Procedural and shunt‐related complications and mortality of the transjugular intrahepatic portosystemic shunt (TIPSS)

Bettinger, Dominik; Schultheiß, Michael; Böettler, Tobias; Muljono, Michelle Patricia; Thimme, Robert; Rössle, Martin

doi:10.1111/apt.13809

Cited by 63 publications

(46 citation statements)

References 39 publications

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“…The efficacy of TIPSS has to be balanced against the risk of serious side effects, in particular HE. Post‐TIPSS HE manifested or worsened in 30% of our patients, which was comparable with other reported experience . The majority of post‐TIPSS HE could be managed medically, but in some cases, a stent diameter reduction was necessary.…”

Section: Discussionmentioning

confidence: 99%

“…Post-TIPSS HE manifested or worsened in 30% of our patients, which was comparable with other reported experience. 18,23,27,28 The majority of post-TIPSS HE could be managed medically, but in some cases, a stent diameter reduction was necessary. A recent report suggests that there might be an optimum of 8 mm TIPSS diameter to effectively decompress the portal system in relation to the encephalopathy risk.…”

Section: Patients With E-pfte-covered Stents (N = 45)mentioning

confidence: 99%

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Variable efficacy of TIPSS in the management of ectopic variceal bleeding: a multicentre retrospective study

Oey

Wit

Moelker

et al. 2018

Aliment Pharmacol Ther

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SummaryBackgroundEvidence for the efficacy of TIPSS in ectopic variceal bleeding (EctVB) is largely based on relatively small series.AimTo define the efficacy of TIPSS in EctVB.MethodsRetrospective analysis of consecutive patients with chronic liver disease who presented with EctVB and received TIPSS in three tertiary centres in 1992‐2016.ResultsThe study included 53 patients (70% male, median age 61 years, median model for end‐stage liver disease (MELD) score 11). The ectopic varices were located around the insertion of stomas (40%), duodenum (23%), rectum (17%) and at other sites (20%). Three‐quarters of the patients had previously received unsuccessful medical, endoscopic or surgical therapy. The median follow‐up was 14.0 months. Following TIPSS, bleeding recurred in 12 patients: 6 of 12 (50%) with duodenal varices, 2 of 9 (22%) with rectal varices and one each with stomal (1/21), intraperitoneal (1/3), hepaticojejunostomy (1/2) and ascending colon varices (1/2). The risk factors for re‐bleeding were MELD score at TIPSS placement (HR: 1.081 per point; 95% confidence interval (CI): 1.012‐1.153; P = 0.034), varices located at site other than an enterostomy (HR: 9.770; 95%CI: 1.241‐76.917; P = 0.030) and previous local therapy (HR: 5.710; 95%CI: 1.211‐26.922; P = 0.028). The estimated cumulative re‐bleeding rate was 23% at 1 year, 26% at 3 years and 32% at 5 years. Post‐TIPSS hepatic encephalopathy manifested or worsened in 16 of 53 patients (30%).Conclusion TIPSS provides long‐term control of bleeding in most cirrhotic patients with EctVB. TIPSS is particularly effective in stomal EctVB, the most frequent cause of EctVB, but might not be as effective in duodenal EctVB.

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Section: Discussionmentioning

confidence: 99%

Section: Patients With E-pfte-covered Stents (N = 45)mentioning

confidence: 99%

Variable efficacy of TIPSS in the management of ectopic variceal bleeding: a multicentre retrospective study

Oey

Wit

Moelker

et al. 2018

Aliment Pharmacol Ther

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“…Likewise, TIPS placement for treating sequalae of PH requires a high degree of technical and clinical expertise to limit complications and achieve optimal patient outcomes [38-40]. More recently, Sarwar et al [41] demonstrated that mortality in patients undergoing TIPS decreases with rising annual TIPS volume, defining an annual threshold of 20 TIPS/year beyond which in patient mortality is better for both emergent and elective procedures.…”

Section: Discussionmentioning

confidence: 99%

Transjugular Intrahepatic Portosystemic Shunt in Patients with Portal Hypertension: Patency Depends on Coverage and Interventionalist’s Experience

Buechter¹,

Manka²,

Gerken³

et al. 2018

Dig Dis

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Background and Aims: Transjugular intrahepatic portosystemic shunt (TIPS) is the treatment of choice in decompensated portal hypertension. TIPS revision due to thrombosis or stenosis increases morbidity and mortality. Our aim was to investigate patient- and procedure-associated risk factors for TIPS-revision. Patients and Methods: We retrospectively evaluated 189 patients who underwent the TIPS procedure. Only patients who required TIPS revision within 1 year (Group I, 34 patients) and patients who did not require re-intervention within the first year (Group II [control group], 54 patients) were included. Results: Out of 88 patients, the majority were male (69.3%) and mean age was 56 ± 11 years. Indications for TIPS were refractory ascites (68%), bleeding (24%), and Budd-Chiari syndrome (8%). The most frequent liver disease was alcohol-induced cirrhosis (60%). Forty-three patients (49%) received bare and 45 patients (51%) covered stents, thus resulting in reduction of hepatic venous pressure gradient (HVPG) from 19.0 to 9.0 mm Hg. When comparing patient- and procedure-related factors, the type of stent (p < 0.01) and interventionalist’s experience (number of performed TIPS implantations per year; p < 0.05) were the only factors affecting the risk of re-intervention due to stent dysfunction, while age, gender, indication, Child-Pugh, and model of end-stage liver disease score, platelet count, pre- and post-HVPG, additional variceal embolization, stent diameter, and number of stents did not significantly differ. Conclusion: Patients undergoing TIPS procedure should be surveilled closely for shunt dysfunction while covered stents and high-level experience are associated with increased patency.

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“…Hepatic encephalopathy (HE) is the major and most frequent complication of the TIPS [5]. Its incidence and severity depend on the individual risk of the patient (pre-TIPS HE, age, Child-Pugh class) and the diameter of the stent which determines the degree of shunting [5][6][7][8][9][10][11].…”

Section: Introductionmentioning

confidence: 99%

“…Its incidence and severity depend on the individual risk of the patient (pre-TIPS HE, age, Child-Pugh class) and the diameter of the stent which determines the degree of shunting [5][6][7][8][9][10][11]. Thus, larger stent diameters with a greater reduction in the portosystemic pressure gradient (the difference between the portal and right atrial pressures) have a higher incidence of TIPS-induced HE.…”

Section: Introductionmentioning

confidence: 99%

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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Procedural and shunt‐related complications and mortality of the transjugular intrahepatic portosystemic shunt (TIPSS)

Abstract: Except hepatic encephalopathy, severe procedure- and shunt-related complications are rare and early mortality is low.

Cited by 63 publications

References 39 publications

Variable efficacy of TIPSS in the management of ectopic variceal bleeding: a multicentre retrospective study

Variable efficacy of TIPSS in the management of ectopic variceal bleeding: a multicentre retrospective study

Transjugular Intrahepatic Portosystemic Shunt in Patients with Portal Hypertension: Patency Depends on Coverage and Interventionalist’s Experience

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

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