Transjugular intrahepatic portosystemic shunt in patients with end-stage liver disease: Results in 85 patients

Abstract

Transjugular intrahepatic portosystemic shunt (TIPS) is becoming an accepted procedure as a bridge to orthotopic liver transplantation (OLT) in patients with end-stage liver disease (ESLD) and bleeding from portal hypertension. It allows the immediate control of acute bleeding and decreases the risk of recurrent acute bleeding while the patient is awaiting OLT. We review in this report, our experience with 85 patients who underwent a TIPS procedure for gastrointestinal variceal bleeding from September 1991 until April 1994. All patients had liver cirrhosis and all had previous sclerotherapy before TIPS. Child-Pugh score was calculated at enrollment, and all patients were evaluated for possible OLT. Thirteen patients were Child A, 49 were Child B, and 23 were Child C. Fifty-three patients were candidates for OLT, and 32 were not. TIPS was performed urgently in 25 patients. At a median follow-up of pper gastrointestinal tract bleeding is a major U cause of death in patients with end-stage liver disease (ESLD) second only to progressive liver failure. 1,2 Surgical shunts and/or sclerotherapy are able to control the bleeding but have no effect on the underlying liver d i~e a s e .~.~ With improved management of patients undergoing orthotopic liver transplantation (OLT), this form of treatment has clearly become the most effective therapy for patients with ESLD.5,h However, this form of treatment is limited to patients who are able to withstand such major surgery. The waiting time for OLT candidate patients has been increasing because of the limited donor pool and the continuous expansion of indications for OLT. Recently, transjugular intrahepatic portosystemic shunt (TIPS) has been considered in patients with ESLD mainly for acute variceal bleeding that cannot be successfully controlled with medical treatment and recurrent variceal bleeding in patients who are refractory or intolerant to conventional medical management.'-I4 TIPS may serve as a bridge to OLT without the negative technical effect observed with central surgical shunts during the transplantation 582 days (range, 1 to 1,095), 35 patients underwent transplantation, 21 patients died, and 29 patients are still alive and did not undergo transplantation. Technical complications were observed in 7% of patients and new onset of clinical encephalopathy in 37%. The 30-day mortality rate after TIPS was 13%. Actuarial survival was 60% at 1 and 3 years. Child class C and urgent TIPS were shown to be two independent predictor factors for mortality. TIPS was shown to be a valuable procedure, not only as a bridge to OLT but also as palliation for bleeding from portal hypertension in patients who were not candidates for either surgical shunt or OLT. However, its role in bleeding patients with acceptable liver function needs further investigation. Copyright 0 1996 by the American Association for the Study of Liver Diseases procedure and the possible morbidity and mortality associated with shunt procedure itself.We report our experience in patients who underwent TIPS reg...

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

“…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.…”

Mortality and complications in patients with portal hypertension who underwent transjugular intrahepatic portosystemic shunt (TIPS) - 12 years experience

“…Variceal rebleeding was observed in 23 (31.9%) cases matching the reports of Zhuang et al (30) (32.26%) and Rosado and Kamath (23) (32%). TIPS dysfunction/stenosis was observed in 19 (26.4%) of cases, lower indices than those found in most of the studies as Jabbour et al (14) (52%), Zhuang et al (30) (43.16%), Russo et al (24) (49%), Yoon et al (28) (45%) and Sanyal et al (25) (75%). Acute infections were found in 15 (20.8%), acute kidney insufficiency in 11 (15.2%) and cardiologic complications with arrhythmia in 2 (2.9%) of cases, however these complications are not reported in indices in literature (4) .…”

“…Zhuang et al (30) studies report early mortality of 23 (22.3%) from 103 patients. In a 2 ½ year follow-up, Jabbour et al (14) report global mortality in 21 (24.7%) from the 85 patients studied in the sample, being that 25 of these underwent urgency TIPS with mortality of 13 (52%) patients. Russo et al (24) in a 3-year follow up show a global mortality of 30 (33%) and early mortality of 18 (20.4%) from 88 patients evaluated, and in a sample of 129 patients followed during a 2 ½ year period; Chalasani et al (5) point global mortality of 54 (41.9%) and early mortality of 30 (23.2%).…”

“…Stent dysfunction is the most common cause of rebleeding which is reported in 26% within 1 year after procedure and in 32% in 2 years. Jabbour et al (14) , analyzing 85 patients who underwent TIPS, report that 35 (47.3%) developed encephalopathy, and 17 (20%) cases of rebleeding, finding stent dysfunction in 7 (41%) of these patients. During average follow-up of 6 months, 45 (52%) patients presented stent dysfunction.…”

Liver transplantation complicated by embedded transjugular intrahepatic portosystemic shunt: A new method for portal anastomosis?a surgical salvage procedure

“…1 Although most series have reported that TIPSs are a safe bridge to transplantation in selected patients, [2][3][4] there have been recent warnings to transplant surgeons regarding the specific complications of stent migration and malposition. 5,6 A TIPS may necessitate modification of the surgical procedure, but this is generally a surmountable problem.…”