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Clinical outcomes after parallel TIPS and DIPS using stent-grafts
SUNDAY: Scientific Sessions
S30
’
Sunday
Scientific Session
Results: Of 215 TIPS placed for purposes other than hemorrhage, the TIPS was inserted at the bifurcation in 41 patients and intrahepatic in 62 patients. Red blood cell transfusions were administered in 10% of patients in each group within 3 days post procedure (p ¼ 1.0). Pharmacologic vasopressor support was utilized in 7% of the bifurcation TIPS and 5% of the intrahepatic TIPS (p ¼ 0.68). There were no significant differences in 30-day mortality rates (2% for bifurcation TIPS compared to 3% for intrahepatic TIPS, p ¼ 1.0). Similarly, no significant difference comparing left to right-sided TIPS. No deaths were directly related to hemorrhagic complications. Neither thrombocytopenia nor a high INR correlated significantly with hemorrhage risk. Conclusions: The risk of hemorrhagic complications was similar in both groups, without any hemorrhage-related deaths. Therefore, TIPS insertion at or near the portal bifurcation may be considered a reasonable access in the setting of Viatorr stent graft use.
3:18 PM
Abstract No. 63
Clinical outcomes after parallel TIPS and DIPS using stent-grafts I. Idakoji1, J. Louie1, D. Sze1, D. Wang1; 1Stanford University Medical Center, Stanford, CA Purpose: In cirrhotic patients with recurrent variceal hemorrhage or refractory ascites despite an existing portosystemic shunt (PSS), percutaneous creation of a second PSS may be needed. We reviewed outcomes from our experience with placing parallel transjugular intrahepatic portosystemic (TIPS) or direct intrahepatic portocaval (DIPS) shunts. Materials: 19 patients (median age 58 y, MELD 12) with an existing PSS who had a parallel TIPS or DIPS placed from 20022015 were retrospectively reviewed. Indications for second PSS, procedural details, technical and clinical success rates, peri-procedural laboratory test results, and complications were evaluated. Results: Second PSS was indicated in 12 patients with persistent refractory ascites and 7 with recurrent variceal hemorrhage. The primary PSS was occluded and could not be recanalized in 10 patients. In 9 other patients, the primary PSS was patent but insufficiently decompressed the portal system despite revisions (mean portosystemic gradient [PSG] 15.4 ± 2.3 mmHg). A parallel TIPS or DIPS was created in 11 and 8 patients, respectively, using stent-grafts in all cases (10mm diameter n ¼ 12; 8mm n ¼ 6; 7mm n ¼ 1). Technical success rate was 100% with mean reduction of PSG from 14.2 ± 0.8 to 6.5 ± 0.6 mmHg (po0.001). DIPS was chosen in 5 cases due to anatomical limitations related to the first PSS. Procedure time for DIPS trended towards being faster (94 vs 114 mins, p ¼ 0.23). Median follow-up after parallel PSS creation was 293 d (range 18-2813), excluding 4 patients lost to follow-up. Ascites improved and variceal hemorrhage did not recur in all patients. 3 patients (15.7%), all with both shunts patent, developed worsened hepatic encephalopathy (HE) that was managed medically (33.3% of patients with 2 patent shunts). No acute liver failure occurred. Two patients died within 30 d of parallel PSS creation, due to sepsis in 1 and pulmonary neoplasm in 1. Conclusions: Parallel TIPS or DIPS effectively treats recurrent variceal hemorrhage or ascites if a primary PSS is
’
JVIR
occluded or of insufficient capacity to decompress portal hypertension. Parallel DIPS may be anatomically preferable in some patients. Patients with 2 patent shunts may be at increased risk for HE.
3:27 PM
Abstract No. 64
Cost analysis of using Viatorr stent vs. Fluency/ Wallstent for TIPS at a community hospital K. Zhang1, J. Cruz2, C. Kim3, C. Ishak4, S. Doddakashi5; 1 Einstein Medical Center, Brooklyn, NY; 2Einstein Medical Center Philadelphia, Philadelphia, PA; 3Albert Einstein Medical Center, Philadelphia, PA; 4BronxCare Health System IA/NYRA, New York City, Scarsdale, NY; 5 St. Luke's Roosevelt Hospital Center, New York, NY Purpose: To perform cost analysis of stocking Viatorr vs. Fluency/Wallstent combination for potential TIPS procedures at community hospitals, with companion case illustration. Materials: Cost analysis was performed on using Viatorr vs. Fluency/Wallstent combination for TIPS placement. In addition, the analysis includes time value of money, cost of complication, variability of TIPS patient volume, and sunk cost of expired equipment. Two scenarios were reviewed: Emergent TIPS for bleeding, and elective TIPS for ascites/ effusion. A mathematical algorithm is generated based on literature data to predict potential volume of TIPS at a community hospital based on demographics, community size and disease prevalence. A companion case of Fluency/ Wallstent combination performed at a community hospital was presented and potential TIPS volume was generated for this community hospital based on the algorithm. Results: Viatorr stent TIPS cost on average $2500 more than Fluency/Wallstent TIPS in equipment only. However, when include time value of money, cost of complication/reintervention, Viatorr TIPS procedure cost $5345 less than combination stent graft TIPS. One variable that alters the comparison is TIPS volume due to sunk cost of expired stent graft. It is more cost effective to stock Viatorr when a hospital performs more than one emergency TIPS per year. A mathematical algorithm is generated for potential maximum TIPS volume for a community hospital. For our hospital in New Jersey, the maximum volume is 14 per year. Conclusions: Viatorr stent is more cost effective than the Fluency/Wallstent combination when there is greater than 1 TIPS procedure per year at a community hospital. The newly devised algorithm to predict potential TIPS volume at a community hospital is much higher than reality. Expansion of TIPS in the community would highly benefit patient population and hospitals.
3:36 PM
Abstract No. 65
Emergency transjugular intrahepatic portosystemic shunt outcomes in the unstable, bleeding cirrhotic: a retrospective cohort J. Elbich1, T. Powell2; 1VCU Health Systems, Richmond, VA; 2N/A, Richmond, VA
S30
’
Sunday
Scientific Session
Results: Of 215 TIPS placed for purposes other than hemorrhage, the TIPS was inserted at the bifurcation in 41 patients and intrahepatic in 62 patients. Red blood cell transfusions were administered in 10% of patients in each group within 3 days post procedure (p ¼ 1.0). Pharmacologic vasopressor support was utilized in 7% of the bifurcation TIPS and 5% of the intrahepatic TIPS (p ¼ 0.68). There were no significant differences in 30-day mortality rates (2% for bifurcation TIPS compared to 3% for intrahepatic TIPS, p ¼ 1.0). Similarly, no significant difference comparing left to right-sided TIPS. No deaths were directly related to hemorrhagic complications. Neither thrombocytopenia nor a high INR correlated significantly with hemorrhage risk. Conclusions: The risk of hemorrhagic complications was similar in both groups, without any hemorrhage-related deaths. Therefore, TIPS insertion at or near the portal bifurcation may be considered a reasonable access in the setting of Viatorr stent graft use.
3:18 PM
Abstract No. 63
Clinical outcomes after parallel TIPS and DIPS using stent-grafts I. Idakoji1, J. Louie1, D. Sze1, D. Wang1; 1Stanford University Medical Center, Stanford, CA Purpose: In cirrhotic patients with recurrent variceal hemorrhage or refractory ascites despite an existing portosystemic shunt (PSS), percutaneous creation of a second PSS may be needed. We reviewed outcomes from our experience with placing parallel transjugular intrahepatic portosystemic (TIPS) or direct intrahepatic portocaval (DIPS) shunts. Materials: 19 patients (median age 58 y, MELD 12) with an existing PSS who had a parallel TIPS or DIPS placed from 20022015 were retrospectively reviewed. Indications for second PSS, procedural details, technical and clinical success rates, peri-procedural laboratory test results, and complications were evaluated. Results: Second PSS was indicated in 12 patients with persistent refractory ascites and 7 with recurrent variceal hemorrhage. The primary PSS was occluded and could not be recanalized in 10 patients. In 9 other patients, the primary PSS was patent but insufficiently decompressed the portal system despite revisions (mean portosystemic gradient [PSG] 15.4 ± 2.3 mmHg). A parallel TIPS or DIPS was created in 11 and 8 patients, respectively, using stent-grafts in all cases (10mm diameter n ¼ 12; 8mm n ¼ 6; 7mm n ¼ 1). Technical success rate was 100% with mean reduction of PSG from 14.2 ± 0.8 to 6.5 ± 0.6 mmHg (po0.001). DIPS was chosen in 5 cases due to anatomical limitations related to the first PSS. Procedure time for DIPS trended towards being faster (94 vs 114 mins, p ¼ 0.23). Median follow-up after parallel PSS creation was 293 d (range 18-2813), excluding 4 patients lost to follow-up. Ascites improved and variceal hemorrhage did not recur in all patients. 3 patients (15.7%), all with both shunts patent, developed worsened hepatic encephalopathy (HE) that was managed medically (33.3% of patients with 2 patent shunts). No acute liver failure occurred. Two patients died within 30 d of parallel PSS creation, due to sepsis in 1 and pulmonary neoplasm in 1. Conclusions: Parallel TIPS or DIPS effectively treats recurrent variceal hemorrhage or ascites if a primary PSS is
’
JVIR
occluded or of insufficient capacity to decompress portal hypertension. Parallel DIPS may be anatomically preferable in some patients. Patients with 2 patent shunts may be at increased risk for HE.
3:27 PM
Abstract No. 64
Cost analysis of using Viatorr stent vs. Fluency/ Wallstent for TIPS at a community hospital K. Zhang1, J. Cruz2, C. Kim3, C. Ishak4, S. Doddakashi5; 1 Einstein Medical Center, Brooklyn, NY; 2Einstein Medical Center Philadelphia, Philadelphia, PA; 3Albert Einstein Medical Center, Philadelphia, PA; 4BronxCare Health System IA/NYRA, New York City, Scarsdale, NY; 5 St. Luke's Roosevelt Hospital Center, New York, NY Purpose: To perform cost analysis of stocking Viatorr vs. Fluency/Wallstent combination for potential TIPS procedures at community hospitals, with companion case illustration. Materials: Cost analysis was performed on using Viatorr vs. Fluency/Wallstent combination for TIPS placement. In addition, the analysis includes time value of money, cost of complication, variability of TIPS patient volume, and sunk cost of expired equipment. Two scenarios were reviewed: Emergent TIPS for bleeding, and elective TIPS for ascites/ effusion. A mathematical algorithm is generated based on literature data to predict potential volume of TIPS at a community hospital based on demographics, community size and disease prevalence. A companion case of Fluency/ Wallstent combination performed at a community hospital was presented and potential TIPS volume was generated for this community hospital based on the algorithm. Results: Viatorr stent TIPS cost on average $2500 more than Fluency/Wallstent TIPS in equipment only. However, when include time value of money, cost of complication/reintervention, Viatorr TIPS procedure cost $5345 less than combination stent graft TIPS. One variable that alters the comparison is TIPS volume due to sunk cost of expired stent graft. It is more cost effective to stock Viatorr when a hospital performs more than one emergency TIPS per year. A mathematical algorithm is generated for potential maximum TIPS volume for a community hospital. For our hospital in New Jersey, the maximum volume is 14 per year. Conclusions: Viatorr stent is more cost effective than the Fluency/Wallstent combination when there is greater than 1 TIPS procedure per year at a community hospital. The newly devised algorithm to predict potential TIPS volume at a community hospital is much higher than reality. Expansion of TIPS in the community would highly benefit patient population and hospitals.
3:36 PM
Abstract No. 65
Emergency transjugular intrahepatic portosystemic shunt outcomes in the unstable, bleeding cirrhotic: a retrospective cohort J. Elbich1, T. Powell2; 1VCU Health Systems, Richmond, VA; 2N/A, Richmond, VA