The Transjugular Intrahepatic Portosystemic Stent-Shunt Procedure for Variceal Bleeding

Rössle, Martin; Haag, K.; Ochs, Andreas; Sellinger, M.; Nöldge, G.; Perarnau, Jean–Marc; Berger, É.; Blum, U; Gabelmann, Andreas; Hauenstein, Karlheinz; Langer, Michael; Gerok, W.

doi:10.1056/nejm199401203300303

Cited by 691 publications

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“…The transjugular intrahepatic portosystemic shunt (TIPS) procedure has recently been introduced for the management of complications of portal hypertension, 1 namely, control of refractory acute variceal hemorrhage, 2 prevention of recurrent variceal bleeding, 3 and treatment of intractable ascites. 4 Currently, it is not known whether TIPS has any effect on survival in these patients, nor are the factors associated with poor survival known.…”

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confidence: 99%

“…It is well recognized that the need for an emergency TIPS, that is, TIPS being performed for the control of acute variceal hemorrhage, is associated with a high mortality. 5,6 Some factors predictive of poor survival after elective TIPS, such as advanced liver disease 3,4,7,8 and hyperbilirubinemia, 9 have been recognized. However, there has been no model developed that can accurately predict survival after elective TIPS.…”

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A model to predict poor survival in patients undergoing transjugular intrahepatic portosystemic shunts

et al. 2000

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A model to predict poor survival in patients undergoing transjugular intrahepatic portosystemic shunts

et al. 2000

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“…[1][2][3][4] A considerable portion of these patients who had ascites at the time of TIPS insertion reduced the degree of ascites following TIPS. Therefore, patients with refractory or recurrent ascites were treated with TIPS, most of them with remarkable success.…”

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Renal effects of transjugular intrahepatic portosystemic shunt in cirrhosis: Comparison of patients with ascites, with refractory ascites, or without ascites

et al. 1998

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Renal effects of the transjugular intrahepatic portosystemic shunt (TIPS) were compared in 6 patients without ascites (group 1), 11 patients with ascites responding to diuretic treatment (group 2), and 6 patients with refractory ascites (group 3). Seven days after insertion of TIPS, 24-hour urinary sodium excretion had increased in patients with ascites: 113 ؎ 16 mmol to 170 ؎ 30 mmol (P ‫؍‬ .012) in group 2, and 22 ؎ 8 mmol to 77 ؎ 27 mmol (P ‫؍‬ .050) in group 3. In group 3, fractional sodium excretion tended to increase from 0.26% ؎ 0.14% to 0.62% ؎ 18% (P ‫؍‬ .081). The relative increase of urinary sodium excretion (to 444% ؎ 122%) and fractional sodium excretion (to 413% ؎ 127%) in group 3 was significantly (P F .05) higher than in group 1 and group 2, respectively. Creatinine clearance and 24-hour urinary volume were not significantly changed in either group. Patients with Child-Pugh class C had a more pronounced effect of TIPS on urinary sodium excretion (increase to 396% ؎ 115% vs. 139% ؎ 15%; P ‫؍‬ .066) and on fractional sodium excretion (increase to 415% ؎ 103% vs. 94% ؎ 15%; P ‫؍‬ .020) than patients with less-severe liver disease. Fractional sodium excretion of less than 0.35% before TIPS was found to be an indicator of renal response to TIPS. The effect of TIPS on urinary sodium excretion and on fractional sodium excretion was related to the patients' Child-Pugh score (r ‫؍‬ .55; P ‫؍‬ .007 and r ‫؍‬ .68; P ‫؍‬ .001, respectively) and inversely to their fractional sodium excretion (r ‫؍‬ Ϫ.44; P ‫؍‬ .047 and r ‫؍‬ Ϫ.54; P ‫؍‬ .012, respectively) before TIPS. These data demonstrate that TIPS affects renal sodium handling in patients with ascites, particularly in patients with refractory ascites. Severity of liver disease and fractional sodium excretion before TIPS are parameters to predict the extent of the renal response. (HEPATOLOGY 1998;28:683-688.)The transjugular intrahepatic portosystemic shunt (TIPS), a nonsurgical side-to-side shunt, has been introduced to prevent variceal rebleeding or to control refractory variceal bleeding by reducing the portal pressure gradient. 1-4 A considerable portion of these patients who had ascites at the time of TIPS insertion reduced the degree of ascites following TIPS. Therefore, patients with refractory or recurrent ascites were treated with TIPS, most of them with remarkable success. [5][6][7][8][9] These observations prompted studies on the effects of TIPS on sodium handling in patients with refractory ascites. Little is known, however, about the effects of TIPS on renal function in patients without ascites or with ascites not refractory to diuretic treatment. Moreover, predictors of renal response to TIPS have not yet been identified. Furthermore, information about the early influence of TIPS on renal function is limited. [6][7][8][9][10][11][12][13] Most of the previous studies were performed without diuretics or with the dose of diuretics decreasing throughout the observation period. While withholding diuretic treatment from those patients does not repr...

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“…1 In group 1, 21 patients received a mean of 2.0 Ϯ 0. 8 The calculation of the number of patients needed for statistical analysis of the study data was based on an estimated reduction of the rate of shunt stenosis from 50% in the control group to 30%.…”

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Platelet aggregation and platelet-derived growth factor inhibition for prevention of insufficiency of the transjugular intrahepatic portosystemic shunt: A randomized study comparing trapidil plus ticlopidine with heparin treatment

et al. 1999

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Intimal proliferation at the interface between prosthetic material and tissue is an intrinsic phenomenon of stenting and the major cause of insufficiency of the transjugular intrahepatic portosystemic shunt (TIPS). For its prevention, a randomized study was performed comparing standard heparin treatment with a combination of trapidil, a drug with anti-platelet-derived growth factor (PDGF) activity, and ticlopidine, a platelet aggregation inhibitor. Ninety patients with cirrhosis who received a transjugular shunt were randomized, and 84 patients completed the trial. Group 1 (n ‫؍‬ 42) received a bolus of heparin (12 to 24 U/kg) at shunt placement, followed by 1 week of intravenous and 4 weeks of subcutaneous heparin treatment. Group 2 (n ‫؍‬ 42) received the same heparin bolus, followed by a 1-day intravenous heparin treatment and a 6-month treatment with trapidil (400 mg/d) and ticlopidine (250 mg/d). Shunt function was assessed by duplex-sonography and angiography. Stenoses were classified according to their location as type 1 (within the stent) and type 2 (in the draining hepatic vein). The estimated rate of overall stenoses (intention-to-treat analysis) at 1 year showed a significant reduction in patients receiving trapidil and ticlopidine (group 2) as compared with heparin (33 vs. 57%; P ‫؍‬ .047). There was no difference in the estimated 1-year rate of type 1 stenoses between the two groups, but there was a significant reduction in type 2 stenoses (group 1: 58%, group 2: 19%; P ‫؍‬ .016). The treatment effect continued after withdrawal of the drugs and was accompanied by a decreased incidence of rebleeding. The study demonstrates that the incidence of type 2 stenosis of the transjugular shunt can be reduced by combined inhibition of platelet aggregation and PDGF activity. The findings may be of relevance not only for the transjugular shunt, but also for other stent applications, e.g., vascular and biliary, as well as for bypass and shunt surgery. (HEPATOLOGY 1999;29:33-38.)The transjugular intrahepatic portosystemic shunt (TIPS) is compromised by a high rate of shunt insufficiency ranging from 44% to 84%, depending on the definition and mode of assessment of shunt function.

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The Transjugular Intrahepatic Portosystemic Stent-Shunt Procedure for Variceal Bleeding

Abstract: These results suggest that the transjugular placement of an intrahepatic portosystemic stent is an effective and safe treatment for variceal hemorrhage in patients with portal hypertension due to cirrhosis.

Cited by 691 publications

References 39 publications

A model to predict poor survival in patients undergoing transjugular intrahepatic portosystemic shunts

A model to predict poor survival in patients undergoing transjugular intrahepatic portosystemic shunts

Renal effects of transjugular intrahepatic portosystemic shunt in cirrhosis: Comparison of patients with ascites, with refractory ascites, or without ascites

Platelet aggregation and platelet-derived growth factor inhibition for prevention of insufficiency of the transjugular intrahepatic portosystemic shunt: A randomized study comparing trapidil plus ticlopidine with heparin treatment

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