Transjugular Intrahepatic Portosystemic Shunt Group Research Articles

Prophylactic Use of Transjugular Intrahepatic Portosystemic Shunt Aids in the Treatment of Refractory Ascites

The aim of this study was to explore whether prophylactic use of transjugular intrahepatic portosystemic shunt (TIPS) could aid in the treatment of refractory ascites on the basis of current randomized controlled trials. TIPS is more effective for refractory ascites versus large-volume paracentesis. At present, however, the survival advantage is not clear within populations of undifferentiated patients. Correlative studies were searched through online journal databases, and a manual search was done from 1974 to 2012. Six trials involving 390 patients were included. TIPS could ameliorate refractory ascites on the basis of short-term analysis [odds ratio (OR) 8.66; 95% confidence interval (CI), 5.27-14.24] and long-term analysis (OR 6.07; 95% CI, 3.60-10.22). Hepatic encephalopathy (HE) appeared more common in the TIPS arm (OR 2.95; 95% CI, 1.87-4.66). Mortality in the 2 groups did not show any difference (OR 0.82; 95% CI, 0.46-1.50). Trial sequential analysis confirmed the effect of TIPS upon ascites control and upon the risk of HE recurrence, whereas insufficient trials were available to distinguish between the arms on mortality. Metaregression analysis showed that the level of urine sodium, serum bilirubin, and portal pressure gradient reduction value could be used as survival predictors. Subgroup analysis showed an elevated survival effect in TIPS (OR 0.45; 95% CI, 0.24-0.81), and patients survived longer with recurrent ascites (OR 0.40; 95% CI, 0.19-0.83). TIPS was confirmed to improve ascites control in both the short term and the long term. Although HE frequently appeared in the TIPS group, patients with better hepatic and renal function survived longer when they were treated with TIPS. Serum bilirubin and urine sodium could be used as pre-TIPS predictors for patient survival. Portal pressure gradient reduction values could be used as post-TIPS predictors of survival.

Abstract No. 298 - Effectiveness of transarterial chemoembolization after transjugular intrahepatic portosystemic shunt creation: a case-matched analysis

Although many patients with hepatocellular carcinoma (HCC) undergo transjugular intrahepatic portosystemic shunt (TIPS) creation, with significant resultant hemodynamic changes, the literature contains few studies on the effectiveness of transarterial chemoembolization (TACE) in patients with TIPS. The purpose of this study is to evaluate the effectiveness of TACE for HCC in patients with TIPS versus those without TIPS. All patients who underwent TIPS at our institution from 2008 to 2012 were identified via records review; 12 of these patients also had HCC and were treated with TACE. A matched control group of 22 patients treated with TACE without TIPS during the study period was created, based on demographic characteristics, MELD scores, and tumor size. Post-TACE imaging was systematically evaluated and compared to pre-TACE imaging by modified response evaluation criteria in solid tumors (mRECIST). Time to progression, survival, and transplant rate were noted. No difference was seen between TIPS and control groups in immediate post-TACE complete response rate (45% vs. 55%, p= 1.0) and combined response rate (both complete and partial) (67% vs. 82%, p = .41). Mean follow-up intervals were 382 days (TIPS) and 465 days (control). Mean time to progression (local recurrence) was significantly shorter in the TIPS group than the control group: 135 days (SD 56) vs. 315 days (SD 167), p = 0.013. Overall survival was lower in the TIPS group than in the control group (75% vs. 91%), suggesting a trend but not statistically significant (p = 0.32). Transplant rates were similar in the TIPS and control groups, 27% vs. 25%, respectively. Although immediate post-TACE complete response rate by mRECIST was similar in patients with TIPS compared with those without TIPS, patients with TIPS demonstrated significantly faster local progression and a trend towards shorter overall survival, which may indicate decreased effectiveness of TACE after TIPS.

Short-Term Rebleeding Rates for Isolated Gastric Varices Managed by Transjugular Intrahepatic Portosystemic Shunt versus Balloon-Occluded Retrograde Transvenous Obliteration

PurposeTo assess the short-term rebleeding rate associated with the use of a transjugular intrahepatic portosystemic shunt (TIPS) compared with balloon-occluded retrograde transvenous obliteration (BRTO) for management of gastric varices (GV). Materials and MethodsA single-center retrospective comparison of 50 patients with bleeding from GV treated with a TIPS or BRTO was performed. Of 50 patients, 27 (17 men and 10 women; median age, 55 y; range, 31–79 y) received a TIPS with covered stents, and 23 (12 men and 11 women; median age, 52 y; range, 23–83 y) underwent a BRTO procedure with a foam sclerosant. All study subjects had clinical and endoscopic evidence of isolated bleeding GV and were hemodynamically stable at the time of the procedure. Clinical and endoscopic follow-up was performed. Kaplan-Meier analysis was used to evaluate rebleeding rates from the GV. ResultsThe technical success rate was 100% in the TIPS group and 91% in the BRTO group (P = .21). Major complications occurred in 4% of the patients receiving TIPS and 9% of patients the undergoing BRTO (P = .344). Encephalopathy was reported in 4 of 27 (15%) patients in the TIPS group and in none of the patients in the BRTO group (0%; P = .12). At 12 months, the incidence of rebleeding from a GV source was 11% in the TIPS group and 0% in the BRTO group (P = .25). ConclusionsBRTO appears to be equivalent to TIPS in the short-term for management of bleeding GV. Further comparative studies are warranted to determine optimal management strategies in individual patients.

Efficacy analysis of emergency transjugular intrahepatic portosystemic shunt in the treatment of variceal bleeding in liver cirrhosis

Objective To investigate the feasibility,safety and efficacy of emergency transjugular intrahepatic portosystemic shunt (TIPS) in the treatment of esophageal and gastric variceal bleeding (EGVB) in liver cirrhosis.Methods The clinical data of 12 patients with liver cirrhosis and EGVB undergoing emergency TIPS were retrospectively analyzed,and were compared with those of 90 patients with cirrhosis undergoing selective TIPS for preventing rebleeding.The haemostasis,rebleeding,hepaticportal vein pressure gradient (HPPG),liver function,hepatic encephalopathy and death were observed.The t-test was performed for measurement data,while Chi-square test was used for counting data and Kaplan-Meier survival curves was used to compare the cumulative rebleeding rate.Results All emergency TIPS of the 12 patients were successful,the bleeding stopped after operation.Among them,eight patients underwent HPPG examination,which significantly decreased after operation ((15.8 ±5.9) mmHg,1 mmHg=0.133 kPa) compared with that before operation ((20.7±5.0) mmHg) and the difference was statistically significant (t =4.022,P=0.005).The liver function (Child-Turcotte-Pugh,CTP) score was 6.6 ± 1.5 before operation and 6.5 ± 1.3 after operation,there was no significant difference (P＞0.05).Hepatic encephalopathy occurred in three patients of the 12 cases undergoing emergency TIPS within one week after operation.The rate of hepatic encephalopathy in selective TIPS group was 18％ (16/90) and there was no significant difference (P＞0.05).During the follow-up period,rebleeding occurred in one patient of the 11 followed up cases undergoing emergency TIPS,while the cumulative rebleeding rate was 21 ％ (19/90) in the selective TIPS group and there was no significant difference in cumulative rebleeding between two groups (P＞0.05).There was no dead case in the emergency TIPS group while the overall mortality of selective TIPS group was 13％ (12/90),in which the EGVB and liver function failure-related mortality was 9％ (8/90).Conclusion The emergency TIPS is feasible,safe and with satisfactory efficacy in the treatment of acute EGVB in liver cirrhosis. Key words: Portosystemic shunt, transjugular intrahepatic; Liver cirrhosis; Esophageal and gastric varices; Gastrointestinal hemorrhage

EVS vs TIPS shunt for gastric variceal bleeding in patients with cirrhosis: A meta-analysis.

To evaluate the clinical effects of transjugular intrahepatic portosystemic shunt (TIPS) vs endoscopic variceal sclerotherapy (EVS) in the management of gastric variceal (GV) bleeding in terms of variceal rebleeding, hepatic encephalopathy (HE), and survival by meta-analysis. Medline, Embase, and CNKI were searched. Studies compared TIPS with EVS in treating GV bleeding were identified and included according to our predefined inclusion criteria. Data were extracted independently by two of our authors. Studies with prospective randomized design were considered to be of high quality. Hazard ratios (HRs) or odd ratios (ORs) were calculated using a fixed-effects model when there was no inter-trial heterogeneity. Oppositely, a random-effects model was employed. Three studies with 220 patients who had at least one episode of GV bleeding were included in the present meta-analysis. The proportions of patients with viral cirrhosis and alcoholic cirrhosis were 39% (range 0%-78%) and 36% (range 12% to 41%), respectively. The pooled incidence of variceal rebleeding in the TIPS group was significantly lower than that in the EVS group (HR = 0.3, 0.35, 95%CI: 0.17-0.71, P = 0.004). However, the risk of the development of any degree of HE was significantly increased in the TIPS group (OR = 15.97, 95%CI: 3.61-70.68). The pooled HR of survival was 1.26 (95%CI: 0.76-2.09, P = 0.36). No inter-trial heterogeneity was observed among these analyses. The improved effect of TIPS in the prevention of GV rebleeding is associated with an increased risk of HE. There is no survival difference between the TIPS and EVS groups. Further studies are needed to evaluate the survival benefit of TIPS in cirrhotic patients with GV bleeding.

Transjugular Intrahepatic Portosystemic Shunt for a Wait List Patient Is Not a Contraindication for Orthotopic Liver Transplant Outcomes

A transjugular intrahepatic portosystemic shunt for treating recurrent variceal bleeding or refractory ascites can be used as bridge therapy in patients awaiting a liver transplant. However, incorrect placement of the transjugular intrahepatic portosystemic shunt may complicate surgery during a liver transplant. This study sought to analyze a cohort of transplanted recipients to underscore whether transjugular intrahepatic portosystemic shunts can negatively affect liver transplant outcomes. We retrospectively analyzed 207 patients who had undergone a liver transplant between January 2001 and December 2009 in the Rome "La Sapienza" center. Transjugular intrahepatic portosystemic shunt was performed before the liver transplant in 36 cases (17%). The analyzed population was stratified into 2 groups (no transjugular intrahepatic portosystemic shunt [n=171 ] and transjugular intrahepatic portosystemic shunt [n=36 ]), and patient survival outcomes were compared. In the no-transjugular intrahepatic portosystemic shunt group, 60 of 171 deaths (35%) were reported, 20 of which were seen in the first 3 months after the liver transplant. In the same group, 61 graft losses (36%) were observed, with 19 of which were seen in the first 3 months after the liver transplant. In transjugular intrahepatic portosystemic shunt group, 12 of the 36 deaths (33%) were seen; 5 patients died within 3 months of the liver transplant. In this latter group, 12 grafts (33%) were lost, 4 of which were reported during the first 3 months after surgery. The median patient survival was 64 months and 69 months in the 2 groups. On survival analysis, no significant differences were found between the 2 groups. Transjugular intrahepatic portosystemic shunt does not seem to affect outcomes after a liver transplant. We suggest that clinicians recognized the location of the stent to prevent any difficulty during surgery.

Effects of percutaneous transhepatic interventional treatment for symptomatic Budd-Chiari syndrome secondary to hepatic venous obstruction.

Budd-Chiari syndrome (BCS) is a rare and life-threatening disorder characterized by hepatic venous outflow obstruction. The management of BCS includes anticoagulation and thrombolysis, percutaneous transhepatic stent angioplasty (PTSA), and transjugular intrahepatic portosystemic shunt (TIPS), but the effect of these approaches varies greatly. The aim of our study was to retrospectively evaluate the medium-term effects of PTSA and TIPS of BCS secondary to hepatic venous outflow obstruction and to determine the critical factors affecting the efficacy. From June 2007 to June 2012, 18 patients (15 males and 3 females; mean age, 36± 9 years) with BCS (obstruction of the hepatic veins) treated by PTSA (n= 15) and TIPS (n= 3) were studied retrospectively. Clinical records were analyzed with respect to underlying disease, therapeutic interventions, complications, quality of life, and overall outcome. Percutaneous transhepatic interventional treatment was technically successful in all patients. In PTSA group, the primary and secondary stent patency rates were 80% and 86.7%, respectively. In the TIPS group, ascites resolved completely, and liver congestion and function were relieved greatly in all three patients. Hemodynamic features and clinical symptoms inpatients with successful treatment improved significantly. Physical aspects evaluated by SF-36 were improved greatly at the end of follow-up. For segmental stenosis or occlusion of hepatic vein caused by thrombosis or membranous webs, PTSA should be recommended as the first choice. TIPS should be applied for diffuse stenosis or occlusion in all the hepatic veins and branches. Standard anticoagulation may promote stent patency. Quality of life after interventional treatment was improved partially, and the mental aspects need to be further investigated.

Recurrent Variceal Bleeding and Shunt Patency: Prospective Randomized Controlled Trial of Transjugular Intrahepatic Portosystemic Shunt Alone or Combined with Coronary Vein Embolization

To prospectively evaluate the efficacy of a transjugular intrahepatic portosystemic shunt (TIPS) alone and TIPS in association with embolotherapy (TIPS+E) in the variceal coronary vein to prevent recurrent variceal bleeding and stent dysfunction after TIPS creation. Institutional review board approval was obtained; all participants provided informed consent. A total of 106 patients (66 men, 40 women; age range, 18-70 years) with recurrent variceal bleeding due to hepatic cirrhosis were assigned randomly to the TIPS+E (n = 54) or TIPS (n = 52) group from May 2007 to July 2011. The TIPS was created by using covered stents. Patients in the TIPS+E group underwent embolotherapy via the jugular vein before TIPS implantation. Rates of recurrent variceal bleeding, stent patency, and survival were evaluated. Scores for liver function and life quality were calculated. TIPS placement was successful in all patients. Recurrent variceal bleeding ranked second among causes of death after TIPS placement. Although the 3-year cumulative rates of shunt patency, recurrent variceal bleeding, and survival in the two groups were not significantly different (P > .05), the 6-month overall rate of shunt patency in the TIPS+E group was significantly higher than that in the TIPS group (96.2% vs 82.0%, P = .019), and the 6-month overall rate of recurrent variceal bleeding was also significantly lower than that in the TIPS group (5.7% vs 20.0%, P = .029). The TIPS+E regimen may reduce the risk of recurrent variceal bleeding during the first 6 months after the TIPS procedure by preventing shunt dysfunction, which may improve liver function and quality of life. © RSNA, 2013.

Transjugular intrahepatic portosystemic shunt (TIPS) versus laparoscopic splenectomy (LS) plus preoperative endoscopic varices ligation (EVL) in the treatment of recurrent variceal bleeding

The aim of the present study was to compare elective transjugular intrahepatic portosystemic shunt (TIPS) and laparoscopic splenectomy (LS) plus preoperative endoscopic varices ligation (EVL) in their efficacy in preventing recurrent bleeding and improving the long-term liver function in patients with liver cirrhosis and portal hypertension. Between January 2009 and March 2012, we enrolled 83 patients (55 with TIPS, defined as the TIPS group, and 28 with LS plus preoperative EVL, defined as the LS group) with portal hypertension and a history of gastroesophageal variceal bleeding resulting from liver cirrhosis. The clinical characteristics, perioperative outcomes, and follow-up were recorded. No significant differences were observed between the two treatment groups with respect to the patients' characteristics and preoperative variables. Within 30 days after surgery, one patient in the TIPS group died of multiple organ dysfunction syndrome, whereas no patient in the LS group died. Complications occurred in 14 patients in the TIPS group, which included rebleeding, encephalopathy, ascites, bleeding from a pseudoaneurysm of the thoracoabdominal aorta, and pulmonary infection, compared with 5 patients in the LS group, which included pulmonary effusion, pancreatic leakage, and portal vein thrombosis. During a mean follow-up of 13.6 months in the TIPS group and 12.3 months in the LS group, the actuarial survival was 85.5 % in the TIPS group versus 100 % in the LS group. The long-term complications included rebleeding and encephalopathy in the TIPS group. LS plus EVL was superior to TIPS in the prevention of gastroesophageal variceal rebleeding in cirrhotic patients. This treatment was associated with a low rate of portosystemic encephalopathy and improvements in the long-term liver function.

Hepatic Encephalopathy after Transjugular Intrahepatic Portosystemic Shunt in Patients with Recurrent Variceal Hemorrhage

Purpose. The purpose of this study was to determine the incidence and predictors of hepatic encephalopathy (HE) after transjugular intrahepatic portosystemic shunt (TIPS) and endoscopic therapy (ET) in the elective treatment of recurrent variceal hemorrhage. Methods. Seventy patients were treated with elective TIPS and fifty-six patients with ET. Median observation time was 46.28 months in the TIPS group and 42.31 months in the ET group. Results. 30 patients (42.8%) developed clinically evident portosystemic encephalopathy in TIPS group and 20 patients (35.6%) in ET group. The difference between the groups was not statistically significant (P = 0.542; χ 2 test). The incidence of new or worsening portosystemic encephalopathy was 24.3% in TIPS group and 10.7% in ET group. Multivariate analysis showed that ET treatment (P = 0.031), age of >65 years (P = 0.022), pre-existing HE (P = 0.045), and Child's class C (P = 0.051) values were independent predictors for the occurrence of HE. Conclusions. Procedure-related HE is a complication in a minority of patients treated with TIPS or ET. Patients with increased age, preexisting HE, and higher Child-Pugh score should be carefully observed after TIPS procedure because the risk of post-TIPS HE in these patients is higher.

Coated Transjugular Intrahepatic Portosystemic Shunt Does Not Improve Thrombocytopenia in Patients with Liver Cirrhosis

Thrombocytopenia is a common complication of chronic liver disease. The theory of portal decompression to improve thrombocytopenia due to hypersplenism has led to the study of transjugular intrahepatic portosystemic shunt (TIPS) as a potential therapy. However, there is a paucity of data and results have been conflicting. The aim of this study was to determine whether platelet counts improved in cirrhotic patients after placement of the new polytetrafluoroethylene (PTFE)-coated TIPS, developed in 2004. This is a retrospective cohort study of 68 patients with chronic liver disease who underwent a TIPS procedure. One-hundred twenty controls who did not undergo a TIPS procedure were matched on average for age, sex, race, model for end-stage liver disease (MELD) score, and etiology of liver disease. Platelet and hemoglobin counts were recorded during the month prior to the TIPS procedure (baseline) and over the following 12-14 months or until transplanted or death. While platelet counts improved during the first 3 months after TIPS with a mean increase of 11.25 × 103/μL (p = 0.064), they returned to baseline (pre-TIPS) with mean platelets of 91.31 × 103 μL by 12-14 months in comparison with a mild decrease of 10.2 × 103 μL in platelet counts in the control group from 100.4 × 103 μL to 90.2 × 103 (p = 0.119). There was also no significant correlation between platelet counts and etiology of liver disease, age, race, gender, or MELD score. Hemoglobin counts were found to have a small increase of 0.657 g/dL over the 12-14 month course in the TIPS group, which was statistically significant (p = 0.003). There does not appear to be a significant improvement in thrombocytopenia in cirrhotic patients after TIPS placement, despite advances in TIPS stents. However, there may be a mild improvement in anemia after TIPS implantation.

Transjugular intrahepatic portosystemic shuntvsendoscopic therapy in preventing variceal rebleeding

To compare early use of transjugular intrahepatic portosystemic shunt (TIPS) with endoscopic treatment (ET) for the prophylaxis of recurrent variceal bleeding. In-patient data were collected from 190 patients between January 2007 and June 2010 who suffured from variceal bleeding. Patients who were older than 75 years; previously received surgical treatment or endoscopic therapy for variceal bleeding; and complicated with hepatic encephalopathy or hepatic cancer, were excluded from this research. Thirty-five cases lost to follow-up were also excluded. Retrospective analysis was done in 126 eligible cases. Among them, 64 patients received TIPS (TIPS group) while 62 patients received endoscopic therapy (ET group). The relevant data were collected by patient review or telephone calls. The occurrence of rebleeding, hepatic encephalopathy or other complications, survival rate and cost of treatment were compared between the two groups. During the follow-up period (median, 20.7 and 18.7 mo in TIPS and ET groups, respectively), rebleeding from any source occurred in 11 patients in the TIPS group as compared with 31 patients in the ET group (Kaplan-Meier analysis and log-rank test, P = 0.000). Rebleeding rates at any time point (6 wk, 1 year and 2 year) in the TIPS group were lower than in the ET group (Bonferroni correction α' = α/3). Eight patients in the TIPS group and 16 in the ET group died with the cumulative survival rates of 80.6% and 64.9% (Kaplan-Meier analysis and log-rank test χ(2) = 4.864, P = 0.02), respectively. There was no significant difference between the two groups with respect to 6-wk survival rates (Bonferroni correction α' = α/3). However, significant differences were observed between the two groups in the 1-year survival rates (92% and 79%) and the 2-year survival rates (89% and 64.9%) (Bonferroni correction α' = α/3). No significant differences were observed between the two treatment groups in the occurrence of hepatic encephalopathy (12 patients in TIPS group and 5 in ET group, Kaplan-Meier analysis and log-rank test, χ(2) = 3.103, P = 0.08). The average total cost for the TIPS group was higher than for ET group (Wilcxon-Mann Whitney test, 52 678 RMB vs 38,844 RMB, P < 0.05), but hospitalization frequency and hospital stay during follow-up period were lower (Wilcxon-Mann Whitney test, 0.4 d vs 1.3 d, P = 0.01; 5 d vs 19 d, P < 0.05). Early use of TIPS is more effective than endoscopic treatment in preventing variceal rebleeding and improving survival rate, and does not increase occurrence of hepatic encephalopathy.

Early Transjugular Intrahepatic Portosystemic Shunt for Acute Variceal Bleeding Lowers Treatment Failure and Mortality

A study published in The New England Journal of Medicine finds that early rescue treatment with a transjugular intrahepatic portosystemic shunt (TIPS) for cirrhosis patients who are hospitalized for acute variceal bleeding could significantly lower treatment failure and mortality. If large varices develop in the esophagus or upper stomach, patients with cirrhosis are at risk for serious bleeding due to rupture of these varices. Once varices have bled, they tend to rebleed and the probability that a patient will die from each bleeding episode is high (30%–35%). Among current practice guidelines recommended for treating patients with acute variceal bleeding are fluid resuscitation, antibiotic prophylaxis, and vasoactive drugs such as octreotide, terlipressin, or somatostatin, followed by early endoscopy and either ligation or sclerosis of the varices. Despite these measures, failure to control index bleeding occurs in 10%–20% of patients. TIPS is indicated in patients who fail to respond to β-blockers, variceal sclerotherapy, or banding. TIPS can also be considered in treating patients with ascites that does not respond to salt and fluid restriction and diuretics. Researchers with the Early TIPS Cooperative Study Group randomized 63 patients with Child class B or C cirrhosis and acute variceal bleeding who had been treated with vasoactive drugs plus endoscopic therapy, either to treatment with a polytetrafluoroethylene (PFTE)-covered stent within 72 hours of randomization (early TIPS group, 32 patients) or to continuation of vasoactive drug therapy followed by propranolol or nadolol and long-term endoscopic band ligation (EBL), with insertion of a TIPS if needed as rescue therapy (31 patients). In this multicenter international study, patients who received early TIPS had a significantly better chance of remaining free of bleeding than did those who received the standard care (97% vs 50%). The rate of survival at 6 weeks was 97% in the TIPS group as compared with 67% in the medical therapy group, as a result of reductions in rebleeding, sepsis, and liver failure. In addition, “the number of days in the intensive care unit and percentage of time in the hospital during follow-up were significantly higher in the pharmacotherapy-EBL group,” the authors state. An editorial in the same issue of the journal notes that the study “should stimulate a reevaluation of how we approach variceal bleeding in patients with Child–Pugh class B or C disease. Instead of taking a wait-and-see approach, physicians should consider the early use of TIPS with a PFTE–covered stent as first-line therapy rather than as rescue treatment if rebleeding occurred. Additional clinical trials of adequate size should be performed to confirm these findings and to examine the effect of a rapid reduction in portal pressure on disease progression in patients with cirrhosis of various causes.” See NEJM 2010;362:2370–2379, 2421–2422. Also see Hepatology 2010:51, for AASLD TIPS practice guidelines and overview.

Transjugular intrahepatic portosystemic shunt versus paracentesis plus albumin in patients with refractory ascites who have good hepatic and renal function: a prospective randomized trial

Transjugular intrahepatic portosystemic shunt (TIPS) has recently been reported to be effective in the treatment of cirrhotic patients with refractory ascites. However, the clinical utility of TIPS in the subset of refractory ascitic patients with good hepatic and renal function is uncertain. The aim of this study was to compare the efficacy of TIPS to that of large-volume paracentesis in cirrhotic patients with refractory ascites who have good hepatic and renal function. Sixty cirrhotic patients with refractory ascites who presented with a Child-Pugh score of <11, serum bilirubin of <3 mg/dl and creatinine of <1.9 mg/dl were assigned randomly to TIPS (n = 30) or large-volume paracentesis plus albumin (n = 30). The primary endpoint was survival. The secondary endpoints were response to treatment and development of hepatic encephalopathy. The baseline characteristics were similar in the two groups. Seventeen patients treated with TIPS and 21 treated with paracentesis died during the study period. The cumulative probabilities of survival at 1 and 2 years were 80 and 64% in the TIPS group and 49 and 35% in the paracentesis group (p < 0.005). TIPS was significantly superior to paracentesis in the control of ascites (p < 0.005). Treatment failure was more frequent in the paracentesis group, whereas the frequency of hepatic encephalopathy was greater in the TIPS group. In cirrhotic patients with refractory ascites who have good hepatic and renal function, TIPS improves survival and provides better control of ascites than large-volume paracentesis.

Transjugular Intrahepatic Portosystemic Shunt versus Endoscopic Sclerotherapy in the Elective Treatment of Recurrent Variceal Bleeding

The present study was designed to compare elective transjugular intrahepatic portosystemic shunts (TIPS) and endoscopic sclerotherapy (EST) in terms of their efficacy in preventing recurrent bleeding from gastro-oesophageal varices in patients with advanced liver cirrhosis and portal hypertension. Of 96 patients with at least three gastro-oesophageal variceal rebleeds, 50 were treated with elective TIPS and 46 with EST. Recurrent variceal bleeding was significantly more frequent in patients receiving EST treatment compared with those receiving TIPS (45.7% versus 6.3%, respectively). Cumulative 1- and 4-year survival in the TIPS group was 83.0% and 73.5%, respectively, compared with 69.8% and 39.8% in the EST group, respectively. The rate of portosystemic encephalopathy was 33.3% in the TIPS group and 37.0% in the EST group. Elective TIPS was more effective than EST in the prevention of gastro-oesophageal variceal rebleeding in cirrhotic patients, it improved survival and it was associated with a similar rate of portosystemic encephalopathy.

Clinical study on transjugular intrahepatic portosystemic shunt in treatment of portal hypertension of patients with hepatocellular carcinoma

Objective To evaluate the therapeutic efficacy and safety of transjugular intrahepatic portosystemic shunt (TIPS) for the treatment of portal hypertension of patients with hepatocellular carcinoma.Methods Ninety-five portal hypertension patients with hepatic carcinoma were enrolled.TIPS was performed in 63 patients and the other 32 patients received support medical care.The data referred to survival time of the 95 patients after treatment was collected by follow-up visit.The informations about success rate of TIPS,hepatic encephalopathy,rebleeding and causes of death were assessed.The Kaplan-Meier method was used to compare the survival time between two groups.The association of survival time with Child-Pugh classification and model for end-stage liver disease (MELD) score was analyzed.Results The success rate of TIPS was 97.8% with reduction of mean portal vein pressure of 13.6 cmH2O(1 cmH2O=0.098 kPa).The incidence of hepatic encephalopathy was 20.6% and rebleeding was 26.3% six months after TIPS treatment.Fifty-six patients treated with TIPS died at the end of follow-up.Twelve of which were died of variceal bleeding complicated with portal hypertension.The median survival time of TIPS group (3.67 months) was significantly longer than that of control group (1 month). Moreover, the median survival time in patients with low MELD score (≤13) was significantly longer than that in those with high MELD seore (＞13, x2=4.71,P=0.03). Whereas the median survival time was decreasing from Child-Pugh A to C(x2=15.6,P=0.00). Conclusions TIPS is one of effective and safe therapeutic methods to control portal hypertension. However, liver function is an important factor for selcetion of TIPS. Key words: Carcinoma,hepatocellular; Hypertension,Portal; Portosystemie shunt,Transjugular intrahepatic

Budd-Chiari Syndrome: Long term success via hepatic decompression using transjugular intrahepatic porto-systemic shunt

BackgroundBudd-Chiari syndrome (BCS) generally implies thrombosis of the hepatic veins and/or the intrahepatic or suprahepatic inferior vena cava. Treatment depends on the underlying cause, the anatomic location, the extent of the thrombotic process and the functional capacity of the liver. It can be divided into medical treatment including anticoagulation and thrombolysis, radiological procedures such as angioplasty and transjugular intrahepatic porto-systemic shunt (TIPS) and surgical interventions including orthotopic liver transplantation (OLT). Controlled trials or reports on larger cohorts are limited due to rare disease frequency. The aim of this study was to report our single centre long term results of patients with BCS receiving one of three treatment options i.e. medication only, TIPS or OLT on an individually based decision of our local expert group.Methods20 patients with acute, subacute or chronic BCS were treated between 1988 and 2008. Clinical records were analysed with respect to underlying disease, therapeutic interventions, complications and overall outcome.Results16 women and 4 men with a mean age of 34 ± 12 years (range: 14-60 years) at time of diagnosis were included. Myeloproliferative disorders or a plasmatic coagulopathy were identified as underlying disease in 13 patients, in the other patients the cause of BCS remained unclear. 12 patients presented with an acute BCS, 8 with a subacute or chronic disease. 13 patients underwent TIPS, 4 patients OLT as initial therapy, 2 patients required only symptomatic therapy, and one patient died from liver failure before any specific treatment could be initiated. Eleven of 13 TIPS patients required 2.5 ± 2.4 revisions (range: 0-8). One patient died from his underlying hematologic disease. The residual 12 patients still have stable liver function not requiring OLT. All 4 patients who underwent OLT as initial treatment, required re-OLT due to thrombembolic complications of the graft. Survival in the TIPS group was 92.3% and in the OLT group 75% during a median follow-up of 4 and 11.5 years, respectively.ConclusionOur results confirm the role of TIPS in the management of patients with acute, subacute and chronic BCS. The limited number of patients with OLT does not allow to draw a meaningful conclusion. However, the underlying disease may generate major complications, a reason why OLT should be limited to patients who cannot be managed by TIPS.

Endoscopic cyanoacrylate versus transjugular intrahepatic portosystemic shunt for gastric variceal bleeding: a single-center U.S. analysis

Gastric variceal hemorrhage treatment remains a difficult issue for clinicians. There is controversy regarding whether first-line treatment should be endoscopic therapy with cyanoacrylate glue or placement of a transjugular intrahepatic portosystemic shunt (TIPS). We compared these methods on the basis of rebleeding, survival, and complications. DESIGN, SETTING, PATIENTS, AND INTERVENTIONS: This was a retrospective cohort analysis of cirrhotic patients with gastric variceal hemorrhage treated with endoscopic cyanoacrylate therapy or TIPS placement at a single U.S. center from 1997 to 2007. The groups were compared for rebleeding at 72 hours, 3 months, and 1 year; survival rates at 3 months and 1 year; and acute and extended complications and morbidity. A total of 105 patients were included. There were no significant pretreatment differences between the 2 groups in age, sex, MELD (Model for End-Stage Liver Disease) score at the time of admission, or cause of liver disease. There were no significant differences in rebleeding at 72 hours, 3 months, and 1 year; survival at 3 months and 1 year; and aggregate long-term survival or acute complications. However, the TIPS group had a higher rate of long-term morbidity requiring hospitalization (41% with a TIPS and 1.6% in the cyanoacrylate arm, P < .0001). Retrospective and uncontrolled samples. In patients with similar characteristics, cyanoacrylate therapy performed as well as a TIPS in controlling and preventing gastric variceal hemorrhage with no significant differences in survival. Patients receiving cyanoacrylate therapy experienced significantly less long-term morbidity related to therapy than patients who received a TIPS. Cyanoacrylate therapy appears to be safe and effective and compares favorably with TIPS therapy.

TIPS vs. cyanoacrylate injection in the prevention of gastric variceal rebleeding

I would like to thank Drs. Spahr et al. for their comments on our article regarding the prevention of gastric variceal rebleeding [1]. All of our patients received cyanoacrylate injection at index bleed. The numbers of patients with actively bleeding varices at index endoscopy were shown in Table 1: 13 patients (37 %) in the transjugular intrahepatic portosystemic shunt (TIPS) group and 14 patients (38 %) in the cyanoacrylate group. The mean time from enrollment to initial session of elective treatment was 14 days (range: 7 - 25 days) in the cyanoacrylate group and 4 days (range: 1 - 7 days) in the TIPS group. The mean time from enrollment to first session of elective treatment was thus longer in the cyanoacrylate group than in the TIPS group. This may be partly responsible for the striking difference in rebleeding rates between the two groups. Since all patients had already received cyanoacrylate injection at index bleed, we delayed the initial session of elective treatment in our cyanoacrylate group in order to avoid the occurrence of gastric ulcers induced by repeat cyanoacrylate injection after a short interval [2]. I agree that secondary prophylaxis of variceal bleeding should be started as soon as possible after control of acute hemorrhage. However, the appropriate interval between cyanoacrylate injections for acute treatment and for first elective therapy of gastric varices awaits further investigation. Our results showed the TIPS was more effective than cyanoacrylate injection in reducing variceal rebleeding, with smaller amounts of blood required and similar complication and survival rates. It is for this reason that we suggested that TIPS could be the choice of modality in the prevention of rebleeding from gastric varices. The following interpretation is also possible that although TIPS is more effective than cyanoacrylate injection in reducing gastric variceal bleeding, TIPS is an invasive procedure with the potential to induce hepatic encephalopathy, and hence TIPS should be reserved for patients in whom endoscopic treatment has failed - as in the recommendations in the policy statement by the American Association for the Study of Liver Diseases [3]. Whether TIPS should be the first choice for the prevention of gastric variceal rebleeding depends on the availability of local expertise, the complexity of the patient’s varices, (e. g., concomitant severe esophageal varices and gastric varices), and the patient’s preference. Since hepatic encephalopathy can usually be improved by administration of lactulose, and rebleeding from gastric varices is generally formidable with a high risk of mortality, the choice of TIPS instead of cyanoacrylate injection to prevent gastric variceal rebleeding appears to be the more logical choice. It is indeed the case that more controlled trials are required to verify the role of TIPS in the reduction of variceal rebleeding.

Is TIPS really superior to endoscopic therapy in the prevention of rebleeding from gastric varices?

We read with interest the paper by Lo et al. that compared transjugular intrahepatic portosystemic shunt (TIPS) with endoscopic cyanoacrylate injection for the prevention of rebleeding from gastric varices [1]. The authors randomized 72 patients with cirrhosis admitted to a single center for acute gastric variceal bleeding to receive either TIPS or repeated sessions of cyanoacrylate glue injection until obliteration of gastric varices was considered endoscopically to be complete. During the 36-month follow-up, they reported a higher rebleeding rate in the endoscopic treatment group than in the TIPS group (38 % vs. 11 %, P = 0.014), but no differences in survival or complications. As expected, episodes of hepatic encephalopathy were more frequent in patients from the TIPS group than in patients receiving endoscopic treatment [2]. The authors concluded that TIPS could be the treatment of choice to prevent rebleeding from gastric varices in patients with cirrhosis.