Survival benefit of TIPS versus serial paracentesis in patients with refractory ascites: a single institution case-control propensity score analysis

Gaba, Ron C.; Parvinian, Ahmad; Casadaban, Leigh C.; Couture, Patrick; Zivin, Sean P.; Lakhoo, Janesh; Minocha, Jeet; Ray, Charles E.; Knuttinen, M. Grace; Bui, James T.

doi:10.1016/j.crad.2015.02.002

Cited by 36 publications

(24 citation statements)

References 36 publications

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“…As for the survival observed in the present study, it is consistent with that of patients undergoing LVP included in recent studies for RA . To note, our survival data at 6 and 12 months were similar to those of patients treated with LVP in a meta‐analysis of trials investigating LVP vs TIPSS for RA .…”

Section: Discussionsupporting

confidence: 90%

Treatment of refractory ascites with an automated low‐flow ascites pump in patients with cirrhosis

Stirnimann¹,

Berg²,

Zeuzem³

et al. 2017

Aliment Pharmacol Ther

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SummaryBackgroundRefractory ascites (RA) is a frequent complication of cirrhosis, requiring large volume paracentesis or placement of a transjugular intrahepatic portosystemic shunt (TIPSS). The automated low‐flow ascites pump (alfapump, Sequana Medical AG, Zurich, Switzerland) is an innovative treatment option for patients with RA.AimTo assess safety and efficacy of this treatment in patients with a contraindication to TIPSS.MethodsFifty‐six patients (43 males; mean age 62 years) from centres in Germany, Switzerland, UK and Spain were included and followed for up to 24 months. Complications, device deficiencies, paracentesis frequency and patient survival were recorded.ResultsAt the time of this analysis, 3 patients completed the 24‐month observation period, monitoring of 3 was ongoing, 9 underwent liver transplantation, 17 patients were withdrawn due to serious adverse events and 23 patients died. Most frequently observed technical complication was blocking of the peritoneal catheter. Twenty‐three pump‐related reinterventions (17 patients) and 12 pump exchanges (11 patients) were required during follow‐up. The pump system was explanted in 48% of patients (in 17 patients due to serious adverse events, in 9 at the time of liver transplantation and in 1 due to recovery from RA). Median frequency of paracentesis dropped from 2.17 to 0.17 per month.ConclusionsThe alfapump can expand therapeutic options for cirrhotic patients with RA. Continuous drainage of ascites in a closed loop automated system led to significant reduction in paracentesis frequency. Technical and procedural improvements are required to reduce the rate of adverse events and reinterventions. https://clinicaltrials.gov/ct2/show/NCT01532427

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Section: Discussionsupporting

confidence: 90%

Treatment of refractory ascites with an automated low‐flow ascites pump in patients with cirrhosis

Stirnimann¹,

Berg²,

Zeuzem³

et al. 2017

Aliment Pharmacol Ther

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“…This finding was highlighted in the EASL guidelines, which described that the reported management of ascites resulted more frequently in HE in the TIPS group compared to the paracentesis group 45. More recently, a retrospective study evaluating 70 covered TIPS and 80 serial paracenteses for refractory ascites treatment concluded that covered "stents" improved the survival to medium- and long-term without a significant increase in the short-term mortality of patients with refractory ascites in clinical treatment failure 46.…”

Section: Discussionmentioning

confidence: 98%

Clinical Features of Refractory Ascites in Outpatients

Caly¹,

Abreu²,

Bitelman³

et al. 2017

Clinics

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OBJECTIVES:To present the clinical features and outcomes of outpatients who suffer from refractory ascites.METHODS:This prospective observational study consecutively enrolled patients with cirrhotic ascites who submitted to a clinical evaluation, a sodium restriction diet, biochemical blood tests, 24 hour urine tests and an ascitic fluid analysis. All patients received a multidisciplinary evaluation and diuretic treatment. Patients who did not respond to the diuretic treatment were controlled by therapeutic serial paracentesis, and a transjugular intrahepatic portosystemic shunt was indicated for patients who required therapeutic serial paracentesis up to twice a month.RESULTS:The most common etiology of cirrhosis in both groups was alcoholism [49 refractory (R) and 11 non-refractory ascites (NR)]. The majority of patients in the refractory group had Child-Pugh class B cirrhosis (p=0.034). The nutritional assessment showed protein-energy malnutrition in 81.6% of the patients in the R group and 35.5% of the patients in the NR group, while hepatic encephalopathy, hernia, spontaneous bacterial peritonitis, upper digestive hemorrhage and type 2 hepatorenal syndrome were present in 51%, 44.9%, 38.8%, 38.8% and 26.5% of the patients in the R group and 9.1%, 18.2%, 0%, 0% and 0% of the patients in the NR group, respectively (p=0.016, p=0.173, p=0.012, p=0.012, and p=0.100, respectively). Mortality occurred in 28.6% of the patients in the R group and in 9.1% of the patients in the NR group (p=0.262).CONCLUSION:Patients with refractory ascites were malnourished, suffered from hernias, had a high prevalence of complications and had a high postoperative death frequency, which was mostly due to infectious processes.

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“…10 Gaba et al noted new or worsening HE in 31% of TIPS recipients and 28% of LVP recipients (p ¼ 0.720). 14 Bureau et al found the rate of overt HE to be 34% in TIPS recipients and 33% in LVP recipients (no significant difference). 15 The study by Narahara et al was the only RCT that reported a significantly higher incidence of HE in TIPS recipients at follow-up (67% in TIPS recipients versus 17% in LVP recipients, p < 0.001).…”

Section: Posttreatment Incidence Of Hepatic Encephalopathymentioning

confidence: 98%

“…As previously mentioned, Gaba et al reported new or worsening HE in 31% of covered stent TIPS recipients. 14 Bercu et al found the overall incidence of HE to be 59.0% and the incidence of severe HE to be 19.7% following covered stent TIPS insertion. 14 Tan et al reported a lower incidence of HE of any grade in bare stent TIPS recipients compared with ePTFE stent TIPS recipients; however, this difference was not significant (27.8% versus 28.6%, p ¼ 0.30).…”

Section: Posttreatment Incidence Of Hepatic Encephalopathymentioning

confidence: 98%

Transjugular Intrahepatic Portosystemic Shunt in Ascites: Updates

2017

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The 2009 update of the American Association for the Study of Liver Diseases (practice guidelines recommends transjugular intrahepatic portosystemic shunt (TIPS) for the treatment of refractory ascites in patients who do not tolerate repeated large volume paracentesis (LVP). It also stated uncertain survival benefit and possible increase in the risk of hepatic encephalopathy (HE). Since this update was published, new studies concerning TIPS as therapy for refractory ascites have emerged. Five studies reported a significant survival improvement in patients who underwent TIPS compared with LVP for refractory ascites, while a single study noted improved survival rates in covered stent TIPS recipients. Three studies found a significantly greater prevalence of severe HE in TIPS recipients compared with LVP recipients; however, only one study reported a significant association between TIPS and increased development of HE of all grades. Based on our review of the current literature, we recommend TIPS over LVP for the treatment of refractory ascites. Further, covered stents should be used for TIPS creation whenever possible.

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Survival benefit of TIPS versus serial paracentesis in patients with refractory ascites: a single institution case-control propensity score analysis

Cited by 36 publications

References 36 publications

Treatment of refractory ascites with an automated low‐flow ascites pump in patients with cirrhosis

Treatment of refractory ascites with an automated low‐flow ascites pump in patients with cirrhosis

Clinical Features of Refractory Ascites in Outpatients

Transjugular Intrahepatic Portosystemic Shunt in Ascites: Updates

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