Pulmonary hypertension after transjugular intrahepatic portosystemic shunt: effects on right ventricular function

The short- and mid-term hemodynamic effects of transjugular intrahepatic portosystemic shunt (TIPS) were studied in 16 sedated cirrhotic patients. Indications included relapsing variceal bleeding (n = 10) and refractory ascites (n = 6). The decrease of porto-atrial pressure gradient (from 20.4 +/- 4.2 mm Hg to 10.1 +/- 2.4 mmHg; P < .05) was associated with an increase of mean pulmonary artery pressure (MPAP) (from 12.3 +/- 3.0 mm Hg to 20.3 +/- 5.3 mm Hg; P < .05) and of right atrial pressure (RAP) from 3.4 +/- 2.6 mm Hg to 8.3 +/- 3.7 mm Hg; P < .05), whereas right ventricular end-diastolic volume (RVEDVI) remained unchanged. The significant increase of cardiac index (CI) (from 4.5 +/- 1.2 L/min/m2 to 5.0 +/- 1.1 L/min/m2; P < .05) was essentially attributable to an increase of heart rate (HR) (from 81 +/- 11 to 88 +/- 10 beats/min; P < .05). Systemic vascular resistance (SVR) decreased (from 812 +/- 281 to 666 +/- 191 dynes/sec/cm5; P < .05), whereas pulmonary vascular resistance (PVR) increased (from 60.6 +/- 29.6 to 82.0 +/- 34.6 dynes/sec/cm5; P < .05). After transient shunt occlusion with a balloon catheter, all of the hemodynamic parameters returned to baseline values, except pulmonary artery pressure, which also decreased but remained significantly increased. One month after TIPS, pulmonary pressure remained elevated, and CI further increased. It is concluded that increased PVR is the major hemodynamic alteration occurring after TIPS placement. It correlates with the decrease of porto-atrial gradient and is probably mediated by both mechanical and neurohumoral factors.     

The management of the cirrhotic patient after transjugular intrahepatic portosystemic shunt

Transjugular intrahepatic portosystemic shunts (TIPS) achieve portal decompression in a manner analogous to side-to-side surgical portacaval shunts but avoid the risks of general anesthesia and major surgery. These considerations have popularized this procedure for the treatment of refractory variceal hemorrhage. However, its increasing use has also led to the recognition of both expected as well as unexpected complications associated with TIPS. Also, the natural history of cirrhosis and portal hypertension after TIPS has now been well described. Such data allow optimizing management strategies for individual patients after TIPS placement. The use of TIPS for active variceal bleeding and the clinical factors influencing subsequent management are discussed in this article.     

Clinical results and hemodynamic changes of portal venous system in transjugular intrahepatic portosystemic stent shunt

We describe on a case of a patient with Mayer-v. Rokitansky-Küster-syndrome the formation of a vagina by a laparoscopic modification of the Vecchietti-procedure. A further simplification of this procedure is the use of a laparoscopic needle-holder to tense the strings above the abdominal wall. We even abandoned the use of a prothesis after finishing the tension phase. Instead, we allowed early intercourse on the third day of extraction of the vaginal phantom.     

Efficacy of Doppler ultrasonography for assessment of transjugular intrahepatic portosystemic shunt patency

PURPOSE: To assess the efficacy of Doppler ultrasonography (US) as a noninvasive method for monitoring patency of the transjugular intrahepatic portosystemic shunt (TIPS). METHODS: Twenty-nine patients who had received TIPS for bleeding esophagogastric varices and/or refractory ascites with portal hypertension underwent Doppler US studies within 2 weeks after TIPS. Further studies were performed in 15 of them at 6 months, in 9 at 1 year, and in 4 at 2 years for a total of 57 US studies. The US findings were compared with the angiographic findings obtained at the same time. RESULTS: In 45 of the 57 studies, shunt patency was found by Doppler US, correlating to 44 patencies and one occlusion on angiography. Doppler signal in the shunt could not be detected in 12 studies resulting in the diagnosis of shunt occlusion. This correlated with angiographic occlusion in 8 studies and patency in the remaining 4. All angiographically patent shunts that were occluded by Doppler US had various degrees of stenosis. A number of technical factors were found to be responsible for Doppler US false-positive or false-negative diagnoses, some related to the type of stent used. The Doppler US sensitivity was therefore 92%, the specificity 89%. CONCLUSION: Doppler US is a reliable noninvasive method to evaluate patency of TIPS.     

Outcome of 100 patients after transjugular intrahepatic portosystemic shunt for variceal hemorrhage

OBJECTIVES: One hundred consecutive patients with recurrent or refractory acute variceal hemorrhage treated with a transjugular intrahepatic portosystemic shunt (TIPS) from June 1990 to June 1993 at Oregon Health Sciences University or the Portland Veterans Affairs Medical Center were evaluated to assess shunt patency and clinical outcome, including complications of TIPS, rebleeding, and survival. METHODS: Success of shunt placement, reduction in portal pressure, complications, survival, recurrent hemorrhage, severity of ascites, hepatic encephalopathy before and after TIPS, and shunt patency were assessed in each patient. RESULTS: The mean follow-up period was 17.7 months (range, 0.1-56.7 months). TIPS was successfully completed in all patients, with a mean reduction in portosystemic gradient from 24 to 11 mm Hg. Major complications occurred in 11 patients, including one death. Survival after TIPS was 85% at 30 days, 71% at 1 yr, and 56% at 2 yr. Variceal bleeding stopped within 24 hours after TIPS in all eight patients with active hemorrhage. Recurrent variceal hemorrhage occurred in 18 patients at a mean of 4.3 months (range, 1-713 days) after TIPS. The cumulative rate of recurrent variceal bleeding was 20% at 1 yr and 25% at 2 yr after TIPS. Recurrent variceal bleeding was associated with shunt stenosis or occlusion in all patients with endoscopically documented variceal hemorrhage, which was successfully managed by reopening obstructed shunts and performing variceal embolization. The prevalence of ascites was significantly reduced among surviving patients evaluated 3 months after TIPS (67 vs 25%, p < 0.005). Three months after TIPS, the incidence of new or worsening hepatic encephalopathy was 20%, but encephalopathy improved in an equal proportion of patients. Seventy-three of 77 (95%) shunts examined for patency were open at the last follow-up examination. However, most shunts required intervention to maintain patency, and only 48% (37 of 77) were primarily patent at a mean of 168 days (range, 2-538 days) of follow-up. Shunt stenosis or occlusion, as determined by venography, became increasingly frequent with longer follow-up (52% at 3-9 months and 70% at 9-15 months). CONCLUSIONS: TIPS is effective in lowering elevated portal pressures in patients with refractory variceal hemorrhage, has acceptable postprocedure complication and mortality rates, ameliorates ascites, and in, a minority of patients, worsens encephalopathy. Shunt stenosis occurs in the majority of patients but can be effectively treated by interventional techniques to maintain patency. The incidence of recurrent variceal hemorrhage is low and is associated with shunt stenosis or occlusion.     

Clinical events after transjugular intrahepatic portosystemic shunt: correlation with hemodynamic findings

BACKGROUND & AIMS: Transjugular intrahepatic portosystemic shunt (TIPS) procedures are increasingly being used, but the relationship between the hemodynamic effects of TIPS and the clinical events on follow-up remains undefined. Hence, we have investigated the hemodynamic correlations of portal hypertension-related events after a TIPS procedure. METHODS: Prospective follow-up of 122 cirrhotic patients who had a TIPS procedure performed because of variceal hemorrhage was conducted. RESULTS: The portacaval pressure gradient (PPG) significantly decreased after the TIPS procedure (from 19.7 +/- 4.6 to 8.6 +/- 2.7 mm Hg; P > 0.001), but increased thereafter and at rebleeding (n = 25) was > 12 mm Hg in all patients (18.4 +/- 4.6 mm Hg). Twenty-six patients developed ascites; the PPG (measured in 19) was always > 12 mm Hg. Increasing the PPG to > 12 mm Hg occurred very frequently (83% at 1 year). Within 1 year, 77% of patients underwent balloon angioplasty or restenting. However, 80% had again a PPG of > 12 mm Hg 1 year after reintervention. Hepatic encephalopathy developed in 31% of patients at 1 year; 21 of 23 patients had a PPG of < 12 mm Hg. CONCLUSIONS: Total protection from the risk of recurrent complications of portal hypertension after a TIPS procedure requires that the PPG be decreased and maintained < 12 mm Hg. However, reintervention will be required in most patients within 1 year and again the second year. On the other hand, such portal decompression is associated with an increased risk of hepatic encephalopathy.     

Effects of transjugular intrahepatic portosystemic shunt (TIPS) on quantitative liver function tests

BACKGROUND/AIMS: The transjugular intrahepatic portosystemic stent-shunt (TIPS) has been established as a new effective treatment for portal hypertension in advanced liver disease. Impairment of liver function due to reduced portal venous perfusion is considered to be a major risk of TIPS, and the shunt leads to an increase in the incidence of hepatic encephalopathy (HE). Known complications, like the increase in the incidence of HE or TIPS stenosis, are diagnosed either clinically or by doppler ultrasound. It is not practicable to use quantitative liver function tests in the diagnostic work-up of HE, and medical or interventional therapy can be established after clinical diagnosis. Still, information is limited about the influence of TIPS on quantitative liver function tests in patients with liver cirrhosis. Therefore, the aim of this prospective study was to assess the effects of TIPS on various liver function tests. METHODOLOGY: Fifteen patients with liver cirrhosis, a hepatopetal portal flow before TIPS, and an uncomplicated course without stenosis after elective TIPS were analysed. Liver function was quantitatively measured using the [14C]aminopyrine breath test (ABT), considered to be independent of hepatic blood flow, the monoethylglycinexylidide test (MEGX), believed to be largely dependent on hepatic blood flow, serum bilirubin, serum albumin, and prothrombin time. Measurements were performed before, 1, 3 and 6 months after TIPS. RESULTS: TIPS decreased the portal venous pressure gradient from 31.0+/-2.0 cm (SEM) H2O to 16.9+/-1.8 cm H2O (p<0.01). One, 3 and 6 months after TIPS there was no significant deterioration of liver function as assessed by ABT, MEGX or serum bilirubin, serum albumin, and prothrombin time compared to baseline values before TIPS. ABT and MEGX were significantly correlated before TIPS (r=0.72; p<0.01) and after TIPS (r=0.76; p<0.05). CONCLUSIONS: These data show no significant deterioration of microsomal liver function as measured by the quantitative liver function tests ABT and MEGX over a period of 6 months after elective TIPS. In particular, there was no significant reduction of the MEGX-test considered to depend predominantly on hepatic blood flow. Thus, there is no need for the quantitative liver function tests ABT and MEGX in the routine management of patients following the TIPS procedure.     

Rectal variceal bleeding treated by transjugular intrahepatic portosystemic shunt. Potentials and pitfalls

Bleeding from anorectal varices can be massive and life threatening. Prompt differentiation between hemorrhoids and anorectal varices is crucial in treating these patients. Many different treatments are available for bleeding anorectal varices, but none has proved efficacy. We report a case of successful transjugular intrahepatic portosystemic shunt (TIPS) in controlling massive rectal variceal bleeding in an elderly patient with primary biliary cirrhosis and portal hypertension. After TIPS, rapid decompensation of liver function and encephalopathy developed and led to her death. Although TIPS may be effective in controlling acute life-threatening bleeding from anorectal varices, it can be associated with life-threatening complications.     

Does transjugular intrahepatic portosystemic shunt (TIPS) resolve thrombocytopenia associated with cirrhosis?

Thrombocytopenia is frequently present in patients with cirrhosis. The effect of portal decompression on thrombocytopenia using a variety of shunt procedures has been contradictory. Transjugular intrahepatic portosystemic shunt (TIPS) has been proposed as a less invasive procedure for portal decompression, mainly for control of variceal bleeding or intractable ascites. Its effect on thrombocytopenia has not been defined yet. The aim of this review is to define the effect of TIPS on patients with cirrhosis and thrombocytopenia. Sixty-two patients who underwent TIPS at the University of Pittsburgh and survived without transplant for more than two months were included. Platelet count was determined prior to TIPS as well as at one-week, one-month, and three-month intervals after TIPS. The prevalence of thrombocytopenia prior to TIPS was 49%. TIPS had no effect on thrombocytopenia even when the portosystemic gradient was reduced to less than 12 mm Hg. In conclusion, portal decompression after TIPS did not affect the degree of thrombocytopenia.     

Shunt patency after creation of a transjugular intrahepatic portosystemic shunt: evaluation with Doppler ultrasound

The presence of lactic acidosis in the cerebral spinal fluid of 50 patients with severe head injury was studied. The GCS scores of these patients were < or = 8. The patients were divided into two groups. We treated 25 patients with a dose of 4 to 5 ml/kg of THAM infused intravenously 2 to 3 times for daily administration. Other 25 patients who were not treated with THAM served as a control group. In each case, a ventricular pressure monitoring device was installed. The ICP was the contineously recorded. In addition, laboratory study, including lactate, pH, HCO-3 and BE in CSF was performed. THAM infusion was associated with improved survival, decreased ICP as compared to that in the control group. We believe that THAM treatment may significantly improve the prognosis of presence of lactic acidosis as a result of severe head injury.     

Differential effects on portal and effective hepatic blood flow. A comparison between transjugular intrahepatic portasystemic shunt and small-diameter H-graft portacaval shunt

OBJECTIVE: This study was undertaken to determine the effects of transjugular intrahepatic portasystemic shunt (TIPS) and small-diameter prosthetic H-graft portacaval shunt (HGPCS) on portal and effective hepatic blood flow. SUMMARY BACKGROUND DATA: Mortality after TIPS is higher than after HGPCS for bleeding varices. This higher mortality is because of hepatic failure, possibly a result of excessive diminution of hepatic blood flow. METHODS: Forty patients randomized prospectively to undergo TIPS or HGPCS had effective hepatic blood flow determined 1 day preshunt and 5 days postshunt using low-dose galactose clearance. Portal blood flow was determined using color-flow Doppler ultrasound. RESULTS: Treatment groups were similar in age, gender, and Child's class. Each procedure significantly reduced portal pressures and portasystemic pressure gradients. Portal flow after TIPS increased (21 mL/second +/- 11.9 to 31 mL/second +/- 16.9, p < 0.05), whereas it remained unchanged after HGPCS (26 mL/second +/- 27.7 to 14 mL/second +/- 41.1, p = n.s.). Effective hepatic blood flow was diminished significantly after TIPS (1684 mL/minute +/- 2161 to 676 mL/minute +/- 451, p < 0.05) and was unaffected by HGPCS (1901 mL/ minute +/- 1818 to 1662 mL/minute +/- 1035, p = n.s.). CONCLUSIONS: Both TIPS and HGPCS achieved significant reductions in portal vein pressure gradients. Portal flow increased after TIPS, although most portal flow was diverted through the shunt. Effective hepatic flow is reduced significantly after TIPS but well preserved after HGPCS. Hepatic decompensation and mortality after TIPS may be because, at least in part, of reductions in nutrient hepatic flow.     

Paradoxical cerebral emboli after transjugular intrahepatic portosystemic shunt and coil embolization for treatment of duodenal varices

The use of the transjugular intrahepatic portosystemic shunt to treat portal hypertension has resulted in increased recognition of its associated complications. We report a patient with refractory duodenal variceal bleeding treated with transjugular intrahepatic portosystemic shunt, as well as coil embolization, who subsequently developed bilateral cerebral and cerebellar infarcts consistent with arterial emboli. This complication has not been previously described. The patient was found to have a patent foramen ovale and a right to left intracardiac shunt leading to paradoxical embolization of clots traveling from portal to systemic venous circulation, then to the left atrium. With the relative frequency of patent foramen ovale in the population, our observation has potential importance for patients with right to left cardiac shunts who are being considered for portosystemic shunt procedures, or who are undergoing embolization of bleeding varices.     

Intractable gastrointestinal bleeding caused by pancreatic arteriovenous malformation: successful treatment with transjugular intrahepatic portosystemic shunt

A case of childhood cutaneous mucinosis is described. This is a clinical condition that is rarely seen and has only recently been included in the group of primary mucinosis.