Transjugular Intrahepatic Portosystemic Shunt For Refractory Ascites Research Articles

LVP vs TIPS for Refractory Ascites: Where Do We Stand?

AbstractAscites is the most common complication of end stage liver disease. Refractory ascites is considered a poor prognostic indicator and impacts quality of life, overall survival and contributes significantly to the cost associated with its management. Serial large volume paracentesis (LVP) and transjugular intrahepatic portosystemic shunt (TIPS) placement are the most utilized procedures for the management of refractory ascites and have their advantages and disadvantages. The pathophysiology of ascites in cirrhosis is multifactorial which makes management complex, requiring the consideration of multiple clinical and biochemical variables to guide the appropriate management. This article provides a broad overview of LVP and TIPS, with review of the latest clinical trials and meta-analyses to help guide the management of refractory ascites and improve patient outcomes.

Long-term effects and complications of the transjugular intrahepatic portosystemic shunt: a single-centre experience

Background and aims: Accurate estimates of the long-term risks of adverse outcomes after transjugular intrahepatic portosystemic shunt (TIPS) treatment are needed. The aim of this cohort study was to estimate the risks of stent dysfunction, variceal bleeding, refractory ascites, hepatic encephalopathy (HE), and death after TIPS treatment.Methods: We extracted data from electronic medical records of 104 consecutive TIPS patients. Gore® Viatorr® TIPS endoprostheses were used in all patients. We conducted competing risks analysis of the risk of stent dysfunction and variceal bleeding, and Kaplan–Meier estimation of overall survival.Results: The overall 1-year survival after TIPS insertion was 82% (95% confidence interval [CI]: 73–88%), and the 1-year risk of stent dysfunction was 15% (95% CI: 9–22%). In patients who had a TIPS for variceal bleeding, the 1-year risk of rebleeding was 23% (95% CI: 13–35%). In patients who had a TIPS for refractory ascites, the risk of having an unsuccessful ascites outcome 1 year after TIPS for refractory ascites was 35% (95% CI: 21–52%). Overall, the 1-year risk of overt HE was 38% (95% CI: 32–43%). The risk of experiencing any of the defined complications during the first year was 56% (95% CI: 45–66%).Conclusion: TIPS is an effective treatment for variceal bleeding and refractory ascites in most cases, but more than half of the patients experience either death, stent dysfunction, recurrence of symptoms, or overt HE within the first year after the procedure.

Transjugular intrahepatic portosystemic shunt in Vienna – A decade later

Implantation of a transjugular intrahepatic portosystemic shunt (TIPS) for therapy of portal hypertension has been available in Vienna, Austria, since 1991. Ten years of experience with this technique led the Vienna TIPS Study Group to retrospectively analyse characteristics and outcome of all patients undergoing TIPS in Vienna between 1991 and 2001. Survival and subgroup analyses were performed using Mann Whitney U-tests, log-rank tests, Spearman's correlation and Kaplan-Meier analyses. A total of 523 patients underwent TIPS; 23 for acute variceal bleeding, 350 for prevention of variceal bleeding, and 109 for therapy of refractory ascites. Portal hypertension was caused by cirrhosis in 503 patients; 20 presented with other diseases. 253 patients died within the study period, median follow-up was 5.07 years, median survival 4.51 years. The 3-month, 1-year, 3-year, and 5-year survival rates were 83%, 71%, 57%, and 49%, respectively. Etiology of cirrhosis had no effect on survival; patients with TIPS for refractory ascites had poorer survival rates than those undergoing TIPS for prevention of rebleeding. TIPS is a safe and effective therapy for patients with portal hypertension. The first decade of TIPS in Vienna has shown, in line with other publications, that good criteria for patient selection, effective post-interventional management, and close cooperation between internists, interventional radiologists and liver-transplant centers are the key for a good outcome.

Transjugular intrahepatic portosystemic shunt for refractory ascites: an analysis of the literature on efficacy, morbidity, and mortality

Objectives Transjugular intrahepatic portosystemic shunt (TIPS) is frequently used to treat patients with refractory ascites, but its role is controversial. We sought to determine from the literature the efficacy, morbidity, and mortality associated with TIPS for refractory ascites. Methods We searched MEDLINE and identified studies published in English from January, 1985, to March, 2003, that evaluated the effect of TIPS in patients with refractory ascites. Outcomes that were analyzed included complete resolution of ascites, reduction in ascites, mortality, encephalopathy, stenosis, and renal function. Data were analyzed on an intention to treat basis. Results Of 25 studies identified, 16 were included in the analysis. The pooled estimate for complete response at 6 months was 45% and for any response (complete and partial) was 63%. Pooled 6-month mortality after TIPS was 36%. Risk factors for mortality included renal insufficiency (serum creatinine >1.5 mg/dl), hyperbilirubinemia (total bilirubin >3 mg/dl), advanced age (>60 yr), and poor response to TIPS. The pooled rate of new or worsening encephalopathy after TIPS was 32%. In most cases, encephalopathy was managed medically or by reduction in shunt size; however, refractory cases were associated with 100% mortality in most studies. Studies reporting the effect of TIPS on kidney function showed improvement in creatinine clearance and urinary sodium excretion. Conclusions TIPS is effective in eliminating ascites or substantially reducing ascites in cases refractory to medical therapy. Renal insufficiency, refractory encephalopathy, and hyperbilirubinemia were consistently associated with mortality after TIPS. In individuals with risk factors for mortality, alternative strategies should be recommended.

Transjugular intrahepatic portosystemic shunt: a limited role in refractory ascites.

To evaluate the role of the transjugular intrahepatic portosystemic shunt (TIPS) in the management of patients with refractory ascites. A retrospective study of 25 consecutive patients for whom refractory ascites was the primary indication for TIPS insertion. Regional liver unit at Freeman Hospital, Newcastle upon Tyne, UK. Twelve male and 13 female patients with a mean age of 58 years and mean Child-Pugh score of 10, treated with TIPS for refractory ascites between July 1992 and September 1995. Effect of TIPS on mortality, ascites and hospital admission rate. TIPS was successfully placed in all patients with a 59% mean reduction in portosystemic pressure gradient. Response rate was 68%, 48% and 33% at 1, 3 and 12 months, respectively. Mortality was 48% at 3 months and 67% at 12 months, being higher in those patients older than 60, those with renal impairment and those with higher Child-Pugh score. Amongst nine patients surviving long term (> 12 months) the mean time spent in hospital in the 3 months before TIPS was 35 days and in the year following TIPS 30 days. Patients who died (16 in total) spent a mean of 19 days in hospital before TIPS, 10 never leaving hospital, and 6 who were discharged spent a mean of 19 days post procedure in hospital (mean survival 84 days). TIPS has a limited role in the management of patients with refractory ascites. It is not an appropriate treatment where patients are older than 60, have renal impairment (creatinine > 200 mumol/l) or have a Child-Pugh score greater than 10.