Candidates For Transjugular Intrahepatic Portosystemic Shunt Research Articles

Role of erector spinae plane block in transjugular intrahepatic portosystemic shunt procedure: A randomized controlled trial

ABSTRACT Background Anesthesia for transjugular intrahepatic portosystemic shunt (TIPS) for lowering raised portal pressure is clinically challenging. As patients, candidates for TIPS are medically complex due to chronic liver disease, adding to remote area anesthesia’s complexities. Multimodal analgesia, including erector spinae plane block (ESPB), can improve anesthesia quality with patient satisfaction. Methods Fifty-six patients scheduled for TIPS, aged 18–60 years and with Child classification A or B, were randomly allocated into two groups. The ESPB group experienced ESPB (n = 24), while the control group was introduced with sedation spontaneously breathing (n = 24). Primarily, we investigated the records of the hemodynamic profile and analgesia nociceptive index (ANI). As a secondary aim, we recorded the opioid consumption, complication incidence, and patient and interventional radiologist satisfaction scores. Results Heart rate was significantly lower in the ESPB group at the beginning of the procedure, liver puncture, and balloon dilatation events, while there were no significant differences in mean blood pressure. Analgesia assessment by ANI was significantly higher in the ESPB group indicating adequate analgesia. Opioid consumption was significantly lower in the ESPB group than in the control group. Statistical analysis for patient satisfaction showed better results in the ESPB group, while the surgeon satisfaction score showed no significant statistical differences. Conclusion ESPB could be recommended as an alternative to analgesia in TIPS and its vulnerable patients to improve safety by reducing sedation-related morbidity and complications with improving the patient’s degree of satisfaction.

Transjugular intrahepatic portosystemic shunt in portal hypertension: How to go further while staying on track?

Transjugular intrahepatic portosystemic shunt in portal hypertension: How to go further while staying on track?

Left atrial dysfunction is an independent predictor of mortality in patients with cirrhosis treated by transjugular intrahepatic portosystemic shunt.

The present study aimed to investigate (1) the association between left ventricular diastolic dysfunction (LVDD), graded according to the algorithm proposed by the Cirrhotic Cardiomyopathy Consortium, and long‐term survival in patients with cirrhosis undergoing transjugular intrahepatic portosystemic shunt (TIPS) and (2) the additive prognostic value of left atrial (LA) function, as assessed by LA reservoir strain, using two‐dimensional speckle‐tracking echocardiography (2D‐STE). A total of 129 TIPS candidates (mean ± SD, 61 ± 12 years; 61% men) underwent a comprehensive preprocedural echocardiography. LA dysfunction was defined by LA reservoir strain ≤35%, based on a previously suggested cut‐off value. The outcome was all‐cause mortality after TIPS. In the current cohort, 65 (50%) patients had normal diastolic function, 26 (20%) patients had grade 1 LVDD, 21 (16%) patients had grade 2 LVDD, and 17 (13%) patients had indeterminate diastolic function. Additionally, LA dysfunction (based on LA reservoir strain ≤35%) was noted in 67 (52%) patients. After a median follow‐up of 36 months (range, 12–80), 65 (50%) patients died. All‐cause mortality rates increased along worse grades of LVDD (log‐rank p = 0.007) and with LA dysfunction (log‐rank p = 0.001). On multivariable Cox regression analysis, Model for End‐Stage Liver Disease score (hazard ratio [HR],1.06; p = 0.003), hemoglobin (HR, 0.74; p = 0.022), and LA strain, expressed as a continuous variable (HR, 0.96; p = 0.005) were independently associated with all‐cause mortality. Notably, the addition of LA strain to the model provided incremental prognostic value over the established prognostic variables (delta χ 2 = 8.27, p = 0.004). Conclusion: LA dysfunction assessed with 2D‐STE is independently associated with all‐cause mortality in patients with cirrhosis treated by TIPS.

25\xa0years of experience with transjugular intrahepatic portosystemic shunt (TIPS): changes in patient selection and procedural aspects

BackgroundTIPS is an established treatment for portal hypertension. The aim was to analyze how patient selection for TIPS implantation and procedural aspects have changed over 25 years. Routinely collected demographic, clinical, laboratory, and procedural data of 835 patients treated with TIPS in a single center were used. Time trends over the observational period from 1993 to 2018 were retrospectively analyzed. Descriptive statistical analysis was performed.ResultsThe most common indication for TIPS implantation has changed significantly from secondary prevention of variceal hemorrhage in the early years to treatment of recurrent ascites. During the observation period, increasingly more severely ill patients became TIPS candidates. There was little change in MELD scores over this period (in total median 13.00; IQR 10.00–18.00). The proportion of patients with Child–Pugh C cirrhosis increased. The most frequent underlying diseases in total were alcohol-related liver disease (66.5%) and viral hepatitis (11.9%). However, shares of cryptogenic liver cirrhosis, autoimmune hepatitis, and NASH increased over time. The proportion of patients post liver transplant also increased. While bare metal stents were standard in the past, use of covered stents increased. The success rate of TIPS (defined by successful implantation and a decrease in the portosystemic pressure gradient ≤ 12 mmHg) increased significantly over time. The total success rate according to this definition was 84.9%.ConclusionThe results of our analysis reflect technical developments in TIPS, especially in terms of stent material and gains in clinical experience, particularly regarding indications and patient selection for TIPS implantation.

Development and Validation of Prognostic Models to Estimate the Risk of Overt Hepatic Encephalopathy After TIPS Creation: A Multicenter Study.

INTRODUCTION:Overt hepatic encephalopathy (HE) is a major complication of transjugular intrahepatic portosystemic shunt (TIPS). This study aimed to develop and validate prognostic models to identify patients at different risks of overt HE within 3 months after TIPS.METHODS:Two cohorts of patients with cirrhosis undergoing TIPS insertion were retrospectively included. In the derivation cohort of 276 patients, 3 models were established in increasing order of complexity: core model (age + Child-Pugh class), sarcopenia model (core model + sarcopenia), and full model (sarcopenia model + post-TIPS portal pressure gradient). All models were internally validated for discrimination and calibration and externally validated in an independent cohort of 182 patients.RESULTS:During a 3-month follow-up period, 61 (22.1%) and 33 patients (18.1%) developed overt HE in the derivation and validation cohort, and sarcopenia was associated with increased risk of the outcome. In the derivation cohort, the core model showed a c-statistic of 0.68 (95% confidence interval [CI] 0.61–0.75), and discrimination improved in the sarcopenia model (c-statistic 0.73; 95% CI 0.66–0.80). The full model that extended the core model with inclusion of sarcopenia and post-TIPS portal pressure gradient showed a significant improvement in discriminative ability (0.77; 95% CI 0.71–0.83; P = 0.001). Both sarcopenia and full model yielded comparable performances in the validation cohort.DISCUSSION:We developed and externally validated 2 prediction models applied before (sarcopenia model) and after TIPS (full model) to estimate the risk of post-TIPS overt HE. These tools could aid to select appropriate candidates for TIPS and guide postoperative management.

Updated strategies in the management of acute variceal haemorrhage.

This article reviews the most recent studies regarding the management of acute esophageal variceal haemorrhage. New randomized control trials and meta-analyses confirmed the role of early transjugular intrahepatic portosystemic shunt (TIPS) in the management of acute variceal haemorrhage in Child-Pugh C (10-13) and B patients with active bleeding. A recent randomized controlled trial focused on the duration of vasoactive therapy showed no difference between 2 and 5 days of octreotide. A randomized trial showed decreased use of blood products for the correction of coagulopathy using a thromboelastography-guided approach (vs. conventional parameters) as well as decreased bleeding rates when compared with standard of care. A meta-analysis found that for rescue of variceal bleeding, self-expanding metallic stents were more efficacious and safer than balloon tamponade. In addition, studies showed that Child-Pugh C patients and those with hepatic vein pressure gradient more than 20 were at the highest risk of treatment failure, while model for end-stage liver disease was highly predictive of in-hospital mortality. In patients with severe coagulopathy and uncontrolled bleeding, TEG-based transfusion strategies are recommended. Antibiotics should be used for all cirrhotic patients presenting with upper gastrointestinal bleeding, but should be tailored in accordance to local resistance patterns. Early TIPS for high-risk patients has been shown to have a significant survival benefit. Certain aspects of the management of variceal bleeding remain poorly studied such as the role of early TIPS in Child-B patients as well as strategies for rescue therapy in patients who are not TIPS candidates, and require further investigation.

S1139 Transjugular Intrahepatic Portosystemic Shunt vs Balloon-Occluded Transvenous Obliteration for the Management of Non-Esophagogastric Varices

INTRODUCTION: There are few options for bleeding rectal or peristomal varices in patients unable to undergo transjugular intrahepatic portosystemic shunt (TIPS). There is extensive experience with balloon-occluded antegrade or retrograde transvenous obliteration (BA-RTO) of gastric and esophageal (GE) varices. However, there is a paucity of data regarding the use of BA-RTO for the management of non-esophagogastric (Non-GE) varices. In this study, we assess the outcomes of patients with bleeding Non-GE varices managed by BA-RTO vs. TIPS. METHODS: Patients undergoing TIPS vs. BA-RTO procedures for Non-GE varices at our liver center were compared for demographics, MELD-Na labs prior to and following procedure, rebleeding, frequency of paracentesis and hepatic encephalopathy and mortality. RESULTS: 14 patients underwent procedures for bleeding Non-EV varices. Nine patients had rectal varices, four peristomal and one duodenal. Six patients undergoing BA-RTO were compared to eight patients undergoing TIPS. Of the BA-RTO patients, 5 had BATO and 1 BRTO. There were no differences in age, gender, race or cause of liver disease. In the BA-RTO groups, mean MELD-Na prior to procedures was 23.3 ± 9.4 declining to 20.0 ± 10.4 and 18.0 ± 4.2 at 30 and 90 days after procedure. TIPS patients had a MELD-Na prior to procedure of 18.5 ± 6.1 increasing to 21.7 ± 5.5 and 24.0 ± 7.5.4. Of the BA-RTO patients, 4 were felt to be too ill for TIPS and, of these, 2 died within 90 days: 1 from uncontrolled bleeding and 1 from sepsis. 2 of 8 TIPs patients died within 90 days with 1 from uncontrolled bleeding. Rebleeding rates were 16.7 for BA-RTO vs. 12.5% for TIPS (P = 1.00) and no procedures were repeated. Comparing BA-RTO to TIPS, median length of stay was 14.5 ± 9.8 vs. 7.8 ± 7.5 (P = 0.14), paras 90 days prior and after procedure were 3.5 ± 4.5 vs. 0.0 ± 0.0 (P = 0.018) and 3.0 ± 4.6 vs. 0.0 ± 0.0 (P = 0.028). There were no differences in hepatic encephalopathy in the 90 days before and after the procedure (66.7 vs. 50% and 33.3 vs. 25.0%). CONCLUSION: TIPS remains an excellent option for bleeding Non-EV varices. Despite the fact that BA-RTO patients were more ill and typically not candidates for TIPS, BA-RTO was an excellent alternative with non-inferiority in terms of rebleeding and mortality. Patients undergoing BA-RTO had a decline in MELD score whereas TIPS patients had an increase. Either modality should be considered early before patients are increasingly ill.Figure 1.: Overall survival between groups with three patients removed Note: Patient which had the event of interest at 3000 days was censored at 2000 days.

Improvement in Quality of Life and Decrease in Large-Volume Paracentesis Requirements With the Automated Low-Flow Ascites Pump.

The automated low‐flow ascites pump (alfapump) is an implantable device that drains ascites directly into the urinary bladder. We studied its safety (absence of serious complications) and efficacy (decreased large‐volume paracentesis [LVP] requirement and improved quality of life [QoL]) in the management of ascites in a cohort of North American patients with cirrhosis and recurrent ascites ineligible for transjugular intrahepatic portosystemic shunt (TIPS). QoL was measured by the Chronic Liver Disease Questionnaire (CLDQ) and Ascites Questionnaire (Ascites Q). Following alfapump implantation, patients were monitored for ascites control, laboratory abnormalities, QoL, adverse events, and survival at 12 months. A total of 30 patients (60.0 ± 9.9 years; 57% male; Model for End‐Stage Liver Disease score, 11.4 ± 2.7) received an alfapump, mostly by an interventional radiology approach (97%), followed by longterm prophylactic antibiotics. The alfapump removed a mean ascites volume of 230.6 ± 148.9 L/patient at 12 months, dramatically reducing the mean LVP frequency from 2.4 ± 1.4/patient/month before pump implantation to 0.2 ± 0.4/patient/month after pump implantation. All surviving patients had improved QoL (baseline versus 3 months; CLDQ, 3.9 ± 1.21 versus 5.0 ± 1.0; Ascites Q, 51.7 ± 21.9 versus 26.7 ± 18.6; P < 0.001 for both) and a better biochemical index of nutritional status (prealbumin 87.8 ± 37.5 versus 102.9 ± 45.3 mg/L at 3 months; P = 0.04). Bacterial infections (15 events in 13 patients), electrolyte abnormalities (11 events in 6 patients), and renal complications (11 events in 9 patients) were the most common severe adverse events. By 12 months, 4 patients died from complications of cirrhosis. Alfapump insertion may be a definitive treatment for refractory ascites in cirrhosis, especially in patients who are not TIPS candidates.

Transjugular intrahepatic portosystemic shunt (TIPS): current indications and strategies to improve the outcomes.

Transjugular intrahepatic portosystemic shunt (TIPS) represents a very effective treatment of complications of portal hypertension. Established indications to TIPS in cirrhotic patients include portal hypertensive bleeding and refractory ascites. Over the years additional indications have been proposed, such as the treatment of vascular disease of the liver, hepatic hydrothorax, hepatorenal syndrome and bleeding from ectopic varices. Indications under evaluation include treatment of portal hypertension prior to major abdominal surgery and treatment of portal vein thrombosis. In spite of these advances, there are still uncertainties regarding the appropriate workup for patients to be scheduled for TIPS. Moreover, prevention and management of post-TIPS complications including hepatic encephalopathy and heart failure are still suboptimal. These issues are particularly relevant considering aging in TIPS candidates in Western countries. Correct selection of patients is mandatory to prevent complications which may eventually frustrate the good hemodynamic results and worsen the patient's quality of life or even life expectancy. The possible role of small diameter TIPS to prevent post-procedural complications is discussed.

Predictive value of induced hyperammonaemia and neuropsychiatric profiling in relation to the occurrence of post-TIPS hepatic encephalopathy.

Hepatic encephalopathy (HE) occurs in 20-50% of patients after transjugular intrahepatic portosystemic shunt (TIPS) placement. Older age, HE history and severe liver failure have all been associated with post-TIPS HE but it remains difficult to identify patients at risk. The aim of the present pathophysiological, pilot study was to assess the role of induced hyperammonaemia and associated neuropsychological and neurophysiological changes as predictors of post-TIPS HE. Eighteen TIPS candidates with no overt HE history (56 ± 8yrs., MELD 11 ± 3) underwent neurophysiological [Electroencephalography (EEG)], neuropsychological [Psychometric Hepatic Encephalopathy Score (PHES) and Scan tests], ammonia and sleepiness assessment at baseline and after the induction of hyperammonaemia by an oral amino acid challenge (AAC). Pre-AAC, 17% of patients had abnormal EEG, 5% abnormal PHES, and 33% abnormal Scan performance. Post-AAC, 17% had abnormal EEG, 0% abnormal PHES, and 17% abnormal Scan performance. Pre-AAC, ammonia concentrations were 201 ± 73μg/dL and subjective sleepiness 2.5 ± 1.2 (1-9 scale). Post-AAC, patients exhibited the expected increase in ammonia/sleepiness. Six months post-TIPS, 3 patients developed an episode of HE requiring hospitalization; these showed significantly lower pre-AAC fasting ammonia concentrations compared to patients who did not develop HE (117 ± 63 vs. 227 ± 57μg/dL p = 0.015). They also showed worse PHES/Scan performance pre-AAC, and worse Scan performance post-AAC. Findings at 12months follow-up (n = 5 HE episodes) were comparable. In conclusion, baseline ammonia levels and both pre- and post-AAC neuropsychiatric indices hold promise in defining HE risk in TIPS candidates with no HE history.

P: 19 Predictive Value of Induced Hyperammonaemia and Neuropsychiatric Profiling in Relation to the Occurrence of Post-tips Hepatic Encephalopathy (HE)

BACKGROUND: Hepatic encephalopathy (HE) occurs in 20%–50% of patients after transjugular intrahepatic portosystemic shunt (TIPS). While indices such as an older age, a history of overt HE and severe liver failure have been associated with post-TIPS HE, it remains difficult to identify patients at risk. The aim of this study was to evaluate the predictive value of a large set of clinical, laboratory and neuropsychiatric parameters, both at baseline and after the induction of hyperammonaemia, in relation to the development of post-TIPS HE for 12 months in a group of well-characterised TIPS candidates. METHODS: 18 TIPS candidates (58 ± 8 yrs, MELD 11 ± 3; 13 refractory ascites, 1 hydrothorax, 4 uncontrolled bleeding) underwent neurophysiological [Electroencephalography (EEG)], neuropsychological [Psychometric Hepatic Encephalopathy Score (PHES) and Scan test], capillary ammonia and subjective sleepiness assessment both at baseline and after the induction of hyperammonaemia by an oral amino acid challenge (AAC). RESULTS: At baseline, 3 (17%) patients had abnormal EEG, 1 (5%) abnormal PHES, and 6 (33%) abnormal Scan performance; fasting capillary ammonia concentrations were 199 ± 88 μg/dL and subjective sleepiness 2.5 ± 1.2 (1–9 scale). Post-AAC, 3 (17%) patients had abnormal EEG, none abnormal PHES, and 3 (17%) abnormal Scan performance. Post-AAC, patients exhibited the expected increase in ammonia [F(4, 56) = 2.7213, P = 0.038] and subjective sleepiness [F(4, 52) = 5.4002, P = 0.001]. Six months after TIPS, 3 patients had had an HE-related hospitalization. Compared to their counterparts who had not, they showed significantly lower, pre-AAC fasting ammonia concentrations (96 ± 93 vs. 225 ± 58 μg/dL, P = 0.017). They also showed worse PHES and Scan performance at baseline, as well as worse Scan performance and slower EEG post-AAC. Twelve months post-TIPS, 5 patients had had an HE-related hospitalization, and comparisons between the two groups confirmed the findings at 6 months. CONCLUSIONS: TIPS candidates, who are by definition at low risk of HE, seem to encompass two different populations: i) those who are well and have not had overt HE because their ammonia levels are near-normal, ii) those who are well and have not had overt HE despite hyperammonaemia, either because of habituation or a personal inclination not to exhibit the HE phenotype. Fasting ammonia may be a promising and easily obtained parameter for future validation and inclusion in models for the prediction of post-TIPS HE.

Investigating the risk factors of hepatocellular carcinoma and survival analysis for cirrhosis after transjugular intrahepatic portosystemic shunt in treating portal hypertension

This study aimed to explore the risk factors of hepatocellular carcinoma (HCC) and survival analysis for cirrhosis after transjugular intrahepatic portosystemic shunt (TIPS) in treating portal hypertension. A retrospective database review was performed, including 106 patients (33 females and 73 males; aged 26-68 years with mean age of 55.3 ± 9.1 years) who received TIPS for treating recurrent gastroesophageal variceal bleeding or refractory ascites with portal hypertension. All the patients were recruited from the Interventional Oncology Department at Beijing Ditan Hospital between October 2008 and December 2011. The TIPS was successfully performed on all involved patients by puncturing at the right branch of portal vein via right hepatic vein. After TIPS, the patients were consecutively followed up at the outpatient clinic. The patients were examined by contrast-enhanced computed tomography (CT) or magnetic resonance imaging (MRI) of the abdomen every 3 months for 3 years, for detecting the occurrence of malignant nodules and early HCC. The post-TIPS medical database was reviewed with univariate and multivariate analysis to identify the risk factors for new nodules retrospectively. The overall incidence of HCC was 38.7% (41/106). The multivariate analysis showed that an increased odds ratios (OR) of HCC was observed in the complication of portal hypertension (OR, 0.396; 95% confidence interval [CI], 0.171-0.918; P = 0.031) and preoperative cirrhosis classification (OR, 0.060; 95% CI, 0.021-0.175; P = 0.000). P < 0.05was considered statistically significant. After TIPS, the cumulative probabilities of survival time for patients with cirrhosis at 1, 2, and 3 years were 100%, 68%, and 61%, respectively (log rank test, P = 0.18). The cumulative incidence of new nodules was significantly lower among patients with refractory ascites than those with upper gastrointestinal hemorrhage. Specifically, the survival rates of patients with upper gastrointestinal hemorrhage at years 1, 2, and 3 were 100%, 65%, and 51%, respectively, compared to 100%, 88%, and 85% corresponding to patients with refractory ascites (P = 0.009). The cumulative incidence of HCC was significantly lower in cirrhosis patients with CT identified grade III than those with grade IV. At years 1, 2, and 3, the survival rates of cirrhosis patients with CT identified grade IV were 96%, 22%, and 20%, respectively, compared to 100%, 98%, and 90% in controls (P = 0.012). The identification of clinical variables associated with increased risks of HCC may be useful for selecting appropriate candidates for TIPS. Results suggested that the patients with cirrhosis of CT identified grade IV and with upper gastrointestinal hemorrhage might be relevant to increased odds of HCC after TIPS.

Transjugular intrahepatic portosystemic shunt for esophagogastric variceal bleeding in liver cirrhosis: intended population and timing

Esophagogastric variceal bleeding is a life-threatening complication of cirrhotic portal hypertension. Transjugular intrahepatic portosystemic shunt (TIPS) is an effective method for the treatment and prevention of esophagogastric variceal bleeding; however, right timing of TIPS and selection of appropriate candidates for TIPS are of vital importance in improving patients' survival rate and reducing mortality rate. This article reviews the intended population and right timing of TIPS for the treatment and prevention of esophagogastric variceal bleeding in liver cirrhosis.

Could there be light at the end of the tunnel? Mesocaval shunting for refractory esophageal varices in patients with contraindications to transjugular intrahepatic portosystemic shunt.

Cirrhotic patients with recurrent variceal bleeds who have failed prior medical and endoscopic therapies and are not transjugular intrahepatic portosystemic shunt candidates face a grim prognosis with limited options. We propose that mesocaval shunting be offered to this group of patients as it has the potential to decrease portal pressures and thus decrease the risk of recurrent variceal bleeding. Mesocaval shunts are stent grafts placed by interventional radiologists between the mesenteric system, most often the superior mesenteric vein, and the inferior vena cava. This allows flow to bypass the congested hepatic system, reducing portal pressures. This technique avoids the general anesthesia and morbidity associated with surgical shunt placement and has been successful in several case reports. In this paper we review the technique, candidate selection, potential pitfalls and benefits of mesocaval shunt placement.

Risk Factors for Hepatic Encephalopathy after Transjugular Intrahepatic Portosystemic Shunt in Patients with Hepatocellular Carcinoma and Portal Hypertension.

This study aimed at assessing the risk factors for hepatic encephalopathy (HE) after transjugular intrahepatic portosystemic shunt (TIPS) in patients with hepatocellular carcinoma (HCC) and portal hypertension. Consecutive patients (n=279) with primary HCC who underwent TIPS between January 1997 and March 2012 at a single institution were retrospectively reviewed. Patients were followed up for 2 years. Pre-TIPS, peri-TIPS and post-TIPS clinical variables were reviewed using univariate and multivariate analyses to identify risk factors for HE after TIPS. The overall incidence of HE was 41% (114/279). Multivariate analysis showed an increased odds for HE in patients with: &gt;3 treatments with transcatheter arterial chemoembolization (TACE) and/or trans-arterial embolization (TAE) (odds ratio [OR], 4.078; 95% confidence interval [95%CI], 1.748-9.515); hepatopetal portal flow (OR, 2.362; 95%CI, 1.032-5.404); high portosystemic pressure gradient (OR, 1.198; 95%CI, 1.073-1.336) and high pre-TIPS MELD score (OR, 1.693; 95%CI, 1.390-2.062). Odds for HE were increased 1.693 fold for each 1-point increase in the MELD score, and 1.198 fold for each 1-mmHg decrease in the post-TIPS portosystemic pressure gradient. The identification of clinical variables associated with increased odds of HE may be useful for the selection of appropriate candidates for TIPS. Results suggest that an inappropriate decrease in the portosystemic pressure gradient might be associated with HE after TIPS. In addition, >3 treatments with TACE/TAE, hepatopetal portal flow, and high MELD score were also associated with increased odds of HE after TIPS.

Educational Exhibit Abstract No. 464 - Endovascular varix occlusion interventions for portal hypertensive varices: techniques, pearls, and pitfalls

Educational Exhibit Abstract No. 464 - Endovascular varix occlusion interventions for portal hypertensive varices: techniques, pearls, and pitfalls

The History and Evolution of Balloon-occluded Retrograde Transvenous Obliteration (BRTO): From the United States to Japan and Back

The concept of obliterating varices that complicate portal hypertension dates back to the 1970s, but its minimally invasive clinical utilization was probably lost with the advent of the transjugular intrahepatic portosystemic shunt (TIPS). The conception of retrograde obliteration of a gastrorenal shunt via the left renal vein was reported by Olson et al from the University of Indiana. However, the definition, development, technical perfection, and clinical implementation of the balloon-occluded retrograde transvenous obliteration (BRTO) occurred in Japan (by Kanagawa et al and others). The BRTO-procedure is currently undergoing a renaissance in the United States particularly for patients who are not TIPS candidates.

Transjugular intrahepatic portosystemic shunt in the management of complications of portal hypertension

Transjugular intrahepatic portosystemic shunt (TIPS) is a commonly used approach for managing many complications of portal hypertension. It is an attractive option due to its relative ease of creation (> 90% success rate) and the availability at most hospitals of an interventional radiologist capable of performing the procedure. TIPS is the preferred approach to control acutely bleeding esophageal or gastric varices that cannot be controlled with medical management. It is also now preferred to surgical shunts for preventing rebleeding in patients who rebleed despite adequate medical management. TIPS is more effective than large-volume paracentesis in controlling refractory cirrhotic ascites, with possibly a slight survival benefit but also increased encephalopathy. TIPS should be used to control refractory ascites in patients who cannot be managed with large-volume paracentesis. The role of TIPS in the treatment of hepatorenal syndrome is unclear; currently only patients with type 2 hepatorenal syndrome should be considered candidates for TIPS.

Indications for chronic albumin infusion

While transjugular intrahepatic portosystemic shunt (TIPS) is a common therapy for cirrhotic patients with diuretic-resistant or diuretic-refractory ascites, some patients are unsuitable for the procedure for technical or medical reasons. We report our experience with the use of chronic intravenous albumin infusions to achieve diuresis in this difficult patient population and review the historic experience of chronic albumin infusions as a treatment for ascites. Nineteen patients with cirrhosis and diuretic-resistant or diuretic-refractory ascites who were deemed unsuitable for TIPS received outpatient intravenous albumin infusions (50 g) weekly for at least 4 weeks. The following endpoints were retrospectively recorded: serum sodium, serum creatinine, blood urea nitrogen, hematocrit, bilirubin, albumin, international normalized ratio, body weight, and Model for End-stage Liver Disease (MELD) score. The contraindications for TIPS included the following: portal vein thrombosis, two; advanced age, one; encephalopathy, nine; hyperbilirubinemia, five; and other, two. Compared to pretreatment, posttreatment weight decreased in 17 patients, remained unchanged in 0 patients, and increased in 2 patients. The overall mean change in body weight (before vs. after therapy) was 8 lb (P < 0.05). The only significant change in biochemistries was an increase in serum albumin from 2.5 g/dl before therapy to 3.5 g/dl after therapy (P < 0.05). We conclude that (1) recurrent intravenous weekly albumin infusions resulted in significant loss of edema and ascites as measured by loss of body weight, and (2) clinicians may want to consider chronic albumin infusions for selected patients with refractory ascites who are not candidates for TIPS.

Chronic Albumin Infusions to Achieve Diuresis in Patients with Ascites Who Are Not Candidates for Transjugular Intrahepatic Portosystemic Shunt (TIPS)

While transjugular intrahepatic portosystemic shunt (TIPS) is a common therapy for cirrhotic patients with diuretic-resistant or diuretic-refractory ascites, some patients are unsuitable for the procedure for technical or medical reasons. We report our experience with the use of chronic intravenous albumin infusions to achieve diuresis in this difficult patient population and review the historic experience of chronic albumin infusions as a treatment for ascites. Nineteen patients with cirrhosis and diuretic-resistant or diuretic-refractory ascites who were deemed unsuitable for TIPS received outpatient intravenous albumin infusions (50 g) weekly for at least 4 weeks. The following endpoints were retrospectively recorded: serum sodium, serum creatinine, blood urea nitrogen, hematocrit, bilirubin, albumin, international normalized ratio, body weight, and Model for End-stage Liver Disease (MELD) score. The contraindications for TIPS included the following: portal vein thrombosis, two; advanced age, one; encephalopathy, nine; hyperbilirubinemia, five; and other, two. Compared to pretreatment, posttreatment weight decreased in 17 patients, remained unchanged in 0 patients, and increased in 2 patients. The overall mean change in body weight (before vs. after therapy) was 8 lb (P < 0.05). The only significant change in biochemistry was an increase in serum albumin from 2.5 g/dl before therapy to 3.5 g/dl after therapy (P < 0.05). We conclude that (1) recurrent intravenous weekly albumin infusions resulted in significant loss of edema and ascites as measured by loss of body weight, and (2) clinicians may want to consider chronic albumin infusions for selected patients with refractory ascites who are not candidates for TIPS.