Safety and efficacy of transfemoral intrahepatic portosystemic shunt for portal hypertension: A single-center retrospective study
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Transfemoral intrahepatic portosystemic shunt (TFIPS) can be performed to treat portal hypertension. However, few studies have evaluated the safety and efficacy of this technique.To retrospectively evaluate the safety and clinical outcomes of TFIPS and compare them with those of typical transjugular intrahepatic portosystemic shunt (TIPS).This retrospective study was approved by our hospital ethics committee. From November 2012 to November 2015, 19 patients who underwent successful TFIPS placement were included. In addition, 21 patients treated with TIPS during the same period were selected as controls. Data collected included the success rate and complications of TIPS and TFIPS. Continuous data were expressed as the mean ± SD and were compared using the Student's t test. All categorical data were expressed as count (percentage) and were compared using the χ2 test or Fisher's exact test. The Kaplan-Meier method was used to calculate cumulative survival rate and survival curves.Baseline characteristics were comparable between the two groups. The success rate of TFIPS and TIPS was 95% (19/20) and 100% (21/21), respectively. Effective portal decompression and free antegrade shunt flow was completed in all patients. The portal pressure gradient prior to TIPS and TFIPS placement was 23.91 ± 4.64 mmHg and 22.61 ± 5.39 mmHg, respectively, and it was significantly decreased to 10.85 ± 3.33 mmHg and 10.84 ± 3.33 mmHg after stent placement, respectively. Time-to-event calculated rates of shunt patency at one and two years in the TFIPS and TIPS groups were not statistically different (94.7% vs 95.2% and 94.7% vs 90.5%, respectively). De nova hepatic encephalopathy was 27.5% (11/40) with five patients in the TFIPS group (26.3%) and six patients (28.6%) in the TIPS group experiencing it (P = 0.873). The cumulative survival rates were similar between the two groups: 94.7% and 94.7% at 1 and 2 years, respectively, in the TFIPS group vs 100% and 95.2% at 1 and 2 years, respectively, in the TIPS group (P = 0.942).TFIPS may be a valuable adjunct to traditional approaches in patients with portal hypertension.Keywords:
Single Center
Portosystemic shunt
The transjugular intrahepatic portosystemic shunt (TIPS) is an acceptable procedure that has proven benefits in the treatment of patients who have complications from portal hypertension due to liver cirrhosis.Delayed liver laceration is a rare complication of the TIPS procedure.We describe a patient with portal hypertension due to liver cirrhosis, who suddenly presented with abdominal hemorrhage and liver laceration 8 d after TIPS.Few reports have described complications after TIPS placement.To the best of our knowledge, this is the first report describing delayed liver laceration.This potential and serious complication appears to be specific and fatal for TIPS in portal hypertension.We advocate careful attention to the technique to avoid this complication, and timely treatment is extremely important.
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The pathologic increase in the pressure gradient between portal vein and inferior venacava is called portal hypertension. Increased portal blood flow and increased resistance in the portal venous system cause portal hypertension. The structural components and the functional components contribute to the resistance. Hepatic venous pressure gradient (HVPG) reflects the degree of portal pressure in liver disease. HVPG is calculated as the difference between the wedged hepatic venous pressure (WHVP) and the free hepatic venous pressure (FHVP). Clinically significant portal hypertension (CSPH) is defined as HVPG ≥10. Different values of HVPG have been defined as threshold for different consequences of portal hypertension. Variceal hemorrhage, portal hypertensive gastropathy, ascites, colopathy, biliopathy and hepatopulmonary syndrome are main complications of portal hypertension. Besides nonselective beta blockers, other drugs like statins, antioxidants, antidiabetic, anti-inflammatory and antiapoptotic drugs have also been seen to be effective in reducing portal pressure.
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Abstract: Portal hypertension is the main driver of complications in patients with advanced chronic liver disease (ACLD) and is defined by values of hepatic venous pressure gradient measurement (HVPG) > 5 mmHg. Values of HVPG ≥ 10 mmHg determine the presence of clinically significant portal hypertension (CSPH), the main predictor of the risk of variceal bleeding, hepatic decompensation, and mortality. However, its measurement is invasive and requires high expertise, so its routine use outside third level centers or clinical trials is limited. In the last decades, several non-invasive tests (NITs) have been developed and validated for the diagnosis of portal hypertension. Among these, liver (LSM) and spleen stiffness measurement (SSM) are the most promising tools available, as they have been proven accurate to predict CSPH, high-risk esophageal varices, decompensation, and mortality in patients with ACLD. In the last Baveno VI Consensus proceedings, LSM evaluation was recommended for the first time for diagnosis of CSPH (LSM > 20-25 kPa) and the screening of patients with a low probability of having high-risk varices (LSM < 20 kPa and platelet count > 150.000/mm 3 ). In this review, we aimed to summarize the growing evidence supporting the use of non-invasive tests for the evaluation of portal hypertension in patients with chronic liver disease. Keywords: liver stiffness, spleen stiffness, portal hypertension, hepatic venous pressure gradient, liver cirrhosis
Decompensation
Chronic liver disease
Liver disease
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Hydrothorax
Portosystemic shunt
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Grieco, Stefania MD; Sulekova, Lucia Fontanelli MD; Nardelli, Silvia MD; Riggio, Oliviero PhD; Venditti, Mario MD; Taliani, Gloria PhD Author Information
Portosystemic shunt
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Portal hypertension is a major consequence of any chronic liver disease and it represents the main mechanism of complication occurrence. Therefore, the assessment of portal hypertension presence is one of the most important steps in the management of any chronic liver diseases. The most accurate tool for portal pressure assessment is hepatic venous pressure gradient (HVPG) measurement, which has diagnostic and prognostic relevance. In this paper we review the methodology of HVPG measuring, together with the clinical relevance of this technique. Portal hypertension is defined as a HVPG higher than 5 mmHg, but clinically significant portal hypertension that predisposes to clinical decompensation is defined as HVPG higher than 10 mmHg. HVPG is useful for portal hypertension treatment monitoring. A decrease in HVPG greater than 20% or under the threshold of 12 mmHg is considered to be protective against portal hypertension-related events. Even if HVPG measurement is a safe procedure, it is still considered an invasive technique and not widely available. Therefore, non-invasive markers of portal hypertension were searched for. Until now only liver stiffness measurement by transient elastography has proved to be sufficiently accurate but there is still heterogeneity among the cut-off values for portal hypertension diagnosis.
Transient elastography
Decompensation
Chronic liver disease
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Transjugular intrahepatic portosystemic shunt (TIPS) is an established intervention to treat complicated portal hypertension refractory to medical or endoscopic management. TIPS dysfunction results in the recurrence of portal hypertension symptoms. In cases of TIPS dysfunction or persistent portal hypertension despite a patent primary TIPS, the creation of parallel TIPS may be the only intervention to effectively reduce portal pressure. Since the introduction of dedicated TIPS stents (Viatorr®) the incidence of TIPS dysfunction has reduced profoundly. Nevertheless, the creation of a parallel TIPS can still be necessary in the current dedicated TIPS stent era.We report one such patient who experienced ongoing portal hypertension induced upper gastro-intestinal haemorrhage despite multiple TIPS revisions and a patent primary TIPS.Following creation of a parallel TIPS, the patient remains in clinical remission with no further bleeding.
Refractory (planetary science)
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Hepatic Encephalopathy
Portal hypertensive gastropathy
Liver disease
Gastrointestinal bleeding
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It is now well established that portal hypertension is not a purely mechanical phenomenon. Primary hemodynamic alterations develop in the hepatic and systemic circulatory systems; these alterations in combination with mechanical factors contribute to the development of portal hypertension. In the hepatic circulation, these hemodynamic alterations are characterized by vasoconstriction and impaired hepatic vasodilatory responses, whereas in the systemic circulation, particularly in the splanchnic bed, vessels are hyperemic with increased flow. Thus, an increase in intrahepatic resistance in conjunction with increased portal venous inflow, mediated through splanchnic dilation, contributes to the development of portal hypertension. The ensuing development of elevated flow and transmural pressure through collateral vessels from the hypertensive portal vasculature into the lower pressure systemic venous circulation accounts for many of the complications, such as bleeding esophageal varices, observed with portal hypertension. The importance of the primary vascular origin of portal hypertension is emphasized by the utility of current therapies aimed at reversing these hemodynamic alterations, such as nitrates, which reduce portal pressure through direct intrahepatic vasodilatation, and ,B blockers and octreotide, which reduce splanchnic vasodilatation and portal venous inflow. New evidence concerning relevant molecular mechanisms of contractile signaling pathways in hepatic stellate cells and the complex regulatory pathways of vasoactive molecules in liver endothelial cells makes a better understanding of these processes essential for developing further experimental therapies for portal hypertension. This article examines the current concepts relating to cellular mechanism that underlie the hemodynamic alterations that characterize and account for the development of portal hypertension.
Hyperdynamic circulation
Splanchnic Circulation
Collateral circulation
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AIM:To evaluate the feasibility of a second parallel transjugular intrahepatic portosystemic shunt (TIPS) to reduce portal venous pressure and control complications of portal hypertension. METHODS:From January 2011 to December 2012, 10 cirrhotic patients were treated for complications of portal hypertension.The demographic data, operative data, postoperative recovery data, hemodynamic data, and complications were analyzed. RESULTS:Ten patients underwent a primary and parallel TIPS.Technical success rate was 100% with no technical complications.The mean duration of the first operation was 89.20 ± 29.46 min and the second operation was 57.0 ± 12.99 min.The mean portal system pressure decreased from 54.80 ± 4.16 mmHg to 39.0 ± 3.20 mmHg after the primary TIPS and from 44.40 ± 3.95 mmHg to 26.10 ± 4.07 mmHg after the parallel TIPS creation.The mean portosystemic pressure gradi-ent decreased from 43.80 ± 6.18 mmHg to 31.90 ± 2.85 mmHg after the primary TIPS and from 35.60 ± 2.72 mmHg to 15.30 ± 3.27 mmHg after the parallel TIPS creation.Clinical improvement was seen in all patients after the parallel TIPS creation.One patient suffered from transient grade Ⅰ hepatic encephalopathy (HE) after the primary TIPS and four patients experienced transient grade Ⅰ-Ⅱ after the parallel TIPS procedure.Mean hospital stay after the first and second operations were 15.0 ± 3.71 d and 16.90 ± 5.11 d (P = 0.014), respectively.After a mean 14.0 ± 3.13 mo follow-up, ascites and bleeding were well controlled and no stenosis of the stents was found.CONCLUSION: Parallel TIPS is an effective approach for controlling portal hypertension complications.
Hepatic Encephalopathy
Portosystemic shunt
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