Original Contribution

Liver and Biliary Tract

Incidence, Natural History, and Risk Factors of Hepatic Encephalopathy After Transjugular Intrahepatic Portosystemic Shunt With Polytetrafluoroethylene-Covered Stent Grafts

  • The American Journal of Gastroenterology volume 103, pages 27382746 (2008)
  • doi:10.1111/j.1572-0241.2008.02102.x
  • Download Citation
Received:
Accepted:
Published:

Abstract

BACKGROUND AND AIMS:

The aim of this study was to assess the incidence, natural history, and risk factors of hepatic encephalopathy (HE) after transjugular intrahepatic portosystemic shunt (TIPS) with the new polytetrafluoroethylene (PTFE)-covered stent grafts in cirrhotic patients.

PATIENTS AND METHODS:

Seventy-eight cirrhotic patients treated by TIPS with PTFE-covered stent grafts and followed by the same medical team—according to a prospective protocol for diagnostic workup and surveillance strategy—were reviewed. The follow-up was 19.9 ± 20.6 months.

RESULTS:

 At least one episode of HE occurred in 35 of 78 (44.8%) patients. The probability of remaining free of HE was 53.8% (95% confidence interval [CI] 41.4–66.2] at 1 yr and 50.9% at 2 yr (95% CI 38.2–63.8%). The total number of HE episodes was 89. Fifty-five percent of the episodes were grades III–IV. The occurrence of HE tended to be constant during the follow-up, probably because of the very low incidence of shunt dysfunction (13.6% at 2 yr). Moreover, in six patients, a refractory HE required the reduction of the shunt diameter. One patient died due to variceal bleeding after this procedure. At a multivariate analysis, an older age, high creatinine levels, and low serum sodium and low albumin values were shown to be independent factors for the occurrence of HE. Serum creatinine level was the only variable related to the development of refractory HE at the logistic multivariate analysis.

CONCLUSIONS:

 HE after TIPS with PTFE-covered stent grafts is frequent; its incidence is not confined to the first post-TIPS period, but it has the tendency to be frequent over time. Refractory HE occurred in 8% of patients and may be successfully managed by reducing the stent diameter. The selection of patients undergoing TIPS placement should be very accurate, especially for those subjects with abnormal creatinine level.

  • Subscribe to The American Journal of Gastroenterology for full access:

    $870

    Subscribe

Additional access options:

Already a subscriber?  Log in  now or  Register  for online access.

References

  1. 1.

    , , , et al. Transjugular intrahepatic portosystemic shunt versus sclerotheraphy in the elective treatment of variceal hemorrage. Gastroenterology 1996;110:832–839.

  2. 2.

    , , , et al. Transjugular intrahepatic portosystemic shunts for patients with active variceal hemorrhage unresponsive to sclerotheraphy. Gastroenterology 1996;111:138–146.

  3. 3.

    , , , et al. Randomised trial of transjugular-intrahepatic-portosystemic shunt versus endoscopy plus propanolol for prevention of variceal rebleeding. Lancet 1997;349:1043–1049.

  4. 4.

    , , , et al. Transjugular intrahepatic portosystemic shunt versus endoscopic sclerotheraphy for the prevention of variceal bleeding in cirrhosis: A randomized multicenter trial. Hepatology 1998;27:40–45.

  5. 5.

    , , , et al. Transjugular intrahepatic portosystemic shunts: Comparison with paracentesis in patient with cirrhosis and refractory ascites: A randomized trial. J Hepatol 1996;25:135–144.

  6. 6.

    , , , et al. A comparison of paracentesis and transjugular intrahepatic portosystemic shunting in patients with ascites. N Engl J Med 2000;342:1701–1707.

  7. 7.

    , , , et al. Transjugular intrahepatic portosystemic shunt versus paracentesis plus albumin for refractory ascites in cirrhosis. Gastroenterology 2002;123:1839–1847.

  8. 8.

    , , , et al. The North American study for the treatment of refractory ascites. Gastroenterology 2003;124:634–641.

  9. 9.

    , , , et al. Randomized controlled study of TIPS versus paracentesis plus albumin in cirrhosis with severe ascites. Hepatology 2004;40:629–635.

  10. 10.

    , , , et al. Incidence of shunt occlusion or stenosis following transjugular intrahepatic portosystemic shunt placement. Gastroenterology 1994;106:1277–1283.

  11. 11.

    , , , et al. Two-year outcome following transjugular intrahepatic portosystemic shunt for variceal bleeding: Results in 90 patients. Gastroenterology 1995;108:1143–1151.

  12. 12.

    , , , et al. Development of stenoses in transjugular intrahepatic portosystemic shunts. Radiology 1994;192:231–234.

  13. 13.

    , , , et al. Patency and reintervention rates during routine TIPSS surveillance. Cardiovasc Intervent Radiol 1998;21:234–239.

  14. 14.

    , , , et al. Portosystemic encephalopathy after transjugular intrahepatic portosystemic shunt: Results of a prospective controlled study. Hepatology 1994;20:46–55.

  15. 15.

    , , , et al. Analysis of prognostic variables in the prediction of mortality, shunt failure, variceal rebleeding and encephalopathy following the transjugular intrahepatic portosystemic shunt for variceal haemorrhage. J Hepatol 1995;23:123–128.

  16. 16.

    , , , et al. Hepatic encephalopathy after transjugular intrahepatic portosystemic shunt: Incidence and risk factors. Am J Gastroenterol 1995;90:549–555.

  17. 17.

    , , , et al. Hepatic encephalopathy after transjugular intrahepatic portosystemic shunt. Incidence and risk factors. Dig Dis Sc 1996;41:578–584.

  18. 18.

    , , , et al. Encephalopathy after transjugular intrahepatic portosystemic shunt: Analysis and incidence of potential risk factors. Am J Roentgenol 1997;169:1727–1731.

  19. 19.

    , , , et al. Portosystemic hepatic encephalopathy after transjugular intrahepatic portosystemic shunt in patients with cirrhosis: Clinical, laboratory, psychometric and electroencephalographic investigations. Hepatology 1998;28:1215–1225.

  20. 20.

    , , , et al. Creation of transjugular intrahepatic portosystemic shunts with stent-grafts: Initial experiences with a polytetrafluoroethylene-covered nitinol endoprothesis. Radiology 2001;221:437–446.

  21. 21.

    , , , et al. Preliminary results of a new expanded-polytetrafluoroethylene-covered stent-graft for transjugular intrahepatic portosystemic shunt procedures. Am J Roentgenol 2002;178:141–147.

  22. 22.

    , , , et al. Early and long-term clinical and radiological follow-up results of expanded polytetrafluorethylene-covered stent-grafts for for transjugular intrahepatic portosystemic shunt procedures. Eur Radiol 2004;14:1842–1850.

  23. 23.

    , , , et al. Survival in patients undergoing transjugular intrahepatic portosystemic shunt: ePTFE-covered stent-grafts versus bare stents. Hepatology 2003;38:1043–1050.

  24. 24.

    , , , et al. Results of polytetrafluoroethylene-covered stent grafts for transjugular portosystemic shunt creation. J Vasc Interv Radiol 2004;15:1219–1230.

  25. 25.

    , , , et al. TIPS with expanded polytetrafluoroethylene-covered stent: Results of an Italian multicenter study. AJR Am J Roentgenol 2005;185:472–480.

  26. 26.

    , , , et al. Comparison of transjugular intrahepatic portosystemic shunt dysfunction in PTFE-covered stent-grafts versus bare stents. Eur J Radiol 2005;55:120–124.

  27. 27.

    , , , et al. Covered transjugular intrahepatic portosystemic stents maintain lower portal pressure and require fewer reinterventions than uncovered stents. Scand J Gastroenterol 2004;10:994–999.

  28. 28.

    , , , et al. Improved clinical outcome using polytetrafluoroethylene-coated stents for TIPS: Results of a randomized study. Gastroenterology 2004;126:469–475.

  29. 29.

    , , , et al. Polytetrafluorethylene-covered stent-graft for TIPS procedure: 1-year patency and clinical results. Am J Gastroenterol 2004;99:280–285.

  30. 30.

    , , , et al. Improved clinical outcome with transjugular intrahepatic portosystemic stent-shunt utilizing polytetrafluoroethylene-covered stents. Eur J Gastroenterol Hepatol 2006;18:225–232.

  31. 31.

    , . Transjugular intrahepatic portosystemic shunt versus endoscopic therapy: Randomized trials for secondary prophylaxis of variceal bleeding: An updated meta-analysis. Scand J Gastroenterol 2002;37:249–252.

  32. 32.

    , . Treatment for hepatic encephalopathy: Tips from TIPS? J Hepatol 2005;42:626–628.

  33. 33.

    , , , 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;27:742–747.

  34. 34.

    , , , et al. Comparison of lactulose and neomycin in the treatment of chronic portal-systemic encephalopathy. A double blind controlled trial. Gastroenterology 1977;72:573–583.

  35. 35.

    , , . Use of a laryngeal mask in transjugular intrahepatic portosystemic shunt procedures. J Vasc Interv Radiol 1998;9:169.

  36. 36.

    , , , et al. Polytetrafluorethylene-covered nitinol stent-graft for transjugular intrahepatic portosystemic shunt creation: 3-year experience. Radiology 2004;231:820–830.

  37. 37.

    , , . Transection of the oesophagus for bleeding oesophageal varices. Br J Surg 1973;60:646–664.

  38. 38.

    , , , et al. A model to predict poor survival in patients undergoing transjugular intrahepatic portosystemic shunts. Hepatology 2000;31:864–871.

  39. 39.

    The Italian Liver Cirrhosis Project. Reliability of endoscopy in the assessment of varices features. J Hepatol 1987;4:93–98.

  40. 40.

    , , , et al. Variability of trail making test, symbol digit test and line trait test in normal people. A normative study taking into account age-dependent decline and sociobiological variables. Aging Clin Exp Res 2002;14:117–131.

  41. 41.

    , . Non-parametric estimation from incomplete observations. J Am Stat Assoc 1958;53:457–481.

  42. 42.

    , , , et al. Statistical models based on counting processes. Springer: New York, 1993.

  43. 43.

    , . Model selection and multimodel inference: A practical information-theoretic approach, 2nd ed. Springer-Verlag: New York, 2002.

  44. 44.

    , , , et al. Classification and regression trees. Wadsworth: Belmont, CA, 1984.

  45. 45.

    , , , et al. Pharmacological prophylaxis of hepatic encephaolpathy after transjugular intrahepatic portosystemic shunt: A randomized controlled study. J Hepatol 2005;42:674–679.

  46. 46.

    , , , et al. Transjugular intrahepatic portosystemic stent shunt (TIPSS) modification in the management of post-TIPSS refractory hepatic encephalopathy. Gut 2006;55:1617–1623.

  47. 47.

    , , , et al. Relationship between pre-TIPS liver perfusion by the portal vein and the incidence of post-TIPS chronic hepatic encephalopathy. Am J Gastroenterol 2001;96:1205–1209.

Download references

Author information

Affiliations

  1. II Gastroenterologia, Dipartimento di Medicina Clinica, “Sapienza” Università di Roma, Rome, Italy

    • Oliviero Riggio
    • , Stefania Angeloni
    • , Adriano De Santis
    • , Federica Cerini
    • , Adolfo Francesco Attili
    •  & Manuela Merli
  2. Dipartimento di Scienze Radiologiche, “Sapienza” Università di Roma, Rome, Italy

    • Filippo Maria Salvatori
  3. Dipartimento di Medicina Sperimentale, Sezione Statistica, “Sapienza” Università di Roma, Rome, Italy

    • Alessio Farcomeni

Authors

  1. Search for Oliviero Riggio in:

  2. Search for Stefania Angeloni in:

  3. Search for Filippo Maria Salvatori in:

  4. Search for Adriano De Santis in:

  5. Search for Federica Cerini in:

  6. Search for Alessio Farcomeni in:

  7. Search for Adolfo Francesco Attili in:

  8. Search for Manuela Merli in:

Corresponding author

Correspondence to Oliviero Riggio.