TIPS for Adults Without Cirrhosis With Chronic Mesenteric Venous Thrombosis and EHPVO Refractory to Standard‐of‐Care Therapy

Abstract

BaCKgRoUND aND aIMS: Extrahepatic portal vein occlusion (EHPVO) from portal vein thrombosis is a rare condition associated with substantial morbidity and mortality. The purpose of this study is to investigate the efficacy of transjugular intrahepatic portosystemic shunts (TIPS) for the treatment of chronic EHPVO, cavernomatosis, and mesenteric venous thrombosis in adults without cirrhosis who are refractory to standard-of-care therapy.appRoaCH aND ReSUltS: Thirty-nine patients with chronic EHPVO received TIPS. Laboratory parameters and follow-up were assessed at 1, 3, 6, 12, and 24 months, and every 6 months thereafter. Two hepatologists adjudicated symptom improvement attributable to mesenteric thrombosis and EHPVO before/after TIPS. Kaplan-Meier was used to assess primary and overall TIPS patency, assessing procedural success. Adverse events, radiation exposure, hospital length-ofstay and patency were recorded. Cavernoma was present in 100%, with TIPS being successful in all cases using splenic, mesenteric, and transhepatic approaches. Symptom improvement was noted in 26 of 30 (87%) at 6-month follow-up. Twelve patients (31%) experienced TIPS thrombosis. There were no significant long-term laboratory adverse events or deaths. At 36 months, freedom from primary TIPS thrombosis was 63%; following secondary interventions, overall patency was increased to 81%.CoNClUSIoNS: TIPS in chronic, noncirrhotic EHPVO with cavernomas and mesenteric venous thrombosis is technically feasible and does not adversely affect liver function. Most patients demonstrate subjective and objective benefit from TIPS. Improvement in patency rates are needed with proper timing of adjuvant anticoagulation. (Hepatology 2021;74:2735-2744.

Portal vein recanalisation alone to treat severe portal hypertension in non-cirrhotic patients with chronic extrahepatic portal vein obstruction

“…In this series, 3 patients developed HE, 1 cardiac failure, and 3 hepatic hematomas likely related to TIPS insertion. 22 In the other available series of the combined approach (PVR + TIPS) in patients with CNC-EHPVO, up to 20% incidence of HE has been reported, whereas no cardiac failure was observed. 18 , 20 , [35] , [36] , [37] , [38] , [39] , [40] , [41] Although these adverse events were less commonly observed in patients with cirrhosis who undergo TIPS insertion (HE incidence around 40% 42 and cardiac failure around 10% 43 ), none of these events were observed in our experience of PVR alone.…”

“…In the study by Knight et al. , 22 48.7% of the procedures were performed through transsplenic access. As opposed to the transhepatic approach in which, before PVR, the vein flow is absent, the transsplenic approach requires the puncture of a high-pressure venous system.…”

“…A recent study by Knight et al. 22 reported the favourable outcome of 39 patients with CNC-EHPVO who underwent a combined approach (TIPS + PVR) with a primary patency of 63% at 36 months. Patients were mainly referred for variceal bleeding and abdominal pain.…”

“… [15] , [16] , [17] In CNC-EHPVO, thrombolysis is not performed because of the nature of the obstruction. In published literature, few articles reported favourable outcomes of extrahepatic portal vein obstruction (EHPVO) recanalisation associated with TIPS placement in patients with or those without cirrhosis, [18] , [19] , [20] , [21] , [22] confirming the feasibility of the procedure. However, in patients without significant liver fibrosis and with sinusoidal portal hypertension, adjunct TIPS may not be necessary, although it could contribute to hepatic encephalopathy (HE), heart failure, or liver insufficiency.…”

Imaging-guided interventions modulating portal venous flow: Evidence and controversies

“… 84 In a recent study on 39 patients with cavernous transformation of the portal vein, symptom improvement was observed in 87% of patients with an overall TIPS patency of 81% at 36 months. 85 …”