Transjugular Intrahepatic Portosystemic Stent Shunt Placement Research Articles

Clinical Experience with Real-Time 3-D Guidance Based on C-Arm-Acquired Cone-Beam CT (CBCT) in Transjugular Intrahepatic Portosystemic Stent Shunt (TIPSS) Placement.

The aim of this study was to evaluate the feasibility of cone-beam computed tomography (CBCT)-based real-time 3-D guidance of TIPSS placement and its positioning compared to standard guiding methods. In a prospective, randomized, consecutive study design from 2015 to 2017, we included 21 patients in the CBCT guided group and 15 patients in the ultrasound (US) guided group. The prospective groups were compared in terms of success rate of intervention, portal vein puncture/procedure time, number of puncture attempts and applied dose. We furthermore retrospectively analyzed the last 23 consecutive cases with fluoroscopic guided portal vein puncture in terms of success rate, procedure time and applied dose, as it has been the standard method before US guidance. The median number of puncture attempts (CBCT: n=2, US: n=4, p=0.249) and the mean puncture time (CBCT: 32±45min, US: 36±45min, p=0.515) were not significantly different. There were furthermore no significant differences in the mean time needed for the total TIPSS procedure (CBCT: 115±52min, US: 112±41min, fluoroscopy: 110±33min, p=0.996). The mean applied dose of the complete procedure also showed no statistically significant differences (CBCT: 563±289Gy·cm2, US: 322±186Gy·cm2, fluoroscopy: 469±352Gy·cm2, p=0.069). There were no image guidance related complications. Real-time 3-D needle guidance based on CBCT is feasible for TIPSS placement. In terms of puncture attempts, duration and dose, CBCT guidance was not inferior to the control groups and may be a valuable support for interventionists in TIPSS procedures.

Prevention of Rebleeding From Esophageal Varices in Patients With Cirrhosis Receiving Small-Diameter Stents Versus Hemodynamically Controlled Medical Therapy

Patients with cirrhosis and variceal hemorrhage have a high risk of rebleeding. We performed a prospective randomized trial to compare the prevention of rebleeding in patients given a small-diameter covered stent vs those given hepatic venous pressure gradient (HVPG)-based medical therapy prophylaxis. We performed an open-label study of patients with cirrhosis (92% Child class A or B, 70% alcoholic) treated at 10 medical centers in Germany. Patients were assigned randomly more than 5 days after variceal hemorrhage to groups given a small covered transjugular intrahepatic portosystemic stent-shunt (TIPS) (8 mm; n = 90), or medical reduction of portal pressure (propranolol and isosorbide-5-mononitrate; n = 95). HVPG was determined at the time patients were assigned to groups (baseline) and 2 weeks later. In the medical group, patients with an adequate reduction in HVPG (responders) remained on the drugs whereas nonresponders underwent only variceal band ligation. The study was closed 10 months after the last patient was assigned to a group. The primary end point was variceal rebleeding. Survival, safety (adverse events), and quality of life (based on the Short Form-36 health survey) were secondary outcome measures. A significantly smaller proportion of patients in the TIPS group had rebleeding within 2 years (7%) than in the medical group (26%) (P = .002). A slightly higher proportion of patients in the TIPS group experienced adverse events, including encephalopathy (18% vs 8% for medical treatment; P = .05). Rebleeding occurred in 6 of 23 patients (26%) receiving medical treatment before hemodynamic control was possible. Per-protocol analysis showed that rebleeding occurred in a smaller proportion of the 32 responders (18%) than in nonresponders who received variceal band ligation (31%) (P = .06). Fifteen patients from the medical group (16%) underwent TIPS placement during follow-up evaluation, mainly for refractory ascites. Survival time and quality of life did not differ between both randomized groups. Placement of a small-diameter, covered TIPS was straightforward and prevented variceal rebleeding in patients with Child A or B cirrhosis more effectively than drugs, which often required step-by-step therapy. However, TIPS did not increase survival time or quality of life and produced slightly more adverse events. Clinical Trial no: ISRCTN 16334693.

The effects of transjugular intrahepatic portosystemic stent shunt on systemic cardiocirculatory parameters

PurposeWe aimed to evaluate the effects of transjugular intrahepatic portosystemic stent shunt (TIPS) on systemic cardiocirculatory parameters in patients treated with TIPS for portal hypertension–associated complications. Materials and MethodsThis prospective study was conducted in an intensive care unit of a German university hospital (October 2010–July 2013). We assessed hemodynamic parameters before and after TIPS placement using single-indicator transpulmonary thermodilution and pulse contour analysis. After exclusion of 5 patients treated with vasoactive agents during study measurements, 15 patients were included in the final statistical analysis. ResultsTransjugular intrahepatic portosystemic stent shunt induced a statistically significant decrease in portal pressure (median, 29 [25%-75% percentile range, 23-37] mm Hg before TIPS vs 21 [18-27] mm Hg after TIPS; P < .01) in parallel with a statistically significant increase in central venous pressure (10 [6-15] mm Hg before TIPS vs 13 [9-16] mm Hg after TIPS; P = .01), cardiac index (3.8 [2.9-4.6] L min−1 m−2 before TIPS vs 4.5 [3.8-5.4] L min−1 m−2 14 hours after TIPS; P = .01), and stroke volume index (54 [42-60] mL/m2 before TIPS vs 60 [47-63] mL/m2 14 hours after TIPS; P = .03). Arterial blood pressure and systemic vascular resistance index were statistically significantly lower after TIPS. ConclusionsTransjugular intrahepatic portosystemic stent shunt placement is associated with an increase in central venous pressure and an improvement of global blood flow (cardiac index and stroke volume index) in patients with portal hypertension.

Study of virtual touch tissue quantification in noninvasive assessment of the effect of transjugular intrahepatic portosystemic stent shunt

Objective To explore the feasibility of virtual touch tissue quantification(VTQ) technique in noninvasive assessment of transjugular intrahepatic portosystemic stent shunt (TIPSS).Methods Twenty-four patients were enrolled in this study.Shear wave velocity(SWV) of the liver and spleen were obtained by VTQ technique on one day before TIPSS insertion and one week after TIPSS placement,and the portal vein pressure was measured while placing the TIPSS.The correlation between SWV of the liver and spleen and portal venous pressure were analysed.In addition,fourteen patients were followed up for one month after TIPSS placement.Results There was significant difference in portal vein pressure pre [(27.82 ± 4.07) mm Hg] and post [(16.26-± 3.10) mm Hg] TIPSS insertion.The SWV of the liver in patients pre and post TIPSS measured (2.43 ± 0.37)m/s and (2.40 ± 0.34)m/s,respectively.The SWV of the spleen in patients pre and post TIPSS were (3.49 ± 0.40)m/s and (3.08 ± 0.39)m/s,respectively,there was significant difference (P =0.000).However,SWV of the liver pre and post TIPSS placement was no significant difference(P =0.130).And as well as the patients which were followed up for one month after TIPSS placement.A significant,direct,linear correlation(r =0.602,P =0.000) was found between SWV of the spleen and portal vein pressure,but liver SWV was not correlated with the portal venous pressure.Conclusions SWV of the spleen measured by VTQ technique has a significant correlation with portal vein pressure.Hence,the spleen SWV based on VTQ technique can be used as a non-invasive method for quantitatively in monitoring the portal vein pressure as the function of the TIPSS.However,evidence to support a similar role for liver stiffness is lacking. Key words: Ultrasonography; Portosystemic shunt, transjugular intrahepatic; Hypertension, portal; Virtual touch tissue quantification

Transjugular intrahepatic portosystemic shunt using the FLUENCY expanded polytetrafluoroethylene-covered stent

The aim of this study was to evaluate the feasibility of transjugular intrahepatic portosystemic shunts using FLUENCY expanded polytetraf luoroethylene (PTFE)-covered stents and the effect on the patency rate. A total of 114 cirrhotic patients who were treated by transjugular intrahepatic portosystemic stent shunt (TIPS) placement using a FLUENCY expanded, PTFE-covered stent were enrolled in the present study. Of the patients, 15 underwent an additional bare metal stent implantation on the portal side of the covered stent, simultaneously. Patients underwent Doppler sonography during the follow-up. Mean portal venous pressure dropped from 2.499±0.588 cmHg to 1.764±0.294 cmHg. The cumulative patency rates for one and two years were 86.7% and 75.2%, respectively. The results demonstrate the feasibility of TIPS placement with the FLUENCY expanded PTFE-covered stent. TIPS placement with the FLUENCY expanded PTFE-covered stent was able to improve patency when compared with the use of conventional bare-metal stents.

Abstract No. 75: Transjugular intrahepatic portosystemic stent-shunt placement in liver-transplant recipients

To determine the feasibility, efficacy and safety of transjugular intrahepatic portosystemic stent-shunt (TIPSS) in liver transplant (LT) recipients. Between July 1995 and June 2010, 30 transplanted patients (mean age 53 years) with recurrent hepatitis B or C virus infection (n=15), secondary biliary cirrhosis due to chronic rejection (n=2), portal vein thrombosis (n=4), Budd-Chiari disease (n=2), small-for-size syndrome after LDLT (n=3), or other uncommon causes of recurrent portal hypertension on the graft(n=4) underwent TIPSS implantation. Indications for portal decompression include refractory ascites (n=18), hydrothorax (n=3), recurrent variceal bleeding (n=3), early portal vein occlusion (n=3), liver insufficiency after LDLT (n=2) and portal pressure reduction before surgical biliary repair (n=1). The median time interval from LT to TIPSS was 21 months (2–61). Bare and covered stents were implanted in 13 and 17 patients, respectively. A portal targetting was needed in 3 patients. TIPSS procedure succeeded in all patients. The mean portosystemic pressure gradient was reduced from 16.9 to 7.1 mmHg. (Near)-complete ascites remission was achieved in 72% of patients with ascites. All patients with hydrothorax or variceal bleeding did respond dramatically to TIPSS. One among the two patients with small-for-size syndrome improved significantly. 18 patients (60%) developped new onset or worsening encephalopathy at a median of 21 days post TIPSS and 2 among them needed reducer device implantation. 17 of the 30 patients (57%) died during the study period, mainly from liver failure or sepsis. Four of five patients who underwent retransplantation survived. The median survival after TIPSS was 6.2 months (1.5–72). TIPSS indications may be extended to liver transplant recipients. Control of ascites or bleeding could be achieved in most cases. A poor survival rate due to liver failure or immunosupression-related sepsis is observed. Redo transplantation within 5 months after TIPSS placement could improve survival.

Prognostic role of the initial portal pressure gradient reduction after TIPS in patients with cirrhosis

The aim of this study was to determine the prognostic relevance of the portal pressure gradient (PPG) before and after transjugular intrahepatic portosystemic stent shunt (TIPS) insertion in patients with liver cirrhosis and recurrent oesophageal variceal bleeding. 118 cirrhotic patients (Child A/B/C, 41/56/21; Child score, 7.7+/-2.0; baseline PPG, 21.8+/-4.7 mmHg) underwent TIPS for the prevention of variceal rebleeding. A multivariate logistic regression analysis was applied to identify the independent determinants of rebleeding and survival. The estimated rebleeding rate and the estimated survival were compared by log-rank testing. TIPS insertion reduced the PPG by 53.2+/-17.7%. During follow-up 21 patients suffered significant rebleeding (17.8%); bleeding-related mortality was 3.4% (four patients). The median survival [95% confidence intervals (CI)] was 48.2 (39.8; 60.8) months. The multivariate Cox model identified creatinine as the only independent predictor of survival, and the initial decrease of the PPG after TIPS as the only independent predictor of rebleeding. PPG before TIPS (21.8+/-4.7 mmHg) and the gradient at the time of rebleeding (22.0+/-2.9 mmHg) did not differ significantly. Patients with an initial decrease of the PPG after TIPS <30% were at the highest risk for rebleeding. Patients with an initial decrease of the PPG >60% rarely suffered from rebleeding. The initial decrease in the PPG after TIPS is a predictor for the risk of rebleeding but not for survival after TIPS. For that reason, in patients undergoing TIPS placement for the prevention of recurrent bleeding from oesophageal varices, an initial reduction of the PPG of 30-50% should be attempted.

The management of ascites in cirrhosis: Report on the consensus conference of the International Ascites Club

Ascites is a common complication of cirrhosis, and heralds a new phase of hepatic decompensation in the progression of the cirrhotic process. The development of ascites carries a significant worsening of the prognosis. It is important to diagnose noncirrhotic causes of ascites such as malignancy, tuberculosis, and pancreatic ascites since these occur with increased frequency in patients with liver disease. The International Ascites Club, representing the spectrum of clinical practice from North America to Europe, have developed guidelines by consensus in the management of cirrhotic ascites from the early ascitic stage to the stage of refractory ascites. Mild to moderate ascites should be managed by modest salt restriction and diuretic therapy with spironolactone or an equivalent in the first instance. Diuretics should be added in a stepwise fashion while maintaining sodium restriction. Gross ascites should be treated with therapeutic paracentesis followed by colloid volume expansion, and diuretic therapy. Refractory ascites is managed by repeated large volume paracentesis or insertion of a transjugular intrahepatic portosystemic stent shunt (TIPS). Successful placement of TIPS results in improved renal function, sodium excretion, and general well-being of the patient but without proven survival benefits. Clinicians caring for these patients should be aware of the potential complications of each treatment modality and be prepared to discontinue diuretics or not proceed with TIPS placement should complications or contraindications develop. Liver transplantation should be considered for all ascitic patients, and this should preferably be performed prior to the development of renal dysfunction to prevent further compromise of their prognosis. (H epatology 2003;38:258-266.)

Systemic and regional changes in plasma endothelin following transient increase in portal pressure.

An acute increase in portal pressure or reduction in portal inflow has been shown to decrease renal plasma flow (RPF). The aim of the study was to evaluate regional and systemic hemodynamics after acute occlusion of a transjugular intrahepatic portosystemic stent-shunt (TIPSS) and study the effect of the same on plasma endothelin (ET-1) levels in the systemic circulation, renal vein, and hepatic vein. Sixteen patients attending for portography after previous TIPSS placement were studied. The shunt was acutely occluded with an angioplasty balloon for 12 minutes. Changes in portal pressure gradient (PPG), hepatic plasma flow (HPF), RPF, cardiac output (CO), and systemic vascular resistance (SVR) were measured before and after shunt occlusion. Blood was collected from the femoral artery and hepatic and renal veins for ET-1 measurement. At T = 0, SVR correlated with circulating arterial ET-1 level (r = 0.74; P <.05). After shunt occlusion (T = 12 minutes), heart rate, CO, and mean arterial pressure decreased (P <.05), whereas PPG increased (P <.05). RPF decreased from 485 +/- 55 to 282 +/- 47 mL/min (P <.01), whereas HPF increased from 700 +/- 39 to 779 +/- 33 mL/min (P <.001). There was a significant increase in arterial concentration and renal production, and decrease in hepatic production of ET-1. Veno-arterial (V-A) concentration difference in ET-1 level in the renal vein, as well as renal flux of ET-1, increased significantly, whereas hepatic vein V-A concentration difference and hepatic flux of ET-1 decreased significantly. At T = 12 minutes, ET-1 renal output correlated negatively with RPF (r = 0.72; P <.05). Results of this study show that an acute increase in portal pressure and reduction in portal inflow brought about by occlusion of a TIPSS shunt decreases RPF and increases HPF. These hemodynamic changes are accompanied by increases in arterial, renal vein, and hepatic vein ET-1 concentrations, which may possibly mediate the observed findings.

Effects of ascites resolution after successful TIPS on nutrition in cirrhotic patients with refractory ascites

OBJECTIVE: Malnutrition is common in patients with decompensated cirrhosis and refractory ascites. The use of transjugular intrahepatic portosystemic stent shunt (TIPS) is effective in eliminating ascites. The purpose of this study was to investigate the effect of TIPS and resolution of refractory ascites on the nutritional status of patients with decompensated cirrhosis. METHODS: Fourteen consecutive patients with refractory ascites and a Pugh score of 9.0 ± 0.5 had a TIPS insertion. Biochemical data, resting energy expenditure (REE), total body nitrogen (TBN), body potassium (TBK), body fat (TBF), muscle force (MF), and food intake were recorded before TIPS, and at 3 and 12 months after the procedure. RESULTS: Ten patients completed the study. Baseline values for REE, TBN, TBF, MF, and energy intake were below normal at baseline. There was a significant increase in dry weight, TBN, and REE at 3 and 12 months compared with baseline. TBF improved significantly at 12 months. There was a trend toward an increase in energy intake ( p = 0.072). There was no change in protein intake, TBK, MF, and Pugh score. CONCLUSION: In cirrhotic patients with refractory ascites, resolution of the ascites after TIPS placement resulted in improvement of several nutritional parameters, especially for body composition.

Effects of ascites resolution after successful TIPS on nutrition in cirrhotic patients with refractory ascites.

Malnutrition is common in patients with decompensated cirrhosis and refractory ascites. The use of transjugular intrahepatic portosystemic stent shunt (TIPS) is effective in eliminating ascites. The purpose of this study was to investigate the effect of TIPS and resolution of refractory ascites on the nutritional status of patients with decompensated cirrhosis. Fourteen consecutive patients with refractory ascites and a Pugh score of 9.0+/-0.5 had a TIPS insertion. Biochemical data, resting energy expenditure (REE), total body nitrogen (TBN), body potassium (TBK), body fat (TBF), muscle force (MF), and food intake were recorded before TIPS, and at 3 and 12 months after the procedure. Ten patients completed the study. Baseline values for REE, TBN, TBF, MF, and energy intake were below normal at baseline. There was a significant increase in dry weight, TBN, and REE at 3 and 12 months compared with baseline. TBF improved significantly at 12 months. There was a trend toward an increase in energy intake (p = 0.072). There was no change in protein intake, TBK, MF, and Pugh score. In cirrhotic patients with refractory ascites, resolution of the ascites after TIPS placement resulted in improvement of several nutritional parameters, especially for body composition.

Acute effects of transjugular intrahepatic portosystemic stent-shunt (TIPSS) procedure on renal blood flow and cardiopulmonary hemodynamics in cirrhosis

Objective: An acute increase in portal pressure is associated with an immediate reduction in renal blood flow. It has been suggested that this supports the presence of an hepatorenal reflex. In this study, we used TIPSS placement as a model to investigate the effect of an acute reduction in portal pressure on renal blood flow and cardiopulmonary hemodynamic parameters. Methods: Eleven cirrhotic patients were studied during elective TIPSS placement for variceal hemorrhage (n = 9) or refractory ascites (n = 2). Unilateral renal blood flow (RBF) was measured before and at 5, 15, 30, 45, and 60 min after shunt insertion. Heart rate (HR), mean arterial pressure (MAP), right atrial pressure (RAP), mean pulmonary artery pressure (PAP), pulmonary capillary wedge pressure (PCWP), cardiac output (CO), and systemic vascular resistance (SVR) were also measured before and 30 min after TIPSS placement. Results: Despite significant increases in CO ( p = 0.001), RAP ( p < 0.001), PAP ( p < 0.001), and PCWP ( p = 0.001), and a fall in SVR ( p = 0.003), no change was observed in RBF, HR, or MAP after TIPSS placement. The fall in the portoatrial pressure gradient correlated only with the rise in CO ( p < 0.05) and the drop in SVR ( p < 0.05). Conclusion: Despite the fall in portal pressure and the systemic hemodynamic changes caused by TIPSS placement, there is no immediate effect on RBF. Any improvement in renal function after TIPSS procedure does not appear to be due to an acute increase in RBF.

Acute effects of transjugular intrahepatic portosystemic stent-shunt (TIPSS) procedure on renal blood flow and cardiopulmonary hemodynamics in cirrhosis.

An acute increase in portal pressure is associated with an immediate reduction in renal blood flow. It has been suggested that this supports the presence of an hepatorenal reflex. In this study, we used TIPSS placement as a model to investigate the effect of an acute reduction in portal pressure on renal blood flow and cardiopulmonary hemodynamic parameters. Eleven cirrhotic patients were studied during elective TIPSS placement for variceal hemorrhage (n = 9) or refractory ascites (n = 2). Unilateral renal blood flow (RBF) was measured before and at 5, 15, 30, 45, and 60 min after shunt insertion. Heart rate (HR), mean arterial pressure (MAP), right atrial pressure (RAP), mean pulmonary artery pressure (PAP), pulmonary capillary wedge pressure (PCWP), cardiac output (CO), and systemic vascular resistance (SVR) were also measured before and 30 min after TIPSS placement. Despite significant increases in CO (p = 0.001), RAP (p < 0.001), PAP (p < 0.001), and PCWP (p = 0.001), and a fall in SVR (p = 0.003), no change was observed in RBF, HR, or MAP after TIPSS placement. The fall in the portoatrial pressure gradient correlated only with the rise in CO (p < 0.05) and the drop in SVR (p < 0.05). Despite the fall in portal pressure and the systemic hemodynamic changes caused by TIPSS placement, there is no immediate effect on RBF. Any improvement in renal function after TIPSS procedure does not appear to be due to an acute increase in RBF.

Transjugular Intrahepatic Portosystemic Stent Shunt for Hepatorenal Syndrome and Ascites

Refractory ascites is defined as ascites that cannot be mobilized, or the early recurrence of which cannot be prevented despite maximal diuretic therapy of 400 mg of spironolactone or 30 mg of amiloride plus up to 120 mg of furosemide daily for at least 1 week despite being on dietary sodium restriction of 50 mEq or less per day. Patients who cannot tolerate diuretic therapy because of complications are also regarded as having refractory ascites [1]. Approximately 5% of all patients with ascites are refractory to conventional medical therapy of sodium restriction, diuretics and large volume paracentesis, and the management of these patients has been unsatisfactory. The recent development of a transjugular intrahepatic portosystemic stent shunt (TIPS) as a treatment for refractory variceal hemorrhage [2–4] led to the observation that after TIPS placement, concomitant ascites in these patients seemed to disappear or became easier to control [5–7]. There followed a flurry of enthusiasm on the use of TIPS as a treatment for refractory ascites.

Phenprocoumon for prevention of shunt occlusion after transjugular intrahepatic portosystemic stent shunt: A randomized trial

Development of stenosis or occlusion of the transjugular intrahepatic portosystemic stent shunt (TIPSS) is one of the major limiting factors in the long-term viability of this procedure. The efficacy of anticoagulation with heparin which is used in different centers is still unclear. In the present study, we evaluated the effect of phenprocoumon on shunt patency after TIPSS placement using Palmaz stents; 49 patients with Child's A and B cirrhosis, who underwent successful TIPSS placement were randomized into the treatment group (n = 24) who received phenprocoumon and a control group (n = 25). After 11 to 13 weeks, all patients were admitted and had a reevaluation that included control angiography by transjugular approach. Phenprocoumon treatment was stopped after the first reevaluation and both groups were followed for 1 year after randomization. During the 3-month treatment period 11 of 22 patients of the treatment group and 12 of 23 patients of the control group required reintervention because of an increased portosystemic gradient. Five of the 12 patients in the control group showed complete occlusion of the shunt, whereas no occlusion in the treatment group was observed (P < .05). During the mean follow-up of 8 months after the treatment was stopped, in both groups stenosis occurred in 50% of patients, but no further occlusion of the stent was observed. These data indicate that occlusion of the stent is related to thrombosis, whereas stenosis does not appear to be dependent on blood coagulation. In patients with preserved liver function occlusion of the shunt may be prevented by phenprocoumon treatment in the first 3 months after TIPSS placement. Thereafter shunt occlusion was not observed and further phenprocoumon treatment seemed unnecessary.

Phenprocoumon for prevention of shunt occlusion after transjugular intrahepatic portosystemic stent shunt: A randomized tria

Development of stenosis or occlusion of the transjugular intrahepatic portosystemic stent shunt (TIPSS) is one of the major limiting factors in the long-term viability of this procedure. The efficacy of anticoagulation with heparin which is used in different centers is still unclear. In the present study, we evaluated the effect of phenprocoumon on shunt patency after TIPSS placement using Palmaz stents; 49 patients with Child's A and B cirrhosis, who underwent successful TIPSS placement were randomized into the treatment group (n = 24) who received phenprocoumon and a control group (n = 25). After 11 to 13 weeks, all patients were admitted and had a reevaluation that included control angiography by transjugular approach. Phenprocoumon treatment was stopped after the first reevaluation and both groups were followed for 1 year after randomization. During the 3-month treatment period 11 of 22 patients of the treatment group and 12 of 23 patients of the control group required reintervention because of an increased portosystemic gradient. Five of the 12 patients in the control group showed complete occlusion of the shunt, whereas no occlusion in the treatment group was observed (P < .05). During the mean follow-up of 8 months after the treatment was stopped, in both groups stenosis occurred in 50% of patients, but no further occlusion of the stent was observed. These data indicate that occlusion of the stent is related to thrombosis, whereas stenosis does not appear to be dependent on blood coagulation. In patients with preserved liver function occlusion of the shunt may be prevented by phenprocoumon treatment in the first 3 months after TIPSS placement. Thereafter shunt occlusion was not observed and further phenprocoumon treatment seemed unnecessary. (Hepatology 1996 Dec;24(6):1433-6)

Plasma levels of substance P in liver cirrhosis: relationship to the activation of vasopressor systems and urinary sodium excretion.

The mediators of the hyperdynamic circulation of liver cirrhosis are not well characterized. Substance P is a potent vasodilatory peptide produced by the enteric nervous system and partly cleared by the liver. In this work we have investigated the plasma levels of substance P and their relationship to the hemodynamic, neurohormonal, and renal function changes occurring in patients with cirrhosis. Seven healthy subjects (control group), 7 cirrhotic patients without ascites (group I), and 24 cirrhotic patients with ascites (group II) were studied. Cardiac output (CO), femoral blood flow (FBF), blood volume (BV), femoral arteriovenous difference of oxygen content (Ca-v O2), plasma renin activity (PRA), plasma aldosterone concentration (PAC), and plasma norepinephrine (NE) were determined. Five patients underwent trans-jugular intrahepatic porto-systemic stent shunt (TIPSS) because of refractory ascites. Immunoreactive substance P (irSP) was measured by radioimmunoassay after plasma extraction. irSP was higher in ascitic patients than in healthy controls (P < .01) and directly correlated with PRA, PAC, plasma NE, and Pugh's score and was inversely correlated with urinary sodium excretion, glomerular filtration rate, and Ca-v O2. No differences were observed between portal and peripheral vein irSP concentration. TIPSS placement induced a decrease in portal pressure and an increase in CO but circulating irSP remained unchanged. Our data show that circulating irSP is increased in decompensated cirrhotic patients and may be involved in the pathogenesis of the hemodynamic changes of cirrhosis. Alleviation of portal hypertension did not result in decreased plasma levels of this vasodilatory substance.

Plasma levels of substance p in liver cirrhosis: Relationship to the activation of vasopressor systems and urinary sodium excretion

The mediators of the hyperdynamic circulation of liver cirrhosis are not well characterized. Substance P is a potent vasodilatory peptide produced by the enteric nervous system and partly cleared by the liver. In this work we have investigated the plasma levels of substance P and their relationship to the hemodynamic, neurohormonal, and renal function changes occurring in patients with cirrhosis. Seven healthy subjects (control group), 7 cirrhotic patients without ascites (group I), and 24 cirrhotic patients with ascites (group II) were studied. Cardiac output (CO), femoral blood flow (FBF), blood volume (BV), femoral arteriovenous difference of oxygen content (Ca-v O 2), plasma renin activity (PRA), plasma aldosterone concentration (PAC), and plasma norepinephrine (NE) were determined. Five patients underwent trans-jugular intrahepatic porto-systemic stent shunt (TIPSS) because of refractory ascites. Immunoreactive substance P (irSP) was measured by radioimmunoassay after plasma extraction. irSP was higher in ascitic patients than in healthy controls ( P < .01) and directly correlated with PRA, PAC, plasma NE, and Pugh's score and was inversely correlated with urinary sodium excretion, glomerular filtration rate, and Ca-v O 2. No differences were observed between portal and peripheral vein irSP concentration. TIPSS placement induced a decrease in portal pressure and an increase in CO but circulating irSP remained unchanged. Our data show that circulating irSP is increased in decompensated cirrhotic patients and may be involved in the pathogenesis of the hemodynamic changes of cirrhosis. Alleviation of portal hypertension did not result in decreased plasma levels of this vasodilatory substance.

US-guided Paraumbilical Vein Puncture: An Adjunct to Transjugular Intrahepatic Portosystemic Shunt (TIPS) Placement

Transjugular intrahepatic portosystemic stent-shunt placement has shown great promise as a means of protal decompression in patients with severe portal hypertension. Passage of a needle from the hepatic venous system into the portal venous system during this procedure may be technically difficult; while it would be advantageous to precisely target the portal vein, most methods of localization are themselves technically difficult, risky, or time-consuming. The authors describe a method of localization of the portal vein that, when feasible, appears to be both safe and technically simple. This method involves percutaneous catheterization of a paraumbilical portosystemic collateral vein under sonographic guidance.