Bruce Zwiebel

A prospective trial of transjugular intrahepatic portasystemic stent shunts versus small-diameter prosthetic H-graft portacaval shunts in the treatment of bleeding varices.

OBJECTIVE The authors compare transjugular intrahepatic portasystemic stent shunts (TIPS) to small-diameter prosthetic H-graft portacaval shunts (HGPCS). SUMMARY BACKGROUND DATA Transjugular intrahepatic portasystemic stent shunts have been embraced as a first-line therapy in the treatment of bleeding varices due to portal hypertension, although they have not been compared to operatively placed shunts in a prospective trial. METHODS In 1993, the authors began a prospective, randomized trial to compare TIPS with HGPCSs. All patients had bleeding varices and had failed nonoperative management. Shunting was undertaken as definitive therapy in all. Failure of shunting was defined as an inability to accomplish shunting despite repeated attempts, unexpected liver failure leading to transplantation, irreversible shunt occlusion, major variceal rehemorrhage, or death. Mortality and failure rates were analyzed at 30 days (early) and after 30 days (late) using Fischers exact test. RESULTS There were 35 patients in each group, with no difference in age, gender, Childs class, etiology of cirrhosis, urgency of shunting, or incidence of ascites or encephalopathy between groups. In two patients, TIPS could not be placed despite repeated attempts. Transjugular intrahepatic portasystemic stent shunts reduced portal pressures from 32 +/- 7.5 mmHg (standard deviation) to 25 +/- 7.5 mmHg (p < 0.01), whereas HGPCS reduced them from 30 +/- 4.6 mmHg to 19 +/- 5.3 mmHg (p < 0.01; paired Students test). Irreversible occlusion occurred in three patients after placement of TIPS. Total failure rate after TIPS placement was 57%; after HGPCS placement, it was 26% (p < 0.02). CONCLUSIONS Both TIPS and HGPCS reduced portal pressure. Placement of TIPS resulted in more deaths, more rebleeding, and more than twice the treatment failures. Mortality and failure rates promote the application of HGPCS over TIPS.

Surgical and endovascular intervention for infrainguinal vein graft stenosis

PURPOSE The purpose of this study was to evaluate the stenosis-free patency of open repair (vein-patch angioplasty, interposition, jump grafting) and percutaneous transluminal balloon angioplasty (PTA) of 144 vein graft stenoses that were detected during duplex scan surveillance after infrainguinal vein bypass grafting. METHODS Patients who underwent revision of an infrainguinal vein bypass graft were analyzed for type of vein conduit, vascular laboratory findings leading to revision, repair techniques, assisted graft patency rate, procedure mortality rate, and restenosis of the repair site. RESULTS The time of postoperative revision ranged from 1 day to 133 months (mean, 13 months). One hundred eighteen primary and 26 recurrent stenoses (peak systolic velocity, >300 cm/s) in 52 tibial and 35 popliteal vein bypass grafts were identified by means of duplex scanning. The repairs consisted of 77 open procedures (vein-patch angioplasty, 28; vein interposition, 33; jump graft, 9; primary repair, 3) and 67 PTAs. No patient died as a result of intervention. Cumulative assisted graft patency rate (life-table analysis) was 91% at 1 year and 80% at 3 years. At 2 years, cumulative assisted graft patency rate was comparable for saphenous vein grafts (reversed, 94%; in situ, 88%; nonreversed, 63%) and alternative vein grafts (89%). Stenosis-free patency rate at 2 years was identical (P =.55) for surgical intervention (63%) and endovascular intervention (63%) but varied with type of surgical revision (P =.04) and time of intervention (<4 months, 45%; >4 months, 71%; P =.006). The use of duplex scan-monitored PTA to treat focal stenoses (<2 cm) and late-appearing stenoses (>3 months) was associated with a stenosis-free patency rate that was 89% at 1 year. After intervention, the alternative vein bypass grafts necessitated twice the reinterventions per month of graft survival (P =.01). Bypass graft to the popliteal versus infrageniculate arteries, site of graft stenosis (vein conduit, anastomotic region), and repair of a primary versus a recurrent stenosis did not influence the outcome after intervention. CONCLUSION The revision of duplex scan-detected vein graft stenosis with surgical or endovascular techniques was associated with an excellent patency rate, including when intervention on alternative vein conduits or treatment of restenosis was necessary. When PTA was selected on the basis of clinical and duplex scan selection criteria, the endovascular treatment of focal vein graft stenosis was effective, durable, and comparable with the surgical revision of more extensive lesions.

TIPS Versus Peritoneovenous Shunt in the Treatment of Medically Intractable Ascites: A Prospective Randomized Trial

Objective:We undertook a prospective randomized clinical trial comparing TIPS to peritoneovenous (PV) shunts in the treatment of medically intractable ascites to establish relative efficacy and morbidity, and thereby superiority, between these shunts. Methods:Thirty-two patients were prospectively randomized to undergo TIPS or peritoneovenous (Denver) shunts. All patients had failed medical therapy. Results:After TIPS versus peritoneovenous shunts, median (mean ± SD) duration of shunt patency was similar: 4.4 months (6 ± 6.6 months) versus 4.0 months (5 ± 4.6 months). Assisted shunt patency was longer after TIPS: 31.1 months (41 ± 25.9 months) versus 13.1 months (19 ± 17.3 months) (P < 0.01, Wilcoxon test). Ultimately, after TIPS 19% of patients had irreversible shunt occlusion versus 38% of patients after peritoneovenous shunts. Survival after TIPS was 28.7 months (41 ± 28.7 months) versus 16.1 months (28 ± 29.7 months) after peritoneovenous shunts. Control of ascites was achieved sooner after peritoneovenous shunts than after TIPS (73% vs. 46% after 1 month), but longer-term efficacy favored TIPS (eg, 85% vs. 40% at 3 years). Conclusion:TIPS and peritoneovenous shunts treat medically intractable ascites. Absence of ascites after either is uncommon. PV shunts control ascites sooner, although TIPS provides better long-term efficacy. After either shunt, numerous interventions are required to assist patency. Assisted shunt patency is better after TIPS. Treating medically refractory ascites with TIPS risks early shunt-related mortality for prospects of longer survival with ascites control. This study promotes the application of TIPS for medically intractable ascites if patients undergoing TIPS have prospects beyond short-term survival.

Differential effects on portal and effective hepatic blood flow. A comparison between transjugular intrahepatic portasystemic shunt and small-diameter H-graft portacaval shunt.

OBJECTIVE This study was undertaken to determine the effects of transjugular intrahepatic portasystemic shunt (TIPS) and small-diameter prosthetic H-graft portacaval shunt (HGPCS) on portal and effective hepatic blood flow. SUMMARY BACKGROUND DATA Mortality after TIPS is higher than after HGPCS for bleeding varices. This higher mortality is because of hepatic failure, possibly a result of excessive diminution of hepatic blood flow. METHODS Forty patients randomized prospectively to undergo TIPS or HGPCS had effective hepatic blood flow determined 1 day preshunt and 5 days postshunt using low-dose galactose clearance. Portal blood flow was determined using color-flow Doppler ultrasound. RESULTS Treatment groups were similar in age, gender, and Childs class. Each procedure significantly reduced portal pressures and portasystemic pressure gradients. Portal flow after TIPS increased (21 mL/second +/- 11.9 to 31 mL/second +/- 16.9, p < 0.05), whereas it remained unchanged after HGPCS (26 mL/second +/- 27.7 to 14 mL/second +/- 41.1, p = n.s.). Effective hepatic blood flow was diminished significantly after TIPS (1684 mL/minute +/- 2161 to 676 mL/minute +/- 451, p < 0.05) and was unaffected by HGPCS (1901 mL/ minute +/- 1818 to 1662 mL/minute +/- 1035, p = n.s.). CONCLUSIONS Both TIPS and HGPCS achieved significant reductions in portal vein pressure gradients. Portal flow increased after TIPS, although most portal flow was diverted through the shunt. Effective hepatic flow is reduced significantly after TIPS but well preserved after HGPCS. Hepatic decompensation and mortality after TIPS may be because, at least in part, of reductions in nutrient hepatic flow.

Transjugular intrahepatic portasystemic stent shunt in the treatment of variceal bleeding in hepatocellular cancer

Hepatocellular carcinoma (HCC) generally arises in the cirrhotic liver. Exacerbating the consequences of cirrhosis, HCC leads to the development of arteriovenous (AV) shunting between the hepatic artery and the portal system. Arteriovenous communications are a unique characteristic of hepatocellular carcinoma and occur in more than 60% of patients affected by HCC (1). Hemorrhage associated with varices in patients with HCC is often fatal. The cachectic state due to the cancer and coagulopathy due to the underlying cirrhosis in ̄ uence the prognosis of these patients. Ho and co-workers, for example, determined that more than 45% of 287 patients with HCC died acutely from variceal bleeding (2). Pharmacotherapy, hepatic artery embolizat ion, sclerotherapy, surgical resection, and surgical shunting represent the conventional treatments used in the management of variceal hemorrhage in patients with HCC. Unfortunately, such procedures are accompanied by a high morbidity and mortality. Also, unfortunately, the risk of recurrence of bleeding is highest with therapies having the least procedural morbidity. Transjugular intrahepat ic portasystemic stent shunting (TIPSS) has gained popularity in treating variceal hemorrhage due to portal hypertension, but TIPSS has not been utilized to treat portal hypertension complicated by HCC. We report the occurrence of variceal hemorrhage in a patient with advanced cirrhosis and HCC, in whom angiography demonstrated a large arterioportal communication. In this patient, after failure of several sessions of sclerotherapy, bleeding was completely controlled with a TIPSS. Our concern was that TIPSS would increase the arterioportal shunting and, thereby, decrease nutrient hepatic blood ̄ ow and lead to further hepatic dysfunction or failure. The patient was released 5 days after shunting without symptoms or signs of encephalopathy, increased hepatic dysfunction, or cardiac failure, and without any further bleeding. This is the ® rst report of a TIPSS procedure in a patient with cirrhosis, HCC, and a large arterioportal shunt.

Configuration affects parallel stent grafting results

Objective: A number of adjunctive “off‐the‐shelf” procedures have been described to treat complex aortic diseases. Our goal was to evaluate parallel stent graft configurations and to determine an optimal formula for these procedures. Methods: This is a retrospective review of all patients at a single medical center treated with parallel stent grafts from January 2010 to September 2015. Outcomes were evaluated on the basis of parallel graft orientation, type, and main body device. Primary end points included parallel stent graft compromise and overall endovascular aneurysm repair (EVAR) compromise. Results: There were 78 patients treated with a total of 144 parallel stents for a variety of pathologic processes. There was a significant correlation between main body oversizing and snorkel compromise (P = .0195) and overall procedural complication (P = .0019) but not with endoleak rates. Patients were organized into the following oversizing groups for further analysis: 0% to 10%, 10% to 20%, and >20%. Those oversized into the 0% to 10% group had the highest rate of overall EVAR complication (73%; P = .0003). There were no significant correlations between any one particular configuration and overall procedural complication. There was also no significant correlation between total number of parallel stents employed and overall complication. Composite EVAR configuration had no significant correlation with individual snorkel compromise, endoleak, or overall EVAR or procedural complication. The configuration most prone to individual snorkel compromise and overall EVAR complication was a four‐stent configuration with two stents in an antegrade position and two stents in a retrograde position (60% complication rate). The configuration most prone to endoleak was one or two stents in retrograde position (33% endoleak rate), followed by three stents in an all‐antegrade position (25%). There was a significant correlation between individual stent configuration and stent compromise (P = .0385), with 31.25% of retrograde stents having any complication. Conclusions: Parallel stent grafting offers an off‐the‐shelf option to treat a variety of aortic diseases. There is an increased risk of parallel stent and overall EVAR compromise with <10% main body oversizing. Thirty‐day mortality is increased when more than one parallel stent is placed. Antegrade configurations are preferred to any retrograde configuration, with optimal oversizing >20%.

Rapid aneurysm growth after transarterial chemoembolization

Chemotherapy has been anecdotally related to aneurysm growth, but no correlation has been noted to date for localized transarterial chemoembolization. We present the case of a 64-year-old man with clearly documented accelerated aortic and iliac artery aneurysm dilation after two rounds of transarterial chemoembolization for hepatocellular carcinoma. Given the large size with rapid growth of his aneurysms and inability to be listed for transplant consideration before repair, he was offered endovascular repair and was successfully treated.