Prevention of Rebleeding From Esophageal Varices in Patients With Cirrhosis Receiving Small-Diameter Stents Versus Hemodynamically Controlled Medical Therapy

Sauerbruch, Tilman; Mengel, Martin; Dollinger, Matthias; Zipprich, Alexander; Rössle, Martin; Panther, Elisabeth; Wiest, Reiner; Caca, Karel; Hoffmeister, Albrecht; Lutz, Holger H.; Schoo, Rüdiger; Lorenzen, Henning; Trebicka, Jonel; Appenrodt, Beate; Schepke, Michael; Fimmers, Rolf

doi:10.1053/j.gastro.2015.05.011

Cited by 216 publications

(207 citation statements)

References 41 publications

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“…Hemodynamic non-responders to secondary FLT should be considered earlier for TIPS. Preliminary, albeit uncontrolled, data indicate that allocation of these patients to TIPS reduces rebleeding rate and bleeding-associated mortality [5, 97,106,[110][111][112][113].…”

Section: Tips Is Not Indicated For the Prophylaxis Of First Variceal mentioning

confidence: 99%

Consensus conference on TIPS management: Techniques, indications, contraindications

Fagiuoli

Bruno

Venon

et al. 2017

Digestive and Liver Disease

130

120

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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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Section: Tips Is Not Indicated For the Prophylaxis Of First Variceal mentioning

confidence: 99%

Consensus conference on TIPS management: Techniques, indications, contraindications

Fagiuoli

Bruno

Venon

et al. 2017

Digestive and Liver Disease

130

120

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“…In patients who cannot tolerate NSBB (see below), TIPS should be considered to prevent rebleeding. TIPS (using the smaller diameter 8 mm stents) has been recently compared to hepatic venous pressure gradient-guided therapy in the prevention of rebleeding in patients with Child A or B cirrhosis showing that TIPS prevented rebleeding more effectively than drugs, but without a survival benefit, and was associated with more adverse events (mainly encephalopathy) [10] .…”

Section: Variceal Hemorrhagementioning

confidence: 99%

Current Management of the Complications of Cirrhosis and Portal Hypertension: Variceal Hemorrhage, Ascites, and Spontaneous Bacterial Peritonitis

García–Tsao

2016

Dig Dis

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Cirrhosis is not a single entity but represents a disease progression across different prognostic stages, with the compensated and decompensated stages being the most important. Variceal hemorrhage (VH) and ascites are complications of cirrhosis that denote the presence of a decompensated stage. Spontaneous bacterial peritonitis (SBP) is a common bacterial infection unique to patients with cirrhosis that can precipitate the development of recurrent VH and hepatorenal syndrome (HRS), complications that denote the presence of a ‘further decompensated' stage of cirrhosis. Main current issues in the management of VH include identification of different prognostic stages that allow for individualized patient care. Management of VH cannot be performed in an isolated manner, and the presence of other complications of cirrhosis (ascites, encephalopathy) should be taken into account both in the management and in the design of clinical trials. Because management of ascites per se has not resulted in significant changes in mortality, main management issues consist of preventing further decompensating events by preventing factors that will lead to worsening vasodilatation and hemodynamic status (infections, vasodilators), preventing volume depletion (overdiuresis, GI hemorrhage) and preventing structural kidney injury (nephrotoxins). Prophylaxis of bacterial infections such as SBP currently consists of the administration of antibiotics. By preventing infections, there is evidence that recurrent VH and HRS can also be prevented. However, response to recommended empirical antibiotics in patients with suspected infection, such as SBP, is currently significantly lower than in the past because of an increase in infections secondary to multidrug resistant (MDR) organisms. One of the main predictors of the development of MDR organisms is antibiotic prophylaxis and unnecessary and prolonged use of antibiotics in hospital. Therefore, appropriate antibiotics should be used in patients with a high suspicion of infection, and antibiotic prophylaxis should be restricted to patients with the highest risk of infection.

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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: 87%

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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Prevention of Rebleeding From Esophageal Varices in Patients With Cirrhosis Receiving Small-Diameter Stents Versus Hemodynamically Controlled Medical Therapy

Cited by 216 publications

References 41 publications

Consensus conference on TIPS management: Techniques, indications, contraindications

Consensus conference on TIPS management: Techniques, indications, contraindications

Current Management of the Complications of Cirrhosis and Portal Hypertension: Variceal Hemorrhage, Ascites, and Spontaneous Bacterial Peritonitis

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

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