Two-year outcome following transjugular intrahepatic portosystemic shunt for variceal bleeding: Results in 90 patients

LaBerge, Jeanne M.; Somberg, Kenneth A.; Lake, John R.; Gordon, Roy L.; Kerlan, Robert K.; Ascher, Nancy L.; Roberts, John P.; Simor, Margaret M.; Doherty, Catherine; Hahn, Judith; BachettiI, Peter; Ring, Ernest J.

doi:10.1016/0016-5085(95)90213-9

Cited by 301 publications

(135 citation statements)

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“…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.…”

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confidence: 77%

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

et al. 1998

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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, ...

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confidence: 77%

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

et al. 1998

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“…[1][2][3][4] The influence of TIPS on renal function, however, has been investigated only in patients with refractory or recurrent ascites. [6][7][8][9][10][11][12][13] Compared with a practical clinical setting, most of these studies lack important information: they investigated renal function the day after TIPS, when it might be influenced by the procedure itself (e.g., contrast medium, analgesics, or anesthesia) and at 1 month, when it might be influenced by other factors (e.g., influence of TIPS on the nutritional status).…”

Section: Discussionmentioning

confidence: 99%

“…[1][2][3][4] A considerable portion of these patients who had ascites at the time of TIPS insertion reduced the degree of ascites following TIPS. Therefore, patients with refractory or recurrent ascites were treated with TIPS, most of them with remarkable success.…”

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confidence: 99%

Renal effects of transjugular intrahepatic portosystemic shunt in cirrhosis: Comparison of patients with ascites, with refractory ascites, or without ascites

et al. 1998

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Renal effects of the transjugular intrahepatic portosystemic shunt (TIPS) were compared in 6 patients without ascites (group 1), 11 patients with ascites responding to diuretic treatment (group 2), and 6 patients with refractory ascites (group 3). Seven days after insertion of TIPS, 24-hour urinary sodium excretion had increased in patients with ascites: 113 ؎ 16 mmol to 170 ؎ 30 mmol (P ‫؍‬ .012) in group 2, and 22 ؎ 8 mmol to 77 ؎ 27 mmol (P ‫؍‬ .050) in group 3. In group 3, fractional sodium excretion tended to increase from 0.26% ؎ 0.14% to 0.62% ؎ 18% (P ‫؍‬ .081). The relative increase of urinary sodium excretion (to 444% ؎ 122%) and fractional sodium excretion (to 413% ؎ 127%) in group 3 was significantly (P F .05) higher than in group 1 and group 2, respectively. Creatinine clearance and 24-hour urinary volume were not significantly changed in either group. Patients with Child-Pugh class C had a more pronounced effect of TIPS on urinary sodium excretion (increase to 396% ؎ 115% vs. 139% ؎ 15%; P ‫؍‬ .066) and on fractional sodium excretion (increase to 415% ؎ 103% vs. 94% ؎ 15%; P ‫؍‬ .020) than patients with less-severe liver disease. Fractional sodium excretion of less than 0.35% before TIPS was found to be an indicator of renal response to TIPS. The effect of TIPS on urinary sodium excretion and on fractional sodium excretion was related to the patients' Child-Pugh score (r ‫؍‬ .55; P ‫؍‬ .007 and r ‫؍‬ .68; P ‫؍‬ .001, respectively) and inversely to their fractional sodium excretion (r ‫؍‬ Ϫ.44; P ‫؍‬ .047 and r ‫؍‬ Ϫ.54; P ‫؍‬ .012, respectively) before TIPS. These data demonstrate that TIPS affects renal sodium handling in patients with ascites, particularly in patients with refractory ascites. Severity of liver disease and fractional sodium excretion before TIPS are parameters to predict the extent of the renal response. (HEPATOLOGY 1998;28:683-688.)The transjugular intrahepatic portosystemic shunt (TIPS), a nonsurgical side-to-side shunt, has been introduced to prevent variceal rebleeding or to control refractory variceal bleeding by reducing the portal pressure gradient. 1-4 A considerable portion of these patients who had ascites at the time of TIPS insertion reduced the degree of ascites following TIPS. Therefore, patients with refractory or recurrent ascites were treated with TIPS, most of them with remarkable success. [5][6][7][8][9] These observations prompted studies on the effects of TIPS on sodium handling in patients with refractory ascites. Little is known, however, about the effects of TIPS on renal function in patients without ascites or with ascites not refractory to diuretic treatment. Moreover, predictors of renal response to TIPS have not yet been identified. Furthermore, information about the early influence of TIPS on renal function is limited. [6][7][8][9][10][11][12][13] Most of the previous studies were performed without diuretics or with the dose of diuretics decreasing throughout the observation period. While withholding diuretic treatment from those patients does not repr...

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“…The efficacy of TIPS in treating bleeding complications of portal hypertension has been shown in several large studies [4,5]. Early TIPS were performed using bare metal stents, which were associated with high rates of shunt stenosis and dysfunction [6,7].…”

Section: Introductionmentioning

confidence: 99%

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

et al. 2010

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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.

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Two-year outcome following transjugular intrahepatic portosystemic shunt for variceal bleeding: Results in 90 patients

Cited by 301 publications

References 12 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

Renal effects of transjugular intrahepatic portosystemic shunt in cirrhosis: Comparison of patients with ascites, with refractory ascites, or without ascites

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

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