Transjugular Intrahepatic Portosystemic Shunt Failure Research Articles

Partial splenic embolization as a rescue and emergency treatment for portal hypertension and gastroesophageal variceal hemorrhage

BackgroundPartial splenic embolization (PSE) is a non-surgical procedure which was initially used to treat hypersplenism. Furthermore, partial splenic embolization can be used for the treatment of different conditions, including gastroesophageal variceal hemorrhage. Here, we evaluated the safety and efficacy of emergency and non-emergency PSE in patients with gastroesophageal variceal hemorrhage and recurrent portal hypertensive gastropathy bleeding due to cirrhotic (CPH) and non-cirrhotic portal hypertension (NCPH).MethodsFrom December 2014 to July 2022, twenty-five patients with persistent esophageal variceal hemorrhage (EVH) and gastric variceal hemorrhage (GVH), recurrent EVH and GVH, controlled EVH with a high risk of recurrent bleeding, controlled GVH with a high risk of rebleeding, and portal hypertensive gastropathy due to CPH and NCPH underwent emergency and non-emergency PSE. PSE for treatment of persistent EVH and GVH was defined as emergency PSE. In all patients pharmacological and endoscopic treatment alone had not been sufficient to control variceal bleeding, and the placement of a transjugular intrahepatic portosystemic shunt (TIPS) was contraindicated, not reasonable due to portal hemodynamics, or TIPS failure with recurrent esophageal bleeding had occurred. The patients were followed-up for six months.ResultsAll twenty-five patients, 12 with CPH and 13 with NCPH were successfully treated with PSE. In 13 out of 25 (52%) patients, PSE was performed under emergency conditions due to persistent EVH and GVH, clearly stopping the bleeding. Follow-up gastroscopy showed a significant regression of esophageal and gastric varices, classified as grade II or lower according to Paquet’s classification after PSE in comparison to grade III to IV before PSE. During the follow-up period, no variceal re-bleeding occurred, neither in patients who were treated under emergency conditions nor in patients with non-emergency PSE. Furthermore, platelet count increased starting from day one after PSE, and after one week, thrombocyte levels had improved significantly. After six months, there was a sustained increase in the thrombocyte count at significantly higher levels. Fever, abdominal pain, and an increase in leucocyte count were transient side effects of the procedure. Severe complications were not observed.ConclusionThis is the first study analyzing the efficacy of emergency and non-emergency PSE for the treatment of gastroesophageal hemorrhage and recurrent portal hypertensive gastropathy bleeding in patients with CPH and NCPH. We show that PSE is a successful rescue therapy for patients in whom pharmacological and endoscopic treatment options fail and the placement of a TIPS is contraindicated. In critically ill CPH and NCPH patients with fulminant gastroesophageal variceal bleeding, PSE showed good results and is therefore an effective tool for the rescue and emergency management of gastroesophageal hemorrhage.

Combined transjugular/percutaneous intrahepatic portosystemic shunts (cTIPS) for cavernous transformation of the portal vein after conventional transjugular approach TIPS failure.

This study aim was to compare the safety and efficacy of combined transjugular/percutaneous intrahepatic portosystemic shunts (cTIPS) and transjugular intrahepatic portosystemic shunt (TIPS) in cirrhotic patients with cavernous transformation of the portal vein (CTPV) after conventional transjugular approach TIPS failure. Cirrhotic patients who were diagnosed as CTPV and treated by cTIPS or TIPS between July 2012 and April 2022 were retrospectively analyzed. Patients' characteristics and clinical data were recorded. The clinical outcomes, long-term survival rates and patency rates between the 2 groups were compared. A total of 68 patients with CTPV were enrolled, of whom 23 were treated with TIPS and 45 with cTIPS. The initial technical success was 30.9% in TIPS group and 91.1% in cTIPS group. The hospitalization days increased significantly in the cTIPS group compared with TIPS group (P = .0131). However, the complication rate, patency rates and survival rates were similar between the 2 groups. In conclusion, cTIPS appeared to be safe and effective in cirrhotic patients with CTPV after conventional transjugular approach TIPS failure.

Portal Fibrotic Cord is Associated with Transjugular Intrahepatic Portosystemic Shunt Failure and Death in Cirrhotic Patients.

Occlusive portal vein thrombosis (PVT) often causes portal hypertension-related complications in cirrhotic patients. Transjugular intrahepatic portosystemic shunt (TIPS) is an effective treatment for this difficult problem. However, the factors influencing TIPS success and overall survival in patients with occlusive PVT are unknown. This study investigated the factors influencing TIPS success and overall survival in cirrhotic patients with occlusive PVT. Cirrhotic patients with occlusive PVT were selected from a prospective database of consecutive patients treated with TIPS in Xijing Hospital between January 2015 and May 2021. Baseline characteristics, TIPS success rate, complications, and survival were collected, and the factors associated with the TIPS success rate and transplant-free survival were analyzed. A total of 155 cirrhotic patients with occlusive PVT were enrolled. TIPS succeeded in 126 (81.29%) cases. The 1-year survival rate was 74%. Compared with those without, patients with portal fibrotic cord had a lower TIPS success rate (39.02% vs. 96.49%, p<0.001), shorter median overall survival (300 vs. 1,730 days, p<0.001) and more operation-related complications (12.20% vs. 1.75%, p<0.01). Logistic regression analysis found that portal fibrotic cord (odds ratio 0.024) was a risk factor for TIPS failure. Univariate and multivariate analysis showed that portal fibrotic cord was an independent predictor of death (hazard ratio 2.111; 95% CI: 1.094-4.071, p=0.026). Portal fibrotic cord increased the TIPS failure rate and is a risk factor for poor prognosis in cirrhotic patients.

Computed tomography-based score model/nomogram for predicting technical and midterm outcomes in transjugular intrahepatic portosystemic shunt treatment for symptomatic portal cavernoma.

Transjugular intrahepatic portosystemic shunt (TIPS) may be technically difficult in patients with cavernous transformation of the portal vein (CTPV). Computed tomography (CT) is widely used for assessing the situation of the portal vein and its tributaries before TIPS, and an ultrasound-based Yerdel grading system has been developed, which is deemed useful for liver transplantation. Therefore, we hypothesized that a CT-based CTPV scoring system could be useful for predicting technical and midterm outcomes in TIPS treatment for symptomatic portal cavernoma. To investigate the clinical significance of a CT-based score model/nomogram for predicting technical success and midterm outcome in TIPS treatment for symptomatic CTPV. Patients with symptomatic CTPV who had undergone TIPS from January 2010 to June 2017 were retrospectively analysed. The CTPV was graded with a score of 1-4 based on contrast-CT imaging findings of the diseased vessel. Outcome measures were technical success rate, stent patency rate, and midterm survival. Cohen's kappa statistic, the Kaplan-Meier and log-rank tests, and uni- and multivariable analyses were performed. A nomogram was constructed and verified by calibration and decision curve analysis. A total of 76 patients (45 men and 31 women; mean age, 52.3 ± 14.7 years) were enrolled in the study. The inter-reader agreement (κ) of the CTPV score was 0.81. TIPS was successfully placed in 78% of patients (59/76). The independent predictor of technical success was CTPV score (odds ratio [OR] = 5.56, 95% confidence interval [CI]: 3.55-9.67, P = 0.002). The independent predictors of primary TIPS patency were CTPV score and splenectomy (OR = 9.22, 95%CI: 4.78-13.45, P = 0.009; OR = 4.67, 95%CI: 2.59-7.44, P = 0.017). The survival rates differed significantly between the TIPS success and failure groups. The clinical nomogram was made up of patient age, model for end-stage liver disease score, and CTPV score. The calibration curves and decision curve analysis verified the usefulness of the CTPV score-based nomogram for clinical practice. TIPS should be considered a safe and feasible therapy for patients with symptomatic CTPV. Furthermore, the CT-based score model/nomogram might aid interventional radiologists in therapeutic decision-making.

Predictive Value of Abnormal Findings on Covered Transjugular Intrahepatic Portosystemic Shunt Baseline Doppler Sonography.

Doppler ultrasound (DUS) is frequently performed as a screening and diagnostic modality to evaluate the transjugular intrahepatic portosystemic shunt (TIPS) for short- and intermediate-term complications of the procedure. However, the clinical significance of initial frequently observed abnormalities in flow velocities, gradient, and direction in patients with covered TIPS is less studied. A retrospective study was performed between January 2005 and December 2014, and all patients undergoing covered TIPS procedure for the management of portal hypertension were included. Abnormal DUS findings were defined as intrashunt peak systolic velocities (PSVs) less than 90 or greater than 190 cm/s, intrashunt gradient greater than 50 cm/s, and abnormal flow direction in the main, right, and/or left portal veins. A total of 283 patients with adequate clinical follow-up and baseline TIPS DUS were included in the study. Median follow-up was 18.2 months. During the follow-up period, portal hypertension symptoms recurred in 83 patients who underwent TIPS angiography and/or revision. Of the 83, 57 had an elevated portosystemic gradient (>12 mm Hg) requiring angioplasty/stenting. With regard to baseline ultrasound, low PSVs were present in 88 patients (31.1%), high PSVs in 44 patients (15.5%), and elevated gradient in 98 patients (34.6%). The rate of developing TIPS stenosis in the future was not higher in patients with abnormal DUS parameters. For example, 26 (19.7%) of 132 patients with abnormal TIPS velocities developed stenosis compared with 31 (20.5%) of 151 patients with normal velocities (P = 0.9). Based on these results, abnormal DUS findings observed on baseline TIPS ultrasound examination have low predictive value for future covered TIPS dysfunction and failure.

Predictors of Re-bleeding and Mortality Among Patients with Refractory Variceal Bleeding Undergoing Salvage Transjugular Intrahepatic Portosystemic Shunt (TIPS).

Transjugular intrahepatic portosystemic shunt (TIPS) has proven clinical efficacy as rescue therapy for cirrhotic patients with acute portal hypertensive bleeding who fail endoscopic treatment. To investigate predictive factors of 6-week and 1-year mortality in patients undergoing salvage TIPS for refractory portal hypertensive bleeding. A total of 144 consecutive patients were retrospectively evaluated. Three logistic regression multivariate models were estimated to individualize prognostic factors for 6-week and 12-month mortality. Log-rank test was used to evaluate survival according to Child-Pugh classes and Bureau's criteria. Mean age 51 ± 10years, 66% male, mean MELD 18.5 ± 8.3, Child-Pugh A/B/C 8%/38%/54%. TIPS failure occurred in 23(16%) patients and was associated with pre-TIPS portal pressure gradient and pre-TIPS intensive care unit stay. Six-week and 12-month mortality was 36% and 42%, respectively. Pre-TIPS intensive care unit stay, MELD, and Child-Pugh score were independently associated with mortality at 6weeks. Independent predictors of mortality at 12months were pre-TIPS intensive care unit stay and Child-Pugh score. In this large cohort of patients undergoing salvage TIPS, MELD and Child-Pugh scores were predictive of short- and long-term mortality, respectively. Pre-TIPS intensive care unit stay was independently associated with TIPS failure and mortality at 6weeks and 12months. Salvage TIPS is futile in patients with Child-Pugh score of 14-15.

Early radiological intervention and haematology screening is associated with excellent outcomes in Budd-Chiari syndrome.

Budd-Chiari syndrome (BCS) is a rare and life-threatening disorder, resulting from thrombosis of the hepatic veins. Various treatments, including pharmacological, radiological and surgical interventions, have been used. To describe retrospectively our institution's experience with management of patients with BCS. A retrospective study of all cases of primary Budd-Chiari syndrome presenting to our institution between January 2000 and August 2012 was performed. Patients with secondary Budd-Chiari syndrome due to malignancy or local mass compression were excluded. Between 2000 and 2012, 27 patients with primary BCS presented with a median Rotterdam score of 1.16 (range: 0.07-2.11). A total of 24 patients (89%) had at least one risk factor, with the commonest being myeloproliferative neoplasm (MPN), detected in 17 of 24 (71%) of the tested patients, including four patients with normal blood counts at diagnosis. All patients were anticoagulated with warfarin or low-molecular-weight heparin (LMWH). A total of 25 (92.6%) patients also had primary radiological interventions, consisting of transjugular intrahepatic portosystemic shunt (TIPS) in 18 (67%) patients and/or angioplasty/stenting in 11 (40%). A total of 14 patients developed TIPS stenoses, requiring a median of 1.5 (range: 1-14) revisions. No patient developed TIPS failure requiring alternative therapy. Two patients were lost to follow-up. At a median follow up of 59 months (range: 2-248 months), the overall survival was 96% at 1 year and 81% at 5 years, much greater than predicted by the Rotterdam score. No patients required liver transplantation. There is a high incidence of MPN in patients with primary BCS, including patients with normal peripheral blood counts at the time of diagnosis. Our approach of anticoagulation, aggressive and early radiological intervention aimed at rapid decompression of the congested liver resulted in excellent medium-term outcomes.

Transjugular intrahepatic portosystemic shunt for portal vein thrombosis with variceal bleeding in liver cirrhosis: outcomes and predictors in a prospective cohort study.

The role of transjugular intrahepatic portosystemic shunt (TIPS) for the secondary prophylaxis of variceal bleeding in cirrhotic patients with portal vein thrombosis (PVT) remains obscure. This prospective cohort study aimed to assess the risk factors associated with TIPS technical success, outcome and prognosis in cirrhotic patients with PVT and a history of variceal bleeding. Between May 2009 and April 2011, 51 cirrhotic patients with PVT who attempted TIPS procedures for the prevention of variceal rebleeding were enrolled. TIPS success rate was 84% (43/51). An increased degree of thrombosis within the portal trunk and portal vein branches was inversely associated with TIPS success. Median follow-up time was 40.07months (range: 0.02-56.87). The cumulative risk of rebleeding was significantly different between TIPS success and failure group (P=0.002). The univariate analysis also demonstrated that TIPS failure was the only significant predictor associated with rebleeding (hazard ratio [HR]=4.174, 95% confidence interval [CI]: 1.558-11.186). In TIPS success group, the cumulative rates free of shunt dysfunction at the 6th and 12th month were 79% and 76% respectively. Absence of total superior mesenteric vein (SMV) thrombosis was the only independent predictor (HR=0.189, 95% CI: 0.047-0.755). In TIPS success group, the 1- and 3-year cumulative survival rates were 77% and 62% respectively. Albumin level was the only independent predictor (HR=0.877, 95% CI: 0.779-0.986). Successful TIPS insertions could effectively prevent from rebleeding in cirrhotic patients with PVT and variceal bleeding. Degree of PVT and SMV thrombosis was associated with TIPS failure and shunt dysfunction respectively.

Educational Exhibit Abstract No. 368 - Portal vein interventions

Learning Objectives To discuss various portal venous interventions offered by interventional radiology including their indications, contraindications, clinical utility, expected outcome, and common complications. Background Different portal vein interventions include portal vein stent (PVS), portal vein embolizaion (PVE), transjugular intrahepatic portosystemic shunt (TIPS), and direct intrahepatic portocaval shunt (DIPS). Clinical Findings/Procedure Details Portal Vein Stent (PVS ): Performed in the setting of portal venous stenosis or occlusion that commonly occurs in neoplastic conditions or post liver transplantation. Liver abscess has been reported as a post procedural complication. Portal Vein Embolization (PVE) : Performed in preoperative treatment of major hepatic resection in patient when the future liver remnant is too small. PVE complications are rare but include transient hemobilia, infection, need for reembolization, portal vein thrombosis, and portal hypertension. Portal Vein Thrombolysis (PVT) : PVT is the preferred treatment for acute intravascular thrombosis. Percutaneous portal vein clot lysis can be initiated in a few minutes providing almost immediate clot dissolution without the need for surgical intervention. Transjugular Intrahepatic Portosystemic Shunt (TIPS) : Indications for TIPS procedure include recurrent or refractory variceal bleeding, Budd Chiari syndrome, hepatic hydrothorax, hepatorenal syndrome, and intractable ascites. Complications include but are not limited to hepatic encephalopathy, heart failure. There is improved survival of patients with refractory ascites when treated with TIPS. Direct Intrahepatic Portocaval Shunt (DIPS) : Indications are similar to TIPS procedure for decompression of portal venous system. DIPS procedure includes direct puncture from the IVC through the caudate lobe to the main portal vein. The safety and effectiveness is increased by eliminating blind PV puncture and hepatic vein stenosis which is the most common cause of chronic TIPS failure. Conclusion and/or Teaching Points Knowledge of portal vein interventions including their indication, clinical utility and expected outcome is critical for clinicians to improve patient care.

Transjugular intrahepatic portosystemic shunt for portal vein thrombosis with symptomatic portal hypertension in liver cirrhosis

Data on the management of portal vein thrombosis (PVT) in patients with decompensated cirrhosis are extremely limited, particularly in the cases of the transjugular intrahepatic portosystemic shunt (TIPS). We assessed the outcome of TIPS for PVT in patients with cirrhosis and symptomatic portal hypertension and determined the predictors of technical success and survival. In the retrospective study, 57 consecutive patients receiving TIPS were enrolled between December 2001 and September 2008. All were diagnosed with chronic PVT, and 30 had portal cavernoma. Indications for TIPS were variceal hemorrhage (n = 56) and refractory ascites (n = 1). TIPS were successfully placed in 75% of patients (43/57). The independent predictors of technical success included portal cavernoma, and the degree of thrombosis within the main portal vein (MPV), the portal vein branches, and the superior mesenteric vein. Only one patient died of severe procedure-related complication. The cumulative 1-year shunt dysfunction and hepatic encephalopathy rates were 21% and 25%, respectively. The cumulative 1- and 5-year variceal re-bleeding rates differed significantly between the TIPS success and failure groups (10% and 28% versus 43% and 100%, respectively; p = 0.0004), while the cumulative 1- and 5-year survival rates were similar between the two groups (86% and 77% versus 78% and 62%, respectively; p = 0.34). The independent predictor of survival in PVT patients with decompensated cirrhosis was the degree of MPV occlusion (hazard ratio 0.189, 95% CI 0.042-0.848). TIPS should be considered a safe and feasible alternative therapy for chronic PVT in selected patients with decompensated cirrhosis. Both technical success and survival were closely associated with the degree of MPV occlusion.

Causes of TIPS Dysfunction

Transjugular intrahepatic portosystemic shunt (TIPS) creation is an effective method to control portal hypertension. TIPS creations with bare stents have shown limited and unpredictable patency. In nearly all cases of rebleeding or recurrent ascites after TIPS creation, there is shunt stenosis or occlusion. The purpose of this article is to review the biologic and technical factors that predispose to TIPS failure and how the use of an expandable polytetrafluoroethylene (PTFE)-covered-stent has significantly improved TIPS patency. Biologic and technical factors may predispose to shunt failure. The combination of improved technique and expandable PTFE has significantly improved TIPS patency. The need for follow-up venography and secondary interventions has been reduced significantly as a result of improved shunt patency.

Conversion of failed transjugular intrahepatic portosystemic shunt to distal splenorenal shunt in patients with Child A or B cirrhosis.

The authors demonstrate the feasibility of converting failed transjugular intrahepatic portosystemic shunt (TIPS) to distal splenorenal shunt (DSRS) in patients with good hepatic reserve for long-term control of variceal bleeding. TIPS is an effective method for decompressing the portal venous system and controlling bleeding from esophageal and gastric varices. TIPS insufficiency is, however, a common problem, and treatment alternatives in patients with an occluded TIPS are limited because most have already failed endoscopic therapy. The records of five patients who underwent conversion from TIPS to DSRS because of TIPS failure or complication in the past 36 months were reviewed. Four patients had ethanol-induced cirrhosis and one patient had hepatitis C virus cirrhosis. Three patients were Child-Pugh class A and two were class B. All patients had excellent liver function, with galactose elimination capacities ranging from 388 to 540 mg/min (normal 500 +/- 100 mg/min). The patients had TIPS placed for acute (2) or sclerotherapy-resistant (3) variceal hemorrhage. All five TIPS stenosed 3 to 23 months after placement, with recurrent variceal hemorrhage and failed TIPS revision. One patient had stent migration to the superior mesenteric vein that was removed at the time of DSRS. All five patients underwent successful DSRS, and none have had recurrent hemorrhage 18 to 36 months after surgery. TIPS provides inadequate long-term therapy for some Child-Pugh A or B patients with recurrent variceal hemorrhage. TIPS failure in patients with good liver function can be salvaged by DSRS in many cases.