Transjugular Intrahepatic Portasystemic Shunt Research Articles

Hepatic venous pressure gradient and rebleeding risk of patients with nonalcoholic steatohepatitis cirrhosis after variceal bleeding.

Hepatic venous pressure gradient (HVPG) has a strong predictive value for variceal rebleeding in cirrhotic patients, but the accuracy of HVPG may be compromised in nonalcoholic steatohepatitis (NASH) cirrhosis. This study aimed to evaluate the accuracy of HVPG and portal pressure gradient (PPG) for predicting rebleeding in NASH cirrhosis after acute variceal bleeding. Thirty-eight NASH cirrhosis patients and 82 hepatitis B virus (HBV) cirrhosis patients with acute variceal bleeding were included in this study. All patients recived transjugular intrahepatic portalsystemic shunt (TIPS). The prognostic value of HVPG and PPG for variceal rebleeding was evaluated. Compared with HBV cirrhosis, NASH cirrhosis demonstrated a lower HVPG (15.3 ± 3.8 vs. 18.0 ± 4.8; p = 0.003) and lower PPG (18.0 ± 3.7 vs. 20.0 ± 3.4; p = 0.005). HVPG (AUC = 0.82; p = 0.002) and PPG (AUC = 0.72; p = 0.027) had promising prognostic value among NASH cirrhosis patients. The optimal threshold of HVPG and PPG for predicting rebleeding in NASH cirrhosis was 17 mmHg and 20 mmHg. At multivariate analysis, HVPG ≥17 mmHg was a significant predictor of variceal rebleeding (HR 9.40; 95% CI 1.85-47.70; p = 0.007). In the patients with cirrhosis and vairceal bleeding, the levels of HVPG and PPG were found to be low in NASH cirrhosis than HBV cirrhosis. However, the prevalence of rebleeding was similar between two groups. HVPG measurement is still an accurate way to assess the risk of variceal rebleeding in NASH cirrhosis.

Abdominal Vascular Evaluation

The vascular lab (VL) is instrumental in diagnosing vascular diseases such as renal artery stenosis and mesenteric ischemia or following a patient after transjugular intrahepatic portal systemic shunt (TIPS) creation. This article discusses indications, protocol, and diagnostic criteria for abdominal vascular ultrasound. The vascular lab can be used to investigate pathology in the abdomen either as a preliminary screening tool to evaluate for a pathology such as mesenteric artery stenosis in a patient with food fear and weight loss, renal artery stenosis in a patient with refractory hypertension or renal failure, or as a diagnostic tool in follow up after a patient has undergone a transjugular intrahepatic portal systemic shunt (TIPS) for portal hypertension. The technical success of duplex ultrasonography of the abdomen can be compromised by respiratory motion, obesity, and intestinal gas. Therefore, duplex scanning is performed in the fasting state particularly in elective outpatient cases. In emergent cases when pathology such as acute mesenteric ischemia is suspected evaluation with CT angiography may be best.

TIPS Is Not Associated with a Higher Risk of Developing HCC in Cirrhotic Patients: A Systematic Review and Meta-analysis.

Background and Aims: The association between portal-systemic shunt and hepatocellular carcinoma (HCC) development in patients who have cirrhosis is still controversial. This systematic review with meta-analysis was performed to systematically clarify the potential role of portal-systemic shunt in the development of HCC.Methods: The PubMed, Embase, and Cochrane Library databases were searched for potentially eligible literature. Meta-analysis with random-effects model was performed to combine the incidence rates of HCC after portal-systemic shunt. Finally, seven studies were included. In the present review, we mainly focused on 859 patients (365 in the transjugular intrahepatic portal-systemic shunt (TIPS) group and 494 in the non-TIPS group) from five studies to analyze incidence rates after TIPS.Results: At the end of follow-up, there were 66 (18%, 66/365) patients who developed HCC after TIPS intervention and 63 (13%, 63/494) patients who developed HCC after non-TIPS treatments. Pooled estimates with random-effects model did not demonstrate a significant increase of incidence of HCC after TIPS (risk ratio: 1.37 [confidence interval (CI): 0.96 to 1.97]; p = 0.08) compared with non-TIPS treatments. Subgroup analyses for those patients with transplanted liver also did not detect a significant difference between the TIPS group and non-TIPS group (risk ratio: 1.10 [CI: 0.59 to 2.07]; p = 0.75).Conclusions: Current evidence suggests that portal-systemic shunt is not associated with a higher risk of HCC development in cirrhotic patients.

Early detection of hepatic encephalopathy after transjugular intrahepatic portsystemic shunt using multiparametric magnetic resonance with spectroscopy

BackgroundHepatic encephalopathy (HE) is a complication of transjugular intrahepatic portosystemic shunt (TIPS). AimsExtend the knowledge about the early detection of multiple brain metabolic abnormalities following TIPS; these abnormalities can be detected and managed prior to the clinical manifestation of HE with use of Multiparametric Magnetic Resonance with Spectroscopy. Methods12 cirrhotic Patients underwent TIPS; each Patient underwent a 3 T MRI evaluation before and after TIPS. The spectroscopic images were processed measuring the values of the metabolites N-acetylaspartate (NAA) - Glutamine / Glutamate (Glx) - Colina (Cho) - Myinositol (mI) at the level of the nuclei of the base. ResultsSpectroscopic examination performed before the TIPS procedure showed low values of Cho and Mi, instead following the procedure: an increase in the Glx value, a mean reduction in the values of Cho and mI, a statistically significant reduction in the Cho / Creatine ratio, in the mI / Creatine ratio and an increase of the Glx / Creatine ratio. ConclusionsOur study demonstrated the efficacy of spectroscopy in Patient subjected to TIPS. MR 3 T with spectroscopy can become a valid tool for monitor the dynamics of changes in brain metabolism after TIPS and to provide an early diagnosis of HE allowing an early treatment.

Method for Calculating the Bending Angle of Puncture Needle in Preoperative Planning for Transjugular Intrahepatic Portal Systemic Shunt (TIPS).

Transjugular Intrahepatic Portal Systemic Shunt is a comprehensive interventional therapy for portal hypertension. During this intervention, puncturing from hepatic vein into portal vein is a difficult step. Selecting puncture needle with a proper bending angle is vital to accurate puncture. Thus, this prospective study provides a method to calculate the angle of the puncture needle using preinterventional contrast-enhanced CT imaging. According to the geometrical characteristics of puncture needle, Bezier curve equation was adopted to describe its bending part. By testing whether each point in a specific region satisfied the equation set of Bezier curves, the possible position of needle tip was obtained. Then, the bending angle of puncture needle was obtained by calculating curvature. The method was evaluated in 13 patients from 2 centers showing now a success rate of 100% and a duration of the procedure of 141 and 161 minutes. The method based on Bezier curve equation for calculating a proper bending angle of puncture needle was proven to be effective. And the clinical study is preliminary and additional work for clinical evaluation is necessary.

Abstract No. 620 Incidence and pathophysiology of transjugular intrahepatic portsystemic shunt (TIPS) complicated with lower extremity edema

TIPS is consistently proven to benefit patients with ascites, hydrothorax and gastrointestinal bleeding, however adverse events do occur after TIPS. Lower extremity edema (LEE), an under reported complication of TIPS, can cause significant morbidity. This study aims to measure the incidence and pathophysiology of LEE after TIPS. Between 2006-2016, a total of 220 patients underwent TIPS at our institution. LEE was defined as new onset or worsened edema up to one year after TIPS. Changes in diuretic use, clinical outcome of LEE, etiology of cirrhosis and effectiveness of TIPS in reducing ascites/hydrothorax were documented. Cardiac ventricular function was evaluated by echocardiography. Patients without close follow-up were excluded. Improvement in ascites was defined 25% fewer paracenteses. 205 patients were eligible for inclusion. 132 (64%) were male. Mean (SD) age was 54 (11) years old. Mean portosystemic shunt gradient changed from 18 to 7 mm Hg with mean (SD) post TIPS gradient of 7 (3). 80 (39%) patients had LEE at baseline. 101 patients (49%) had new onset or worsened LEE with median onset at one month follow-up. 62 out of 101 patients with LEE (61%) subsequently improved their edema (9 with conservative measures, 53 with diuretics). LEE was persistent despite diuretics in 36 patients (35%) at median follow-up of 21 months. Of note 30 out of 80 (37%) with baseline LEE had worsening edema. Multiple logistic regression analysis showed no significant impact from age, gender, ejection fraction, portosystemic gradient change and improvement in ascites on LEE. Presence of baseline edema prior to TIPS was protective in multivariate analysis (OR = -2.7, p = 0.007). LEE can complicate TIPS in almost half of patients, independent of left ventricular function. Close clinical follow-up after TIPS, without initially changing diuretics is recommended. Baseline edema does not necessarily lead to worsening edema after TIPS. Further studies are needed to better clarify the pathophysiology of LEE after TIPS.

Radiological Management of Hepatocellular Carcinoma Associated With Hepatic Venous Outflow Tract Obstruction

Background and Aim: Hepatocellular carcinoma (HCC) associated with hepatic venous outflow tract obstruction (HVOTO) is an unusual entity which has recently gained recognition. Treatment of both entities is essential in prolonging survival. Interventional radiologic techniques are the established therapeutic options for HVOTO and HCC and thus treatment becomes challenging. We illustrate two representative cases treated successfully treated at our centre. Methods: Patients with clinical diagnosis of HVOTO were evaluated by ultrasound Doppler, multiphase CT liver (MPCT)/dynamic MRI. HVOTO was confirmed by the presence of intrahepatic venous obstruction on Doppler and the treatment was based on the site/type of venous obstruction and included inferior vena cava(IVC) angioplasty or hepatic vein angioplasty (both with or without stenting) and trans-jugular intrahepatic port-systemic shunt (TIPS)/direct intrahepatic port-systemic shunt. On MPCT, HCC diagnosis was based on the modified EASL criteria. Staging and treatment options were according to the Barcelona clinic liver cancer (BCLC) staging. Results: Case one was diagnosed with absent all three hepatic veins with BCLC B stage HCC on MPCT and Doppler. TIPS was performed for HVOTO and subsequently TACE was undertaken for HCC. Follow up Doppler confirmed normal flow through the shunt and HCC depicted complete response. Case two was diagnosed with stenosis of all hepatic veins and IVC stenosis at cavo-atrial junction with intrahepatic collaterals. He also had BCLC B stage HCC on MPCT. IVC angioplasty was performed following which there was persistent stenosis on Doppler assessment, IVC stenting was subsequently performed which restored the normal calibre and flow in IVC. TACE was done for HCC and the residual tumor was completed treated by acetic acid ablation. Conclusion: Radiological techniques play a key role in the diagnosis and management of HVOTO-HCC. Both the entities need to be treated and this makes the treatment very challenging. The authors have none to declare.

Transjugular Intrahepatic Portal-Systemic Shunt for Palliative Treatment of Radioembolization-Induced Liver Disease in a Patient with Metastatic Lung Cancer

Introduction: Radioembolization induced liver disease (REILD) is a rare disease secondary to hepatic outflow obstruction after intra-arterial injection of radioactive embolic microspheres. It manifests as hepatomegaly, jaundice, and ascites shortly after therapy. Treatment for REILD is limited, but some studies suggest that portal-systemic shunting may potentially slow disease progression. This case report describes an instance where transjugular intrahepatic portal-systemic shunt (TIPS) provided palliative benefit in a cancer patient suffering from REILD. Case Presentation: A 64 year old female was diagnosed with metastatic pulmonary adenocarcinoma. Palliative chemotherapy with Crizotinib was initiated and the tumor burden significantly improved, however new liver metastasis were later identified and the patient underwent radioembolization with yttrium-90 (90Y-RE). One month later she developed new ascites and elevated bilirubin and increased transaminases. Crizotinib was discontinued and the patient was treated supportively for presumed REILD. Over the next 4 weeks her bilirubin peaked at 18.3 mg/dL and she was hospitalized with tense ascites and hydrothorax. She underwent transjugular intrahepatic portal-systemic shunt (TIPS) which improved her portal hypertension (HVPG from 15mmHg to 4mmHg). A liver biopsy was performed and sinusoidal obstruction syndrome (SOS), consistent with REILD, was identified (Figure 1). The patient continued to improve and on day 7 following TIPS she was discharged. Discussion: 90Y-RE is a radioactive embolization therapy that can be used as palliative, sometimes curative therapy in patients with unresectable tumor. REILD results from injury and eventual fibrosis of hepatic sinusoids; histologically identical to sinusoidal obstruction syndrome. REILD occurs more often in patients who have cirrhosis, are treated with larger doses of radiation, and those treated with radiation-sensitizing chemotherapeutic drugs. Crizotinib is not a known radiation sensitizing agent, but it may have contributed to this patient's REILD. TIPS has been utilized as a method of reducing portal hypertension and improving symptoms in patients with SOS, but there have been no prior case reports describing the use of TIPS for treatment of 90Y-RE induced REILD. Crizotinib may be a radiation-sensitizing chemotherapy that has yet to be recognized. TIPS procedure may be considered for select patients suffering from REILD in the future.

Modified technique for preparation of venous circulation resin casts in the cirrhotic liver.

This study describes two major adaptations for the preparation of resin casts in human cirrhotic liver, harvested at the time of transplantation. The first is the way of fixing the catheter in the ostia of the hepatic and portal veins through a cerclage, so as to prevent displacement of the catheter and / or leakage of the resin during its injection. The second is the extension of corrosion time in the NaOH solution, averaging 6.8 days, with daily replacement the solution until complete removal of parenchymal tissue. We applied the method in 14 cirrhotic livers, with good filling and coloring of the portal and hepatic vein territories, using different colors. This allows an anatomical study of these vessels, able to complement the knowledge of the histopathology in research work, and the planning of therapeutic procedures, such as the Trans-Jugular Intrahepatic Port-Systemic Shunt (TIPS). RESUMO Este estudo descreve duas importantes adaptações para o preparo de moldes de resina em fígado humano cirrótico, captado no momento do transplante: a primeira, é a maneira de fixação dos cateteres nos "óstios" das veias hepáticas e porta, através de uma "cerclagem" dos mesmos, de modo a evitar o deslocamento do cateter e/ou extravasamento da resina durante sua injeção, e a segunda, é o prolongamento do tempo de corrosão na solução de NaOH, atingindo a média de 6,8 dias, com a substituição diária da solução, até a remoção completa do tecido parenquimatoso. O método foi empregado em 14 fígados cirróticos com bom preenchimento e coloração dos territórios das veias porta e hepáticas, utilizando cores distintas. Isto permite um estudo anatômico desses vasos, capaz de complementar os conhecimentos da histopatologia em trabalhos de pesquisa, e planejar procedimentos terapêuticos como a derivação porto-sistêmica intra-hepática transjugular (TIPS - Transjugular Intrahepatic Postosystemic Shunt).

Contrast enhanced computed tomography and reconstruction of hepatic vascular system for transjugular intrahepatic portal systemic shunt puncture path planning.

To describe a method for the transjugular intrahepatic portal systemic shunt (TIPS) placement performed with the aid of contrast-enhanced computed tomography (CECT) and three-dimensional reconstructed vascular images (3D RVIs), and to assess its safety and effectiveness. Four hundred and ninety patients were treated with TIPS between January 2005 and December 2012. All patients underwent liver CECT and reconstruction of 3D RVIs of the right hepatic vein to portal vein (PV) prior to the operation. The 3D RVIs were carefully reviewed to plan the puncture path from the start to target points for needle pass through the PV in the TIPS procedure. The improved TIPS procedure was successful in 483 (98.6%) of the 490 patients. The number of punctures attempted was one in 294 (60%) patients, 2 to 3 in 147 (30%) patients, 4 to 6 in 25 (5.1%) patients and more than 6 in 17 (3.5%) patients. Seven patients failed. Of the 490 patients, 12 had punctures into the artery, 15 into the bile duct, eight into the gallbladder, and 18 through the liver capsule. Analysis of the portograms from the 483 successful cases indicated that the puncture points were all located distally to the PV bifurcation on anteroposterior images, while the points were located proximally to the bifurcation in the three cases with intraabdominal bleeding. The complications included three cases of bleeding, of whom one died and two needed surgery. Use of CECT and 3D RVIs to plan the puncture path for TIPS procedure is safe, simple and effective for clinical use.

Management of rectal varices in portal hypertension.

Rectal varices are portosystemic collaterals that form as a complication of portal hypertension, their prevalence has been reported as high as 94% in patients with extrahepatic portal vein obstruction. The diagnosis is typically based on lower endoscopy (colonoscopy or sigmoidoscopy). However, endoscopic ultrasonography has been shown to be superior to endoscopy in diagnosing rectal varices. Color Doppler ultrasonography is a better method because it allows the calculation of the velocity of blood flow in the varices and can be used to predict the bleeding risk in the varices. Although rare, bleeding from rectal varices can be life threatening. The management of patients with rectal variceal bleeding is not well established. It is important to ensure hemodynamic stability with blood transfusion and to correct any coagulopathy prior to treating the bleeding varices. Endoscopic injection sclerotherapy has been reported to be more effective in the management of active bleeding from rectal varices with less rebleeding rate as compared to endoscopic band ligation. Transjugular intrahepatic portsystemic shunt alone or in combination with embolization is another method used successfully in control of bleeding. Balloon-occluded retrograde transvenous obliteration is an emerging procedure for management of gastric varices that has also been successfully used to treat bleeding rectal varices. Surgical procedures including suture ligation and porto-caval shunts are considered when other methods have failed.

Fifty-three Years’ Experience With Randomized Clinical Trials of Emergency Portacaval Shunt for Bleeding Esophageal Varices in Cirrhosis

Emergency treatment of bleeding esophageal varices (BEV) consists mainly of endoscopic and pharmacologic measures, with transjugular intrahepatic portal-systemic shunt (TIPS) performed when bleeding is not controlled. Surgical shunt has been relegated to salvage. At the University of California, San Diego, Medical Center, our group has conducted 10 studies of emergency portacaval shunt (EPCS) during 46 years. To describe 2 randomized clinical trials (RCTs) conducted from 1988 to 2011 in unselected consecutive patients who received emergency treatment for BEV. In RCT No. 1, a total of 211 unselected consecutive patients with cirrhosis and acute BEV were randomized to emergency endoscopic sclerotherapy (EEST) (n=106) or EPCS (n=105). In RCT No. 2, a total of 154 unselected consecutive patients with cirrhosis and acute BEV were randomized to TIPS (n=78) or EPCS (n=76). Diagnostic workup was completed within 6 hours of initial contact, and primary treatment was initiated within 8 to 12 hours. Regular follow-up for up to 10 years was accomplished in 100% of the patients. In RCT No. 1, EEST or EPCS; in RCT No. 2, TIPS or EPCS. The 2 groups were compared with regard to survival, control of bleeding, portal-systemic encephalopathy, and direct cost of care. RESULTS Distribution in Child risk classes was almost identical. One-third of patients were in Child class C. Permanent control of bleeding was achieved by EEST in only 20% of the patients and by TIPS in only 22%. In contrast, EPCS permanently controlled bleeding in 97% and 100% of the patients in RCT No. 2 and RCT No. 1, respectively (P<.001). Survival was significantly greater following EPCS than after EEST and TIPS (P<.001). Median survival was more than 10 years following EPCS compared with 1.99 years after TIPS. Occlusion of TIPS was demonstrated in 84% of the patients, 63% of whom underwent TIPS revision, which failed in 80% of the cases. Recurrent portal-systemic encephalopathy developed in 35% of the patients who underwent EEST and 61% of those who received TIPS. In contrast, portal-systemic encephalopathy occurred in 15% of the patients who received EPCS in RCT No. 1 and 21% of those in RCT No. 2. Direct costs of care were 5 to 7 times greater in the EEST ($168100) and TIPS ($264800) groups than in the EPCS ($39000) group (P<.001). Emergency portacaval shunt permanently stopped variceal bleeding, almost never became occluded, accomplished 5 times the long-term survival than EEST or TIPS, and was much less costly than EEST or TIPS. The widespread practice of using EPCS mainly as salvage for failure of endoscopic therapy or TIPS is not supported by the definitive results of these long-term RCTs in unselected patients with cirrhosis. TRIAL REGISTRATION clinicaltrials.gov Identifier: NCT00690027 and NCT00734227.

Transjugular Intrahepatic Portosystemic Shunt (TIPS) for the Treatment of Anorectal Varices

Purpose: Despite the high prevalence of anorectal varices in portal hypertension, serious hemorrhage is quite rare, but may be fatal. Although several techniques for treating acute bleeding have been reported, the optimal therapeutic management has not been established. We report a patient with severe recurrent rectal bleeding from anorectal varices successfully treated by a transjugular intrahepatic portosystemic shunt (TIPS). A 53-year-old man with known history of hepatitis C-induced liver cirrhosis, listed for possible liver transplantation and prior decompensation in the form of esophageal variceal bleed maintained on beta-blockers, presented to the emergency department with the chief complaint of rectal bleeding for one week's duration, associated with weakness, dizziness, shortness of breath, and generalized abdominal pain. On admission, labs showed: WBC 1.3, hb 10.4, hct 31.4, INR 1.5, total bilirubin 1.4, alkaline phos 136, ALT 43, AST 70. CT abdomen and pelvis performed the day of admission revealed: diffuse cirrhosis without hepatic lesion, splenomegaly, large-caliber gonadal varices that extend to the pelvis and surround the rectum, as well as concentric thickening of the rectum. Due to presentation and findings, gastroenterology was consulted. EGD showed grade 2 esophageal varices without stigmata of recent bleeding, and gastric antral vascular ectasia (GAVE) without active bleeding. Colonoscopy showed very large rectal varices. One column had a small mucosal hemorrhage present, no active bleeding esd present, and a nonbleeding cecal AVM. After extensive discussion between the hepatology and GI departments about options for treatment, it was decided to pursue transjugular intrahepatic portal systemic shunt (TIPS) to relieve portal pressure causing the rectal varices. The patient underwent successful TIPS procedure, performed by the interventional radiology department. Contrast injections during the examination demonstrated hepatofugal flow in the portal vein. The patient was also noted to have splenorenal shunting, as well as massive inferior mesenteric vein filling rectal varices. A Rosen wire was placed. The tract was dilated to 8 mm. A 10-mm x 80-mm covered VIATORR stent was placed. Follow-up pressures demonstrated a mean portal pressure of 29 mmHg with a central venous pressure of 29/22, with a mean of 25 mmHg. There remained flow in the inferior mesenteric vein; however, it subjectively appeared to be slower. After the procedure, the patient was discharged to be followed closely as an outpatient. A follow-up colonoscopy was performed two months after TIPS procedure. showing one cord of rectal varices, approximately 75% improved since prior colonoscopy, and small internal hemorrhoids.

Percutaneous transhepatic variceal embolization with cyanoacrylate vs. transjugular intrahepatic portal systematic shunt for esophageal variceal bleeding.

To compare the long-term results of modified percutaneous transhepatic variceal embolization with cyanoacrylate (PTVE) and the transjugular intrahepatic portal systemic shunt (TIPS) for treating esophageal variceal bleeding. Patients with cirrhosis and variceal bleeding who underwent TIPS and PTVE with cyanoacrylate between January 2006 and December 2010 were selected. We performed chart reviews to determine the rebleeding rate, survival and the rate of encephalopathy. This retrospective study included 96 PTVE patients and 43 TIPS patients, with a median follow-up of 30.4 and 31.6months in the two groups, respectively. Rebleeding occurred in 13 patients (30.2%) in the TIPS group and in 20 patients (20.8%) in the PTVE group (p=0.229). For patients with model for end-stage liver disease (MELD) scores>18 at 1, 3 and 5years, the survival rates were 84.2, 39.9 and 16.0%, respectively, in the TIPS group, and they were 96.7, 72.0 and 36.0%, respectively, in the PTVE group (p=0.037). Sixteen (16.7%) PTVE patients and 25 (58.1%) TIPS patients developed encephalopathy (p=0.000). Mean MELD and Child-Pugh scores improved significantly in modified PTVE patients. However, no such changes were observed in TIPS patients. PTVE and TIPS were comparable in terms of variceal rebleeding prevention. However, in>18-MELD-score patients, PTVE offered better survival than TIPS. In addition, PTVE offered lower incidence of encephalopathy than TIPS.

Successful transjugular intrahepatic portal-systemic shunt in an ineligible liver transplant patient with primary biliary cirrhosis with refractory ascites and aplastic anemia

A transjugular intrahepatic portal-systemic shunt (TIPS) is a standard way to decompress the portal system in cirrhotic patients as a bridge to orthotopic liver transplantation (OLT). Traditionally, TIPS has been indicated for certain portal hypertensive sequelae such as refractory ascites, varices treatment and even hepato-hydrothorax. Herein is a case report on the efficacy of TIPS in an OLT ineligible patient with primary biliary cirrhosis and aplastic anemia who had developed refractive ascites requiring serial paracentesis and esophageal varices. He survived 2.5 years post-TIPS placement and died from complications related to severe leucopenia and the development of sepsis.

Letter: non‐cirrhotic portal hypertension and end‐stage liver disease

SIRS, The report by Schouten et al. on mortality in idiopathic non-cirrhotic portal hypertension (INCPH) was interesting. It adds to the growing evidence that INCPH can lead to features of end-stage liver disease in the absence of cirrhosis. Indeed some of the patients in this report had also suffered hepatic encephalopathy after transjugular intrahepatic port-systemic shunt (TIPSS) which is unusual given the fact that hepatic synthetic dysfunction is believed to be unusual. All these features indicate that INCPH indeed results in end-stage liver dysfunction in a subset of patients. It would be interesting if the authors could clarify the exact histologic findings in these patients who did need transplantation and also those who developed hepatic encephalopathy after TIPSS. Others have previously suggested that nodular transformation may represent a more severe end of the disease spectrum. Also it would be of interest to know any reasons which resulted in encephalopathy in TIPSS group but not in the surgical group.

Ultrasound-guided transhepatic puncture of the hepatic veins for TIPS placement

This retrospective analysis was carried out to assess the feasibility and results of transjugular intrahepatic portal systemic shunt (TIPS) performed with ultrasound (US)-guided percutaneous puncture of the hepatic veins. Over a period of 3 years, 153 patients were treated with TIPS at our centre. In eight cases, a percutaneous puncture of the middle (n=7) or right (n=1) hepatic vein was required because the hepatic vein ostium was not accessible. Indications for TIPS were bleeding (n=1), Budd-Chiari syndrome (n=1), ascites (n=2), reduced portal flow (n=1) and incomplete portal thrombosis (n=3). A 0.018-in. guidewire was anterogradely introduced into the hepatic vein to the inferior vena cava (IVC) through a 21-gauge needle. In the meantime, a 25-mm snare-loop catheter was introduced through the jugular access to retrieve the guidewire, achieving through-andthrough access. Then, a Rosch-Uchida set was used to place the TIPS with the traditional technique. Technical success was achieved in all patients. There was one case of stent thrombosis. One patient died of pulmonary oedema. Three patients were eligible for liver transplantation, whereas the others were excluded due to shunt thrombosis (n=1) and previous nonhepatic neoplasms (n=3). The percutaneous approach to hepatic veins is rapid and safe and may be useful for avoiding traumatic liver injuries.

Prosthetic H-Graft Portacaval Shunts vs Transjugular Intrahepatic Portasystemic Stent Shunts: 18-Year Follow-Up of a Randomized Trial

Widespread application of transjugular intrahepatic portasystemic shunt (TIPS) continues despite the lack of trials documenting efficacy superior to surgical shunting. Here we present an 18-year follow-up of a prospective randomized trial comparing TIPS with small-diameter prosthetic H-graft portacaval shunt (HGPCS) for portal decompression. Beginning in 1993, patients were prospectively randomized to undergo either TIPS or HGPCS as definitive therapy for portal hypertension due to cirrhosis. Complications of shunting and long-term outcomes were noted. Failure of shunting was prospectively defined as the inability to place shunt, irreversible shunt occlusion, major variceal rehemorrhage, unanticipated liver transplantation, or death. Survival and shunt failure were compared using Kaplan-Meier curve analysis. Median data are reported. Patient presentation, circumstances of shunting, causes of cirrhosis, severity of hepatic dysfunction (eg, Child's class, Model for End-Stage Liver Disease score), and predicted survival after shunting did not differ between patients undergoing TIPS (n = 66) or HGPCS (n = 66). Survival was significantly longer after HGPCS for patients of Child's class A (91 vs 19 months; p = 0.009) or class B (63 vs 21 months; p = 0.02). Shunt failure occurred later after HGPCS than TIPS (45 vs 22 months; p = 0.04). Compared with TIPS, survival after HGPCS was superior for patients with better liver function (eg, Child's class A or B). Shunt failure after HGPCS occurred later than after TIPS. Rather than TIPS, application of HGPCS is preferred for patients with complicated cirrhosis and better hepatic function.

Transjugular Intrahepatic Portosystemic Shunt: State of the Art

Since the first description of transjugular portal venography and radiologic portacaval shunt placement by Rosch n 19691 and the subsequent introduction of the transjugular intrahepatic portasystemic shunt (TIPS) into clinical medicine by Colapinto in 1982, TIPS has been increasingly adopted as a means of reducing portal pressures in patients with complications related to portal hypertension, such as refractory variceal bleeding. The procedure has also evolved to encompass other indications, such as refractory ascites2,3 and ts related complications, such as hepatorenal syndrome4 and epatic hydrothorax.5,6 In addition TIPS has also been sucessfully applied to patients with Budd–Chiari syndrome,7,8 portal vein occlusion,9 and ectopic variceal bleeding.10 Created with the use of catheters, balloons, and stents inserted under radiologic guidance, TIPS intrinsically functions as a side-to-side porta-caval shunt. The 2 major drawbacks of the TIPS procedure are progressive encephalopathy caused by direct portosystemic shunting and shunt dysfunction. Since the late 1990s the practice of TIPS has been greatly influenced by the introduction of the model for end-stage liver disease (MELD) scoring system for risk assessment of short-term mortality in patients undergoing TIPS and also by the introduction of polytetrafluoroethylene-covered endografts, which achieve durable long-term patency. These endografts and their effect on producing long-term shunt patency are redefining the role of TIPS for treating complications of portal hypertension. In this review article, we describe the common indications of TIPS procedure, the pathophysiology of portal hypertension, and anatomic aspects relevant to the safe creation of a TIPS. We describe the preprocedure evaluation of patients undergoing a TIPS procedure and techniques for step-wise placement of a TIPS as well as monitoring for and management of shunt dysfunction. We also look at newer techniques, such as direct intrahepatic portocaval shunting

Transjugular Intrahepatic Portalsystemic Shunt is an Effective Bridge to Liver Transplant in the Management of Hepatic Hydrothorax

Transjugular Intrahepatic Portalsystemic Shunt is an Effective Bridge to Liver Transplant in the Management of Hepatic Hydrothorax