Emergency Transjugular Intrahepatic Portosystemic Shunt Research Articles

Esophageal Stent in Acute Refractory Variceal Bleeding: A Systematic Review and a Meta-Analysis.

Background: Acute esophageal variceal bleeding accounts for up to 70% of upper-gastrointestinal bleeding in cirrhotic patients. About 10-20% of patients with acute variceal bleeding have refractory bleeding that is not controlled by medical or endoscopic therapy, and this condition can be life-threatening. Balloon tamponade is a long-standing therapy which is only effective temporarily and has several complications, while transjugular intrahepatic portosystemic shunt (TIPS) and liver transplantation may not be readily available at some centers. The use of self-expandable metal stents (SEMSs) in refractory esophageal variceal bleeding has been studied for effectiveness and adverse events and has been recommended for use as a bridge to a more definitive treatment. Aim: To investigate the effectiveness and safety of SEMSs in managing refractory variceal bleeding. Methods: A systematic search of the MEDLINE, EMBASE, and Cochrane library databases was performed from inception to October 2022 using the following terms: "esophageal stent", "self-expandable metal stents", "endoscopic hemostasis", "refractory esophageal varices", and "esophageal variceal bleeding". Studies were included in the meta-analysis if they met the following criteria: (1) patients' age older than 18 and (2) a study (or case series) that has at least 10 patients in the study. Exclusion criteria included (1) non-English publications, (2) in case of overlapping cohorts, data from the most recent and/or most appropriate comprehensive report were collected. DerSimonian-Laird random-effects meta-analysis was performed using the meta package in R statistical software(version 4.2.2). Results: Twelve studies involving 225 patients with 228 stents were included in the analyses. The mean age and/or median age ranged from 49.4 to 69 years, with a male-to-female ratio of 4.4 to 1. The median follow-up period was 42 days. The mean SEMS dwell time was 9.4 days. The most common cause of acute refractory variceal bleeding in chronic liver disease patients included alcohol use followed by viral hepatitis. The pooled rate of immediate bleeding control was 91% (95% CI 82-95%, I2 = 0). The pooled rate of rebleeding was 17% (95% CI 8-32%, I2 = 69). The pooled rate of stent ulceration was 7% (95% CI 3-13%, I2 = 0), and the pooled rate of stent migration was 18% (95% CI 9-32%, I2 = 38). The pooled rate of all-cause mortality was 38% (95% CI 30-47%, I2 = 34). Conclusions: SEMSs should be primarily considered as salvage therapy when endoscopic band ligation and sclerotherapy fail and can be used as a bridge to emergent TIPS or definitive therapy, such as liver transplantation.

Emergent TIPS for acute gastroesophageal variceal bleeding in cirrhotic patients with hepatocellular carcinoma.

To estimate the safety and effectiveness of emergent transjugular intrahepatic portosystemic shunt (TIPS) creation for acute variceal bleeding (AVB) in cirrhotic patients with hepatocellular carcinoma (HCC). Data of thirty-three patients with AVB and HCC undergoing emergent TIPS creation from January 2016 to January 2022 were enrolled and were retrospectively analyzed. The primary outcomes were the safety of emergent TIPS creation, the bleeding control rate, and the rebleeding rate. The secondary outcomes included overall survival (OS), liver function, overt hepatic encephalopathy (HE), and shunt dysfunction. Emergent TIPS creation was technically successful in 33 patients (100%) and one (3.0%) patient suffered a major procedure-related adverse event. The control rate of bleeding (within 5days) was 100%. During a median follow-up period of 26.3months, rebleeding occurred in 6 (18.2%) patients. The median OS was 20.0months. The 6-week and 1-year survival rates were 87% and 65%, respectively. Laboratory tests showed no significant impairment of liver function following TIPS creation. The incidences of overt HE and shunt dysfunction were 24.2% and 6.1%, respectively. Emergent TIPS creation is feasible and effective for treatment of AVB in cirrhotic patients with HCC.

Feasibility of computed tomography portal venography in the preoperative evaluation of emergent TIPS creation for cirrhotic patients with acute variceal bleeding

ObjectivesTo evaluate the feasibility of computed tomography portal venography (CTPV) in the preoperative evaluation of emergent transjugular intrahepatic portosystemic shunt (TIPS) creation for cirrhotic patients with acute variceal bleeding (AVB). MethodsOne hundred and forty-eightcirrhotic patients with AVB undergoing emergent TIPS creation from January 2016 to December 2022 in our institution were enrolled in the retrospective study. The primary outcome was the consistency between CTPV and endoscopy in the classification and grading of gastroesophageal varices (GEVs). The second outcome was extraluminal CTPV findings. The consistency of CTPV and endoscopy in the classification and grading of GEVs was determined by Kappa values. ResultsEmergent TIPS creation was technically successful in all patients. Forty-five patients underwent preoperative endoscopy. The results of CTPV diagnosis of GEVs classification were that 112, 28, and 8 patients were classified as gastroesophageal varices type 1 (GOV1), GOV2, and isolated gastric varices type 1 (IGV1), respectively. In diagnosing the classification and grading of GEVs, CTPV showed substantial agreement with preoperative endoscopy, with Kappa values of 0.823 and 0.625, respectively. CTPV provided the afferent and afferent vessels of GEVs for emergent TIPS creation. ConclusionCTPV is feasible and effective to act as an alternative preoperative evaluation method to endoscopy for cirrhotic patients with AVB undergoing emergent TIPS creation.

Viatorr Stent Migration and Retrieval during Transjugular Intrahepatic Portosystemic Shunt Revision.

Transjugular intrahepatic portosystemic shunt (TIPS) is an important interventional option for the treatment of complications related to cirrhosis and portal hypertension. Emergent TIPS placement can be a life-saving measure in patients with uncontrolled variceal hemorrhage. After TIPS placement, patients may benefit from additional interventions for clinical optimization including stent dilation, stent extension, and embolization of varices. Here, we describe a case of emergent TIPS placement and revision which resulted in TIPS stent migration requiring stent removal and replacement. We discuss our technique and review previously reported methods for the management of migrated TIPS stents.

Emergent Transjugular Intrahepatic Portosystemic Shunt as a First-Line Therapy in Patients with Cirrhosis with Acute Gastroesophageal Variceal Hemorrhage

PurposeTo investigate the safety and effectiveness of emergent transjugular intrahepatic portosystemic shunt (TIPS) as first-line therapy in patients with advanced cirrhosis with acute variceal hemorrhage. Materials and MethodsFrom July 2016 to June 2019, 76 patients with advanced cirrhosis and acute variceal hemorrhage were included in this retrospective study. All patients underwent emergent TIPS as first-line therapy within 24 hours. Gastroesophageal varices in patients with cirrhosis were diagnosed with contrast-enhanced computed tomography because emergent endoscopy has not been routinely performed in this center. The primary outcomes were the control rate of bleeding and the rate of rebleeding. Secondary outcomes were the technical success rate of procedure, transplantation-free survival, the mean hospitalization time, the time of stay in the intensive care unit, and adverse events. ResultsAll patients underwent TIPS creation successfully and were transferred to general wards. The median follow-up time was 21.7 months (interquartile range, 12.6–28.1 months). The control rate of bleeding (≤5 days) was 100%. The rates of early (>5 days to 6 weeks) and late (>6 weeks to 2 years) rebleeding were 6.6% and 1.3%, respectively. The 6-week, 1-year, and 2-year transplantation-free survival rates were 94.7%, 93.4%, and 84.6%, respectively. The incidences of acute liver failure, hepatic encephalopathy, and shunt dysfunction were 5.3%, 25%, and 5.3%, respectively. ConclusionsEmergent TIPS as a first-line therapy in patients with advanced cirrhosis with acute variceal hemorrhage is safe and effective. This study provides an alternative approach for medical centers without emergent endoscopy facility to manage the condition.

Emergent Transjugular Intrahepatic Portosystemic Shunt Creation for Acute Gastric Variceal Bleeding in Patients with Hepatocellular Carcinoma

A total of 42 cirrhotic patients (mean age, 51.7 years ± 10.8; 38 men) with hepatocellular carcinoma who underwent emergent transjugular intrahepatic portosystemic shunt (TIPS) creation for controlling acute gastric variceal bleeding (GVB) were included in this multicenter retrospective study. Of these, 37 (88.1%) patients underwent emergent TIPS creation as the first-line treatment to control acute GVB. Five (11.9%) patients underwent emergent TIPS creation as a rescue/salvage treatment to control acute GVB after emergent endoscopic therapy and pharmacotherapy. Emergent TIPS creation was technically successful in 40 (95.2%) patients. Two (4.8%) patients had severe and moderate procedural adverse events. The median follow-up duration was 16.9 months (range, 0.1–100.8 months). Failure to control acute bleeding and failure to prevent rebleeding occurred in 8 (19.0%) patients during follow-up. Eighteen (42.9%) patients died during follow-up. Three (7.1%) patients had shunt dysfunction during follow-up. Overt hepatic encephalopathy occurred in 6 (14.3%) patients during follow-up.

Unique Method of Transjugular Intrahepatic Portosystemic Shunt Reduction for Refractory Hepatic Encephalopathy

We report the case of a 27-year-old female patient with a history of cryptogenic cirrhosis who was admitted to the hospital due to multiple episodes of hematemesis secondary to bleeding esophageal varices. The varices were persistent and refractory to endoscopic intervention, so an emergent transjugular intrahepatic portosystemic shunt (TIPS) was performed by interventional radiology (IR). Months later, the patient returned to the hospital unresponsive with acute intermittent hepatic encephalopathy which required a TIPS reduction by IR. Once the TIPS reduction was performed, the patient’s hepatic encephalopathy declined, and her symptoms improved. Here, we present a unique method of TIPS reduction utilizing a single Viabahn VBX balloon-expandable stent (W. L. Gore & Associates, Inc; Flagstaff, AZ) to constrain the existing TIPS stent.

Emergent Transjugular Intrahepatic Portosystemic Shunt Creation in Acute Variceal Bleeding.

Emergent transjugular intrahepatic portosystemic shunt (TIPS) creation is most commonly employed in the setting of acute variceal hemorrhage. Given a propensity for decompensation, these patients often require a multidisciplinary, multimodal approach involving prompt diagnosis, pharmacologic therapy, and endoscopic intervention. While successful in the majority of cases, failure to medically control initial bleeding can prompt interventional radiology consultation for emergent portal decompression via TIPS creation. This article discusses TIPS creation in emergent, acute variceal hemorrhage, reviewing the natural history of gastroesophageal varices, presentation and diagnosis of acute variceal hemorrhage, pharmacologic therapy, endoscopic approaches, patient selection and risk stratification for TIPS, technical considerations for TIPS creation, adjunctive embolotherapy, and the role of salvage TIPS versus early TIPS in acute variceal hemorrhage.

Chronic Extra-Hepatic Portal Vein Obstruction in a Pregnant Patient Requiring TIPS: A Case Report

Abstract Extra-Hepatic Portal Vein Obstruction (EHPVO) is due to non-cirrhotic or malignant causes and may present with signs and symptoms of chronic portal hypertension. Here we discuss a patient on her fifth pregnancy who was discovered to have EHPVO with cavernous transformation and perisplenic, gastohepatic and retroperitoneal varices after presenting with abdominal pain, splenomegaly, and unremarkable labs. An emergent Transjugular Intrahepatic Portosystemic Shunt (TIPS), although rarely feasible in the presence of cavernous formation, with percutaneous thrombectomy of the superior mesenteric vein, splenic vein, and hepatic portal veins was performed. Unfortunately, post-procedural complications resulted in hypovolemic shock and spontaneous abortion. Genetic testing and bone marrow biopsy confirmed the diagnosis of essential thrombocythemia in the setting of a Janus Kinase2 (JAK2) V617F mutation. Portal vein thrombosis in pregnancy is rare, however, hemodynamic changes of pregnancy may increase the risk of complications due to portal hypertension. Additionally, the diagnosis of primary myeloproliferative disorders is a known risk factor for EHPVO. While prophylaxis and close monitoring is suggested in patients with a history of EHPVO before conception, there is no clear protocol in treating patients who are diagnosed for the first time with chronic EHPVO during pregnancy. Keywords JAK2V617F Mutation; Portal vein thrombosis; Pregnancy; TIPS Abbreviations EHPVO: Extra-hepatic portal vein obstruction; ET: Essential thrombocythemia; JAK2: Janus Kinase2; MPD: Myeloproliferative disorders; PV: Polycythemia Vera; PVT: Portal vein thrombosis; TIPS: Transjugular intrahepatic portosystemic shunt

AngioJet thromectomy treat acute stent thrombosis after emergency transjugular intrahepatic portosystemic shunt: a case report

经颈静脉肝内门体分流术(TIPS)联合食管胃底静脉栓塞术为治疗肝硬化门静脉高压导致上消化道出血的有效方法，术后分流道功能障碍是其常见并发症。本文1例上消化道出血患者行TIPS，术后支架内急性血栓形成后使用AngioJet血栓抽吸。术后未再出血，予以抗凝治疗，随访9个月，支架通畅。

1933 A Case of a Hidden Varix: Massive Duodenal Variceal Hemorrhage Requiring Emergent TIPS

INTRODUCTION: Variceal hemorrhage is a potentially life-threatening cause of bleeding in cirrhotic patients. While typically associated with esophageal or gastric varices, clinically significant variceal hemorrhage may occasionally originate from the small bowel, colon, rectum or biliary tract. Duodenal variceal hemorrhage is an uncommon cause of GI tract bleeding and is associated with a mortality rate up to 40%. We present a case of severe duodenal variceal hemorrhage necessitating emergent transjugular intrahepatic portosystemic shunt (TIPS) and variceal coil embolization. CASE DESCRIPTION/METHODS: A 58-year-old female with a history of cryptogenic cirrhosis decompensated by ascites presented to the ER with melena and dull, generalized abdominal pain over 2 days. Vital signs were notable for tachycardia to 114 bpm and she was normotensive. Her abdomen was non-tender to palpation and rectal exam was notable for melenic stools. Her hemoglobin was 9.5 g/dL on presentation. She continued to have melena over the course of the day with associated tachycardia and a decrease in hemoglobin to 5.6 g/dL. She was transferred to the intensive care unit where she underwent an upper endoscopy revealing small esophageal varices with no stigmata of bleeding and a normal duodenum. However, she continued to have melena unresponsive to blood product resuscitation leading to profound hypotension. A stat CT Angiogram showed intraluminal hyperdensities within the second portion of the duodenum due to hemorrhage from adjacent varices. Interventional Radiology was consulted and performed a right hepatic vein to right portal vein TIPS. They also performed fluoroscopic guided coil embolization of large duodenal varices arising from the main portal vein. The patient’s hemoglobin stabilized and she had no further bleeding during the course of her hospitalization. DISCUSSION: Duodenal variceal hemorrhage is a rare and life-threatening manifestation of portal hypertension. Due to the rarity of the condition, there are no established guidelines regarding treatment. Endoscopic therapy aimed at achieving hemostasis, such as sclerotherapy and clipping have shown limited success in case reports. TIPS, as seen in this case, is a viable treatment option. Our case illustrates the importance of considering ectopic varices in cirrhotic bleeders. Moreover, it highlights the importance of utilizing angiographic evaluation for patients in whom the source of bleeding is not identified on endoscopy.

2026 Successful Hemostasis in Acute Gastric Variceal Hemorrhage With Hemospray (Hemostatic Powder)

INTRODUCTION: Currently there are few effective therapies for acute gastric variceal hemorrhage: endoscopic variceal ligation (EVL), cyanoacrylate injection, and endoscopic sclerotherapy (ESL). For variceal hemorrhage that is not amenable to these therapies, Transjugular intrahepatic portosystemic shunt (TIPS) or Balloon-occluded retrograde transvenous obliteration (BRTO) are recommended. For patients with contraindications to these procedures there is no effective treatment. Here we present a case of acute gastric variceal hemorrhage, in which hemostasis was successfully achieved with the use of Hemospray (hemostatic powder). CASE DESCRIPTION/METHODS: A 63-year-old hispanic man with PMH of HCV and alcoholic cirrhosis presented with coffee-ground emesis and melena. Admission vitals: T-37.7, HR-117, RR-20, BP-139/72, O2 sat-100% on RA. Physical exam was significant for only mild jaundice. Hemoglobin was 6.3. We started Protonix IV BID, Octreotide drip and Ceftriaxone QD. CT abdomen showed multiple metastatic appearing liver lesions, cirrhosis, varices, and cavernous transformation of the portal vein. Overnight his hemoglobin decreased to 4.5. During EGD, multiple gastric varices were noted including a large, actively hemorrhaging, GOV-2 varix. Unfortunately, we were unable to perform EVL due to the sheer volume of bleeding present. IR was consulted for emergent TIPS. However the patient was not a candidate for TIPS or BRTO due to the cavernous transformation of his portal vein. The decision was made to utilize Hemospray. EGD was repeated and the large GOV-2 gastric varix was seen actively hemorrhaging. A large, obstructing clot was removed and the site of bleeding was visualized. Hemospray was applied and hemostasis was quickly and effectively achieved. After application, the patient did not have recurrent bleeding. DISCUSSION: Hemostasis in the setting of acute gastric variceal hemorrhage can be very challenging to achieve. Hemospray should be considered when traditional therapies fail. It becomes cohesive and adhesive when it comes into contact with moisture, forming a stable mechanical barrier. Although there are few studies investigating its use in acute variceal hemorrhage, it was very effective in this case. Hemospray can also be useful for providing temporary hemostasis in an emergent situation; giving physicians more time to organize more definite treatments. Hemospray is a powerful endoscopic tool and should be considered when standard bleeding therapies are inadequate.

Evaluation of model performance to predict survival after transjugular intrahepatic portosystemic shunt placement.

Background/AimsThe MELD score was developed to predict survival after transjugular intrahepatic portosystemic shunt (TIPS) placement. Given changes in practice patterns and development of new prognostic tools in cirrhosis, we aimed to evaluate common models to predict mortality after TIPS placement.MethodsAnalysis of consecutive patients who underwent TIPS placement for ascites or bleeding. Performance to predict 90-day mortality was assessed by C statistic for six models (MELD, MELD-Na, CLIF-C ACLF, Child-Pugh, Platelet-Albumin-Bilirubin, and Emory score). Added predictive value to MELD score was assessed for univariate predictors of 90-day mortality. Stratified analysis by TIPS indication, emergent placement status, and TIPS stent type was performed.Results413 patients were analyzed (248 with variceal bleeding, 165 with refractory ascites). 90-day mortality was 27% (113/413). Mean MELD score was 15 ± 7.9. MELD score best predicted mortality for all patients (c = 0.779), for variceal bleeding (c = 0.844), and for emergent TIPS (c = 0.817). CLIF-C ACLF score best predicted mortality for refractory ascites (c = 0.707). Addition of sodium to the MELD score did not improve predictive value across multiple strata. Addition of hemoglobin improved MELD score’s predictive value in variceal bleeding. Addition of age improved MELD score’s predictive value in refractory ascites.ConclusionsMELD score best predicted 90-day mortality. Addition of sodium to the MELD score did not improve its performance, though mortality prediction was improved using Age-MELD for ascites and Hemoglobin-MELD for bleeding. An individualized risk stratification approach may be best when considering candidates for TIPS placement.

SAT-007-Survival and risk factors of mortality after emergency transjugular intrahepatic portosystemic shunt for uncontrolled acute variceal bleeding caused by cirrhosis-related portal hypertension

SAT-007-Survival and risk factors of mortality after emergency transjugular intrahepatic portosystemic shunt for uncontrolled acute variceal bleeding caused by cirrhosis-related portal hypertension

Surgical decision making in patients with cirrhosis: a systematic review of the literature

Background: The incidence of cirrhosis is increasing and many patients affected by this disease process will require some form of operation (elective vs emergent). In these individuals, the decision making process can be quite demanding. These individuals require adequate assessment for the degree of hepatic dysfunction, extent of both portal hypertension and their comorbidities for perioperative optimization. Some of the common operations performed in patients with cirrhosis involve biliary, colorectal disease and ventral hernias. The primary aim of this study is a systematic review of the literature to determine the decision making process involved with three common emergent surgical cases. Methods: A systematic review of the literature using Pubmed, Medline and Embase was performed. Non case reports and retrospective reviews of patients with cirrhosis undergoing emergency surgery were identified. In addition to the systematic review, 3 specific cases were utilized to highlight the issues involving patients with cirrhosis and common gastrointestinal emergencies. These cases involved patients with cirrhosis who developed: ischemic bowel, acute cholecystitis and an incarcerated umbilical hernia. The decision making aspect in each case involved deciding whether to perform a primary anastomosis post bowel resection versus creation of a stoma, laparoscopic cholecystectomy versus percutaneous drainage and finally the ideal management of an incarcerated umbilical hernia with ascites. Results: High grade evidence for decision making is lacking. In patients with cirrhosis complicated by ischemic bowel, individuals with Child Pugh A or a MELD score <10 display the best outcomes. Whether to create a stoma versus resection and primary anastomosis in end stage liver disease, there is no level 1 evidence to support either. There were no studies identified for this patient population and most studies involved individuals with colorectal disease. However, in the French Association of Surgery series, patients with cirrhosis that had a protective stoma are at risk for stoma complications such as ascites leakage, ascites infection, peristomal varices. There was a 7% fistula rate in individuals with resection and primary anastomosis. Acute cholecystitis in patients with Child Pugh A/B can be treated with laparoscopic cholecystectomy and or subtotal cholecystectomy. For Child Pugh C medical management should be attempted followed by percutaneous transhepatic cholecystostomy tube as necessary. Finally, individuals with an incarcerated umbilical hernia should have emergent surgery and repair of their hernia. Intraoperatively placed closed suction drains can be used to control post-operative ascites and allow for adequate wound healing. Ascites should also be managed aggressively with medical therapy and possible emergent Transjugular Intrahepatic Portosystemic Shunt (TIPS) as necessary. Conclusion: Advanced liver disease complicates many common gastrointestinal surgeries. The decision making process surrounding these operations is far from standardized as high grade evidence recommending optimal management is lacking. Management of cirrhosis in these not un- common emergency settings rely mostly on retrospective data and small cohort studies thus the treatment can vary from surgeon to surgeon.

Emergency Transjugular Intrahepatic Portosystemic Shunt: an Effective and Safe Treatment for Uncontrolled Variceal Bleeding

BackgroundUncontrolled variceal bleeding (VB) remains a great challenge for clinical treatment. Emergency transjugular intrahepatic portosystemic shunt (TIPS) is a salvage procedure, but unsatisfactory clinical outcomes and a high incidence of complications have been reported. This study aimed to investigate the effect and safety of emergency TIPS performed in our institution during recent years. MethodsFifty-eight consecutive cirrhotic patients with uncontrolled VB who underwent emergency TIPS from March 2009 to November 2017 in our hospital were followed until the last clinical evaluation, liver transplantation (LT), or death. ResultsOverall, 5, 36, and 17 patients belonged to Child-Pugh class A, B, and C, respectively. TIPS was successfully performed in 57 (98.3%) patients at 89.5 h (mean) after initial bleeding. After TIPS, bleeding ceased in 52 (91.2%) patients, and 51 (89.5%) patients had a portal pressure gradient below 12 mmHg. Only one (1.8%) major procedure-related complication occurred without any clinical consequences, and no procedure-related deaths occurred. During follow-up, 55 hepatic encephalopathy (HE) episodes occurred in 19 (33.3%) patients, and the median time of the first HE episode was 3.1 months. Seven (12.3%) patients experienced shunt dysfunction after 8.7 months (median). The 6-week, 1-year, and 2-year variceal rebleeding rates were 10.5%, 17.1%, and 20.0%, respectively. The LT-free survival rates at 6 weeks, 1 year, and 2 years were 87.7%, 81.8% and 73.6%, respectively. ConclusionOur study highlights the fact that emergency TIPS could be effective for patients with liver cirrhosis and uncontrolled VB with few potential complications.

Esophageal Stenting for Refractory Esophageal Variceal Bleeding

Esophageal variceal bleeding is a lethal complication in patients with cirrhosis. Occasionally, esophageal variceal bleeding is refractory to standard endoscopic and pharmacologic therapies. We discuss a case of bleeding esophageal varices that was treated with esophageal stenting as a bridge to emergent transjugular intrahepatic portosystemic shunt (TIPS). A 55-year-old female with a past medical history of alcoholic and hepatitis C virus (HCV) cirrhosis presented with large volume hematemesis. One week previously, she was admitted with hematemesis and during upper endoscopy, five bands were placed treating large distal esophageal varices. During the current admission, labs were remarkable for a hemoglobin of 8.8, down from 9.6 two days earlier, INR of 1.7, platelets of 146, and MELD-Na of 22. The patient was transfused one unit of packed red blood cells (PRBC) and maintained on intravenous octreotide and pantoprazole. During endoscopy, multiple large varices were found in the middle and distal third of the esophagus. Two bands were placed on the esophageal varices in the distal esophagus. One band detached immediately and large volume bleeding ensued. Placement of additional bands at the bleeding site was not possible due to scarring. A temporizing covered esophageal stent was deployed across the gastroesophageal junction to achieve hemostasis by tamponade while emergent TIPS was arranged. Meanwhile, her vitals remained stable and there were no further episodes of hematemesis. She underwent emergent TIPS with retrograde embolization of the esophageal collaterals, which she tolerated well. The plan was to remove the esophageal stent in two weeks. Unfortunately, the patient continued to decompensate and passed away during liver transplantation surgery. Current standard management of acute variceal bleeding includes adequate resuscitation, vasoactive medications, acid suppression, antibiotic prophylaxis, and endoscopic banding. Previously balloon tamponade was used and had complications including migration, aspiration, and tissue ischemia with mortality rates around 20%. Placement of self-expanding metal stents (SEMS) is an effective option for refractory variceal bleeding due to its high initial bleeding control rate, low rebleeding rate, and lower rate of adverse events compared to balloon tamponade. Our case revealed that SEMS is an effective temporizing measure for refractory esophageal variceal bleeding until TIPS can be performed.1981_A Figure 1. Large esophageal varices with presence of postbanding ulcer1981_B Figure 2. Wallflex stent deployed

Perioperative Transjugular Intrahepatic Portosystemic Shunt (TIPS) Placement in Cirrhotics Undergoing Abdominal Surgery: A Case Series

Introduction: Operative risk in cirrhotics is related to severity of liver disease and nature of the procedure. Elective and emergent abdominal surgery in cirrhotics is associated with increased perioperative mortality. Surgery can precipitate hepatic decompensation, as well as intraoperative bleeding and ascites, which can cause wound dehiscence and peritonitis. Preoperative portal decompression via TIPS may reduce the risk of complications and impact survival. However, in emergent surgeries pre-op TIPS is not feasible, and can be considered post-op. We report on the utility of pre- and post-operative TIPS in decompensated cirrhotics, and its effect on perioperative mortality. Methods: Between 2010-2017 at the UAB, 19 cirrhotics underwent TIPS prior to abdominal surgery, and four after. Mayo Clinic post-operative mortality risk calculator was used to determine the expected 30 and 90-day mortality, which was compared to the observed mortality in our cohort. Results: TIPS was successfully performed in 23 decompensated cirrhotics, 19 preoperatively and 4 postoperatively. The hepatic venous pressure gradient decreased from 13.7±3.1 to 5.8±2.1 mm Hg after postop TIPS, and from 16±4.7 to 5.3±2.5 mm Hg after pre-op TIPS. Mean time between pre-op TIPS and surgery was 39 days, and from surgery to post-op TIPS 9 days. The mean MELD score increased from 12.7±4.2 to 15.2±4.3 after preoperative-TIPS. Mean MELD at surgery was 13.2±3.9, and increased to 17.2±6.2 at post-operative TIPS. After preoperative TIPS, hepatic encephalopathy was reported in all 19 patients and ascites in six patients with two requiring revision of TIPS within 30 days after the surgery. One preoperative TIPS patient, with a Mayo 30-day mortality risk of 41%, died 78 days from surgery. One patient, with a Mayo 30-day mortality risk of 23%, died 48 hours post-op due to surgical complications, with TIPS placed 24 hours post-op. No wound dehiscence or peritonitis was reported. Conclusion: Decompression of the portal system has been noted to reduce mortality in high-risk surgical candidates prior to elective surgery. We show that both pre- and post-operative TIPS placement in decompensated cirrhotics may reduce mortality. Further studies are needed to validate our findings and identify a patient cohort that would most benefit. A key variable to be determined is the ideal time interval between TIPS and surgery to prevent multiple hits to the liver and limit the risk of hepatic decompensation.

Abstract No. 65 - Emergency transjugular intrahepatic portosystemic shunt outcomes in the unstable, bleeding cirrhotic: A retrospective cohort

Abstract No. 65 - Emergency transjugular intrahepatic portosystemic shunt outcomes in the unstable, bleeding cirrhotic: A retrospective cohort

Treating Duodenal Varices with Cyanoacrylate Glue Injection

Introduction: Treatment methods for some bleeding complications of portal hypertension such as portal hypertensive gastropathy (PHG), gastric antral vascular ectasias and duodenal varices are diverse and non-uniform. We present the case of a patient with a life threatening upper GI bleed secondary to a duodenal varix, who achieved adequate hemostasis with cyanoacrylate glue injection. Case presentation: A 46 year old female with history of active alcoholic liver disease was admitted with hemorrhagic shock due to a massive GI bleed. Initial resuscitation necessitated intubation, vasopressors and massive transfusion support. Initial EGD demonstrated small esophageal varices without stigmata, mild PHG and a nonbleeding gastric ulcer. Bleeding continued, therefore interventional radiology performed Balloon-Occluded Retrograde Transvenous Obliteration (BRTO) with embolization of gastric and esophageal Hemodynamic instability continued and repeat EGD demonstrated a large, actively bleeding duodenal varix at the third portion of the duodenum. Cyanoacrylate glue was directly injected into the varix and hemostasis was achieved. The patient was discharged home within a few days. Surveillance EGD performed 2 months after discharge, while patient remained sober, revealed mild ulceration in the third portion of the duodenum at the site of glue injection, without presence of varices. After an episode of alcohol binge, she was readmitted with recurrent GI bleed. EGD revealed the previously injected duodenal varix actively bleeding. Endoscopic glue injection was again performed and hemostasis was achieved. Emergent Transjugular Intrahepatic Portosystemic Shunt (TIPS) procedure was performed after which the patient was discharged in good condition, without known sequelae, complications or recurrent bleeding. Discussion: Although the successful use of cyanoacrylate glue injection to control bleeding duodenal varices has been reported in numerous cases, its use remains seldom, as gastroenterologists tend to prefer use of alternative methods in such instances. As described in our case and those previously reported, severe portal hypertension remains a risk factor for re-bleeding and complications. Our case demonstrates that adequate control of duodenal variceal bleeds can be achieved initially via cyanoacrylate glue injection but permanent treatment includes TIPS or transplant.