Intrahepatic Portosystemic Shunt For Treatment Research Articles

S2700 Transjugular Intrahepatic Portosystemic Shunt for Treatment of Recurrent Isolated Chylothorax Caused by Cirrhosis

S2700 Transjugular Intrahepatic Portosystemic Shunt for Treatment of Recurrent Isolated Chylothorax Caused by Cirrhosis

Efficacy of transjugular intrahepatic portosystemic shunt in treatment of sinusoidal obstruction syndrome caused by gynura segetum

Objective To evaluate the safety and efficacy of transjugular intrahepatic portosystemic shunt (TIPS) in the treatment of sinusoidal obstruction syndrome (SOS) caused by gynura segetum. Methods The clinical data of 9 patients with SOS caused by gynura segetum (5 males and 4 females) who underwent TIPS were retrospectively analyzed from February 2017 to June 2018. The Child-Pugh scores were (9.5±1.3) and the MELD scores were (12.5±5.0). The success rates, complications and follow-up results were evaluated. Results TIPS was performed successfully in all the 9 patients. The portal venous pressure gradient dropped from (22.4±2.7) mmHg to (10.4±3.2) mmHg (P<0.05). There was no complication such as abdominal hemorrhage and biliary peritonitis. Nine patients were followed-up for 1~17months, mean 7.8±6.0 months. One month after treatment, the Child-Pugh scores were (7.1±1.8), compared with that of the preoperative scores, the difference was statistically significant (P<0.05). The MELD scores were (5.3±4.6), compared with that of the preoperative scores, the difference was also statistically significant (P<0.05). At the end point of the follow-up, color Doppler ultrasound and portal CTA showed that the TIPS shunt was patent and hepatic congestion was relieved in all the 9 patients. All patients were alive. Conclusion TIPS was a safe and efficacious treatment for SOS caused by gynura segetum. Key words: Portasystemic shunt, transjugular intrahepatic; Gynura segetum; Sinusoidal obstruction syndrome

Percutaneous transhepatic intrahepatic portosystemic shunt for treatment of portal hypertension due to chronic portal vein occlusion after splenectomy

Objective To study the feasibility and efficacy of percutaneous transhepatic intrahepatic portosystemic shunt (PTIPS) in patients with portal hypertension due to chronic portal vein occlusion after splenectomy. Methods 27 patients who had portal hypertension due to chronic portal vein occlusion after splenectomy underwent PTIPS between December 2010 and March 2015. These patients were enrolled in this retrospective study. The success rates, efficacy, and complications were evaluated. Significance in the differences in the portosystemic pressure gradient (PPG) as measured before and after PTIPS procedure was assessed. Results PTIPS was successfully carried out in 25 patients but failed in 2. No fatal procedural complications were observed. The mean PPG dropped from (22.3±5.7) mmHg to (12.4±3.1) mmHg after successful PTIPS (1 mmHg=0.133 kPa, P<0.05). The median follow-up in the 25 patients with successful PTIPS were 22 months and there were 3 (12.0%) deaths from liver failure due to severe cirrhosis, and 1 death (4.0%) from stroke during the follow-up period. Shunt dysfunction happened in 4 (16.0%) patients. The original symptoms reoccurred in 2 patients (8.0%) and the remaining patients were diagnosed by routine CT or US examination. Three patients recovered after shunt revision with stent implantation or balloon angioplasty, while one patient refused any further therapy except oral medication. This patient suffered from the first episode of rebleeding 36 months after PTIPS. Hepatic encephalopathy developed in 2 (8.0%) patients, 1 patient recovered after medical treatment, while the other who developed Grade 3 hepatic encephalopathy recovered after implanting a smaller cover stent. The remaining patients were asymptomatic with patent shunts. Conclusion PTIPS was a feasible, safe, and efficacious treatment for portal hypertension due to chronic portal vein occlusion after splenectomy. Key words: Venous thrombosis; Portal vein, hypertension; Splenectomy; Portosystemic shunt

Balloon-occluded retrograde transvenous obliteration versus transjugular intrahepatic portosystemic shunt for treatment of gastric varices due to portal hypertension: A meta-analysis.

The aim of this study was to compare the feasibility and safety of both balloon-occluded retrograde transvenous obliteration (BRTO) versus transjugular intrahepatic portosystemic shunt (TIPS) for treatment of gastric varices due to portal hypertension through the method of meta-analysis. PubMed, Embase, and Cochrane Library were searched for both randomized controlled trials and cohort studies concerning BRTO compared with TIPS in the treatment of gastric varices from their inception to April 26, 2015. The Cochrane network RevMan 5.3 software was used for statistic analysis. The primary markers that need to be evaluated contained technical success rate, hemostasis rate, incidence rate of postoperative rebleeding, incidence rate of hepatic encephalopathy, and postoperative procedure-related complication. Study-specific odds ratios (ORs) were combined to calculate pooled value by using random effects model. Five original studies were included in total. Meta-analysis showed that BRTO and TIPS had no difference in aspects of technical success rate (OR, 0.19; 95% confidence interval [CI], 0.03-1.08; P = 0.06), hemostasis rate (OR, 3.41; 95% CI, 0.33-35.40; P = 0.30), and incidence rate of postoperative procedure-related complication (OR, 1.98; 95% CI, 0.44-8.84; P = 0.37). However, BRTO had a lower incidence rate of post-operative rebleeding (OR, 0.27; 95% CI, 0.09-0.81; P = 0.02) and a lower incidence rate of postoperative encephalopathy (OR, 0.05; 95% CI, 0.02-0.13; P < 0.00001). Balloon-occluded retrograde transvenous obliteration was a technically feasible as well as a secure method for the treatment of gastric varices originated from portal hypertension. It may have the potential to be an alterative shunt approach of TIPS, when suitable patients selected.

Endovascular evaluation and treatment of intrahepatic portosystemic shunts in dogs: 100 cases (2001–2011)

To evaluate short- and long-term outcome following endovascular treatment of intrahepatic portosystemic shunts in dogs. Retrospective case series. 100 dogs. All patients had angiographic evaluation with or without endovascular shunt attenuation. The medical records were reviewed for pertinent data, complications, outcome, and survival time. 95 dogs with congenital intrahepatic portosystemic shunts received 111 procedures (83% [79/95] had 1 treatment, and 17% [16/95] had > 1 treatment; 5 dogs had no treatment because of excessive portal venous pressure-central venous pressure gradients). Angiography identified 38 right, 33 left, and 19 central divisional single shunts (n = 90) and 10 complex or multiple shunts. Partial shunt attenuation was performed in 92 dogs by means of caval stent placement and insertion of thrombogenic coils within the shunt, and 3 had complete acute shunt occlusion. Major intraoperative complications (3/111 [3%]) included temporary severe portal hypertension in 2 dogs and gastrointestinal hemorrhage in 1 dog. Major postoperative (< 1 week after surgery) complications (14/111 [13%]) included seizures or hepatoencephalopathy (7/111 [6%]), cardiac arrest (2/111 [2%]), jugular site bleeding (2/111 [2%]), pneumonia (1/111 [1%]), suspected portal hypertension (1/111 [1%]), and acute death (1/111 [1%]). Median follow-up time was 958 days (range, 0 to 3,411 days). Median survival time for treated dogs was 2,204 days (range, 0 to 3,411 days). Outcome was considered excellent (57/86 [66%]) or fair (13/86 [15%]) in 70 of 86 (81%) treated dogs. Results suggested that endovascular treatment of intrahepatic shunts in dogs may result in lower morbidity and mortality rates, with similar success rates, compared with previously reported outcomes for open surgical procedures. Gastrointestinal ulceration was a common finding among this population of dogs, and lifelong gastroprotectant medications are now recommended.

Transjugular Intrahepatic Portosystemic Shunt for Treatment of Cirrhosis-related Chylothorax and Chylous Ascites: Single-institution Retrospective Experience

To investigate the efficacy and safety of the use of transjugular intrahepatic portosystemic shunt (TIPS) creation to treat cirrhosis-related chylous collections (chylothorax and chylous ascites). We retrospectively reviewed data from four patients treated for refractory cirrhosis-related chylous collections with TIPS at our institution over an 8year period. One patient had chylothorax, and three patients had concomitant chylothorax and chylous ascites. There were no major complications, and the only procedure-related complications occurred in two patients who had mild, treatable hepatic encephalopathy. All patients had improvement as defined by decreased need for thoracentesis or paracentesis, with postprocedure follow-up ranging from 19 to 491days. TIPS is a safe procedure that is effective in the treatment of cirrhosis-related chylous collections.

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

Successful treatment of pulmonary hypertension secondary to congenital extrahepatic portocaval shunts (Abernethy type 2) by living donor liver transplantation after surgical shunt ligation

In this report, we describe a living donor liver transplantation (LDLT) in a patient (7-year-old boy) with Abernethy type 2 congenital extrahepatic portocaval shunts (CEPS). This patient underwent a surgical shunt ligation as the first treatment for pulmonary hypertension; pulmonary hypertension was improved and controlled successfully 4 years after the first operation. However, pulmonary hypertension recurred gradually because of multiple intrahepatic portosystemic shunts; therefore, LDLT was performed as a radical treatment of intrahepatic portosystemic shunts. His pulmonary arterial pressure was also controlled 22 months after LDLT, the postoperative continuous intravenous prostaglandin I(2) (PGI(2)) treatment could be withdrawn successfully. We suggest that clinicians carefully follow up the recurrent portosystemic shunt and cardiopulmonary disorders secondary to Abernethy type 2 CEPS.

Bleeding Stomal Varices: Case Series and Systematic Review of the Literature

Bleeding stomal varices are a common problem in patients with surgical stomas and portal hypertension, and remain difficult to diagnose and manage. We identified all patients at our institution with bleeding stomal varices from 1989 to 2004. We surveyed all patients undergoing ileal pouch-anal anastomosis from 1997 to 2007 for bleeding anastomotic varices. Finally, we performed a systematic review of the literature focusing on diagnosis and treatment of bleeding stomal varices that included 74 English language studies of 234 patients. We identified 8 patients with bleeding stomal varices. Recognition of stomal varices typically was delayed, particularly when failing to examine the ostomy without the appliance. Stomal variceal bleeding was confirmed by Doppler ultrasound or angiographic imaging. Simple local therapy usually stopped bleeding, albeit temporarily. Sclerotherapy was effective, but at the expense of unacceptable stomal damage. Decompressive therapy was required for secondary prophylaxis, including transjugular intravascular transhepatic shunts (2 patients), surgical portosystemic shunts (2 patients), and liver transplantation (1 patient). No patient with an ileal pouch-anal anastomosis developed anastomotic bleeding from varices. Primary prevention of bleeding stomal varices requires avoidance of creating enterocutaneous stomas in patients with portal hypertension. Careful inspection of the uncovered ostomy is essential for bleeding stomal varices diagnosis. Once identified, conservative measures will stop bleeding temporarily with definitive therapy required, including transjugular intravascular transhepatic shunts, surgical shunts, or liver transplantation.

Transjugular intrahepatic portosystemic shunt for treatment of intractable colonic ischemia associated with portal hypertension: A bridge to liver transplantation

A 64-year-old man with portal hypertension secondary to hepatic nodular transformation was awaiting liver transplantation when he presented with severe, unrelenting abdominal pain, fever, and hypotension. Computed tomographyrevealed pneumatosis within the cecum and ascending colon. Because of his advanced liver disease and the perceived high likelihood of a poor outcome after colonic resection, he was managed medically. He improved initially but had a lengthy hospital course notable for intractable intestinal ischemia and gastrointestinal bleeding. Magnetic resonance angiography demonstrated patent mesenteric, portal, and hepatic vessels. His blood pressure was typically 90/55 mm Hg (mean arterial pressure, 65-70 mm Hg) despite intravenous fluids and blood product replacement. The hypothesis developed that the patient's level of portal hypertension was sufficiently severe (in the face of his low mean systemic arterial pressure) to compromise perfusion of the colonic mucosa. Were this hypothesis correct, then portal decompression might enhance the blood pressure gradient across the bowel and improve mucosal perfusion. With this in mind, a transjugular intrahepatic portosystemic shunt (TIPS) was placed. There was reduction of the portal vein to inferior vena cava gradient from 29 mm Hg to 9 mm Hg and his abdominal pain and gastrointestinal bleeding ceased. His prompt and sustained improvement following TIPS shunt placement is consistent with the hypothesis that high portal pressure was flow limiting, thus contributing to persisting intestinal ischemia. This case represents the first report of use of a TIPS shunt to address colonic ischemia associated with portal hypertension.

Transjugular intrahepatic portosystemic shunt for treatment of bleeding ectopic varices with portal hypertension.

In the setting of hepatic failure and portal hypertension, hemorrhage from stomal and rectal varices is a well-described problem. It has recently been suggested that transjugular intrahepatic portosystemic shunting may be useful in the therapy of bleeding from parastomal or anorectal varices in patients unresponsive to conservative therapy. We retrospectively review our institution's experience of five patients with parastomal varices and seven patients with anorectal varices who underwent transjugular intrahepatic portosystemic shunting for hemorrhage refractory to conservative management between 1994 and 1998. The study group consisted of four Child's A, five Child's B, and three Child's C patients. The mean age of the patients was 60.3 (range, 37-85) years. Mean follow-up was 15 (range, 5-27) months. The mean portosystemic pressure gradient before transjugular intrahepatic portosystemic shunting was 17.4+/-3.1 mm Hg. After transjugular intrahepatic portosystemic shunting, the mean portosystemic pressure gradient was reduced to 5.8+/-1.8 mm Hg (P<0.05). Transjugular intrahepatic portosystemic shunting were successful in complete resolution of bleeding in all patients. Three patients had encephalopathic changes after transjugular intrahepatic portosystemic shunting. Two patients died within 30 days of transjugular intrahepatic portosystemic shunting of causes unrelated to the procedure. Four patients required shunt revision within one year of placement. The transjugular intrahepatic portosystemic shunting procedure is an effective modality in the therapy of cirrhotic patients with bleeding stomal or anorectal varices unresponsive to conservative management. There is an acceptable procedure-related morbidity and mortality.

Surgical treatment of intrahepatic portosystemic shunts in 45 dogs

The surgical attenuation of an intrahepatic portosystemic shunt in 45 dogs is described. Twenty-nine (64 per cent) had left divisional shunts consistent with a patent ductus venosus (PDv), 15 (33...

Surgical treatment of intrahepatic portosystemic shunts in six cats.

The surgical treatment of intrahepatic portosystemic shunts in six cats is described. The preoperative diagnoses were based on the results of abdominal ultrasonography, and mesenteric portography was used during surgery to confirm the diagnosis and establish the morphology of the shunting vessel. In four of the cats the shunt vessel passed through the left division of the liver, compatible with a patent ductus venosus (PDV), in one cat the shunt passed through the central hepatic division and in the other cat it passed through the right hepatic division. During surgery the shunt vessel was manipulated directly either intrahepatically, or post hepatically in the four cats with PDV. In five cats the shunt vessel was partially ligated, and in the other the vessel was completely ligated. The attenuation procedure produced a mean increase in mesenteric venous pressure of 17 cm H2O, with a range from 14 to 20 cm. All the cats recovered from the surgical procedure, but one developed neurological signs shortly after the operation and died from respiratory failure. Four of the cats were clinically normal and required no medication by one month after the operation. One cat required long-term medication to control its continued clinical signs.

Severe ascites: efficacy of the transjugular intrahepatic portosystemic shunt in treatment.

To evaluate the transjugular intrahepatic portosystemic shunt (TIPS) as primary treatment in patients with cirrhosis and severe ascites. A TIPS placement was attempted in 54 consecutive patients with intractable ascites. Clinical assessment findings, shunt patency, complications, and survival were analyzed. A TIPS was successfully placed in 50 patients (93%). Follow-up for clinical effectiveness in 51 patients was a mean of 285 days (range, 1-981 days). Forty patients (78%) gained clinical benefit from the shunt. Of these, 29 (57%) had a complete response (required no further paracentesis) and 11 patients (22%) had a partial response (required less frequent but additional paracentesis for control of ascites). The absence of preprocedure renal insufficiency (creatinine < 1.5 mg/dL [< 130 mumol/L]) was the only characteristic identified as an indicator of clinical success (P < .05). Eleven patients (22%) required shunt revision during follow-up to gain or prolong control of symptoms. Cumulative survival in the population evaluated for clinical efficacy was 53% at 6 months and 48% at 1 year. A complete response was the only variable that indicated increased survival (P < .05; R2 = 12%) with a 6-month survival rate of 76% and a 1-year rate of 71%. TIPS placement appears to be effective as a primary treatment of patients with cirrhosis and severe ascites.

The role of transjugular intrahepatic portosystemic shunt for treatment of portal hypertension and its complications: A conference sponsored by the National Digestive Diseases Advisory Board

TIPS is a new and exciting modality for treatment of portal hypertension and its complications. Indications for TIPS remain to be better defined in terms of efficacy and cost-benefit in relationship to other established modes of therapy of portal hypertension. Prospective, randomized controlled trials are needed for these comparisons. Until the role of TIPS in the routine management of the complications of portal hypertension is better defined, TIPS should be used only in situations in which conventional medical and endoscopic therapies have failed.

The role of transjugular intrahepatic portosystemic shunt for treatment of portal hypertension and its complications: A conference sponsored by the national digestive diseases advisory board

TIPS is a new and exciting modality for treatment of portal hypertension and its complications. Indications for TIPS remain to be better defined in terms of efficacy and cost-benefit in relationship to other established modes of therapy of portal hypertension. Prospective, randomized controlled trials are needed for these comparisons. Until the role of TIPS in the routine management of the complications of portal hypertension is better defined, TIPS should be used only in situations in which conventional medical and endoscopic therapies have failed.

Resolution of Hepatic Hydrothorax After Transjugular Intrahepatic Portosystemic Shunt (TIPS) Placement

A 59-year-old woman underwent chest tube placement, repeated pleurodesis, and pleuroperitoneal shunt implantation for unsuccessful treatment of a large refractory hepatic hydrothorax. Two days after placement of a transjugular intrahepatic portosystemic shunt for treatment of variceal hemorrhage, her pleural effusion resolved. At 10 months' follow-up, only minimal fluid remains.