Petr Hulek

A double-blind dose-escalating trial comparing novel mesalazine pellets with mesalazine tablets in active ulcerative colitis

Background : Mesalazine as the treatment standard for ulcerative colitis can be applied in different galenical preparations.

Wedged hepatic venography for targeting the portal vein during TIPS: comparison of carbon dioxide and iodinated contrast agents.

Purpose: Carbon dioxide (CO2) can traverse the hepatic sinusoids better than iodinated contrast medium and has been used by many interventionalists for wedged hepatic venography during transjugular intrahepatic portosystemic shunt (TIPS) procedures. Our study was designed to compare the extent of the portal vein opacification using either CO2 or iodinated contrast medium. Methods: Wedged hepatic venography for portal vein opacification during TIPS was performed using hand injection through a 6.5 Fr diagnostic catheter. Portograms of 36 patients performed with 10 ml of iodinated contrast medium were retrospectively compared with portograms of 45 patients performed with 30-40 ml of CO2. Opacification of the right portal vein branch including the portal vein bifurcation was defined as a successful study. Results: Using CO2 the right portal vein branch and the portal vein bifurcation were opacified in 87% of patients (39 of 45); only a part of the right portal vein branch was opacified in 6% of patients and no opacification of any portal vein branch was seen in 7% of patients. Using iodinated contrast medium, there was opacification of the portal vein bifurcation in 25% of patients (9 of 36), of a part of the portal vein branch in 36% and no opacification of any branch in 39%. There was one case of hepatic laceration from CO2 wedged venography which was treated with microcoil embolization. Conclusions: Using CO2 as a contrast medium, opacification of the portal vein bifurcation by wedged hepatic venography was seen in 87% of patients, in comparison with only 25% when iodinated contrast medium was used (p < 0.001). CO2 is superior to iodinated contrast medium for wedged hepatic venography during TIPS.

Quality Improvement Guidelines for Transjugular Intrahepatic Portosystemic Shunt (TIPS)

Portal hypertension is a syndrome caused by increased resistance in the portohepatic circulation and an increase in the splanchnic vein blood supply. In the normal liver, the difference between pressures in the portal vein and the free hepatic veins or right atrium usually does not exceed 5 mm Hg. Portal hypertension is defined as a gradient larger than 6 mm Hg, but clinical complications seem to occur only when the pressure gradient exceeds 10–12 mm Hg. Wedged hepatic pressure measurement has two components. The portal component is the pressure transmitted from the hepatic sinusoids, and the systemic component is the blood pressure transmitted from the central veins. It is the portal component that causes the development of portal systemic collaterals. The term corrected sinusoidal pressure includes only the portal component and is calculated by subtracting the mean right atrial or inferior vena cava pressure from the wedged hepatic venous pressure. Wedged hepatic pressure is obtained through an end-hole catheter that is advanced into a hepatic vein until it can go no further. Alternatively, pressure can be measured through the wire channel of a double lumen balloon catheter inflated in a more central vein. Transjugular intrahepatic portosystemic shunt (TIPS) is the percutaneous method of creating a portosystemic shunt to decrease or treat portal hypertension. TIPS is a side-to-side shunt of a determined diameter designed to function as a partial shunt that preserves a portion of portal flow to the liver [2]. Flow through the completed shunt is assessed by comparing the degree of preferential filling of the shunt to the that of the portal vein branches and portosystemic collaterals (mainly in the gastric veins). The identification of hepatofugal (reversed) blood flow in portal vein branches (total shunting) is a sign of good flow through the shunt. Technical success is defined as a decrease of the portosystemic pressure gradient to 12 mm Hg or less, or a reduction of at least 20 %. Clinical success is defined as cessation of variceal bleeding, decrease of ascites, and conversion into diuretic-sensitive ascites, as well as improvement of liver function in patients referred for massive thrombosis of hepatic veins. Hepatic encephalopathy is defined as the complex of all cerebral dysfunctions that can occur during the course of serious liver disease. Clinical symptomatology, which as a rule is potentially reversible, ranges from disorientation, somnolence, and lethargy to sopor and coma. Hepatic encephalopathy has three forms: type A, associated with acute liver failure; type B, associated with portosystemic bypass without liver disease; and type C, or chronic, associated with liver cirrhosis.

Influence of the Secondary Deployment of Expanded Polytetrafluoroethylene–covered Stent Grafts on Maintenance of Transjugular Intrahepatic Portosystemic Shunt Patency

PURPOSE To evaluate the effects of secondary deployment of expanded polytetrafluoroethylene (ePTFE)-covered stent grafts in the treatment of dysfunctional transjugular intrahepatic portosystemic shunts (TIPSs) in comparison with other common approaches (conventional angioplasty or implantation of bare metal stents). MATERIALS AND METHODS A retrospective review of 121 dysfunctional bare metal TIPS presenting between 2000 and 2004 was conducted. The group was divided into four subgroups according to the type of intervention: conventional angioplasty (52 cases; 43%), bare metal stent deployment (35 cases; 28.9%), nondedicated ePTFE-covered stent-graft deployment (15 cases; 12.4%), and dedicated ePTFE-covered stent-graft deployment (19 cases; 15.7%). In all four groups, the primary patency after the specific intervention was calculated and mutually compared. RESULTS Primary patency rates after 12 and 24 months were 49.7% and 25.3%, respectively, in conventional angioplasty; 74.9% and 64.9%, respectively, with bare metal stents; 75.2% and 64.5%, respectively, with nondedicated ePTFE-covered stent grafts; and 88.1% and 80.8%, respectively, with dedicated ePTFE-covered stent grafts. CONCLUSIONS In the treatment of dysfunctional TIPS, better patency after the intervention was obtained by deploying dedicated ePTFE-covered stent grafts in comparison with conventional angioplasty, bare metal stents, and nondedicated ePTFE-covered stents.

Management of Acute Variceal Bleeding

Portal hypertension as a consequence of liver cirrhosis is responsible for its most common complications: ascites, spontaneous bacterial peritonitis, hepatorenal syndrome, hepatic encephalopathy and the most important one – variceal hemorrhage. Variceal bleeding results in considerable morbidity and mortality. This review covers all areas of importance in the therapy of acute variceal hemorrhage – endoscopic and pharmacological treatment, transjugular intrahepatic portosystemic shunt, surgery and balloon tamponade. Indications and limitations of these therapeutic modalities are widely discussed.

TIPS creation in a patient with situs inversus totalis.

We describe the successful creation of a transjugular intrahepatic portosystemic shunt (TIPS) in a patient with complete situs inversus using a simple modification of the standard TIPS technique.

Elevated cardiac markers are associated with higher mortality in patients after transjugular intrahepatic portosystemic shunt insertion.

Background Transjugular intrahepatic portosystemic shunts (TIPSs) have become a widely accepted tool in the treatment of patients with symptomatic portal hypertension. The aim of our study was to assess the value of cardiac markers before and after TIPS insertion for the prediction of one-year mortality in cirrhotic patients. Methods The study population consisted of 55 patients (38 men and 17 women, aged 55.6 ± 8.9 y, range 37-74) with liver cirrhosis treated with transjugular portosystemic shunting. Biochemical markers were measured before and 24 h after TIPS. High-sensitivity cardiac troponin T (hs-cTnT) was tested by high-sensitivity immunoassay for Elecsys analyser (Roche Diagnostics). Concentrations of creatine kinase MB isoenzyme, myoglobin (MYO), glycogenphosphorylase BB isoenzyme (GPBB) and heart type of fatty acid binding protein (FABP) were measured by the Evidence Investigator protein biochip system (Randox Laboratories). Results In patients before TIPS insertion, hs-cTnT was increased above the cut-off (0.014 μg/L) in 39.2% of patients. Higher hs-cTnT and FABP concentrations were associated with poor survival in patients before TIPS (hs-cTnT: P = 0.018; FABP: P = 0.016). Twenty-four hours after the TIPS procedure, we found a significant elevation in serum GPBB in comparison with preprocedural values (P < 0.001). There was an association between postprocedural concentrations of cardiac markers (MYO, hs-cTnT, FABP) and overall survival. Conclusions Measurement of cardiac markers, mainly hs-cTnT and FABP, may be useful for mortality prediction in cirrhotic patients after TIPS. Cardiac markers are better mortality predictors than other risk factors such as age, gender or Child-Pugh score.

Stent-grafts in TIPS

The transjugular intrahepatic portosystemic shunt (TIPS) is a percutaneous, minimally invasive method of reducing an increased portal pressure in patients with symptomatic portal hypertension. TIPS is done under local anesthesia on awake, mildly sedated patients and can be performed in emergency settings, in patients at both extremes of age, and in those with poor liver function and massive ascites who often are not considered candidates for shunt surgery. In the past decade, TIPS has been shown to be effective in variceal bleeding, refractory ascites, portal gastropathy, hepatic hydrothorax, and the Budd-Chiari syndrome [1]. During a TIPS procedure an intrahepatic shunt is performed by using an expandable stent to connect a large hepatic vein with a main branch of the portal vein. The major disadvantage of TIPS is the high rate of stenoses or occlusions necessitating careful follow-up of these patients and repeated interventional corrections of insufficient shunts. Depending on the definition of the shunt stenosis and surveillance protocols, stenoses of greater than 50% have been reported in 25% to 50% of cases within 6 to 12 months of shunt creation [2–5]. However, these patients were rarely symptomatic, and recurrent variceal bleeding was seen in fewer than 25% of patients with significant TIPS stenosis [6, 7]. The high rate of shunt stenoses is the major reason for the relatively poor cost effectiveness of TIPS when compared with endoscopic or surgical treatment. Significant research has been carried out to improve primary shunt patency. In a series of animal and human studies, several investigators have reported a significant reduction in the development of TIPS stenoses with the use of covered stents, i.e., stent-grafts. The graft material can provide a barrier between the flowing blood and the traumatized liver parenchyma. In addition to improving primary and secondary patency of TIPS, stent-grafts play an important role in sealing off an extrahepatic portal vein leak during TIPS [8]. Worsened encephalopathy after TIPS can be treated more easily by using a special design of constrained stent-graft creating shunt stenosis than by previously described shunt reduction methods [9]. The use of stent-grafts that traverse malignant hepatic tumor in TIPS potentially can prevent tumor invasion into the shunt and reduce the possibility of vascular spread and seeding of tumor in the lungs [10, 11]. The purpose of this paper is to analyze the causes of TIPS stenoses and occlusion and summarize the current results of experimental and clinical uses of stent-grafts. The role of stent-graft implantation in sealing an extrahepatic portal vein leak, a rare but potentially fatal complication of TIPS procedure, also is discussed.

Glycogen phosphorylase BB levels are associated with haemodynamic parameters in cirrhotic patients undergoing transjugular intrahepatic portosystemic shunt insertion

BACKGROUND Transjugular intrahepatic portosystemic shunts (TIPS) have become a widely accepted tool in the treatment of patients with symptomatic portal hypertension. The aim of our study was to assess glycogen phosphorylase BB (GPBB) concentration in relation to echocardiographic and haemodynamic parameters in patients before and after TIPS insertion. METHODS The study population consisted of 55 patients (38 men and 17 women, age 55.6±8.9 years, range 37-74 years) with liver cirrhosis treated with transjugular portosystemic shunting. GPBB, echocardiographic, and haemodynamic parameters were measured before TIPS insertion and 24 h after the procedure. GPBB concentrations were assessed using the Cardiac Array for Evidence Investigator protein biochip. Correlation between parameters was assessed using the Spearmans coefficient. RESULTS Serum post-procedural GPBB concentrations were increased in comparison with baseline (5.58 vs. 2.67 μg/L, P<0.001). GPBB concentration after TIPS significantly correlated with baseline systemic vascular resistence (r=0.330; P=0.017) and cardiac index (r=0.313; P=0.025). CONCLUSION GPBB concentration measurement may be a useful tool for monitoring myocardial ischemia during a TIPS procedure.