a MELD score more than or equal to 15.

The spleen is the most commonly injured organ in blunt abdominal trauma. Unstable patients undergo laparotomy and splenectomy. Stable patients with lower grade injuries are treated conservatively; those stable patients with moderate to severe splenic injuries (grade III-V) benefit from endovascular splenic artery embolization. Two widely used embolization approaches are proximal and distal splenic artery embolization. Proximal splenic artery embolization decreases the perfusion pressure in the spleen but allows for viability of the spleen to be maintained via collateral pathways. Distal embolization can be used in cases of focal injury. In this article we review relevant literature on splenic embolization indication, and technique, comparing and contrasting proximal and distal embolization. Additionally, we review relevant anatomy and discuss collateral perfusion pathways following proximal embolization. Finally, we review potential complications of splenic artery embolization.