TIPS: 25 years later.
TL;DR: In the 25 years since the first TIPS intervention has been performed, technical standards, indications, and contraindications have been set up and TIPS has gained increasing acceptance in the treatment of the various complications of portal hypertension and vascular diseases of the liver.
About: This article is published in Journal of Hepatology.The article was published on 2013-11-01 and is currently open access. It has received 297 citations till now. The article focuses on the topics: Portal vein thrombosis & Transjugular intrahepatic portosystemic shunt.
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182 citations
TL;DR: The best available evidence supports the use of TIPS in secondary prevention of variceal bleeding and in refractory ascites, although TIPS is also commonly used for other indications such as Budd-Chiari syndrome, hepatic hydrothorax, and acutevariceal hemorrhage.
Abstract: OBJECTIVE. The purpose of this article is to review the indications, outcomes, complications, patient selection, and technical aspects of creating a transjugular intrahepatic portosystemic shunt (TIPS). CONCLUSION. The best available evidence supports the use of TIPS in secondary prevention of variceal bleeding and in refractory ascites, although TIPS is also commonly used for other indications such as Budd-Chiari syndrome, hepatic hydrothorax, and acute variceal hemorrhage. The TIPS procedure was revolutionized by the introduction of covered stents, which dramatically improved long-term shunt patency.
154 citations
TL;DR: It is found muscle wasting, probably owing to reduced processing of ammonia, to be associated with the development of HE after TIPS placement, and nutritional status should be evaluated in patients with sarcopenia before TIPS placed, which might reduce the incidence of HE.
131 citations
TL;DR: The possibility of spontaneous resolution of partial PVT questions the necessity of anticoagulation for the treatment ofpartial PVT, and a relatively low recanalization rate of complete PVT after antICOagulation therapy suggests its limited usefulness in patients with complete PVt.
Abstract: Portal vein thrombosis (PVT) is a fairly common complication of liver cirrhosis. Importantly, occlusive PVT might influence the prognosis of patients with cirrhosis. Evidence from a randomized controlled trial has shown that anticoagulation can prevent the occurrence of PVT in patients with cirrhosis without prior PVT. Evidence from several case series has also demonstrated that anticoagulation can achieve portal vein recanalization in patients with cirrhosis and PVT. Early initiation of anticoagulation therapy and absence of previous portal hypertensive bleeding might be positively associated with a high rate of portal vein recanalization after anticoagulation. However, the possibility of spontaneous resolution of partial PVT questions the necessity of anticoagulation for the treatment of partial PVT. In addition, a relatively low recanalization rate of complete PVT after anticoagulation therapy suggests its limited usefulness in patients with complete PVT. Successful insertion of a transjugular intrahepatic portosystemic shunt (TIPS) not only recanalizes the thrombosed portal vein, but also relieves the symptomatic portal hypertension. However, the technical difficulty of TIPS potentially limits its widespread application, and the risk and benefits should be fully balanced. Notably, current recommendations regarding the management of PVT in liver cirrhosis are insufficient owing to low-quality evidence.
131 citations
TL;DR: Covered TIPS placement in patients with PVT and moderately decompensated cirrhosis was more effective than EBL combined with propranolol for the prevention of rebleeding, with a higher probability of PVT resolution without increasing the risk of OHE and adverse effects, but this benefit did not translate into improved survival.
Abstract: Objective Limited data are available on the prevention of variceal rebleeding in cirrhotic patients with portal vein thrombosis (PVT). This study aimed to compare transjugular intrahepatic portosystemic shunt (TIPS) with covered stents versus endoscopic band ligation (EBL) plus propranolol for the prevention of variceal rebleeding among patients with cirrhosis and PVT. Design Consecutive cirrhotic patients (94% Child-Pugh class A or B) with PVT who had variceal bleeding in the past 6 weeks were randomly assigned to TIPS group (n=24) or EBL plus propranolol group (EBL+drug, n=25), respectively. Primary endpoint was variceal rebleeding. Secondary endpoints included survival, overt hepatic encephalopathy (OHE), portal vein recanalisation and rethrombosis, other complications of portal hypertension and adverse events. Results During a median follow-up of 30 months in both groups, variceal rebleeding was significantly less frequent in the TIPS group (15% vs 45% at 1 year and 25% vs 50% at 2 years, respectively; HR=0.28, 95% CI 0.10 to 0.76, p=0.008), with a significantly higher portal vein recanalisation rate (95% vs 70%; p=0.03) and a relatively lower rethrombosis rate (5% vs 33%; p=0.06) compared with the EBL+drug group. There were no statistically significant differences in survival (67% vs 84%; p=0.152), OHE (25% vs 16%; p=0.440), other complications of portal hypertension and adverse events between groups. Conclusion Covered TIPS placement in patients with PVT and moderately decompensated cirrhosis was more effective than EBL combined with propranolol for the prevention of rebleeding, with a higher probability of PVT resolution without increasing the risk of OHE and adverse effects, but this benefit did not translate into improved survival. Trial registration number ClinicalTrials.gov: NCT01326949.
118 citations
References
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TL;DR: The MELD scale is a reliable measure of mortality risk in patients with end‐stage liver disease and suitable for use as a disease severity index to determine organ allocation priorities in patient groups with a broader range of disease severity and etiology.
4,184 citations
TL;DR: This Mayo TIPS model may predict early death following elective TIPS for either prevention of variceal rebleeding or for treatment of refractory ascites, superior to both the Child‐Pugh classification and the Child-Pugh score in predicting survival.
2,479 citations
"TIPS: 25 years later." refers methods in this paper
...Thereby, the MELD score [77] including bilirubin, creatinine and INR, was found to be superior to the Child-Pugh score at predicting post-TIPS mortality [78,80], or the Emory score [79]....
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TL;DR: A Baveno V workshop was held on May 21–22, 2010, attended by many of the experts responsible for most of the major achievements of the last years in this field, and produced consensus statements on some important points, although some issues remained unsettled.
2,074 citations
"TIPS: 25 years later." refers background or methods in this paper
...Since HE was considered to have a greater negative impact than rebleeding on quality of life, medical treatment was regarded as first line treatment in the prevention of variceal rebleeding [18,90]....
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...Consequently, the Baveno V conference in 2010 recommended considering early TIPS (within 72 h) in patients with high risk of treatment failure [90]....
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TL;DR: The MELD scale is a reliable measure of mortality risk in patients with end-stage liver disease and suitable for use as a disease severity index to determine organ allocation priorities in patient groups with a broader range of disease severity and etiology.
1,452 citations
"TIPS: 25 years later." refers methods in this paper
...Thereby, the MELD score [77] including bilirubin, creatinine and INR, was found to be superior to the Child-Pugh score at predicting post-TIPS mortality [78,80], or the Emory score [79]....
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TL;DR: In patients with cirrhosis who were hospitalized for acute variceal bleeding and at high risk for treatment failure, the early use of TIPS was associated with significant reductions in treatment failure and in mortality.
Abstract: Background Patients with cirrhosis in Child–Pugh class C or those in class B who have persistent bleeding at endoscopy are at high risk for treatment failure and a poor prognosis, even if they have undergone rescue treatment with a transjugular intrahepatic portosystemic shunt (TIPS). This study evaluated the earlier use of TIPS in such patients. Methods We randomly assigned, within 24 hours after admission, a total of 63 patients with cirrhosis and acute variceal bleeding who had been treated with vasoactive drugs plus endoscopic therapy to treatment with a polytetrafluoroethylene-covered stent within 72 hours after randomization (early-TIPS group, 32 patients) or continuation of vasoactive-drug therapy, followed after 3 to 5 days by treatment with propranolol or nadolol and long-term endoscopic band ligation (EBL), with insertion of a TIPS if needed as rescue therapy (pharmacotherapy–EBL group, 31 patients). Results During a median follow-up of 16 months, rebleeding or failure to control bleeding occurr...
970 citations
"TIPS: 25 years later." refers background or methods in this paper
...The studies by Garcia-Pagan [87,88] selected patients with Child-Pugh class B and active bleeding at index endoscopy and class C patients (score 10–12)....
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...The studies by Garcia-Pagan [87,88] selected patients with Child-Pugh class B and active bleeding at index...
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...[87] used a more clinical approach for patients’ selection....
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...Results of two randomized controlled trials [86,87] and one retro-...
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...The second study by García-Pagán et al. [87] used a more clinical approach for patients’ selection....
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