Gastrointestinal Intervention 2018; 7(1): 14-17
Published online April 30, 2018 https://doi.org/10.18528/gii180009
Copyright © International Journal of Gastrointestinal Intervention.
Department of Gastroenterology, Nanjing Drum Tower Hospital, Nanjing University School of Medicine, Nanjing, China
Correspondence to: Department of Gastroenterology, Nanjing Drum Tower Hospital, The Affiliated Hospital of Nanjing University Medical School, No. 321, Zhongshan Road, Gulou Qu, Nanjing 210008, China.
This is an open-access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/3.0) which permits unrestricted noncommercial use, distribution, and reproduction in any medium, provided the original work is properly cited.
Transjugular intrahepatic portosystemic shunt (TIPS) is now considered as a major treatment option for cirrhotic patients with portal hypertension. Globally, it is getting markedly increase attention, and a similar phenomenon is occurring in China. On average, the number of TIPS procedures is increasing at a rate of 15% per year. Published research papers are also continuously growing every year. Similar but unique compared to western countries, most Chinese physicians follow Chinese specialized guidelines when treating patients with portal hypertension. In this review, we briefly introduce the history of TIPS in China, the present and the future of TIPS in China.
Keywords: China, Hypertension, portal, Incidence, Transjugular intrahepatic portosystemic shunt
Transjugular intrahepatic portosystemic shunt (TIPS) is an important therapy for complications of portal hypertension in cirrhotic patients, especially in patients with variceal bleeding or refractory ascites. First TIPS in patients was reported by Richter et al1 in 1990. In 1992, the first TIPS in patient was successfully performed in China.2 Clinical articles about TIPS application then published successively by Xu et al2 from China Medical University, Zhang et al3 from PLA General Hospital, and Li YanHao from Sun Yat-Sen University of Medical Sciences.2–4 During this period, TIPS was gradually spread across China with the tireless efforts of interventional radiology experts and formed so-called TIPS fever in China. However, as the following studies found that the medium and long-term effect of TIPS was not very promising compared with endoscopic therapy, the number of TIPS procedures decreased dramatically. The rate of shunt dysfunction at 1, 2, and 5 years after operation was up to 5%–64%, 33%–70%, and 60%–85%, respectively, and restenosis or occlusion of the shunt was the primary cause for the poor clinical effect of TIPS.5 Although the recurrent bleeding rate after TIPS treatment was significantly lower than that of endoscopic treatment (10%–25% vs 35%–50%), the incidence of hepatic encephalopathy was obviously increased compared to endoscopic treatment (30% vs 15%). In addition, there was no advantage in survival rate, quality of life and economic benefits.6 Therefore, TIPS was treated as a transitional treatment option before liver transplantation, and the “TIPS fever” diminished quickly. This disinterest in TIPS was easily notable from the number of research papers published in Chinese journals indexed by China National Knowledge Infrastructure (CNKI) each year (Fig. 1). As the advent of covered stents, exciting research results about “early-TIPS” and the strategy of selecting appropriate patients for TIPS treatment, the efficacy of TIPS has been significantly improved. Since 2008, the number of TIPS operations has begun to rise again in China.
In China, the volume of TIPS is rapidly rising in recent years. There were about 7,300 TIPS procedures been conducted in 2016, and this number can reach to 8,300 in 2017. Chinese expert consensus on TIPS for treatment of cirrhotic portal hypertension was established and updated in the year of 2004, 2014, and 2017 (Fig. 2).7–9 Now, TIPS procedures are mainly carried out in the following centers: Xijing Hospital in Xian, West China Hospital in Chengdu, Nanfang Hospital in Guangzhou, Nanjing Drum Tower Hospital in Nanjing, and several hospitals in Beijing and Shenyang. Hospitals that can independently implement TIPS have developed from several top-grade medical centers to some prefecture-level city hospitals (Fig. 3). Most of TIPS procedures were conducted as secondary prophylaxis for esophageal and gastric variceal hemorrhage after the failure of standard medical treatment. A few TIPS are also conducted as salvage treatment in an emergent situation or as early-TIPS.
The major concern after TIPS procedure is how to ensure the patency of the TIPS stent. Until the VIATORR® TIPS stent graft (Gore Medical, Flagstaff, AZ, USA) was approved in 2015 October in China, the Fluency® (Bard Peripheral Vascular, Tempe, AZ, USA) fully covered stent was used in most TIPS (Fig. 2). To achieve a similar effect of partially covered VIATORR® stent, the Fluency® stent was often used in combination with a bare metal stent. A series of studies focused on the different combination of full covered stent and bare stent were published.10–12 Due to a higher cost of VIATORR® stent and user preference, the Fluency® stent is still widely used. However, with the proven efficacy and safety of VIATORR® stent available in the literature, the proportion of VIATORR® stent in China has been increasing. In regards to the selection of TIPS stent diameter, a randomized controlled study found that 8 mm covered TIPS stents do not compromise shunt function, but halved the risk of spontaneous overt HE and reduced hepatic impairment in preventing variceal rebleeding compared with 10 mm stents.13 Therefore, 8 mm TIPS stents seem to be a preferred TIPS treatment option for the prevention of variceal rebleeding in China.
As more and more high-quality research papers have emerged, TIPS indications have expanded dramatically worldwide, and TIPS indications in China also have expanded in line with international trends. According to Chinese expert consensus on TIPS, the TIPS indications mainly include following items.
Because of the risks of hepatic encephalopathy, liver failure, and other complications, TIPS is not recommended for primary prophylaxis for esophageal and gastric varices bleeding (EGVB). Patients with cirrhosis and active EGVB in Child-Pugh class C or those in class B who have actively bleeding during the endoscopic examination are at high risk for endoscopic treatment failure or early rebleeding; therefore, an early-TIPS within 24 to 72 hours after endoscopic therapy is recommended.14 The concept of early-TIPS is widely accepted in China now. While for patients in Child-Pugh class A, standard treatment (combined endoscopic variceal ligation and NSBBs therapy) is recommended as the first line therapeutic strategy for secondary prophylaxis. TIPS could only be used as salvage method in patients who had failed standard therapy. In some hospitals, hepatic vein pressure gradient (HVPG) is used for the risk stratification before standard therapy and TIPS can be used as a first-line treatment if HVPG is higher than 20 mmHg.
In China, the Sarin classification is employed widely to evaluate esophageal and gastric varices under endoscopy. Gastric varices could be classified into GOV1 (gastro-esophageal varices along lesser curvature), GOV2 (varices of esophagus and fundus), IGV1 (isolated gastric fundus varices), and IGV2 (isolated gastric varices located in gastro-duodenum). Bleeding from gastric varices was mostly seen in GOV1, GOV2, and IGV1.15 Combined endoscopic variceal ligation and NSBBs therapy are regularly used for GOV1 patients. For patients with GOV2 and IGV1, the treatment is controversial. The gastroenterologists prefer to use endoscopic treatment, while interventional radiologists prefer TIPS or balloon-occluded retrograde transvenous obliteration (BRTO). For patients with gastric varices, the HVPG stratification is not reliable, as HVPG in these patients was always lower than those with esophageal varices.16 Therefore, the final portosystemic gradient required to achieve variceal decompression may be lower than what is required for esophageal variceal bleeding. More research on gastric variceal treatment is needed to assess the curative effects of different therapies.
TIPS should be first advised in patients failed pharmacologic and endoscopic therapy. For patients whose liver function is not suitable for TIPS, liver transplantation is the final treatment.
Patients with large volume ascites resistant to high doses of diuretic therapy should be given the option of TIPS treatment.17 However, the efficacy of TIPS in refractory ascites is not so clear in our clinical practice in China; therefore, more clinical research is needed.
Portal vein thrombosis (PVT) is regarded as a predictor of poor outcomes in patients with decompensated cirrhosis and usually accompanied by severe or recurrent variceal bleeding. Assisted by ultrasound and other instruments, TIPS can be performed successfully in PVT patients, even in patients with cavernous transformation of the portal vein. Han GuoHong reported that in patients with PVT and moderately decompensated cirrhosis, TIPS was more effective than endoscopic therapy combined with propranolol for the prevention of rebleeding with a higher probability of PVT resolution. However, no improvement in survival rate was noted.18
Hepatic veno-occlusive disease (HVOD) is commonly caused by hematopoietic stem cell transplantation in western countries. In China, HVOD is seen mostly due to the intake of herbs containing pyrrole alkaloids, which we called PA-HVOD. Symptoms vary from mild abdominal distention to progressive liver failure leading to death. In patients with the severe form of this disease, ascites is common due to acute portal hypertension. A retrospective study from Zhuge et al19 showed that TIPS improved the prognosis of patients with PA-HVOD who did not respond to anticoagulation therapy, but further randomized controlled studies are needed.
China is a country with high incidence of hepatitis; therefore, the incidence of cirrhosis due to chronic liver disease will not change significantly. However, by 2030 with successful immunization for HBV, the main etiology of the cirrhosis will shift from hepatitis to chronic alcohol consumption and non-alcoholic fatty liver disease.20 With the effectiveness of VIATORR® stents and better-designed TIPS access kits, the challenges and complications of TIPS can be further reduced. With less complexity of TIPS procedure, more physicians can perform TIPS procedures. It is somewhat predictable that the number of TIPS treatments will increase significantly shortly. Accordingly, more multicenter randomized controlled trials will be initiated and performed. Although the future of TIPS looks bright, there are many challenges that the Chinese interventional doctors need to focus and overcome such as patient selection for TIPS treatment and methods of reduction of TIPS complications.
This review was invited and edited by Edward Wolfgang Lee, MD, PhD (UCLA).
No potential conflict of interest relevant to this article was reported.
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