Post-Test Questions

Article One (227–234)

1. All of the following are percutaneous portosystemic shunts in current clinical use EXCEPT:

   • Mesocaval shunt

   • Direct intrahepatic portocaval shunt (DIPS)

   • Splenocaval shunt

   • Transjugular intrahepatic portosystemic shunt (TIPS)

2. Which of the following is an indication for direct decompression of the portal venous system?

   • Primary prevention of variceal hemorrhage

   • Hepatic encephalopathy

   • Right-sided heart failure with elevated central venous pressure

   • Refractory hepatic hydrothorax

3. Advantages of direct intrahepatic portacaval shunt (DIPS) creation include all of the following EXCEPT:

   • Avoidance of liver transcapsular puncture

   • Averting unsuitable or inaccessible hepatic veins

   • Shorter liver parenchymal shunt reduces likelihood of stenosis

   • Improved visualization during puncture in cases of difficult venous anatomy

   Article Two (235–242)

4. Which of the following is NOT an appropriate indication for placement of a TIPS?

   • Secondary prophylaxis of esophageal variceal hemorrhage

   • Management of Budd-Chiari Syndrome in those presenting weeks to months after the initial formation of hepatic vein thrombosis

   • Treatment of gastric antral vascular ectasia (GAVE)

   • Management of ectopic variceal hemorrhage

   • Management of refractory ascites

5. Which of the following is TRUE regarding patient work-up for potential placement of a TIPS?

   • Portal vein patency should be evaluated with Doppler ultrasound if no hepatic imaging within the past month is available

   • Echocardiogram is rarely mandated in the patient work-up prior to TIPS placement

   • Large volume paracentesis should not be performed within 48 hours of TIPS

   • A complete blood count, comprehensive metabolic panel, liver function tests, and coagulation profile within the past 7 days is appropriate.

   • None of the above

6. In all of the following patients, placement of a TIPS is contraindicated EXCEPT:

   • A 49-year-old female with pulmonary hypertension and a mean pulmonary arterial pressure of 53 mm Hg

   • A 53-year-old male with alcoholic cirrhosis and a MELD score of 16

   • A 61-year-old male with severe congestive heart failure

   • A 55-year-old female with innumerable hepatic cysts predominately central in location

   • All of the above

   Article Three (243–247)

7. When considering pretransplant TIPS as a prelude/preoperative preparation to liver transplant surgery, patients undergoing TIPS utilize:

   • Less fewer blood products because the TIPS decompresses the portal circulation and reduces bleeding

   • Less shorter hospital stay

   • Less shorter ICU stay

   • Less fewer hospital resources (A + B + C)

   • None of the above

8. What is the most challenging surgical anatomy aspects to performing a TIPS on a liver transplant recipient?

   • Split liver grafts

   • Capacious caval ends in piggyback anastomoses.

   • Piggyback anastomoses that are angulated downward

   • All of the above

   • None of the above

9. When comparing technical results of TIPS in transplant recipients compared to TIPS in native livers (nontransplants) in experienced institutions, which of the following statements is the most accurate?

   • Technical success rates are statistically lower in transplant patients.

   • Technical success rates are statistically lower in nontransplant patients.

   • Some TIPS in transplants can be challenging, but statistically there is no difference in technical success.

   • TIPS should not be performed in transplant recipients, and the latest consensus is that transplant is a contraindication to TIPS

   • Transplants do not pose any additional technical challenges to TIPS, and the technical success is the same for transplants and nontransplants alike.

10. What is the most common indication for TIPS in liver transplant patients?

    • Variceal bleeding

    • Portal hypertensive gastropathy

    • Ascites

    • Hydrothorax

    • Portal vein thrombosis

11. What is the most common cause of recurrent portal hypertension in liver transplant recipients in the United States?

    • Primary graft failure

    • Hepatitis B recurrence

    • Hepatitis C recurrence

    • Venous vascular complications

    • Arterial vascular complications

    Article Four (248–251)

12. Which of the following factors are associated with increased mortality following transjugular intrahepatic portosystemic shunting (TIPS)?

    • Child class B cirrhosis

    • MELD score less than 15

    • Hepatic venous pressure gradient less than 8 mm Hg

    • Serum creatinine less than 2 mg/dL

    • Total serum bilirubin less than 2 mg/dL

13. True or False. The 2009 American Association for the Study of Liver Diseases (AALSD) guidelines update does not recommend use of expanded polytetrafluoroethylene-coated (ePTFE) TIPS given a lack of controlled studies.

    • True

    • False

14. What is the approximate smallest amount of pleural fluid in a patient with cirrhosis that will result in severe symptomatology?

    • 0.25 to 0.5 L

    • 1 to 2 L

    • 3 to 5 L

    • 5 to 8 L

    • 8 to 10 L

15. True or False. TIPS is not as effective for refractory ascites in the posttransplant setting as compared with the pretransplant setting.

    • True

    • False

    Article Five (252–257)

16. Established or emerging indications for TIPS treatment of variceal hemorrhage include all of the following EXCEPT:

    • Prevention of recurrent variceal hemorrhage in patients who demonstrate intolerance to medical and endoscopic treatment

    • Rescue therapy in cases of refractory acute bleeding

    • Early first-line (nonsalvage) treatment for acute hemorrhage combined with standard pharmacologic and endoscopic treatment

    • Primary prevention of bleeding from portal hypertensive gastropathy

17. When applied as rescue therapy for acutely bleeding esophageal varices, TIPS technical success, immediate clinical success (bleeding cessation), and early rebleeding rates approximate:

    • Greater than 90%, greater than 90%, and less than 20%, respectively

    • Greater than 90%, 70 to 90%, and less than 20%, respectively

    • Greater than 70 to 90%, greater than 90%, and less than 20%, respectively

    • Greater than 70 to 90%, 70-90%, and less than 20%, respectively

18. True or false: Adjunctive variceal embolization performed at the time of TIPS creation reduces rebleeding rates and improves patient survival.

    • True

    • False

    Article Six (258–261)

19. What is the most common portosystemic shunt created in current practice?

    • Warren-Salam Lieno-renal (splenorenal) shunt.

    • Shigura operation

    • Percutaneous mesocaval shunt

    • Transjugular intrahepatic portosystemic shunt (TIPS)

    • Hassab procedure

20. Name the coverage material for the TIPS stents.

    • Silicone

    • Autologous Vein

    • Expanded poly-tetra flouro-ethylene

    • Ceramic-textile

    • Tacrolimus

21. What is the pathogenesis of hepatic encephalopathy after TIPS

    • Worsening liver function

    • Bypassing the liver (Type-B hepatic encephalopathy) Accumulation of gut-derived neurotoxins

    • Possibly all of the above None of the above

22. By how much has e-PTFE covered stent grafts improved TIPS patency?

    • 10 to 20%

    • 20 to 40%

    • 40 to 60%

    • 60 to 80%

    • >80%

    Article Seven (262–265)

23. What are the types of hepatic encephalopathy?

    • Synthetic (hepatocellular dysfunction) type

    • Type-B ("B" for bypass) associated with spontaneous portosystemic shunts

    • Type-A ("A" for ascites) associated with ascites

    • Type-C ("C" for cancer) associated with hepatocellular cancer

    • A+B

24. Name the spontaneous right-sided intrahepatic shunt.

    • Splenorenal shunt

    • Gastrorenal shunt

    • TIPS

    • Paraumbilical vein

    • Spontaneous Meso-caval shunt

25. What is the pathogenesis of hepatic encephalopathy

    • Accumulation of bacteria systemically

    • Very high serum glucose levels

    • Accumulation of gut-derived neurotoxins

    • Liver failure

    • Accumulation of serum free fatty acids and triglycerides

26. What is the mortality rate 1 year after the diagnosis of hepatic encephalopathy?

    • 10%

    • 25%

    • 40%

    • 50%

    • 60%

    Article Eight (266–268)

27. What is clearly the best endovascular treatment option for gastric varices?

    • TIPS only

    • TIPS and coil embolization of varices

    • TIPS and BRTO

    • BRTO only

    • None of the above are decisively the best endovascular treatment option

28. What are the adverse effects that might be expected after BRTO without TIPS?

    • Ascites

    • Hydrothorax

    • Esophageal varices

    • Splenomegaly

    • All of the above

29. What is the gastric variceal bleeding rate after a combined TIPS-BRTO procedure?

    • 0 to 5%

    • 10%

    • 15%

    • 20%

    • 25%