The Transjugular Intrahepatic Portosystemic Stent–Shunt Procedure for Refractory Ascites

Ochs, Andreas; Rössle, Martin; Haag, K.; Hauenstein, Karlheinz; Deibert, Peter; Siegerstetter, V.; Huonker, M.; Langer, M.; Blum, Hubert E.

doi:10.1056/nejm199505043321803

Cited by 389 publications

(139 citation statements)

References 28 publications

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“…[10][11][12][13][14] TIPS for refractory ascites has lead to an improved control of ascites in as many as 50% to 80% of treated patients. The neurohumoral and cardiovascular changes after TIPS placement and their association with clinical response are currently under investigation.…”

Section: Discussionmentioning

confidence: 99%

“…In addition, patients with more advanced liver disease and advanced age appear to be at increased risk for worsening liver function and early death after TIPS, which may occur in as many as 7% to 45% of treated patients. 10,22 Currently, information on the use of TIPS for refractory hepatic hydrothorax is limited to several small series. 14,15 In the earliest series, a clinical benefit was demonstrated in all 5 treated subjects.…”

Section: Discussionmentioning

confidence: 99%

“…3,[6][7][8][9] Portal decompression via the creation of a transjugular intrahepatic portosystemic shunt (TIPS) has recently been proposed as a means of treating patients with refractory ascites. [10][11][12][13] In addition, several reports of the beneficial effect of TIPS in treatment of patients with refractory hepatic hydrothorax have recently been published. 14,15 In one series, a beneficial response was observed in 79% of treated patients, but substantial early and late mortality was also encountered.…”

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confidence: 99%

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Transjugular intrahepatic portosystemic shunts and liver transplantation in patients with refractory hepatic hydrothorax

et al. 1998

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Hepatic hydrothorax is a relatively infrequent but potentially serious complication of cirrhosis resulting from the accumulation of ascitic fluid in the chest cavity. Medical management is initially directed at controlling ascites formation, but invasive therapeutic procedures may be required if symptoms persist. The aim of this study was to report on the long-term efficacy and safety of transjugular intrahepatic portosystemic shunt (TIPS) placement to reduce portal hypertension in 12 consecutive subjects with refractory hepatic hydrothorax. Most subjects had evidence of advanced cirrhosis of varying causes (Child-Pugh class A, 1; B, 5; C, 6). Mean subject age was 54 years, and subjects were followed up for a mean of 173 days (range, 7-926 days). The portosystemic pressure gradient after TIPS was reduced to F12 mmHg in all cases. Periprocedural morbidity was noted in 2 subjects, and 30-day survival after TIPS placement was 75%. Overall, 58% of subjects experienced either a complete or partial response following TIPS placement. Subject response did not correlate with age, baseline creatinine clearance, or Child-Pugh score. Cumulative subject survival was 42%, and 4 of the 5 long-term survivors required eventual liver transplantation. Subject age G65 years was associated with early mortality after TIPS placement, but this trend was not statistically significant. All 4 subjects undergoing liver transplantation required perioperative pleural fluid drainage, but only 1 subject has experienced recurrent effusion. We conclude that TIPS may be a safe and effective temporizing treatment for carefully selected patients with refractory hepatic hydrothorax. However, patient survival is limited after TIPS and is primarily determined by availability of liver transplantation.

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Section: Discussionmentioning

confidence: 99%

Section: Discussionmentioning

confidence: 99%

mentioning

confidence: 99%

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Transjugular intrahepatic portosystemic shunts and liver transplantation in patients with refractory hepatic hydrothorax

et al. 1998

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“…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. 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.…”

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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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confidence: 99%

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

et al. 2000

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Intravascular stents do not cause microangiopathic hemolysis or thrombotic microangiopathy

1999

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An increased incidence of TTP has been noted among patients receiving intravascular stents to improve patency in diseased coronary, renal, and peripheral arteries. Placement of transjugular intrahepatic porto‐systemic shunt stents is often associated with subsequent development of severe hemolysis. We have propsectively studied the development of microangiopathic hemolysis or TTP in patients undergoing intravascular stent placement for peripheral vascular or renal artery disease. Hemolysis was evaluated both before and after stent placement by measuring complete blood count, total bilirubin, lactate dehydrogenase (LDH), haptoglobin and reticulocyte count, and examining peripheral blood films of all patients. Coagulation parameters, blood urea nitrogen and creatinine were measured to exclude disseminated intravascular coagulation or thrombotic thrombocytopenic purpura as a potential cause of hemolysis. Seventeen patients (median age 69 years) were evaluated. One patient was on ticlopidine. Mean hematocrit fell from 41.8% pre‐stenting to 35.5% post‐stenting (P = 0.003) but without significant change in reticulocyte count (1.7 vs. 1.6%, P = 0.605), LDH (546 vs. 560 IU/l; P = 0.836), bilirubin (0.62 vs. 0.63 mg/dl; P = 1.0), or haptoglobin (183 vs. 158 mg/dl; P = 0.083). Thus, this drop in hematocrit could not be attributed to hemolysis. Peripheral blood films revealed fewer than 1% schistocytes before and after stent placement in all cases. Absence of significant changes in mean platelet count (240 vs. 210 × 109/L; P = 0.088), fibrinogen (385 vs. 378 mg/dl; P = 0.789), BUN (24.5 vs. 16.8; P = 0.079), and creatinine (1.38 vs. 1.24; P = 0.757) argue against development of TTP or DIC resulting from stent placement. No patient developed new renal impairment, a neurological syndrome, or unexplained fever after stent placement. At a mean of 6 weeks follow‐up after stent placement, patients have not developed signs of hemolytic anemia or worsening renal function. Our findings argue against a primary risk of microangiopathic hemolytic anemia or TTP due to intravascular stents in patients not receiving ticlopidine. J. Clin. Apheresis 14:130–134, 1999. © 1999 Wiley‐Liss, Inc.

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The Transjugular Intrahepatic Portosystemic Stent–Shunt Procedure for Refractory Ascites

Abstract: Our findings in an uncontrolled prospective study suggest that the transjugular intrahepatic porto-systemic stent-shunt procedure was an effective treatment for many patients with liver cirrhosis and refractory ascites, but mortality from underlying diseases was substantial.

Cited by 389 publications

References 28 publications

Transjugular intrahepatic portosystemic shunts and liver transplantation in patients with refractory hepatic hydrothorax

Transjugular intrahepatic portosystemic shunts and liver transplantation in patients with refractory hepatic hydrothorax

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

Intravascular stents do not cause microangiopathic hemolysis or thrombotic microangiopathy

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