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Effectiveness of transjugular intrahepatic portosystemic stent shunt(TIPS) in rebleeding prophylaxis from gastroesophageal varices in cirrhotics
Treatment of cirrhosis and its complications
$135
RESCUE OF EARLY THROMBOSEDTIPS BY INTRASTENT FIBRINOLYSIS: EFFICACY,SAFETYANDMEDIUMTERMFOLLOW-UP
""TOTAL VERSUS REPEATED LARGE VOLUTE PARACENTESIS IN PATIENTS WITH REFRACTORY TENSE ASCITES ""
L Gsrefa-Villarreal. T Hero~fndez. F Marffnez. J Dfaz. R Fuentes. J Mayor, C Guevara. A Sierra. Gastroenterology, Radiology and Hematology Services. Hospital Insular. Las Palmas GC. Spain. Early shunt thrombosis after TIPS is unusual and managed by different ways: balloon dilatation, new coaxial stant or new TIPS. Factors affecting thrombosis include length of the shunt, platelet count and poMal or slant blood flow. Intravascular fibrinolysis is widely used in coronary and limb arterial occlusion; however, it is contraindicated in cirrhotic patients and after recent digestive hemorrhage. We present our experience with fibrinolysis in two cirrhotic patients with early shunt thrombosis after TIPS. Patlemts and methods: Two patients (from a group of 40 TIPS) with early thrombosis has been managed with local iotrastent thrombolytic therapy. Both presented long shunts ( > 5 cm) and platelet count above 200.000/mm3. Follow-up (4 months) included sbnography on weeks 1, 2, 4, 16 and portography on weeks 4 and 16. Results: The first patient received emergent TIPS after variceal bleeding not arrested by sclerotherapy. The 4th day presented paaial thrombosis managed by balloon dilate-floe. Sonography (1 lth day) showed complete thrombosis; thrombus was crossed and perfusion started with urokinas¢ (UK)(20.000 IU/h) plus sislemic heparin 05.000 IU/d). After 24 hours thrombus persisted and UK was increased to 100.000 IU/h what achieved thrombus lysis. A second coaxial steal was placed end he started with low molecular weight heparin during 1 month. The second patient, with refractory ascites presented good initial natriuresis (200 meq/d). Thrombosis was noticed on day 7th and could be crossed on day 13th. UK was started with 100.000 IU/h plus sistemic heparin, increasing to 150.000 IU/h after 24 hours for persistence of thrombus, achieving its lysls after 72 hours. Coagulation studies showed increases in fibrinogen degradation products and D-Dimer and decreases in fibrinogeo not lowering under 1 g/I. No patient presented any hemorrhagic complication. The first patient presented on first month portography a small parietal thrombus solved with Simpson "s etherocath and no thrombus on 4th month study. The second patient has shown patent shunt on follow-up and no ascites. Conclusions: Balloon dilatation may be an incomplete therapy in early thrombosis. lntrsstent UK thrombolysis seems to be efficient and safe for early shunt thrombosis after TIPS in cirrhotic patients even following variceal hemorrhage. High doses must be used but under close coagulation control. Patients with high t'~sk of thrombosis may benefit from prophylactic anticoagulant therapy. This therapy may be applied to late shunt thrombosis to avoid new TIPS if earlydiagnosed,thoughthe maximaldelay is not "knownin cirdaotic
C. Petroyiannopoulos, A. Zaharof, J. Pana~opoulos, K. Kehagioglou and J. Poulikakos. 2nd and 3rd Dpt of Medicine,Red Cross Hospital Athens,Greece.
patients.
EFFECTIVENESS OF TRANSJUGULAR INTRAHEPATIC P O R T O S Y S T E M I C STENT SHUNT(TIPS) IN REBLEEDING P R O P H Y L A X I S FROM GASTROESOPHAGEAL VARICES IN CIRRHOTICS
M Nufiez, B Sangro, J Quiroga, I Bilbao, J Lon~o, M Bet~s, I Herrero, E Macfas, N G6mez, L Garcfa-Villarreal, JM Zozaya, J Prieto. Liver Unit. University Clinic. Pamplona. Spain. Sclerotherapy and propranolol are not fully preventive of variceal bleeding (VB) and have no impact on patient (pt) survival. We have evaluated TIPS in preventing variceal rebleeding in pt failing to other prophylactic measures. Patients and methods: 25 pt (Child:A-13; B9; C-3) with previous VB (I-7 episodes/pt; median,3) despite prophylactic sclerotherapy + propranolol and at high risk of rebleeding (large-size varices, red spots) underwent prophylactic TIPS 0Vallstent, 8mmf~) within 90 days lbllowing the last hemorrhage. Follow-up ranged 1-28 mo (median: 13 mo) and included periodic checking of the stent and the portosystemic pressure gradient (PSPG) (l-6/pt/year). Rebleeding index (RI) betbre and after TIPS was calculated according: Mo free of bleeding/(number of bleeding episodes + I). R~ults: After TIPS, PSPG decreased immediately (21.3+0.8 to 14.9+0.7 mmHg:p<0.001), and persistently (last measurement: 15.2+1.1. p<0.001). Rebleeding: 4% (1 pt with stent thrombosis), notrebleeding: 96%. resulting in a significant increase of RI (3.5+0.9 vs 14.2 + 1.8; p < 0.001 ). Stem or hepatic vein stenosis developed in 8 pt (33%) and were succesfully treated. Actuarial survival rates at 6, 12 and 24 mo were 95%. 85% and 85% respectively. Conclusion:l .TIPS is very effective in preventing VB in pt failing to other procedures. 2. Periodic assessment of the stent isrequired to maintain the long term efficacy of TIPS. 3. Controlled studies comparing TIPS and the current procedures for prevention of VB are warranted.
Purpose of the study was to evaluate how much effective and safe are these two ways of paracentesis and compare each other. Material and methods: This study included 40 cirrhotic patients with refractory tense ascites divided in two groups of 20 patients each.The patients of group A had a total paracentesis while the patients of group B had repeated large volume paracentesis (4 to 6 litre per day).All the patients received intravenous albumin(6 gr per liter of ascites removed). Clinical and biochemical follow-up has obtained in both groups. Results: All the patients of group A tolerated very well the total psracentesis while, 2 patients of group B developed clinical symptoms of bacterial peritonitis .From the 20 patients of group B 4 of them(20%) showed a higher incidence of hyponatremia increased levels of urea and creatinin while liver function test didn't change in both groups. Conclusions: a)Total and repeated large volume paracentesis are quite effective for the management of refractory tense ascites. b)The danger of hyponatremia and bacterial peritonitis is lower in total paracentesis. c) Total psracentesis is much more tolerable in cirrhotic patients.
THE SERUM-ASCITES PREALBUMIN GRADIENT (SAPG): AN INDIRECT INDEX OF PORTAL PRESSURE GRADIENT CHANGES IN CIRRHOTICS UNDERGOING TOTAL PARACENTESIS. M.Pozzi, C.Lambrughi, P.Colombo, *L.Pirovano, L.Roffi, F.Villani, V.Pecci, A.Piperno, F.Panizzuti and G.Mancia. Chair of Internal Medicine, Dept. of Medicine 1, and *Clinical Chemistry Laboratory, S.Gerardo Hospital, University of Milan, Monza (Mi), Italy. BACKGROUND A serum-ascites albumin gradient (SAAG) threshold > 1.1 g/dL strongly suggests portal hypertension-related ascites: wider SAAG directly correlate with higher portal pressure gradients in cirrhotics (J. Lab. Clin. "Mad. 1983: 102:260-273) . AIM Large volume or even total paracentesis (TP) plus Albumin infusion are widely employed procedures to treat tense ascites of cirrhosis. The present study was undertaken to evaluate 1) changes of SAAG and of SAPG after TP, and to assess 2) the alternative role of SAPG determination (Albumin infusions can affect SAAG, making it unreliable to detect changes of portal pressure gradient). METHODS 22 cirrhotic patients, Child C class, undergoing TP and i.v. Albumin administration (6-8 g/liter of ascites) for an episode of tense ascites, were studied. SAAG and SAPG were determined at baseline and 15 days after TP along with biochemical and hormonal parameters (data not shown). RESULTS 10.4+3.6 SD liters of ascites were drained, with culture always negative. Baseline SAAG was greater than 1.1 g/dL in all patients (mean 1.6+0.3 SD). Mean SAPG was 4.4+1.4 SD mg/dL (in only two cases out of 22 values lower than 3.0 mg/dL were found). In 12 patients ascites was still detectable (culture negative) 15 days after TP, despite diuretic treatment. At this later time a slight increase of SAPG (from 4.7+1.5 to 5.7~-2.5, NS), but not of SAAG, was observed. CONCLUSIONS These results further confirm the reliability of SAAG in detecting portal hypertension-related ascites. However in cirrhotic patients treated with Albumin after TP (or for other therapeutic purposes) SAPG seems a more appropriate indirect index of portal pressure gradient changes.
$135
RESCUE OF EARLY THROMBOSEDTIPS BY INTRASTENT FIBRINOLYSIS: EFFICACY,SAFETYANDMEDIUMTERMFOLLOW-UP
""TOTAL VERSUS REPEATED LARGE VOLUTE PARACENTESIS IN PATIENTS WITH REFRACTORY TENSE ASCITES ""
L Gsrefa-Villarreal. T Hero~fndez. F Marffnez. J Dfaz. R Fuentes. J Mayor, C Guevara. A Sierra. Gastroenterology, Radiology and Hematology Services. Hospital Insular. Las Palmas GC. Spain. Early shunt thrombosis after TIPS is unusual and managed by different ways: balloon dilatation, new coaxial stant or new TIPS. Factors affecting thrombosis include length of the shunt, platelet count and poMal or slant blood flow. Intravascular fibrinolysis is widely used in coronary and limb arterial occlusion; however, it is contraindicated in cirrhotic patients and after recent digestive hemorrhage. We present our experience with fibrinolysis in two cirrhotic patients with early shunt thrombosis after TIPS. Patlemts and methods: Two patients (from a group of 40 TIPS) with early thrombosis has been managed with local iotrastent thrombolytic therapy. Both presented long shunts ( > 5 cm) and platelet count above 200.000/mm3. Follow-up (4 months) included sbnography on weeks 1, 2, 4, 16 and portography on weeks 4 and 16. Results: The first patient received emergent TIPS after variceal bleeding not arrested by sclerotherapy. The 4th day presented paaial thrombosis managed by balloon dilate-floe. Sonography (1 lth day) showed complete thrombosis; thrombus was crossed and perfusion started with urokinas¢ (UK)(20.000 IU/h) plus sislemic heparin 05.000 IU/d). After 24 hours thrombus persisted and UK was increased to 100.000 IU/h what achieved thrombus lysis. A second coaxial steal was placed end he started with low molecular weight heparin during 1 month. The second patient, with refractory ascites presented good initial natriuresis (200 meq/d). Thrombosis was noticed on day 7th and could be crossed on day 13th. UK was started with 100.000 IU/h plus sistemic heparin, increasing to 150.000 IU/h after 24 hours for persistence of thrombus, achieving its lysls after 72 hours. Coagulation studies showed increases in fibrinogen degradation products and D-Dimer and decreases in fibrinogeo not lowering under 1 g/I. No patient presented any hemorrhagic complication. The first patient presented on first month portography a small parietal thrombus solved with Simpson "s etherocath and no thrombus on 4th month study. The second patient has shown patent shunt on follow-up and no ascites. Conclusions: Balloon dilatation may be an incomplete therapy in early thrombosis. lntrsstent UK thrombolysis seems to be efficient and safe for early shunt thrombosis after TIPS in cirrhotic patients even following variceal hemorrhage. High doses must be used but under close coagulation control. Patients with high t'~sk of thrombosis may benefit from prophylactic anticoagulant therapy. This therapy may be applied to late shunt thrombosis to avoid new TIPS if earlydiagnosed,thoughthe maximaldelay is not "knownin cirdaotic
C. Petroyiannopoulos, A. Zaharof, J. Pana~opoulos, K. Kehagioglou and J. Poulikakos. 2nd and 3rd Dpt of Medicine,Red Cross Hospital Athens,Greece.
patients.
EFFECTIVENESS OF TRANSJUGULAR INTRAHEPATIC P O R T O S Y S T E M I C STENT SHUNT(TIPS) IN REBLEEDING P R O P H Y L A X I S FROM GASTROESOPHAGEAL VARICES IN CIRRHOTICS
M Nufiez, B Sangro, J Quiroga, I Bilbao, J Lon~o, M Bet~s, I Herrero, E Macfas, N G6mez, L Garcfa-Villarreal, JM Zozaya, J Prieto. Liver Unit. University Clinic. Pamplona. Spain. Sclerotherapy and propranolol are not fully preventive of variceal bleeding (VB) and have no impact on patient (pt) survival. We have evaluated TIPS in preventing variceal rebleeding in pt failing to other prophylactic measures. Patients and methods: 25 pt (Child:A-13; B9; C-3) with previous VB (I-7 episodes/pt; median,3) despite prophylactic sclerotherapy + propranolol and at high risk of rebleeding (large-size varices, red spots) underwent prophylactic TIPS 0Vallstent, 8mmf~) within 90 days lbllowing the last hemorrhage. Follow-up ranged 1-28 mo (median: 13 mo) and included periodic checking of the stent and the portosystemic pressure gradient (PSPG) (l-6/pt/year). Rebleeding index (RI) betbre and after TIPS was calculated according: Mo free of bleeding/(number of bleeding episodes + I). R~ults: After TIPS, PSPG decreased immediately (21.3+0.8 to 14.9+0.7 mmHg:p<0.001), and persistently (last measurement: 15.2+1.1. p<0.001). Rebleeding: 4% (1 pt with stent thrombosis), notrebleeding: 96%. resulting in a significant increase of RI (3.5+0.9 vs 14.2 + 1.8; p < 0.001 ). Stem or hepatic vein stenosis developed in 8 pt (33%) and were succesfully treated. Actuarial survival rates at 6, 12 and 24 mo were 95%. 85% and 85% respectively. Conclusion:l .TIPS is very effective in preventing VB in pt failing to other procedures. 2. Periodic assessment of the stent isrequired to maintain the long term efficacy of TIPS. 3. Controlled studies comparing TIPS and the current procedures for prevention of VB are warranted.
Purpose of the study was to evaluate how much effective and safe are these two ways of paracentesis and compare each other. Material and methods: This study included 40 cirrhotic patients with refractory tense ascites divided in two groups of 20 patients each.The patients of group A had a total paracentesis while the patients of group B had repeated large volume paracentesis (4 to 6 litre per day).All the patients received intravenous albumin(6 gr per liter of ascites removed). Clinical and biochemical follow-up has obtained in both groups. Results: All the patients of group A tolerated very well the total psracentesis while, 2 patients of group B developed clinical symptoms of bacterial peritonitis .From the 20 patients of group B 4 of them(20%) showed a higher incidence of hyponatremia increased levels of urea and creatinin while liver function test didn't change in both groups. Conclusions: a)Total and repeated large volume paracentesis are quite effective for the management of refractory tense ascites. b)The danger of hyponatremia and bacterial peritonitis is lower in total paracentesis. c) Total psracentesis is much more tolerable in cirrhotic patients.
THE SERUM-ASCITES PREALBUMIN GRADIENT (SAPG): AN INDIRECT INDEX OF PORTAL PRESSURE GRADIENT CHANGES IN CIRRHOTICS UNDERGOING TOTAL PARACENTESIS. M.Pozzi, C.Lambrughi, P.Colombo, *L.Pirovano, L.Roffi, F.Villani, V.Pecci, A.Piperno, F.Panizzuti and G.Mancia. Chair of Internal Medicine, Dept. of Medicine 1, and *Clinical Chemistry Laboratory, S.Gerardo Hospital, University of Milan, Monza (Mi), Italy. BACKGROUND A serum-ascites albumin gradient (SAAG) threshold > 1.1 g/dL strongly suggests portal hypertension-related ascites: wider SAAG directly correlate with higher portal pressure gradients in cirrhotics (J. Lab. Clin. "Mad. 1983: 102:260-273) . AIM Large volume or even total paracentesis (TP) plus Albumin infusion are widely employed procedures to treat tense ascites of cirrhosis. The present study was undertaken to evaluate 1) changes of SAAG and of SAPG after TP, and to assess 2) the alternative role of SAPG determination (Albumin infusions can affect SAAG, making it unreliable to detect changes of portal pressure gradient). METHODS 22 cirrhotic patients, Child C class, undergoing TP and i.v. Albumin administration (6-8 g/liter of ascites) for an episode of tense ascites, were studied. SAAG and SAPG were determined at baseline and 15 days after TP along with biochemical and hormonal parameters (data not shown). RESULTS 10.4+3.6 SD liters of ascites were drained, with culture always negative. Baseline SAAG was greater than 1.1 g/dL in all patients (mean 1.6+0.3 SD). Mean SAPG was 4.4+1.4 SD mg/dL (in only two cases out of 22 values lower than 3.0 mg/dL were found). In 12 patients ascites was still detectable (culture negative) 15 days after TP, despite diuretic treatment. At this later time a slight increase of SAPG (from 4.7+1.5 to 5.7~-2.5, NS), but not of SAAG, was observed. CONCLUSIONS These results further confirm the reliability of SAAG in detecting portal hypertension-related ascites. However in cirrhotic patients treated with Albumin after TP (or for other therapeutic purposes) SAPG seems a more appropriate indirect index of portal pressure gradient changes.