Anticoagulation and Transjugular Intrahepatic Portosystemic Shunt for the Management of Portal Vein Thrombosis in Cirrhosis: A Prospective Observational Study.

INTRODUCTION: Current guidelines recommend anticoagulation as the mainstay of portal vein thrombosis (PVT) treatment in cirrhosis. However, because of the heterogeneity of PVT, anticoagulation alone does not always achieve satisfactory results. This study aimed to prospectively evaluate an individualized management algorithm using a wait-and-see strategy (i.e., no treatment), anticoagulation, and transjugular intrahepatic portosystemic shunt (TIPS) to treat PVT in cirrhosis. METHODS: Between February 2014 and June 2018, 396 consecutive patients with cirrhosis with nonmalignant PVT were prospectively included in a tertiary care center, of which 48 patients (12.1%) were untreated, 63 patients (15.9%) underwent anticoagulation, 88 patients (22.2%) underwent TIPS, and 197 patients (49.8%) received TIPS plus post-TIPS anticoagulation. The decision of treatment option mainly depends on the stage of liver disease (symptomatic portal hypertension or not) and degree and extension of thrombus. RESULTS: During a median 31.7 months of follow-up period, 312 patients (81.3%) achieved partial (n = 25) or complete (n = 287) recanalization, with 9 (3.1%) having rethrombosis, 64 patients (16.2%) developed major bleeding (anticoagulation-related bleeding in 7 [1.8%]), 88 patients (22.2%) developed overt hepatic encephalopathy, and 100 patients (25.3%) died. In multivariate competing risk regression models, TIPS and anticoagulation were associated with a higher probability of recanalization. Long-term anticoagulation using enoxaparin or rivaroxaban rather than warfarin was associated with a decreased risk of rethrombosis and an improved survival, without increasing the risk of bleeding. However, the presence of complete superior mesenteric vein thrombosis was associated with a lower recanalization rate, increased risk of major bleeding, and poor prognosis. DISCUSSION: In patients with cirrhosis with PVT, the individualized treatment algorithm achieves a high-probability recanalization, with low rates of portal hypertensive complications and adverse events.

Safety and efficacy of angiographic occlusion of duodenal varices as an alternative to TIPS: review of 32 cases.

UNLABELLED: BACKGROUND/RATIONALE OF STUDY: Analyze safety and efficacy of angiographic-occlusion-with-sclerotherapy/embolotherapy-without-transjugular-intrahepatic-portosystemic-shunt (TIPS) for duodenal varices. Although TIPS is considered the best intermediate-to-long term therapy after failed endoscopic therapy for bleeding varices, the options are not well-defined when TIPS is relatively contraindicated, with scant data on alternative therapies due to relative rarity of duodenal varices. Prior cases were identified by computerized literature search, supplemented by one illustrative case. Favorable clinical outcome after angiography defined as no rebleeding during follow-up, without major procedural complications. RESULTS: Thirty-two cases of duodenal varices treated by angiographic-occlusion-with-sclerotherapy/embolotherapy- without-TIPS were analyzed. Patients averaged 59.5 ± 12.2 years old (female = 59%). Patients presented with melena-16, hematemesis & melena-5, large varices-5, growing varices-2, ruptured varices-1, and other- 3. Twenty-nine patients had cirrhosis; etiologies included: alcoholism-11, hepatitis C-11, primary biliary cirrhosis- 3, hepatitis B-2, Budd-Chiari-1, and idiopathic-1. Three patients did not have cirrhosis, including hepatic metastases from rectal cancer-1, Wilson's disease-1, and chronic liver dysfunction-1. Thirty-one patients underwent esophagogastroduodenoscopy before therapeutic angiography, including fifteen undergoing endoscopic variceal therapy. Therapeutic angiographic techniques included balloon-occluded retrograde-transvenous-obliteration (BRTO) with sclerotherapy and/or embolization-21, DBOE (double-balloon-occluded-embolotherapy)-5, and other-6. Twenty-eight patients (87.5%; 95%-confidence interval: 69-100%) had favorable clinical outcomes after therapeutic angiography. Three patients were therapeutic failures: rebleeding at 0, 5, or 10 days after therapy. One major complication (Enterobacter sepsis) and one minor complication occurred. CONCLUSIONS: This work suggests that angiographic-occlusion-with sclerotherapy/ embolotherapy-without-TIPS is relatively effective (~90% hemostasis-rate), and relatively safe (3% major-complication-rate). This therapy may be a useful treatment option for duodenal varices when endoscopic therapy fails and TIPS is relatively contraindicated.

Repeated transcatheter arterial chemoembolization is safe for hepatocellular carcinoma in cirrhotic patients with transjugular intrahepatic portosystemic shunt.

PURPOSE: We aimed to investigate the safety and long-term outcomes of repeated transcatheter arterial chemoembolization (TACE) in cirrhotic patients with transjugular intrahepatic portosystemic shunt (TIPS). METHODS: Data of patients with hepatocellular carcinoma, who had previous TIPS implantation and received TACE between January 2010 and December 2012, were reviewed retrospectively. The primary outcome measure was liver function, which was represented by model for end-stage liver disease score, Child-Pugh-Turcotte score, serum total bilirubin, alanine aminotransferase, and aspartate aminotransferase. Changes in liver function before and after the initial TACE procedure and hepatobiliary severe adverse events (SAEs) were compared. Liver function following the initial TACE session was compared with that obtained in later TACE sessions. The secondary outcome measures were tumor response to multiple TACE sessions and survival. RESULTS: Seventeen patients underwent at least two TACE sessions, while nine patients underwent at least three sessions during the follow-up period. There was no statistically significant difference between the liver function tests performed before and one-month after the TACE procedure. Grade 3 or 4 SAEs occurred in six (31.6 %) patients within one month. The one, two-, and three-year survival rates were 88%, 53%, and 32%, respectively. Tumor response of multiple TACE sessions was the only predictive risk factor of mortality (OR=4.40; P = 0.030; 95% CI, 1.15-16.85). CONCLUSION: Our results suggest that repeated TACE is safe in selected patients with TIPS.

[Pleural effusions and ascites--surgical and palliative aspects]. / Pleuraerguss und Aszites--chirurgische und palliative Aspekte.

BACKGROUND: Pleural effusions and ascites are associated with distressing symptoms like dyspnoea, intestinal obstruction, vomiting, nausea and pain. In patients with underlying malignancy, the prognosis is limited to few months. After unsuccessful medical treatment, surgical and experimental palliative treatment is indicated. METHODS: This review includes a systematic analysis of surgical, experimental and palliative options. RESULTS: In patients with pleural effusions, thoracocentesis, permanent percutaneous drainage, thoracoperitoneal shunts as well as pleurodesis by tubes or thoracoscopy are available, which will be used depending on the re-expansion of the lung. In patients with ascites, paracentesis is able to control acute symptoms. For long-lasting treatment, portosystemic shunts (TIPS) are favourable for patients with liver cirrhosis. Peritoneovenous shunts can be implanted by laparotomy, but are correlated with high rates of complications and occlusions. In patients with malignancy, pleural effusions and ascites may also be controlled by complete cytoreductive surgery and hyperthermic chemoperfusion. This aggressive surgical concept is limited to single carefully selected patients. In malignant ascites, intraperitoneal immunotherapy by catumaxomab is a novel and highly effective option, which controls ascites by targeted destruction of peritoneal cancer cells. CONCLUSION: Various options for treatment of pleural effusions and ascites are available. Careful evaluation of the individual patient is necessary to improve quality of life and survival.