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Gastroenterologie up2date 2016; 12(04): 321-339
DOI: 10.1055/s-0042-117560
Leber/Galle/Pankreas
© Georg Thieme Verlag KG Stuttgart · New York

Transjugulärer intrahepatischer portosystemischer Shunt (TIPS) – Update 2016

Inge Kaare Tesdal
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Publication Date:
22 December 2016 (online)

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Kernaussagen

TIPS bei Varizenblutungen

  • Ein Hochrisikopatient ist definiert als ein Patient in Child-Pugh-Gruppe C (bis 13 Punkte) oder ein Patient in Child-Pugh-Gruppe B mit aktiver Blutung während der Endoskopie.

  • TIPS bei Hochrisikopatienten führt zu einer signifikanten Senkung der Rezidivblutungsrate und zu einer signifikanten Verbesserung der Überlebensrate.

  • Eine angiomorphologische Klassifikation der portosystemischen Kollateralen vor und nach TIPS-Anlage ist hilfreich, um das Blutungsrisiko einzuschätzen.

  • Bei der Kombination von großen Ösophagus- und Magenvarizen und schlechter Leberfunktion (Child-Pugh > 8) steigt die Rezidivblutungsrate signifikant.

  • Die Varizenembolisation stellt weiterhin eine wichtige additive Methode dar, um die Rezidivblutungsgefahr dauerhaft zu reduzieren.

  • Es besteht eine eindeutige Indikation zur Varizenembolisation, wenn der portosystemische Gradient nach TIPS nicht ausreichend gesenkt wurde und/oder die hepatofugal perfundierten Varizen einen Konkurrenzfluss zum TIPS-Shunt darstellen.

TIPS bei anderen Indikationen

  • Die Mehrzahl der Studien zeigt, dass nach TIPS Aszites und aszitesassoziierte Komplikationen oft sistieren oder besser medikamentös therapierbar sind.

  • Die Therapie des Budd-Chiari-Syndroms sollte stufenweise erfolgen: Eine Verschlechterung der Leberfunktion muss ohne Zeitverzögerung zum Therapiewechsel führen.

  • Bei der symptomatischen Pfortaderthrombose sollte immer über eine TIPS-Anlage als Therapieoption nachgedacht werden.

Komplikationen

  • Die Komplikation mit der höchsten Morbidität und Letalität sind Blutungen. Um sie zu vermeiden, ist die prätherapeutische Abklärung der Leberdurchblutung essenziell.

  • Zur Therapie der Enzephalopathie steht die medikamentöse Beeinflussung der Darmflora durch nicht resorbierbare Disaccharide und ein darmselektives Breitbandantibiotikum im Vordergrund.

 

  • Literatur

  • 1 Tesdal IK. Transjugulärer intrahepatischer portosystemischer Shunt (TIPS): Indikation, Durchführung, Komplikationen. Gastoenterologie up2date 2007; 3: 359-373
    PubMedSearch in Google Scholar
  • 2 Hanafee W, Weiner M. Transjugular percutaneous cholangiography. Radiology 1967; 88: 35-39
    CrossrefPubMedSearch in Google Scholar
  • 3 Weiner M, Hanafee W. Review of transjugular venography. Radiol Clin North Am 1970; 8: 53-68
    PubMedSearch in Google Scholar
  • 4 Rösch J, Hanafee WN, Snow H. Transjugular portal venography and radiologic portacaval shunt: an experimental study. Radiology 1969; 92: 1112-1114
    CrossrefPubMedSearch in Google Scholar
  • 5 Colapinto RF, Stronell RD, Birch SJ et al. Creation of an intrahepatic portosystemic shunt with Grüntzig balloon catheter. Can Med Assoc J 1982; 113: 137-138
    PubMedSearch in Google Scholar
  • 6 Palmaz JC, Sibbitt RR, Reuter SR et al. Expandable intrahepatic portacaval shunt stents: early experience in the dog. AJR Am J Roentgenol 1985; 145: 821-825
    CrossrefPubMedSearch in Google Scholar
  • 7 Rössle M, Richter GM, Nöldge G et al. Performance of an intrahepatic portacaval shunt (PCS) using a catheter technique: A case report. Hepatology 1988; 8: 1348A
    PubMedSearch in Google Scholar
  • 8 Lunderquist A, Vang J. Transhepatic catheterization and obliteration of the coronary vein in patients with portal hypertension and esophageal varices. N Engl J Med 1974; 291: 646-649
    CrossrefPubMedSearch in Google Scholar
  • 9 Mitra SK. Hepatic vascular changes in human and experimental cirrhosis. J Pathol Bacteriol 1966; 92: 405-414
    CrossrefPubMedSearch in Google Scholar
  • 10 Bosch J, Navasa M, Garcia-Pagan JC et al. Portal hypertension. Med Clin North Am 1989; 73: 931-953
    PubMedSearch in Google Scholar
  • 11 Christensen E, Faverholdt L, Schlichting P et al. Aspects of the natural history of gatrointestinal bleeding in cirrhosis and the effect of prednisone. Gastroenterology 1981; 81: 944-952
    CrossrefPubMedSearch in Google Scholar
  • 12 The Veterans Affairs Cooperative Variceal Sclerotherapy Group. Prophylactic sclerotherapy for esophageal varices in men with alcoholic liver disease. N Engl J Med; 1991 324. 1779-1784
    PubMedSearch in Google Scholar
  • 13 The North Italian Endoscopic Club for the Study and Treatment of Esophageal Varices. Prediction of the first variceal hemorrhage in patients with cirrhosis of the liver and esophageal varices. A prospective multicenter study. N Engl J Med; 1988 319. 983-989
    PubMedSearch in Google Scholar
  • 14 Burroughs AK. The natural history of varices. J Hepatol 1993; 17: 10-13
    CrossrefPubMedSearch in Google Scholar
  • 15 Olafsson S, Blei AT. Diagnosis and management of ascites in the age of TIPS. AJR Am J Roentgenol 1995; 165: 9-15
    CrossrefPubMedSearch in Google Scholar
  • 16 Shiffman ML, Jeffers L, Hoofnagle JH et al. The role of transjugular intrahepatic portosystemic shunt for treatment of portal hypertension and its complications: A conference sponsored by the national digestive diseases advisory board. Hepatology 1995; 22: 131-137
    PubMedSearch in Google Scholar
  • 17 Haskal ZJ, Martin L, Cardella JF et al. Quality improvement guidelines for transjugular intrahepatic portosystemic shunts. SCVIR Standards of Practice Committee. J Vasc Interv Radiol 2001; 12: 131-136
    CrossrefPubMedSearch in Google Scholar
  • 18 Boyer TD, Haskal ZJ The role of transjugular intrahepatic portosystemic shunt in the American Association for the Study of Liver Diseases.management of portal hypertension: update 2009. Hepatology; 2010 51. 306
    PubMedSearch in Google Scholar
  • 19 García-Pagán JC, Caca K, Bureau C et al. Early use of TIPS in patients with cirrhosis and variceal bleeding. N Engl J Med 2010; 362: 2370-2379
    CrossrefPubMedSearch in Google Scholar
  • 20 Henderson JM. Surgery versus transjugular intrahepatic portal systemic shunt in the treatment of severe variceal bleeding. Clin Liver Dis 2006; 10: 599-612
    CrossrefPubMedSearch in Google Scholar
  • 21 Tesdal IK, Wikström M, Flechtenmacher C et al. Percutaneous treatment of hepatocellular carcinoma in patients with transjugular intrahepatic portosystemic shunt. Cardiovasc Intervent Radiol 2006; 29: 778-784
    CrossrefPubMedSearch in Google Scholar
  • 22 Qi X, Han G. TIPS in the treatment of portal vein thrombosis: a critical review of literature. Hepatol Int 2012; 6: 576-590
    CrossrefPubMedSearch in Google Scholar
  • 23 Malinchoc M, Kamath PS, Gordon FD et al. A model to predict poor survival in patients undergoing transjugular intrahepatic portosystemic shunts. Hepatology 2000; 31: 864-871
    CrossrefPubMedSearch in Google Scholar
  • 24 Angermayr B, Cejna M, Karnel F et al. Child-Pugh versus MELD score in predicting survival in patients undergoing transjugular intrahepatic portosystemic shunt. Gut 2003; 52: 879-885
    CrossrefPubMedSearch in Google Scholar
  • 25 Burroughs AK, Vangeli M. Transjugular intrahepatic portosystemic shunt versus endoscopic therapy: randomized trials for secondary prophylaxis of variceal bleeding: an updated meta-analysis. Scand J Gastroenterol 2002; 3: 249-252
    PubMedSearch in Google Scholar
  • 26 Sauerbruch T, Mengel M, Dollinger M et al. Prevention of rebleeding from esophageal varices in patients with cirrhosis receiving small-diameter stents versus hemodynamically controlled medical therapy. Gastroenterology 2015; 149: 660-668
    CrossrefPubMedSearch in Google Scholar
  • 27 Angermayr B, Cejna M, Koenig F et al. for the Vienna TIPS Study Group. Survival in patients undergoing TIPS: ePTFE-covered stent grafts versus bare stents. Hepatology 2003; 38: 1043-1050
    CrossrefPubMedSearch in Google Scholar
  • 28 Carbonell N, Pauwels A, Serfaty L et al. Improved survival after variceal bleeding in patients with cirrhosis over the past two decades. Hepatology 2004; 40: 652-659
    CrossrefPubMedSearch in Google Scholar
  • 29 Rössle M, Haag K, Ochs A et al. The transjugular intrahepatic portosystemic shunt. N Engl J Med 1994; 330: 165-171
    CrossrefPubMedSearch in Google Scholar
  • 30 Sahagun G, Benner KG, Saxon R et al. Outcome of 100 patients after transjugular intrahepatic portosystemic shunt for variceal hemorrhage. Am J Gastroenterol 1997; 9: 1444-1452
    PubMedSearch in Google Scholar
  • 31 Sanyal AJ, Freedman AM, Luketic VA et al. The natural history of portal hypertension after transjugular intrahepatic portosystemic shunts. Gastroenterology 1997; 112: 889-898
    CrossrefPubMedSearch in Google Scholar
  • 32 Borg J PC, Hollemans M, Henk B RV et al. Transjugular intrahepatic portosystemic shunts: long-term patency and clinical results in a patient cohort observed for 3–9 years. Radiology 2004; 231: 537-545
    CrossrefPubMedSearch in Google Scholar
  • 33 Tesdal IK, Filser T, Weiss C et al. Transjugular intrahepatic portosystemic shunts: adjunctive embolotherapy of gastroesophageal collateral vessels in the prevention of variceal rebleeding. Radiology 2005; 236: 360-367
    CrossrefPubMedSearch in Google Scholar
  • 34 Gaba RC, Bui JT, Cotler SJ et al. Rebleeding rates following TIPS for variceal hemorrhage in the Viatorr era: TIPS versus TIPS with variceal embolization. Hepatol Int 2010; 4: 749-756
    CrossrefPubMedSearch in Google Scholar
  • 35 Qi X, Liu L, Bai M et al. Transjugular intrahepatic portosystemic shunt in combination with or without variceal embolization for the prevention of variceal rebleeding: a meta-analysis. J Gastroenterol Hepatol 2014; 29: 688-696
    CrossrefPubMedSearch in Google Scholar
  • 36 Russo MW, Sood A, Jacobson IM et al. Transjugular intrahepatic portosystemic shunt for refractory ascites: an analysis of the literature on efficacy, morbidity, and mortality. Am J Gastroenterol 2003; 98: 2521-2527
    CrossrefPubMedSearch in Google Scholar
  • 37 Lebrec D, Giuily N, Hadengue A et al. Transjugular intrahepatic portosystemic shunts: comparison with paracentesis in patients with cirrhosis and refractory ascites: a randomized trial. J Hepatol 1996; 25: 135-144
    CrossrefPubMedSearch in Google Scholar
  • 38 Rössle M, Ochs A, Gulberg V et al. A comparison of paracentesis and transjugular intrahepatic portosystemic shunting in patients with ascites. N Engl J Med 2000; 342: 1701-1707
    CrossrefPubMedSearch in Google Scholar
  • 39 Gines P, Uriz J, Calaborra B et al. Transjugular intrahepatic portosystemic shunting versus paracentesis plus albumin for refractory ascites in cirrhosis. Gastroenterology 2002; 123: 1839-1847
    CrossrefPubMedSearch in Google Scholar
  • 40 Sanyal A, Genning C, Reddy KR et al. The North American study for the treatment of refractory ascites. Gastroenterology 2003; 124: 634-641
    CrossrefPubMedSearch in Google Scholar
  • 41 Salerno F, Merli M, Riggio O et al. Randomized controlled study of TIPS versus paracentesis plus albumin in cirrhosis with severe ascites. Hepatology 2004; 40: 629-635
    CrossrefPubMedSearch in Google Scholar
  • 42 Narahara Y, Kanazawa H, Fukuda T et al. Transjugular intrahepatic portosystemic shunt versus paracentesis plus albumin in patients with refractory ascites who have good hepatic and renal function: a prospective randomized trial. J Gastroenterol 2011; 46: 78-85
    CrossrefPubMedSearch in Google Scholar
  • 43 Rössle M, Olschewski M, Siegerstetter V et al. The Budd-Chiari syndrome: outcome after treatment with transjugular intrahepatic portosystemic shunt. Surgery 2004; 135: 394-403
    CrossrefPubMedSearch in Google Scholar
  • 44 Darwish MS, Valla DC, de Groen PC et al. Determinants of survival and the effect of portosystemic shunting in patients with Budd-Chiari syndrome. Hepatology 2004; 39: 500-508
    CrossrefPubMedSearch in Google Scholar
  • 45 Garcia-Pagán JC, Heydtmann M, Raffa S et al. TIPS for Budd-Chiari syndrome: long-term results and prognostics factors in 124 patients. Gastroenterology 2008; 135: 808-815
    CrossrefPubMedSearch in Google Scholar
  • 46 Neumann AB, Andersen SD, Nielsen DT et al. Treatment of Budd-Chiari syndrome with a focus on transjugular intrahepatic portosystemic shunt. World J Hepatol 2013; 5: 38-42
    CrossrefPubMedSearch in Google Scholar
  • 47 Darwish MS, Luong TK, Pattynama PM et al. Long-term outcome of a covered vs. uncovered TIPS-Shunt in Budd-Chiari syndrome. Liver Int 2008; 28: 249-256
    CrossrefPubMedSearch in Google Scholar
  • 48 Seijo S, Plessier A, Hoekstra J et al. Good long-term outcome of budd-chiari syndrome with a step-wise management. Hepatology 2013; 57: 1962-1968
    CrossrefPubMedSearch in Google Scholar
  • 49 Darwish MS, Kamath PS. Liver transplantation for Budd-Chiari syndrome: when is it really necessary?. Liver Transpl 2008; 14: 133-135
    CrossrefPubMedSearch in Google Scholar
  • 50 Senzolo M, Tibbals J, Cholongitas E et al. Transjugular intrahepatic portosystemic shunt for portal vein thrombosis with and without cavernous transformation. Aliment Pharmacol Ther 2006; 23: 767-775
    CrossrefPubMedSearch in Google Scholar
  • 51 Qi X, He C, Guo W et al. Transjugular intrahepatic portosystemic shunt for portal vein thrombosis with variceal bleeding in liver cirrhosis: outcomes and predictors in a prospective cohort study. Liver Int 2016; 36: 667-676
    CrossrefPubMedSearch in Google Scholar
  • 52 Tesdal IK, Jaschke W, Bühler M et al. Transjugular intrahepatic portosystemic shunting (TIPS) with balloon-expandable and self-expanding stents: technical and clinical aspects after 31/2 years experience. Cardiovasc Interv Radiol 1997; 20: 29-37
    CrossrefPubMedSearch in Google Scholar
  • 53 Bureau C, Garcia-Pagan JC, Otal P et al. Improved clinical outcome using polytetrafluoroethylene-coated stents for TIPS: results of a randomized study. Gastroenterology 2004; 126: 469-475
    CrossrefPubMedSearch in Google Scholar
  • 54 Wilhelm K, Textor J, Strunk H et al. Kohlendioxid (CO2)als Kontrastmittel zur Neuauflage und Kontrolle von TIPS. Rofo 1997; 166: 238-242
    Thieme ConnectPubMedSearch in Google Scholar
  • 55 Coldwell DM, Ring EJ, Rees CR et al. Multicenter investigation of the role of transjugular intrahepatic portosystemic shunt in management of portal hypertension. Radiology 1995; 196: 335-340
    CrossrefPubMedSearch in Google Scholar
  • 56 Shiffman ML, Cole PE. Complications of TIPS implantation. In: Conn HO, Palmaz JC, Rösch J, Rössle M, , eds. Transjugular intrahepatic portosystemic shunts. New York: Igaku-Shoin; 1996
    Search in Google Scholar
  • 57 Davis AG, Haskal ZJ. Extrahepatic portal vein puncture and intra-abdominal hemorrhage during transjugular intrahepatic portosystemic shunt creation. J Vasc Interv Radiol 1996; 7: 863-866
    CrossrefPubMedSearch in Google Scholar
  • 58 Rössle M, Haag K, Blum HE. The transjugular intrahepatic portosystemic stent-shunt: a review of the literature and own experiences. J Gastroenterol Hepatol 1996; 11: 293-298
    CrossrefPubMedSearch in Google Scholar
  • 59 Grosso M, Spalluto F, Muratore P et al. Palmaz stent dislodgement into the left pulmonary artery complicating TIPS: percutaneous retrieval and extraction after venotomy. Cardiovasc Intervent Radiol 1995; 18: 106-108
    CrossrefPubMedSearch in Google Scholar
  • 60 Córdoba J, López-Hellín J, Planas M et al. Normal protein diet for episodic hepatic encephalopathy: results of a randomized study. J Hepatol 2004; 41: 38-43
    CrossrefPubMedSearch in Google Scholar
  • 61 Brunner F, Dufour JF, Gottardi AD. Therapie und Prävention der hepatischen Enzephalopathie. Schweiz Med Forum 2014; 14: 523-525
    PubMedSearch in Google Scholar
  • 62 Sidhu SS, Goyal O, Mishra BP et al. Rifaximin improves psychometric performance and health-related quality of life in patients with minimal hepatic encephalopathy (the RIME Trial). Am J Gastroenterol 2011; 106: 307-316
    CrossrefPubMedSearch in Google Scholar
  • 63 Bajaj JS, Heuman DM, Wade JB et al. Rifaximin improves driving simulator performance in a randomized trial of patients with minimal hepatic encephalopathy. Gastroenterology 2011; 140: 478-487
    CrossrefPubMedSearch in Google Scholar
  • 64 Blei AT, Cordoba J. Hepatic encephalopathy. Am J Gastroenterol 2001; 96: 1968-1976
    CrossrefPubMedSearch in Google Scholar
  • 65 Zhan T, Stremmel W. Diagnostik und Therapie der minimalen hepatischen Enzephalopathie. Dtsch Arztebl Int 2012; 109: 180-187
    PubMedSearch in Google Scholar
  • 66 Wu D, Wu SM, Lu J et al. Rifaximin versus nonabsorbable disaccharides for the treatment of hepatic encephalopathy: a meta-analysis. Gastroenterol Res Pract 2013; 2013: 236963
    PubMedSearch in Google Scholar
  • 67 Jiang Q, Jiang XH, Zheng MH et al. Rifaximin versus nonabsorbable disaccharides in the management of hepatic encephalopathy: a meta-analysis. Eur J Gastroenterol Hepatol 2008; 20: 1064-1070
    CrossrefPubMedSearch in Google Scholar
  • 68 Sharma P, Sharma BC, Agrawal A et al. Primary prophylaxis of overt hepatic encephalopathy in patients with cirrhosis: an open labeled randomized controlled trial of lactulose versus no lactulose. J Gastroenterol Hepatol 2012; 27: 1329-1335
    CrossrefPubMedSearch in Google Scholar
  • 69 Pereira K, Carrion AF, Salsamendi J et al. Endovascular management of refractory hepatic encephalopathy complication of TIPS: comprehensive review and clinical practice algorithm. Cardiovasc Intervent Radiol 2016; 39: 170-182
    CrossrefPubMedSearch in Google Scholar