Cognitive Impairment Predicts The Occurrence Of Hepatic Encephalopathy After Transjugular Intrahepatic Portosystemic Shunt.

OBJECTIVES: Hepatic encephalopathy (HE) is a major problem in patients treated with TIPS. The aim of the study was to establish whether pre-TIPS covert HE is an independent risk factor for the development of HE after TIPS. METHODS: Eighty-two consecutive cirrhotic patients submitted to TIPS were included. All patients underwent the PHES to identify those affected by covert HE before a TIPS. The incidence of the first episode of HE was estimated, taking into account the nature of the competing risks in the data (death or liver transplantation). RESULTS: Thirty-five (43%) patients developed overt HE. The difference of post-TIPS HE was highly significant (P=0.0003) among patients with or without covert HE before a TIPS. Seventy-seven percent of patients with post-TIPS HE were classified as affected by covert HE before TIPS. Age: (sHR 1.05, CI 1.02-1.08, P=0.002); Child-Pugh score: (sHR 1.29, CI 1.06-1.56, P=0.01); and covert HE: (sHR 3.16, CI: 1.43-6.99 P=0.004) were associated with post-TIPS HE. Taking into consideration only the results of PHES evaluation, the negative predicting value was 0.80 for all patients and 0.88 for the patients submitted to TIPS because of refractory ascites. Thus, a patient with refractory ascites, without covert HE before a TIPS, has almost 90% probability of being free of HE after TIPS. CONCLUSIONS: Psychometric evaluation before TIPS is able to identify most of the patients who will develop HE after a TIPS and can be used to select patients in order to have the lowest incidence of this important complication.

No effect of albumin infusion on the prevention of hepatic encephalopathy after transjugular intrahepatic portosystemic shunt.

Hepatic encephalopathy (HE) is a major problem in patients submitted to TIPS. Previous studies identified low albumin as a factor associated to post-TIPS HE. In cirrhotics with diuretic-induced HE and hypovolemia, albumin infusion reduced plasma ammonia and improved HE. Our aim was to evaluate if the incidence of overt HE (grade II or more according to WH) and the modifications of venous blood ammonia and psychometric tests during the first month after TIPS can be prevented by albumin infusion. Twenty-three patients consecutively submitted to TIPS were enrolled and treated with 1 g/Kg BW of albumin for the first 2 days after TIPS followed by 0,5 g/Kg BW at day 4th and 7th and then once a week for 3 weeks. Forty-five patients included in a previous RCT (Riggio et al. 2010) followed with the same protocol and submitted to no pharmacological treatment for the prevention of HE, were used as historical controls. No differences in the incidence of overt HE were observed between the group of patients treated with albumin and historical controls during the first month (34 vs 31 %) or during the follow-up (39 vs 48 %). Two patients in the albumin group and three in historical controls needed the reduction of the stent diameter for persistent HE. Venous blood ammonia levels and psychometric tests were also similarly modified in the two groups. Survival was also similar. Albumin infusion has not a role in the prevention of post-TIPS HE.

Non-vascular interventional procedures: effective dose to patient and equivalent dose to abdominal organs by means of DICOM images and Monte Carlo simulation.

This study evaluates X-ray exposure in patient undergoing abdominal extra-vascular interventional procedures by means of Digital Imaging and COmmunications in Medicine (DICOM) image headers and Monte Carlo simulation. The main aim was to assess the effective and equivalent doses, under the hypothesis of their correlation with the dose area product (DAP) measured during each examination. This allows to collect dosimetric information about each patient and to evaluate associated risks without resorting to in vivo dosimetry. The dose calculation was performed in 79 procedures through the Monte Carlo simulator PCXMC (A PC-based Monte Carlo program for calculating patient doses in medical X-ray examinations), by using the real geometrical and dosimetric irradiation conditions, automatically extracted from DICOM headers. The DAP measurements were also validated by using thermoluminescent dosemeters on an anthropomorphic phantom. The expected linear correlation between effective doses and DAP was confirmed with an R(2) of 0.974. Moreover, in order to easily calculate patient doses, conversion coefficients that relate equivalent doses to measurable quantities, such as DAP, were obtained.

Combined radiological-endoscopic management of difficult bile duct stones: 18-year single center experience.

OBJECTIVES: Clinical evidence regarding radiological-endoscopic management of intrahepatic bile duct stones is currently lacking. Our aim is to report our 18-year experience in combined radiological-endoscopic management of intrahepatic difficult bile duct stones. METHODS: From June 1994 to June 2012, 299 symptomatic patients with difficult bile duct stones were admitted to our institution. Percutaneous transhepatic cholangiography (PTC)/biliary drainage/s was performed, dilating the PTC track to 10 or 16 French within 3-7 days. Afterward we carried out percutaneous transhepatic cholangioscopy (PTCS) with electrohydraulic lithotripsy (EHL) and/or interventional radiology techniques. Follow up was made with clinical/laboratory tests and ultrasound (US). We retrospectively analyzed our radiological-endoscopic approach and reported our technical and clinical outcomes. RESULTS: Complete stone clearance was achieved in 298 patients after a maximum of 4 consecutive sessions. Most patients (64.6%) were treated with PTCS/EHL alone, while the remaining with radiological techniques alone (26%) or a combination of both techniques (13.3%). Recurrence of stones occurred in 45 cases (15%, Tsunoda class III and class IV) within 2 years and were successfully retreated. Major adverse events were: 5 (1.6%) cases of massive bleeding that required embolisation, 2 (0.66%) perforations of the common bile duct and 31 cases (10.3%) of acute cholangitis managed with medical therapy or intervention. CONCLUSION: After 18 years of experience we demonstrated that our combined radiological-endoscopic approach to 'difficult bile duct stones' may result in both immediate and long-term clearance of stones with a low rate of adverse events.

Use of ultrasound in the insertion of a vascular closure device: a comparative retrospective study with the standard blind technique.

PURPOSE: To evaluate whether ultrasound (US) assistance can decrease the rate of complications related to the use of vascular closure devices (VCDs). MATERIALS AND METHODS: A retrospective comparative study was done on 150 consecutive patients who had a VCD inserted under US guidance after retrograde common-femoral-artery (CFA) puncture. This group was compared to a historical control group of 150 consecutive patients who had the same VCDs inserted with the standard blind technique. After the procedures, patients were placed at bedrest for at least 6 h. Technical success, defined as correct deployment without adjunctive manual compression, blood count and US evaluation of the arterial puncture site was done at 24 h and at 3 months. Differences in terms of efficacy and safety were statistically evaluated using US guidance as a predictor for a lower complication rate. RESULTS: Technical success was achieved in 147/150 patients (98 %) in the study group vs. 141/150 cases (94 %) of the control group (p = 0.038). In three cases (2 %) adjunctive manual compression (≤5 min) was required. One pseudoaneurysm (0.65 %) occurred after 24 h, solved with manual compression. Six minor complications (4 %)--haematoma (n = 5; 3.35 %), recurrent wound bleeding (n = 1; 0.65 %)--were reported. In the control group four (2.65 %) major complications occurred: CFA occlusion managed with surgical bypass, CFA dissection solved by surgical bypass, two pseudoaneurysms solved with manual compression. Thirteen (8.65 %) minor complications were observed with haematoma (n = 10; 6.65 %), and recurrent wound bleeding (n = 3; 2.0 %). The comparative analysis of the total complication rate and major complication rate between the study group and the control group was statistically significant (p = 0.016 and p = 0.049, respectively). A 24-h evaluation showed a triphasic flow within the CFA in 150/150 patients (100 %) of the study group and in 146/150 cases (97.35 %) of the control group. CONCLUSION: VCD inserted under US guidance increases the success rate reducing the number of complications.

Transplantation of human fetal biliary tree stem/progenitor cells into two patients with advanced liver cirrhosis.

BACKGROUND: Efforts to identify cell sources and approaches for cell therapy of liver diseases are ongoing, taking into consideration the limits recognized for adult liver tissue and for other forms of stem cells. In the present study, we described the first procedure of via hepatic artery transplantation of human fetal biliary tree stem cells in patients with advanced cirrhosis. METHODS: The cells were immune-sorted from human fetal biliary tree by protocols in accordance with current good manufacturing practice (cGMP) and extensively characterized. Two patients with advanced liver cirrhosis (Child-Pugh C) have been submitted to the procedure and observed through a 12 months follow-up. RESULTS: The resulting procedure was found absolutely safe. Immuno-suppressants were not required, and the patients did not display any adverse effects correlated with cell transplantation or suggestive of immunological complications. From a clinical point of view, both patients showed biochemical and clinical improvement during the 6 month follow-up and the second patient maintained a stable improvement for 12 months. CONCLUSION: This report represents proof of the concept that the human fetal biliary tree stem cells are a suitable and large source for cell therapy of liver cirrhosis. The isolation procedure can be carried out under cGMP conditions and, finally, the infusion procedure is easy and safe for the patients. This represents the basis for forthcoming controlled clinical trials.

Hepatocellular carcinoma in cirrhotic patients with transjugular intrahepatic portosystemic shunt: a retrospective case-control study.

BACKGROUND: An association between Transjugular Intrahepatic Porto-Systemic Shunt (TIPS) and the development of hepatocellular carcinoma in patients with cirrhosis has been suggested, but not confirmed. AIM: To evaluate the potential role of TIPS in hepatocellular carcinoma development. METHODS: We performed a retrospective case-control study among patients with cirrhosis; all cases had undergone TIPS placement. Cases and controls were followed as outpatients at a single liver care centre in the same timeframe. RESULTS: Overall, 101 patients with cirrhosis (mean age 58 ± 9 years, 64.3% male) were included in each group. Median duration of follow-up was 56.7 months (range 8.2-174.5) for TIPS patients and 67.8 months (range 8.3-183.1) for controls (p=0.08). In both groups 94% of patients had Child-Pugh Class A or B cirrhosis. The cumulative incidence of hepatocellular carcinoma at 1, 3, 5, and 10 years was 2%, 7%, 18%, and 46% among TIPS patients, and 3%, 10%, 19%, and 39% among controls (log rank test p=0.19). Compared to controls, hepatocellular carcinoma nodules in TIPS patients were more frequently situated in the right lobe (p<0.05). CONCLUSIONS: TIPS does not seem to increase the risk of hepatocellular carcinoma in patients with Child-Pugh Class A or B cirrhosis; for these patients ultrasound surveillance should not be modified.

Percutaneous vertebroplasty with the rotational fluoroscopy imaging technique.

OBJECTIVE: To evaluate the feasibility of the rotational angiography unit (RAU) as a single technique to guide percutaneous vertebroplasty (PVP). MATERIALS AND METHODS: Twenty-five consecutive patients (35 vertebral bodies, 20 lumbar and 15 thoracic) were treated using RA fluoroscopy. Using a state-of-the-art flat-panel angiographer (Artis zee, Siemens, Erlangen, Germany), rotational acquisitions were obtained in all patients for immediate post-procedure 2D/3D reconstructions. Pre- and postoperative back pain was assessed with the visual analog scale (VAS). Fluoroscopy time, patient radiation dose exposure, technical success, mean procedure time, mean number of rotational acquisitions and procedural complications were recorded. All features were compared with a historical cohort of patients (N = 25) who underwent PVP under CT and mobile C-arm fluoroscopy guidance. RESULTS: In all cases, safe and accurate control of the needle insertion and bone-cement injection was successfully obtained with high-quality fluoroscopy images. One cement leakage was detected in the RAU group, and two leakages were detected in the CT and C-arm fluoroscopy group. Technical features were significantly different between the two groups (RAU vs. CT): mean procedure time: 38.2 min vs. 60.2 min (p = 0.02); median fluoroscopy time: 14.58 and 4.58 min (p = 0.02); median number of rotational acquisitions: 5 vs. 10 (p = 0.02); mean patient dose: 6 ± 1.3 mSv vs. 23 ± 1.3 mSv (p = 0.02). There were minor complications (pain, small hematoma) in two patients (8%) in the study group and three cases (12%) in the control group. CONCLUSION: RAU guidance is an effective and safe technique for performing PVP because it reduces the procedural time and radiation exposure.

Selective splenic artery embolization for the treatment of thrombocytopenia and hypersplenism in paroxysmal nocturnal hemoglobinuria.

BACKGROUND: PNH is associated with abdominal vein thrombosis, which can cause splenomegaly and hypersplenism. The combination of thrombosis, splenomegaly, and thrombocytopenia (TST) is challenging because anticoagulants are indicated but thrombocytopenia may increase the bleeding risk. Splenectomy could alleviate thrombocytopenia and reduce portal pressure, but it can cause post-operative thromboses and opportunistic infections. We therefore sought to determine whether selective splenic artery embolization (SSAE) is a safe and effective alternative to splenectomy for TST in patients with PNH. METHODS: Four patients with PNH and TST received successive rounds of SSAE. By targeting distal vessels for occlusion, we aimed to infarct approximately 1/3 of the spleen with each procedure. RESULTS: Three of 4 patients had an improvement in their platelet count, and 3 of 3 had major improvement in abdominal pain/discomfort. The one patient whose platelet count did not respond had developed marrow failure, and she did well with an allo-SCT. Post-procedure pain and fever were common and manageable; only one patient developed a loculated pleural effusion requiring drainage. One patient, who had had only a partial response to eculizumab, responded to SSAE not only with an improved platelet count, but also with an increase in hemoglobin level and decreased transfusion requirement. CONCLUSIONS: These data indicate that SSAE can decrease spleen size and reverse hypersplenism, without exposing the patient to the complications of splenectomy. In addition, SSAE probably reduces the uptake of opsonised red cells in patients who have had a limited response to eculizumab, resulting in an improved quality of life for selected patients.

Re-TEVAR for complications after blunt aortic traumatic injury stenting.

We report an endovascular approach that was used to treat two patients with previous thoracic aortic repair or endovascular repair (TEVAR) for blunt thoracic aortic injury. The first patient was a 38-year-old man who presented with distal intragraft thrombosis 24 months after TEVAR. The second patient, a 32-year-old man, developed a symptomatic distal device collapse at 39th month follow-up, associated with buttock claudication. Both patients were offered an endograft relining, complicated in the first case by distal embolization.

Transjugular intrahepatic portosystemic shunt for a wait list patient is not a contraindication for orthotopic liver transplant outcomes.

OBJECTIVES: A transjugular intrahepatic portosystemic shunt for treating recurrent variceal bleeding or refractory ascites can be used as bridge therapy in patients awaiting a liver transplant. However, incorrect placement of the transjugular intrahepatic portosystemic shunt may complicate surgery during a liver transplant. This study sought to analyze a cohort of transplanted recipients to underscore whether transjugular intrahepatic portosystemic shunts can negatively affect liver transplant outcomes. MATERIALS AND METHODS: We retrospectively analyzed 207 patients who had undergone a liver transplant between January 2001 and December 2009 in the Rome "La Sapienza" center. Transjugular intrahepatic portosystemic shunt was performed before the liver transplant in 36 cases (17%). The analyzed population was stratified into 2 groups (no transjugular intrahepatic portosystemic shunt [n=171 ] and transjugular intrahepatic portosystemic shunt [n=36 ]), and patient survival outcomes were compared. RESULTS: In the no-transjugular intrahepatic portosystemic shunt group, 60 of 171 deaths (35%) were reported, 20 of which were seen in the first 3 months after the liver transplant. In the same group, 61 graft losses (36%) were observed, with 19 of which were seen in the first 3 months after the liver transplant. In transjugular intrahepatic portosystemic shunt group, 12 of the 36 deaths (33%) were seen; 5 patients died within 3 months of the liver transplant. In this latter group, 12 grafts (33%) were lost, 4 of which were reported during the first 3 months after surgery. The median patient survival was 64 months and 69 months in the 2 groups. On survival analysis, no significant differences were found between the 2 groups. CONCLUSIONS: Transjugular intrahepatic portosystemic shunt does not seem to affect outcomes after a liver transplant. We suggest that clinicians recognized the location of the stent to prevent any difficulty during surgery.

Minimally invasive treatment of gastric leak after sleeve gastrectomy.

PURPOSE: Obesity is a leading problem in Western countries, and laparoscopic sleeve gastrectomy (SG) is the most commonly used procedure for the surgical management of morbid obesity. SG is recognised as one of the safest and most effective bariatric procedures but it is limited by a rate of gastric leaks (GL) ranging from 1.4% to 20%. No international consensus exists about the treatment of GL. This paper reports our experience with the noninvasive management of GL. MATERIALS AND METHODS: From July 2004 to December 2010, 16 patients with GL after SG were referred to our unit. All patients underwent contrast radiography (Gastrografin) and computed tomography (CT) examination. On the basis of the radiographic findings, patients were divided into those eligible for drainage and those not eligible. RESULTS: Twelve patients (75%) were eligible for percutaneous drainage. Of these, seven patients (44%) were successfully treated with percutaneous drainage alone, whereas five patients (31%) required placement of a covered stent due to incomplete resolution of the collection. After 1009.8±456.7 days of follow-up, one patient died from a cardiovascular event and two patients required a bilio-pancreatic-digestive bypass (BPD-BP). Twelve patients (75%) were in an excellent state of health with significant reduction of their body mass index (BMI). CONCLUSIONS: Our experience confirms the value of an algorithm based on patient eligibility for percutaneous drainage in the treatment of GL. The patient's general condition and in particular the presence of sepsis supports the value of this approach in preference to the conventional surgical approach.

Endovascular treatment of false-aneurysm ten years after dacron patch aortoplasty for coarctation of the aortic isthmus. Report of a case.

False aneurysm degeneration is a known complication of patch aortoplasty for coarctation of the aortic isthmus. Open surgical treatment consists of prosthetic graft repair of the involved aorta, often requires circulatory arrest to achieve a safe proximal aortic control and perform proximal anastomosis, and finally is associated with substantial perioperative morbidity. Endografting of the diseased aorta is a valuable alternative to open repair, when feasible, with good short and long term results. We now report one more case of false aneurysm ten years after Dacron patch aortoplasty for isthmic coarctation in a 26-year-old woman, successfully treated by endovascular repair via the left common iliac artery, and a complete exclusion of the aneurysm at two year follow-up.

Celiac injury due to arcuate ligament: an endovascular approach.

Celiac trunk injures are rare events, with high mortality rates and difficult management. Endovascular treatment may be considered to avoid bleeding. We report a case of severe bleeding in a 37-year-old man resulting from celiac trunk stretching after a motorcycle crash. Because direct celiac trunk catheterization was not possible, a retrograde catheterization of the common hepatic artery was performed via the superior mesenteric artery. Two vascular plugs (type IV) were released, and the exclusion of the celiac trunk origin was completed with the deployment of an aortic cuff. The patient's clinical condition immediately improved, and after 6 months' follow-up, imaging confirmed the complete exclusion of the celiac trunk.

Lower limb multilevel treatment with drug-eluting balloons: 6-month results from the DEBELLUM randomized trial.

PURPOSE: To report 6-month results of the DEBELLUM (Drug-Eluting Balloon Evaluation for Lower Limb MUltilevel TreatMent) randomized trial to evaluate the efficacy of a drug-eluting balloon (DEB) to reduce restenosis after treatment of multilevel lower limb occlusive disease vs. a conventional angioplasty balloon (AB). METHODS: Between September 2010 and March 2011, 50 consecutive patients (37 men; mean age 66±4 years) with 122 lesions (96 stenoses and 26 occlusions) of the femoropopliteal (92, 75.4%) or below-the-knee (BTK) arteries (30, 24.6%) were enrolled and randomly assigned to the DEB (25 patients with 57 lesions) or AB (25 patients with 65 lesions) group. Twenty patients presented multilevel lesions. Mean lesion length was 7.5±3.5 cm. Thirty-one (62%) of the patients were Fontaine stage IIb, while 19 (38%) were stage III or IV. DEBs or ABs were used for dilation of de novo lesions or for postdilation after primary stenting (superficial femoral artery only). Patients requiring provisional stenting after angioplasty secondary to flow-limiting dissection or residual stenosis >50% were ineligible. Primary endpoint was late lumen loss at 6 months. Secondary endpoints were target lesion revascularization (TLR), amputation, and thrombosis. RESULTS: Late lumen loss was lower in the DEB group (0.5±1.4 vs. 1.6±1.7 mm, p<0.01). TLR was necessary in 6.1% of the DEB group vs. 23.6% of the AB group (p=0.02). Comparing the DEB to AB groups, the thrombosis rates were 3.0% vs. 5.2% (p=0.6), and the amputation rates were 3.0% vs. 7.9% (p=0.36). The binary restenosis rates were 9.1% (3/33 limbs) in the DEB group vs. 28.9% (11/38 limbs) in the control group (p=0.03). The ankle-brachial index improved to a greater degree in the DEB group: 0.87±0.22 vs. 0.70±0.13 (p<0.05). The Fontaine stage improved in both groups but more so in patients treated with DEBs (p=0.04). CONCLUSION: The DEBELLUM trial confirmed the ability of paclitaxel-eluting balloons to reduce restenosis vs. conventional balloons at 6 months after treatment of multilevel (femoropopliteal and BTK) arterial disease in patients affected by claudication and CLI. A lower TLR rate and better clinical outcomes appear to be associated with the use of DEBs regardless of stent placement.

Case report: Percutaneous treatment of multiple honeycomb-like liver hydatid cysts (type III CE2, according to WHO classification).

Percutaneous treatment has been developing as a reliable and effective alternative to surgery in the treatment of liver hydatid cysts. However, percutaneous treatment is strongly recommended only for some types of hydatid cysts (types I and II). We report a patient with type III (CE2, according to the WHO classification) multiple liver hydatid cysts treated with the PAIR (puncture-aspiration-injection-reaspiration) technique. The patient developed a secondary biliary fistula, which ultimately healed.

Selective embolization of thyroid arteries for preresection or palliative treatment of large cervicomediastinal goiters.

BACKGROUND: The authors have applied the selective embolization of thyroid arteries in the treatment of voluminous cervicomediastinal goiters, especially in patients at high surgical risk or reluctant to undergo surgical intervention and radioiodine therapy. METHOD: Selective arteriography was used to embolize the thyroid arteries in 2 patients with voluminous hyperfunctioning cervicomediastinal goiters and mediastinal compressive symptoms. The first patient had already undergone unsuccessful radioiodine metabolic therapy and had severe left ventricular insufficiency contraindicating surgery. The second patient, despite having no contraindications, declined surgery and radioiodine metabolic therapy. RESULTS: Radiological embolization markedly reduced the goiters in volume, resolved the compressive symptoms, and also normalized thyroid hyperfunction. The second patient needed a second embolization procedure because the embolized arterial branches had partly recanalized. CONCLUSION: Selective embolization of thyroid arteries can be successfully used to treat selected patients as a preoperative procedure and as an alternative to thyroid resection. Embolization can be repeated to achieve the required therapeutic aims.

Transjugular intrahepatic portosystemic shunt with expanded-polytetrafuoroethylene-covered stents in non-cirrhotic patients with portal cavernoma.

AIMS: To evaluate the feasibility and efficacy of Transjugular intrahepatic portosystemic shunt (TIPS) in non-cirrhotic patients with symptomatic portal hypertension secondary to portal cavernoma. METHODS: Our cohort includes 13 consecutive patients. Eleven were considered for Transjugular intrahepatic portosystemic shunt placement for complications not manageable by medical/endoscopic treatment and two because of the need of oral anticoagulation in presence of high-risk varices. Expanded-polytetrafluoroethylene-covered stents were used in all. RESULTS: One of the 13 patients was excluded because of a thrombosis of the superior cava and jugular veins. In 10 patients, Transjugular intrahepatic portosystemic shunt was successfully implanted [83.3%; 95% confidence interval: 52-98%]. One patient had an early shunt dysfunction with recurrence of variceal bleeding which required an emergency surgical shunt. Late shunt dysfunction occurred in two patients, successfully treated with angioplasty and re-stenting. Two patients experienced an episode of encephalopathy. CONCLUSIONS: Transjugular intrahepatic portosystemic shunt is feasible in most of the patients with portal cavernoma and should be considered in those with severe complications uncontrolled by conventional therapy. The use of Transjugular intrahepatic portosystemic shunt to achieve a lifelong anticoagulation therapy in selected patients with high-risk varices may be another possible indication. These patients should be referred to selected Units with large experience in Transjugular intrahepatic portosystemic shunt placement.

Clinical efficacy of transjugular intrahepatic portosystemic shunt created with covered stents with different diameters: results of a randomized controlled trial.

BACKGROUND & AIMS: The incidence of post-TIPS hepatic encephalopathy (HE) could be reduced by using stents with a small diameter. The aim of this study was to compare the incidence of HE and the clinical efficacy of TIPS created with 8- or 10-mm PTFE-covered stents. METHODS: Consecutive cirrhotics submitted to TIPS for variceal bleeding or refractory ascites were randomized to receive a 8- or 10-mm covered stent. As recommended by our Ethical Committee, the trial was stopped after the inclusion of 45 patients. RESULTS: The two groups were comparable for age, sex, etiology, and psychometric performance. After TIPS, the portosystemic pressure gradient was significantly higher in the 8-mm stent group (8.9+/-2.7 versus 6.5+/-2.7 mmHg; p=0.007). Consequently, the probability of remaining free of complications due to portal hypertension was significantly higher in the 10-mm than in the 8-mm stent group: 82.9% versus 41.9% at one year; log-rank test, p=0.002. In particular, the persistence of ascites with the need for repeated paracentesis was significantly more frequent in the patients treated with 8-mm stent diameter for refractory ascites (log-rank test, p=0.008). The probability of remaining free of HE was similar in both groups. Cumulative survival rate was similar in both groups. CONCLUSIONS: The use of 8-mm diameter stents for TIPS leads to a significantly less efficient control of complications of portal hypertension. HE remains an unsolved major problem after TIPS.

Peripheral and splanchnic indole and oxindole levels in cirrhotic patients: a study on the pathophysiology of hepatic encephalopathy.

OBJECTIVES: Intestinal bacteria metabolize tryptophan into indole, which is then further metabolized into oxindole, a sedative compound putatively involved in the pathophysiology of hepatic encephalopathy (HE). The aim of this study was to measure indole and oxindole levels in patients with cirrhosis with or without HE and to establish whether an intestinal production and a hepatic metabolism of these substances exist. METHODS: We studied 10 healthy subjects (controls) and 51 cirrhotic patients: 17 without HE, 14 with a minimal HE, 8 with overt HE, and 12 who had undergone a transjugular intrahepatic portosystemic shunt (TIPS) procedure. In the last group, blood was collected from the artery, and the portal and hepatic veins during TIPS construction and from the peripheral veins before, immediately after, and at weekly intervals during the first month after TIPS. RESULTS: Plasma indole levels were significantly higher in patients with overt HE. Oxindole levels were higher in cirrhotics than in controls. Indole and ammonia were significantly correlated (r=0.66). Peripheral and splanchnic determinations showed that indole was produced in the intestine and cleared by the liver, similar to ammonia. TIPS implantation increased both indole and ammonia levels. After TIPS, the psychometric performance worsened in 4 of the 12 patients. The increase in indole plasma concentrations in these four patients was higher than in those who remained stable after undergoing TIPS. CONCLUSIONS: Indole correlates with HE and has a significant intestinal production and hepatic extraction; its level increases after TIPS and is related to psychometric performance. These data suggest that indole may be involved in the pathophysiology of HE.