Portosystemic Shunt In Patients Research Articles

Surgical portosystemic shunts for treatment of portal hypertensive bleeding: Outcome and effect on liver function

Since the advent of liver transplantation and transjugular intrahepatic portosystemic shunts (TIPS), the role of surgical portosystemic shunts in the treatment of portal hypertension has changed. However, we have continued to use portosystemic shunts in patients with noncirrhotic portal hypertension and in patients with Child's A cirrhosis. We performed 48 surgical portosystemic shunt procedures between 1988 and 1998. The outcomes of these patients were evaluated to assess the efficacy of this treatment. Data from 39 of 48 patients were available for analysis. The average follow-up was 42 months. Liver function generally remained stable for the patients; only 2 patients had progressive liver failure and required transplant procedures. Gastrointestinal bleeding (3 patients), encephalopathy (3 patients), and shunt thrombosis (3 patients) were rare. Patient survival was 81% at 4 years, similar to survival with liver transplantation (P = .22). Surgical shunts remain the treatment of choice for prevention of recurrent variceal bleeding in patients with good liver function and portal hypertension.

Transjugular Intrahepatic Portosystemic Shunts in Patients with Hereditary Hemorrhagic Telangiectasia: Failure to Palliate Gastrointestinal Bleeding

Transjugular Intrahepatic Portosystemic Shunts in Patients with Hereditary Hemorrhagic Telangiectasia: Failure to Palliate Gastrointestinal Bleeding

Portosystemic hepatic encephalopathy after transjugular intrahepatic portosystemic shunt in patients with cirrhosis: clinical, laboratory, psychometric, and electroencephalographic investigations.

A prospective study of hepatic encephalopathy (HE) including neuropsychiatric and psychometric evaluation, electroencephalography, and determination of arterial ammonia levels was performed in 55 cirrhotic patients treated consecutively by transjugular intrahepatic portosystemic shunt (TIPS). The cumulative HE rate increased from 23.6% within the 3-month interval before TIPS to 50. 9% within the first 3-month interval post-TIPS (P = .003). Significant and independent predictors of HE post-TIPS were the presence of HE pre-TIPS and reduced liver function. The cumulative HE rate declined in the second 3-month interval post-TIPS and reached the pre-TIPS level. Chronic forms of HE exceeding grade I were not observed. In a subgroup of 22 nonencephalopathic TIPS patients, the prevalence of subclinical HE did not change after TIPS. Among individual psychometric tests, the block design test gave the highest proportion of pathological results (about 50%), whereas selective reminding gave the lowest (10%-25%). Electroencephalography (EEG) showed a temporary increase of pathological results at 1 month after TIPS, when patients with overt HE (grade I) were included (proportion of 21.1% before vs. 57.1%, P = .005). Arterial ammonia concentration increased from a mean of 94 +/- 26 microgram/dL to 140 +/- 28 microgram/dL at 3 months after TIPS (P < .001). Elevated ammonia levels persisted. TIPS led to a temporary increase of HE incidence within 3 months. The decline of the HE rate beyond 3 months despite a sustained increase of arterial ammonia levels could not entirely be explained by reduction of shunt flow, nor by alteration of liver function. Instead, cerebral adaptation to gut-derived neurotoxins might be anticipated.

Changes in plasma endothelin-1 level by transjugular intrahepatic portosystemic shunt in patients with cirrhosis.

Changes in plasma endothelin-1 level by transjugular intrahepatic portosystemic shunt in patients with cirrhosis.

Budd-Chiari syndrome: shunt or transplant?

Background: Budd-Chiari syndrome is an uncommon disorder caused by obstruction to hepatic venous outflow, causing varying degrees of hepatic injury depending on the extent, severity, and acuity of the obstruction. Patients and Methods: We reviewed the indications for operative intervention and the results of treating 32 patients with Budd-Chiari syndrome seen at Toronto Hospital between 1968 and 1995. Results: Twenty-one patients underwent porto-systemic shunt (PSS) and 7 patients underwent liver transplantation (LT) as their initial operative management. Three patients who initially had PSS subsequently required LT. Patients with cirrhosis found on biopsy and preservation of hepatocellular function were treated with PSS and showed no difference in outcome when compared with patients without cirrhosis (P=0.35). Patients who were treated by PSS with retrohepatic vena caval compression, as shown by high caval gradients had outcomes similar to those for patients with low gradients (P=0.31). Using the Kaplan- Meier method, 5-year survival of PSS patients was 57%. Liver transplantation was used to manage patients with hepatic decompensation, as well as patients with vena caval occlusion or failed PSS. The 5-year Kaplan-Meier survival for LT was 67%. Conclusions: Both PSS and LT are effective options in the management of Budd-Chiari syndrome. Portosystemic shunt is the preferred initial approach even with cirrhosis or retrohepatic caval compression as long as there is preservation of liver function and a patent vena cava. Liver transplantation should be used as primary therapy for patients with irreversible hepatic decompensation or vena caval occlusion, and it can be an effective salvage procedure following failed PSS.

Transjugular Intrahepatic Portosystemic Shunt in Patients with Active Variceal Bleeding Due to Portal Hypertension and Portal Vein Thrombosis

Transjugular Intrahepatic Portosystemic Shunt in Patients with Active Variceal Bleeding Due to Portal Hypertension and Portal Vein Thrombosis

Changes in plasma endothelin-1 and Big endothelin-1 induced by transjugular intrahepatic portosystemic shunts in patients with cirrhosis and refractory ascites

Background/Aims: Endothelin-1 (ET-1) is a potent vasoconstrictor that may be involved in the pathogenesis of splanchnic and renal hemodynamic changes associated with portal hypertension. The aim of this study was to measure the concentration of ET-1 and of its precursor Big endothelin-1 (Big ET-1) in the systemic circulation as well as in the splanchnic and renal venous beds and to evaluate changes after the relief of portal hypertension following transjugular intraheptic portosystemic shunt placement. Methods: Plasma concentrations of ET-1 and of Big ET-1 were measured in the vena cava, renal vein, hepatic vein and portal vein in ten patients with cirrhosis and refractory ascites before and 1–2 months after transjugular intrahepatic portosystemic shunt. The porto-caval gradient, creatinine clearance, plasma aldosterone and renin activity, as well as daily urinary sodium excretion were measured at the same time. Results: The plasma concentration of ET-1 and Big ET-1, respectively, in peripheral blood of normal volunteers were 0.28±03 and 3.95±0.34 pg/ml; the concentrations of both peptides were higher in patients with cirrhosis, both in vena cava (0.61±0.14 and 10.01±1.47 pg/ml), hepatic vein (0.62±0.13 and 13.93±1.77 pg/ml), portal vein (1.21±0.12 and 17.84±1.98 pg/ml) and renal vein (0.76±0.12 and 14.21±1.55 pg/ml). Moreover ET-1 and Big ET-1 concentrations were more elevated in the portal vein that in the vena cava (+98% and +70%) and slightly higher in the renal vein as compared to the vena cava (+25% and +42%). After transjugular intrahepatic portosystemic shunt, a rise in creatinine clearance and urinary sodium excretion (+49%; and +53%) was observed together with a marked reduction in plasma aldosterone and renin activity (−59% and −49%). ET-1 and Big ET-1 concentrations remained unchanged in the vena cava whereas a significant reduction of ET-1 and Big ET-1 occured both in the portal vein (−43% and − 44%) and in the renal vein (−53% and −29%). Portal vein and renal vein concentrations of both peptides became similar to vena cava levels. Conclusions: Splanchnic and renal hemodynamic changes occurring in patients with cirrhosis and refractory ascites could be related to the production of ET-1 by splanchnic and renal vascular beds. This was abolished by transjugular intrahepatic portosystemic shunt, which could explain the exacerbation of systemic vasodilation and the improvement in renal perfusion observed after the procedure.

Transjugular intrahepatic portosystemic shunt in patients with end-stage liver disease: results in 85 patients.

Transjugular intrahepatic portosystemic shunt (TIPS) is becoming an accepted procedure as a bridge to orthotopic liver transplantation (OLT) in patients with end-stage liver disease (ESLD) and bleeding from portal hypertension. It allows the immediate control of acute bleeding and decreases the risk of recurrent acute bleeding while the patient is awaiting OLT. We review in this report, our experience with 85 patients who underwent a TIPS procedure for gastrointestinal variceal bleeding from September 1991 until April 1994. All patients had liver cirrhosis and all had previous sclerotherapy before TIPS. Child-Pugh score was calculated at enrollment, and all patients were evaluated for possible OLT. Thirteen patients were Child A, 49 were Child B, and 23 were Child C. Fifty-three patients were candidates for OLT, and 32 were not. TIPS was performed urgently in 25 patients. At a median follow-up of 582 days (range, 1 to 1,095), 35 patients underwent transplantation, 21 patients died, and 29 patients are still alive and did not undergo transplantation. Technical complications were observed in 7% of patients and new onset of clinical encephalopathy in 37%. The 30-day mortality rate after TIPS was 13%. Actuarial survival was 60% at 1 and 3 years. Child class C and urgent TIPS were shown to be two independent predictor factors for mortality. TIPS was shown to be a valuable procedure, not only as a bridge to OLT but also as palliation for bleeding from portal hypertension in patients who were not candidates for either surgical shunt or OLT. However, its role in bleeding patients with acceptable liver function needs further investigation.

Treatment of Budd-Chiari syndrome with portosystemic shunt or liver transplantation

Budd-Chiari syndrome is an uncommon disorder caused by obstruction to hepatic venous outflow, causing varying degrees of hepatic injury depending on the extent, severity, and acuity of the obstruction. We reviewed the indications for operative intervention and the results of treating 32 patients with Budd-Chiari syndrome seen at Toronto Hospital between 1968 and 1995. Twenty-one patients underwent portosystemic shunt (PSS) and 7 patients underwent liver transplantation (LT) as their initial operative management. Three patients who initially had PSS subsequently required LT. Patients with cirrhosis found on biopsy and preservation of hepatocellular function were treated with PSS and showed no difference in outcome when compared with patients without cirrhosis (P = 0.35). Patients who were treated by PSS with retrohepatic vena caval compression, as shown by high caval gradients had outcomes similar to those for patients with low gradients (P = 0.31). Using the Kaplan-Meier method, 5-year survival of PSS patients was 57%. Liver transplantation was used to manage patients with hepatic decompensation, as well as patients with vena caval occlusion or failed PSS. The 5-year Kaplan-Meier survival for LT was 67%. Both PSS and LT are effective options in the management of Budd-Chiari syndrome. Portosystemic shunt is the preferred initial approach even with cirrhosis or retrohepatic caval compression as long as there is preservation of liver function and a patent vena cava. Liver transplantation should be used as primary therapy for patients with irreversible hepatic decompensation or vena caval occlusion, and it can be an effective salvage procedure following failed PSS.

Emergency shunt. Role in the present management of variceal bleeding.

To evaluate the results of selective and nonselective emergency portosystemic shunts in patients with acute variceal hemorrhage. Retrospective review. University medical center and Veterans Affairs medical center. Forty-two consecutive patients who underwent emergency portosystemic shunts from 1978 through 1994. All patients had chronic liver disease (29 [69%] had alcoholic cirrhosis) and half had Child's class C disease. Sixteen patients were actively bleeding at the time of surgery, and 26 had bled within 48 hours. Twenty-two patients underwent a nonselective shunt and 20 underwent a distal splenorenal shunt. The percentages of patients with Child's class C disease and with active bleeding at the time of surgery were significantly higher in the nonselective shunt group. Operative mortality; early postoperative rebleeding, shunt patency, encephalopathy, and ascites; and long-term survival. Operative mortality rates were higher in patients with Child's class C disease (43% [9/21]) than in patients with Child's class A or B disease (9% [2/21]) and were higher in patients with active bleeding (all of whom underwent nonselective shunt) (44% [7/16]) than in patients who underwent distal splenorenal shunt (10% [2/20]). All shunts were patent after surgery, and no patient had rebleeding during the early postoperative interval. Early postoperative ascites and encephalopathy rates were similar after nonselective shunt and distal splenorenal shunt. Long-term survival was superior in the lower-risk distal splenorenal shunt group. Even though more effective nonoperative treatments are now available, emergency portosystemic shunt remains an important option for selected patients with acute variceal hemorrhage. When bleeding can be temporarily controlled by nonoperative means, distal splenorenal shunt is an effective and safe emergency procedure. The mortality rate remains high for patients with Child's class C disease undergoing protal decompression.

CT and MRI in Detection of Intrahepatic Portosystemic Shunts in Patients with Liver Cirrhosis

Our goal was to determine the prevalence and anatomic location of intrahepatic portosystemic shunts (IPSs) in patients with hepatic cirrhosis as shown by CT and MRI. We retrospectively reviewed CT and MR scans of 33 cirrhotic patients who had IPSs. In addition, two series of 100 consecutive CT or MR were reviewed to determine the prevalence of IPSs and the percentage of intrahepatic and extrahepatic paraumbilical veins. Intrahepatic portosystemic shunts were divided into three groups according to the intrahepatic course: paraumbilical shunt between the left portal vein and the paraumbilical vein anterior to the liver (n = 29); inferior vena caval shunt between the posterior branch of the right portal vein and the inferior vena cava (n = 2); and miscellaneous (n = 2). Shunts of the paraumbilical type ran through the medial (n = 23), lateral (n = 3), or both medial and lateral (n = 3) segments of the left lobe of the liver. Twenty-five patients had one shunt, and four had more than one. Six cases were also associated with extrahepatic paraumbilical veins. Intrahepatic portosystemic shunts, especially the paraumbilical type, were not infrequently visualized in patients with hepatic cirrhosis.

Transjugular intrahepatic portosystemic shunts in patients with portal vein occlusion.

The feasibility and efficacy of transjugular intrahepatic portosystemic shunts (TIPS) were evaluated in 10 patients with preexisting portal vein occlusions. A standard transjugular approach was used in six of the 10 patients for both portal vein recanalization and TIPS placement. The protal veins were successfully recanalized and TIPS were established in three of the six patients. TIPS placement was unsuccessful in the other three patients because the catheters could not be advanced through the occluded segments. A transhepatic approach was used in four of the 10 patients for portal vein recanalization before transjugular catheterization and TIPS placement were attempted. Both portal vein recanalization and TIPS placement were technically successful in all four patients. Bleeding stopped in all patients after successful shunt placement. TIPS can be used to control variceal bleeding in some patients, despite preexisting portal vein occlusion. Preliminary recanalization of the occluded portal segment by means of the transhepatic approach may facilitate TIPS placement.

Role of parallel transjugular intrahepatic portosystemic shunts in patients with persistent portal hypertension.

Transjugular intrahepatic portosystemic shunts (TIPS) were placed in 93 patients between June 1990 and January 1992 for treatment of variceal hemorrhage. In each case, a Wallstent (Schneider USA, Minneapolis) was used to support the hepatic parenchymal tract between the hepatic and portal veins. Currently, these stents have a maximal diameter of 10 mm. In eight of 93 patients, major portal hypertension persisted after placement of a 10-mm-diameter shunt, manifested by continued rapid variceal filling and elevated portosystemic gradients. A second TIPS was placed parallel to the first in these patients to allow further portal decompression. In two other patients, a second TIPS was placed because the initial shunt functioned suboptimally. The mean postprocedural portosystemic gradient in the patients who received one TIPS was 10.2 mm Hg +/- 3.7. In patients who received two TIPS, the mean postprocedural gradient was 19.1 mm Hg +/- 3.8 after placement of the first TIPS and 12.5 mm Hg +/- 3.5 after placement of the second. Two patients developed their first episode of encephalopathy after placement of two TIPS. The methods and indications for placing two TIPS in this select population are discussed.