Abstract
Background
Uncontrolled variceal bleeding (VB) remains a great challenge for clinical treatment. Emergency transjugular intrahepatic portosystemic shunt (TIPS) is a salvage procedure, but unsatisfactory clinical outcomes and a high incidence of complications have been reported. This study aimed to investigate the effect and safety of emergency TIPS performed in our institution during recent years.
Methods
Fifty-eight consecutive cirrhotic patients with uncontrolled VB who underwent emergency TIPS from March 2009 to November 2017 in our hospital were followed until the last clinical evaluation, liver transplantation (LT), or death.
Results
Overall, 5, 36, and 17 patients belonged to Child-Pugh class A, B, and C, respectively. TIPS was successfully performed in 57 (98.3%) patients at 89.5 h (mean) after initial bleeding. After TIPS, bleeding ceased in 52 (91.2%) patients, and 51 (89.5%) patients had a portal pressure gradient below 12 mmHg. Only one (1.8%) major procedure-related complication occurred without any clinical consequences, and no procedure-related deaths occurred. During follow-up, 55 hepatic encephalopathy (HE) episodes occurred in 19 (33.3%) patients, and the median time of the first HE episode was 3.1 months. Seven (12.3%) patients experienced shunt dysfunction after 8.7 months (median). The 6-week, 1-year, and 2-year variceal rebleeding rates were 10.5%, 17.1%, and 20.0%, respectively. The LT-free survival rates at 6 weeks, 1 year, and 2 years were 87.7%, 81.8% and 73.6%, respectively.
Conclusion
Our study highlights the fact that emergency TIPS could be effective for patients with liver cirrhosis and uncontrolled VB with few potential complications.
Similar content being viewed by others
References
Tayyem O, Bilal M, Samuel R, Merwat SK. Evaluation and management of variceal bleeding. Dis Mon. 2018;64:312–320.
de Franchis R. Expanding consensus in portal hypertension: Report of the Baveno VI Consensus Workshop: Stratifying risk and individualizing care for portal hypertension. J Hepatol. 2015;63:743–752.
D'Amico G, Pasta L, Morabito A, D'Amico M, Caltagirone M, Malizia G, Tine F, Giannuoli G, Traina M, Vizzini G, Politi F, Luca A, Virdone R, Licata A, Pagliaro L. Competing risks and prognostic stages of cirrhosis: a 25-year inception cohort study of 494 patients. Aliment Pharmacol Ther. 2014;39:1180–1193.
Fortune BE, Garcia-Tsao G, Ciarleglio M, Deng Y, Fallon MB, Sigal S, Chalasani NP, Lim JK, Reuben A, Vargas HE, Abrams G, Lewis MD, Hassanein T, Trotter JF, Sanyal AJ, Beavers KL, Ganger D, Thuluvath PJ, Grace ND, Groszmann RJ. Child-Turcotte-Pugh Class is Best at Stratifying Risk in Variceal Hemorrhage: Analysis of a US Multicenter Prospective Study. J Clin Gastroenterol. 2016;51:446–453.
Parker R. Role of transjugular intrahepatic portosystemic shunt in the management of portal hypertension. Clin Liver Dis. 2014;18:319–334.
Lv Y, Qi X, He C, Wang Z, Yin Z, Niu J, Guo W, Bai W, Zhang H, Xie H, Yao L, Wang J, Li T, Wang Q, Chen H, Liu H, Wang E, Xia D, Luo B, Li X, Yuan J, Han N, Zhu Y, Xia J, Cai H, Yang Z, Wu K, Fan D, Han G. Covered TIPS versus endoscopic band ligation plus propranolol for the prevention of variceal rebleeding in cirrhotic patients with portal vein thrombosis: a randomised controlled trial. Gut. 2017 0:1–13.
Lin LL, Du SM, Fu Y, Gu HY, Wang L, Jian ZY, Shen XF, Luo J, Zhang C. Combination therapy versus pharmacotherapy, endoscopic variceal ligation, or the transjugular intrahepatic portosystemic shunt alone in the secondary prevention of esophageal variceal bleeding: a meta-analysis of randomized controlled trials. Oncotarget. 2017;8:57399–57408.
Garcia-Pagan JC, Caca K, Bureau C, Laleman W, Appenrodt B, Luca A, Abraldes JG, Nevens F, Vinel JP, Mossner J, Bosch J. Early use of TIPS in patients with cirrhosis and variceal bleeding. N Engl J Med. 2010;362:2370–2379.
Dariushnia SR, Haskal ZJ, Midia M, Martin LG, Walker TG, Kalva SP, Clark TW, Ganguli S, Krishnamurthy V, Saiter CK, Nikolic B. Quality Improvement Guidelines for Transjugular Intrahepatic Portosystemic Shunts. J Vasc Interv Radiol. 2016;27:1–7.
Njei B, McCarty TR, Laine L. Early transjugular intrahepatic portosystemic shunt in US patients hospitalized with acute esophageal variceal bleeding. J Gastroenterol Hepatol. 2017;32:852–858.
Bañares R, Casado M, Rodríguez-Láiz JM, Camúñez F, Matilla A, Echenagusía A, Simó G, Piqueras B, Clemente G, Cos E. Urgent transjugular intrahepatic portosystemic shunt for control of acute variceal bleeding. The American Journal of Gastroenterology. 1998;93:75–79.
Gazzera C, Righi D, Doriguzzi Breatta A, Rossato D, Camerano F, Valle F, Gandini G. Emergency transjugular intrahepatic portosystemic shunt (TIPS): results, complications and predictors of mortality in the first month of follow-up. La radiologia medica. 2012;117:46–53.
Casadaban LC, Parvinian A, Zivin SP, Lakhoo J, Minocha J, Knuttinen MG, Ray CE, Jr., Bui JT, Gaba RC. MELD score for prediction of survival after emergent TIPS for acute variceal hemorrhage: derivation and validation in a 101-patient cohort. Ann Hepatol. 2015;14:380–388.
Patch D, Nikolopoulou V, McCormick A, Dick R, Armonis A, Wannamethee G, Burroughs A. Factors related to early mortality after transjugular intrahepatic portosystemic shunt for failed endoscopic therapy in acute variceal bleeding. J Hepatol. 1998;28:454–460.
Azoulay D, Castaing D, Majno P, Saliba F, Ichai P, Smail A, Delvart V, Danaoui M, Samuel D, Bismuth H. Salvage transjugular intrahepatic portosystemic shunt for uncontrolled variceal bleeding in patients with decompensated cirrhosis. J Hepatol. 2001;35:590–597.
Garcia-Tsao G, Abraldes JG, Berzigotti A, Bosch J. Portal hypertensive bleeding in cirrhosis: Risk stratification, diagnosis, and management: 2016 practice guidance by the American Association for the study of liver diseases. Hepatology. 2017;65:310–335.
Luo X, Wang Z, Tsauo J, Zhou B, Zhang H, Li X. Advanced Cirrhosis Combined with Portal Vein Thrombosis: A Randomized Trial of TIPS versus Endoscopic Band Ligation Plus Propranolol for the Prevention of Recurrent Esophageal Variceal Bleeding. Radiology. 2015;276:286–293.
Bucsics T, Schoder M, Diermayr M, Feldner-Busztin M, Goeschl N, Bauer D, Schwabl P, Mandorfer M, Angermayr B, Cejna M, Ferlitsch A, Sieghart W, Trauner M, Peck-Radosavljevic M, Karner J, Karnel F, Reiberger T. Transjugular intrahepatic portosystemic shunts (TIPS) for the prevention of variceal re-bleeding - A two decades experience. PLoS One. 2018;13:e0189414.
Lyon KC, Likar E, Martello JL, Regier M. Retrospective cross-sectional pilot study of rifaximin dosing for the prevention of recurrent hepatic encephalopathy. J Gastroenterol Hepatol. 2017;32:1548–1552.
de Franchis R. Revising consensus in portal hypertension: report of the Baveno V consensus workshop on methodology of diagnosis and therapy in portal hypertension. J Hepatol. 2010;53:762–768.
Yang Z, Han G, Wu Q, Ye X, Jin Z, Yin Z, Qi X, Bai M, Wu K, Fan D. Patency and clinical outcomes of transjugular intrahepatic portosystemic shunt with polytetrafluoroethylene-covered stents versus bare stents: a meta-analysis. J Gastroenterol Hepatol. 2010;25:1718–1725.
Angermayr B, Cejna M, Koenig F, Karnel F, Hackl F, Gangl A, Peck-Radosavljevic M. Survival in patients undergoing transjugular intrahepatic portosystemic shunt: ePTFE-covered stentgrafts versus bare stents. Hepatology. 2003;38:1043–1050.
Bureau C, Garcia-Pagan JC, Otal P, Pomier-Layrargues G, Chabbert V, Cortez C, Perreault P, Peron JM, Abraldes JG, Bouchard L, Bilbao JI, Bosch J, Rousseau H, Vinel JP. Improved clinical outcome using polytetrafluoroethylene-coated stents for TIPS: results of a randomized study. Gastroenterology. 2004;126:469–475.
Barrio J, Ripoll C, Banares R, Echenagusia A, Catalina MV, Camunez F, Simo G, Santos L. Comparison of transjugular intrahepatic portosystemic shunt dysfunction in PTFE-covered stent-grafts versus bare stents. Eur J Radiol. 2005;55:120–124.
Gandini R, Konda D, Simonetti G. Transjugular intrahepatic portosystemic shunt patency and clinical outcome in patients with Budd-Chiari syndrome: covered versus uncovered stents. Radiology. 2006;241:298–305.
Grant Support
This study was supported by the National Natural Science Foundation of China (No. 81570554) and the Graduate Student’s Research and Innovation Fund of Sichuan University (No. 2018YJSY104). The authors declare no conflicts of interest regarding this paper.
Author information
Authors and Affiliations
Contributions
Xiao Li and Xuefeng Luo contributed equally to TIPS operations. Yongjun Zhu and Xiaotan Xi were both in charge of collecting patient information and clinical data. Yongjun Zhu and Xiaoze Wang contributed to the statistics. All the authors helped to draft the manuscript. Li Yang and Xuefeng Luo approved the final manuscript.
Corresponding authors
Ethics declarations
The protocol was approved by the West China Hospital of Sichuan University Biomedical Research Ethics Committee. The study was conducted according to the Declaration of Helsinki.
Additional information
Publisher’s Note
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
Prof. Li Yang and Prof. Xuefeng Luo equally share the corresponding authorship.
Rights and permissions
About this article
Cite this article
Zhu, Y., Wang, X., Xi, X. et al. Emergency Transjugular Intrahepatic Portosystemic Shunt: an Effective and Safe Treatment for Uncontrolled Variceal Bleeding. J Gastrointest Surg 23, 2193–2200 (2019). https://doi.org/10.1007/s11605-019-04146-8
Received:
Accepted:
Published:
Issue Date:
DOI: https://doi.org/10.1007/s11605-019-04146-8