Effects of interferon-alpha monotherapy on hepatic drug metabolism in cancer patients

Twenty-five patients with liver cirrhosis and portal hypertension were admitted for creation of a transjugular intrahepatic portosystemic shunt (TIPS). The procedure was successful in 22 patients (technical success 88%). The mean portal pressure gradient was lowered from 24.5 mmHg before to 11.4 mmHg after TIPS. Two early and three late occlusions were observed (primary patency rate 78%). The rate of secondary interventions was 41%. Five times a hepatic vein stenosis was dilated and stented, two times an occluded shunt was recanalized, two times a new shunt was created parallel to an occluded (secondary patency rate within a maximum of 16 months 95%). In two patients sepsis occurred which was effectively treated with antibiotics, two patients died shortly after TIPS due to hepatorenal syndrome and hepatic failure, respectively. There was no recurrent bleeding. Two patients developed hepatic encephalopathy; both improved after protein restriction. The authors conclude that TIPS is an alternative procedure to shunt surgery, especially for patients who cannot benefit from sclerotherapy.     

Effects of transjugular intrahepatic portosystemic shunt (TIPS) on quantitative liver function tests

BACKGROUND/AIMS: The transjugular intrahepatic portosystemic stent-shunt (TIPS) has been established as a new effective treatment for portal hypertension in advanced liver disease. Impairment of liver function due to reduced portal venous perfusion is considered to be a major risk of TIPS, and the shunt leads to an increase in the incidence of hepatic encephalopathy (HE). Known complications, like the increase in the incidence of HE or TIPS stenosis, are diagnosed either clinically or by doppler ultrasound. It is not practicable to use quantitative liver function tests in the diagnostic work-up of HE, and medical or interventional therapy can be established after clinical diagnosis. Still, information is limited about the influence of TIPS on quantitative liver function tests in patients with liver cirrhosis. Therefore, the aim of this prospective study was to assess the effects of TIPS on various liver function tests. METHODOLOGY: Fifteen patients with liver cirrhosis, a hepatopetal portal flow before TIPS, and an uncomplicated course without stenosis after elective TIPS were analysed. Liver function was quantitatively measured using the [14C]aminopyrine breath test (ABT), considered to be independent of hepatic blood flow, the monoethylglycinexylidide test (MEGX), believed to be largely dependent on hepatic blood flow, serum bilirubin, serum albumin, and prothrombin time. Measurements were performed before, 1, 3 and 6 months after TIPS. RESULTS: TIPS decreased the portal venous pressure gradient from 31.0+/-2.0 cm (SEM) H2O to 16.9+/-1.8 cm H2O (p<0.01). One, 3 and 6 months after TIPS there was no significant deterioration of liver function as assessed by ABT, MEGX or serum bilirubin, serum albumin, and prothrombin time compared to baseline values before TIPS. ABT and MEGX were significantly correlated before TIPS (r=0.72; p<0.01) and after TIPS (r=0.76; p<0.05). CONCLUSIONS: These data show no significant deterioration of microsomal liver function as measured by the quantitative liver function tests ABT and MEGX over a period of 6 months after elective TIPS. In particular, there was no significant reduction of the MEGX-test considered to depend predominantly on hepatic blood flow. Thus, there is no need for the quantitative liver function tests ABT and MEGX in the routine management of patients following the TIPS procedure.     

Transjugular intrahepatic portosystemic shunt (TIPS): a pediatric perspective

The TIPS (transjugular intrahepatic portosystemic shunt) procedure is a relatively new therapeutic treatment option for variceal bleeding secondary to portal hypertension. The TIPS procedure evolved in response to the need for a safe, nonoperative shunting procedure, and is becoming a practical alternative to surgically placed shunts. Possible complications of a TIPS include hemorrhage, postprocedure sepsis, shunt encephalopathy or decompensation. Development of shunt stenosis or occlusion is associated with re-bleeding. Three children (ages 10-13) with recurrent, significant variceal bleeding were referred for the TIPS procedure. Two had recurrent GI hemorrhage despite sclerotherapy. To date, all have maintained shunt patency for up to 1 year. None of these children have had significant re-bleeding episodes, and the only recurrence of varices was associated with an obstructed shunt. In this article, the author reviews both conventional treatment and the TIPS procedure for the child with bleeding varices. Nursing implications from a pediatric perspective are emphasized. Pediatric GI nurses must understand TIPS in order to prepare the child and family and to monitor for complications or shunt failure afterward.     

Lung resection after pneumonectomy for bronchogenic carcinoma

AIMS/BACKGROUND: TIPS, an effective procedure applied for the treatment of complications of portal hypertension, is potentially followed by worsening of the hyperdynamic circulation of cirrhosis and the impairment of liver function. The aim of the present study was to evaluate short-term changes of functional liver plasma flow after application of TIPS, using the hepatic (extrarenal) clearance of D-sorbitol (S-HCl). METHODS: Twenty-five cirrhotic patients submitted to TIPS for prevention of variceal rebleeding entered the study. At steady-state, during constant infusion of a solution of D-sorbitol (25 mg/min), appropriate blood and urine samples were collected in order to calculate S-HCI before and 120 min after TIPS opening. In addition, the hepatic extraction ratio of D-sorbitol was directly measured at the level of the right (Er), where TIPS was applied, and of the left (El) hepatic veins; meanwhile the portocaval gradient (PCG) was registered, before and after stent dilation. A comparison of values obtained before and after TIPS application was performed by Student's t-test for paired data. RESULTS: After application of TIPS, a substantial reduction was observed in PCG (12.1+/-4.2 vs 24.8+/-4.3 mmHg; p<0.001) and Er values (20.6+/-14.8 vs 57.5+/-22.3 %; p<0.001) but not El values (47.4+/-22.0 vs 53.4+/-21.4 %; p=0.178). S-HCl measured 120 min after TIPS opening was not statistically different from pre-TIPS values (389.2+/-212.1 vs 394.6+/-152.7 ml/min; p=0.892), although S-HCl variations in Child-Pugh class B patients were positively correlated with portal pressure variations (r=0.63, p=0.016). CONCLUSION: Our results demonstrate that in patients with advanced cirrhosis, TIPS procedure, while effective in reducing portal hypertension, does not lead to alterations in the functional liver plasma flow within the first 2 h.     

Influence of nutritional status on clinical outcome after acute stroke

PURPOSE: To evaluate the performance of Doppler ultrasound as a screening test for detecting elevated portosystemic gradients in failing transjugular intrahepatic portosystemic shunts (TIPS). MATERIALS AND METHODS: Twenty-seven of 61 patients who underwent TIPS creation between November 1991 and March 1996 were studied. At routine intervals, angle-corrected velocity measurements of portal venous and intrashunt blood flow (at the portal venous, middle, and hepatic venous levels of the shunt) were obtained. These were compared with portal hemodynamics for diagnostic accuracy in predicting clinically significant elevation of the portosystemic gradient. Venographic and manometric correlations were obtained on all patients available for follow-up and were not limited to those with symptoms or "abnormal" Doppler studies. Receiver-operating characteristic (ROC) curves were done. Linear regression was done to study correlation of shunt velocities with portal pressure, and logistic regression was done to predict shunt stenosis with use of shunt velocities. RESULTS: The most accurate location for shunt velocity measurement was the main portal vein, but this had an area under the ROC curve of only 0.70. Accuracy of any velocity threshold (including maximum shunt velocity) was no greater than 70%. Maximum shunt velocity of less than 60 cm/sec was 93% specific for detecting shunt restenosis, but only 25% sensitive, for an overall accuracy of 64%. High sensitivity (90%) could only be achieved with poor specificity (< 33%). Linear regression revealed poor correlation between shunt or portal vein velocity measurements and portal pressure (/r/ < 0.23 for all). CONCLUSIONS: Intrashunt and portal venous Doppler velocities alone do not accurately predict elevation of the portosystemic gradient on long-term follow-up after TIPS.     

Current status and future possibilities of transjugular intrahepatic portosystemic shunts in the management of portal hypertension

Transjugular intrahepatic portosystemic shunt (TIPS) is an exciting new method for treating complications of cirrhosis. Technical advances have allowed TIPS to be widely applied in the treatment of variceal bleeding. This article presents and discusses the results of recent experiences in TIPS placement. TIPS can be successfully placed in almost all patients. The complication rate of the procedure is low. TIPS is an effective means of controlling variceal bleeding and is especially useful for controlling bleeding in patients awaiting liver transplantation. It may also have a role in the treatment of ascites and other conditions related to portal hypertension. The most important issue facing TIPS is the long-term patency of the shunt. Potential solutions to the problem of long-term shunt patency are discussed.     

Clinical events after transjugular intrahepatic portosystemic shunt: correlation with hemodynamic findings

BACKGROUND & AIMS: Transjugular intrahepatic portosystemic shunt (TIPS) procedures are increasingly being used, but the relationship between the hemodynamic effects of TIPS and the clinical events on follow-up remains undefined. Hence, we have investigated the hemodynamic correlations of portal hypertension-related events after a TIPS procedure. METHODS: Prospective follow-up of 122 cirrhotic patients who had a TIPS procedure performed because of variceal hemorrhage was conducted. RESULTS: The portacaval pressure gradient (PPG) significantly decreased after the TIPS procedure (from 19.7 +/- 4.6 to 8.6 +/- 2.7 mm Hg; P > 0.001), but increased thereafter and at rebleeding (n = 25) was > 12 mm Hg in all patients (18.4 +/- 4.6 mm Hg). Twenty-six patients developed ascites; the PPG (measured in 19) was always > 12 mm Hg. Increasing the PPG to > 12 mm Hg occurred very frequently (83% at 1 year). Within 1 year, 77% of patients underwent balloon angioplasty or restenting. However, 80% had again a PPG of > 12 mm Hg 1 year after reintervention. Hepatic encephalopathy developed in 31% of patients at 1 year; 21 of 23 patients had a PPG of < 12 mm Hg. CONCLUSIONS: Total protection from the risk of recurrent complications of portal hypertension after a TIPS procedure requires that the PPG be decreased and maintained < 12 mm Hg. However, reintervention will be required in most patients within 1 year and again the second year. On the other hand, such portal decompression is associated with an increased risk of hepatic encephalopathy.     

Transjugular intrahepatic portosystemic shunts (TIPS)

Transjugular intrahepatic portosystemic shunt (TIPS) is a procedure recently introduced for the management of complications of portal hypertension. TIPS can be placed in the liver with relative ease by a skilled radiologist with a low risk of mortality. The major complications following the procedure are infection, especially in patients undergoing emergency TIPS, intra-abdominal haemorrhage from capsular punctures, and long-term problems related to encephalopathy and stenosis of the shunt. Encephalopathy is more of a problem in older patients with wide diameter shunts. Stenosis of the shunt is related to pseudo-intimal hyperplasia, probably related to transection of bile ductules during placement of the shunt. In view of the high rate of encephalopathy and stenosis following the shunt, a careful follow-up of all patients, including ultrasonographic and angiographic examination of the shunt, is mandatory. TIPS is used predominantly for the control of acute variceal haemorrhage, prevention of recurrent variceal bleeding, and refractory ascites when conventional treatment has failed. However, the role of TIPS in the management of complications of portal hypertension still awaits the outcome of clinical trials.     

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 Child's 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.     

Testosterone concentrations, testes weight and morphology of mule drakes (Muscovy drake x Khaki Campbell)

BACKGROUND: Transjugular intrahepatic portosystemic shunts (TIPS) are sometimes used to reduce the risk of variceal bleeding or treat intractable ascites before orthotopic liver transplantation (OLT). TIPS usually do not make OLT more difficult, but rarely, malposition of TIPS can significantly complicate OLT. METHOD and RESULTS: The following report describes a patient in whom an initially well-placed Wallstent migrated to the confluence of the splenic and superior mesenteric veins. During liver transplantation, the portal vein containing the Wallstent was completely resected, and the portal vein was reconstructed with donor iliac vein. After sewing the iliac vein onto the portal remnant, the liver transplant was completed under portosystemic bypass. The patient had an uneventful recovery. CONCLUSIONS: Wallstents can migrate within the portal vein. An interposition graft of donor vein allows full resection of the portal vein containing a migrated stent and facilitates portosystemic bypass and portal anastomosis.     

The management of the cirrhotic patient after transjugular intrahepatic portosystemic shunt

Transjugular intrahepatic portosystemic shunts (TIPS) achieve portal decompression in a manner analogous to side-to-side surgical portacaval shunts but avoid the risks of general anesthesia and major surgery. These considerations have popularized this procedure for the treatment of refractory variceal hemorrhage. However, its increasing use has also led to the recognition of both expected as well as unexpected complications associated with TIPS. Also, the natural history of cirrhosis and portal hypertension after TIPS has now been well described. Such data allow optimizing management strategies for individual patients after TIPS placement. The use of TIPS for active variceal bleeding and the clinical factors influencing subsequent management are discussed in this article.     

The changing spectrum of treatment for variceal bleeding

OBJECTIVE: The objective of this study was to assess the impact of endoscopic therapy, liver transplantation, and transjugular intrahepatic portosystemic shunt (TIPS) on patient selection and outcome of surgical treatment for this complication of portal hypertension, as reflected in a single surgeon's 18-year experience with operations for variceal hemorrhage. SUMMARY BACKGROUND DATA: Definitive treatment of patients who bleed from portal hypertension has been progressively altered during the past 2 decades during which endoscopic therapy, liver transplantation, and TIPS have successively become available as alternative treatment options to operative portosystemic shunts and devascularization procedures. METHODS: Two hundred sixty-three consecutive patients who were surgically treated for portal hypertensive bleeding between 1978 and 1996 were reviewed retrospectively. Four Eras separated by the dates when endoscopic therapy (January 1981), liver transplantation (July 1985), and TIPS (January 1993) became available in our institution were analyzed. Throughout all four Eras, a selective operative approach, using the distal splenorenal shunt (DSRS), nonselective shunts, and esophagogastric devascularization, was taken. The most common indications for nonselective shunts and esophagogastric devascularization were medically intractable ascites and splanchnic venous thrombosis, respectively. Most other patients received a DSRS. RESULTS: The risk status (Child's class) of patients undergoing surgery progressively improved (p = 0.001) throughout the 4 Eras, whereas the need for emergency surgery declined (p = 0.002). The percentage of nonselective shunts performed decreased because better options to manage acute bleeding episodes (sclerotherapy, TIPS) and advanced liver disease complicated by ascites (liver transplantation, TIPS) became available (p = 0.009). In all Eras, the operative mortality rate was directly related to Child's class (A, 2.7%; B, 7.5%; and C, 26.1 %) (p = 0.001). As more good-risk patients underwent operations for variceal bleeding, the incidence of postoperative encephalopathy decreased (p = 0.015), and long-term survival improved (p = 0.012), especially since liver transplantation became available to salvage patients who developed hepatic failure after a prior surgical procedure. There were no differences between Eras with respect to rebleeding or shunt occlusion. Distal splenorenal shunts (p = 0.004) and nonselective shunts (p = 0.001) were more protective against rebleeding than was esophagogastric devascularization. CONCLUSIONS: The sequential introduction of endoscopic therapy, liver transplantation, and TIPS has resulted in better selection and improved results with respect to quality and length of survival for patients treated surgically for variceal bleeding. Despite these innovations, portosystemic shunts and esophagogastric devascularization remain important and effective options for selected patients with bleeding secondary to portal hypertension.     

Transjugular intrahepatic portosystemic shunt for the management of severe venoocclusive disease following bone marrow transplantation

Hepatic venoocclusive disease (VOD) is a common, life-threatening complication of bone marrow transplantation (BMT). Portal hypertension is usually present and accounts for many of the clinical manifestations of this syndrome. We describe the results of transjugular intrahepatic portosystemic shunt (TIPS) for the management of VOD after BMT TIPS was performed in six patients with histologically confirmed VOD who had progressive jaundice and ascites. Portal hypertension was improved by TIPS in all patients (mean portal pressure gradient before TIPS, 20.2 +/- 4.6 vs. 6.7 +/- 1.9 mm Hg post-TIPS, P < .004). Three patients who underwent TIPS late in the course of VOD did not demonstrate any clinical improvement after TIPS and expired within 2 weeks of the procedure. The remaining three patients had less advanced disease and demonstrated decreases in serum bilirubin, improvement in coagulopathy, and decreased ascites after TIPS. Two patients subsequently expired, one with persistent histological changes of VOD. The lone survivor continues to do well with resolution of ascites, jaundice, and coagulopathy as of her last outpatient visit. TIPS was an effective method for portal decompression in patients with VOD after BMT, and was associated with clinical improvement in some patients. However, these effects may be transient and may not improve overall survival.     

Evaluation of trauma care in a developing country highlighted by a major aircraft accident

Transjugular intrahepatic portosystemic shunt (TIPS) is a side-to-side portocaval shunt for threatening complications of portal hypertension. The purpose of this study was to evaluate in first 33 patients indicated for TIPS insertion in our institution the efficacy, complications, and mortality. Indication was failure of sclerotherapy or ligation in control either of acute (n = 4) or repetitive (n = 25) variceal bleeding and refractory ascites (n = 4). The technical success rate was with 70% (21/30) lower than expected, but the complication rate was also very low. There were no fatal complications, only one subcapsular liver hematome, and in one patient repetitive punction of biliary tract. The 30-days mortality was 10% (2/21) and rebleeding was 15% (3/20), caused always by thrombosis of the shunt. TIPS seems to be a promising therapeutic procedure after failed endoscopic therapy of esophageal varices without the mortality and morbidity of an open surgical procedure. Recent indications for TIPS are acute variceal hemorrhage refractory to endoscopic treatment and recurrent variceal bleeding despite sclerotherapy or band ligation. Promising seems to be TIPS insertion in the treatment of refractory ascites.     

Transjugular intrahepatic portosystemic shunts (TIPS) in children

The transjugular intrahepatic portosystemic shunt procedure is an accepted treatment for adults with complications of portal hypertension. We performed a retrospective review of all pediatric TIPS placements performed at the University of California, San Francisco between 1990 and 1996. Twelve procedures were attempted in nine children, with a mean age (+/- SD) of 9.4 +/- 3.9 years (range, 5 to 15 years) and a mean weight of 31 +/- 18 kg (range, 16 to 70 kg). The indications for TIPS placement were portal hypertension complicated by chronic variceal hemorrhage not controlled with sclerotherapy (n = 7) and hypersplenism with thrombocytopenia (n = 2). TIPS placement was successfully completed initially in seven of nine (78%) patients. Unfavorable vascular anatomy was the cause of failure in two cases. The seven patients who underwent successful TIPS placement were followed up for an average of 136 days (range, 1 to 800 days); two still have patent shunts, three underwent liver transplantation, one had a splenorenal shunt after stenosis, and one died of underlying liver disease. Variceal bleeding was controlled in four of five patients who successfully underwent TIPS placement. Shunt occlusion occurred in four patients; patency was restored by transjugular shunt revision in three, and a splenorenal shunt was performed in one.     

Recanalized umbilical vein in portal hypertension

Experience with splenoportography suggests that patency of the umbilical vein occurs in about 9% of the patients with portal hypertension. A widely patent umbilical vein might serve as a decompressive portosystemic shunt. Percutaneous transhepatic portography was performed in 107 patients with cirrhosis of the liver and portal hypertension. A patent umbilical vein was found in 28 patients (26%). This finding significantly paralleled the number and size of other collateral veins, apart from gastroesophageal varices. No significant relation was found between umbilical vein patency and portal pressure, extrahepatic shunting, variceal bleeding, or ascites. It is concluded that a large patent umbilical vein does not effectively relieve portal hypertension, prevent gastroesophageal varices, or protect against variceal bleeding or ascites.     

Extrahepatic portal hypertension following liver transplantation: a rare but challenging problem

This study reports our experience of 8 cases of extrahepatic portal hypertension after 273 orthotopic liver transplantations in 244 adult patients over a 10-year period. The main clinical feature was ascites, and the life-threatening complication was variceal bleeding. Extrahepatic portal hypertension was caused by portal vein stenosis in 6 patients, and left-sided portal hypertension in 2 patients after inadventent ligation of portal venous tributaries or portasystemic shunts. All patients with portal vein stenosis had complete relief of portal hypertension after percutaneous transhepatic venoplasty (n = 4) or surgical reconstruction (n = 2), after a median follow-up of 33 (range: 6-62) months. Of the 2 patients with left-sided portal hypertension, one died after splenectomy and one rebled 6 months after left colectomy. This study suggests that extrahepatic portal hypertension is a series complication after liver transplantation that could be prevented by meticulous portal anastomosis and closure of portal tributaries or portasystemic shunts to improve the portal venous flow. However, any ligation has to be performed under ultrasound guidance to avoid inadventent venous ligations.     

Food, obesity and non-insulin-dependent diabetes: are there molecular links?

BACKGROUND & AIMS: The effects of transjugular intrahepatic portosystemic shunt (TIPS) on portal hemodynamics, esophageal and gastric varices, and hepatic function have not been fully defined. The aim of this study was to define prospectively the effects of TIPS on portal pressures and flow, variceal resolution, and hepatic function. METHODS: Pressure and flow measurements were made by angiography and Doppler sonography, respectively. Varices were assessed by endoscopy and angiography. Liver functions were evaluated by a battery of tests. RESULTS: In 100 consecutive subjects, mean portosystemic gradient decreased from 24 to 11 mm Hg (means) (P < 0.001) after TIPS. Recurrent portal hypertension caused by stent thrombosis (n = 5), stent retraction (n = 2), and stent stenosis (n = 51) occurred at 6 months but, by year 5, was not present in survivors (n = 0 of 8). Fundic gastric varices failed to resolve in 6 of 12 cases. Systemic venous pressures of >15 mm Hg, stent dysfunction, and continued alcoholism were risk factors for recurrent hemorrhage. Angiography was superior to endoscopy, which was superior to Doppler sonography for detection of recurrent portal hypertension. Progressive liver failure occurred in 8 patients. CONCLUSIONS: Recurrent portal hypertension caused by stent stenosis occurs commonly in the first 2 years after TIPS. Fundic gastric varices often fail to disappear after TIPS. The effects of TIPS on liver function are unpredictable.     

Doppler US of helical flow in the portal vein

In helical portal venous blood flow, the usual laminar flow in the portal vein is replaced by a spiral. This changes the color Doppler ultrasound (US) appearance to one of alternating or parallel red and blue bands. Duplex US may appear to show hepatopetal, hepatofugal, or simultaneous bidirectional flow depending on placement of the cursor within the helix. Helical portal venous flow is unusual in normal individuals (2.2% of 135 patients). Its presence should prompt further scrutiny for signs of liver disease, particularly portosystemic shunts, as in 20% of 41 patients who subsequently underwent liver transplantation. It is a normal finding immediately after liver transplantation (43% of 35 patients) and transjugular intrahepatic portosystemic shunt (TIPS) creation (28% of 36 patients). In both liver transplant and TIPS recipients, helical flow is usually transient. Its persistence long after transplantation in association with a prolonged increase in portal venous velocity is a useful sign of portal vein stenosis. Helical flow may also occur in cases of neoplastic invasion or displacement of the portal vein.     

Increased restenosis in diabetes mellitus after coronary interventions is due to exaggerated intimal hyperplasia. A serial intravascular ultrasound study

Hepatic hydrothorax is a rare complication of portal hypertension. Conservative therapy may be successful but refractory hepatic hydrothorax is not uncommon. Management of refractory hydrothorax is usually ineffective and can result in a worsened clinical status. Transjugular intrahepatic portosystemic shunts (TIPS) lower portal pressure and have been used in the treatment of refractory ascites. The aim of this study was to determine the efficacy of TIPS in the treatment of symptomatic refractory hepatic hydrothorax. A TIPS was placed in 24 consecutive cirrhotic patients with symptomatic refractory hepatic hydrothorax. Five patients (20.8%) were Child's/Pugh class B and 19 (79.2%) were class C. All had undergone multiple thoracenteses and were hypoalbuminemic. Mean follow-up was 7.2 months (range, 0.25-49 months). Fourteen (58.3%) of 24 patients had complete relief of symptoms after shunt placement and did not require further thoracentesis. Five (20.8%) additional patients required fewer thoracenteses. Five (20.8%) patients developed worsening liver function and died within 45 days. In eight (66.7%) of 12 patients with > or = 60 days of follow-up, the serum albumin increased by a mean of 1.2 g/dL (range, 0.1-2.2 g/dL). The Child's-Pugh score improved in 7 (58.3%) of these 12 patients and two patients improved from class C to class A. These two patients no longer require liver transplantation. This study shows that TIPS can be effective in the management of symptomatic, refractory hepatic hydrothorax. Clinical and laboratory improvement may be seen and liver transplantation may become unnecessary.