Efficacy and safety of transjugular intrahepatic portosystemic shunt in difficult‐to‐manage hydrothorax in cirrhosis

Abstract

Background Pleural effusions (PE) complicate cirrhosis in ~5% of patients. Identification of cause and related complications is imperative. Unlike refractory ascites, large‐scale studies on interventions for refractory PE are limited. Methods Consecutive hospitalized cirrhotics having PE were retrospectively analysed. None had liver transplantation (LT) within 6‐month follow‐up. We determined safety, efficacy and mortality predictors for PE managed with standard medical treatment (SMT), thoracentesis, catheter drainage and TIPS. Results Of 1149 cirrhotics with PE (mean Child‐Pugh 10.6 ± 1.8 and MELD 21.2 ± 7.4), 82.6% had hepatic hydrothorax (HH) and 12.3% were suspected tubercular PE (TBPE). Despite comparable HVPG and MELD scores, patients with HH developed more AKI, encephalopathy and septic shock (all P < .01) on follow‐up. Among HH, 73.5% were symptomatic, 53.2% isolated right‐sided PE and 21.3% had SBE. Presence of SBP [Odd's ratio, OR: 4.5] and catheter drainage [OR: 2.1] were independent predictors for SBE. In 70.3% of admissions, HH responded to SMT alone, 12.9% required thoracentesis and 11.5% underwent catheter drainage. Fifty‐one patients were selected for TIPS [lower mean CTP 9.9 ± 1.6 and MELD score 18.7 ± 5.4]. Despite reduction in pressure gradient from 23.1 ± 3.8 mm Hg to 7.2 ± 2.5 mm Hg, 25 patients had partial response, 10 had complete HH resolution. Major post‐TIPS complications were portosystemic encephalopathy (eight patients, six resolved) and ischaemic hepatitis (four patients, two resolved). Overall, 35.9% patients with HH had 6‐month mortality and independent predictors were MELD > 25, SBP and septic shock. Conclusion Refractory PE in cirrhosis requiring interventions including TIPS has poor outcome. The role of haemodynamics in predicting post‐TIPS response and complications is limited. Early referral for LT is imperative.

The role of transjugular intrahepatic portosystemic shunt in patients with portal hypertension: Advantages and pitfalls

“…[46][47][48][49][50][51] In addition, a recent study that compared TIPS using PTFE-covered stents with other modalities (i.e., medical treatment, thoracentesis, and catheter drainage) in patients with hepatic hydrothorax demonstrated no difference in mortality among the various treatment groups. 52 Therefore, TIPS is the preferred alternative treatment for patients who require repeated thoracentesis due to refractory hepatic hydrothorax. Further investigation is necessary to disclose the efficacy of TIPS using PTFEcovered stents in refractory hepatic hydrothorax.…”

“…Although there has been limited evidence to support the efficacy of TIPS for refractory hepatic hydrothorax, especially when using PTFE-covered stents, complete or partial resolution of hepatic hydrothorax after TIPS was reported to range from 59% to 81% in case series [ 45 - 50 ]. In addition, a recent study that compared TIPS using PTFE-covered stents with other modalities (i.e., medical treatment, thoracentesis, and catheter drainage) in patients with hepatic hydrothorax showed no difference in mortality among the various treatment groups [ 51 ]. Therefore, TIPS is the preferred alternative treatment in patients who require repeated thoracentesis due to refractory hepatic hydrothorax.…”

Implantation of transjugular intrahepatic portosystemic shunt (TIPS): indication and patient selection

“…In comparison to patients with ascites and no hepatic hydrothorax, response rates are reduced and a complete response is achieved in less than 20%. Partial response is expected in less than 65% [29,30]. If there is no sufficient response to TIPS implantation, a tunneled pleural catheter can be inserted to improve patients symptoms such as dyspnea [31].…”

Transjugular intrahepatic portosystemic shunt in cirrhosis: An exhaustive critical update

“…In the absence of controlled studies comparing TIPS with standard medical treatment, the benefit of TIPS on TFS in HH cannot be commented upon. In a recent retrospective single-center analysis, despite the selection of patients with lower mean CTP (9.9 ± 1.6) and MELD score (18.7 ± 5.4), the 6-mo mortality after TIPS for HH was close to 36%[ 111 ]. The independent predictors of mortality were MELD > 25, spontaneous bacterial peritonitis, and septic shock.…”