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DOI: 10.1055/s-0044-102107
Doppler ultrasound surveillance of TIPS-patency in the era of covered stents – retrospective analysis of a large single-center cohort
Dopplersonografische Überwachung der TIPS-Funktion im Zeitalter beschichteter Stents – retrospektive Analyse einer großen unizentrischen KohortePublication History
27 November 2017
29 January 2018
Publication Date:
17 September 2018 (online)
Abstract
Purpose The purpose of this study was to determine accuracy and necessity of long-term Doppler ultrasound (DU) surveillance of transjugular intrahepatic portosystemic shunt (TIPS) patency after implantation of an ePTFE-covered stent-graft (Viatorr).
Methods This single-center retrospective study includes 228 consecutive cirrhotic patients with TIPS implantation due to portal hypertensive complications. Standardized DU surveillance was scheduled 3 – 5 days, 3 months, and 6 months after TIPS implantation and every 6 months thereafter. Portal venography was performed in case of DU findings suspicious of TIPS dysfunction, clinical signs of recurrent portal hypertension, or refractory hepatic encephalopathy.
Results During a mean follow-up of 16.6 ± 23.4 months, 866 DU examinations were performed. Twenty-two cases of TIPS dysfunction were observed in 16 patients with no first dysfunction more than 4 years after implantation. Routine DU in asymptomatic patients had little therapeutic impact (0.75 %). DU and venography were concordant in 39/46 (84.8 %) paired examinations, and 1-, 2-, and 5-year primary TIPS patency was 87.4 %, 83.7 %, and 79.97 %, respectively. Patients with TIPS dysfunction and subsequent successful revision during the first 2 years of follow-up had a significantly higher risk (p = 0.001) of new dysfunction compared to those without TIPS dysfunction. Cumulative 1-, 2-, and 5-year survival was 68.7 %, 61.3 %, and 42.7 %, respectively.
Conclusions Despite acceptable accuracy, scheduled DU surveillance proved to have minor therapeutic impact. Thus, detailed DU surveillance is not useful in asymptomatic patients after 2 years of unremarkable follow-up. In contrast, long-term DU surveilleance should be performed in patients after successful revision of TIPS dysfunction and patients with prothrombotic states (e. g., portal vein thrombosis, Budd-Chiari syndrome).
Zusammenfassung
Ziel Evaluation der diagnostischen Genauigkeit und Notwendigkeit einer langfristigen dopplersonografischen Überwachung der TIPS-Funktion nach Implantation eines ePTFE-beschichteten Stents (Viatorr).
Material und Methode In diese retrospektive monozentrische Studie wurden 228 Patienten eingeschlossen, die aufgrund portal hypertensiver Komplikationen einer Leberzirrhose eine TIPS-Anlage erhielten. Standardisierte dopplersonografische Kontrollen wurden 3 – 5 Tage, 3 Monate und 6 Monate nach TIPS-Implantation, sowie anschließend halbjährlich geplant. Eine Portografie erfolgte bei dopplersonografischem Verdacht einer TIPS-Dysfunktion sowie bei klinischen Zeichen einer erneuten portalen Hypertension oder einer refraktären hepatischen Encephalopathie.
Ergebnisse Während einer mittleren Nachbeobachtungszeit von 16.6 ± 23.4 Monaten wurden 866 Doppler-Kontrollen durchgeführt. Bei 16 Patienten wurden 22 Fälle einer TIPS-Dysfunktion beobachtet. Keine erstmalige Dysfunktion trat später als 4 Jahre nach TIPS-Implantation auf. Bei asymptomatischen Patienten hatten die Dopplerkontrollen nur selten eine therapeutische Konsequenz (0.75 %). Dopplersonografie und Portografie ergaben konkordante Ergebnisse bei 39/46 Untersuchungen (84.8 %). Die primäre 1-, 2- und 5- Jahres TIPS-Offenheit betrug 87.4 %, 83.7 % und 79.97 %. Patienten mit erfolgreicher Revision einer TIPS-Dysfunktion innerhalb der ersten zwei Jahre hatten ein signifikant höheres Risiko (p = 0.001) einer erneuten TIPS-Dysfunktion im Vergleich zu Patienten ohne TIPS-Dysfunktion in diesem Zeitraum. Das kummulative 1-, 2-und 5-Jahres Überleben betrug 68.7 %, 61.3 % und 42.7 %.
Schlussfolgerungen Trotz guter diagnostischer Genauigkeit hatte die Doppler-Surveillance nur selten eine therapeutische Konsequenz. Eine Fortführung regelmäßiger Dopplerkontrollen ist bei asymptomatischen Patienten nach unauffälliger Nachbeobachtung über zwei Jahre unnötig. Langfristige Dopplerkontrollen sollten hingegen nach erfolgreicher Revision einer TIPS-Dysfunktion sowie bei Patienten mit prothombotischen Erkrankungen (z. B. Pfortaderthrombose, Budd Chiari Syndrom) durchgeführt werden.
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References
- 1 Garcia-Tsao G, Abraldes JG, Berzigotti A. et al. Portal hypertensive bleeding in cirrhosis: risk stratification, diagnosis and management: 2016 practice guidance by the American Association for the Study of Liver Diseases. Hepatology 2017; 65: 310-335
- 2 European Association for theStudy of the Liver. EASL clinical practice guidelines on the management of ascites, spontaneous bacterial peritonitis, and hepatorenal syndrome in cirrhosis. J Hepatol 2010; 53: 397-417
- 3 Runyon BA. Introduction to the revised American Association for the Study of Liver Diseases Practice Guideline management of adult patients with ascites due to cirrhosis 2012. Hepatology 2013; 1651-1653
- 4 García-Pagán JC, Caca K, Bureau C. et al. Early use of TIPS in patients with cirrhosis and variceal bleeding. N Engl J Med 2010; 362: 2370-2379
- 5 Rössle M. TIPS: 25 years later. J Hepatol 2013; 59: 1081-1093
- 6 Casado M, Bosch J, García-Pagán JC. et al. Clinical events after transjugular intrahepatic portosystemic shunt: correlation with hemodynamic findings. Gastroenterology 1998; 114: 1296-1303
- 7 Weber CN, Nadolski GJ, White SB. et al. Long-term patency and clinical analysis of expanded polytetrafluoroethylene-covered transjugular intrahepatic portosystemic shunt stent grafts. J Vasc Interv Radiol 2014; 26: 1257-1265
- 8 Geeroms B, Laleman W, Laenen A. et al. Expanded polytetrafluoroethylene-covered stent-grafts for transjugular intrahepatic portosystemic shunts in cirrhotic patients: long-term patency and clinical outcome results. Eur Radiol 2017; 27: 1795-1803
- 9 Engstrom BI, Horvath JJ, Suhocki PV. et al. Covered transjugular intrahepatic portosystemic shunts: accuracy of ultrasound in detecting malfunction. Am J Roentgenol 2013; 200: 904-908
- 10 Huang Q, Wu X, Fan X. et al. Comparison study of Doppler ultrasound surveillance of expanded versus bare stent in transjugular intrahepatic portosystemic shunt. J Clin Ultrasound 2010; 38: 353-360
- 11 Bureau C, García-Pagán JC, Pomier-Layrargues G. et al. Patency of stents covered with polytetrafluoroethylene in patients treated by transjugular intrahepatic portosystemic shunts: long- term results of a randomized multicentre study. Liver Int 2007; 742-747
- 12 Sommer CM, Gockner TL, Stampfl U. et al. Technical and clinical outcome of transjugular intrahepatic portosystemic stent shunt: bare metal stents (BMS) versus Viatorr stent-grafts (VSG). Eur J Radiol 2012; 81: 2273-2280
- 13 Tripathi D, Ferguson J, Barkell H. et al. Improved clinical outcome with transjugular intrahepatic portosystemic stent-shunt utilizing polytetrafluoroethylene-covered stents. Eur J Gastroenterol Hepatol 2006; 18: 225-232
- 14 Lauermann J, Potthoff J, Mc CavertM. et al. Comparison of technical and clinical outcome of transjugular portosystemic shunt placement between a bare metal stent and a PTFE-stentgraft device. Cardiovasc Interv Radiol 2016; 39: 547-556
- 15 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
- 16 Qi X, Tian Y, Zhang W. et al. Covered versus bare stents for transjugular intrahepatic portosystemic shunt: an updated meta-analysis of randomized controlled trials. Therap Adv Gastroenterol 2017; 10: 32-41
- 17 Cura M, Cura A, Suri R. et al. Causes of TIPS dysfunction. Am J Roentgenol 2008; 191: 1751-1757
- 18 Ferral H, Gomez-Reyes E, Fimmel CJ. Post-transjugular intrahepatic portosystemic shunt follow-up and management in the VIATORR era. Tech Vasc Interv Radiol 2016; 19: 82-88
- 19 Fagiuoli S, Bruno R, Venon WD. et al. Consensus conference on TIPS management: techniques, indications, contraindications. Dig Liver Dis 2017; 49: 121-137
- 20 Cejna M. Should stent-grafts replace bare stents for primary transjugular intrahepatic portosystemic shunts?. Semin Intervent Radiol 2005; 22: 287-299
- 21 Carr CE, Tuite CM, Soulen MC. et al. Role of ultrasound surveillance of transjugular intrahepatic portosystemic shunts in the covered stent era. J Vasc Interv Radiol 2006; 17: 1297-1305
- 22 Foshager MC, Ferral H, Nazarian GK. et al. Duplex sonography after transjugular intrahepatic portosystemic shunts (TIPS): normal hemodynamic findings and efficacy in predicting shunt patency and stenosis. Am J Roentgenol 1995; 165: 1-7
- 23 Zizka J, Eliás P, Krajina A. et al. Value of Doppler sonography in portosystemic shunt malfunction: a 5-year experience in 216 patients. Am J Roentgenol 2000; 175: 141-148
- 24 Abraldes JG, Gilabert R, Turnes J. et al. Utility of color Doppler ultrasonography predicting TIPS dysfunction. Am J Gastroenterol 2005; 100: 2696-2701
- 25 Pan J, Chen C, Geller B. et al. Is sonographic surveillance of polytetrafluoroethylene-covered transjugular intrahepatic portosystemic shunts (TIPS) necessary? A single centre experience comparing both types of stents. Clin Radiol 2008; 63: 1142-1148
- 26 Owen JM, Gaba RC. Transjugular intrahepatic portosystemic shunt dysfunction: concordance of clinical findings, Doppler ultrasound examination, and shunt venography. J Clin Imaging Sci 2016; 6: 1-7
- 27 Lafortune M, Martinet JP, Patriquin H. et al. Short- and long-term hemodynamic effects of transjugular intrahepatic portosystemic shunts: a Doppler/manometric correlative study. Am J Gastroenterol 1995; 164: 997-1002
- 28 Kochar N, Tripathi D, Ireland H. et al. Transjugular intrahepatic portosystemic stent shunt (TIPSS) modification in the management of post-TIPSS refractory hepatic encephalopathy. Gut 2006; 55: 1617-1623
- 29 DʼAmico G, Pasta L, Morabito A. et al. Competing risks and prognostic stages of cirrhosis: a 25-year inception cohort study of 494 patients. Aliment Pharmacol Ther 2014; 39: 1180-1193
- 30 Salerno F, Cammà C, Enea M. et al. Transjugular intrahepatic portosystemic shunt for refractory ascites: a meta-analysis of individual patient data. Gastroenterology 2007; 133: 825-834