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An Algorithm for Management After Transjugular Intrahepatic Portosystemic Shunt Placement According to Clinical Manifestations

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Abstract

We propose an algorithm for management after transjugular intrahepatic portosystemic shunt (TIPS) placement according to clinical manifestations. For patients with an initial good clinical response, surveillance Doppler ultrasound is recommended to detect stenosis or occlusion. A TIPS revision can be performed using basic or advanced techniques to treat stenosis or occlusion. In patients with an initial poor clinical response, a TIPS venogram with pressure measurements should be performed to assess shunt patency. The creation of a parallel TIPS may also be required if the patient is symptomatic and the portal pressure remains high after TIPS revision. Additional procedures may also be necessary, such as peritoneovenous shunt (Denver shunt) placement for refractory ascites, tunneled pleural catheter for hepatic hydrothorax, and balloon-occluded retrograde transvenous obliteration procedure for gastric variceal bleeding. A TIPS reduction procedure can also be performed in patients with uncontrolled hepatic encephalopathy or hepatic failure.

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References

  1. Fidelman N, Kwan SW, LaBerge JM, Gordon RL, Ring EJ, Kerlan RK. The transjugular intrahepatic portosystemic shunt: an update. AJR. 2012;199:746–755.

    Article  PubMed  Google Scholar 

  2. Boyer TD, Haskal ZJ. The role of transjugular intrahepatic portosystemic shunt (TIPS) in the management of portal hypertension: update 2009. Hepatology. 2010;51:306.

    Article  PubMed  Google Scholar 

  3. Haskal ZJ, Pentecost MJ, Soulen MC, Shlansky- Goldberg RD, Baum RA, Cope C. Transjugular intrahepatic portosystemic shunt stenosis and revision: early and midterm results. AJR. 1994;163:439–444.

    Article  CAS  PubMed  Google Scholar 

  4. Tripathi D, Helmy A, Macbeth K, et al. Ten years’ follow-up of 472 patients following transjugular intrahepatic portosystemic stent-shunt insertion at a single centre. Eur J Gastroenterol Hepatol. 2004;16:9–18.

    Article  PubMed  Google Scholar 

  5. Bureau C, Pagan JC, Layrargues GP, et al. Patency of stents covered with polytetrafluoroethylene in patients treated by transjugular intrahepatic portosystemic shunts: long-term results of a randomized multicentre study. Liver Int. 2007;27:742–747.

    Article  CAS  PubMed  Google Scholar 

  6. Tripathi D, Ferguson J, Barkell H, et al. Improved clinical outcome with transjugular intrahepatic portosystemic stent-shunt utilizing polytetrafluoroethylene-covered stents. Eur J Gastroenterol Hepatol. 2006;18:225–232.

    Article  CAS  PubMed  Google Scholar 

  7. Hausegger KA, Karnel F, Georgieva B, et al. Transjugular intrahepatic portosystemic shunt creation with the Viatorr expanded polytetrafluoroethylene-covered stent-graft. J Vasc Interv Radiol. 2004;15:239–248.

    Article  PubMed  Google Scholar 

  8. Vignali C, Bargellini I, Grosso M, et al. TIPS with expanded polytetrafluoroethylene-covered stent: results of an Italian multicenter study. AJR. 2005;185:472–480.

    Article  PubMed  Google Scholar 

  9. Charon JP, Alaeddin FH, Pimpalwar SA, et al. Results of a retrospective multicenter trial of the Viatorr expanded polytetrafluoroethylene-covered stent-graft for transjugular intrahepatic portosystemic shunt creation. J Vasc Interv Radiol. 2004;15:1219–1230.

    Article  PubMed  Google Scholar 

  10. Rossi P, Salvatori FM, Fanelli F, et al. Polytetrafluoroethylene-covered nitinol stent-graft for transjugular intrahepatic portosystemic shunt creation: 3-year experience. Radiology. 2004;231:820–830.

    Article  PubMed  Google Scholar 

  11. Cura M, Cura A, Suri R, El-Merhi F, Lopera J, Kroma G. Causes of TIPS dysfunction. AJR. 2008;191:1751–1757.

    Article  PubMed  Google Scholar 

  12. Nazarian GK, Ferral H, Castaneda-Zuniga WR, et al. Development of stenoses in transjugular intrahepatic portosystemic shunts. Radiology. 1994;192:231–234.

    Article  CAS  PubMed  Google Scholar 

  13. Darcy M. Evaluation and management of transjugular intrahepatic portosystemic shunts. AJR. 2012;199:730–736.

    Article  PubMed  Google Scholar 

  14. Kanterman RY, Darcy MD, Middleton WD, Sterling KM, Teefey SA, Pilgram TK. Doppler sonography findings associated with transjugular intrahepatic portosystemic shunt malfunction. AJR. 1997;168:467–472.

    Article  CAS  PubMed  Google Scholar 

  15. Surratt RS, Middleton WD, Darcy MD, Melson GL, Brink JA. Morphologic and hemodynamic findings at sonography before and after creation of a transjugular intrahepatic portosystemic shunt. AJR. 1993;160:627–630.

    Article  CAS  PubMed  Google Scholar 

  16. Engstrom BI, Horvath JJ, Suhocki PV, et al. Covered transjugular intrahepatic portosystemic shunts: accuracy of ultrasound in detecting shunt malfunction. AJR. 2013;200:904–908.

    Article  PubMed  Google Scholar 

  17. Chopra S, Dodd GD 3rd, Chintapalli KN, et al. Transjugular intrahepatic portosystemic shunt: accuracy of helical CT angiography in the detection of shunt abnormalities. Radiology. 2000;215:115–1122.

    Article  CAS  PubMed  Google Scholar 

  18. Fanelli F, Bezzi M, Bruni A, et al. Multidetector-row computed tomography in the evaluation of transjugular intrahepatic portosystemic shunt performed with expanded-polytetrafluoroethylene-covered stent-graft. Cardiovasc Interv Radiol. 2011;34:100–105.

    Article  Google Scholar 

  19. Hausegger KA, Sternthal HM, Klein GE, Karaic R, Stauber R, Zenker G. Transjugular intrahepatic portosystemic shunt: angiographic follow-up and secondary interventions. Radiology. 1994;191:177–181.

    Article  CAS  PubMed  Google Scholar 

  20. Jirkovsky V, Fejfar T, Safka V, et al. Influence of the secondary deployment of expanded polytetrafluoroethylene-covered stent grafts on maintenance of transjugular intrahepatic portosystemic shunt patency. J Vasc Interv Radiol. 2011;22:55–60.

    Article  PubMed  Google Scholar 

  21. Echenagusia M, Rodriguez-Rosales G, Simo G, Camuñez F, Bañares R, Echenagusia A. Expanded PTFE-covered stent-grafts in the treatment of transjugular intrahepatic portosystemic shunt (TIPS) stenoses and occlusions. Abdom Imaging. 2005;30:750–754.

    Article  CAS  PubMed  Google Scholar 

  22. Luo XF, Nie L, Wang Z, et al. Stent-grafts for the treatment of TIPS dysfunction: fluency stent vs Wallgraft stent. World J Gastroenterol. 2013;19:5000–5005.

    Article  PubMed  PubMed Central  Google Scholar 

  23. Tanaka T, Günther RW, Isfort P, Kichikawa K, Mahnken AH. Pull-through technique for recanalization of occluded portosystemic shunts (TIPS): technical note and review of the literature. Cardiovasc Interv Radiol. 2011;34:406–412.

    Article  Google Scholar 

  24. Zhu K, Meng X, Zhou B, et al. Percutaneous transsplenic portal vein catheterization: technical procedures, safety, and clinical applications. J Vasc Interv Radiol. 2013;24:518–527.

    Article  PubMed  Google Scholar 

  25. He FL, Wang L, Yue ZD, Zhao HW, Liu FQ. Parallel transjugular intrahepatic portosystemic shunt for controlling portal hypertension complications in cirrhotic patients. World J Gastroenterol. 2014;20:11835–11839.

    Article  PubMed  PubMed Central  Google Scholar 

  26. Parvinian A, Gaba RC. Parallel TIPS for treatment of refractory ascites and hepatic hydrothorax. Dig Dis Sci. 2013;58:3052–3056.

    Article  PubMed  Google Scholar 

  27. Petersen BD, Clark TW. Direct intrahepatic portocaval shunt. Tech Vasc Interv Radiol. 2008;11:230–234.

    Article  PubMed  Google Scholar 

  28. Hoppe H, Wang SL, Petersen BD. Intravascular US-guided direct intrahepatic portocaval shunt with an expanded polytetrafluoroethylene-covered stent-graft. Radiology. 2008;246:306–314.

    Article  PubMed  Google Scholar 

  29. Salerno F, Cammà C, Enea M, Rössle M, Wong F. Transjugular intrahepatic portosystemic shunt for refractory ascites: a meta-analysis of individual patient data. Gastroenterology. 2007;133:825–834.

    Article  CAS  PubMed  Google Scholar 

  30. Rossle M, Ochs A, Gulberg V, et al. A comparison of paracentesis and transjugular intrahepatic portosystemic shunting in patients with ascites. N Engl J Med. 2000;342:1701–1707.

    Article  CAS  PubMed  Google Scholar 

  31. Lodato F, Berzigotti A, Lisotti A, et al. Transjugular intrahepatic portosystemic shunt placement for refractory ascites: a single-centre experience. Scand J Gastroenterol. 2012;47:1494–1500.

    Article  PubMed  Google Scholar 

  32. Sanyal AJ, Genning C, Reddy KR, et al. The North American study for the treatment of refractory ascites. Gastroenterology. 2003;124:634–641.

    Article  PubMed  Google Scholar 

  33. Gines P, Uriz J, Calahorra B, et al. Transjugular intrahepatic portosystemic shunting versus paracentesis plus albumin for refractory ascites in cirrhosis. Gastroenterology. 2002;123:1839–1847.

    Article  PubMed  Google Scholar 

  34. Martin LG. Percutaneous placement and management of the Denver shunt for portal hypertensive ascites. AJR. 2012;199:W449–W453.

    Article  PubMed  Google Scholar 

  35. Essawy MM, El-Khayat HR, Omar MM, Mustafa I. Evaluation of peritoneovenous Denver shunt in the management of intractable non-malignant hepatic ascites. Egypt J Surg. 2001;20:783–795.

    Google Scholar 

  36. Lopez-Viego MA, Cornell JM. Pneumoperitoneum and signs of peritonitis from a pleuroperitoneal shunt. Surgery. 1992;111:228–229.

    CAS  PubMed  Google Scholar 

  37. Foroulis CN, Desimonas NA. Massive pneumoperitoneum: a late complication of the Denver pleuroperitoneal shunt. Ann Thorac Surg. 2005;80:e13.

    Article  PubMed  Google Scholar 

  38. Bratby MJ, Hussain FF, Lopez AJ. Radiological insertion and management of peritoneovenous shunt. Cardiovasc Interv Radiol. 2007;30:415–418.

    Article  CAS  Google Scholar 

  39. Kiafar C, Gilani N. Hepatic hydrothorax: current concepts of pathophysiology and treatment options. Ann Hepatol. 2008;7:313–320.

    CAS  PubMed  Google Scholar 

  40. Dhanasekaran R, West JK, Gonzales PC, et al. Transjugular intrahepatic portosystemic shunt for symptomatic refractory hepatic hydrothorax in patients with cirrhosis. Am J Gastroenterol. 2010;105:635–641.

    Article  PubMed  Google Scholar 

  41. Siegerstetter V, Deibert P, Ochs A, Olschewski M, Blum HE, Rössle M. Treatment of refractory hepatic hydrothorax with transjugular intrahepatic portosystemic shunt: long-term results in 40 patients. Eur J Gastroenterol Hepatol. 2001;13:529–534.

    Article  CAS  PubMed  Google Scholar 

  42. Wilputte JY, Goffette P, Zech F, Godoy-Gepert A, Geubel A. The outcome after transjugular intrahepatic portosystemic shunt (TIPS) for hepatic hydrothorax is closely related to liver dysfunction: a long-term study in 28 patients. Acta Gastroenterol Belg. 2007;70:6–10.

    PubMed  Google Scholar 

  43. Spencer EB, Cohen DT, Darcy MD. Safety and efficacy of transjugular intrahepatic portosystemic shunt creation for the treatment of hepatic hydrothorax. J Vasc Interv Radiol. 2002;13:385–390.

    Article  PubMed  Google Scholar 

  44. Mercky P, Sakr L, Heyries L, Lagrange X, Sahel J, Dutau H. Use of a tunnelled pleural catheter for the management of refractory hepatic hydrothorax: a new therapeutic option. Respiration. 2010;80:348–352.

    Article  PubMed  Google Scholar 

  45. Bhatnagar R, Reid ED, Corcoran JP, et al. Indwelling pleural catheters for non-malignant effusions: a multicentre review of practice. Thorax. 2014;69:959–961.

    Article  PubMed  Google Scholar 

  46. Chen A, Massoni J, Jung D, Crippin J. Indwelling tunneled pleural catheters for the management of hepatic hydrothorax. A pilot study. Ann Am Thorac Soc. 2016;13:862–866.

    Article  PubMed  Google Scholar 

  47. Garcia-Pagan JC, Caca K, Bureau C, et al. Early use of TIPS in patients with cirrhosis and variceal bleeding. N Engl J Med. 2010;362:2370–2379.

    Article  CAS  PubMed  Google Scholar 

  48. Garcia-Pagán JC, Di Pascoli M, Caca K, et al. Use of early-TIPS for high-risk variceal bleeding: results of a post-RCT surveillance study. J Hepatol. 2013;58:45–50.

    Article  PubMed  Google Scholar 

  49. Holster IL, Tjwa ET, Moelker A, et al. Covered transjugular intrahepatic portosystemic shunt versus endoscopic therapy + β-blocker for prevention of variceal rebleeding. Hepatology. 2016;63:581–589.

    Article  CAS  PubMed  Google Scholar 

  50. Chau TN, Patch D, Chan YW, Nagral A, Dick R, Burroughs AK. “Salvage” transjugular intrahepatic portosystemic shunts: gastric fundal compared with esophageal variceal bleeding. Gastroenterology. 1998;114:981–987.

    Article  CAS  PubMed  Google Scholar 

  51. Barange K, Péron JM, Imani K, et al. Transjugular intrahepatic portosystemic shunt in the treatment of refractory bleeding from ruptured gastric varices. Hepatology. 1999;30:1139–1143.

    Article  CAS  PubMed  Google Scholar 

  52. Rees CJ, Nylander DL, Thompson NP, Rose JD, Record CO, Hudson M. Do gastric and oesophageal varices bleed at different portal pressures and is TIPS an effective treatment? Liver. 2000;20:253–256.

    Article  CAS  PubMed  Google Scholar 

  53. Choi YH, Yoon CJ, Park JH, Chung JW, Kwon JW, Choi GM. Balloon-occluded retrograde transvenous obliteration for gastric variceal bleeding: its feasibility compared with transjugular intrahepatic portosystemic shunt. Korean J Radiol. 2003;4:109–116.

    Article  PubMed  PubMed Central  Google Scholar 

  54. Sabri SS, Abi-Jaoudeh N, Swee W, et al. Short-term rebleeding rates for isolated gastric varices managed by transjugular portosystemic shunt versus balloon-occluded retrograde transvenous obliteration. J Vasc Interv Radiol. 2014;25:355–361.

    Article  PubMed  Google Scholar 

  55. Sauk S, Niemeyer M, Kim SK, Korenblat K. Outcomes from balloon-occluded retrograde transvenous obliteration (BRTO) versus transjugular intrahepatic portosystemic shunt (TIPS) in the management of isolated gastric varices: a retrospective study in single US medical center. J Vasc Interv Radiol. 2014;25:S80.

    Article  Google Scholar 

  56. Ninoi T, Nishida N, Kaminou T, et al. Balloon-occluded retrograde transvenous obliteration of gastric varices with gastrorenal shunt: long-term follow-up in 78 patients. AJR. 2005;185:1340–1346.

    Article  Google Scholar 

  57. Kanagawa H, Mima S, Kouyama H, Gotoh K, Uchida T, Okuda K. Treatment of gastric fundal varices by balloon-occluded retrograde transvenous obliteration. J Gastroenterol Hepatol. 1996;11:51–58.

    Article  CAS  PubMed  Google Scholar 

  58. Sonomura T, Sato M, Kishi K, et al. Balloon-occluded retrograde transvenous obliteration for gastric varices: a feasibility study. Cardiovasc Interv Radiol. 1998;21:27–30.

    Article  CAS  Google Scholar 

  59. Kitamoto M, Imamura M, Kamada K, et al. Balloon-occluded retrograde transvenous obliteration of gastric fundal varices with hemorrhage. Am J Roentgenol. 2002;178:1167–1174.

    Article  Google Scholar 

  60. Arai H, Abe T, Shimoda R, Takagi H, Yamada T, Mori M. Emergency balloon-occluded retrograde transvenous obliteration for gastric varices. J Gastroenterol. 2005;40:964–971.

    Article  PubMed  Google Scholar 

  61. Cho SK, Shin SW, Lee IH, et al. Balloon-occluded retrograde transvenous obliteration of gastric varices: outcomes and complications in 49 patients. Am J Roentgenol. 2007;189:W365–W372.

    Article  Google Scholar 

  62. Hiraga N, Aikata H, Takaki S, et al. The long-term outcome of patients with bleeding gastric varices after balloon-occluded retrograde transvenous obliteration. J Gastroenterol. 2007;42:663–672.

    Article  PubMed  Google Scholar 

  63. Chao Y, Lin HC, Lee FY, et al. Hepatic hemodynamic features in patients with esophageal or gastric varices. J Hepatol. 1993;19:85–89.

    Article  CAS  PubMed  Google Scholar 

  64. Saad WE, Darcy MD. Transjugular intrahepatic portosystemic shunt (TIPS) versus balloon-occluded retrograde transvenous obliteration (BRTO) for the management of gastric varices. Semin Interv Radiol. 2011;28:339–349.

    Article  Google Scholar 

  65. Luca A, Miraglia R, Maruzzelli L, D’Amico M, Tuzzolino F. Early liver failure after transjugular intrahepatic portosystemic shunt in patients with cirrhosis with model for end-stage liver disease score of 12 or less: incidence, outcome, and prognostic factors. Radiology. 2016;280:622–629.

    Article  PubMed  Google Scholar 

  66. Rajan DK, Haskal ZJ, Clark TWI. Serum bilirubin and early mortality after transjugular intrahepatic portosystemic shunts: results of a multivariate analysis. J Vasc Interv Radiol. 2002;13:155–161.

    Article  PubMed  Google Scholar 

  67. Chalasani N, Clark WS, Martin LG, et al. Determinants of mortality in patients with advanced cirrhosis after transjugular intrahepatic portosystemic shunting. Gastroenterology. 2000;118:138–144.

    Article  CAS  PubMed  Google Scholar 

  68. Salerno F, Merli M, Cazzaniga M, et al. MELD score is better than Child–Pugh score in predicting 3-month survival of patients undergoing transjugular intrahepatic portosystemic shunt. J Hepatol. 2002;36:494–500.

    Article  PubMed  Google Scholar 

  69. Ferral H, Gamboa P, Postoak DW, et al. Survival after elective transjugular intrahepatic portosystemic shunt creation: prediction with model for end-stage liver disease score. Radiology. 2004;231:231–236.

    Article  PubMed  Google Scholar 

  70. Peter P, Andrej Z, Katarina SP, Manca G, Pavel S. Hepatic encephalopathy after transjugular intrahepatic portosystemic shunt in patients with recurrent variceal hemorrhage. Gastroenterol Res Pract. 2013;2013:398172.

    Article  PubMed  PubMed Central  Google Scholar 

  71. Masson S, Mardini HA, Rose JD, Record CO. Hepatic encephalopathy after transjugular intrahepatic portosystemic shunt insertion: a decade of experience. QJM. 2008;101:493–501.

    Article  CAS  PubMed  Google Scholar 

  72. Riggio O, Angeloni S, Salvatori FM, et al. Incidence, natural history, and risk factors of hepatic encephalopathy after transjugular intrahepatic portosystemic shunt with polytetrafluoroethylene-covered stent grafts. Am J Gastroenterol. 2008;103:2738–2746.

    Article  PubMed  Google Scholar 

  73. Casadaban LC, Parvinian A, Minocha J, et al. Clearing the confusion over hepatic encephalopathy after TIPS creation: incidence, prognostic factors, and clinical outcomes. Dig Dis Sci. 2015;60:1059–1066.

    Article  PubMed  Google Scholar 

  74. Sze DY, Hwang GL, Kao JS, et al. Bidirectionally adjustable TIPS reduction by parallel stent and stent-graft deployment. J Vasc Interv Radiol. 2008;19:1653–1658.

    Article  PubMed  Google Scholar 

  75. Fanelli F, Salvatori FM, Rabuffi P, et al. Management of refractory hepatic encephalopathy after insertion of TIPS: long-term results of shunt reduction with hourglass-shaped balloon-expandable stent-graft. AJR. 2009;193:1696–1702.

    Article  PubMed  Google Scholar 

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  1. Interventional Radiology, Mallinckrodt Institute of Radiology, Washington University School of Medicine in St. Louis, 510 S Kingshighway Boulevard, Campus Box 8131, St. Louis, MO, 63110, USA

    Seung Kwon Kim, Bryan G. Belikoff & Carlos J. Guevara

  2. Department of Radiology, College of Medicine, Kyung Hee University, Seoul, Korea

    Seung Kwon Kim & Seong Jin Park

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  1. Seung Kwon Kim
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Kim, S.K., Belikoff, B.G., Guevara, C.J. et al. An Algorithm for Management After Transjugular Intrahepatic Portosystemic Shunt Placement According to Clinical Manifestations. Dig Dis Sci 62, 305–318 (2017). https://doi.org/10.1007/s10620-016-4399-4

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