Reduction of portosystemic gradient during transjugular intrahepatic portosystemic shunt achieves good outcome and reduces complications.

BACKGROUND: Transjugular intrahepatic portosystemic shunt (TIPS) is placed important role in the therapy of complications of portal hypertension, there is still no suitable criterion for a reduction in portosystemic gradient (PSG), which can both reduce PSG and maximize clinical results and minimize hepatic encephalopathy (HE). AIM: To compare the clinical outcomes and incidence of HE after one-third PSG reduction during TIPS in patients with variceal bleeding and refractory ascites. METHODS: A total of 1280 patients with portal-hypertension-related complications of refractory ascites or variceal bleeding who underwent TIPS from January 2016 to January 2019 were analyzed retrospectively. Patients were divided into group A (variceal hemorrhage and PSG reduced by one third, n = 479); group B (variceal hemorrhage and PSG reduced to < 12 mmHg, n = 412); group C (refractory ascites and PSG reduced by one third, n = 217); and group D (refractory ascites and PSG reduced to < 12 mmHg of PSG, plus medication, n = 172). The clinical outcomes were analyzed. RESULTS: By the endpoint of follow-up, recurrent bleeding was no different between groups A and B (χ 2 = 7.062, P = 0.374), but recurrent ascites did differ significantly between groups C and D (χ 2 = 14.493, P = 0.006). The probability of total hepatic impairment within 3 years was significantly different between groups A and B (χ 2 = 11.352, P = 0.005) and groups C and D (χ 2 = 13.758, P = 0.002). The total incidence of HE differed significantly between groups A and B (χ 2 = 7.932, P = 0.016), groups C and D (χ 2 = 13.637, P = 0.007). There were no differences of survival rate between groups A and B (χ 2 = 3.376, P = 0.369, log-rank test), but did differ significantly between groups C and D (χ 2 = 13.582, P = 0.014, log-rank test). CONCLUSION: The PSG reduction by one third may reduce the risk of HE, hepatic function damage and achieve good clinical results.

Systematic review and meta-analysis of trans-jugular intrahepatic portosystemic shunt for cirrhotic patients with portal vein thrombosis.

BACKGROUND: Portal vein thrombosis (PVT) was previously a contraindication for trans-jugular intrahepatic portosystemic shunt (TIPS). AIM: To perform a systematic review and meta-analysis of the current available studies investigating outcomes of TIPS for cirrhotic patient with PVT. METHODS: Multiple databases were systematically searched to identify studies investigating the outcomes of TIPS for cirrhotic patients with PVT. The quality of studies was assessed by Cochrane Collaboration method and Methodological Index for Non-Randomized Studies. The demographic data, outcomes, combined treatment, and anticoagulation strategy were extracted. RESULTS: Twelve studies were identified with 460 patients enrolled in the analysis. The technical success rate was 98.9% in patients without portal vein cavernous transformation and 92.3% in patients with portal vein cavernous transformation. One-year portal vein recanalization rate was 77.7%, and TIPS patency rate was 84.2%. The cumulative encephalopathy rate was 16.4%. One-year overall survival was 87.4%. CONCLUSION: TIPS is indicated for portal hypertension related complications and the restoration of pre-transplantation portal vein patency in cirrhotic patients with PVT. Cavernous transformation is an indicator for technical failure. Post-TIPS anticoagulation seems not mandatory. Simultaneous TIPS and percutaneous mechanical thrombectomy device could achieve accelerated portal vein recanalization and decreased thrombolysis-associated complications, but further investigation is still needed.

Incidence of portal vein thrombosis after splenectomy and its influence on transjugular intrahepatic portosystemic shunt stent patency.

BACKGROUND: Transjugular intrahepatic portosystemic shunt (TIPS) is widely accepted as an alternative to surgery for management of complications of portal hypertension. TIPS has been used to treat portal vein thrombosis (PVT) in many centers since the 1990s. Although TIPS has good therapeutic effects on the formation of PVT, the effect of PVT on TIPS stenting has rarely been reported. Patients with splenectomy and pericardial devascu-larization have a high incidence of PVT, which can markedly affect TIPS stent patency and increase the risk of recurrent symptoms associated with shunt stenosis or occlusion. AIM: To investigate the incidence of PVT after splenectomy and its influence on the patency rate of TIPS in patients with cirrhosis and portal hypertension. METHODS: Four hundred and eighty-six patients with portal hypertension for refractory ascites and/or variceal bleeding who required TIPS placement between January 2010 and January 2016 were included in this retrospective analysis. Patients without prior splenectomy were defined as group A (n = 289) and those with prior splenectomy as group B (n = 197). The incidence of PVT before TIPS was compared between the two groups. After TIPS placement, primary patency rate was compared using Kaplan-Meier analysis at 3, 6, 9 and 12 mo, and 2 and 3 years. The clinical outcomes were analyzed. RESULTS: Before TIPS procedure, the incidence of PVT in group A was lower than in group B (P = 0.003), and TIPS technical success rate in group A was higher than in group B (P = 0.016). The primary patency rate in group A tended to be higher than in group B at 3, 6, 9 and 12 mo, 2 years and 3 years (P = 0.006, P = 0.011, P = 0.023, P = 0.032, P = 0.037 and P = 0.028, respectively). Recurrence of bleeding and ascites rate in group A was lower than in group B at 3 mo (P ≤ 0.001 and P = 0.001), 6 mo (P = 0.003 and P = 0.005), 9 mo (P = 0.005 and P = 0.012), 12 mo (P = 0.008 and P = 0.024), 2 years (P = 0.011 and P = 0.018) and 3 years (P = 0.016 and P = 0.017), respectively. During 3-years follow-up, the 1-, 2- and 3-year survival rate in group A were higher than in group B (P = 0.008, P = 0.021, P = 0.018, respectively), but there was no difference of the incidence of hepatic encephalopathy (P = 0.527). CONCLUSION: Patients with prior splenectomy have a high incidence of PVT, which potentially increases the risk of recurrent symptoms associated with shunt stenosis or occlusion.

Safety and efficacy of transjugular intrahepatic portosystemic shunt combined with palliative treatment in patients with hepatocellular carcinoma.

BACKGROUND: There is a close relationship between cirrhosis and hepatocellular carcinoma (HCC). Transjugular intrahepatic portosystemic shunt (TIPS) has good clinical effect in treating the complication of portal hypertension. However, because of the risk of postoperative liver failure, severe complications, and low survival rate for HCC, TIPS is contraindicated in patients with portal hypertension and liver cancer. We studied a large cohort of patients with cirrhosis and HCC who underwent TIPS for recurrent variceal bleeding and/or ascites. AIM: To assess the safety, efficacy, and survival rate in patients with HCC who underwent TIPS. METHODS: Group A comprised 217 patients with HCC and portal hypertension who underwent the TIPS procedure between 1999 and 2014. After TIPS deployment, these patients received palliative treatment for HCC. Group B comprised a cohort of 136 HCC patients with portal hypertension who did not undergo TIPS placement. Group B received palliative treatment for HCC plus medical therapy for portal hypertension. The clinical outcomes and survival rate were assessed. RESULTS: In Group A, the primary technical success rate was 97.69% for TIPS placement, and no severe procedure-related complications of TIPS placement were reported. The control of variceal bleeding (VB) within 1 mo did not differ significantly between the groups (P = 0.261). Absorption of refractory ascites within 1 mo, recurrence of VB, and recurrence of refractory ascites differed significantly between the groups (P = 0.017, 0.023, and 0.009, respectively). By comparison, the rate of hepatic encephalopathy in Group B was lower than that in Group A (P = 0.036). The 1-, 2-, 3-, 4-, and 5-year survival rates were significantly different between Groups A and B (χ2 = 12.227, P = 0.018; χ2 = 12.457, P = 0.014; χ2 = 26.490, P = 0.013; χ2 = 21.956, P = 0.009, and χ2 = 24.596, P = 0.006, respectively). The mean survival time was 43.7 mo in Group A and 31.8 mo in Group B. Median survival time was 50.0 mo in Group A and 33.0 mo in Group B. Mean and median survival differed significantly between the two groups (P = 0.000, χ2 = 35.605, log-rank test). The mortality rate from VB in Group A was low than that in Group B (P = 0.006), but the rates of hepatic tumor, hepatic failure, and multiorgan failure did not differ significantly between the two groups (P = 0.173, 0.246 and 0.257, respectively). CONCLUSION: TIPS combined with palliative treatment is safe and effective for portal hypertension in patients with HCC.

Targeted puncture of left branch of intrahepatic portal vein in transjugular intrahepatic portosystemic shunt to reduce hepatic encephalopathy.

BACKGROUND: Transjugular intrahepatic portosystemic shunt (TIPS) is currently used for the treatment of complications of portal hypertension. The incidence of hepatic encephalopathy (HE) remains a problem in TIPS placement. It has been reported that the right branch mainly receives superior mesenteric venous blood while the left branch mainly receives blood from the splenic vein. We hypothesized that targeted puncture of the left portal vein would divert the non-nutritive blood from the splenic vein into the TIPS shunt; therefore, targeted puncture of the left branch of the intrahepatic portal vein during TIPS may reduce the risk of HE. AIM: To evaluate the influence of targeted puncture of left branch of portal vein in TIPS on HE. METHODS: A retrospective analysis of 1244 patients with portal-hypertension-related complications of refractory ascites or variceal bleeding who underwent TIPS from January 2000 to January 2013 was performed. Patients were divided into group A (targeting left branch of portal vein, n = 937) and group B (targeting right branch of portal vein, n = 307). TIPS-related HE and clinical outcomes were analyzed. RESULTS: The symptoms of ascites and variceal bleeding disappeared within a short time. By the endpoint of follow-up, recurrent bleeding and ascites did not differ significantly between groups A and B (P = 0.278, P = 0.561, respectively). Incidence of HE differed significantly between groups A and B at 1 mo (14.94% vs 36.80%, χ 2 = 4.839, P = 0.028), 3 mo (12.48% vs 34.20%, χ 2 = 5.054, P = 0.025), 6 mo (10.03% vs 32.24%, χ 2 = 6.560, P = 0.010), 9 mo (9.17% vs 31.27%, χ 2 = 5.357, P = 0.021), and 12 mo (8.21% vs 28.01, χ 2 = 3.848, P = 0.051). There were no significant differences between groups A and B at 3 years (6.61% vs 7.16%, χ 2 = 1.204, P = 0.272) and 5 years (5.01% vs 6.18%, χ 2 = 0.072, P = 0.562). The total survival rate did not differ between groups A and B (χ 2 = 0.226, P = 0.634, log-rank test). CONCLUSION: Targeted puncture of the left branch of the intrahepatic portal vein during TIPS may reduce the risk of HE but has no direct influence on prognosis of portal-hypertension-related complications.

Effect of initial stent position on patency of transjugular intrahepatic portosystemic shunt.

AIM: To evaluate the effect of initial stent position on transjugular intrahepatic portosystemic shunt (TIPS). METHODS: We studied 425 patients from January 2004 to January 2015 with refractory ascites or variceal bleeding who required TIPS placement. Patients were randomly divided into group A (stent in hepatic vein, n = 57), group B (stent extended to junction of hepatic vein and inferior vena cava, n = 136), group C (stent in left branch of portal vein, n = 83) and group D (stent in main portal vein, n = 149). Primary unassisted patency was compared using Kaplan-Meier analysis, and incidence of recurrence of bleeding, ascites and hepatic encephalopathy (HE) were analyzed. RESULTS: The mean primary unassisted patency rate in group B tended to be higher than in group A at 3, 6 and 12 mo (P = 0.001, 0.000 and 0.005), and in group D it tended to be lower than in group C at 3, 6 and 12 mo (P = 0.012, 0.000 and 0.028). The median shunt primary patency time for group A was shorter than for group B (5.2 mo vs 9.1 mo, 95%CI: 4.3-5.6, P = 0.013, log-rank test), while for group C it was longer than for group D (8.3 mo vs 6.9 mo, 95%CI: 6.3-7.6, P = 0.025, log-rank test). Recurrence of bleeding and ascites in group A was higher than in group B at 3 mo (P = 0.014 and 0.020), 6 mo (P = 0.014 and 0.019) and 12 mo (P = 0.024 and 0.034. Recurrence in group D was higher than in group C at 3 mo (P = 0.035 and 0.035), 6 mo (P = 0.038 and 0.022) and 12 mo (P = 0.017 and 0.009). The incidence of HE was not significantly different among any of the groups (P = 0.965). CONCLUSION: The initial stent position can markedly affect stent patency, which potentially influences the risk of recurrent symptoms associated with shunt stenosis or occlusion.

Strontium ranelate causes osteophytes overgrowth in a model of early phase osteoarthritis.

BACKGROUND: Osteoarthritis (OA) involves cartilage changes as well as modifications of subchondral bone and synovial tissues. Strontium ranelate (SR), an anti-osteoporosis compound, which is currently in phase III clinical trial for treatment of OA. Evidences suggest that SR preferably deposited in osteophyte, other than in subchondral bone in early phase of OA. This phenomenon raises concern about its utility for OA treatment as a disease-modifying drug. To evaluate the effect of SR on cartilage, subchondral bone mass and subchondral trabecular bone structure in medial meniscectomized (MNX) guinea pigs. METHOD: Thirty-six 3-month-old male Dunkin Hartley albino guinea pigs received either sham or medial meniscectomy operations. One week after the procedure, meniscectomized animals began 12 weeks of SR (625 mg/kg, daily) treatment by oral gavage for MNX + SR group, or normal saline for MNX + V group. All animals were euthanized 12 weeks later, cartilage degeneration and subchondral bone micro-architecture was analyzed. RESULTS: Both OARSI scores (P = 0.523 for marcoscopic scores, P = 0.297 for histological scores) and Cartilage thickness (P = 0.335) in MNX + SR group were comparable to MNX + V group. However, osteophyte sizes were larger in MNX + SR group (P = 0.014), and collapsed osteophytes in MNX + SR group (7 by 12) were significantly more than in MNX + V group (1 by 12) (P = 0.027), while immunohistochemistry indicates catabolic changes in osteophyte/plateau junction. Micro-CT analysis showed bone mineral density (BMD) (P = 0.001), bone volume fraction (BV/TV) (P = 0.008), trabecular spacing (Tb.Sp) (P = 0.020), trabecular thickness (Tb.Th) (P = 0.012) and structure model index (SMI) (P = 0.005) levels to be significantly higher in the MNX + SR group than in the MNX + V group. CONCLUSIONS: SR (625 mg/kg/day) did not protect cartilage from degeneration in MNX guinea pigs but subchondral bone was significantly enhanced. In early phase OA, SR administration causes osteophyte overgrowth, which may be related to incorporation into mineralizing osteophytes. This adverse effect is important for future studies of SR in OA.

Increased Synovial Fluid YKL-40 Levels are Linked with Symptomatic Severity in Knee Osteoarthritis Patients.

BACKGROUND: Elevated serum and synovial fluid (SF) YKL-40 levels have been detected in knee osteoarthritis (OA) patients. The current study was focused on the correlation between YKL-40 levels in serum or SF and symptomatic severity in patients with knee osteoarthritis. METHODS: 144 patients with knee OA and 151 healthy individuals were recruited into this study. Symptomatic severity was determined using Western Ontario and McMaster Universities Arthritis Index (WOMAC) scores from OA patients. Serum and SF levels of YKL-40 were explored by enzyme-linked immunosorbent assay. RESULTS: We found that YKL-40 levels in SF but not serum were independently and positively related to WOMAC pain (r = 0.531, p = 0.001), physical disability (r = 0.380, p = 0.025), and total scores (r = 0.407, p = 0.01) in knee OA patients. CONCLUSIONS: YKL-40 in SF could represent a potential biomarker for assessing the symptomatic severity of OA.

[A comparison of efficacies between transjugular intrahepatic portosystemic shunt versus portoazygos devascularization in the treatment of portal hypertension with variceal bleeding].

OBJECTIVE: To compare the efficacies between transjugular intrahepatic portosystemic shunt (TIPS) and portoazygos devascularization (PAD) in the treatment of portal hypertension with variceal bleeding. METHODS: From December 1993 to December 2010, 309 patients with portal hypertension and variceal bleeding were admitted. According to their general conditions and Child-Pugh grades, they were assigned to undergo TIPS (group A, n = 235) or PAD (group B, n = 74). Before operation, compared with the PAD group, the TIPS group possessed worse liver functions, more severe ascites and a greater frequency of bleeding. After operation, the therapeutic efficacies and changes of portal hemodynamics, recurrent variceal bleeding, post-operative encephalopathy and long-term survival were evaluated between two groups. RESULTS: The postoperative portal pressure in the TIPS group ((42.6 ± 7.0) vs (26.3 ± 4.1) cm H2O) decreased much more than that in the PAD group ((38.7 ± 5.2) vs (33.5 ± 5.8) cm H2O, P < 0.01). The rebleeding rates during early postoperation were 0.85% (2/235) and 6.76% (5/74) in TIPS and PAD groups respectively, the occurring rates of hepatic encephalopathy 4.68% (11/235) and 4.05% (3/74) and the rates of operative mortality 1.70% (4/235) and 6.76% (5/74) respectively. Survival rates of 1, 3, 5 and 10 years were 98.30% (231/235) vs 92.24% (69/74), 92.41% (146/158) vs 88.06% (59/67), 80.77% (84/104) vs 79.25% (42/53), 51.43% (36/79) vs 51.85% (14/27) in TIPS and PAD groups respectively. CONCLUSIONS: As compared with PAD, TIPS offers the such advantages as less trauma, wider indication, faster hemostasis and satisfactory therapeutic efficacies. Especially for the emergency treatment of a patient with massive variceal bleeding and Child-Pugh C grade liver function, TIPS is a better option than PAD.

[Use of direct portal vein puncture portography with modified TIPS treatment in patients with portal hypertension and gastro-esophageal varices bleeding].

OBJECTIVE: To explore a better procedure for transjugular intrahepatic portosystemic shunt (TIPS) in order to improve its safety and to extend its indications. METHODS: To puncture the right portal branch under sonographic guidance in 20 patients with portal hypertension and gastro-esophageal bleeding. The Teflon sheath with gold marker was put into the portal vein; anterior and lateral portography was made, portal pressure was measured and the gastric coronal vein was embolized. The gold marker was put into the portal vein puncture site and the Rups-100 was guided under the gold marker during the TIPS puncture procedure. Anterior and lateral portography was again made to make sure the puncture site was 2 cm away from the portal vein bifurcation. In some cases a 10F sheath was used to suck the thrombosis in the portal vein, and a balloon was used to dilate the parenchyma channel and then a stent was released smoothly. RESULTS: 20 reformed TIPS were successfully performed on all patients and their gastric-esophageal bleedings were controlled immediately. 37 punctures were made in 20 of those cases; the average puncture per patient was 1.85+/-0.67, lower than that of the traditional method. The pressure of the portal vein declined from (30.5+/-1.1) mmHg to (16.9+/-0.9) mmHg, P < 0.05, showing that the difference of portal vein pressure before and after the reformed TIPS was significant. 25 stents were placed, and no complications occurred during the procedure in any of the cases. CONCLUSION: Direct portal vein puncture portography and gold marker guided TIPS procedure is feasible and safe; the indications of TIPS could be further extended.