Transjugular Intrahepatic Portosystemic Shunt in the Management of Refractory Ascites

 

 Buy Article Permissions and Reprints

ABSTRACT

The purpose of this article is to describe the pathophysiological basis for the use of transjugular intrahepatic portosystemic shunt (TIPS) in patients with cirrhosis and refractory ascites, the short- and long-term hemodynamic, biochemical, and hormonal changes after TIPS, and the results of controlled trials of TIPS in cirrhotic patients with refractory ascites. TIPS placement is associated with normalization of sinusoidal pressure and a significant improvement in urinary sodium excretion that correlates with suppression of plasma renin activity (indicative of an improvement in effective arterial blood volume). Although effective in preventing the recurrence of ascites, the efficacy of TIPS is offset by an increase in the incidence of severe hepatic encephalopathy, a high incidence of shunt dysfunction, and a higher cost without an overall survival benefit, which should be reevaluated in light of polytetrafluoroethylene-covered stents. TIPS placement is currently indicated in seleceted cirrhotic patients with refractory ascites who require more than two to three large-volume paracenteses per month.

REFERENCES

• 1 Loureiro-Silva M R, Cadelina G W, Groszmann R J. Deficit in nitric oxide production in cirrhotic rat livers is located in the sinusoidal and postsinusoidal areas.  Am J Physiol Gastrointest Liver Physiol. 2003;  284 G567-G574
  CrossrefPubMedGoogle Scholar
• 2 Rector W G. Portal hypertension: a permissive factor only in the development of ascites and variceal bleeding.  Liver. 1986;  6 221-226
  PubMedGoogle Scholar
• 3 Morali G A, Sniderman K W, Deitel K M et al.. Is sinusoidal portal hypertension a necessary factor for the development of hepatic ascites?.  J Hepatol. 1992;  16 249-250
  CrossrefPubMedGoogle Scholar
• 4 Villanueva C, Minana J, Ortiz J et al.. Endoscopic ligation compared with combined treatment with nadolol and isosorbide mononitrate to prevent recurrent variceal bleeding.  N Engl J Med. 2001;  345 647-655
  CrossrefPubMedGoogle Scholar
• 5 Abraldes J G, Tarantino I, Turnes J et al.. Hemodynamic response to pharmacological treatment of portal hypertension and long-term prognosis of cirrhosis.  Hepatology. 2003;  37 902-908
  CrossrefPubMedGoogle Scholar
• 6 Schrier R W, Arroyo V, Bernardi M et al.. Peripheral arterial vasodilation hypothesis: a proposal for the initiation of renal sodium and water retention in cirrhosis.  Hepatology. 1988;  8 1151-1157
  CrossrefPubMedGoogle Scholar
• 7 Arroyo V, Gines P, Gerbes A L et al.. Definition and diagnostic criteria of refractory ascites and hepatorenal syndrome in cirrhosis.  Hepatology. 1996;  23 164-176
  CrossrefPubMedGoogle Scholar
• 8 Salerno F, Borroni G, Moser P et al.. Survival and prognostic factors of cirrhotic patients with ascites: a study of 134 outpatients.  Am J Gastroenterol. 1993;  88 514-519
  PubMedGoogle Scholar
• 9 Moore K P, Wong F, Gines P et al.. The management of ascites in cirrhosis: consensus conference of the International Ascites Club.  Hepatology. 2003;  38 258-266
  PubMedGoogle Scholar
• 10 Gines A, Fernandez-Esparrach G, Monescillo A et al.. Randomized trial comparing albumin, dextran-70 and polygeline in cirrhotic patients with ascites treated by paracentesis.  Gastroenterology. 1996;  111 1002-1010
  CrossrefPubMedGoogle Scholar
• 11 Ruiz del Arbol L, Monescillo A, Jimenez W et al.. Paracentesis-induced circulatory dysfunction: mechanism and effect on hepatic hemodynamics in cirrhosis.  Gastroenterology. 1997;  113 579-586
  CrossrefPubMedGoogle Scholar
• 12 Gines P, Arroyo V, Vargas V et al.. Paracentesis with intravenous infusion of albumin as compared with peritoneovenous shunting in cirrhosis with refractory ascites.  N Engl J Med. 1991;  325 829-835
  PubMedGoogle Scholar
• 13 Gines A, Planas R, Angeli P et al.. Treatment of patients with cirrhosis and refractory ascites by LeVeen shunt with titanium tip. Comparison with therapeutic paracentesis.  Hepatology. 1995;  22 124-131
  CrossrefPubMedGoogle Scholar
• 14 Castells A, Salo J, Planas R et al.. Impact of shunt surgery for variceal bleeding in the natural history of ascites in cirrhosis: a retrospective study.  Hepatology. 1994;  20 584-591
  CrossrefPubMedGoogle Scholar
• 15 Voorhees A BJ, Price J BJ, Britton R C. Portasystemic shunting procedures for portal hypertension: twenty-six year experience in adults with cirrhosis of the liver.  Am J Surg. 1970;  119 501-505
  CrossrefPubMedGoogle Scholar
• 16 Orloff M J, Orloff M S, Orloff S L et al.. Experimental, clinical, and metabolic results of side-to-side portacaval shunt for intractable cirrhotic ascites.  J Am Coll Surg. 1997;  184 557-570
  PubMedGoogle Scholar
• 17 Franco D, Vons C, Traynor O et al.. Should portosystemic shunt be reconsidered in the treatment of intractable ascites in cirrhosis?.  Arch Surg. 1988;  123 987-991
  PubMedGoogle Scholar
• 18 Luca A, D'Amico G, LaGalla R et al.. TIPS for prevention of recurrent bleeding in patients with cirrhosis: meta-analysis of randomized clinical trials.  Radiology. 1999;  212 411-421
  CrossrefPubMedGoogle Scholar
• 19 Wong F, Sniderman K, Liu P et al.. Transjugular intrahepatic portosystemic stent shunt: effects on hemodynamics and sodium homeostasis in cirrhosis and refractory ascites.  Ann Intern Med. 1995;  122 816-822
  CrossrefPubMedGoogle Scholar
• 20 Wong F, Sniderman K, Liu P et al.. The mechanism of the initial natriuresis after transjugular intrahepatic portosystemic shunt.  Gastroenterology. 1997;  112 899-907
  CrossrefPubMedGoogle Scholar
• 21 Lebrec D, Giuily N, Hadengue A et al.. Transjugular intrahepatic portosystemic shunts-comparison with paracentesis in patients with cirrhosis and refractory ascites: a randomized trial.  J Hepatol. 1996;  25 135-144
  CrossrefPubMedGoogle Scholar
• 22 Quiroga J, Sangro B, Nunez M et al.. Transjugular intrahepatic portal-systemic shunt in the treatment of refractory ascites: effect on clinical, renal, humoral, and hemodynamic parameters.  Hepatology. 1995;  21 986-994
  CrossrefPubMedGoogle Scholar
• 23 Gerbes A L, Gulberg V, Waggershauser T et al.. Renal effects of transjugular intrahepatic portosystemic shunt in cirrhosis: comparison of patients with ascites, with refractory ascites or without ascites.  Hepatology. 1998;  28 683-688
  CrossrefPubMedGoogle Scholar
• 24 Wong W, Liu P, Blendis L et al.. Long-term renal sodium handling in patients with cirrhosis treated with transjugular intrahepatic portosystemic shunts for refractory ascites.  Am J Med. 1999;  106 315-322
  CrossrefPubMedGoogle Scholar
• 25 Somberg K A, Lake J R, Tomlanovich S J et al.. Transjugular intrahepatic portosystemic shunts for refractory ascites: assessment of clinical and hormonal response and renal function.  Hepatology. 1995;  21 709-716
  CrossrefPubMedGoogle Scholar
• 26 Ferral H, Bjarnason H, Wegryn S A et al.. Refractory ascites: early experience with transjugular intrahepatic portosystemic shunt.  Radiology. 1993;  189 795-801
  PubMedGoogle Scholar
• 27 Russo M W, Sood A, Jacobson I M et al.. Transjugular intrahepatic portosystemic shunt for refractory ascites: an analysis of the literature on efficacy, morbidity, and mortality.  Am J Gastroenterol. 2003;  98 2521-2527
  CrossrefPubMedGoogle Scholar
• 28 Garcia-Tsao G. Transjugular intrahepatic portosystemic shunt for the management of refractory ascites in cirrhosis. In: Gines P, Arroyo V, Rodes J, Schrier RW Ascites and Renal Dysfunction in Liver Disease 2nd edition. Oxford; Blackwell Publishing 2005: 251-259
  Google Scholar
• 29 Rossle M, Ochs A, Gulberg V et al.. A comparison of paracentesis and transjugular intrahepatic portosystemic shunting in patients with ascites.  N Engl J Med. 2000;  342 1701-1707
  CrossrefPubMedGoogle Scholar
• 30 Gines P, Uriz J, Calahorra B et al.. Transjugular intrahepatic portosystemic shunting versus repeated paracentesis plus intravenous albumin for refractory ascites in cirrhosis: a multicenter randomized comparative study.  Gastroenterology. 2002;  123 1839-1847
  CrossrefPubMedGoogle Scholar
• 31 Sanyal A J, Genning C, Reddy K R et al.. The North American Study for the treatment of refractory ascites.  Gastroenterology. 2003;  124 634-641
  CrossrefPubMedGoogle Scholar
• 32 Salerno F, Merli M, Riggio O et al.. Randomized controlled study of TIPS versus paracentesis plus albumin in cirrhosis with severe ascites.  Hepatology. 2004;  40 629-635
  CrossrefPubMedGoogle Scholar
• 33 Arroyo V, Rodes J, Gutierrez Lizarraga M A et al.. Prognostic value of spontaneous hyponatremia in cirrhosis with ascites.  Am J Dig Dis. 1976;  21 249-256
  CrossrefPubMedGoogle Scholar
• 34 Llach J, Gines P, Arroyo V et al.. Prognostic value of arterial pressure, endogenous vasoactive systems, and renal function in cirrhotic patients admitted to the hospital for the treatment of ascites.  Gastroenterology. 1988;  94 482-487
  PubMedGoogle Scholar
• 35 Schepke M, Roth F, Koch L et al.. Prognostic impact of renal impairment and sodium imbalance in patients undergoing transjugular intrahepatic portosystemic shunting for the prevention of variceal rebleeding.  Digestion. 2003;  67 146-153
  CrossrefPubMedGoogle Scholar
• 36 Saab S, Nieto J, Ly D et al.. TIPS versus paracentesis for cirrhotic patients with refractory ascites.  Cochrane Database Syst Rev. 2004;  3 CD004889
  PubMedGoogle Scholar
• 37 Deltenre P, Mathurin P, Dharancy S et al.. Transjugular intrahepatic portosystemic shunt in refractory ascites: a meta-analysis.  Liver Int. 2005;  25 349-356
  CrossrefPubMedGoogle Scholar
• 38 Gulberg V, Liss I, Bilzer M et al.. Improved quality of life in patients with refractory or recidivant ascites after insertion of transjugular intrahepatic portosystemic shunts.  Digestion. 2002;  66 127-130
  CrossrefPubMedGoogle Scholar
• 39 Bureau C, Garcia-Pagan J C, Otal P et al.. Improved clinical outcome using polytetrafluoroethylene-coated stents for TIPS: results of a randomized study.  Gastroenterology. 2004;  126 469-475
  CrossrefPubMedGoogle Scholar
• 40 Angermayr B, Cejna M, Koenig F et al.. Survival in patients undergoing transjugular intrahepatic portosystemic shunt: ePTFE-covered stentgrafts versus bare stents.  Hepatology. 2003;  38 1043-1050
  CrossrefPubMedGoogle Scholar
• 41 Rosemurgy A S, Zervos E E, Clark W C et al.. TIPS versus peritoneovenous shunt in the treatment of medically intractable ascites: a prospective randomized trial.  Ann Surg. 2004;  239 883-889
  CrossrefPubMedGoogle Scholar
• 42 Trotter J F, Suhocki P V. Incarceration of umbilical hernia following transjugular intrahepatic portosystemic shunt for the treatment of ascites.  Liver Transpl Surg. 1999;  5 209-210
  CrossrefPubMedGoogle Scholar
• 43 Riggio O, Masini A, Efrati C et al.. Pharmacological prophylaxis of hepatic encephalopathy after transjugular intrahepatic portosystemic shunt: a randomized controlled study.  J Hepatol. 2005;  42 674-679
  CrossrefPubMedGoogle Scholar
• 44 Banares R, Nunez O, Escudero M et al.. Patients with cirrhosis and bare-stent TIPS may have increased risk of hepatocellular carcinoma.  Hepatology. 2005;  41 566-571
  CrossrefPubMedGoogle Scholar
• 45 Martinet J P, Fenyves D, Legault L et al.. Treatment of refractory ascites using TIPS: a caution.  Dig Dis Sci. 1997;  42 161-166
  CrossrefPubMedGoogle Scholar
• 46 Casado M, Bosch J, Garcia-Pagan J C et al.. Clinical events following transjugular intrahepatic portosystemic shunt: correlation with hemodynamic findings.  Gastroenterology. 1998;  114 1296-1303
  CrossrefPubMedGoogle Scholar
• 47 Riggio O, Merli M, Pedretti G et al.. Hepatic encephalopathy after transjugular intrahepatic portosystemic shunt: incidence and risk factors.  Dig Dis Sci. 1996;  41 578-584
  PubMedGoogle Scholar
• 48 Crenshaw W B, Gordon F D, McEniff N J et al.. Severe ascites: efficacy of the transjugular intrahepatic portosystemic shunt in treatment.  Radiology. 1996;  200 185-192
  PubMedGoogle Scholar
• 49 Nazarian G K, Bjarnason H, Dietz C AJ et al.. Refractory ascites: results of treatment with a transjugular intrahepatic portosystemic shunt.  Radiology. 1997;  205 173-180
  PubMedGoogle Scholar
• 50 Deschenes M, Dufresne M P, Bui B et al.. Predictors of clinical response to transjugular intrahepatic portosystemic shunt (TIPS) in cirrhotic patients with refractory ascites.  Am J Gastroenterol. 1999;  94 1361-1365
  PubMedGoogle Scholar
• 51 Ochs A, Rossle M, Haag K et al.. The transjugular intrahepatic portosystemic stent-shunt procedure for refractory ascites.  N Engl J Med. 1995;  332 1192-1197
  CrossrefPubMedGoogle Scholar
• 52 Malinchoc M, Kamath P S, Gordon F D et al.. A model to predict poor survival in patients undergoing transjugular intrahepatic portosystemic shunts.  Hepatology. 2000;  31 864-871
  CrossrefPubMedGoogle Scholar
• 53 Salerno F, Merli M, Cazzaniga M et al.. MELD score is better than Child-Pugh score in predicting 3-month survival of patients undergoing transjugular intrahepatic portosystemic shunt.  J Hepatol. 2002;  36 494-500
  CrossrefPubMedGoogle Scholar
• 54 Schepke M, Roth F, Fimmers R et al.. Comparison of MELD, Child-Pugh, and Emory model for the prediction of survival in patients undergoing transjugular intrahepatic portosystemic shunting.  Am J Gastroenterol. 2003;  98 1167-1174
  CrossrefPubMedGoogle Scholar
• 55 Angermayr B, Cejna M, Karnel F et al.. Child-Pugh versus MELD score in predicting survival in patients undergoing transjugular intrahepatic portosystemic shunt.  Gut. 2003;  52 879-885
  CrossrefPubMedGoogle Scholar
• 56 Membreno F, Baez A L, Pandula R et al.. Differences in long-term survival after transjugular intrahepatic portosystemic shunt for refractory ascites and variceal bleed.  J Gastroenterol Hepatol. 2005;  20 474-481
  CrossrefPubMedGoogle Scholar

Guadalupe Garcia-TsaoM.D. 

Section of Digestive Diseases, Yale University School of Medicine

One Gilbert Street, TAC, Room #S241B, New Haven, CT 06510