Transjugular Intrahepatic Portosystemic Shunt in Patients with Portal Hypertension: Patency Depends on Coverage and Interventionalist’s Experience

Abstract

Background and Aims: Transjugular intrahepatic portosystemic shunt (TIPS) is the treatment of choice in decompensated portal hypertension. TIPS revision due to thrombosis or stenosis increases morbidity and mortality. Our aim was to investigate patient- and procedure-associated risk factors for TIPS-revision. Patients and Methods: We retrospectively evaluated 189 patients who underwent the TIPS procedure. Only patients who required TIPS revision within 1 year (Group I, 34 patients) and patients who did not require re-intervention within the first year (Group II [control group], 54 patients) were included. Results: Out of 88 patients, the majority were male (69.3%) and mean age was 56 ± 11 years. Indications for TIPS were refractory ascites (68%), bleeding (24%), and Budd-Chiari syndrome (8%). The most frequent liver disease was alcohol-induced cirrhosis (60%). Forty-three patients (49%) received bare and 45 patients (51%) covered stents, thus resulting in reduction of hepatic venous pressure gradient (HVPG) from 19.0 to 9.0 mm Hg. When comparing patient- and procedure-related factors, the type of stent (p < 0.01) and interventionalist’s experience (number of performed TIPS implantations per year; p < 0.05) were the only factors affecting the risk of re-intervention due to stent dysfunction, while age, gender, indication, Child-Pugh, and model of end-stage liver disease score, platelet count, pre- and post-HVPG, additional variceal embolization, stent diameter, and number of stents did not significantly differ. Conclusion: Patients undergoing TIPS procedure should be surveilled closely for shunt dysfunction while covered stents and high-level experience are associated with increased ­patency.

A case of fatal cutaneous caput medusae hemorrhage

“…Traditional medical therapy with terlipressin, alternatively somatostatin, or analogues (octreotide) is effective on esophageal variceal bleeding and should be empirically applied to umbilical variceal hemorrhage . Considering that transjugular intrahepatic portosystemic shunt (TIPS) is the most effective interventional treatment for lowering portal hypertension, it is strongly recommended for inpatient care . Patients with caput medusae bleeding have an increased risk of recurrent bleeding within the first few weeks.…”

“…24 Considering that transjugular intrahepatic portosystemic shunt (TIPS) is the most effective interventional treatment for lowering portal hypertension, it is strongly recommended for inpatient care. 25,26 Patients with caput medusae bleeding have an increased risk of recurrent bleeding within the first few weeks. This patient underwent only suture ligation, and he had a fatal recurrent bleeding after one month.…”

Transjugular intrahepatic portosystemic shunt placement: portal vein puncture guided by 3D/2D image registration of contrast-enhanced multi-detector computed tomography and fluoroscopy

“…Thus, the interventionalist has to estimate the optimal needle path on pre-interventional acquired three-dimensional (3D) contrast-enhanced (CE) multi-detector computed tomography (MDCT) or magnetic resonance imaging (MRI) [ 11 , 12 ]. Several guidance techniques have been reported to facilitate the portal vein puncture aiming to reduce puncture times and peri-procedural complications, which are usually affected by the experience of the interventionalist [ 11 , 13 ]. Blind fluoroscopic puncture can be augmented with direct or indirect 2D visualization of the portal vein by wedged portography or transsplenic/transarterial mesenteric portography [ 14 , 15 ].…”

Evaluation of impact of elective invasive examinations in patients with transjugular intrahepatic portosystemic shunt in the long-term follow up

“…Survival rates and occurrence of LREs match within the known ranges in patients after TIPS insertion. As described before, occurrence of complications and survival are dependent from history of prior episodes of HE and severity of liver disease [15,17,32,33]. Furthermore, occurrence of LREs differs depending on ▶ Fig.…”

“…In the era of covered stents, necessity of re-intervention to maintain shunt patency was reduced, too. Whilst re-intervention was required in 70-90 % of patients within 2 years after TIPS insertion in case of use of BM-stents, only up to 35 % of patients underwent shunt revision in the era of PTFE-covered stents [15][16][17][18]. Since revascularization of TIPS is technically difficult if shunt occlusion is already present, strategies are needed to detect TIPS dysfunction at an earlier state.…”