Advertisement

Liver Diseases pp 651-660 | Cite as

Portacaval Shunting for Portal Hypertension

  • Francis G. Celii
  • Jayesh M. Soni
  • Anil K. PillaiEmail author
Chapter

Abstract

Normal portal venous blood pressure varies between 5 and 10 mmHg. Portal hypertension exists when the pressure gradient between the portal and systemic venous circulation exceeds 5 mmHg. Portal hypertension is a sequela of cirrhosis in more than 90% of cases. Most common clinical manifestations include variceal bleeding, intractable ascites, and hepatic encephalopathy. Decompression of the portal system by the creation of shunts between the portal and systemic veins is a well-recognized option for the treatment of portal hypertension. Various surgical and percutaneous techniques have been used to create these shunts. In this chapter, we will discuss the types of portocaval shunts, their indications and contraindications, a brief technical description of their creation, and their outcomes and complications.

Keywords

Portacaval shunt Portal hypertension Transjugular intrahepatic portosystemic shunt Portosystemic shunt TIPS Surgical shunt Direct portosystemic shunt DIPS 

References

  1. 1.
    Benoit JN, Womack WA, Hernandez L, Neil Granger D. “Forward” and “backward” flow mechanisms of portal hypertension: relative contributions in the rat model of portal vein stenosis. Gastroenterology. 1985;89:1092–6.PubMedCrossRefPubMedCentralGoogle Scholar
  2. 2.
    Iwakiri Y. Pathophysiology of portal hypertension. Clin Liver Dis. 2014;18:281–91.PubMedPubMedCentralCrossRefGoogle Scholar
  3. 3.
    Garcia-Tsao G. Current management of the complications of cirrhosis and portal hypertension: variceal hemorrhage, ascites, and spontaneous bacterial peritonitis. Gastroenterology. 2001;120:726–48.PubMedCrossRefPubMedCentralGoogle Scholar
  4. 4.
    Reiberger T, Püspök A, Schoder M, et al. Austrian consensus guidelines on the management and treatment of portal hypertension (Billroth III). Wien Klin Wochenschr. 2017;129:135–58.PubMedPubMedCentralCrossRefGoogle Scholar
  5. 5.
    Roccarina D, Rosselli M, Genesca J, Tsochatzis EA. Elastography methods for the non-invasive assessment of portal hypertension. Expert Rev Gastroenterol Hepatol. 2018;12:155–64.PubMedCrossRefPubMedCentralGoogle Scholar
  6. 6.
    Graham DY, Smith JL. The course of patients after variceal hemorrhage. Gastroenterology. 1981;80:800–9.PubMedCrossRefPubMedCentralGoogle Scholar
  7. 7.
    Jackson FC, Perrin EB, Felix WR, Smith AG. A clinical investigation of the portacaval shunt. V. Survival analysis of the therapeutic operation. Ann Surg. 1971;174:672–701.PubMedPubMedCentralCrossRefGoogle Scholar
  8. 8.
    Rueff B, Prandi D, Degos F, Sicot J, Degos JD, Sicot C, Maillard JN, Fauvert R, Benhamou JP. A controlled study of therapeutic portacaval shunt in alcoholic cirrhosis. Lancet. 1976;1:655–9.PubMedCrossRefPubMedCentralGoogle Scholar
  9. 9.
    Resnick RH, Iber FL, Ishihara AM, Chalmers TC, Zimmerman H. A controlled study of the therapeutic portacaval shunt. Gastroenterology. 1974;67:843–57.PubMedCrossRefPubMedCentralGoogle Scholar
  10. 10.
    Henderson JM, Kutner MH, Millikan WJ Jr, Galambos JT, Riepe SP, Brooks WS, Bryan FC, Warren WD. Endoscopic variceal sclerosis compared with distal splenorenal shunt to prevent recurrent variceal bleeding in cirrhosis. A prospective, randomized trial. Ann Intern Med. 1990;112:262–9.PubMedCrossRefPubMedCentralGoogle Scholar
  11. 11.
    D’amico G, Pagliaro L, Bosch J. The treatment of portal hypertension: a meta-analytic review. Hepatology. 1995;22:332–54.PubMedPubMedCentralGoogle Scholar
  12. 12.
    Sarfeh IJ, Rypins EB. Partial versus total portacaval shunt in alcoholic cirrhosis. Results of a prospective, randomized clinical trial. Ann Surg. 1994;219:353–61.PubMedPubMedCentralCrossRefGoogle Scholar
  13. 13.
    Papatheodoridis GV, Goulis J, Leandro G, Patch D, Burroughs AK. Transjugular intrahepatic portosystemic shunt compared with endoscopic treatment for prevention of variceal rebleeding: a meta-analysis. Hepatology. 1999;30:612–22.PubMedCrossRefPubMedCentralGoogle Scholar
  14. 14.
    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;133:825–34.PubMedCrossRefPubMedCentralGoogle Scholar
  15. 15.
    Bureau C, Thabut D, Oberti F, et al. Transjugular intrahepatic portosystemic shunts with covered stents increase transplant-free survival of patients with cirrhosis and recurrent ascites. Gastroenterology. 2017;152:157–63.PubMedCrossRefPubMedCentralGoogle Scholar
  16. 16.
    Bai M, Qi X-S, Yang Z-P, Yang M, Fan D-M, Han G-H. TIPS improves liver transplantation-free survival in cirrhotic patients with refractory ascites: an updated meta-analysis. World J Gastroenterol. 2014;20:2704–14.PubMedPubMedCentralCrossRefGoogle Scholar
  17. 17.
    Miraglia R, Maruzzelli L, Tuzzolino F, Petridis I, D’Amico M, Luca A. Transjugular intrahepatic portosystemic shunts in patients with cirrhosis with refractory ascites: comparison of clinical outcomes by using 8- and 10-mm PTFE-covered stents. Radiology. 2017;284:281–8.PubMedCrossRefPubMedCentralGoogle Scholar
  18. 18.
    D’Amico G, Luca A. TIPS is a cost effective alternative to surgical shunt as a rescue therapy for prevention of recurrent bleeding from esophageal varices. J Hepatol. 2008;48:387–90.PubMedCrossRefPubMedCentralGoogle Scholar
  19. 19.
    Boyer TD, Haskal ZJ. AASLD practice guidelines the role of transjugular intrahepatic portosystemic shunt (TIPS) in the management of portal hypertension update 2009. Hepatology. 2010;51:306.PubMedCrossRefPubMedCentralGoogle Scholar
  20. 20.
    Hayek G, Ronot M, Plessier A, Sibert A, Abdel-Rehim M, Zappa M, Rautou P-E, Valla D, Vilgrain V. Long-term outcome and analysis of dysfunction of transjugular intrahepatic portosystemic shunt placement in chronic primary Budd-Chiari syndrome. Radiology. 2017;283:280–92.PubMedCrossRefPubMedCentralGoogle Scholar
  21. 21.
    Fidelman N, Kwan SW, LaBerge JM, Gordon RL, Ring EJ, Kerlan RK Jr. The transjugular intrahepatic portosystemic shunt: an update. AJR Am J Roentgenol. 2012;199:746–55.PubMedCrossRefPubMedCentralGoogle Scholar
  22. 22.
    Siramolpiwat S. Transjugular intrahepatic portosystemic shunts and portal hypertension-related complications. World J Gastroenterol. 2014;20:16996–7010.PubMedPubMedCentralCrossRefGoogle Scholar
  23. 23.
    Wong F, Pantea L, Sniderman K. Midodrine, octreotide, albumin, and TIPS in selected patients with cirrhosis and type 1 hepatorenal syndrome. Hepatology. 2004;40:55–64.PubMedCrossRefPubMedCentralGoogle Scholar
  24. 24.
    Mezawa S, Homma H, Ohta H, Masuko E, Doi T, Miyanishi K, Takada K, Kukitsu T, Sato T, Niitsu Y. Effect of transjugular intrahepatic portosystemic shunt formation on portal hypertensive gastropathy and gastric circulation. Am J Gastroenterol. 2001;96:1155–9.PubMedCrossRefPubMedCentralGoogle Scholar
  25. 25.
    Patidar KR, Sanyal AJ. Transjugular intrahepatic portosystemic shunt for refractory ascites in patients with high model for end-stage liver disease scores. Clin Liver Dis. 2016;7:84–7.CrossRefGoogle Scholar
  26. 26.
    Franklin VR, Simmons LQ, Baker AL. Transjugular intrahepatic portosystemic shunt: a literature review. J Diagn Med Sonogr. 2018;34:114–22.CrossRefGoogle Scholar
  27. 27.
    Andring B, Kalva SP, Sutphin P, Srinivasa R, Anene A, Burrell M, Xi Y, Pillai AK. Effect of technical parameters on transjugular intrahepatic portosystemic shunts utilizing stent grafts. World J Gastroenterol. 2015;21:8110–7.PubMedPubMedCentralCrossRefGoogle Scholar
  28. 28.
    Bureau C, Garcia-Pagan JC, Otal P, et al. Improved clinical outcome using polytetrafluoroethylene-coated stents for TIPS: results of a randomized study. Gastroenterology. 2004;126:469–75.PubMedCrossRefPubMedCentralGoogle Scholar
  29. 29.
    Bureau C, Pagan JCG, 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;27:742–7.PubMedCrossRefPubMedCentralGoogle Scholar
  30. 30.
    Perarnau JM, Le Gouge A, Nicolas C, et al. Covered vs. uncovered stents for transjugular intrahepatic portosystemic shunt: a randomized controlled trial. J Hepatol. 2014;60:962–8.PubMedCrossRefPubMedCentralGoogle Scholar
  31. 31.
    Triantafyllou T, Aggarwal P, Gupta E, Svetanoff WJ, Bhirud DP, Singhal S. Polytetrafluoroethylene-covered stent graft versus bare stent in transjugular intrahepatic portosystemic shunt: systematic review and meta-analysis. J Laparoendosc Adv Surg Tech A. 2018;28:867–79.PubMedCrossRefPubMedCentralGoogle Scholar
  32. 32.
    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.PubMedCrossRefPubMedCentralGoogle Scholar
  33. 33.
    Deltenre P, Trépo E, Rudler M, et al. Early transjugular intrahepatic portosystemic shunt in cirrhotic patients with acute variceal bleeding: a systematic review and meta-analysis of controlled trials. Eur J Gastroenterol Hepatol. 2015;27:e1–9.PubMedCrossRefPubMedCentralGoogle Scholar
  34. 34.
    Monescillo A, Martínez-Lagares F, Ruiz-del-Arbol L, et al. Influence of portal hypertension and its early decompression by TIPS placement on the outcome of variceal bleeding. Hepatology. 2004;40:793–801.PubMedCrossRefPubMedCentralGoogle Scholar
  35. 35.
    Garcia-Tsao G, Bosch J. Management of varices and variceal hemorrhage in cirrhosis. N Engl J Med. 2010;362:823–32.PubMedCrossRefPubMedCentralGoogle Scholar
  36. 36.
    Petersen B, Uchida BT, Timmermans H, Keller FS, Rosch J. Intravascular US-guided direct intrahepatic portacaval shunt with a PTFE-covered stent-graft: feasibility study in swine and initial clinical results. J Vasc Interv Radiol. 2001;12:475–86.PubMedCrossRefPubMedCentralGoogle Scholar
  37. 37.
    Casadaban LC, Gaba RC. Percutaneous portosystemic shunts: TIPS and beyond. Semin Intervent Radiol. 2014;31:227–34.PubMedPubMedCentralCrossRefGoogle Scholar
  38. 38.
    Petersen BD, Clark TWI. Direct intrahepatic portocaval shunt. Tech Vasc Interv Radiol. 2008;11:230–4.PubMedCrossRefPubMedCentralGoogle Scholar
  39. 39.
    Kawahara Y, Tanaka Y, Isoi N, et al. Direct intrahepatic portocaval shunt for refractory hepatic hydrothorax: a case report. Acute Med Surg. 2017;4:306–10.PubMedCrossRefPubMedCentralGoogle Scholar
  40. 40.
    Kirby JM, Cho KJ, Midia M. Image-guided intervention in management of complications of portal hypertension: more than TIPS for success. Radiographics. 2013;33:1473–96.PubMedCrossRefPubMedCentralGoogle Scholar
  41. 41.
    Nyman UR, Semba CP, Chang H, Hoffman C, Dake MD. Percutaneous creation of a mesocaval shunt. J Vasc Interv Radiol. 1996;7:769–73.PubMedCrossRefPubMedCentralGoogle Scholar

Copyright information

© Springer Nature Switzerland AG 2020

Authors and Affiliations

  • Francis G. Celii
    • 1
  • Jayesh M. Soni
    • 2
  • Anil K. Pillai
    • 2
    Email author
  1. 1.University of Texas Health Science CenterHoustonUSA
  2. 2.Diagnostic and Interventional ImagingUniversity of Texas Health Science CenterHoustonUSA

Personalised recommendations