Transjugular portal vein recanalization with creation of intrahepatic portosystemic shunt (PVR-TIPS) in patients with chronic non-cirrhotic, non-malignant portal vein thrombosis

Abstract

Purpose To determine safety and efficacy of transjugular portal vein recanalization with creation of intrahepatic portosystemic shunt (PVR-TIPS) in patients with chronic non-cirrhotic, non-malignant portal vein thrombosis (PVT).

Methods This retrospective study includes 17 consecutive patients with chronic non-cirrhotic PVT (cavernous transformation n = 15). PVR-TIPS was indicated because of variceal bleeding (n = 13), refractory ascites (n = 2), portal biliopathy with recurrent cholangitis (n = 1), or abdominal pain (n = 1). Treatment consisted of a combination of transjugular balloon angioplasty, mechanical thrombectomy, and—depending on extent of residual thrombosis—transjugular intrahepatic portosystemic shunt and additional stenting of the portal venous system.

Results Recanalization was successful in 76.5 % of patients despite cavernous transformation in 88.2 %. Both 1- and 2-year secondary PV and TIPS patency rates were 69.5 %. Procedure-related bleeding complications occurred in 2 patients (intraperitoneal bleeding due to capsule perforation, n = 1; liver hematoma, n = 1) and resolved spontaneously. However, 1 patient died due to subsequent nosocomial pneumonia. During follow-up, 3 patients with TIPS occlusion and PVT recurrence experienced portal hypertensive complications.

Conclusions PVR-TIPS is safe and effective in selected patients with chronic non-cirrhotic PVT. Due to technical complexity and possible complications, it should be performed only in specialized centers with high experience in TIPS procedures.

Zusammenfassung

Ziel Untersuchung der Sicherheit und Effektivität der transjugulären Pfortaderrekanalisation mit intrahepatischem portosystemischem Shunt (PVR-TIPS) bei Patienten mit chronischer nicht-zirrhotischer, nicht-maligner Pfortaderthrombose (PVT).

Methoden In diese retrospektive Studie wurden 17 konsekutive Patienten mit chronischer nicht-zirrhotischer PVT (kavernöse Transformation, n = 15) eingeschlossen. Indikationen zur interventionellen Therapie waren Varizenblutung (n = 13), therapierefraktärer Aszites (n = 2), portale Biliopathie mit rezidivierenden Cholangitiden (n = 1) sowie abdominelle Schmerzen (n = 1). Die interventionelle Therapie bestand aus einer Kombination von transjugulärer Ballonangioplastie, mechanischer Thrombektomie und Anlage eines transjugulären intrahepatischen portosystemischen Shunts (TIPS). Abhängig von der Ausdehnung einer evtl. noch vorhandenen Restthrombose erfolgte ggf. eine zusätzliche Stenteinlage im portalvenösen System.

Ergebnisse Die Rekanalisation mittels PVR-TIPS war bei 76,5 % der Patienten erfolgreich, obwohl bei 88,2 % eine kavernöse Transformation vorlag. Die sekundären 1- und 2-Jahresoffenheitraten betrugen 69,5 %. Selbstlimitierende Blutungskomplikationen traten bei 2 Patienten auf (intraperitoneale Blutung aufgrund einer Perforation der Leberkapsel, n = 1; Leberhämatom, n = 1). Einer der beiden Patienten verstarb jedoch im Verlauf des Indexaufenthalts aufgrund einer nosokomialen Pneumonie. Während des Follow-Ups entwickelten drei Patienten aufgrund eines PVT-Rezidivs portalhypertensive Komplikationen.

Schlussfolgerung PVR-TIPS ist eine sichere und effektive Methode zur Behandlung ausgewählter Patienten mit chronischer nicht-zirrhotischer PVT. Aufgrund der Komplexität des Eingriffs sowie der möglichen Risiken sollte die Methode nur in spezialisierten Zentren mit einer hohen Erfahrung bezüglich TIPS-Prozeduren durchgeführt werden.

Key words

portal vein thrombosis - transjugular intrahepatic portosystemic shunt - JAK2 - portal hypertension - treatment - thrombectomy

Schlüsselwörter

Pfortaderthrombose - transjugulärer intrahepatischer portosystemischer Shunt - JAK2 - portale Hypertension - Behandlung - Thrombektomie

• References

• 1 DeLeve LD, Valla DC, Garcia-Tsao G. Vascular disorders of the liver. Hepatology 2009; 49: 1729-1764
• 2 EASL. EASL clinical practical guidelines: vascular diseases of the liver. J Hepatol 2016; 64: 179-202
• 3 Kumar A, Sharma P, Arora A. Review article: portal vein obstruction – epidemiology, pathogenesis, natural history, prognosis and treatment. Aliment Pharmacol Ther 2015; 41: 276-292
• 4 Primignani M. Portal vein thrombosis, revisited. Dig Liver Dis 2010; 42: 163-170
• 5 Sarin SK, Valla DC, de Franchis R. Revising consensus in portal hypertension: report of the Baveno v Consensus Workshop on methodology of diagnosis and therapy in portal hypertension. J Hepatol 2011; 54: 1082-1083
• 6 Senzolo M, Tibbals J, Cholongitas E. et al. Transjugular intrahepatic portosystemic shunt for portal vein thrombosis with and without cavernous transformation. Aliment Pharmacol Ther 2006; 23: 767-775
• 7 Fanelli F, Angeloni S, Salvatori FM. et al. Transjugular intrahepatic portosystemic shunt with expanded-polytetrafuoroethylene-covered stents in non-cirrhotic patients with portal cavernoma. Dig Liver Dis 2011; 43: 78-84
• 8 Luo X, Nie L, Zhou B. et al. Transjugular intrahepatic portosystemic shunt for the treatment of portal hypertension in noncirrhotic patients with portal cavernoma. Gastroenterol Res Pr 2014; 2014: 659726
• 9 Bilbao JI, Elorz M, Vivas I. et al. Transjugular intrahepatic portosystemic shunt (TIPS) in the treatment of venous symptomatic chronic portal thrombosis in non-cirrhotic patients. Cardiovasc Intervent Radiol 2004; 27: 474-480
• 10 Rosenqvist K, Eriksson LG, Rorsman F. et al. Endovascular treatment of acute and chronic portal vein thrombosis in patients with cirrhotic and non-cirrhotic liver. Acta Radiol 2016; 57: 572-579
• 11 Qi X, Han G, Yin Z. et al. Transjugular intrahepatic portosystemic shunt for portal cavernoma with symptomatic portal hypertension in non-cirrhotic patients. Dig Dis Sci 2012; 57: 1072-1082
• 12 Wils A, van der Linden E, van Hoek B. et al. Transjugular intrahepatic portosystemic shunt in patients with chronic portal vein occlusion and cavernous transformation. J Clin Gastroenterol 2009; 43: 982-984
• 13 Kallini JR, Gabr A, Kulik L. et al. Noncirrhotic complete obliterative portal vein thrombosis: novel management using trans-splenic transjugular intrahepatic portosystemic shunt with portal vein recanalization. Hepatology 2016; 63: 1387-1390
• 14 Luca A, Miraglia R, Caruso S. et al. Short- and long-term effects of the transjugular intrahepatic portosystemic shunt on portal vein thrombosis in patients with cirrhosis. Gut 2011; 60: 846-852
• 15 Wang Z, Jiang M, Zhang H. et al. Is post-TIPS anticoagulation therapy necessary in patients with cirrhosis and portal vein thrombosis?. A randomized controlled trial. Radiology 2016; 279: 943-951
• 16 Han G, Qi X, He C. et al. Transjugular intrahepatic portosystemic shunt for portal vein thrombosis with symptomatic portal hypertension in liver cirrhosis. J Hepatol 2011; 54: 78-88
• 17 Luo X, Wang Z, Tsauo J. et al. Advanced cirrhosis combined with portal vein thrombosis: a randomized trial of TIPS versus endoscopic band ligation plus propranolol for the prevention of recurrent esophageal variceal bleeding. Radiology 2015; 276: 286-293
• 18 Perarnau JM, Baju A, D’Alteroche L. et al. Feasibility and long-term evolution of TIPS in cirrhotic patients with portal thrombosis. Eur J Gastroenterol Hepatol 2010; 22: 1093-1098
• 19 Wang Z, Zhao H, Wang X. et al. Clinical outcome comparison between TIPS and EBL in patients with cirrhosis and portal vein thrombosis. Abdom Imaging 2014; 40: 1813-1820
• 20 Zhao JB, Feng C, Zhu QH. et al. Transjugular intrahepatic portosystemic shunt with covered stents for hepatocellular carcinoma with portal vein tumor thrombosis. World J Gastroenterol 2014; 20: 1602-1607
• 21 Salem R, Vouche M, Baker T. et al. Pretransplant portal vein recanalization – transjugular intrahepatic portosystemic shunt in patients with complete obliterative portal vein thrombosis. Transplantation 2015; 99: 2347-2355
• 22 Habib A, Desai K, Hickey R. et al. Portal vein recanalization-transjugular intrahepatic portosystemic shunt using the transsplenic approach to achieve transplant candidacy in patients with chronic portal vein thrombosis. J Vasc Interv Radiol 2015; 26: 499-506
• 23 Qi X, He C, Guo W. et al. Transjugular intrahepatic portosystemic shunt for portal vein thrombosis with variceal bleeding in liver cirrhosis: outcomes and predictors in a prospective cohort study. Liver Int 2016; 36: 667-676
• 24 Chen Y, Ye P, Li Y. et al. Percutaneous transhepatic balloon-assisted transjugular intrahepatic portosystemic shunt for chronic, totally occluded, portal vein thrombosis with symptomatic portal hypertension: procedure technique, safety, and clinical applications. Eur Radiol 2015; 25: 3431-3437
• 25 Liu L, Zhao Y, Qi X. et al. Transjugular intrahepatic portosystemic shunt for symptomatic portal hypertension in hepatocellular carcinoma with portal vein tumor thrombosis. Hepatol Res 2014; 44: 621-630
• 26 Thornburg B, Desai K, Hickey R. et al. Portal vein recanalization and transjugular intrahepatic portosystemic shunt creation for chronic portal vein thrombosis: technical considerations. Tech Vasc Interventional Rad 2016; 19: 52-60
• 27 Qi X, Liu L, Bai M. et al. Transjugular intrahepatic portosystemic shunt in combination with or without variceal embolization for the prevention of variceal rebleeding: a meta-analysis. J Gastroenterol Hepatol 2014; 29: 688-696
• 28 EASL. EASL Clinical Practice Guidelines on the management of ascites, spontaneous bacterial peritonitis and hepatorenal syndrome in cirrhosis. J Hepatol 2010; 53: 397-417
• 29 Garcia-Tsao G, Abraldes JG, Berzigotti A. et al. Portalhypertensive 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
• 30 Sarin SK, Lahoti D, Saxena SP. et al. Prevalence, classification and natural history of gastric varices: a long-term follow-up study in 568 portal hypertension patients. Hepatology 1992; 16: 1343-1349
• 31 Rössle M. TIPS: 25 years later. J Hepatol 2013; 59: 1081-1093
• 32 De Stefano V, Martinelli I. Splanchnic vein thrombosis: clinical presentation, risk factors and treatment. Intern Emerg Med 2010; 5: 487-494
• 33 Casini A, Fontana P, Lecompte TP. Thrombotic complications of myeloproliferative neoplasms: risk assessment and risk-guided management. J Thromb Haemost 2013; 11: 1215-1227
• 34 Noronha Ferreira C, Seijo S, Plessier A. et al. Natural history and management of esophagogastric varices in chronic non-cirrhotic non-tumoral portal vein thrombosis. Hepatology 2016; 63: 1640-1650
• 35 Condat B, Pessione F, Hillaire S. et al. Current outcome of portal vein thrombosis in adults: risk and benefit of anticoagulant therapy. Gastroenterology 2001; 120: 490-497