Transjugular intrahepatic portosystemic shunt versus sclerotherapy in the elective treatment of variceal hemorrhage

Cabrera, Juan J.; Maynar, Manuel; Granados, Rafael; Gorriz, E.; Reyes, R; Pulido-Duque, J. M.; SanRoman, JL Rodriguez; Guerra, Cayetano; Kravetz, David

doi:10.1053/gast.1996.v110.pm8608893

Cited by 222 publications

(153 citation statements)

References 2 publications

Supporting

Mentioning

140

Contrasting

Unclassified

Order By: Relevance

“…10 However, the question of whether TIPS is better than other accepted treatments in the prevention of variceal rebleeding remains unanswered. The rate of rebleeding after TIPS, in preliminary studies, 5,6,11 seems to be lower than that achieved by sclerotherapy. 2 Thus, more controlled trials comparing these two treatments have been recommended.…”

mentioning

confidence: 76%

“…The proportion of patients who remained free of rebleeding one year after TIPS (79%) is very close to the figures observed in three previous studies. 5,6,11 Both the number of first rebleeding episodes and the number of total rebleeds were markedly lower after TIPS than after sclerotherapy. This is probably caused by the ability of TIPS to reduce the hepatic vein pressure gradient to values lower than 12 mm hg, a level considered a threshold for variceal rupture and bleeding.…”

Section: Discussionmentioning

confidence: 97%

See 1 more Smart Citation

Transjugular intrahepatic portosystemic shunt versus endoscopic sclerotherapy for the prevention of variceal bleeding in cirrhosis: A randomized multicenter trial

et al. 1998

View full text Add to dashboard Cite

Transjugular intrahepatic portosystemic shunt (TIPS), a new technique for the treatment of portal hypertension, has been successful in preliminary studies to treat acute variceal hemorrhage and to prevent variceal rebleeding. The purpose of this multicenter, randomized controlled trial is to compare the efficacy of TIPS with that of endoscopic sclerotherapy in the prevention of variceal rebleeding in cirrhosis. Eighty-one cirrhotic patients, with endoscopically proven variceal bleeding, were randomized to either TIPS (38 patients) or endoscopic sclerotherapy (43 patients). Randomization was stratified according to the following: if bleeding occurred F 1 week (stratum I); if bleeding occurred 1 to 6 weeks (stratum II); and if bleeding occurred 6 weeks to 6 months (stratum III) before enrollment. Follow-up included clinical, biochemical, Doppler Ultrasound, and endoscopic examinations every 6 months. During a mean follow-up of 17.7 months, 51% of the patients treated with sclerotherapy and 24% of those treated with TIPS rebled (P ‫؍‬ .011). Mortality was 19% in sclerotherapy patients and 24% in TIPS patients (P ‫؍‬ .50). Hepatic encephalopathy (HE) developed in 26% and 55%, respectively (P ‫؍‬ .006). A separate analysis of the three strata showed that TIPS was significantly more effective than sclerotherapy (P ‫؍‬ .026) in preventing rebleeding only in stratum I patients. TIPS is significantly better than sclerotherapy in preventing rebleeding only when it is performed shortly after a variceal bleed; however, TIPS does not improve survival and is associated with a significantly higher incidence of HE. The overall performance of TIPS does not seem to justify the adoption of this technique as a first-choice treatment to prevent rebleeding from esophageal varices in cirrhotic patients. (HEPATOLOGY 1998; 27:40-45.)Cirrhotic patients who survive an episode of bleeding from esophageal varices have an extremely high risk of rebleeding. 1 For this reason, several treatment modalities aimed at preventing variceal rebleeding have been tested by means of randomized controlled trials. 2 So far, pharmacological therapy with betablockers and endoscopic injection sclerotherapy are the most widely used treatments. 3 Nevertheless, both treatments are not fully satisfactory, as the average rebleeding rate with each therapy is about 48%. 2 Recently, a new angiographic technique, i.e., the transjugular intrahepatic portosystemic shunt (TIPS) has been proposed to treat portal hypertension. 4 This procedure creates a communication between the hepatic and the portal vein within the liver, thus decompressing portal hypertension. 5 Patency of the shunt is maintained by an expandable metal stent. Currently, TIPS has been successfully used in the following: in acute variceal hemorrhage uncontrolled by medical and endoscopic treatment 6,7 ; in preventing rebleeding in patients in whom sclerotherapy failed 5 ; in refractory ascites 8 ; in the Budd-Chiari Syndrome 9 ; and in patients who bleed while awaiting liver transplantation. 10 However, ...

show abstract

mentioning

confidence: 76%

Section: Discussionmentioning

confidence: 97%

Transjugular intrahepatic portosystemic shunt versus endoscopic sclerotherapy for the prevention of variceal bleeding in cirrhosis: A randomized multicenter trial

et al. 1998

View full text Add to dashboard Cite

show abstract

“…It has been shown that TIPS is useful in the management of acute variceal hemorrhage that cannot be succesfully controlled with medical therapy and in the prevention of recurrent variceal hemorrhage. [10][11][12][13][14] A number of studies have also shown that the reduction in portal pressure induced by TIPS is associated with beneficial effects on renal function and neurohumoral factors in patients with cirrhosis and ascites, including an increase in sodium and water excretion and a reduction in the activity of vasoconstrictor and antinatriuretic systems. [15][16][17][18][19][20][21][22] By contrast, the effects of TIPS in patients with HRS are not well characterized.…”

mentioning

confidence: 99%

Transjugular intrahepatic portosystemic shunt in hepatorenal syndrome: Effects on renal function and vasoactive systems

Guevara¹,

Ginès²,

Bandi³

et al. 1998

Hepatology

387

202

View full text Add to dashboard Cite

Little information exists on the effects of transjugular intrahepatic portosystemic shunts (TIPS) in the management of cirrhotic patients with hepatorenal syndrome (HRS). The current study was aimed to prospectively evaluate the effects of TIPS on renal function and vasoactive systems in patients with type I HRS. Glomerular filtration rate (GFR) (inulin clearance), renal plasma flow (RPF) (para-aminohippurate clearance), plasma renin activity (PRA), aldosterone (ALDO), norepinephrine (NE), and endothelin (ET) were determined in baseline conditions and at different time intervals after TIPS in 7 patients with type I HRS. TIPS induced a marked reduction of portal pressure gradient (PPG) (20 ؎ 1 to 10 ؎ 1 mm Hg; P F .05). Renal function improved in 6 of the 7 patients. Serum creatinine and blood urea nitrogen (BUN) decreased from 5 ؎ 0.8 and 109 ؎ 7 to 1.8 ؎ 0.4 mg/dL and 56 ؎ 11 mg/dL, respectively (P F .05 for both), and GFR and RPF increased from 9 ؎ 4 and 103 ؎ 33 to 27 ؎ 7 mL/min and 233 ؎ 40 mL/min, respectively (P F .05 for both), 30 days after TIPS. These beneficial effects on renal function were associated with a significant (P F .05) reduction of PRA (18 ؎ 5 to 3 ؎ 1 ng/mL · h), ALDO (279 ؎ 58 to 99 ؎ 56 ng/dL), and NE (1,257 ؎ 187 to 612 ؎ 197 pg/mL). ET did not change significantly (28 ؎ 8 to 27 ؎ 11 pg/mL). Mean survival was 4.7 ؎ 2 months (0.3-17 months). Three patients remained alive more than 3 months after TIPS insertion. In conclusion, TIPS improves renal function and reduces the activity of the renin-angiotensin and sympathetic nervous systems in cirrhotic patients with type I HRS. Nevertheless, the efficacy of TIPS in the management of these patients should be confirmed in controlled investigations. (HEPATOLOGY 1998;28:416-422.)Hepatorenal syndrome (HRS) is a common and severe complication of patients with advanced cirrhosis and is characterized by renal failure, marked portal hypertension, abnormalities in the arterial circulation, and overactivity of endogenous vasoactive systems. [1][2][3][4][5] Up to now, the only treatment that has been shown to improve survival in patients with HRS is liver transplantation. 3-7 However, because of the short survival of patients with HRS and the limited availability of organs, only a small percentage of patients with HRS can actually reach transplantation. Therefore, it would be of great value to have a therapeutic method that could improve renal function and increase survival, especially in patients with type I HRS, which is characterized by a rapid progression of renal failure and a very short survival expectancy. 3 The transjugular intrahepatic portosystemic shunt (TIPS) has been introduced recently in clinical practice for the management of cirrhotic patients with variceal bleeding. 8,9 As with surgical portosystemic shunts, the use of TIPS is associated with a marked reduction in portal pressure but with the advantage of a very low operative morbidity and mortality. It has been shown that TIPS is useful in the management of acute variceal hemorrhage th...

show abstract

“…5,8,9 Twelve percent to 28% of patients undergoing follow-up endoscopy have recurrent variceal bleeding and receive TIPS. [10][11][12][13][14][15][16] TIPS reduces the portosystemic gradient by placing a stent joining the hepatic and portal veins. By reducing portal hypertension, TIPS decompresses varices and prevents recurrent bleeding.…”

mentioning

confidence: 99%

“…11,13-16 Although TIPS leads to lower recurrent bleeding rates, it may lead to hepatic encephalopathy. [10][11][12][13][14][15] …”

mentioning

confidence: 99%

Cost-effectiveness analysis of transjugular intrahepatic portosystemic shunt (TIPS) versus endoscopic therapy for the prevention of recurrent esophageal variceal bleeding

et al. 2000

View full text Add to dashboard Cite

For the prevention of recurrent esophageal variceal bleeding, studies show that patients treated with transjugular intrahepatic portosystemic shunt (TIPS) have lower rebleeding rates compared with endoscopic therapy. However, TIPS is associated with higher rates of portosystemic encephalopathy and possibly higher costs. The aim of this study was to conduct a cost-effectiveness analysis comparing TIPS with endoscopic sclerotherapy and endoscopic ligation for the prevention of recurrent esophageal variceal bleeding. Data for rates of rebleeding, death, complications, and crossover from endoscopy to TIPS were obtained from the literature. Variceal bleeding is a major cause of morbidity and mortality in patients with cirrhosis. Variceal bleeding occurs in 33% of patients with cirrhosis and carries a mortality of 30% to 50%. [1][2][3] Up to 70% of patients have recurrent bleeding within the first year of the first bleeding episode. 1,3 Strategies have been developed for the prevention of recurrent esophageal bleeding in the high-risk group of patients who have had a first bleed.Treatment for acute variceal bleeding includes endoscopic therapy and the transjugular intrahepatic portosystemic shunt (TIPS). Endoscopic sclerotherapy can stop bleeding in 75% to 85% of cases, but recurrent bleeding occurs in 30% to 50% of patients within the first year. 4-9 Studies comparing endoscopic sclerotherapy to endoscopic ligation (banding) show higher rates for controlling bleeding with ligation and lower, but still substantial, recurrent bleeding rates of 26% to 36%. 5,8,9 Twelve percent to 28% of patients undergoing follow-up endoscopy have recurrent variceal bleeding and receive TIPS. [10][11][12][13][14][15][16] TIPS reduces the portosystemic gradient by placing a stent joining the hepatic and portal veins. By reducing portal hypertension, TIPS decompresses varices and prevents recurrent bleeding. Randomized controlled trials comparing TIPS with endoscopic sclerotherapy for recurrent variceal bleeding show that recurrent bleeding rates are 15% to 20% at 1 year, which is 28% to 38% lower than sclerotherapy. 11,13-16 Although TIPS leads to lower recurrent bleeding rates, it may lead to hepatic encephalopathy. [10][11][12][13][14][15]

show abstract

Transjugular intrahepatic portosystemic shunt versus sclerotherapy in the elective treatment of variceal hemorrhage

Cited by 222 publications

References 2 publications

Transjugular intrahepatic portosystemic shunt versus endoscopic sclerotherapy for the prevention of variceal bleeding in cirrhosis: A randomized multicenter trial

Transjugular intrahepatic portosystemic shunt versus endoscopic sclerotherapy for the prevention of variceal bleeding in cirrhosis: A randomized multicenter trial

Transjugular intrahepatic portosystemic shunt in hepatorenal syndrome: Effects on renal function and vasoactive systems

Cost-effectiveness analysis of transjugular intrahepatic portosystemic shunt (TIPS) versus endoscopic therapy for the prevention of recurrent esophageal variceal bleeding

Contact Info

Product

Resources

About