Protective Value of TIPS Against the Development of Hydrothorax/Ascites and Upper Gastrointestinal Bleeding after Balloon-Occluded Retrograde Transvenous Obliteration (BRTO)

Saad, Wael E.A.; Wagner, Cynthia E.; Lippert, Allison; Al‐Osaimi, Abdullah; Davies, Mark G.; Matsumoto, Alan H.; Angle, John F.; Caldwell, Stephen H.

doi:10.1038/ajg.2013.232

Cited by 54 publications

(43 citation statements)

References 34 publications

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“…These types of patients require careful follow-up evaluation, including endoscopy at shorter follow-up intervals. An optional therapy such as selective B-RTO or addition of TIPS after B-RTO might prevent excessive worsening of portal hypertension [20]. In some high-risk patients, TIPS alone or no treatment might be a therapeutic option.…”

Section: Discussionmentioning

confidence: 99%

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Factors Associated with Aggravation of Esophageal Varices after B-RTO for Gastric Varices

Jogo

Nishida

Yamamoto

et al. 2013

Cardiovasc Intervent Radiol

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PurposeTo retrospectively evaluate risk factors for aggravation of esophageal varices (EV) within 1 year after balloon-occluded retrograde transvenous obliteration (B-RTO) of gastric varices (GV) and to clarify suitable timing for upper endoscopy to detect EV aggravation after B-RTO.MethodsParticipants included 67 patients who underwent B-RTO for GV between January 2006 and December 2010. Whether EV aggravation occurred within 1 year was evaluated, and the time interval from B-RTO to aggravation was calculated. Factors potentially associated with EV aggravation were analyzed.ResultsB-RTO was successfully performed in all patients. EV aggravation at 1 year after B-RTO was found in 38 patients (56.7 %). Multivariate logistic regression analysis showed that total bilirubin (T-bil) (P = 0.032) and hepatic venous pressure gradient (HVPG) (P = 0.011) were significant independent risk factors for EV aggravation after B-RTO. Cutoff values of T-bil and HVPG yielding maximal combined sensitivity and specificity for EV aggravation were 1.6 mg/dL and 13 mmHg, respectively. The patients with T-bil ≥ 1.6 mg/dL or HVPG ≥ 13 mmHg had a median aggravation time of 5.1 months. All five patients with ruptured EV belonged to this group. In contrast, patients with T-bil < 1.6 mg/dL and HVPG < 13 mmHg had a median aggravation time of 21 months.ConclusionT-bil and HVPG were significant independent risk factors for EV aggravation after B-RTO. The patients with T-bil ≥ 1.6 mg/dL or HVPG ≥ 13 mmHg require careful follow-up evaluation, including endoscopy.

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Section: Discussionmentioning

confidence: 99%

“…Development of refractory ascites after B-RTO may become an issue [20]. We experienced only one patient who developed refractory ascites after B-RTO in 67 patients.…”

Section: Discussionmentioning

confidence: 99%

Factors Associated with Aggravation of Esophageal Varices after B-RTO for Gastric Varices

Jogo

Nishida

Yamamoto

et al. 2013

Cardiovasc Intervent Radiol

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“…Elective TIPS has been shown to improve quality of life and may decrease morbidity and mortality in patients with refractory ascites, variceal hemorrhage, and hepatic hydrothorax . However, it is an invasive procedure performed in an inherently high‐risk population that has a higher mortality than the general population with cirrhosis due to their complications of intractable ascites, esophageal varices, and GI bleeding.…”

Section: Discussionmentioning

confidence: 99%

“…Elective TIPS has been shown to improve quality of life and may decrease morbidity and mortality in patients with refractory ascites, (28)(29)(30)(31)(32) variceal hemorrhage, (33)(34)(35) and hepatic hydrothorax. (36)(37)(38) However, it is an invasive procedure performed in an inherently high-risk population that has a higher mortality than the general population with cirrhosis due to their complications of intractable ascites, esophageal varices, and GI bleeding. Many physicians exclude patients with high MELD scores (18) from receiving TIPS because of concerns that patients with higher MELD scores have a disproportionately higher risk of death from the procedure.…”

Section: Discussionmentioning

confidence: 99%

Transjugular intrahepatic portosystemic shunt does not independently increase risk of death in high model for end stage liver disease patients

Spengler

Hunsicker

Zarei

et al. 2017

Hepatology Communications

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Physicians often exclude patients with a model for end‐stage liver disease (MELD) score ≥ 18 from a transjugular intrahepatic portosystemic shunt (TIPS) procedure due to the concern for higher risk of death. We aimed to determine if TIPS increased the risk of death in these patients. We analyzed the interaction between TIPS and MELD in 106 patients with TIPS and 79 with intractable ascites without TIPS. We performed Cox proportional hazard regression, including both TIPS and MELD as time‐dependent covariates together with their interaction, to calculate the impact of TIPS on the risk of death associated with a high MELD score. We found a negative interaction between a high MELD score and a history of TIPS, with potentially important effect sizes. Patients with MELD scores ≥18 had a 51% lower incremental risk of death (lower risk than would be expected from the combined independent risks of MELD and needing/receiving TIPS) associated with TIPS than patients with MELD scores <18 (hazard ratio for TIPS, 0.49; 95% confidence interval, 0.10‐2.45) in the first 6 months following TIPS. There was an 80% lower incremental risk of death among patients with a MELD score ≥18 (hazard ratio for TIPS, 0.20; 95% confidence interval, 0.03‐1.23) 6 months after the TIPS procedure. Conclusion: Risk of death is associated with underlying disease severity as shown by the MELD score and the need for TIPS, and both history of TIPS and high MELD score independently increased the risk of mortality. However, the risk of death after TIPS was progressively lower than expected as the MELD score increased. (Hepatology Communications 2017;1:460–468)

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“…Until such data exist, it might be an option in patients after failure of endoscopic therapies in which TIPS is not effective and is contraindicated or it is not technically possible. A recent report suggests that the combination of BRTO to obliterate gastric varices and TIPS to control other complications of portal hypertension might be a feasible and effective approach for difficult to treat gastric varices (Saad et al 2013b).…”

Section: Prevention Of Rebleedingmentioning

confidence: 99%

Assessment and Management of Portal Hypertension

Abraldes¹,

Tandon²

2014

PanVascular Medicine

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Cirrhosis is the main cause of portal hypertension. Variceal bleeding is the most serious complication of portal hypertension. All cirrhotic patients should be screened endoscopically for varices which are present in about 50 % of patients at diagnosis. In patients without varices, endoscopy should be repeated every 2 years. Patients with high-risk varices (moderate or large in size, or with red color signs, or in Child-Pugh C patients) should be treated with a nonselective beta-blocker to prevent bleeding. Patients with contraindications to beta-blockers or who cannot tolerate these drugs should receive endoscopic band ligation. Acute variceal hemorrhage calls for intensive care and conservative blood transfusion policy. Treatment is based on the combined use of vasoactive drugs, endoscopic band ligation, and prophylactic antibiotics. Failures are best managed by transjugular intrahepatic portosystemic shunt. Patients surviving variceal bleeding are at high risk of rebleeding; medical therapies, using beta-blockers and endoscopic band ligation, are the recommended treatments.

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Protective Value of TIPS Against the Development of Hydrothorax/Ascites and Upper Gastrointestinal Bleeding after Balloon-Occluded Retrograde Transvenous Obliteration (BRTO)

Abstract: This study concludes that the presence of TIPS has a protective value against the development of post-BRTO ascites/hydrothorax as well as recurrent hemorrhage but this does not translate to improved patient survival.

Cited by 54 publications

References 34 publications

Factors Associated with Aggravation of Esophageal Varices after B-RTO for Gastric Varices

Factors Associated with Aggravation of Esophageal Varices after B-RTO for Gastric Varices

Transjugular intrahepatic portosystemic shunt does not independently increase risk of death in high model for end stage liver disease patients

Assessment and Management of Portal Hypertension

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