Abstract
Purpose
To compare rebleeding rates following treatment of variceal hemorrhage with TIPS alone versus TIPS with variceal embolization in the covered stent-graft era.
Methods
In this retrospective study, 52 patients (M:F 29:23, median age 52 years) with hepatic cirrhosis and variceal hemorrhage underwent TIPS insertion between 2003 and 2008. Median Child–Pugh and MELD scores were 8.5 and 13.5. Generally, 10-mm diameter TIPS were created using covered stent-grafts (Viatorr; W.L. Gore and Associates, Flagstaff, AZ). A total of 37 patients underwent TIPS alone, while 15 patients underwent TIPS with variceal embolization. The rates of rebleeding and survival were compared.
Results
All TIPS were technically successful. Median portosystemic pressure gradient reductions were 13 versus 11 mmHg in the embolization and non-embolization groups. There were no statistically significant differences in Child–Pugh and MELD score, or portosystemic pressure gradients between each group. A trend toward increased rebleeding was present in the non-embolization group, where 8/37 (21.6%) patients rebled while 1/15 (6.7%) patients in the TIPS with embolization group rebled (P = 0.159) during median follow-up periods of 199 and 252 days (P = 0.374). Rebleeding approached statistical significance among patients with acute hemorrhage, where 8/32 (25%) versus 0/14 (0%) rebled in the non-embolization and embolization groups (P = 0.055). A trend toward increased bleeding-related mortality was seen in the non-embolization group (P = 0.120).
Conclusions
TIPS alone showed a high incidence of rebleeding in this series, whereas TIPS with variceal embolization resulted in reduced recurrent hemorrhage. The efficacy of embolization during TIPS performed for variceal hemorrhage versus TIPS alone should be further compared with larger prospective randomized trials.
Similar content being viewed by others
References
ter Borg PC, Hollemans M, Van Buuren HR, et al. Transjugular intrahepatic porto-systemic shunts: long-term patency and clinical results in a patient cohort observed for 3–9 years. Radiology 2004;231:537–545
Boyer TD. Transjugular intrahepatic portosystemic shunt in the management of complications of portal hypertension. Curr Gastroenterol Rep 2008;10:30–35
Berzigotti A, García-Pagán JC. Prevention of recurrent variceal bleeding. Dig Liver Dis 2008;40:337–342
LaBerge JM, Somberg KA, Lake JR, et al. Two-year outcome following transjugular intrahepatic portosystemic shunt for variceal bleeding: results in 90 patients. Gastroenterology 1995;108:1143–1151
Sahagun G, Benner KG, Saxon R, et al. Outcome of 100 patients after transjugular intrahepatic portosystemic shunt for variceal hemorrhage. Am J Gastroenterol 1997;92:1444–1452
Nazarian G, Ferral H, Castaneda-Zuniga W, et al. Development of stenoses in transjugular intrahepatic porto-systemic shunts. Radiology 1994;192:231–234
Haskal Z, Pentecost M, Soulen M, Shlansky-Goldberg R, Baum R, Cope C. Transjugular intrahepatic porto-systemic shunt stenosis and revision: early and midterm results. AJR Am J Roentgenol 1994;163:439–444
Vignali C, Bargellini I, Grosso M, et al. TIPS with expanded polytetrafluoroethylene-covered stent: results of an Italian multicenter study. AJR Am J Roentgenol 2005;185:472–480
Maleux G, Nevens F, Wilmer A, et al. Early and long-term clinical and radiological follow-up results of expanded-polytetrafluoroethylene-covered stent-grafts for transjugular intrahepatic porto-systemic shunt procedures. Eur Radiol 2004;14:1842–1850
Hausegger KA, Karnel F, Georgieva B, et al. Transjugular intrahepatic portosystemic shunt creation with the Viatorr expanded polytetrafluoroethylene-covered stent-graft. J Vasc Interv Radiol 2004;15:239–248
Jung HS, Kalva SP, Greenfield AJ, et al. TIPS: Comparison of shunt patency and clinical outcomes between bare stents and expanded polytetrafluoroethylene Stent-Grafts. J Vasc Intervent Radiol 2009;20:180–185
Tesdal IK, Filser T, Weiss C, Holm E, Dueber C, Jaschke W. Transjugular intrahepatic portosystemic shunts: adjunctive embolotherapy of gastroesophageal collateral vessels in the prevention of variceal rebleeding. Radiology 2005;236:360–367
Martin M, Zajko AB, Orons PD, et al. Transjugular intrahepatic portosystemic shunt in the management of variceal bleeding: indications and clinical results. Surgery 1993;114:719–726
Haskal ZJ, Scott M, Rubin RA, et al. Intestinal varices: treatment with the transjugular intrahepatic portosystemic shunt. Radiology 1994;191:183–187
Patel N. Transjugular Intrahepatic Portosystemic Shunt. In Portal Hypertension: Diagnosis and Intervention, 2nd ed. Fairfax, VA: Society of Cardiovascular & Interventional Radiology; 2001; 31
Tesdal IK, Jaschke W, Buhler M, et al. Transjugular intrahepatic portosystemic shunting with balloon-expandable and self-expanding stents: technical and clinical aspects after 3 1/2 years’ experience. Cardiovasc Intervent Radiol 1997;20:29–37
Kessler J, Trerotola SO. Use of the Amplatzer Vascular Plug for embolization of a large retroperitoneal shunt during transjugular intrahepatic portosystemic shunt creation for gastric variceal bleeding. J Vasc Intervent Radiol 2006;17:135–140
Abi-Jaoudeh N, Matsumoto AH, Angle FJ, et al. TIPS rebleeding rates for different subtypes of varices in the era of covered stents. J Vasc Intervent Radiol 2008;19:S77–S78
Colapinto RF, Stronell RD, Gildiner M, et al. Formation of intrahepatic portosystemic shunts using a balloon dilatation catheter: preliminary clinical experience. AJR Am J Roentgenol 1983;140:709–714
Boyer TD, Haskal ZJ. American Association for the Study of Liver Disease practice guidelines: the role of transjugular intrahepatic portosystemic shunt creation in the management of portal hypertension. J Vasc Intervent Radiol 2005;16:615
Colombato L. The role of transjugular intrahepatic portosystemic shunt (TIPS) in the management of portal hypertension. J Clin Gastroenterol 2007;41:S344–S351
Angermayr B, Cejna M, Koenig F, et al. Survival in patients undergoing transjugular intrahepatic porto-systemic shunt: ePTFE-covered stent-grafts versus bare stents. Hepatology 2003;38:1043–1050
Charon JP, Alaeddin FH, Pimpalwar SA, et al. Results of a retrospective multicenter trial of the Viatorr expanded polytetrafluoroethylene-covered stent-graft for transjugular intrahepatic portosystemic shunt creation. J Vasc Intervent Radiol 2004;15:1219–1230
Tripathi D, Ferguson J, Barkell H, et al. Improved clinical outcome with transjugular intrahepatic portosystemic stent-shunt utilizing polytetrafluoroethylene-covered stents. Eur J Gastroenterol Hepatol 2006;18:225–232
Burroughs AK, Triantos CK, O’Beirne J, Patch D. Predictors of early rebleeding and mortality after acute variceal hemorrhage in patients with cirrhosis. Nat Clin Pract Gastroenterol Hepatol 2009;6:72–73
Sanyal AJ, Freedman AM, Luketic VA, et al. The natural history of portal hypertension after transjugular intrahepatic portosystemic shunts. Gastroenterology 1997;112:889–898
Maruyama H, Yokosuka O. Current management of gastric varices. JNMA J Nepal Med Assoc 2007;46:143–150
Author information
Authors and Affiliations
Corresponding author
Rights and permissions
About this article
Cite this article
Gaba, R.C., Bui, J.T., Cotler, S.J. et al. Rebleeding rates following TIPS for variceal hemorrhage in the Viatorr era: TIPS alone versus TIPS with variceal embolization. Hepatol Int 4, 749–756 (2010). https://doi.org/10.1007/s12072-010-9206-2
Received:
Accepted:
Published:
Issue Date:
DOI: https://doi.org/10.1007/s12072-010-9206-2