Incidence, Natural History, and Risk Factors of Hepatic Encephalopathy After Transjugular Intrahepatic Portosystemic Shunt With Polytetrafluoroethylene-Covered Stent Grafts

Riggio, Oliviero; Angeloni, S.; Salvatori, Filippo Maria; Santis, Adriano De; Cerini, Federica; Farcomeni, Alessio; Attili, Adolfo Francesco; Merli, Manuela

doi:10.1111/j.1572-0241.2008.02102.x

Cited by 236 publications

(197 citation statements)

References 46 publications

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“…The morbidity rates noted herein were comparable with established figures, confirming the relatively high risk of hepatic encephalopathy following TIPS creation (19,20). Unfortunately, final PSG levels that may improve medically refractory ascites also increase the risk of hepatic encephalopathy (21,22).…”

Section: Discussionsupporting

confidence: 70%

Transjugular intrahepatic portosystemic shunt for the treatment of medically refractory ascites

Parvinian¹,

Bui²,

Knuttinen³

et al. 2013

Diagn Interv Radiol

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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...

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Section: Discussionsupporting

confidence: 70%

Transjugular intrahepatic portosystemic shunt for the treatment of medically refractory ascites

Parvinian¹,

Bui²,

Knuttinen³

et al. 2013

Diagn Interv Radiol

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“…Bearing in mind these limitations, the incidence of overt episodic or recurrent HE post-TIPS varies between 15 and 67% in a 2-year follow-up. The incidence of persistent overt HE is around 8% [80] and that of de-novo, covert HE around 35% [14,26,[81][82][83][84][85][86][87][88]. [31,81,82,84] • Baseline arterial hypotension (1a) [4,83] • High serum creatinine and hyponatriemia (Na < 130) (1a) [4, 80,82] • Low serum albumin levels (1b) [80] • Bare vs. covered stent (2b) [85] • Very low porto-systemic pressure gradient after TIPS (<5 mmHg) (1a) [25,[78][79][80][81][82][83]87] a Child A risk of HE close to 0, in Child B up to 33%, in Child C up to 89%.…”

Section: Is There a Risk For Hepatic Encephalopathy After Tips?mentioning

confidence: 99%

Consensus conference on TIPS management: Techniques, indications, contraindications

Fagiuoli

Bruno

Venon

et al. 2017

Digestive and Liver Disease

130

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a b s t r a c tThe trans jugular intrahepatic Porto systemic shunt (TIPS) is no longer viewed as a salvage therapy or a bridge to liver transplantation and is currently indicated for a number of conditions related to portal hypertension with positive results in survival. Moreover, the availability of self-expandable polytetrafluoroethylene (PTFE)-covered endoprostheses has dramatically improved the long-term patency of TIPS. However, since the last updated International guidelines have been published (year 2009) new evidence have come, which have open the field to new indications and solved areas of uncertainty. On this basis, the Italian Association of the Study of the Liver (AISF), the Italian College of Interventional Radiology-Italian Society of Medical Radiology (ICIR-SIRM), and the Italian Society of Anesthesia, Analgesia and Intensive Care (SIAARTI) promoted a Consensus Conference on TIPS. Under the auspices of the three scientific societies, the consensus process started with the review of the literature by a scientific board of experts and ended with a formal consensus meeting in Bergamo on June 4th and 5th, 2015. The final statements presented here were graded according to quality of evidence and strength of recommendations and were approved by an independent jury. By highlighting strengths and weaknesses of current indications to TIPS, the recommendations of AISF-ICIR-SIRM-SIAARTI may represent the starting point for further studies.

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“…51 Narcotics and benzodiazepines worsen encephalopathy and should be avoided including replacement of benzodiazepinederived sleep aids with diphenhydramine, melatonin, or trazodone. Patients with a TIPS who continue to experience refractory encephalopathy may need their TIPS downsized 52 or have an evaluation for portosystemic shunt embolization. 53 …”

Section: Hepatic Encephalopathymentioning

confidence: 99%

Keeping high model for end‐stage liver disease score liver transplantation candidates alive

et al. 2015

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Incidence, Natural History, and Risk Factors of Hepatic Encephalopathy After Transjugular Intrahepatic Portosystemic Shunt With Polytetrafluoroethylene-Covered Stent Grafts

Cited by 236 publications

References 46 publications

Transjugular intrahepatic portosystemic shunt for the treatment of medically refractory ascites

Transjugular intrahepatic portosystemic shunt for the treatment of medically refractory ascites

Consensus conference on TIPS management: Techniques, indications, contraindications

Keeping high model for end‐stage liver disease score liver transplantation candidates alive

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