Polytetrafluoroethylene-covered Nitinol Stent-Graft for Transjugular Intrahepatic Portosystemic Shunt Creation: 3-year Experience

Rossi, Plinio; Salvatori, Filippo Maria; Fanelli, Fabrizio; Bezzi, Mario; Rossi, Michele; Marcelli, G; Pepino, Daniela; Riggio, Oliviero; Passariello, Roberto

doi:10.1148/radiol.2313030349

Cited by 127 publications

(82 citation statements)

References 37 publications

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“…Unfortunately, final PSG levels that may improve medically refractory ascites also increase the risk of hepatic encephalopathy (21,22). Although we found no independent predictors of hepatic encephalopathy, it should be noted that nearly all instances of hepatic encephalopathy were mild cases, graded at 0 or 1, which are generally treatable with dietary modification and medical therapy (23)(24)(25).…”

Section: Discussionmentioning

confidence: 64%

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: Discussionmentioning

confidence: 64%

Transjugular intrahepatic portosystemic shunt for the treatment of medically refractory ascites

Parvinian¹,

Bui²,

Knuttinen³

et al. 2013

Diagn Interv Radiol

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“…Accordingly, understanding the predisposing factors leading to TIPS dysfunction and efforts to solve those problems are necessary to maintain long-term patency after TIPS placement. Currently, the best solution for TIPS dysfunction seems to be the use of polytetrafluoroethylene-covered stent grafts that isolate blood from hepatic tissue, therefore blocking the tentative triggering mechanisms of pseudointimal and intimal hyperplasia or thrombosis (19)(20)(21)(22)(23)(24)(25)(26)(27). Recently, a meta-analysis of six studies demonstrated not only a significant improvement of primary patency (hazard ratio [HR], 0.28) and a significant reduction of risk of hepatic encephalopathy (HR, 0.65), but also a significant decrease of mortality in the covered-stent group (HR, 0.76) (25).…”

Section: Discussionmentioning

confidence: 99%

“…Among many theories, widely accepted ones are thrombosis, pseudointimal hyperplasia caused by bile leaks of transected bile ducts into the stent lumen, and intimal hyperplasia of the hepatic vein outflow tract (16)(17)(18). Recently, use of polytetrafluoroethylene (PTFE)-covered stents has decreased TIPS dysfunction by allowing endoluminal endothelial lining and preventing bile leak into the stent (19)(20)(21)(22)(23)(24)(25)(26)(27).…”

Section: Introductionmentioning

confidence: 99%

Stent Dysfunction After Transjugular Intrahepatic Portosystemic Shunt: A 14-Year Experience from a Single Tertiary Medical Center

Kim

Gwon

et al. 2017

Iran J Radiol

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Background: The predisposing factors leading to transjugular intrahepatic portosystemic shunt (TIPS) dysfunction, other than the use of bare stents, which are often the only available options, have not been elucidated well to date. Objectives: To analyze clinical outcomes after TIPS created with bare stents and to assess risk factors for stent dysfunction. Patients and Methods: A total of 102 patients undergoing TIPS between January 1999 and December 2012 were retrospectively assessed. The incidence of stent dysfunction was evaluated, and associated risk factors were analyzed. Results: Symptom recurrence was observed in 51 (50%) patients, and TIPS revision was required in 37 (36%) during the mean followup period of 1889 days. The median stent patency and survival times were 470 and 1783 days, respectively. The only independent risk factor for stent dysfunction was portal trunk (right, left, or main portal trunk) access (P = 0.006). The median stent patency with segmental branch access (538 days) was significantly longer than that with portal trunk access (245 days) (P = 0.007). There were no significant differences in patient survival (P = 0.648), worsening of encephalopathy (P = .0742), or major complications (P = 1.000). Conclusion: TIPS created with segmental portal venous access has superior patency over that of TIPS with portal trunk access. However, we found no significant difference in patient survival, worsening of encephalopathy, or major complications between segmental access and portal trunk access.

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“…Given the potential conflicting relationship between portal decompression and HE, efforts have been made to develop techniques to balance the desired therapeutic effect while minimizing over-shunting [3,17] . One such technique is to sub-maximally dilate a 10 mm TIPS [18,19] . Sub-maximal dilation theoretically allows for further dilation of the TIPS in the event that the initial portal decompression is insufficient while avoiding overshunting [6,16,18] .…”

Section: Introductionmentioning

confidence: 99%

“…One such technique is to sub-maximally dilate a 10 mm TIPS [18,19] . Sub-maximal dilation theoretically allows for further dilation of the TIPS in the event that the initial portal decompression is insufficient while avoiding overshunting [6,16,18] . However, this technique would only be effective if the sub-maximally dilated TIPS do not expand significantly over time.…”

Section: Introductionmentioning

confidence: 99%

Passive expansion of submaximally dilated transjugular intrahepatic portosystemic shunts and assessment of clinical outcomes

Hsu

Weber

Nadolski³

2016

Journal of Vascular and Interventional Radiology

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AIMTo assess for passive expansion of sub-maximally dilated transjugular intrahepatic portosystemic shunts (TIPS) and compare outcomes with maximally dilated TIPS. METHODS Polytetrafluoroethylene covered TIPS (Viatorr) fromJuly 2002 to December 2013 were retrospectively reviewed at two hospitals in a single institution. Two hundred and thirty patients had TIPS maximally dilated to 10 mm (mTIPS), while 43 patients who were at increased risk for hepatic encephalopathy (HE), based on clinical evaluation or low pre-TIPS portosystemic gradient (PSG), had 10 mm TIPS sub-maximally dilated to 8 mm (smTIPS). Hsu MC et al . Passive expansion of sub-maximally dilated TIPS primary assisted patency, and severe post-TIPS HE. A subset of fourteen patients with smTIPS underwent follow-up computed tomography imaging after TIPS creation, and were grouped based on time of imaging (< 6 mo and > 6 mo). Change in diameter and crosssectional area were measured with 3D imaging software to evaluate for passive expansion. RESULTSPatient characteristics were similar between the smTIPS and mTIPS groups, except for pre-TIPS portosystemic gradient, which was lower in the smTIPS group (19.4 mmHg ± 6.8 vs 22.4 mmHg ± 7.1, P = 0.01). Primary patency and primary assisted patency between smTIPS and mTIPS was not significantly different (P = 0.64 and 0.55, respectively). Four of the 55 patients (7%) with smTIPS required TIPS reduction for severe refractory HE, while this occurred in 6 of the 218 patients (3%) with mTIPS (P = 0.12). For the 14 patients with follow-up computed tomography (CT) imaging, the median imaging follow-up was 373 d. There was an increase in median TIPS diameter, median percent diameter change, median area, and median percent area change in patients with CT follow-up greater than 6 mo after TIPS placement compared to follow-up within 6 mo (8.45 mm, 5.58%, 56.04 mm 2 , and 11.48%, respectively, P = 0.01). CONCLUSIONPassive expansion of smTIPS does occur but clinical outcomes of smTIPS and mTIPS were similar. Sub-maximal dilation can prevent complications related to overshunting in select patients. Core tip: Sub-maximal dilation of transjugular intrahepatic portosystemic shunts (TIPS) is a method to reduce the risk of over-shunting and hepatic encephalopathy. The current study is a retrospective review to compare clinical outcomes of sub-maximally dilated TIPS (smTIPS) with maximally dilated TIPS (mTIPS) and assess for passive expansion of smTIPS. The study demonstrated that passive expansion of smTIPS does occur, however shunts may not fully expand and expansion may occur even after 6 mo. Clinical outcomes of smTIPS and mTIPS were similar, suggesting sub-maximal dilation may be an acceptable method to prevent complications related to over-shunting in select patients.Hsu MC, Weber CN, Stavropoulos SW, Clark TW, Trerotola SO, ShlanskyGoldberg RD, Soulen MC, Nadolski GJ. Passive expansion of submaximally dilated transjugular intrahepatic portosystemic shunts and assessment of clinical outcomes.

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Polytetrafluoroethylene-covered Nitinol Stent-Graft for Transjugular Intrahepatic Portosystemic Shunt Creation: 3-year Experience

Abstract: The new PTFE-covered nitinol stent-graft used appears to be excellent in preventing the need for repeated interventions. A primary patency rate of 83.8% and a secondary patency rate of 98.1% were achieved.

Cited by 127 publications

References 37 publications

Transjugular intrahepatic portosystemic shunt for the treatment of medically refractory ascites

Transjugular intrahepatic portosystemic shunt for the treatment of medically refractory ascites

Stent Dysfunction After Transjugular Intrahepatic Portosystemic Shunt: A 14-Year Experience from a Single Tertiary Medical Center

Passive expansion of submaximally dilated transjugular intrahepatic portosystemic shunts and assessment of clinical outcomes

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