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Endovascular treatment of symptomatic Budd-Chiari syndrome - in favour of early transjugular intrahepatic portosystemic shunt.
Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Radiology.
Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Medical Sciences, Gastroenterology/Hepatology.
Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Radiology.
Karolinska Univ Hosp, Dept Gastroenterol, Stockholm, Sweden.
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2016 (English)In: European Journal of Gastroenterology and Hepathology, ISSN 0954-691X, E-ISSN 1473-5687, Vol. 28, no 6, 656-660 p.Article in journal (Refereed) Published
Abstract [en]

INTRODUCTION: Treatment of Budd-Chiari syndrome (BCS) has shifted from mainly medical treatment, with surgical shunt and orthotopic liver transplantation (OLT) as rescue, to medical treatment combined with an early endovascular intervention in the past two decades.

PURPOSE: To assess the safety and efficiency of endovascular treatment of symptomatic patients with BCS and to compare mortality with symptomatic BCS patients in the same region treated with only sporadic endovascular techniques.

METHODS: This was a retrospective review of clinical data, treatment and survival in 14 patients diagnosed with BCS and treated with endovascular methods from 2003 to 2015. A national epidemiology study of BCS from 1986 to 2003 was used for comparison.

RESULTS: Thirteen of the 14 patients eventually had transjugular intrahepatic portosystemic shunt (TIPS), four after previous liver vein angioplasty. TIPS were performed with polytetrafluoroethylene-covered stents and technical success was 100%. Calculated preinterventional prognostic indices indicated a high risk of TIPS dysfunction, OLT and death. However, only one patient died and one had an OLT, and the 1- and 2-year primary TIPS-patency was 85 and 67%, respectively. Episodes of de-novo hepatic encephalopathy occurred in three patients. Overall 1- and 5-year transplantation-free survival was 100 and 93% compared with 47 and 28%, respectively, in 1986 to 2003.

CONCLUSION: TIPS seems to be a safe and effective treatment for symptomatic BCS and there is an obvious improvement in transplantation-free survival compared with conservatory medical treatment. It should, therefore, be considered early, as first-line intervention, in patients with insufficient response to medical treatment.

Place, publisher, year, edition, pages
2016. Vol. 28, no 6, 656-660 p.
National Category
Medical and Health Sciences
Identifiers
URN: urn:nbn:se:uu:diva-285913DOI: 10.1097/MEG.0000000000000621ISI: 000375147100008PubMedID: 26958788OAI: oai:DiVA.org:uu-285913DiVA: diva2:921328
Available from: 2016-04-20 Created: 2016-04-20 Last updated: 2017-11-30Bibliographically approved
In thesis
1. Transjugular intrahepatic portosystemic shunt in the treatment of symptomatic portal hypertension
Open this publication in new window or tab >>Transjugular intrahepatic portosystemic shunt in the treatment of symptomatic portal hypertension
2017 (English)Doctoral thesis, comprehensive summary (Other academic)
Abstract [en]

Portal hypertension (PHT) is a condition with serious complications, such as variceal bleeding, refractory ascites and bowel ischemia. The cause of PHT may be pre-, intra- or post-hepatic. Initial treatment is pressure-reducing drugs and the treatment of acute symptoms.

Ten patients presented with severe abdominal pain and acute portomesenteric venous thrombosis. Their response to systemic anticoagulation was insufficient. Treatment with primary continuous thrombolysis by a transhepatic or transjugular approach in four patients resulted in major complications, incomplete recanalization and a 75% survival rate. Treatment with repeated transjugular thrombectomy (TT) combined with the creation of a transjugular intrahepatic portosystemic shunt (TIPS) achieved near complete recanalization, prompt symptom relief and 100% survival in five patients treated with this method as the primary intervention. In one patient, treated with TT and TIPS secondary to surgical thrombectomy and bowel resection, the outcome was fatal.

Nineteen patients with portal vein thrombosis presented with acute or threatening variceal bleeding or refractory ascites. TIPS was feasible in 16 of the 18 patients in whom it was attempted and symptom relief was achieved in the majority of them.

In 14 patients with Budd-Chiari syndrome, 13 patients were treated with TIPS, four of them after previous liver vein angioplasty. The 5-year transplantation-free survival rate was 100% in patients treated with primary TIPS.

In 131 patients with variceal bleeding treated with TIPS, the survival at 12 months in patients with and without cirrhosis was 70% and 100% respectively and in accordance with previous studies. A high Child-Pugh score prior to TIPS and severe HE within 12 months after TIPS was related to an increased mortality. The occurrence of HE after TIPS did not correlate with the PSG after TIPS. Re-bleeding within 12 months after TIPS occurred in 10 patients and was associated with TIPS dysfunction.

In conclusion, endovascular intervention, mainly TIPS, seems to be safe and effective for treating patients with complications of PHT, regardless of the underlying cause of disease and site of venous blood flow obstruction. HE may occur more frequently after TIPS than medical and endoscopic treatment, but is often mild and easily treated. In selected patients with PHT, TIPS may improve survival.

Place, publisher, year, edition, pages
Uppsala: Acta Universitatis Upsaliensis, 2017. 63 p.
Series
Digital Comprehensive Summaries of Uppsala Dissertations from the Faculty of Medicine, ISSN 1651-6206 ; 1338
Keyword
Portal hypertension, TIPS, transjugular, portal venous thrombosis, mesenteric venous thrombosis, liver cirrhosis, interventional radiology
National Category
Radiology, Nuclear Medicine and Medical Imaging
Research subject
Radiology
Identifiers
urn:nbn:se:uu:diva-321538 (URN)978-91-554-9940-2 (ISBN)
Public defence
2017-09-01, Enghoffsalen, ingång 50, Akademiska sjukhuset, Uppsala, 09:15 (English)
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Supervisors
Available from: 2017-06-09 Created: 2017-05-10 Last updated: 2017-08-09

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Rosenqvist, KerstinSheikhi, RezaEriksson, Lars-GunnarRorsman, FredrikSangfelt, PerNyman, Rickard

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