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Table of Contents
ORIGINAL ARTICLE
Year : 2019  |  Volume : 2  |  Issue : 1  |  Page : 15-18

Retrospective study of hepatic encephalopathy by different transjugular intrahepatic portosystemic shunt ways in portal hypertension


Department of Vascular Surgery, Zibo Central Hospital, Zibo, China

Date of Submission09-Feb-2018
Date of Acceptance01-Feb-2019
Date of Web Publication24-Jul-2019

Correspondence Address:
Xin Huo
Department of Vascular Surgery, Zibo Central Hospital, Zibo
China
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/VIT.VIT_6_19

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  Abstract 

OBJECTIVE: The objective of the study was to evaluate the effectiveness and safety of the use of different shunting ways in patients with liver cirrhosis undergoing transjugular intrahepatic portosystemic shunt (TIPS).
MATERIALS AND METHODS: We analyzed the data of 36 patients with liver cirrhosis who received de novo TIPS implantation. Sixteen patients had elective TIPS by shunting the blood to the left downstream veins and 20 to the right ones. All patients were followed up for 2 years. We assessed hepatic encephalopathy (HE), rebleeding, and survival rate in all patients post-TIPS.
RESULTS: Under our surgical procedure, more post-TIPS HE was observed in the TIPS-left group, whereas rebleeding was detected in the TIPS-right group (P < 0.05).
CONCLUSIONS: The decision regarding TIPS placement way for portal hypertension patients needs individualization to allow its safe use, with concomitant improvement in perioperative morbidity.

Keywords: Hepatic encephalopathy, portal hypertension, transjugular intrahepatic portosystemic shunt


How to cite this article:
Huo X, Cui XW, Wang M, Jing C, Wu Y, Yu XM, Zhou H, Li WP, Cai XC, Zhou GZ, Zhang YJ. Retrospective study of hepatic encephalopathy by different transjugular intrahepatic portosystemic shunt ways in portal hypertension. Vasc Invest Ther 2019;2:15-8

How to cite this URL:
Huo X, Cui XW, Wang M, Jing C, Wu Y, Yu XM, Zhou H, Li WP, Cai XC, Zhou GZ, Zhang YJ. Retrospective study of hepatic encephalopathy by different transjugular intrahepatic portosystemic shunt ways in portal hypertension. Vasc Invest Ther [serial online] 2019 [cited 2019 Aug 19];2:15-8. Available from: http://www.vitonline.org/text.asp?2019/2/1/15/263390


  Introduction Top


Chronic hepatitis B and C infection accounts for the majority of liver cirrhosis, which progresses to portal hypertension (PH), ascites, or hepatocellular carcinoma (HCC).[1]

Transjugular intrahepatic portosystemic shunt (TIPS) is a percutaneously created low-resistance channel between the portal vein and the hepatic vein. The goal of TIPS is to reduce portal pressure by shunting blood from the portal to the systemic circulation. TIPS has been widely applied for treating refractory PH, and this approach is usually regarded as a bridging treatment to liver transplantation. Successful outcomes of TIPS therapy include the management of variceal bleeding, refractory ascites, hepatic hydrothorax, and faster recovery time. On the other hand, TIPS leads to worsened gut-derived hyperammonemia, shunt stenosis, recurrence of variceal bleeding, and refractory ascites in approximately 50% of patients in 1 year.[2],[3] It is an urgent need to explore new therapy to improve the outcomes post-TIPS.

In the current study, we reported our surgical procedure of shunting blood from the portal to the different systemic blood vessels' circulation. The primary objective of this study was to retrospectively evaluate the effectiveness and safety of the use of different shunting ways in patients with PH undergoing TIPS.


  Materials and Methods Top


Patient information

We analyzed all patients with cirrhosis and portal hypertension who were admitted to hospital due to recurrent bleeding of acute gastroesophageal varices from December 2014 to December 2016.

The inclusion criteria were as follows: a Child–Pugh score up to 12, with a history of three gastroesophageal variceal bleedings, or two bleeding episodes occurring <1 month apart. TIPS patients were included in the study at the time of the procedure, that is, on average of 30 days after the last bleeding episode. The exclusion criteria included (a) chronic occlusion of the portal vein, (b) HCC or other malignant lesions, (c) acute alcoholic hepatitis, (d) age over 75 years, and (e) chronic portosystemic HE.

There were 36 patients enrolled in the study. Of these, 16 patients had elective TIPS by shunting the blood to the left downstream veins and 20 to the right ones. All patients were followed up for 2 years. The current study was approved by the Medical Ethics Committee of Zibo Central Hospital.

Procedures

The procedures of TIPS were followed as the previous studies [4] and are only briefly described here. The hepatic vein was catheterized only when the patient was under sedation and stable hemodynamics. Using a Colapinto needle catheter, a tract is created between one of the hepatic veins and an intrahepatic portion of the portal vein or the left gastric vein [Figure 1]. The tract was then dilated and kept patent by deployment of a bare stent across it. Parallel stents, prophylactic anticoagulants, and antibiotics were not used in any patient. Portal pressure gradient was reduced to 8 mmHg or at least 20% from baseline levels using bare stents dilated with 10- or 12-mm balloon, which was based on the reduction achieved in pressure gradient.
Figure 1: Bleeding of portal vein

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Follow-up

Follow-up observation included clinical assessment, upper gastrointestinal endoscopy, ultrasound (US) examination of the abdomen, and examination of shunt flow using color duplex US. Routine surveillance examinations are performed at the end of 3 months, 6 months, 12 months, and 24 months, while an acute clinical examination was performed anytime in all patients if a patient developed recurrent symptoms, such as variceal bleeding, hepatic encephalopathy (HE), and/or ascites. The baseline color duplex US examination of the TIPS is performed within 24 h after its placement. Shunt patency is reassessed at discharge, and the result serves as a reference value for follow-up examinations. The TIPS was examined by color duplex US. Venography and portosystemic pressure gradient measurements were used to confirm shunt abnormalities.

Statistical analysis

The data were analyzed with the use of SPSS software (SPSS Inc., Chicago, IL, USA) and presented as mean ± standard deviation. The paired t-tests were used to measure the differences among the groups. P < 0.05 was considered statistically significant.


  Results Top


Clinical data

General features were not obviously abnormal in both the groups [Table 1]. The median observation time was 14.61 ± 20.47 months.
Table 1: General characteristics of portal hypertension patients

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Transjugular intrahepatic portosystemic shunt procedure

TIPS had been performed under local anesthesia in all patients with bare stent (10 or 12 mm in diameter and 60–80 mm in length). The average portal pressure was 27.16 ± 3.87 mmHg (range: 23–39) prior to the procedure and 8.13 ± 3.25 mmHg (range: 8–21) after it. The average decrease of the portal pressure was 31.6% (range: 20%–54%).

The splenic vein is generally laminar along the left side of the portal vein, and most of blood in it enters the left branch of the portal vein. The superior mesenteric vein is generally laminar along the right side of the portal vein, and most of blood in it enters the right branch of the portal vein.

Hepatic encephalopathy

As shown in [Table 1], 11 patients (75.0%) in the TIPS-left group and 11 patients (55.0%) in the TIPS-right group developed clinically evident HE. The difference was statistically significant (P = 0.05). The treatment of HE post-TIPS included withdrawal of diuretics, psychotropic medication or the commencement of lactulose (n = 9), the use of antimicrobials (n = 5), and the treatment of rebleeding (n = 5).

Rebleeding

A significantly higher number of patients with rebleeding episodes were observed in the TIPS-right group (12 patients, 60.0%) than in the TIPS-left group (7 patients, 43.75%; P = 0.05) in 2 years. The majority of rebleeding occurred in the 2nd year and was significantly higher in TIPS-right than in TIPS-left patients.

Survival

Cumulative survival in the TIPS-left group was 100% after 1 year and 85.0% after 2 years. In the TIPS-right group, survival was 93.75% after 1 year and 75.0% after 2 years. In the TIPS-left group, the main cause of death was HE, whereas in the TIPS-right group, it was variceal rebleeding.


  Discussion Top


In the current study, our results proved the effectiveness and safety of the use of different shunting ways in patients with PH undergoing TIPS. Under our surgical procedure, more post-TIPS HE was observed in the TIPS-left group, whereas rebleeding was detected in the TIPS-right group. To our knowledge, this is the first report regarding outcomes of TIPS of different shunting ways in the treatments of cirrhotic patients. Our results also suggested that the individualization decision for TIPS placement in portal hypertension patients is helpful to improve their liver function.

TIPS implantation is a safe and effective treatment of complications of portal hypertension.[5] The most important drawback of TIPS implantation is the development of post-TIPS HE, which is secondary to shunting of the blood with toxins in the brain.[6],[7] We tried to shunt the blood in the portal vein to different downstream blood vessels, and our data showed that less post-TIPS HE was observed in the TIPS-right group. In the TIPS-left group, a total of 11 patients (11/16) were reported to develop HE postsurgery. Of 11 patients with HE, 5 were Child–Turcotte–Pugh (CTP) A, 2 were CTP B, and 4 were CTP C class. These data suggested that diverting the blood from the central hepatic vein to the right downstream vein might benefit to relieve the ammonia level in the plasma, thereby improving the liver function. Moreover, careful evaluation of each individual patient with cirrhosis is essential to determine the effect of TIPS for these patients. The other methods reported in the previous studies included using small-diameter shunts to improve the technical aspects of TIPS implantation, while the new options in the medical treatment of HE are explored, such as rifaximin [8] and gastric acid suppression by proton pump inhibitors (PPIs).[9] Taken together, these data indicated a future integrated treatment of cirrhosis.

Next, we analyzed the hemodynamic equilibrium in the current study. Even the hepatic venous pressure reduces immediately after TIPS placement, it needs time to build the new hemodynamic equilibrium and its clinical effects.[10],[11] In the current study, 12 patients (12/20) were suffered of rebleeding in the TIPS-right group, which suggested a higher portal hypertension after TIPS treatment compared to the TIPS-left group. These results also related to hemodynamic equilibrium. One patient who had a pre-TIPS hepatovenous portal gradient (HVPG) of 32 mmHg and a post-TIPS HVPG of 9 mmHg developed right cardiac insufficiency in 2 days after TIPS. This patient had the largest change in HVPG (23 mmHg) among the reported patients. By now, there were no data on the relationship between post-TIPS pressure gradient and the size of shunt in any prediction of TIPS. Further studies need to clarify whether TIPS of different sizes should be individualized based on the patient's pre-TIPS pressure gradient, cardiovascular status, and severity of liver disease.

The main limitation of our study is the retrospective design, which implies the risk of patient selection bias. In the current study, patients in the TIPS-right group were more severe preexisting conditions that might have a higher risk of developing complications such as rebleeding past TIPS. Second, HE was usually a clinical diagnosis before the plasma ammonia level examination. This bears the risk of detection bias since diagnosis and grading of HE is investigator dependent. Furthermore, HE can be confused with other neuropsychiatric disorders, such as forms of deliria. With these limitations in mind, however, this study provides the rationale for designing prospective studies further investigating the effects of different shunting ways on the risk of post-TIPS HE and other complications in patients with liver cirrhosis.

Different shunting ways of TIPS placement for cirrhotic patients have been sought as a viable option to improve their survival rate. The evidence for its safety and its real-world impact on perioperative morbidity is still sparse. More evidence is needed to optimize the selection of stent size to prevent an inadvertent decrease in HVPG and consequently reduce the complication rate. Overall, the decision regarding TIPS placement way for cirrhotic patients needs individualization to allow its safe use, with concomitant improvement in perioperative morbidity.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

1.
Kang W, Kim SU, Ahn SH. Non-invasive prediction of forthcoming cirrhosis-related complications. World J Gastroenterol 2014;20:2613-23.  Back to cited text no. 1
    
2.
Riggio O, Angeloni S, Ridola L. Hepatic encephalopathy after transjugular intrahepatic portosystemic shunt: Still a major problem. Hepatology 2010;51:2237-8.  Back to cited text no. 2
    
3.
Boyer TD, Haskal ZJ; American Association for the Study of Liver Diseases. The role of transjugular intrahepatic portosystemic shunt (TIPS) in the management of portal hypertension: Update 2009. Hepatology 2010;51:306.  Back to cited text no. 3
    
4.
Sturm L, Bettinger D, Giesler M, Boettler T, Schmidt A, Buettner N, et al. Treatment with proton pump inhibitors increases the risk for development of hepatic encephalopathy after implantation of transjugular intrahepatic portosystemic shunt (TIPS). United European Gastroenterol J 2018;6:1380-90.  Back to cited text no. 4
    
5.
Qi XS, Bai M, Yang ZP, Fan DM. Selection of a TIPS stent for management of portal hypertension in liver cirrhosis: An evidence-based review. World J Gastroenterol 2014;20:6470-80.  Back to cited text no. 5
    
6.
Luo SH, Chu JG, Huang H, Zhao GR, Yao KC. Targeted puncture of left branch of intrahepatic portal vein in transjugular intrahepatic portosystemic shunt to reduce hepatic encephalopathy. World J Gastroenterol 2019;25:1088-99.  Back to cited text no. 6
    
7.
Luo X, Zhao M, Wang X, Jiang M, Yu J, Li X, et al. Long-term patency and clinical outcome of the transjugular intrahepatic portosystemic shunt using the expanded polytetrafluoroethylene stent-graft. PLoS One 2019;14:e0212658.  Back to cited text no. 7
    
8.
Hudson M, Schuchmann M. Long-term management of hepatic encephalopathy with lactulose and/or rifaximin: A review of the evidence. Eur J Gastroenterol Hepatol 2019;31:434-50.  Back to cited text no. 8
    
9.
Bian J, Wang A, Lin J, Wu L, Huang H, Wang S, et al. Association between proton pump inhibitors and hepatic encephalopathy: A meta-analysis. Medicine (Baltimore) 2017;96:e6723.  Back to cited text no. 9
    
10.
Kuhn-Fulton J, Trerotola SO, Harris VJ, Snidow JJ, Johnson MS, Carey MA, et al. Transjugular intrahepatic portosystemic shunt procedure: Efficacy of 10-mm versus 12-mm wallstents. Radiology 1996;199:658-64.  Back to cited text no. 10
    
11.
Riggio O, Ridola L, Angeloni S, Cerini F, Pasquale C, Attili AF, et al. Clinical efficacy of transjugular intrahepatic portosystemic shunt created with covered stents with different diameters: Results of a randomized controlled trial. J Hepatol 2010;53:267-72.  Back to cited text no. 11
    


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