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254A AASLD ABSTRACTS HEPATOLOGY October 1995 589 OUTCOME OF TIPS IN NON-CAVERNOMATOUS PORTAL VEIN THROMBOSIS. TA MATALON. S YADAV. A CARDWELL. V Me DONALD and DR GANGER. Dept. of Intervantioual Radiology and Clinical Hepatology. Rush Medical College, Chicago, IL. Portal vein thrombosis (PVT) was considered a contzalndication to TIPS until it was reported to be technically possible (P. Radosevich Rad 1993;186(2),523). Aim: To describe the experience of TIPS placement in patients with complications secondary to non--cavemomatons PVT and to follow their clinical outcome. Setting: Tertiary referral center. Methods: Between September 1994 and May 1995, six adult patients presented with PVT confirmed by portal venography for TIPS placement. Recannalization of the portal vein was accomplished by a combination of occlusion balloon thrombectomy and dilatation, suction thrombectomy and thrombolytic therapy (Urokinase and Heparin) via the transjugular approach. Results Table h Etiology and presentation: ]Presentation Occluded vessels Outcome C to enie n=4 Varieeal bleed FV, SMV, SV 4 alive, OLT l PNH nffil ~ PV OLT/dead PCV n=l ] Variceal bleed, PV, SMV+A, SV Alive ] mesenteric isehemia PNH paroxysmal nocturnal hemoglobinuria, PCV: polycythemia vera. Complications of TIPS placement ineleded intraperitoneal bleeding in two patients, one requiring surgery to repair IVC. Two patients received OLT after TIPS, one of whom expired 19 days later with a cerebral hemorrhage. The other four patients had no recurrence of bleeding and are alive. TIPS stenosis was seen in two patients requiring revision at 3 and 7 months. Sunmmr3,: TIPS can be accomplished by the transjugular approach in patients with PVT. In non transplanted patients, bleeding and thrombosis had not occurred after 7 months of follow up. Conclusion: TIPS is a therapeutic option in patients with non.-cavemomatous PVT and allows PV reclamation in preparation for OLT. TIPS should be performed by experienced personnel due to the complexity of this technique. The role of anticoaguiation post TIPS in this population needs to be studied. 590 LIVER FUNCTION AFTER TRANSJUGULAR INTRAHEPATIC PORTOSYSTEMIC SHUNT (TIPS): SHORT-TERM EFFECTS AND PROGNOSIS. I Alam. P Bacchetti. C McNallv. KA Somberg. Depts. of Medicine, and Biostatistics, Univ. of California, San Francisco. The effect of TIPS on liver function has not been well defined. The aim of this retrospective study was to assess the immediate impact of TIPS on hepatic function, define the predictors of decompensation, and to determine the prognosis of patients with worsened liver function after TIPS. Methods: From 6/90:8/94, 250 TIPS were successfully placed at our hospital. Patients were excluded from analysis for pre-TIPS serum bilirubin > If) mg/dL, prothrombin time (PT) > 20 seconds, serum AST > 500 lUlL or incomplete data. Deterioration in liver function was defined by an increase from pre-TIPS values of serum bilirubin > 3 mg/dL, PT > 2 seconds, AST > 1(~) lUlL or doubling of serum alkaline phosphatase (ALKP). Patient histories, pre- and post-TIPS laboratories and clinical courses were reviewed. 16 pre-TIPS demographic, laboratory, procedural and clinical parameters were assessed as potential predictors of hepatic decompensation. Immediate pre-TIPS laboratory values were compared to the most abnormal value for each test in the 7 days after TIPS using the paired Wilcoxon test. Results: Indications for TIPS were variceal bleeding 81%, refractory ascites 13%, hepatorenal syndrome 2%, and other 4%. Mean age was 50 years, gender 65% male, and alcoholic etiology 40%. Child-Pugh Class was 12% A, 4(1% B, 48% C. In the week following TIPS, the median change in bilirubin concentration was +0.95 mg/dL, PT +0.7 sec, AST +27 IU/L and ALKP +21 IU/L (p<0.fi001). Frequency of worsening of liver tests and relative risk (Cox regression) of death with deterioration of each test (as defined) are summarized in Table h Table 1 Worsened (%) Relative Risk p Bilirubin (n=174)mg/dL 28 2.45 (1.004 PT (n=2111) sec 21 1.63 0.11 AST (n=198) IU/L 20 1.67 0.10 ALKP (n=202) lUlL 18 1.06 0.86 Pre-T1PS Child-Pugh class C and score > 12, active GI bleeding and encephalopathy were predictive of worsening of serum bilirubin. Conclusions: Worsening of liver tests is a common early complication of TIPS. Death among those surviving the first week after TIPS was signif- icantly associated with a post-TIPS increase in serum bilirubin. These findings may be of use in assessing the prognosis of patients after TIPS. 591 TRANSJUGULAR INTRAHEPATIC PORTAL-SYSTEMIC SHUNT (TIPS) FOR THE MANAGEMENT OF SEVERE VENO-OCCLUSlVE DISEASE (VOD) AFTER BONE MARROW TRANSPLANTATION (BMT). MW Fried. DG Connaohan, S Sharma. L Martin, S Devine, K Holland, A Zuckerman. S Kaufman, J Wingard, TD Bover. Depts. of Medicine, Pathology, and Radiology. Emory University School of Medicine, Atlanta, GA. VOD is a frequent, life-threatening complication of BMT. No therapy is of any proven benefit. Portal pressures are usually elevated and anecdotal reports indicate that portacaval shunt may benefit selected patients (pts) with VOD. We report the use of TIPS for the management cfVOD. 6 pts (4 M with hematologic malignancies and 1 F with breast cancer) underwent BMT and developed a progressive clinical syndrome consistent with VOD including jaundice, ascites, abnormal liver tests, coagulopathy, and renal failure. 4/5 pts required multiple large volume paracenteses. All were on hernodialysis at the time of TIPS. Transjugular liver biopsy before TIPS showed obliteration of terminal hepatic venules in 4 pts with centrizonal hemorrhagic necrosis in 3. One pt had only mild centdzonal congestion. ALT (U/L) TBili (mg/dl) Portal Pressure Gradient PT~ Pre Post-TIPS Pre POSt ~ POst-TIPS 1 31 33 24.1 36.3 14 mmHg 8 mmHg 2 66 63 27.9 43.2 19 4 3 19 27 42.4 39.1 27 9 4 494 39 16.8 10.1 23 7 5 21 24 3.4 1.7 17 7 Results: Portal pressures decreased significantly in all pts after TIPS. 3 pts who underwent TIPS 15-84 days post onset of jaundice did not show any clinical improvement and expired 11-13 days post-TIPS. Pts 4 and 5 underwent TIPS within 7 days of onset of jaundice and improved (decreased bilirubin, improved ascites, renal function no longer requiring dialysis). Pt 4 deteriorated 3 wks after TIPS and died of VOD 44 days post-TIPS, despite a normal portal pressure gradient (6 rnmHg). Pt 5 died of recurrent lymphoma 11 days after TIPS. Post-TIPS biopsies, available in 3 pts, showed decreased hepatocellular necrosis in 2 and decreased sinusoidal congestion in one. Conclusions: TIPS can be performed safely and decreases portal hypertension in pts with VOD. Clinical and histologic improvement may occur in pts who undergo TIPS early in the course of VOD, but improvement may be transient. Portal hypertension contributes to, but is not the sole factor responsible for, the clinical manifestations of VOD. 592 TIPS: THROMBOGENICITY AND EARLY SHUNT INSUFFI- CIENCY IN PATIENTS WITH PRESERVED COAGULATION CAPACITY- EFFECT OF HEPARIN AND STENTS. V Sieaerstetter. T Krause. K Haaa. A Ochs. K H Hauenstein. P Deibert. H E Blum. M RSssle. University School of Medicine, Freiburg, Germany. Despite increasing experience with TIPS the need for anticoagulation is still debated. This study evaluates the effect of heparin on thrombo- genicity and shunt insufficiencyduring 24 hours following the TIPS implantation. Thrombogenicity was determined scintigraphyically after iv injec- tion of 120-290 mBq Tc 99m labelled platelets at the time of stent placement and expressed as stent/liver ratio. Shunt insufficiency was assessed by duplex-sonography (shunt flow < 1 i/min) and confirmed by angiography. Four comparable groups of 6 patients with preserved coagulation capacity (PT < 2 sec, platelets > 80,000/~i, normal bleeding time) were examined: Palmaz-stent and Wallstent with or without hepa- rin, respectively. Heparin was given at the time of stent placement in a dose to prolong PTT to 40 to 60 seconds. Results: The stent/liver ratio of labelled platelets was higher in patients with Wallstent than with Palmaz-stent (2.41 ± 0.4 vs 1.88 ± 0.2, p < 0.02), reaching a maximum within 90 minutes of injection. It was significantly reduced by heparin (-35%). 4 of the 6 patients with Wallstents not receiving heparin developed shunt insufficiency whereas none of the patients with heparin did. Only 1 patient with Palmaz- stents not receiving heparin had shunt insufficiency. Conclusions: The Wallstent is more thrombogenic than the Palmaz-stent. In patients with a Wallstent-TIPS and preserved coagulation capacity heparin anticoagulation is recommended.

Outcome of TIPS in non-cavernomatous portal vein thrombosis Dept. of Interventional Radiology and Clinical Hepatology, Rush Medical College, Chicago, IL

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Page 1: Outcome of TIPS in non-cavernomatous portal vein thrombosis Dept. of Interventional Radiology and Clinical Hepatology, Rush Medical College, Chicago, IL

254A AASLD ABSTRACTS HEPATOLOGY October 1995

589 OUTCOME OF TIPS IN NON-CAVERNOMATOUS PORTAL VEIN THROMBOSIS. TA MATALON. S YADAV. A CARDWELL. V Me DONALD and DR GANGER. Dept. of Intervantioual Radiology and Clinical Hepatology. Rush Medical College, Chicago, IL.

Portal vein thrombosis (PVT) was considered a contzalndication to TIPS until it was reported to be technically possible (P. Radosevich Rad 1993;186(2),523). Aim: To describe the experience of TIPS placement in patients with complications secondary to non--cavemomatons PVT and to follow their clinical outcome. Setting: Tertiary referral center. Methods: Between September 1994 and May 1995, six adult patients presented with PVT confirmed by portal venography for TIPS placement. Recannalization of the portal vein was accomplished by a combination of occlusion balloon thrombectomy and dilatation, suction thrombectomy and thrombolytic therapy (Urokinase and Heparin) via the transjugular approach. Results Table h Etiology and presentation:

]Presentation Occluded vessels Outcome C to enie n=4 Varieeal bleed FV, SMV, SV 4 alive, OLT l PNH n f f i l ~ PV OLT/dead PCV n=l ] Variceal bleed, PV, SMV+A, SV Alive

] mesenteric isehemia PNH paroxysmal nocturnal hemoglobinuria, PCV: polycythemia vera. Complications of TIPS placement ineleded intraperitoneal bleeding in two patients, one requiring surgery to repair IVC. Two patients received OLT after TIPS, one of whom expired 19 days later with a cerebral hemorrhage. The other four patients had no recurrence of bleeding and are alive. TIPS stenosis was seen in two patients requiring revision at 3 and 7 months. Sunmmr3,: TIPS can be accomplished by the transjugular approach in patients with PVT. In non transplanted patients, bleeding and thrombosis had not occurred after 7 months of follow up. Conclusion: TIPS is a therapeutic option in patients with non.-cavemomatous PVT and allows PV reclamation in preparation for OLT. TIPS should be performed by experienced personnel due to the complexity of this technique. The role of anticoaguiation post TIPS in this population needs to be studied.

590 LIVER FUNCTION AFTER TRANSJUGULAR INTRAHEPATIC PORTOSYSTEMIC SHUNT (TIPS): SHORT-TERM EFFECTS AND PROGNOSIS. I Alam. P Bacchetti. C McNallv. KA Somberg. Depts. of Medicine, and Biostatistics, Univ. of California, San Francisco.

The effect of TIPS on liver function has not been well defined. The aim of this retrospective study was to assess the immediate impact of TIPS on hepatic function, define the predictors of decompensation, and to determine the prognosis of patients with worsened liver function after TIPS. Methods: From 6/90:8/94, 250 TIPS were successfully placed at our hospital. Patients were excluded from analysis for pre-TIPS serum bilirubin > If) mg/dL, prothrombin time (PT) > 20 seconds, serum AST > 500 lUlL or incomplete data. Deterioration in liver function was defined by an increase from pre-TIPS values of serum bilirubin > 3 mg/dL, PT > 2 seconds, AST > 1(~) lUlL or doubling of serum alkaline phosphatase (ALKP). Patient histories, pre- and post-TIPS laboratories and clinical courses were reviewed. 16 pre-TIPS demographic, laboratory, procedural and clinical parameters were assessed as potential predictors of hepatic decompensation. Immediate pre-TIPS laboratory values were compared to the most abnormal value for each test in the 7 days after TIPS using the paired Wilcoxon test. Results: Indications for TIPS were variceal bleeding 81%, refractory ascites 13%, hepatorenal syndrome 2%, and other 4%. Mean age was 50 years, gender 65% male, and alcoholic etiology 40%. Child-Pugh Class was 12% A, 4(1% B, 48% C. In the week following TIPS, the median change in bilirubin concentration was +0.95 mg/dL, PT +0.7 sec, AST +27 IU/L and ALKP +21 IU/L (p<0.fi001). Frequency of worsening of liver tests and relative risk (Cox regression) of death with deterioration of each test (as defined) are summarized in Table h Table 1 Worsened (%) Relative Risk p Bilirubin (n=174)mg/dL 28 2.45 (1.004 PT (n=2111) sec 21 1.63 0.11 AST (n=198) IU/L 20 1.67 0.10 ALKP (n=202) lUlL 18 1.06 0.86

Pre-T1PS Child-Pugh class C and score > 12, active GI bleeding and encephalopathy were predictive of worsening of serum bilirubin. Conclusions: Worsening of liver tests is a common early complication of TIPS. Death among those surviving the first week after TIPS was signif- icantly associated with a post-TIPS increase in serum bilirubin. These findings may be of use in assessing the prognosis of patients after TIPS.

591 TRANSJUGULAR INTRAHEPATIC PORTAL-SYSTEMIC SHUNT (TIPS) FOR THE MANAGEMENT OF SEVERE VENO-OCCLUSlVE DISEASE (VOD) AFTER BONE MARROW TRANSPLANTATION (BMT). MW Fried. DG Connaohan, S Sharma. L Martin, S Devine, K Holland, A Zuckerman. S Kaufman, J Wingard, TD Bover. Depts. of Medicine, Pathology, and Radiology. Emory University School of Medicine, Atlanta, GA.

VOD is a frequent, life-threatening complication of BMT. No therapy is of any proven benefit. Portal pressures are usually elevated and anecdotal reports indicate that portacaval shunt may benefit selected patients (pts) with VOD. We report the use of TIPS for the management cfVOD.

6 pts (4 M with hematologic malignancies and 1 F with breast cancer) underwent BMT and developed a progressive clinical syndrome consistent with VOD including jaundice, ascites, abnormal liver tests, coagulopathy, and renal failure. 4/5 pts required multiple large volume paracenteses. All were on hernodialysis at the time of TIPS. Transjugular liver biopsy before TIPS showed obliteration of terminal hepatic venules in 4 pts with centrizonal hemorrhagic necrosis in 3. One pt had only mild centdzonal congestion.

ALT (U/L) TBili (mg/dl) Portal Pressure Gradient PT~ Pre Post-TIPS Pre POSt ~ POst-TIPS 1 31 33 24.1 36.3 14 mmHg 8 mmHg 2 66 63 27.9 43.2 19 4 3 19 27 42.4 39.1 27 9 4 494 39 16.8 10.1 23 7 5 21 24 3.4 1.7 17 7 Results: Portal pressures decreased significantly in all pts after TIPS. 3 pts who underwent TIPS 15-84 days post onset of jaundice did not show any clinical improvement and expired 11-13 days post-TIPS. Pts 4 and 5 underwent TIPS within 7 days of onset of jaundice and improved (decreased bilirubin, improved ascites, renal function no longer requiring dialysis). Pt 4 deteriorated 3 wks after TIPS and died of VOD 44 days post-TIPS, despite a normal portal pressure gradient (6 rnmHg). Pt 5 died of recurrent lymphoma 11 days after TIPS. Post-TIPS biopsies, available in 3 pts, showed decreased hepatocellular necrosis in 2 and decreased sinusoidal congestion in one.

Conclusions: TIPS can be performed safely and decreases portal hypertension in pts with VOD. Clinical and histologic improvement may occur in pts who undergo TIPS early in the course of VOD, but improvement may be transient. Portal hypertension contributes to, but is not the sole factor responsible for, the clinical manifestations of VOD.

592 TIPS: THROMBOGENICITY AND EARLY SHUNT INSUFFI- CIENCY IN PATIENTS WITH PRESERVED COAGULATION CAPACITY- EFFECT OF HEPARIN AND STENTS. V Sieaerstetter. T Krause. K Haaa. A Ochs. K H Hauenstein. P Deibert. H E Blum. M RSssle. University School of Medicine, Freiburg, Germany.

Despite increasing experience with TIPS the need for anticoagulation is still debated. This study evaluates the effect of heparin on thrombo- genicity and shunt insufficiencyduring 24 hours following the TIPS implantation. Thrombogenicity was determined scintigraphyically after iv injec- tion of 120-290 mBq Tc 99m labelled platelets at the time of stent placement and expressed as stent/liver ratio. Shunt insufficiency was assessed by duplex-sonography (shunt flow < 1 i/min) and confirmed by angiography. Four comparable groups of 6 patients with preserved coagulation capacity (PT < 2 sec, platelets > 80,000/~i, normal bleeding time) were examined: Palmaz-stent and Wallstent with or without hepa- rin, respectively. Heparin was given at the time of stent placement in a dose to prolong PTT to 40 to 60 seconds. Results: The stent/liver ratio of labelled platelets was higher in patients with Wallstent than with Palmaz-stent (2.41 ± 0.4 vs 1.88 ± 0.2, p < 0.02), reaching a maximum within 90 minutes of injection. It was significantly reduced by heparin (-35%). 4 of the 6 patients with Wallstents not receiving heparin developed shunt insufficiency whereas none of the patients with heparin did. Only 1 patient with Palmaz- stents not receiving heparin had shunt insufficiency. Conclusions: The Wallstent is more thrombogenic than the Palmaz-stent. In patients with a Wallstent-TIPS and preserved coagulation capacity heparin anticoagulation is recommended.