The natural history of portal hypertension after transjugular intrahepatic portosystemic shunts

Sanyal, Arun J.; Freedman, Arthur M.; Luketic, Velimir A.; Purdum, Preston P.; Shiffman, Mitchell L.; DeMeo, J H; Cole, P E; Tisnado, Jaime

doi:10.1053/gast.1997.v112.pm9041251

Cited by 273 publications

(157 citation statements)

References 2 publications

Supporting

Mentioning

146

Contrasting

Unclassified

Order By: Relevance

“…Systemic venous pressures of more than 15 mmHg and stent dysfunction have been found to represent risk factors for recurrent hemorrhage following TIPS [26]. The use of adjunctive coil embolization of gastroesophageal varices potentially addresses these risk factors by occluding venous collateral channels that may recanalize in the setting of elevated systemic venous pressures or stenotic or occluded shunts.…”

Section: Discussionmentioning

confidence: 99%

Rebleeding rates following TIPS for variceal hemorrhage in the Viatorr era: TIPS alone versus TIPS with variceal embolization

et al. 2010

View full text Add to dashboard Cite

Purpose To compare rebleeding rates following treatment of variceal hemorrhage with TIPS alone versus TIPS with variceal embolization in the covered stent-graft era. Methods In this retrospective study, 52 patients (M:F 29:23, median age 52 years) with hepatic cirrhosis and variceal hemorrhage underwent TIPS insertion between 2003 and 2008. Median Child-Pugh and MELD scores were 8.5 and 13.5. Generally, 10-mm diameter TIPS were created using covered stent-grafts (Viatorr; W.L. Gore and Associates, Flagstaff, AZ). A total of 37 patients underwent TIPS alone, while 15 patients underwent TIPS with variceal embolization. The rates of rebleeding and survival were compared. Results All TIPS were technically successful. Median portosystemic pressure gradient reductions were 13 versus 11 mmHg in the embolization and non-embolization groups. There were no statistically significant differences in Child-Pugh and MELD score, or portosystemic pressure gradients between each group. A trend toward increased rebleeding was present in the non-embolization group, where 8/37 (21.6%) patients rebled while 1/15 (6.7%) patients in the TIPS with embolization group rebled (P = 0.159) during median follow-up periods of 199 and 252 days (P = 0.374). Rebleeding approached statistical significance among patients with acute hemorrhage, where 8/32 (25%) versus 0/14 (0%) rebled in the non-embolization and embolization groups (P = 0.055). A trend toward increased bleeding-related mortality was seen in the nonembolization group (P = 0.120).Conclusions TIPS alone showed a high incidence of rebleeding in this series, whereas TIPS with variceal embolization resulted in reduced recurrent hemorrhage. The efficacy of embolization during TIPS performed for variceal hemorrhage versus TIPS alone should be further compared with larger prospective randomized trials.

show abstract

Section: Discussionmentioning

confidence: 99%

Rebleeding rates following TIPS for variceal hemorrhage in the Viatorr era: TIPS alone versus TIPS with variceal embolization

et al. 2010

View full text Add to dashboard Cite

show abstract

“…It is well recognized that the need for an emergency TIPS, that is, TIPS being performed for the control of acute variceal hemorrhage, is associated with a high mortality. 5,6 Some factors predictive of poor survival after elective TIPS, such as advanced liver disease 3,4,7,8 and hyperbilirubinemia, 9 have been recognized. However, there has been no model developed that can accurately predict survival after elective TIPS.…”

mentioning

confidence: 99%

A model to predict poor survival in patients undergoing transjugular intrahepatic portosystemic shunts

et al. 2000

View full text Add to dashboard Cite

“…1,23 The liver appears to respond to this by the migration of mesenchymal cells of smooth muscle phenotype and endothelial cells to line the lumenal wall of the stent. The mesenchymal cells synthesize and secrete collagen, thereby creating a pseudointimal lining of the stent and essentially forming a ''neovessel.''…”

Section: Discussionmentioning

confidence: 99%

“…It is important to note, however, that, eventually, virtually all patients develop stent stenosis. 1,25 Thus, the increased proliferation of SMC and increased collagen synthesis by these SMC accelerate the process of stenosis rather than induce the process of development of stenosis per se.…”

Section: Discussionmentioning

confidence: 99%

Development of pseudointima and stenosis after transjugular intrahepatic portasystemic shunts: Characterization of cell phenotype and function

et al. 1998

View full text Add to dashboard Cite

The clinical utility of transjugular intrahepatic portasystemic shunts (TIPS) is frequently complicated by the ingrowth of tissue into the stent lumen, causing stent stenosis. These studies were undertaken to define the cellular and matrix components of the pseudointima, define the phenotype and function of the mesenchymal cells in the pseudointima and maintain them in culture, and to study the differences between stenotic and nonstenosed stents. A total of 35 stents were evaluated. TIPS pseudointima were examined histologically, by immunohistochemistry and in situ hybridization to determine the cellular and connective tissue constituents. Mesenchymal cells were grown from tissue within the TIPS and around it, and their phenotype was studied and compared with control smooth muscle cells and fibroblasts. Transjugular intrahepatic portasystemic shunt (TIPS) involves creation of a low-resistance tract between the hepatic and portal veins that is kept patent by deployment of an expandable metal stent using radiologic techniques. The ability of TIPS to decompress the portal vein without surgery has led to its widespread use as a treatment for variceal hemorrhage and ascites. However, TIPS is limited by the frequent recurrence of portal hypertension in 70% to 90% 1 of subjects, with recurrent hemorrhage in about 20%. 2 This is primarily due to the development of narrowing of the stent lumen, which presents as either isolated narrowing at the hepatic venous end of the stent or as diffuse narrowing of the stent caused by the ingrowth of tissue (pseudointima) into the stent lumen.To date, only limited data exist on the biology of pseudointima formation and TIPS stenosis. It has been suggested that the mesenchymal cells in TIPS pseudointima are myofibroblasts 3-5 ; however, the phenotype of these cells has not been characterized. Such characterization would be an important first step in understanding the basic mechanism(s) by which pseudointima is formed and how TIPS stenosis develops. It has also been suggested that biliary-TIPS fistulae are important in the genesis of TIPS stenosis. 3,5 However, such fistulae are not always seen, 4 and the pathophysiological abnormalities causing TIPS stenosis have not been identified.The studies presented here were undertaken to: 1) define the time-course of development of TIPS pseudointima; 2) define the cellular and connective tissue components of the TIPS pseudointima in vivo; 3) isolate, characterize, and maintain in culture the mesenchymal cells from TIPS pseudointima; 4) to define the ability of these mesenchymal cells to synthesize and secrete collagen; and 5) to compare and contrast stenotic versus nonstenotic shunts with respect to their clinical and radiologic features, as well as their morphology, mesenchymal cell phenotype, and function. MATERIALS AND METHODS Sources of Tissue and Tissue HandlingTIPS were retrieved from livers either explanted at the time of orthotopic liver transplantation (n ϭ 30) or at the time of autopsy (n ϭ 5). Clinical information and radiographs fro...

show abstract

The natural history of portal hypertension after transjugular intrahepatic portosystemic shunts

Cited by 273 publications

References 2 publications

Rebleeding rates following TIPS for variceal hemorrhage in the Viatorr era: TIPS alone versus TIPS with variceal embolization

Rebleeding rates following TIPS for variceal hemorrhage in the Viatorr era: TIPS alone versus TIPS with variceal embolization

A model to predict poor survival in patients undergoing transjugular intrahepatic portosystemic shunts

Development of pseudointima and stenosis after transjugular intrahepatic portasystemic shunts: Characterization of cell phenotype and function

Contact Info

Product

Resources

About