Transjugular Intrahepatic Portosystemic Shunt in the Management of Refractory Ascites

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.

KEYWORDS

Refractory ascites - cirrhosis - transjugular intrahepatic portosystemic shunt - large-volume paracentesis

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
• 2 Rector W G. Portal hypertension: a permissive factor only in the development of ascites and variceal bleeding.  Liver. 1986;  6 221-226
• 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
• 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
• 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
• 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
• 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
• 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
• 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
• 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
• 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
• 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
• 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
• 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
• 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
• 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
• 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
• 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
• 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
• 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
• 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
• 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
• 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
• 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
• 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
• 26 Ferral H, Bjarnason H, Wegryn S A et al.. Refractory ascites: early experience with transjugular intrahepatic portosystemic shunt.  Radiology. 1993;  189 795-801
• 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
• 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
• 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
• 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
• 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
• 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
• 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
• 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
• 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
• 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
• 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
• 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
• 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
• 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
• 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
• 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
• 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
• 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
• 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
• 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
• 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
• 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
• 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
• 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
• 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
• 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
• 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
• 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
• 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
• 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