&lt;p&gt;Portosystemic shunts and refractory hepatic encephalopathy: patient selection and current options&lt;/p&gt;

Philips, Cyriac Abby; Rajesh, S; Augustine, Philip; Padsalgi, Guruprasad; Ahamed, Rizwan

doi:10.2147/hmer.s169024

Cited by 42 publications

(33 citation statements)

References 31 publications

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“…In cases where the post-TIPS HE cannot successfully be treated by diet or medication, patients with refractory HE suffered from increasing deterioration of liver function and the associated poor prognosis [14,17]. Therefore, we subsequently studied the efficacy of TIPS modification in the management of refractory post-TIPS HE.…”

Section: Discussionmentioning

confidence: 99%

“…However, up to 8% of patients develop refractory HE after TIPS and there is only limited evidence about specific predictive risk factors for this purpose [13][14][15][16]. In addition, refractory HE after TIPS is often associated with further deterioration of liver function and remains a clinical challenge [17]. In these cases, TIPS modification is the only therapeutic option besides liver transplantation [13,18,19].…”

Section: Introductionmentioning

confidence: 99%

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TIPS Modification in the Management of Shunt-Induced Hepatic Encephalopathy: Analysis of Predictive Factors and Outcome with Shunt Modification

Schindler

Seifert

Masthoff

et al. 2020

JCM

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Purpose: To evaluate predictive parameters for the development of Hepatic Encephalopathy (HE) after Transjugular Intrahepatic Portosystemic Shunt (TIPS) placement and for success of shunt modification in the management of shunt-induced HE. Methods: A retrospective analysis of all patients with TIPS (n = 344) has been performed since 2011 in our university liver center. n = 45 patients with HE after TIPS were compared to n = 48 patients without HE after TIPS (case-control-matching). Of n = 45 patients with TIPS-induced HE, n = 20 patients received a reduction stent (n = 18) or TIPS occlusion (n = 2) and were differentiated into responders (improvement by at least one HE grade according to the West Haven classification) and non-responders (no improvement). Results: Older patient age, increased serum creatinine and elevated International Normalized Ratio (INR) immediately after TIPS placement were independent predictors for the development of HE. In 11/20 patients (responders, 55%) undergoing shunt modification, the HE grade was improved compared with nine non-responders (45%), with no relevant recurrence of refractory ascites or variceal bleeding. A high HE grade after TIPS insertion was the only positive predictor of treatment response (p = 0.019). A total of 10/11 responders (91%) survived the 6 months follow-up after modification but only 6/9 non-responders (67%) survived. Discussion: Older patient age as well as an increased serum creatinine and INR after TIPS are potential predictors for the development of HE. TIPS reduction for the treatment of TIPS-induced HE is safe, with particular benefit for patients with pronounced HE.

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Section: Discussionmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

TIPS Modification in the Management of Shunt-Induced Hepatic Encephalopathy: Analysis of Predictive Factors and Outcome with Shunt Modification

Schindler

Seifert

Masthoff

et al. 2020

JCM

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“…Primary TIPS is not recommended for prevention of GV bleeding. Balloon-retrograde transvenous occlusion (BRTO) and it's variant techniques such as coil-assisted retrograde transvenous occlusion (CARTO), plug-assisted retrograde transvenous occlusion (PARTO), balloon antegrade transvenous occlusion (BATO) and our group described novel techniques such as the ‘direct’ (D)-PARTO or direct coil-assisted antegrade transvenous occlusion (CAATO) are not evaluated in high-quality randomized trials for prevention of first gastric variceal bleeding and hence cannot be recommended as primary prophylaxis [ 25 ].…”

Section: Treatmentmentioning

confidence: 99%

Beyond the scope and the glue: update on evaluation and management of gastric varices

et al. 2020

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Gastric varices are encountered less frequently than esophageal varices. Nonetheless, gastric variceal bleeding is more severe and associated with worse outcomes. Conventionally, gastric varices have been described based on the location and extent and endoscopic treatments offered based on these descriptions. With improved understanding of portal hypertension and the dynamic physiology of collateral circulation, gastric variceal classification has been refined to include inflow and outflow based hemodynamic pathways. These have led to an improvement in the management of gastric variceal disease through newer modalities of treatment such as endoscopic ultrasound-guided glue-coiling combination therapy and the emergence of highly effective endovascular treatments such as shunt and variceal complex embolization with or without transjugular intrahepatic portosystemic shunt (TIPS) placement in patients who are deemed ‘difficult’ to manage the traditional way. Furthermore, the decisions regarding TIPS and additional endovascular procedures in patients with gastric variceal bleeding have changed after the emergence of ‘portal hypertension theories’ of proximity, throughput, and recruitment. The hemodynamic classification, grounded on novel theories and its cognizance, can help in identifying patients at baseline, in whom conventional treatment could fail. In this exhaustive review, we discuss the conventional and hemodynamic diagnosis of gastric varices concerning new classifications; explore and illustrate new ‘portal hypertension theories’ of gastric variceal disease and corresponding management and shed light on current evidence-based treatments through a ‘new’ algorithmic approach, established on hemodynamic physiology of gastric varices.

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“… 68 , 87 , 88 Late recurrences are probably related to development of new collaterals or recanalization of previously closed ones. 14 …”

Section: Embolizationmentioning

confidence: 99%

“… 13 At the same time, SPSSs have been considered as a therapeutic target to reverse difficult cases of HE. 14 More recently, special situations, as liver transplant (LT) or a broader TIPS indication, have posed new challenges, in which the role of SPSSs will have to be defined.…”

Section: Introductionmentioning

confidence: 99%

Spontaneous portosystemic shunts in liver cirrhosis: new approaches to an old problem

Vidal‐González

Quiroga

Simón-Talero

et al. 2020

Therap Adv Gastroenterol

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Portal hypertension is the main consequence of liver cirrhosis, leading to severe complications such as variceal hemorrhage, ascites or hepatic encephalopathy. As an attempt to decompress the portal venous system, portal flow is derived into the systemic venous system through spontaneous portosystemic shunts (SPSSs), bypassing the liver. In this review, we aim to provide an overview of the published reports in relation to the prevalence and physiopathology behind the appearance of SPSS in liver cirrhosis, as well as the complications derived from its formation and its management. The role of SPSS embolization is specifically discussed, as SPSSs have been assessed as a therapeutic target, mainly for patients with recurrent/persistent hepatic encephalopathy and preserved liver function. Furthermore, different aspects of the role of SPSS in liver transplantation, as well as in candidates for transjugular intrahepatic portosystemic shunt are reviewed. In these settings, SPSS occlusion has been proposed to minimize possible deleterious effects, but results are so far inconclusive.

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<p>Portosystemic shunts and refractory hepatic encephalopathy: patient selection and current options</p>

Cited by 42 publications

References 31 publications

TIPS Modification in the Management of Shunt-Induced Hepatic Encephalopathy: Analysis of Predictive Factors and Outcome with Shunt Modification

TIPS Modification in the Management of Shunt-Induced Hepatic Encephalopathy: Analysis of Predictive Factors and Outcome with Shunt Modification

Beyond the scope and the glue: update on evaluation and management of gastric varices

Spontaneous portosystemic shunts in liver cirrhosis: new approaches to an old problem

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