Incrementally Expandable Transjugular Intrahepatic Portosystemic Shunts: Single-Center Experience

Cui, Jie; Smolinski, Sara; Liu, Fengyong; Xu, Dihua; Dulaimy, Kal; Irani, Zubin

doi:10.2214/ajr.17.18222

Cited by 14 publications

(10 citation statements)

References 37 publications

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“…Based on the limited data available, the best "small diameter" TIPS to prevent or minimise the incidence of encephalopathy, while effectively preventing rebleeding and/or ascites, should be about 6-8 mm, but a "onesize-fits-all" strategy is most likely unrealistic. 21,23 Similarly, it is unknown whether other parameters linked to outcomes in cirrhosis, such as age, quantitative liver function tests, liver/spleen stiffness or volume, heart function, inflammation, bacterial translocation and malnutrition/sarcopenia, may be factored into a decision-making algorithm that balances between keeping the shunt as small as possible while sufficiently reducing PCG. An additional advantage of using small diameter TIPS is that it may decrease the incidence of post-TIPS heart failure.…”

Section: Current Challengesmentioning

confidence: 99%

“…This goal is obtained in a large proportion of patients with small diameter TIPS that are likely to result in less worsening of portal-systemic shunting and hence a lower likelihood of severe encephalopathy and post-TIPS liver failure. 20,21,23 Of note, in high-risk situations, such as refractory ascites, the recent EASL guidelines already recommended small diameter TIPS, although not suggesting TIPS as small as 6 mm. 25 According to this hypothesis, studies should assess the effectiveness of small diameter TIPS (of 6 mm [or 7 mm] in diameter) complemented by either drug therapy, an associated procedure, or both, with the aim of reducing PCG by 30% of baseline or to < − 14 mmHg.…”

Section: What Else Can We Do To Prevent Post-tips Encephalopathy? Expmentioning

confidence: 99%

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Small diameter shunts should lead to safe expansion of the use of TIPS

Bosch

2021

Journal of Hepatology

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Transjugular intrahepatic portosystemic shunt (TIPS) is increasingly used worldwide to treat the complications of portal hypertension in patients with advanced cirrhosis. However, its use is hampered by the risk of causing hepatic encephalopathy and of worsening liver function. The reported haemodynamic targets used to guide TIPS are too narrow to be achieved in most cases and are perhaps not entirely adequate nowadays as they were obtained in the pre-covered stent era. We propose that small diameter TIPSalone or combined to pharmacological therapy or ancillary interventional radiology proceduresmay overcome these limitations while maintaining the beneficial effects of the procedure.

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Section: Current Challengesmentioning

confidence: 99%

Section: What Else Can We Do To Prevent Post-tips Encephalopathy? Expmentioning

confidence: 99%

Small diameter shunts should lead to safe expansion of the use of TIPS

Bosch

2021

Journal of Hepatology

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“…These results were similar to a previous prospective, nonrandomized study ( 27 ), which compared the clinical outcomes of TIPS creation with 10-mm stents underdilated by smaller-diameter (7 or 6 mm) and larger-diameter balloon (8 mm or more). But in another retrospective single-arm study ( 28 ), 28 patients received underdilated TIPS with 8-mm stents, and the incidence rate of post-TIPS HE was 31.8%, which showed no improvement compared with previously published studies elsewhere. Also, several studies have shown that passive expansion of underdilated stent grafts occurs within a short postprocedure time frame approximating weeks to months ( 29 , 30 ).…”

Section: Discussionmentioning

confidence: 73%

Potential Benefits of Underdilation of 8-mm Covered Stent in Transjugular Intrahepatic Portosystemic Shunt Creation

Liu

Zhou

et al. 2021

Clin Transl Gastroenterol

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INTRODUCTION: Hepatic encephalopathy (HE) is a major complication of transjugular intrahepatic portosystemic shunt (TIPS) creation. This study was aimed to determine whether underdilated TIPS with 8-mm polytetrafluoroethylene-covered stents could reduce the risk of HE and liver damage yet maintain clinical and hemodynamic efficacy. METHODS: This retrospective case-controlled study included 134 patients treated with TIPS from March 2017 to November 2019. All the TIPS procedures were created using 8-mm covered stents, and according to the diameter of expansion balloon catheters, the patients were divided into 2 groups, an underdilated group (6-mm balloon catheter, n = 73) and a control group (8-mm balloon catheter, n = 61). RESULTS: The Kaplan-Meier analysis indicated that the cumulative incidence of overt HE in the underdilated group was significantly lower than that in the control group (11.0% vs 29.5%, log rank P = 0.007), but no statistical differences were found toward variceal rebleeding, shunt dysfunction, and survival between groups. In multivariate analysis, the independent risk factors for overt HE were identified as age (hazard ratio [HR] = 1.036, 95% confidence interval [CI] = 1.003–1.069, P = 0.032), Child-Pugh score (HR = 1.519, 95% CI = 1.212–1.905, P < 0.001), and group assignment (HR = 0.291, 95% CI = 0.125–0.674, P = 0.004). DISCUSSION: Underdilated TIPS with 8-mm polytetrafluoroethylene-covered stents could reduce the risk of HE and liver function impairment compared with completely dilated TIPS, but not increase the risk of variceal rebleeding, shunt dysfunction, and death.

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“…To overcome this limitation, modifications in the TIPS technique have been described by multiple authors, which essentially involve deploying a covered TIPS stent within a smaller balloon-expandable stent allowing calibration of PSPG to a predetermined value at the time of TIPS creation or at a later time, as and when needed. This technique is called as 'incrementally expandable' TIPS stents[ 216 ]. However, this requires the placement of an additional stent, adding to the cost and complexity of the procedure.…”

Section: Update On the Technical Aspects Of Tipsmentioning

confidence: 99%

Transjugular intrahepatic portosystemic shunt in cirrhosis: An exhaustive critical update

Rajesh

George

Philips

et al. 2020

WJG

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More than five decades after it was originally conceptualized as rescue therapy for patients with intractable variceal bleeding, the transjugular intrahepatic portosystemic shunt (TIPS) procedure continues to remain a focus of intense clinical and biomedical research. By the impressive reduction in portal pressure achieved by this intervention, coupled with its minimally invasive nature, TIPS has gained increasing acceptance in the treatment of complications of portal hypertension. The early years of TIPS were plagued by poor long-term patency of the stents and increased incidence of hepatic encephalopathy. Moreover, the diversion of portal flow after placement of TIPS often resulted in derangement of hepatic functions, which was occasionally severe. While the incidence of shunt dysfunction has markedly reduced with the advent of covered stents, hepatic encephalopathy and instances of early liver failure continue to remain a significant issue after TIPS. It has emerged over the years that careful selection of patients and diligent post-procedural care is of paramount importance to optimize the outcome after TIPS. The past twenty years have seen multiple studies redefining the role of TIPS in the management of variceal bleeding and refractory ascites while exploring its application in other complications of cirrhosis like hepatic hydrothorax, portal hypertensive gastropathy, ectopic varices, hepatorenal and hepatopulmonary syndromes, non-tumoral portal vein thrombosis and chylous ascites. It has also been utilized to good effect before extrahepatic abdominal surgery to reduce perioperative morbidity and mortality. The current article aims to review the updated literature on the status of TIPS in the management of patients with liver cirrhosis.

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Incrementally Expandable Transjugular Intrahepatic Portosystemic Shunts: Single-Center Experience

Abstract: A small-diameter expandable TIPS is technically feasible and safe, with efficacy falling within the range of that of conventional TIPS. This technique offers the possibility of individualizing the degree of portal decompression.

Cited by 14 publications

References 37 publications

Small diameter shunts should lead to safe expansion of the use of TIPS

Small diameter shunts should lead to safe expansion of the use of TIPS

Potential Benefits of Underdilation of 8-mm Covered Stent in Transjugular Intrahepatic Portosystemic Shunt Creation

Transjugular intrahepatic portosystemic shunt in cirrhosis: An exhaustive critical update

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