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TIPS Should be Done with Covered Grafts
aggressive anticoagulation and fibrinolytic therapies, and large sheath size. Some of these patients are going to be candidates for stent grafts if their problem cannot be managed conservatively or with minimally invasive techniques (ultrasound guided compression or thrombin injection). Endovascular stent grafting of peripheral aneurysms and trauma is safe, readily available, and fairly easy to perform. I hesitate to place stent grafts, especially in elective situations, in vascular segments smaller than 6 mm and across joints. These situations are prone to stent graft failure. Long-term patency is best in vessels with large diameters that do not cross joints. Early diagnosis and elective intervention are paramount in reducing mortality. Long-term endoleak sUlveillance is essential to a sllccessful stent graft program.
References 1. Howell, M. J Endovasc Ther 2002;9:76-81. 2. Razavi, MR. Radiology 1995; 197:801-804. 3. Sanchez, lAo J Vasc Sugery;30:907-914. 4. Bartorelli, AL. J Endovasc Ther 2001;8:417-421. 5. Hilfiker, PRo JVIR 2000;11:578-584. 6. Beregi, JP. CVIR 1999;22:13-19. 7. Richardson,]W. J Vasc Surgery 1988;8:165-17l. 8. Krupski, We. J Vasc Surg 1998;28:1-13. 9. Razavi, MK. Tech Vasc Int Rad 1998;1:37-41. 10. Brunkwall , ]. J Vasc Surg 1989;10:381-384. 11. Becker, G]. ]VIR 1991 ;2:225-229. 12. George, SM. World J Surg 1951;15:134-139. 13. Marin, ML. J Vasc Surg 1994;19:754-757.
3:20 p.m. TIPS Should be Done with Covered Grafts Ziv j. Haskal, MD, FSIR New York Presbyterian Hospital New York, NY 3:35 p.m. Elective TIPS: Use the MElD Score Hector Fermi, MD VJe University of Texas Health Science Center at San Antonio San AntoniO, TX The TIPS procedure was introduced in 1989 (1) and since its introduction it has become a well established therapeutic option in the management of patients with portal hypertension, mainly, variceal bleeding and refractory ascites (2). The efficacy of TIPS has been evaluated in prospective, controlled trials only for the treatment of variceal bleeding and refractory ascites, however, TIPS has been employed, in a non-controlled fashion, in the management of other conditions such as
hepatic hydrothorax, Budd-Chiari syndrome, veno-occlusive disease, hepatopulmonary and hepatorenal syndromes (3). The use of TIPS has spread Widely, essentially because it has been found to be relatively easy to perform, it has sllown good technical results with effective portal decompression and has been associated with low morbidity and relatively low mortality rates (2, 3). Although the TIPS is considered to be minimally invasive, it is well known that patients undergoing TIPS are subject to mUltiple complications related to the procedure. The early mortality rates after elective TIPS is approximately 12% but can be as high as 55% (4). PhYSicians involved in the management of patients with cirrhosis and portal hypertension have emphasized the importance of identifying those patients who are likely to do poorly after an elective TIPS. The detection of high-risk patients is important because patients at high risk of death shortly after TIPS are probably better served by alternative management strategies (5), Patients undergoing TIPS procedures have been traditionally evaluated by using the Child-Pugh scoring system . This system has the disadvantage of using determinants that are subjective such as the evaluation of the degree of ascites and encephalopathy (5, 6). Other models designed to predict the prognosis of patients undergoing TIPS procedures have been described and tested, however, most models have been designed to evaluate patients undergoing TIPS in an emergency situation (7, 8). The Model for End-Stage Liver Disease (MELD) is a recently described disease severity index scoring system that was originally developed to assess the three-month prognosis of patients undergoing elective TIPS procedures (5), This model has the advantage of using easily obtainable, objective indicators, including serum bilirubin, serum creatinine and INR. Its accuracy in predicting patient prognosis has been evaluated by several investigators in different patient populations. Our purpose is to present a brief ovelview of the experience gained with the application of the MELD score as a model to predict survival in patients undergoing elective TIPS. Evolution of the MElD Score. The original model was described by Malinchoc et al and included two methods for predicting survival: the first method was a formula and required the use of a programmable calculator to obtain the risk score (now known as MELD score); the second method was intended to be used at the patient's bedside and used a velY simple nomogram for its determination (5). The indicators used in the original formula included serum creatinine, serum bilirubin, INR and cause of liver cirrhosis (there was a differentiation between cholestatic! alcoholic and other causes of liver cirrhosis and these carried a different weight in the formula). In their original paper, the authors described accurate prediction of patient survival using both the mathematical formula and the nomogram (5). Patients with a risk score > 1.8
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References 1. Howell, M. J Endovasc Ther 2002;9:76-81. 2. Razavi, MR. Radiology 1995; 197:801-804. 3. Sanchez, lAo J Vasc Sugery;30:907-914. 4. Bartorelli, AL. J Endovasc Ther 2001;8:417-421. 5. Hilfiker, PRo JVIR 2000;11:578-584. 6. Beregi, JP. CVIR 1999;22:13-19. 7. Richardson,]W. J Vasc Surgery 1988;8:165-17l. 8. Krupski, We. J Vasc Surg 1998;28:1-13. 9. Razavi, MK. Tech Vasc Int Rad 1998;1:37-41. 10. Brunkwall , ]. J Vasc Surg 1989;10:381-384. 11. Becker, G]. ]VIR 1991 ;2:225-229. 12. George, SM. World J Surg 1951;15:134-139. 13. Marin, ML. J Vasc Surg 1994;19:754-757.
3:20 p.m. TIPS Should be Done with Covered Grafts Ziv j. Haskal, MD, FSIR New York Presbyterian Hospital New York, NY 3:35 p.m. Elective TIPS: Use the MElD Score Hector Fermi, MD VJe University of Texas Health Science Center at San Antonio San AntoniO, TX The TIPS procedure was introduced in 1989 (1) and since its introduction it has become a well established therapeutic option in the management of patients with portal hypertension, mainly, variceal bleeding and refractory ascites (2). The efficacy of TIPS has been evaluated in prospective, controlled trials only for the treatment of variceal bleeding and refractory ascites, however, TIPS has been employed, in a non-controlled fashion, in the management of other conditions such as
hepatic hydrothorax, Budd-Chiari syndrome, veno-occlusive disease, hepatopulmonary and hepatorenal syndromes (3). The use of TIPS has spread Widely, essentially because it has been found to be relatively easy to perform, it has sllown good technical results with effective portal decompression and has been associated with low morbidity and relatively low mortality rates (2, 3). Although the TIPS is considered to be minimally invasive, it is well known that patients undergoing TIPS are subject to mUltiple complications related to the procedure. The early mortality rates after elective TIPS is approximately 12% but can be as high as 55% (4). PhYSicians involved in the management of patients with cirrhosis and portal hypertension have emphasized the importance of identifying those patients who are likely to do poorly after an elective TIPS. The detection of high-risk patients is important because patients at high risk of death shortly after TIPS are probably better served by alternative management strategies (5), Patients undergoing TIPS procedures have been traditionally evaluated by using the Child-Pugh scoring system . This system has the disadvantage of using determinants that are subjective such as the evaluation of the degree of ascites and encephalopathy (5, 6). Other models designed to predict the prognosis of patients undergoing TIPS procedures have been described and tested, however, most models have been designed to evaluate patients undergoing TIPS in an emergency situation (7, 8). The Model for End-Stage Liver Disease (MELD) is a recently described disease severity index scoring system that was originally developed to assess the three-month prognosis of patients undergoing elective TIPS procedures (5), This model has the advantage of using easily obtainable, objective indicators, including serum bilirubin, serum creatinine and INR. Its accuracy in predicting patient prognosis has been evaluated by several investigators in different patient populations. Our purpose is to present a brief ovelview of the experience gained with the application of the MELD score as a model to predict survival in patients undergoing elective TIPS. Evolution of the MElD Score. The original model was described by Malinchoc et al and included two methods for predicting survival: the first method was a formula and required the use of a programmable calculator to obtain the risk score (now known as MELD score); the second method was intended to be used at the patient's bedside and used a velY simple nomogram for its determination (5). The indicators used in the original formula included serum creatinine, serum bilirubin, INR and cause of liver cirrhosis (there was a differentiation between cholestatic! alcoholic and other causes of liver cirrhosis and these carried a different weight in the formula). In their original paper, the authors described accurate prediction of patient survival using both the mathematical formula and the nomogram (5). Patients with a risk score > 1.8
P227