Transjugular Intrahepatic Portosystemic Shunt: Short–Term and Long–Term Effects on Hepatic and Systemic Hemodynamics in Patients With Cirrhosis

Abstract

The aim of this prospective, nonrandomized study was to assess the short-and long-term effects of transjugular intrahepatic portosystemic shunt (TIPS) on hepatic and systemic hemodynamics and on gastroesophageal collateral flow in patients with cirrhosis and failure of chronic sclerotherapy. Cardiac output (CO), free and wedged pulmonary artery pressure (FPAP and WPAP), systemic vascular resistance (SVR), azygos venous blood flow (AzVBF), and the relative (portal minus vena cava) pressure in the portal vein (rel.PP) were determined immediately before, 30 minutes, 1 week, 3 months, and 1 year after TIPS implantation in 21 patients with alcoholic and biliary cirrhosis with repeated bleeding from esophageal varices despite chronic sclerotherapy. TIPS was inserted when patients were in a stable hemodynamic condition. Palmaz stents were dilated to a 10-mm to 14-mm diameter until gastroesophageal collaterals were no longer visible on direct splenoportography. Relative portal pressure decreased from 21 ؎ 5 mm Hg to 11 ؎ 5 mm Hg 30 minutes after the procedure (P F .001). CO increased from 7.1 ؎ 1.5 L/min at baseline to 8.9 ؎ 2.0 L/min (P F .005) at 30 minutes, 8.2 ؎ 2.0 L/min (P F .01) at 1 week, and 8.0 ؎ 2.0 L/min (P F .01) at 3 months after TIPS, and returned to 7.2 ؎ 1.3 L/min (ns) after 1 year. Before TIPS, SVR was 990 ؎ 285 dyne · sec · cm ؊5 and decreased to 856 ؎ 252 dyne · sec · cm ؊5 (P F .05) and 866 ؎ 267 dyne · sec · cm ؊5 (P F .05) at 30 minutes and 1 week after the procedure, and increased again to 903 ؎ 208 dyne · sec · cm ؊5 (ns) and 1,016 ؎ 260 dyne · sec · cm ؊5 (ns) at 3 months and 1 year, respectively. AzVBF continuously decreased from 474 ؎ 138 mL/min before TIPS to 335 ؎ 116 mL/min, 289 ؎ 147 mL/min, 318 ؎ 157 mL/min, and 250 ؎ 104 mL/min (all P F .005) at 30 minutes, 1 week, 3 months, and 1 year after TIPS. Portal decompression after TIPS is associated with a significant increase of CO for at least 3 months, which is only partly explained by a transient decrease of SVR. After 1 year, CO had returned to baseline levels. Despite an immediate decrease in portal pressure, the reduction of blood flow through gastroesophageal collaterals is delayed and not complete before 1 year after TIPS. In contrast to previous short-term observations, TIPS does not seem to cause long-term aggravation of the hyperkinetic circulation in patients with cirrhosis. (HEPATOLOGY 1999;29:632-639.)

A detailed evaluation of cardiac function in cirrhotic patients and its alteration with or without liver transplantation

“…Further, pulmonary arterial pressure is increased that may further contribute to enlargement of RV dimension. Upon liver transplantation, both the portosystemic shunt and pulmonary arterial pressure will be reduced that may partly explain the reduction in RV dimension [25]. Future prospective studies are nonetheless required to discern the underlying mechanism for RV dimension reduction following liver transplantation.…”

Can an incomplete stent expansion modulate the effects of TIPS?

“…Immediately after the procedure, in fact, the amount of blood reaching the heart increases rapidly, and a rise in the right atrium and the central venous pressure has already been described [2]. This value does not remain stable over time [3,4]; it is therefore possible that a reduction of 25% in the PPG value measured immediately after TIPS may not be the same a few days or weeks later. We therefore wonder whether the authors have some evidence that the PPG value reached immediately after TIPS opening had remained stable over time.…”

Simultaneous Combined Transjugular Intrahepatic Portosystemic Shunt and Partial Splenic Embolization for Decompensated Cirrhosis

“…Bernd Saugel et al [22] reported that the TIPS procedure led to a significant increase in serum bilirubin level, ALT and AST levels, and INR level as well. Earlier studies [23,24] reported that TIPS can result in a deterioration of the liver function in the form of elevation of bilirubin, ALT and AST, probably due to reduction of hepatic blood flow and sinusoidal blood flow resulting from diversion of portal blood through a TIPS, which is even more obvious in patients with advanced liver disease due to incomplete hepatic artery buffer response [25] . Compatible with these studies, our study showed that TBIL, PT, INR, and ALT and AST levels had significantly increased after TIPS in group A, but ALT and AST levels normalized by the 1st month posttreatment.…”