Skip to main content

Advertisement

SpringerLink
Log in

Transjugular intrahepatic portosystemic shunt reduces hospital care burden in patients with decompensated cirrhosis

  • IM - ORIGINAL
  • Published:
Internal and Emergency Medicine Aims and scope Submit manuscript

Abstract

Background and aims

Patients with decompensated cirrhosis frequently require hospital admissions, which are associated with worse prognosis. The aim of this study was to analyze the effect of TIPS on the need for hospital care. Secondary objectives were to assess the clinical and biological impact of TIPS and to identify predictors of post-TIPS hospital care.

Methods

An observational, retrospective study of patients with decompensated cirrhosis treated with TIPS from January 2008 until March 2019. Exclusion criteria were TIPS placed for non-cirrhotic portal hypertension (PH) and patients referred from another hospital without prior or subsequent follow-up at our Unit. Hospital care, PH-related complications, and laboratory data were compared before and after TIPS.

Results

The final cohort comprised 104 patients (72% male) with a mean age of 60 (± 10) years. Follow-up from first decompensation until TIPS and that from procedure to study completion were 7 (4.2–9.8) and 20 (4.6–35.4) months, respectively. TIPS was indicated mainly for refractory ascites (50%) and variceal bleeding (39%). Hemodynamic and clinical success rates were 97% and 92%, respectively. The number of emergency department visits and hospital admissions decreased after the procedure (p < 0.001). Improvement was seen in MELD and Child–Pugh scores, renal function, hyponatremia, and anemia after TIPS. Variceal bleeding as the indication for TIPS (OR 0.047; 95 CI 0.006–0,39; p < 0.05) together with early creation of the shunt (stage 3 vs 5; p < 0.05) were associated with a reduction in risk of post-TIPS hospital care.

Conclusion

TIPS is a safe and effective procedure that reduces hospital care burden by improving PH-related complications, hepatic, renal function, hyponatremia, and anemia. Variceal bleeding as the indication and early placement of the device were associated with a reduction in post-TIPS hospital care. These findings support a role for this treatment, predominantly in the early stages of cirrhosis.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Fig. 1

Similar content being viewed by others

References

  1. D’Amico G, Garcia-Tsao G, Pagliaro L (2006) Natural history and prognostic indicators of survival in cirrhosis: a systematic review of 118 studies. J Hepatol 44(1):217–231

    Article  Google Scholar 

  2. Simonetto DA, Liu M, Kamath PS (2019) Portal hypertension and related complications: diagnosis and management. Mayo Clin Proc 94(4):714–726

    Article  Google Scholar 

  3. de Franchis R, Faculty BVI (2015) Expanding consensus in portal hypertension: report of the Baveno VI consensus workshop: stratifying risk and individualizing care for portal hypertension. J Hepatol 63(3):743–752

    Article  Google Scholar 

  4. Garcia-Tsao G, Abraldes JG, Berzigotti A, Bosch J (2017) Portal hypertensive bleeding in cirrhosis: risk stratification, diagnosis, and management: 2016 practice guidance by the American Association for the study of liver diseases. Hepatology 65(1):310–335

    Article  Google Scholar 

  5. Qi X, Jia J, Bai M, Guo X, Su C, García-Pagán JC, Han G, Fan D (2015) Transjugular intrahepatic portosystemic shunt for acute variceal bleeding: a meta-analysis. J Clin Gastroenterol 49(6):495–505

    Article  Google Scholar 

  6. Salerno F, Cammà C, Enea M, Rössle M, Wong F (2007) Transjugular intrahepatic portosystemic shunt for refractory ascites: a meta-analysis of individual patient data. Gastroenterology 133(3):825–834

    Article  CAS  Google Scholar 

  7. Bureau C, Thabut D, Oberti F, Dharancy S, Carbonell N, Bouvier A, Mathurin P, Otal P, Cabarrou P, Péron JM, Vinel JP (2017) Transjugular intrahepatic portosystemic shunts with covered stents increase transplant-free survival of patients with cirrhosis and recurrent ascites. Gastroenterology 152(1):157–163

    Article  Google Scholar 

  8. Bai M, Qi X, Yang Z, Yin Z, Nie Y, Yuan S, Wu K, Han G, Fan D (2011) Predictors of hepatic encephalopathy after transjugular intrahepatic portosystemic shunt in cirrhotic patients: a systematic review. J Gastroenterol Hepatol 26(6):943–951

    Article  Google Scholar 

  9. Schindler P, Seifert L, Masthoff M, Riegel A, Köhler M, Wilms C, Schmidt HH, Heinzow H, Wildgruber M (2020) TIPS modification in the management of shunt-induced hepatic encephalopathy: analysis of predictive factors and outcome with shunt modification. J Clin Med. https://doi.org/10.3390/jcm9020567

    Article  PubMed  PubMed Central  Google Scholar 

  10. Qi X, Tian Y, Zhang W, Yang Z, Guo X (2017) Covered versus bare stents for transjugular intrahepatic portosystemic shunt: an updated meta-analysis of randomized controlled trials. Therap Adv Gastroenterol 10(1):32–41

    Article  Google Scholar 

  11. Vizzutti F, Schepis F, Arena U, Fanelli F, Gitto S, Aspite S, Turco L, Dragoni G, Laffi G, Marra F (2020) Transjugular intrahepatic portosystemic shunt (TIPS): current indications and strategies to improve the outcomes. Intern Emerg Med 15(1):37–48

    Article  Google Scholar 

  12. Kim HY, Kim CW, Choi JY, Lee CD, Lee SH, Kim MY, Jang BK, Wo HY (2016) Complications requiring hospital admission and causes of in-hospital death over time in alcoholic and nonalcoholic cirrhosis patients. Gut Liver 10(1):95–100

    Article  CAS  Google Scholar 

  13. Ratib S, Fleming KM, Crooks CJ, Aithal GP, West J (2014) 1 and 5 year survival estimates for people with cirrhosis of the liver in England, 1998–2009: a large population study. J Hepatol 60(2):282–289

    Article  Google Scholar 

  14. Neff GW, Duncan CW, Schiff ER (2011) The current economic burden of cirrhosis. Gastroenterol Hepatol (N Y) 7:661–671

    Google Scholar 

  15. Siddique SM, Lane-Fall M, McConnell MJ, Jakhete N, Crismale J, Porges S, Khungar V, Mehta SJ, Goldberg D, Li Z, Schiano T, Regan L, Orloski C, Shea JA (2018) Exploring opportunities to prevent cirrhosis admissions in the emergency department: a multicenter multidisciplinary survey. Hepatol Commun 2(3):237–244

    Article  Google Scholar 

  16. Chirapongsathorn S, Talwalkar JA, Kamath PS (2016) Strategies to reduce hospital readmissions. Semin Liver Dis 36(2):161–166

    Article  Google Scholar 

  17. European Association for the Study of the Liver (2018) EASL Clinical Practice Guidelines for the management of patients with decompensated cirrhosis. J Hepatol 69(2):406–460

    Article  Google Scholar 

  18. Boyer TD, Haskal ZJ (2010) AASLD practice guidelines: the role of transjugular intrahepatic portosystemic shunt (TIPS) in the management of portal hypertension: update 2009. Hepatology 51(1):306

    Article  Google Scholar 

  19. Malinchoc M, Kamath PS, Gordon FD, Peine CJ, Rank J, ter Borg PC (2000) A model to predict poor survival in patients undergoing transjugular intrahepatic portosystemic shunts. Hepatology 31(4):864–871

    Article  CAS  Google Scholar 

  20. Child CG, Turcotte JG (1964) Surgery and portal hypertension. Major Probl Clin Surg 1:1–85

    CAS  PubMed  Google Scholar 

  21. Berzigotti A (2017) Advances and challenges in cirrhosis and portal hypertension. BMC Med 15(1):200

    Article  Google Scholar 

  22. Haskal ZJ, Martin L, Cardella JF, Cole PE, Drooz A, Grassi CJ, McCowan TC, Meranze SG, Neithamer CD, Oglevie SB, Roberts AC, Sacks D, Silverstein MI, Swan TL, Towbin RB, Lewis CA; Society of Interventional Radiology Standards of Practice Committee (2003) Quality improvement guidelines for transjugular intrahepatic portosystemic shunt. J Vasc Interv Radiol 14(9 Pt 2):S265–70.

  23. Krajina A, Hulek P, Fejfar T, Valek V (2012) Quality improvement guidelines for transjugular intrahepatic portosystemic shunt (TIPS). Cardiovasc Intervent Radiol 35(6):1295–1300

    Article  Google Scholar 

  24. Dariushnia SR, Haskal ZJ, Midia M, Martin LG, Walker TG, Kalva SP, Clark TW, Ganguli S, Krishnamurthy V, Saiter CK, Nikolic B (2016) Quality improvement guidelines for transjugular intrahepatic portoystemic shunts. J Vasc Interv Radiol 27(1):1–7

    Article  Google Scholar 

  25. Sanyal AJ, Freedman AM, Luketic VA, Purdum PP 3rd, Shiffman ML, DeMeo J, Cole PE, Tisnado J (1997) The natural history of portal hypertension after transjugular intrahepatic portosystemic shunts. Gastroenterology 112(3):889–898

    Article  CAS  Google Scholar 

  26. Casadaban LC, Gabra MG, Parvinian A, Minocha J, Knuttinen MG, Bui JT, Gaba RC (2014) Impact of transjugular intrahepatic portosystemic shunt creation on intermediate-term model for end-stage liver disease score progression. Transplant Proc 46(5):1384–1388

    Article  CAS  Google Scholar 

  27. Anderson CL, Saad WE, Kalagher SD, Caldwell S, Sabri S, Turba UC, Matsumoto AH, Angle JF (2010) Effect of transjugular intrahepatic portosystemic shunt placement on renal function: a 7-year, single-center experience. J Vasc Interv Radiol 21(9):1370–1376

    Article  Google Scholar 

  28. Busk TM, Bendtsen F, Poulsen JH, Clemmesen JO, Larsen FS, Goetze JP, Iversen JS, Jensen MT, Møgelvang R, Pedersen EB, Bech JN8, Møller S (2018) Transjugular intrahepatic portosystemic shunt: impact on systemic hemodynamics and renal and cardiac function in patients with cirrhosis. Am J Physiol Gastrointest Liver Physiol. 314(2):G275-G286. [PMID: 29074483 DOI: https://doi.org/10.1152/ajpgi.00094.2017].

Download references

Acknowledgements

Ballester MP and Martí-Aguado D are recipients of a Río Hortega award (CM19/00212), Instituto de Salud Carlos III.

Funding

The authors declare no financial support.

Author information

Authors and Affiliations

  1. Digestive Disease Department, Clinic University Hospital of Valencia, Blasco Ibañez 17, 46010, Valencia, Spain

    Maria Pilar Ballester, Paloma Lluch, Concepción Gómez, Maria Capilla, Joan Tosca, David Martí-Aguado & Miguel Mínguez

  2. Neurological Impairment Research Unit, INCLIVA Biomedical Research Institute of Clinic University Hospital of Valencia, Valencia, Spain

    Maria Pilar Ballester

  3. Department of Medicine. Faculty of Medicine and Odontology, University of Valencia, Valencia, Spain

    Paloma Lluch & Miguel Mínguez

  4. Biomedical Imaging Research Group (GIBI230), La Fe Health Research Institute, Valencia, Spain

    David Martí-Aguado

  5. Interventional Radiology Department, Clinic University Hospital of Valencia, Valencia, Spain

    Jorge Guijarro

Authors
  1. Maria Pilar Ballester
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Paloma Lluch
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Concepción Gómez
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Maria Capilla
    View author publications

    You can also search for this author in PubMed Google Scholar

  5. Joan Tosca
    View author publications

    You can also search for this author in PubMed Google Scholar

  6. David Martí-Aguado
    View author publications

    You can also search for this author in PubMed Google Scholar

  7. Jorge Guijarro
    View author publications

    You can also search for this author in PubMed Google Scholar

  8. Miguel Mínguez
    View author publications

    You can also search for this author in PubMed Google Scholar

Contributions

MPB and PL: designed the study. CG, MC, JT, DM-A, JG, and MR: acquired the data. MPB: analyzed and interpreted the data and wrote the manuscript. PL and MM: performed a critical revision.

Corresponding author

Correspondence to Maria Pilar Ballester.

Ethics declarations

Conflict of interest

The authors declare no conflicts of interest.

Ethics approval

The study protocol conformed to the ethical guidelines of the Declaration of Helsinki and was approved by the Health Research Ethics Board.

Informed consent

Informed consent was obtained from each patient at the time of TIPS procedure.

Additional information

Publisher's Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Electronic supplementary material

Below is the link to the electronic supplementary material.

Supplementary material 1 (docx 100 kb)

Rights and permissions

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Ballester, M.P., Lluch, P., Gómez, C. et al. Transjugular intrahepatic portosystemic shunt reduces hospital care burden in patients with decompensated cirrhosis. Intern Emerg Med 16, 1519–1527 (2021). https://doi.org/10.1007/s11739-020-02602-x

Download citation

  • Received:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s11739-020-02602-x

Keywords

Search

Navigation