Background and Aims: Transjugular intrahepatic portosystemic shunt (TIPS) is the treatment of choice in decompensated portal hypertension. TIPS revision due to thrombosis or stenosis increases morbidity and mortality. Our aim was to investigate patient- and procedure-associated risk factors for TIPS-revision. Patients and Methods: We retrospectively evaluated 189 patients who underwent the TIPS procedure. Only patients who required TIPS revision within 1 year (Group I, 34 patients) and patients who did not require re-intervention within the first year (Group II [control group], 54 patients) were included. Results: Out of 88 patients, the majority were male (69.3%) and mean age was 56 ± 11 years. Indications for TIPS were refractory ascites (68%), bleeding (24%), and Budd-Chiari syndrome (8%). The most frequent liver disease was alcohol-induced cirrhosis (60%). Forty-three patients (49%) received bare and 45 patients (51%) covered stents, thus resulting in reduction of hepatic venous pressure gradient (HVPG) from 19.0 to 9.0 mm Hg. When comparing patient- and procedure-related factors, the type of stent (p < 0.01) and interventionalist’s experience (number of performed TIPS implantations per year; p < 0.05) were the only factors affecting the risk of re-intervention due to stent dysfunction, while age, gender, indication, Child-Pugh, and model of end-stage liver disease score, platelet count, pre- and post-HVPG, additional variceal embolization, stent diameter, and number of stents did not significantly differ. Conclusion: Patients undergoing TIPS procedure should be surveilled closely for shunt dysfunction while covered stents and high-level experience are associated with increased -patency.

Keywords:
Bare stent, Covered stent, Patency, Portal hypertension, Transjugular intrahepatic portosystemic shunt
1.
de Franchis R; Baveno VI Faculty: Expanding consensus in portal hypertension: report of the Baveno VI consensus workshop: stratifying risk and individualizing care for portal hypertension. J Hepatol 2015; 63: 743–752.
2.
Boyer TD, Haskal ZJ; American Association for the Study of Liver Diseases: The role of transjugular intrahepatic portosystemic shunt (TIPS) in the management of portal hypertension: update 2009. Hepatology 2010; 51: 306.
3.
Fidelman N, Kwan SW, LaBerge JM, Gordon RL, Ring EJ, Kerlan RK: The transjugular intrahepatic portosystemic shunt: an update. AJR Am J Roentgenol 2012; 199: 746–755.
4.
Richter GM, Noeldge G, Palmaz JC, Roessle M, Slegerstetter V, Franke M, et al: Transjugular intrahepatic portacaval stent shunt: preliminary clinical results. Radiology 1990; 174: 1027–1030.
5.
Richter GM, Noeldge G, Palmaz JC, Roessle M: The transjugular intrahepatic portosystemic stent-shunt (TIPSS): results of a pilot study. Cardiovasc Intervent Radiol 1990; 13: 200–207.
6.
LaBerge JM, Ring EJ, Gordon RL, Lake JR, Doherty MM, Somberg KA, et al: Creation of transjugular intrahepatic portosystemic shunts with the wallstent endoprosthesis: results in 100 patients. Radiology 1993; 187: 413–420.
7.
Ferral H, Gomez-Reyes E, Fimmel CJ: Post-transjugular intrahepatic portosystemic shunt follow-up and management in the VIATORR era. Tech Vasc Interv Radiol 2016; 19: 82–88.
8.
Casado M, Bosch J, García-Pagán JC, Bru C, Bañares R, Bandi JC, et al: Clinical events after transjugular intrahepatic portosystemic shunt: correlation with hemodynamic findings. Gastroenterology 1998; 114: 1296–1303.
9.
Lind CD, Malisch TW, Chong WK, Richards WO, Pinson CW, Meranze SG, et al: Incidence of shunt occlusion or stenosis following transjugular intrahepatic portosystemic shunt placement. Gastroenterology 1994; 106: 1277–1283.
10.
Haskal ZJ, Pentecost MJ, Soulen MC, Shlansky-Goldberg RD, Baum RA, Cope C: Transjugular intrahepatic portosystemic shunt stenosis and revision: early and midterm results. AJR Am J Roentgenol 1994; 163: 439–444.
11.
Sanyal AJ, Freedman AM, Luketic VA, Purdum PP, Shiffman ML, DeMeo J, et al: The natural history of portal hypertension after transjugular intrahepatic portosystemic shunts. Gastroenterology 1997; 112: 889–898.
12.
Perarnau JM, Le Gouge A, Nicolas C, d’Alteroche L, Borentain P, Saliba F, et al: Covered vs. uncovered stents for transjugular intrahepatic portosystemic shunt: a randomized controlled trial. J Hepatol 2014; 60: 962–968.
13.
Cura M, Cura A, Suri R, El-Merhi F, Lopera J, Kroma G: Causes of TIPS dysfunction. AJR Am J Roentgenol 2008; 191: 1751–1757.
14.
Luo XF, Nie L, Wang Z, Tsauo J, Liu LJ, Yu Y, et al: Stent-grafts for the treatment of TIPS dysfunction: fluency stent vs Wallgraft stent. World J Gastroenterol 2013; 19: 5000–5005.
15.
Riggio O, Ridola L, Angeloni S, Cerini F, Pasquale C, Attili AF, et al: Clinical efficacy of transjugular intrahepatic portosystemic shunt created with covered stents with different diameters: results of a randomized controlled trial. J Hepatol 2010; 53: 267–272.
16.
Bureau C, Garcia Pagan JC, Layrargues GP, Metivier S, Bellot P, Perreault P, et al: Patency of stents covered with polytetrafluoroethylene in patients treated by transjugular intrahepatic portosystemic shunts: long-term results of a randomized multicentre study. Liver Int Off J Int Assoc Study Liver 2007; 27: 742–747.
17.
Rössle M, Siegerstetter V, Euringer W, Olschewski M, Kromeier J, Kurz K, et al: The use of a polytetrafluoroethylene-covered stent graft for transjugular intrahepatic portosystemic shunt (TIPS): long-term follow-up of 100 patients. Acta Radiol Stockh Swed 1987 2006; 47: 660–666.
18.
Klasen-Sansone J, Bode J, Lanzman RS, Kubitz R, Immig S, Heusch P, et al: TIPS geometry influences patency. Z Gastroenterol 2015; 53: 28–32.
19.
Andring B, Kalva SP, Sutphin P, Srinivasa R, Anene A, Burrell M, et al: Effect of technical parameters on transjugular intrahepatic portosystemic shunts utilizing stent grafts. World J Gastroenterol 2015; 21: 8110–8117.
20.
Suhocki PV, Lungren MP, Kapoor B, Kim CY: Transjugular intrahepatic portosystemic shunt complications: prevention and management. Semin Interv Radiol 2015; 32: 123–132.
21.
Luo SH, Chu JG, Huang H, Yao KC: Effect of initial stent position on patency of transjugular intrahepatic portosystemic shunt. World J Gastroenterol 2017; 23: 4779–4787.
22.
Bureau C, Garcia-Pagan JC, Otal P, Pomier-Layrargues G, Chabbert V, Cortez C, et al: Improved clinical outcome using polytetrafluoroethylene-coated stents for TIPS: results of a randomized study. Gastroenterology 2004; 126: 469–475.
23.
Lauermann J, Potthoff A, Mc Cavert M, Marquardt S, Vaske B, Rosenthal H, et al: Comparison of technical and clinical outcome of transjugular portosystemic shunt placement between a bare metal stent and a PTFE-stentgraft device. Cardiovasc Intervent Radiol 2016; 39: 547–556.
24.
He F, Dai S, Xiao Z, Wang L, Yue Z, Zhao H, et al: Pathological predictors of shunt stenosis and hepatic encephalopathy after transjugular intrahepatic portosystemic shunt. BioMed Res Int 2016; 2016: 3681731.
25.
Tan HK, James PD, Sniderman KW, Wong F: Long-term clinical outcome of patients with cirrhosis and refractory ascites treated with transjugular intrahepatic portosystemic shunt insertion. J Gastroenterol Hepatol 2015; 30: 389–395.
26.
Sommer CM, Gockner TL, Stampfl U, Bellemann N, Sauer P, Ganten T, et al: Technical and clinical outcome of transjugular intrahepatic portosystemic stent shunt: bare metal stents (BMS) versus viatorr stent-grafts (VSG). Eur J Radiol 2012; 81: 2273–2280.
27.
Luca A, Miraglia R, Caruso S, Milazzo M, Sapere C, Maruzzelli L, 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.
28.
Clark W, Golkar F, Luberice K, Toomey P, Paul H, Marcadis A, et al: Uncovering the truth about covered stents: is there a difference between covered versus uncovered stents with transjugular intrahepatic portosystemic shunts? Am J Surg 2011; 202: 561–564.
29.
Maleux G, Perez-Gutierrez NA, Evrard S, Mroue A, Le Moine O, Laleman W, et al: Covered stents are better than uncovered stents for transjugular intrahepatic portosystemic shunts in cirrhotic patients with refractory ascites: a retrospective cohort study. Acta Gastro-Enterol Belg 2010; 73: 336–341.
30.
Jung HS, Kalva SP, Greenfield AJ, Waltman AC, Walker TG, Athanasoulis CA, et al: TIPS: comparison of shunt patency and clinical outcomes between bare stents and expanded polytetrafluoroethylene stent-grafts. J Vasc Interv Radiol JVIR 2009; 20: 180–185.
31.
Pan JJ, Chen C, Geller B, Firpi R, Machicao VI, Caridi JG, et al: Is sonographic surveillance of polytetrafluoroethylene-covered transjugular intrahepatic portosystemic shunts (TIPS) necessary? A single centre experience comparing both types of stents. Clin Radiol 2008; 63: 1142–1148.
32.
Tripathi D, Redhead D: Transjugular intrahepatic portosystemic stent-shunt: technical factors and new developments. Eur J Gastroenterol Hepatol 2006; 18: 1127–1133.
33.
Barrio J, Ripoll C, Bañares R, Echenagusia A, Catalina MV, Camúñez F, et al: Comparison of transjugular intrahepatic portosystemic shunt dysfunction in PTFE-covered stent-grafts versus bare stents. Eur J Radiol 2005; 55: 120–124.
34.
Angeloni S, Merli M, Salvatori FM, De Santis A, Fanelli F, Pepino D, et al: Polytetrafluoroethylene-covered stent grafts for TIPS procedure: 1-year patency and clinical results. Am J Gastroenterol 2004; 99: 280–285.
35.
Birkmeyer JD, Siewers AE, Finlayson EVA, Stukel TA, Lucas FL, Batista I, et al: Hospital volume and surgical mortality in the United States. N Engl J Med 2002; 346: 1128–1137.
36.
Shuhaiber J, Isaacs AJ, Sedrakyan A: The effect of center volume on in-hospital mortality after aortic and mitral valve surgical procedures: a population-based study. Ann Thorac Surg 2015; 100: 1340–1346.
37.
Young EL, Holt PJE, Poloniecki JD, Loftus IM, Thompson MM: Meta-analysis and systematic review of the relationship between surgeon annual caseload and mortality for elective open abdominal aortic aneurysm repairs. J Vasc Surg 2007; 46: 1287–1294.
38.
Perry BC, Kwan SW: Portosystemic shunts: stable utilization and improved outcomes, two decades after the transjugular intrahepatic portosystemic shunt. J Am Coll Radiol JACR 2015; 12: 1427–1433.
39.
Dariushnia SR, Haskal ZJ, Midia M, Martin LG, Walker TG, Kalva SP, et al: Quality improvement guidelines for transjugular intrahepatic portosystemic shunts. J Vasc Interv Radiol JVIR 2016; 27: 1–7.
40.
Bettinger D, Schultheiss M, Boettler T, Muljono M, Thimme R, Rössle M: Procedural and shunt-related complications and mortality of the transjugular intrahepatic portosystemic shunt (TIPSS). Aliment Pharmacol Ther 2016; 44: 1051–1061.
41.
Sarwar A, Zhou L, Novack V, Tapper EB, Curry M, Malik R, et al: Hospital volume and mortality after trans-jugular intrahepatic portosystemic shunt creation in the United States. Hepatol Baltim Md 2017, Epub ahead of print.
42.
Plessier A, Valla DC: Budd-Chiari syndrome. Semin Liver Dis 2008; 28: 259–269.
43.
Perelló A, García-Pagán JC, Gilabert R, Suárez Y, Moitinho E, Cervantes F, et al: TIPS is a useful long-term derivative therapy for patients with Budd-Chiari syndrome uncontrolled by medical therapy. Hepatology 2002; 35: 132–139.
44.
Mohanty D, Shetty S, Ghosh K, Pawar A, Abraham P: Hereditary thrombophilia as a cause of Budd-Chiari syndrome: a study from Western India. Hepatol Baltim Md 2001; 34: 666–670.
45.
Pieper CC, Jansen C, Meyer C, Nadal J, Lehmann J, Schild HH, et al: Prospective evaluation of passive expansion of partially dilated transjugular intrahepatic portosystemic shunt stent grafts-A three-dimensional sonography study. J Vasc Interv Radiol JVIR 2017; 28: 117–125.
46.
Praktiknjo M, Lehmann J, Fischer S, Strassburg CP, Meyer C, Trebicka J: Novel diameter controlled expansion TIPS (Viatorr CX®)graft reduces readmission compared to regular covered TIPS graft and bare metal graft. J Hepatol 2017;66(suppl):S1–S876.
47.
Engstrom BI, Horvath JJ, Suhocki PV, Smith AD, Hertzberg BS, Smith TP, et al: Covered transjugular intrahepatic portosystemic shunts: accuracy of ultrasound in detecting shunt malfunction. AJR Am J Roentgenol 2013; 200: 904–908.
48.
Gao J, Ran HT, Ye XP, Zheng YY, Zhang DZ, Wang ZG: The stiffness of the liver and spleen on ARFI Imaging pre and post TIPS placement: a preliminary observation. Clin Imaging 2012; 36: 135–141.
49.
Novelli PM, Cho K, Rubin JM: Sonographic assessment of spleen stiffness before and after transjugular intrahepatic portosystemic shunt placement with or without concurrent embolization of portal systemic collateral veins in patients with cirrhosis and portal hypertension: a feasibility study. J Ultrasound Med Off J Am Inst Ultrasound Med 2015; 34: 443–449.
50.
Buechter M, Manka P, Theysohn JM, Reinboldt M, Canbay A, Kahraman A: Spleen stiffness is positively correlated with HVPG and decreases significantly after TIPS implantation. Dig Liver Dis Off J Ital Soc Gastroenterol Ital Assoc Study Liver 2017, Epub ahead of print.
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2018
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