Covered transjugular intrahepatic portosystemic shunt versus endoscopic therapy + β‐blocker for prevention of variceal rebleeding

Holster, Ingrid L.; Tjwa, Eric T.; Moelker, Adriaan; Wils, Alexandra; Hansen, Bettina E.; Vermeijden, J. Reinoud; Scholten, Pieter; Hoek, Bart van; Nicolai, J. J.; Kuipers, Ernst J.; Pattynama, Peter M. T.; Buuren, Henk R. van

doi:10.1002/hep.28318

Cited by 193 publications

(151 citation statements)

References 18 publications

(52 reference statements)

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“…However, this does not translate into a survival advantage and the better rebleeding prophylaxis occurs at the expense of a higher rate of overt encephalopathy [31,45,46]. Hepatic encephalopathy is lowered with the placement of covered small lumen stents [31,47].…”

Section: Prevention Of Rebleeding Depending On Stage and Aetiology Ofmentioning

confidence: 99%

Treatment of Oesophageal Varices in Liver Cirrhosis

Sauerbruch

2018

Digestion

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Background: The development of cirrhosis with resultant portal hypertension can lead to oesophageal varices at a rate of 7% per annum. Bleeding from varices happens when the portal pressure is ≥12 mm Hg and can threaten life. Summary: Eliminating the aetiology of cirrhosis is a pivotal step to prevent the formation of varices. In patients with established varices, primary prophylaxis with non-selective beta blockers (NSBB) may slow down the progression of varices and prevent the first variceal bleed. NSBB, similar to other agents such as renin/angiotensin blockers, statins, and rifaximin, may have the additional advantage of blunting inflammatory stimuli, which can contribute to the progression of varices. Variceal band ligation is an alternative for primary bleeding prophylaxis with excellent results. Any acute variceal bleed should be managed with band ligation after careful resuscitation. Early pre-emptive transjugular intrahepatic portosystemic shunt (TIPS) in decompensated cirrhotic patients is very effective in controlling the bleeding and improves survival. Secondary prophylaxis against further variceal bleeding using NSBB and band ligation is recommended in most other patients. TIPS may be considered in appropriate patients as a secondary prophylaxis against recurrent variceal bleed. Future research should be directed towards the prevention of varices and targeting inflammation to reduce cirrhotic complications. Key Messages: Treatment strategies depend on the stage the patient is at along the natural history of varices: NSBB or band ligation for primary prophylaxis; band ligation or early TIPS for acute bleed; and a combination of NSBB + band ligation or TIPS for secondary prophylaxis (Fig. 1).

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Section: Prevention Of Rebleeding Depending On Stage and Aetiology Ofmentioning

confidence: 99%

Treatment of Oesophageal Varices in Liver Cirrhosis

Sauerbruch

2018

Digestion

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“…This may be the reason for the low incidence of post-TIPS HE of 10% only. In comparison, two recent studies using 8 or 10 mm covered nitinol stents had a risk of HE of 18% and 40%, respectively [27,28]. On the other hand, nonresponse may be increased but could easily be resolved by enlargement of the stent.…”

Section: Discussionmentioning

confidence: 91%

Usefulness of a balloon-expandable, covered stent for the transjugular intrahepatic portosystemic shunt

Rössle¹,

Maruschke²,

Radecke³

et al. 2018

J Radiol Imaging.

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The availability of polytetrafluoroethylene (PTFE) covered, self-expandable nitinol stents in 2001 considerably improved the patency, response rates and survival of the transjugular intrahepatic portosystemic shunt (TIPS). Side effects of portosystemic shunting such as hepatic encephalopathy (HE) and worsening of hepatic function, however, remained a problem. To reduce HE, underdilatation of nitinol stents has been practiced for many years. However, as shown recently, underdilatation was a flop since, due to their intrinsic memory, nitinol stents always expanded to reach their nominal diameter of 8 or 10 mm. To overcome this problem and to be able to perform permanent shunts with a smaller diameter of < 8 mm, we studied the usefulness of a balloon-expandable, covered, metallic stent which allowed adjustment to any diameter between 5 and 12 mm. Methods: 30 patients with cirrhosis and symptomatic portal hypertension were included. The mean Child-Pugh score was 8 ± 2. 17 patients had refractory ascites, 9 patients variceal bleeding and four patients other indications for the TIPS. Results: The TIPS was successfully implanted in all patients within 69.6 ± 21.8 min. The shunt reduced the portosystemic pressure gradient by 57.5 ± 14.2% with a mean stent diameter of 7.4 ± 1.0 mm (5 -10.3 mm). During a mean follow-up of 330 ± 249 days, shunt revision was necessary in 5 patients (17%), four of them had insufficient response and received stent dilatation and one patient had stent misplacement requiring a parallel shunt. Three patients (10%) developed HE. Conclusions: The covered, balloonexpandable stent could be placed accurately and allowed creation of adapted shunts with smaller diameters as usual. This resulted in a comparatively low rate of HE.Keywords: balloon-expandable; stent; portal hypertension; transjugular intrahepatic portosystemic shunt

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“…TIPS is the gold standard for PH-induced UGIB refractory to endoscopic and pharmacological therapy or for patients who present at high risk of secondary treatment failure (e.g., Child Pugh class C < 14 points or Child Pugh class B with active bleeding) [3,[21][22][23][24]. Management of patients with contraindications to TIPS implantation or sinistral PH and regular HVPG is still under debate as generally accepted recommendations do not exist.…”

Section: Discussionmentioning

confidence: 99%