Transjugular intrahepatic portosystemic shunt for the treatment of medically refractory ascites

Abstract

ORIGINAL ARTICLE PURPOSE This study was performed to assess the safety, efficacy, and clinical outcomes of transjugular intrahepatic portosystemic shunt (TIPS) creation for treatment of medically refractory ascites and to identify prognostic factors for clinical response, morbidity, and mortality. MATERIALS AND METHODSIn this retrospective study, 80 patients (male:female, 52:28; mean age, 56 years; mean Model for End-Stage Liver Disease [MELD] score, 15.1) who underwent elective TIPS creation for refractory ascites between 1999-2012 were studied. A medical record review was performed to identify data on demographics, liver disease, procedures, and outcome. The influence of these parameters on 30-day, 90-day, and oneyear mortality was assessed using binary logistic regression. Overall survival was analyzed with Kaplan-Meier statistics. RESULTS TIPS was successfully created using covered (n=70) or bare metal (n=10) stents. Hemodynamic success was achieved in all cases. The mean final portosystemic pressure gradient (PSG) was 6.8 mmHg. Thirty-day complications included mild encephalopathy in 35% of patients. Clinical improvement in ascites occurred in 78% of patients, with complete resolution or a ≥50% decrease in 66% of patients. No predictors of response or optimal PSG threshold were identified. The 30-day, 90-day, and one-year mortality rates were 14%, 23%, and 33%, respectively. Patient age (P = 0.026) was associated with 30-day mortality, while final PSG was associated with 90-day (P = 0.020) and one year (P = 0.032) mortality. No predictors of overall survival were identified. CONCLUSION TIPS creation effectively treats medically refractory ascites with nearly 80% efficacy. The incidence of mild encephalopathy is nontrivial. Older age and final PSG are associated with mortality, and these factors should be considered in patient selection and procedure performance.T he development of medically refractory ascites is associated with a grave prognosis in patients with liver cirrhosis. One-year survival in this population is less than 50%, and there is an increased risk of complications such as spontaneous bacterial peritonitis, hepatorenal syndrome, and dilutional hyponatremia (1). Moreover, these patients typically have low Model for End-Stage Liver Disease (MELD) scores despite their high mortality rate, and thus hold low positions on national transplant listings (2, 3). Transjugular intrahepatic portosystemic shunt (TIPS) creation, an established treatment for complications of portal hypertension, has demonstrated utility in patients with refractory ascites (4). By diverting blood from the portal venous system to the systemic circulation, TIPS acts to lower hepatic sinusoidal pressure and increase effective circulatory flow, thereby reducing excess sodium retention and achieving ascites recurrence rates as low as 30% (5). Two recent studies revealed reduced mortality in patients undergoing TIPS placement, compared with those receiving serial large-volume paracentesis procedures, with one-year survival rates ra...

ePTFE‐TIPS vs repetitive LVP plus albumin for the treatment of refractory ascites in patients with cirrhosis

“…While previous studies have already shown that TIPS is more effective for the treatment of refractory ascites, these studies mixed bare metal and ePTFE stents or have not administered i.v. albumin in all patients, introducing a bias with regard to actual clinical efficacy . A recent, well‐designed study by Bureau et al, however, demonstrated both superior control of ascites and survival for ePTFE‐TIPS as compared to systematic albumin administration.…”

“…ePTFE‐covered TIPS seem to be superior to previously used, uncoated metal stents with regard to patency and stent dysfunction . Although TIPS using bare stents showed good results for controlling refractory ascites in previous trials, data on the effectiveness of ePTFE‐covered TIPS was scarce …”

“…19,22,25,26 Although TIPS using bare stents showed good results for controlling refractory ascites in previous trials, [27][28][29][30] data on the effectiveness of ePTFE-covered TIPS was scarce. 31,32 Recently, Bureau et al 33 published a prospective randomized controlled trial comparing ePTFE-TIPS vs LVP+A in 62 patients with severe and/or recurrent ascites, and found increased transplant-free survival (TFS) in the TIPS group while the risk of developing HE was similar.…”

Accessory hepatic vein recanalization for treatment of Budd-Chiari syndrome due to long-segment obstruction of the hepatic vein: initial clinical experience

“…Although TIPS can effectively decrease the portal vein pressure and significantly improve patient symptoms, hepatic encephalopathy occurs in 17%-35% of patients undergoing TIPS (10,11). In addition, shunt dysfunction is another problem, occurring in up to 13%-50% of patients when metal stents are used for TIPS (5).…”

How quickly does ascites respond to TIPS? Clinical follow-up of a cohort of eighty patients

“…We previously reported on the safety, efficacy, and clinical outcomes of transjugular intrahepatic portosystemic shunt (TIPS) creation for treatment of medically refractory ascites, and identified prognostic factors for clinical response, morbidity, and mortality (1). In examining the outcomes of 80 patients (male-female ratio, 52:28; mean age, 56 years; mean Model for End-Stage Liver Disease score, 15) who underwent hemodynamically successful elective TIPS (mean final portosystemic pressure gradient, 7 mmHg) for refractory ascites between 1999 and 2012, we found initial complete response, partial response, and nonresponse rates as 35% (28 of 80 patients), 43% (34 of 80 patients), and 22% (18 of 80 patients); complete response, partial response, and nonresponse were defined as no further paracentesis procedures, reduction in paracentesis procedure number, and no change or more frequent paracentesis procedures in the three months immediately post-TIPS, respectively.…”