Management of refractory ascites.

The development of refractory ascites in approximately 10% of patients with decompensated cirrhosis heralds the progression to a more advanced stage of cirrhosis. Its pathogenesis is related to significant hemodynamic changes, initiated by portal hypertension, but ultimately leading to renal hypoperfusion and avid sodium retention. Inflammation can also contribute to the pathogenesis of refractory ascites by causing portal microthrombi, perpetuating the portal hypertension. Many complications accompany the development of refractory ascites, but renal dysfunction is most common. Management starts with continuation of sodium restriction, which needs frequent reviews for adherence; and regular large volume paracentesis of 5 L or more with albumin infusions to prevent the development of paracentesisinduced circulatory dysfunction. Albumin infusions independent of paracentesis may have a role in the management of these patients. The insertion of a covered, smaller diameter, transjugular intrahepatic porto-systemic stent shunt (TIPS) in the appropriate patients with reasonable liver reserve can bring about improvement in quality of life and improved survival after ascites clearance. Devices such as an automated low-flow ascites pump may be available in the future for ascites treatment. Patients with refractory ascites should be referred for liver transplant, as their prognosis is poor. In patients with refractory ascites and concomitant chronic kidney disease of more than stage 3b, assessment should be referred for dual liver-kidney transplants. In patients with very advanced cirrhosis not suitable for any definitive treatment for ascites control, palliative care should be involved to improve the quality of life of these patients.

Predictive value of controlled nutritional status score for overt hepatic encephalopathy after transjugular intrahepatic portosystemic stent-shunt of Budd-Chiari syndrome / 中华消化外科杂志

Objective:To investigate the predictive value of controlled nutritional status (CONUT) score for overt hepatic encephalopathy (OHE) after transjugular intrahepatic portosys-temic stent-shunt (TIPSS) in Budd-Chiari syndrome patients.Method:The retrospective case-control study was conducted. The clinicopathological data of 48 Budd-Chiari syndrome patients who underwent TIPSS in the First Affiliated Hospital of Zhengzhou University from August 2014 to March 2021 were collected. There were 26 males and 22 females, aged (46±13)years. Observation indicators: (1) surgical situations and follow-up; (2) analysis of influencing factors of OHE after TIPSS; (3) predic-tion of OHE after TIPSS. Measurement data with normal distribution were represented as Mean± SD, and comparison between groups was performed using the t test. Measurement data with skewed distribution were represented by M( Q1, Q3), and comparison between groups was performed using the Mann-Whitney U test. Count data were expressed as absolute numbers or percentages, and comparison between groups was performed using the chi-square test or Fisher exact probability. Multivariate analysis was performed using the Logistic regression model with forward method. The receiver operating characteristic (ROC) curve was drawn and the area under the curve (AUC) was calculated to evaluate the efficacy. Comparison among AUC was performed using the Delong test. Results:(1) Surgical situations and follow-up. All 48 patients underwent TIPSS successfully, and the operation time of the 48 patients was (131±29)minutes. All patients were implanted with 8 mm covered stent. All 48 patients were followed up for 46(25,71)months, and there were 14 cases with OHE and 34 cases without OHE after TIPSS. Of the 14 cases with OHE, 12 cases were evaluated as West-Haven Ⅱ grade and 2 cases were evaluated as West-Haven Ⅲ grade. (2) Analysis of influencing factors of OHE after TIPSS. Results of multivariate analysis showed that history of hepatic encephalo-pathy and CONUT score were independent factors influencing the incidence of OHE of Budd-Chiari syndrome patients who underwent TIPSS ( odds ratio=8.36, 1.74, 95% confidence interval as 1.02?68.75, 1.12?2.69, P<0.05). (3) Prediction of OHE after TIPSS. Results of ROC curve showed that the AUC of the CONUT score, the Child-Pugh score of liver function and the integrated model of end-stage liver disease (iMELD) score in predicting the incidence of OHE after TIPSS was 0.77(95% confidence interval as 0.64?0.91, P<0.05), 0.71(95% confidence interval as 0.56?0.87, P<0.05) and 0.71(95% confidence interval as 0.53?0.88, P<0.05), respectively, and there was no significant difference between the AUC of the CONUT score and the Child-Pugh score of liver function or the iMELD score ( Z=0.84, 0.59, P>0.05). The optimal cutoff value of CONUT score in predicting the incidence of OHE after TIPSS was 7, with the sensitivity, specificity and Yodon index as 78.6%, 61.8% and 0.40, respectively. Conclusion:The CONUT score can be used to predict the incidence of OHE in Budd-Chiari syndrome patients who underwent TIPSS, and the discrimination of CONUT score is equivalent to the Child-Pugh score of liver function and the iMELD score.

Role of early transjugular intrahepatic portosystemic stent-shunt in acute variceal bleeding: An update of the evidence and future directions.

Variceal bleeding is a serious complication of cirrhosis and portal hypertension. Despite the improvement in management of acute variceal bleed (AVB), it still carries significant mortality. Portal pressure is the main driver of variceal bleeding and also a main predictor of decompensation. Reduction in portal pressure has been the mainstay of management of variceal bleeding. Transjugular intrahepatic porto-systemic stent shunt (TIPSS) is a very effective modality in reducing the portal hypertension and thereby, controlling portal hypertensive bleeding. However, its use in refractory bleeding (rescue/salvage TIPSS) is still associated with high mortality. "Early" use of TIPSS as a "pre-emptive strategy" in patients with AVB at high risk of failure of treatment has shown to be superior to standard treatment in several studies. While patients with Child C cirrhosis (up to 13 points) clearly benefit from early-TIPSS strategy, it's role in less severe liver disease (Child B) and more severe disease (Child C > 13 points) remains less clear. Moreover, standard of care has improved in the last decade leading to improved 1-year survival in high-risk patients with AVB as compared to earlier "early" TIPSS studies. Lastly in the real world, only a minority of patients with AVB fulfil the stringent criteria for early TIPSS. Therefore, there is unmet need to explore role of early TIPSS in management of AVB in well-designed prospective studies. In this review, we have appraised the role of early TIPSS, patient selection and discussed future directions in the management of patients with AVB.

Treatment of aortic thrombosis with retrievable stent filter and thrombolysis: a case report.

BACKGROUND: The retrievable stent filter (RSF) has been previously used for the treatment of vena cava thrombosis. In this study, the RSF was implanted to treat aortic thrombosis and then withdrawn. CASE PRESENTATION: A 47-years-old woman presented with severe abdominal pain and fever. Computed tomography showed massive mural thrombosis in the thoracic and abdominal aorta complicated by portal venous thrombosis. The RSF was implanted, a transjugular intrahepatic portosystemic stent shunt was established and a thrombolytic catheter was inserted for portal vein thrombolysis. The aortic thrombus was successfully compressed and fixed without thrombosis. After 15 days, abdominal pain had ceased, the abdominal aortic thrombus was mostly dissolved and the RSF was retrieved. Catheter angiography confirmed the recovery of portal vein thrombosis. CONCLUSIONS: The RSF was able to compress and fix aortic thrombus without the usual complications of stenting after removal.

The portal vein as a distinct immunological compartment - A comprehensive immune phenotyping study.

Advanced liver diseases are associated with impaired intestinal barrier function, which results in bacterial influx via the portal vein to the liver, causing hepatic and systemic inflammation. Little is known about possible concomitant trafficking of immune cells from the intestines to the liver. We therefore performed a comprehensive immunophenotyping study of the portal venous versus peripheral blood compartment in patients with liver cirrhosis who received a transjugular intrahepatic portosystemic stent shunt (TIPS). Our analysis suggests that the portal vein constitutes a distinct immunological compartment resembling that of the intestines, at least in patients with advanced liver cirrhosis. In detail, significantly lower frequencies of naïve CD4+ T cells, monocytes, dendritic cells and Vδ2 T cells were observed in the portal vein, whereas frequencies of activated CD4+ and CD8+ T cells, as well as of mucosa-associated Vδ1 T cells were significantly higher in portal venous compared to peripheral blood. In conclusion, our data raises interesting questions, e.g. whether liver cirrhosis-associated chronic inflammation of the intestines and portal hypertension promote an influx of activated intestinal immune cells like γδ T cells into the liver.

Clinical Experience with Real-Time 3-D Guidance Based on C-Arm-Acquired Cone-Beam CT (CBCT) in Transjugular Intrahepatic Portosystemic Stent Shunt (TIPSS) Placement.

PURPOSE: The aim of this study was to evaluate the feasibility of cone-beam computed tomography (CBCT)-based real-time 3-D guidance of TIPSS placement and its positioning compared to standard guiding methods. MATERIALS AND METHODS: In a prospective, randomized, consecutive study design from 2015 to 2017, we included 21 patients in the CBCT guided group and 15 patients in the ultrasound (US) guided group. The prospective groups were compared in terms of success rate of intervention, portal vein puncture/procedure time, number of puncture attempts and applied dose. We furthermore retrospectively analyzed the last 23 consecutive cases with fluoroscopic guided portal vein puncture in terms of success rate, procedure time and applied dose, as it has been the standard method before US guidance. RESULTS: The median number of puncture attempts (CBCT: n = 2, US: n = 4, p = 0.249) and the mean puncture time (CBCT: 32 ± 45 min, US: 36 ± 45 min, p = 0.515) were not significantly different. There were furthermore no significant differences in the mean time needed for the total TIPSS procedure (CBCT: 115 ± 52 min, US: 112 ± 41 min, fluoroscopy: 110 ± 33 min, p = 0.996). The mean applied dose of the complete procedure also showed no statistically significant differences (CBCT: 563 ± 289 Gy·cm2, US: 322 ± 186 Gy·cm2, fluoroscopy: 469 ± 352 Gy·cm2, p = 0.069). There were no image guidance related complications. CONCLUSION: Real-time 3-D needle guidance based on CBCT is feasible for TIPSS placement. In terms of puncture attempts, duration and dose, CBCT guidance was not inferior to the control groups and may be a valuable support for interventionists in TIPSS procedures.

TIPS combined with gastric coronary vein embolization for cirrhosis portal hypertension complicated by upper gastrointestinal bleeding / 介入放射学杂志

Objective To compare the clinical curative effect between transjugular intrahepatic portosystemic stent-shunt (TIPS) and TIPS together with gastric coronary vein embolization (GCVE) in treating cirrhosis portal hypertension (PHT) associated with upper gastrointestinal hemorrhage (UGH),and to discuss the necessity,feasibility and clinical curative effect of TIPS plus GCVE.Methods The clinical data of 38 PHT patients with UGH,who were admitted to authors' hospital during the period from April 2010 to May 2012,were retrospectively analyzed.Only TIPS was employed in 15 patients (group A),and TIPS plus GCVE was adopted in 23 patients (group B).Before and after operation,the indexes,hemodynamics of portal vein and spleen,the morphology of spleen,and the degree of gastrointestinal varices were determined and analyzed.The patients were followed up to observe the occurrence of postoperative complications.Results In both groups,the postoperative portal vein pressure showed an obvious reduction with accelerated velocity of flow,and the splenic venous congestion index was decreased,these changes were statistically significant when compared with the preoperative ones (P＜0.05),and which was more obvious in group B than in group A (P＜0.05).After the treatment,the esophagogastric varices (EGV) was obviously improved,the improvement rates of group B and group A were 94.7％ and 66.6％ respectively,the emergency hemostasis rates of group B and group A were 100％ and 75.0％ respectively,The rates of re-bleeding were 4.3％ and 28.5％ respectively;the above results of group B were statistically better than those of group A (P＜0.05).No statistically significant differences in liver function indexes existed between preoperative values and postoperative ones in the same group as well as in group comparison (P＞0.05).The differences in the postoperative hepatic encephalopathy (HE) occurrence and in primary patency rate of stent between the two groups were not statistically significant (P＞0.05).In both groups,the re-intervention patency rate was 100％.The incidence rate of HE in patients in whom the distal end of stent was located in the left branch of portal vein was strikingly lower than that in patients in whom the distal end of stent was located in the right branch of portal vein (P＜0.05).Conclusion For the treatment of PHT associated with UGH,TIPS combined with GCVE carries reliable curative effect,this therapy is superior to simple use of TIPS.

Transjugular intrahepatic portosystemic stent shunt for medically refractory hepatic hydrothorax: A systematic review and cumulative meta-analysis.

AIM: To assess the effectiveness of transjugular intrahepatic portosystemic stent shunt (TIPSS) in refractory hepatic hydrothorax (RHH) in a systematic review and cumulative meta-analysis. METHODS: A comprehensive literature search was conducted on MEDLINE, EMBASE, and PubMed covering the period from January 1970 to August 2014. Two authors independently selected and abstracted data from eligible studies. Data were summarized using a random-effects model. Heterogeneity was assessed using the I (2) test. RESULTS: Six studies involving a total of 198 patients were included in the analysis. The mean (SD) age of patients was 56 (1.8) years. Most patients (56.9%) had Child-Turcott-Pugh class C disease. The mean duration of follow-up was 10 mo (range, 5.7-16 mo). Response to TIPSS was complete in 55.8% (95%CI: 44.7%-66.9%), partial in 17.6% (95%CI: 10.9%-24.2%), and absent in 21.2% (95%CI: 14.2%-28.3%). The mean change in hepatic venous pressure gradient post-TIPSS was 12.7 mmHg. The incidence of TIPSS-related encephalopathy was 11.7% (95%CI: 6.3%-17.2%), and the 45-d mortality was 17.7% (95%CI: 11.34%-24.13%). CONCLUSION: TIPSS is associated with a clinically relevant response in RHH. TIPSS should be considered early in these patients, given its poor prognosis.

Portal vein thrombosis in cirrhosis: Controversies and latest developments.

Portal vein thrombosis (PVT) is encountered in liver cirrhosis, particularly in advanced disease. It has been a feared complication of cirrhosis, attributed to significant worsening of liver disease, poorer clinical outcomes and potential inoperability at liver transplantation; also catastrophic events such as acute intestinal ischaemia. Optimal management of PVT has not yet been addressed in any consensus publication. We review current literature on PVT in cirrhosis; its prevalence, pathophysiology, diagnosis, impact on the natural history of cirrhosis and liver transplantation, and management. Studies were identified by a search strategy using MEDLINE and Google Scholar. The incidence of PVT increases with increasing severity of liver disease: less than 1% in well-compensated cirrhosis, 7.4%-16% in advanced cirrhosis. Prevalence in patients undergoing liver transplantation is 5%-16%. PVT frequently regresses instead of uniform thrombus progression. PVT is not associated with increased risk of mortality. Optimal management has not been addressed in any consensus publication. We propose areas for future research to address unresolved clinical questions.

The preoperative application of MSCT and MSCTP in performing TIPS combined with gastric coronary vein embolization / 介入放射学杂志

Objective To evaluate the clinical application of preoperative multi-slice computed tomography (MSCT) and multi-slice computed tomography portography (MSCTP) in performing transjugular intrahepatic portosystemic stent shunt (TIPSS) combined with gastric coronary vein embolization (GCVE). Methods A total of 126 patients with cirrhosis complicated by upper gastrointestinal bleeding or massive ascites due to portal hypertension were enrolled in this study. The patients were arranged to receive TIPSS together with GCVE. Before the treatment, MSCT and MSCTP were performed in all patients. By using post-processing techniques, including maximum intensity projection (MIP), multiplanar reformation (MPR), volume rendering (VR) and surface shade display (SSD), the anatomy of liver was comprehensively evaluated. Results Both MSCT and MSCTP could clearly display morphologic changes of liver , the spatial relationship of the portal and hepatic veins , the degree and extent of portal collateral circulation , and the severity of ascites, which provided important anatomical information for preoperative evaluation of TIPSS and GCVE. Conclusion MSCT and MSCTP are non-invasive and reliable examinations for the diagnosis of cirrhosis with portal hypertension, it can further clarify the diagnosis and guide the performance of TIPSS and GCVE.

The preoperative application of MSCT and MSCTP in performing TIPS combined with gastric coronary vein embolization / 介入放射学杂志

Objective To evaluate the clinical application of preoperative multi-slice computed tomography (MSCT) and multi-slice computed tomography portography (MSCTP) in performing transjugular intrahepatic portosystemic stent shunt (TIPSS) combined with gastric coronary vein embolization (GCVE). Methods A total of 126 patients with cirrhosis complicated by upper gastrointestinal bleeding or massive ascites due to portal hypertension were enrolled in this study. The patients were arranged to receive TIPSS together with GCVE. Before the treatment, MSCT and MSCTP were performed in all patients. By using post-processing techniques, including maximum intensity projection (MIP), multiplanar reformation (MPR), volume rendering (VR) and surface shade display (SSD), the anatomy of liver was comprehensively evaluated. Results Both MSCT and MSCTP could clearly display morphologic changes of liver , the spatial relationship of the portal and hepatic veins , the degree and extent of portal collateral circulation , and the severity of ascites, which provided important anatomical information for preoperative evaluation of TIPSS and GCVE. Conclusion MSCT and MSCTP are non-invasive and reliable examinations for the diagnosis of cirrhosis with portal hypertension, it can further clarify the diagnosis and guide the performance of TIPSS and GCVE.

[Hemolytic anemia secondary to the placement of a portosystemic stented shunt]. / Anemia hemolítica secundaria a la colocación de Stent transyugular intrahepático porto sistémico.

INTRODUCTION: portal hypertension and variceal hemorrhage are common complications of hepatic cirrhosis, both associated with a high morbimortality. Portal system decompression by the placement of a transjugular intrahepatic portosystemic stented shunt, can reduce portal venus pressure and is effective controling complications of portal hypertension, like variceal hemorrhage and ascitis. The aim of this document is to describe a case of hemolytic anemia secondary to the placement of a transjugular intrahepatic portosystemic stented shunt. CLINICAL CASE: patient with portal hypertension secondary to liver cirrosis was given a transjugular intrahepatic portosystemic stented shunt for recurrent variceal hemorrhage. After the procedure, hemoglobin decreased 2 g/dL, associated with reticulocitosis, hipohaptoglobinemia, elevated lactic dehydrogenase and indirect hyperbilirrubinemia with negative Coombs test. The peripheral blood smear showed abnormal erythrocytes, with the prevalence of schistocytes. The final diagnosis was hemolytic anemia secondary to transjugular intrahepatic portosystemic stented shunt. CONCLUSIONS: the hemolytic anemia secondary to Transjugular Intrahepatic Portosystemic Stented Shunt is a rare complication. Usually, it has a benign prognosis, and it is self-limited once the stent is endothelialized.

Three cases of digestive tract hemorrhage of portal hypertension combine portal vein wide embolism after transjugular intrahepatic portosystemic stent shunt treatment / 中国综合临床

Objective To investigate the effect of transjugular intrahepatic portosystemic stent shunt (TIPS) on gastrointestinal bleeding after portal hypertension and portal vein wide embolism.Methods Three patients with acute upper gastrointestinal bleeding were diagnosed by CT with wide embolus formation in portal vein and superior mesenteric vein,of which,1 case was with spleen vein embolism formation.TIPS hemostatic treatment was applied to stop bleeding,and stents was placed where distal embolus can be observed by angiography.Results After TIPS treatment,no patients were re-bleeding during following-up periods (4-6 weeks).Uncomfortable symptoms of 3 cases were disappeared.Conclusion TIPS was a safe and effective way to treat gastrointestinal bleeding caused by portal hypertension and wide embolus formation.

Clinical outcome and predictors of survival after TIPS insertion in patients with liver cirrhosis.

AIM: To determine the clinical outcome and predictors of survival after transjugular intrahepatic portosystemic stent shunt (TIPS) implantation in cirrhotic patients. METHODS: Eighty-one patients with liver cirrhosis and consequential portal hypertension had TIPS implantation (bare metal) for either refractory ascites (RA) (n = 27) or variceal bleeding (VB) (n = 54). Endpoints for the study were: technical success, stent occlusion and stent stenosis, rebleeding, RA and mortality. Clinical records of patients were collected and analysed. Baseline characteristics [e.g., age, sex, CHILD score and the model for end-stage liver disease score (MELD score), underlying disease] were retrieved. The Kaplan-Meier method was employed to calculate survival from the time of TIPS implantation and comparisons were made by log rank test. A multivariate analysis of factors influencing survival was carried out using the Cox proportional hazards regression model. Results were expressed as medians and ranges. Comparisons between groups were performed by using the Mann-Whitney U-test and the χ2 test as appropriate. RESULTS: No difference could be seen in terms of age, sex, underlying disease or degree of portal pressure gradient (PPG) reduction between the ascites and the bleeding group. The PPG significantly decreased from 23.4 ± 5.3 mmHg (VB) vs. 22.1 ± 5.5 mmHg (RA) before TIPS to 11.8 ± 4.0 vs. 11.7 ± 4.2 after TIPS implantation (P = 0.001 within each group). There was a tendency towards more patients with stage CHILD A in the bleeding group compared to the ascites group (24 vs 6, P = 0.052). The median survival for the ascites group was 29 mo compared to > 60 mo for the bleeding group (P = 0.009). The number of radiological controls for stent patency was 6.3 for bleeders and 3.8 for ascites patients (P = 0.029). Kaplan-Meier calculation indicated that stent occlusion at first control (P = 0.027), ascites prior to TIPS implantation (P = 0.009), CHILD stage (P = 0.013), MELD score (P = 0.001) and those patients not having undergone liver transplantation (P = 0.024) were significant predictors of survival. In the Cox regression model, stent occlusion (P = 0.022), RA (P = 0.043), CHILD stage (P = 0.015) and MELD score (P = 0.004) turned out to be independent prognostic factors of survival. The anticoagulation management (P = 0.097), the porto-systemic pressure gradient (P = 0.460) and rebleeding episodes (P = 0.765) had no significant effect on the overall survival. CONCLUSION: RA, stent occlusion, initial CHILD stage and MELD score are independent predictors of survival in patients with TIPS, speaking for a close follow-up in these circumstances.