Recurrent Portal Hypertension Research Articles

Endovascular Treatment of Venous Outflow and Portal Venous Complications After Liver Transplantation

Liver transplantation continues to rapidly evolve, and in 2020, 8906 orthotopic liver transplants were performed in the United States. As a technically complex surgery with multiple vascular anastomoses, stenosis and thrombosis of the venous anastomoses are among the recognized vascular complications. While rare, venous complications may be challenging to manage and can threaten the graft and the patient. In the last 20 years, endovascular approaches have been increasingly utilized to treat post-transplant venous complications. Herein, the evaluation and interventional treatment of post-transplant venous outflow complications, portal vein stenosis, portal vein thrombosis, and recurrent portal hypertension with transjugular intrahepatic portosystemic shunt (TIPS) are reviewed.

Efficacy, feasibility and safety of TIPS in the treatment of recurrent portal hypertension with variceal bleeding after open splenectomy and esophagogastric devascularization.

To investigate the efficacy, feasibility, and safety of transjugular intrahepatic portosystemic shunt (TIPS) as a treatment for patients with recurrent portal hypertension with variceal bleeding (RPHVB) who have previously undergone open splenectomy and esophagogastric devascularization (OSED). The data were retrospectively retrieved from 39 cirrhotic RPHVB patients who had undergone OSED from August 2015 to December 2020. All patients were treated with TIPS using the Viabahn stent. Out of the 39 patients included in the study, TIPS was successfully performed in 38 patients with a success rate of 97.44%. One patient had a failed attempt due to cavernous transformation of the portal vein (CTPV). Among the 38 patients who underwent TIPS, 33 patients also underwent varicose vein embolization, while the remaining 5 patients only underwent TIPS procedure. A total of 39 Viabahn stents were implanted, with 5 patients receiving stents expanded to their nominal diameter of 8mm and the remaining 33 patients having their shunt maintained at a diameter of 6mm. The postoperative hemostasis rate was 97.37% (37/38). The portal vein pressure (PVP) and portal pressure gradient (PPG) decreased significantly from (31.28 ± 6.24) and (20.61 ± 5.14) mmHg to (19.58 ± 4.69) and (9.24 ± 3.07) mmHg, respectively (P < 0.001). During the follow-up period, the rebleeding rate was 6.09% (2/29), while the incidence of hepatic encephalopathy (HE) and shunt dysfunction was 13.79% (4/29) for each. Transjugular intrahepatic portosystemic shunt is an effective, feasible and safe treatment for RPHVB patients who have previously undergone OSED. A satisfactory clinical outcome could be achieved with a 6mm-diameter shunt in most patients.

S2572 Bleeding Duodenal Varix Treated With Hemostatic Clips

Introduction: Duodenal varices are a rare etiology of upper gastrointestinal bleeding with a prevalence of 0.4% in patients with portal hypertension undergoing esophagogastroduodenoscopy (EGD). Ectopic varices account for 1–5% of variceal bleeding, of which 17–40% are estimated to occur within the duodenum. Definitive guidelines on the management of duodenal varices, which have an estimated mortality rate of 40%, have not been established. We report the use of hemostatic clips to achieve hemostasis in a case of a bleeding duodenal varix due to portal hypertension in an orthotopic liver transplant patient with a dysfunctional mesocaval shunt. Case Description/Methods: A 42-year-old female with advanced liver cirrhosis (MELD 17) secondary to alcohol use and primary biliary cholangitis status post orthotopic liver transplantation complicated by portal vein thrombosis and biliary stricture for which she underwent mesocaval shunting and biliary reconstruction with recurrent portal hypertension. She presented with one day of bright red blood per rectum. On admission, her vital signs were significant for hypotension (81/61 mmHg) and tachycardia (132 bpm). Her hemoglobin was 7.6 g/dL (baseline 12 g/dL). Computed tomography angiography was remarkable for prominent proximal duodenal mucosal varices, portosystemic shunting with prominent splenorenal and gastric/gastroesophageal varices, and portal vein thrombosis. EGD was significant for a large (>5 mm) actively bleeding varix in the second portion of the duodenum, for which two hemostatic clips were successfully placed with resolution of bleeding. The patient remained hemodynamically stable post-procedure and was transferred to her transplant center for further management with no further bleeding episodes. Discussion: Alcoholic-associated liver disease (ALD) is one of the most common causes of cirrhosis. As the incidence and prevalence of ALD continues to rise, it is important that management of duodenal variceal bleeding becomes more standardized. Only a few cases have reported the use of hemostatic clips in these patients. Treatment options include band ligation, coiling, cyanoacrylate injection, balloon-occluded retrograde transvenous obliteration, and transjugular intrahepatic portosystemic shunt. Standardized treatment modalities for duodenal variceal bleeds have not been well-established and further studies are required to investigate appropriate management strategies. Our case demonstrates that hemostatic clips can be effectively used to achieve hemostasis (Figure 1).Figure 1.: (A) Computed tomography angiography (CTA) revealing prominent proximal duodenal mucosal varices, likely from the superior mesenteric vein. (B) Esophagogastroduodenoscopy (EGD) demonstrating a large (>5 mm) actively bleeding varix in the second portion of the duodenum. (C) EGD demonstrating hemostatic clips placed on the duodenal varix with resolution of bleeding.

Emborrhoid technique performed on a patient with portal hypertension and chronic hemorrhoidal bleeding as a salvage therapy

BackgroundHemorrhoidal disease most commonly manifests itself with chronic rectal bleeding and, in its most severe and refractory forms, may lead to chronic anaemia with the need for recurrent blood transfusions. The main pathogenetic mechanism involved seems to be arterial hyperflux in the terminal branches that supply the hemorrhoidal plexus. It is based on this principle, that embolization of the superior rectal artery (emborrhoid technique) has recently re-emerged, with very promising results that support its feasibility, treatment efficacy, and safety.Case presentationWe report a case of a patient with both recurrent hemorrhoidal bleeding and portal hypertension with rectal varices, who underwent SRA embolization as a salvage therapy, with significant clinical improvement and no immediate or short-term complications.ConclusionsWe believe that the positive results from our case raise the possibility that the emborrhoid technique could be effective and safe even in patients with portal hypertension, and that it would be clinically relevant to investigate this hypothesis on larger samples with a longer follow-up.

Expression of miR-9a-5p in cirrhosis patients with recurrent portal hypertension after treatment.

MicroRNA (miR) influences the biological activities of cirrhotic patients with recurrent portal hypertension. The current study was designed to investigate risk factors related to the survival of cirrhosis patients and assessed the possibility of using miR-9a-5p predictability to prevent post-treatment portal hypertension. Patients with portal hypertension due to liver cirrhosis treated from January 2015 to September 2016 were included in this study. Patients without relapse after treatment were selected as the success group while patients with relapse after treatment were selected as the recurrence group. Serum samples from healthy people were also collected. The blood indexes of the 2 groups of patients before and after treatment were compared and the miR-9a-5p serum level in each group was determined. The Kaplan-Meier method was applied to analyze three-year survival, Cox univariate regression was used to analyze the risk factors for recurrence of cirrhotic portal hypertension, and the receiver operating characteristic curve (ROC) was used to evaluate the diagnostic value of serum miR-9a-5p, total bilirubin (TBIL) and platelet (PLT) levels in patients with recurrence. The miR-9a-5p level in the recurrence group was higher than that in the success group after treatment. In patients with recurrence, the miR-9a-5p level was negatively correlated with red blood cell count, TBIL, white blood cell count, and PLT count, and positively correlated with albumin. The miR-9a-5p, TBIL and PLT are potential markers of recurrent portal hypertension in liver cirrhosis. The miR-9a-5p had the highest area under the curve (AUC) value in patients with relapse. The miR-9a-5p is a risk factor for the recurrence of cirrhotic portal hypertension after treatment. It may be used as a marker of recurrence, and so has potential clinical value for the diagnosis and treatment of recurrent portal hypertension.

Diagnostic value of conventional ultrasound and shear wave elastography in detecting transjugular intrahepatic portosystemic shunt dysfunction.

Transjugular intrahepatic portosystemic shunt (TIPS) dysfunction can cause recurrent portal hypertension (PH)-related complications such as ascites and gastroesophageal variceal bleeding. Portography is invasive and costly limits its use as a screening modality. To assess the clinical value of conventional ultrasound in combination with point shear wave elastography (pSWE) to predict TIPS dysfunction. A total of 184 patients with cirrhosis scheduled for TIPS implantation were enrolled in this study and evaluated retrospectively. The splenoportal venous blood flow parameter, liver stiffness (LS), and spleen stiffness (SPS) were measured. Outcome measures included differences in portal vein velocity (PVV), splenic vein velocity (SPVV), LS, and SPS. The accuracy of change in PVV (ΔPVV), SPVV (ΔSPVV), and SPS (ΔSPS) to diagnose TIPS dysfunction was investigated. TIPS dysfunction occurred in 28 of 184 patients (15.2%). Eighteen (64.3%) patients had shunt stenoses and 10 (35.7%) had shunt occlusion. Portal vein diameter (PVD), PVV, splenic vein diameter (SPVD), SPVV, LS, and SPS were not significantly different between the TIPS normal and TIPS dysfunction groups. Compared with the TIPS normal group, PVV and SPVV of the TIPS dysfunction group decreased significantly, whereas SPS increased significantly (P < 0.001). The values of areas under the receiver operating characteristic curves of ΔPVV, ΔSPVV, and ΔSPS for the diagnosis of TIPS dysfunction were 0.97, 0.96, and 0.87, respectively. pSWE showed a diagnostic efficacy comparable to conventional ultrasound for diagnosing TIPS dysfunction and can be used routinely after TIPS procedures.

Use of fenestration to revise shunt dysfunction after transjugular intrahepatic portosystemic shunt.

To explore the feasibility of fenestration in the treatment of shunt dysfunction after transjugular intrahepatic portosystemic shunt(TIPS). Between February 2012 and December 2017, 12 TIPS patients with shunt dysfunction underwent fenestration to resolve recurrent portal hypertension with gastric variceal bleeding or ascites. The demographic data, operative data, postoperative recovery data, hemodynamic data, and complications were analyzed. Twelve patients underwent TIPS revision by fenestration, with a technical success rate of 100%. After stent reconstruction, the portal vein diameters decreased gradually with time (before the procedure: at 5days/1month/3months/6months; after procedure: 1.45 ± 0.11cm/1.38 ± 0.06cm/1.36 ± 0.05cm/1.34 ± 0.05cm/1.32 ± 0.06cm, respectively, P = 0.057). Additionally, the blood flow velocity and blood flow rapidly increased in the portal veins and shunts after TIPS revision (P < 0.001). Surprisingly, after 3months of stent reconstruction, the portal blood flow was 4607.99 ± 1304.10mL/min which was even lower than the shunt flow at 4651.18 ± 612.74mL/min. The mean pressure gradient (PSG) prior to TIPS revision was 36.71 ± 3.36mmHg which decreased to 17.42 ± 3.37mmHg after the procedure (P < 0.001). Clinical improvement was observed in all patients after the shunt reconstruction. Three patients (25%) had mild intra-abdominal hemorrhage at 1week after the operation. After a mean 11.0 ± 1.24months follow-up, ascites and bleeding were well controlled, and no stenosis of the stents was found. For patients with failed TIPS revision, fenestration to reconstruct the shunt provides an excellent alternative procedure, which is effective, safe, and has a certain clinical value, for continuing the treatment of portal hypertension.

Clinical efficacy of transjugular intrahepatic portosystemic shunting for recurrent portal hypertension after liver transplantation

Objective To investigate the clinical efficacy of transjugular intrahepatic portosystemic shunting (TIPS) for recurrent portal hypertension after liver transplantation. Methods The retrospective cross-sectional study was conducted. The clinical data of 15 patients with recurrent portal hypertension after liver transplantation who underwent TIPS in the 9th School of Clinical Medicine between January 2008 to June 2016 were collected. Course of TIPS: the portal vein pressure was measured and varicose veins were embolized after puncture, cannulation and angiography. A balloon catheter with diameter of 7 mm or 8 mm was used to dilate the preshunt channel, and a covered stent or bare stent with a diameter of 7, 8 or 10 mm was implanted to establish the shunt channel. Portal vein angiography was performed and the portal vein pressure was measured again. Observation indicators: (1) Surgical situations; (2) changes of portal vein pressure before and after TIPS; (3) follow-up and survival situations. Follow-up using outpatient examination was performed to record clinical symptoms at postoperative 1, 3, 6 and 12 months. Regular hepatic vascular ultrasonography was done at postoperative 1, 3, 6 and 12 months to detect patency of shunt. The follow-up period was up to June 2018. Measurement data with normal distribution were represented as ±s and analyzed by the paired t test. Measurement data with skewed distribution were described as M (range). Count data were represented as percentage. Results (1) Surgical situations: all the 15 patients underwent successful TIPS, without any serious complications or death. Stent implantation situation: bare stent, covered stent and bare stent + covered stent were implanted in 4, 8 and 3 patients, respectively. Among the 15 patients, 7 mm, 8 mm and 10 mm diameter shunt channel were established in 4, 8 and 3 patients respectively. (2) Changes of portal vein pressure before and after TIPS: portal vein pressure of the 15 patients decreased from (34±8)mmHg (1 mmHg=0.133 kPa) to (21±7)mmHg before and after TIPS, with a statistically significant difference (t=7.07, P<0.05). Portal vein pressure gradient decreased from (26±9)mmHg to (12±5)mmHg before and after TIPS, with a statistically significant difference (t=6.43, P<0.05). (3) Follow-up and survival situations: 15 patients were followed up for 24.0-60.0 months, with a median follow-up time of 37.8 months. Main clinical symptoms: of 12 patients with gastrointestinal hemorrhage, 3 had gastrointestinal rehemorrhage mainly due to portal vein pressure rising again caused by shunt restenosis or occlusion, 9 had no gastrointestinal rehemorrhage. Of 5 patients with portal vein thrombosis, thrombus was disappeared basically in 3 patients and decreased obviously (no effect on blood flow) in 2 patients. Three patients with refractory ascites were effectively improved after TIPS, however, 2 of them were recurred at postoperative 5 months. Postoperative restenosis or occlusion of shunt channel: among 15 patients, 7 developed restenosis or occlusion of the shunt channel (including 4 with bare stents). Five of them underwent shunt recanalization and another 2 without special clinical symptoms had no treatment. Hepatic encephalopathy: 6 of 15 patients including 1 with 7 mm shunt, 3 with 8 mm shunt and 2 with 10 mm shunt developed hepatic encephalopathy, of which grade Ⅰ, Ⅱ, Ⅲ, and Ⅳ hepatic encephalopathy were detected in 2, 3, 0 and 1 patients, respectively. Survival situations: of the 15 patients, 1 died of hepatic failure at postoperative 6 months, 3 were performed liver transplantation again at postoperative 3, 8 and 14 months, respectively, 11 survived more than 2 years with the longest survival time more than 6 years. Conclusion TIPS is safe and effective for recurrent portal hypertension after liver transplantation for patients who have not effective other treatment. Key words: Liver transplantation; Portal hypertension; Transjugular intrahepatic portosystemic shunting; Gastrointestinal hemorrhage; Ascites

Doppler ultrasound surveillance of TIPS-patency in the era of covered stents – retrospective analysis of a large single-center cohort

The purpose of this study was to determine accuracy and necessity of long-term Doppler ultrasound (DU) surveillance of transjugular intrahepatic portosystemic shunt (TIPS) patency after implantation of an ePTFE-covered stent-graft (Viatorr). This single-center retrospective study includes 228 consecutive cirrhotic patients with TIPS implantation due to portal hypertensive complications. Standardized DU surveillance was scheduled 3 - 5 days, 3 months, and 6 months after TIPS implantation and every 6 months thereafter. Portal venography was performed in case of DU findings suspicious of TIPS dysfunction, clinical signs of recurrent portal hypertension, or refractory hepatic encephalopathy. During a mean follow-up of 16.6 ± 23.4 months, 866 DU examinations were performed. Twenty-two cases of TIPS dysfunction were observed in 16 patients with no first dysfunction more than 4 years after implantation. Routine DU in asymptomatic patients had little therapeutic impact (0.75 %). DU and venography were concordant in 39/46 (84.8 %) paired examinations, and 1-, 2-, and 5-year primary TIPS patency was 87.4 %, 83.7 %, and 79.97 %, respectively. Patients with TIPS dysfunction and subsequent successful revision during the first 2 years of follow-up had a significantly higher risk (p = 0.001) of new dysfunction compared to those without TIPS dysfunction. Cumulative 1-, 2-, and 5-year survival was 68.7 %, 61.3 %, and 42.7 %, respectively. Despite acceptable accuracy, scheduled DU surveillance proved to have minor therapeutic impact. Thus, detailed DU surveillance is not useful in asymptomatic patients after 2 years of unremarkable follow-up. In contrast, long-term DU surveilleance should be performed in patients after successful revision of TIPS dysfunction and patients with prothrombotic states (e. g., portal vein thrombosis, Budd-Chiari syndrome).

10. Transjugular intrahepatic porto-systemic shunt (TIPSS) – single tertiary care centre experience

Background and Aims: TIPSS is a life saving procedure in cirrhotic patients with recurrent portal hypertension bleed and a palliative procedure for resistant ascites and hydrothorax. Methods: Clinical data of concurrent patients who underwent TIPSS for various indications from 2014 to 2018 was analyzed retrospectively Results: Total 16 patients underwent TIPSS during this period. Mean age was 53 (12–71) years, predominantly males (M:F:: 11:5), most common cause of underlying cirrhosis was cryptogenic. Mean MELD score was 16 (10–24), most common indication was resistant ascites (RA-10), other indications were RA+ hydrothorax (3), budd chiari syndrome with failed venous plasty (1), hepato renal syndrome (2). One of the patient had partial portal vein thrombosis and one had chronic portal vein thrombosis with large collaterals. TIPSS was placed from right hepatic vein to a collateral. In most of the patients covered stent was used except in 5, all were started on dual antiplatelets and LMWH post procedure, however stent patency rate was similar in both the groups. Most of the patients improved after the procedure, 2 patients required recurrent ascitic tapping for 3 months post TIPSS however ascites responded. 5 patients out of 16 had recurrent hepatic encephalopathy requiring admission but all of them were managed with anti coma measures, none required stent size reduction. One of them underwent liver transplant, 1 had subdural hematoma. Mean survival of our group post TIPSS was 16.6 (0.2–48) months. TIPSS patency was 100% in the study period. Conclusions: TIPSS has good survival benefits in well-chosen patients with life threatening complications related to cirrhosis. TIPSS could provide a good quality of life in those who don’t have option of liver transplant. Anticoagulation may not be a must in all patients to maintain TIPSS patency. The authors have none to declare.

Management of portal hypertension before and after liver transplantation.

Orthotopic liver transplantation (OLT) represents a curative treatment option for end-stage liver disease (ESLD). Although epidemiology of ESLD has recently changed due to the rising prevalence of nonalcoholic fatty liver disease and the decreased burden of hepatitis C virus infections due to highly effective antiviral regimens, the management of portal hypertension (PHT) remains a clinical challenge in the pre- and post-OLT setting. The measurement of the hepatic venous pressure gradient represents the most reliable but invasive tool for assessment of the severity of PHT. Although novel liver ultrasound and magnetic resonance-based elastography methods have been developed, their value to screen for liver fibrosis and PHT in transplanted patients remains to be established. Nonselective beta-blockers represent the cornerstone of medical treatment of PHT, but more studies on their effects on clinical endpoints after OLT are needed. Statins are widely used to treat hyperlipidemia, which is a common condition after OLT. Although a growing body of evidence suggests that statins decrease portal pressure and PHT-related complications in ESLD, studies on potential benefits of statins after OLT are lacking. Finally, transjugular intrahepatic portosystemic shunts (TIPS) are effective in decreasing PHT and seem to decrease mortality on the OLT waiting list. Moreover, TIPS does not have an impact on liver function nor complicate the transplant surgical procedures. TIPS may also be used after OLT, but the evidence is limited. In conclusion, whereas the management of PHT in patients with ESLD is based on strong evidence, further data on the value of noninvasive monitoring tools as well as on medical and invasive treatment options in the post-OLT setting are needed to improve management strategies in patients with recurrent PHT after liver transplantation. Liver Transplantation 24 112-121 2018 AASLD.

Transjugular intrahepatic portosystemic shunt in liver transplant recipients: indications, feasibility, and outcomes.

The role of transjugular intrahepatic portosystemic shunt (TIPS) for treating complications of portal hypertension after orthotopic liver transplantation (OLT) is unclear. In this review of 13 retrospective studies and 8 case reports comprising 213 patients, we assessed the indications, technical success, and clinical outcomes of TIPS procedures performed in patients who had undergone OLT. Indications for TIPS were refractory ascites (n = 168), variceal hemorrhage (n = 36), and hydrothorax (n = 9). Technical success was reported in 98% of cases. Five procedures failed because of portal vein thrombosis, caval tear, technical inability, patient instability, and unknown reasons (one each). Clinical success of TIPS after OLT was 57% in patients with refractory ascites, 69% in those with variceal hemorrhage, and 56% in those with hydrothorax. TIPS revision was required in 16% of cases, while 19% of patients underwent subsequent retransplantation. Postprocedural or worsening encephalopathy occurred in 33% of patients. Survival analysis based on 122 cases with data available revealed a 30-day mortality rate of 11%, a 1-year cumulative survival rate of 53%, and a 1-year cumulative retransplantation-free survival rate of 41%. Given the complexity of post-OLT cases with complications of recurrent portal hypertension, it is not surprising that the overall clinical success rate of TIPS was relatively low. Nevertheless, TIPS may remain a viable choice for the treatment of patients who have undergone OLT with recurrent portal hypertensive complications when medical therapy is unsuccessful.

Transjugular intrahepatic portosystemic shunts in liver transplant recipients

The insertion of a transjugular intrahepatic portosystemic shunt (TIPS) is a minimally invasive procedure used to relieve the signs and symptoms of portal hypertension in patients with liver disease. The most common indications for placement are refractory ascites and variceal hemorrhage. In properly selected candidates, TIPS placement can serve as a bridge to liver transplantation. Expertise in TIPS placement after transplantation has significantly increased, which has allowed the procedure to become a viable option for retransplant candidates suffering the consequences of recurrent portal hypertension due to portal vein thrombosis, recurrent liver disease, or hepatic venous outflow obstruction (HVOO). However, TIPSs in liver transplant recipients are associated with a lower clinical response rate and a higher rate of complications in comparison with patients with native liver disease, and they are, therefore, generally reserved for patients with a Model for End-Stage Liver Disease (MELD) score ≤ 15 and ≤ 12 in patients with HCV. The role of TIPS placement in nonliver transplant recipients has been well studied in large trials, and it translates well into clinical applicability to candidates for orthotopic liver transplantation (OLT). However, the experience with OLT recipients is heterogeneous and restricted to small series. Thus, we focus here on reviewing the current literature and discussing the proper use of TIPSs in liver transplant recipients.

Abstract No. 75: Transjugular intrahepatic portosystemic stent-shunt placement in liver-transplant recipients

To determine the feasibility, efficacy and safety of transjugular intrahepatic portosystemic stent-shunt (TIPSS) in liver transplant (LT) recipients. Between July 1995 and June 2010, 30 transplanted patients (mean age 53 years) with recurrent hepatitis B or C virus infection (n=15), secondary biliary cirrhosis due to chronic rejection (n=2), portal vein thrombosis (n=4), Budd-Chiari disease (n=2), small-for-size syndrome after LDLT (n=3), or other uncommon causes of recurrent portal hypertension on the graft(n=4) underwent TIPSS implantation. Indications for portal decompression include refractory ascites (n=18), hydrothorax (n=3), recurrent variceal bleeding (n=3), early portal vein occlusion (n=3), liver insufficiency after LDLT (n=2) and portal pressure reduction before surgical biliary repair (n=1). The median time interval from LT to TIPSS was 21 months (2–61). Bare and covered stents were implanted in 13 and 17 patients, respectively. A portal targetting was needed in 3 patients. TIPSS procedure succeeded in all patients. The mean portosystemic pressure gradient was reduced from 16.9 to 7.1 mmHg. (Near)-complete ascites remission was achieved in 72% of patients with ascites. All patients with hydrothorax or variceal bleeding did respond dramatically to TIPSS. One among the two patients with small-for-size syndrome improved significantly. 18 patients (60%) developped new onset or worsening encephalopathy at a median of 21 days post TIPSS and 2 among them needed reducer device implantation. 17 of the 30 patients (57%) died during the study period, mainly from liver failure or sepsis. Four of five patients who underwent retransplantation survived. The median survival after TIPSS was 6.2 months (1.5–72). TIPSS indications may be extended to liver transplant recipients. Control of ascites or bleeding could be achieved in most cases. A poor survival rate due to liver failure or immunosupression-related sepsis is observed. Redo transplantation within 5 months after TIPSS placement could improve survival.

Transjugular Intrahepatic Portosystemic Shunts in Liver Transplant Recipients for Management of Refractory Ascites: Clinical Outcome

To determine the effectiveness of transjugular intrahepatic portosystemic shunt (TIPS) creation in liver transplant recipients with recurrent portal hypertension presenting with refractory ascites. A retrospective review of transplant recipients undergoing TIPS creation was performed over a 6-year period. Recipients were noted for age, sex, TIPS indication, Model for End-stage Liver Disease (MELD) score, cause of initial liver disease, and time between first transplantation and TIPS creation. Clinical success was defined as graft survival of longer than 1 month with improvement in ascites. New-onset or worsening encephalopathy was noted. Graft survival and patency were calculated according to the Kaplan-Meier method. MELD score and portosystemic gradient (PSG) before and after TIPS creation were evaluated for prediction of graft loss less than 3 months after TIPS creation. Nineteen liver transplant recipients underwent TIPS creation for ascites. Mean time from transplantation was 3.5 years (range, 3.7-112.2 months). Mean MELD score before TIPS creation was 17 (range, 7-24). The technical, hemodynamic, and clinical success rates were 100%, 95%, and 16%, respectively. Encephalopathy developed in five patients (26%). Thirty- and 90-day mortality rates were 16% (n = 3) and 21% (n = 4), respectively. Primary unassisted patency and graft survival rates at 1, 3, and 6 months were 100%, 90%, and 90% and 79%, 58%, and 47%, respectively. MELD score parameters were significant indicators (P < .05) for graft survival beyond 3 months, but PSG parameters were not. TIPS for the management of ascites in liver transplant recipients is not as clinically effective as it is in patients with native livers (16% vs 50%-80% in the literature). MELD score is a predictor of graft survival; PSG parameters are not.

Recanalization of an Occluded Intrahepatic Portosystemic Covered Stent via the Percutaneous Transhepatic Approach

A 41-year-old woman with liver cirrhosis had recurrent portal hypertension and bleeding from esophageal varices due to complete occlusion of a previously inserted transjugular intrahepatic portosystemic shunt stent. Because recanalization of the stent by the transjugular approach was unsuccessful, ultrasound-guided entry to the splenic vein and portal vein was used. After catheter-directed intrathrombus thrombolysis, successful opening of the stent was achieved and a stent was placed. We herein report a rare case in which thrombolysis and recanalization of a TIPS stent were performed via a percutaneous transhepatic approach.

End‐to‐end portocaval shunt for venous drainage of the native foregut in combined liver–intestinal transplantation

An end-to-side portocaval shunt has been classically described as the standard procedure that needs to be performed to obtain adequate venous drainage of the foregut in combined liver-intestinal transplant. The transplanted organs are placed en bloc in a piggyback fashion on the recipient's vena cava, and graft's porto-mesenteric venous circulation is left intact. Recurrent portal hypertension with hemorrhage has been reported as a complication after such a procedure. In an effort to improve the technical aspects of this complex operation, we began to perform an end-to-end shunt from the recipient portal vein to the infrahepatic donor cava. Here, we describe this new surgical technique and discuss its potential advantages. The new technique is described in detail. Of the 70 intestinal transplants performed in 67 patients at The Mount Sinai Hospital from 1998 to December 2004, three were multivisceral transplants (MVTx) and 28 were combined liver intestine transplants (LITx), post-surgical outcome including recurrent portal hypertension and the presence of splenomegaly and significant thrombocytopenia was retrospectively review between the group that received the classic end-side vs. the new end-end portocaval shunt. Of the 28 LITx, 23 were done with the classic end-side portocaval shunt and in five (one adult, four pediatric) the end-to-end portocaval shunt described in the present study. One patient in this group died on post-operative day 31 (adult); after a mean follow up of 19.5 months there is a 100% patient and graft survival for the pediatric population. Post-operatively there have been no complications related to this technique. Few modifications have been made to the original description of MVTx. This is the first description of this technique that is relatively simple to perform, creating a large vascular conduit with high flow rates and theoretically less turbulence compared with the end-to-side shunt.

The natural history of portal hypertension after transjugular intrahepatic portosystemic shunts

BACKGROUND & AIMS: The effects of transjugular intrahepatic portosystemic shunt (TIPS) on portal hemodynamics, esophageal and gastric varices, and hepatic function have not been fully defined. The aim of this study was to define prospectively the effects of TIPS on portal pressures and flow, variceal resolution, and hepatic function.METHODS: Pressure and flow measurements were made by angiography and Doppler sonography, respectively. Varices were assessed by endoscopy and angiography. Liver functions were evaluated by a battery of tests.RESULTS: In 100 consecutive subjects, mean portosystemic gradient decreased from 24 to 11 mm Hg (means) (P < 0.001) after TIPS. Recurrent portal hypertension caused by stent thrombosis (n = 5), stent retraction (n = 2), and stent stenosis (n = 51) occurred at 6 months but, by year 5, was not present in survivors (n = 0 of 8). Fundic gastric varices failed to resolve in 6 of 12 cases. Systemic venous pressures of >15 mm Hg, stent dysfunction, and continued alcoholism were risk factors for recurrent hemorrhage. Angiography was superior to endoscopy, which was superior to Doppler sonography for detection of recurrent portal hypertension. Progressive liver failure occurred in 8 patients.CONCLUSIONS: Recurrent portal hypertension caused by stent stenosis occurs commonly in the first 2 years after TIPS. Fundic gastric varices often fail to disappear after TIPS. The effects of TIPS on liver function are unpredictable.(Gastroenterology 1997 Mar;112(3):889-98)

Balloon occlusion portography to diagnose new-onset left hepatic vein thrombosis and widening of an existing wallstent TIPS by palmaz stents for recurrent portal hypertension and variceal bleeding

A 31-year-old man with Child's class A micronodular cirrhosis, left lobe hypertrophy, and a transjugular intrahepatic portosystemic shunt (TIPS) which had been placed 6 months earlier, was admitted for recurrent esophageal bleeding and a portosystemic gradient of 42 mmHg. Balloon occlusion portography documented unsuspected ostial thrombosis of the previously patent left hepatic vein. This was considered the cause of the pressure rise. As it was not possible to insert a second TIPS in parallel, the shunt, stented originally with 10-mm Wallstents, was overdilated to 12 mm, and two 12-mm Palmaz stents were placed coaxially, reducing the portosystemic pressure gradient to 13 mmHg.

Balloon Occlusion Portography to Diagnose New-Onset Left Hepatic Vein Thrombosis and Widening of an Existing Wallstent TIPS by Palmaz Stents for Recurrent Portal Hypertension and Variceal Bleeding

Balloon Occlusion Portography to Diagnose New-Onset Left Hepatic Vein Thrombosis and Widening of an Existing Wallstent TIPS by Palmaz Stents for Recurrent Portal Hypertension and Variceal Bleeding