Transjugulärer intrahepatischer portosystemischer Stent-Shunt: Indikationen und Langzeitresultate

Zusammenfassung

Der transjuguläre intrahepatische Stent-Shunt (TIPS) ist ein zwischenzeitlich etabliertes und technisch ausgereiftes Verfahren mit geringer Invasivität zur effektiven Therapie von Komplikationen der portalen Hypertension, insbesondere der rezidivierenden Varizenblutung und des therapierefraktären Aszites. Für diese Indikationen hat es die chirurgische Anlage portosystemischer Shunts weitgehend verdrängt. Reinterventionen sind jedoch wegen Restenosierungsraten von 25-50 % häufig erforderlich. Die wichtigste unerwünschte Wirkung ist das Auftreten oder die Verschlechterung einer hepatischen Enzephalopathie. Neuere Studien mit Verwendung PTFE-beschichteter Stents zeigen eine geringere Stenosierungsrate und einen Trend zu verlängertem Überleben.

Abstract

The transjugular intrahepatic portosystemic stent shunt has replaced surgical shunt procedures as the standard therapy for complications of portal hypertension such as refractory ascites and recurrent variceal bleeding. However, reinterventions due to TIPS stenosis are necessary in 25-50 %. Major complications are the manifestation or worsening of hepatic encephalopathy. Recent studies using PTFE covered stents have shown lower stenosis rates and a trend towards prolonged survival.

portale Hypertension - TIPS - Varizenblutung - therapierefraktärer Aszites

portal hypertension - stent shunt - variceal bleeding - refractory ascites

Literatur

• 1 Richter G M, Noeldge G, Palmaz J C, Roessle M. The transjugular intrahepatic portosystemic stent-shunt (TIPSS): results of a pilot study.  Cardiovasc Intervent Radiol. 1990;  13 200-207
• 2 Rössle M, Haag K, Ochs A, Sellinger M, Noldge G, Perarnau J M, Berger E, Blum U, Gabelmann A, Hauenstein K. The transjugular intrahepatic portosystemic stent-shunt procedure for variceal bleeding.  N Engl J Med. 1994;  330 165-171
• 3 Rössle M, Deibert P, Haag K, Ochs A, Olschewski M, Siegerstetter V, Hauenstein K-H, Siepak C, Keller W, Blum H E. Randomised trial of transjugular-intrahepatic-portosystemic shunt versus endoscopy plus propranolol for prevention of variceal rebleeding.  Lancet. 1997;  349 1043-1049
• 4 Gulberg V, Schepke M, Geigenberger G, Holl J, Brensing K A, Waggershauser T, Reiser M, Schild H H, Sauerbruch T, Gerbes A L. Transjugular intrahepatic portosystemic shunting is not superior to variceal band ligation for prevention of variceal rebleeding in cirrhotic patients: a randomized controlled trial.  Scand J Gastroenterol. 2002;  37 338-343
• 5 Arroyo V, Gines P, Gerbes A L, Dudley F J, Gentilini P, Laffi G, Reynolds T B, Ring-Larsen H, Scolmerich J. Definition and diagnostic criteria of refractory ascites and hepatorenal syndrome in cirrhosis.  Hepatology. 1996;  23 164-176
• 6 Ginès P, Arroyo V, Vargas V, Planas R, Casafont F, Panes J, Hoyos M, Viladomiu L, Rimola A, Morillas R. Paracentesis with intravenous infusion of albumin as compared with peritoneovenous shunting in cirrhosis with refractory ascites.  N Engl J Med. 1991;  325 829-835
• 7 Bories P, Garcia Compean D, Michel H, Bourel M, Capron J P, Gauthier A, Lafon J, Levy V G, Pascal J P, Quinton A. The treatment of refractory ascites by the LeVeen shunt: a multi-centre controlled trial (57 patients).  Hepatology. 1986;  3 212-218
• 8 Orloff M J. Pathogenesis and surgical treatment of intractable ascites associated with alcoholic cirrhosis.  Ann N Y Acad Sci. 1970;  170 213-238
• 9 Ochs A, Rössle M, Haag K, Hauenstein K H, Deibert P, Siegerstetter V, Huonker M, Langer M, Blum H E. The transjugular intrahepatic portosystemic stent-shunt procedure for refractory ascites.  N Engl J Med. 1995;  332 1192-1197
• 10 Somberg K A, Lake J R, Tomlanovich S J, LaBerge J M, Feldstein V, Bass N M. Transjugular intrahepatic portosystemic shunts for refractory ascites: assessment of clinical and hormonal response and renal function.  Hepatology. 1995;  21 709-716
• 11 Lebrec D, Giuily N, Hadengue A, Hadengue A, Vilgrain V, Moreau R, Poynard T, Gadano A, Lassen C, Benhamou J P, Erlinger S. Transjugular intrahepatic portosystemic shunts: comparison with paracentesis in patients with cirrhosis and refractory ascites: a randomized trial.  J Hepatol. 1996;  25 135-144
• 12 Nazarian G K, Bjarnason H, Dietz C A, Bernadas C A, Foshager M C, Ferral H, Hunter D W. Refractory ascites: midterm results of treatment with transjugular intrahepatic portosystemic shunt.  Radiology. 1997;  205 173-180
• 13 Rössle M, Ochs A, Gulberg V, Siegerstetter V, Holl J, Olschewski M, Reiser M, Gerbes A L. A comparison of paracentesis and transjugular intrahepatic portosystemic shunting in patients with ascites.  N Engl J Med. 2000;  342 1745-1747
• 14 Rössle M, Siegerstetter V, Huber M, Ochs A. The first decade of the transjugular intrahepatic portosystemic shunt (TIPS): state of the art.  Liver. 1998;  18 73-89
• 15 Siegerstetter V, Deibert P, Ochs A, Olschewski M, Blum H E, Rössle M. Treatment of refractory hepatic hydrothorax with transjugular intrahepatic portosystemic shunt: long-term results in 40 patients.  Eur J Gastroenterol Hepatol. 2001;  13 529-534
• 16 Brensing K A, Textor J, Perz J, Schiedermaier P, Raab P, Strunk H, Klehr H U, Kramer H J, Spengler U, Schild H, Sauerbruch T. Long term outcome after transjugular intrahepatic portosystemic stent shunt in non-transplant cirrhotics with hepatorenal syndrome: a phase II study.  Gut. 2000;  47 288-295
• 17 Allgaier H P, Haag K, Ochs A, Hauenstein K H, Jeserich M, Krause T, Heilmann C, Gerok W, Rössle M. Hepato-pulmonary syndrome: successful treatment by transjugular intrahepatic portosystemic stent-shunt (TIPS).  J Hepatol. 1995;  23 102
• 18 Blum U, Haag K, Rössle M, Ochs A, Gabelmann A, Boos S, Langer M. Noncavernomatous portal vein thrombosis in hepatic cirrhosis: treatment with transjugular portosystemic shunt and local thrombolysis.  Radiology. 1995;  195 153-157
• 19 Ochs A, Sellinger M, Haag K, Noldge G, Herbst E W, Walter E, Gerok W, Rössle M. Transjugular intrahepatic portosystemic stent shunt (TIPS) in the treatment of Budd-Chiari syndrome.  J Hepatol. 1994;  21 685-686
• 20 Seki S, Sakaguchi H, Kobayashi S, Kitada T, Nakamura K, Yamada R. Transjugular iintrahepatic portosystemic stent shunt in combination with oral anticoagulant for Budd-Chiari-syndrome.  Hepatogastroenterology. 2001;  48 1447-1449
• 21 Zenz T, Rössle M, Bertz H, Siegerstetter V, Ochs A, Kinke J. Severe veno-occlusive disease after allogeneic bone marrow or peripheral stem cell transplantation-role of transjugular intrahepatic portosystemic shunt (TIPS).  Liver. 2001;  21 31-36
• 22 Burger J A, Ochs A, Wirth K, Berger D P, Mertelsmann R, Engelhardt R, Rössle M, Haag K. The transjugular stent implantation for the treatment of malignant portal and hepatic vein obstruction in cancer patients.  Ann Oncol. 1997;  8 200-202
• 23 Somberg K A, Lombardero M S, Lawlor S M, Ascher N L, Lake J R, Wiesner R H, Zettermann R K. A controlled analysis of the transjugular intrahepatic portosystemic shunt in liver transplant recipients.  Transplantation. 1997;  63 1074-1079
• 24 Rössle M, Piotraschke J. Transjugular intrahepatic portosystemic shunt and hepatic encephalopathy.  Dig Dis. 1996;  14 12-19
• 25 Bureau C, Garcia-Pagan J C, Otal P, Pomier-Layrargues G, Chabbert V, Cortez C, Perreult P, Peron J M, Abraldes J G, Bouchard L, Bilbao J I, Rousseau H, Vinel J P. Improved clinical outcome using polytetraethylene-coated stents for TIPS: results of a randomized study.  Gastroenterology. 2004;  126 469-475
• 26 Angermayr B, Cejna M, Koenig F, Karnel F, Hackl F, Gangl A, Peck-Radosavljevic M.. Vienna TIPS Study Group . Survival in patients undergoing transjugular intrahepatic portosystemic shunt: ePTFE-covered stentgrafts versus bare stents.  Hepatology. 2003;  38 1043-1050
• 27 Sze D Y, Vestring T, Liddell R P, Kato N, Semba C P, Razavi M K, Kee S T, Dake M D. Recurrent TIPS failure associated with biliary fistulae: treatment with PTFE-covered stents.  Cardiovasc Interv Radiol. 1999;  22 298-304