Diagnostic and Interventional Radiology
Interventional Radiology - Original Article

Small-diameter TIPS combined with splenic artery embolization in the management of refractory ascites in cirrhotic patients

1.

Division of Interventional Radiology, Department of Radiology, MedStar Georgetown University Hospital, Washington, District of Columbia, USA

2.

Dotter Department of Interventional Radiology, Oregon Health and Science University, Oregon, USA

3.

Division of Interventional Radiology, Department of Radiology, Boston Medical Center, Boston University School of Medicine, Boston, Massachusetts, USA

4.

Institute for Technology Assessment, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA

5.

Division of Nephrology, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA

6.

Liver Center and Division of Gastrointestinal Medicine, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA

7.

Division of Interventional Radiology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA

Diagn Interv Radiol 2021; 27: 232-237
DOI: 10.5152/dir.2021.19530
Read: 189 Downloads: 79 Published: 04 March 2021

PURPOSE 
Maximally decreasing portal pressures with transjugular intrahepatic portosystemic shunt (TIPS) is associated with improved ascites control but also increased encephalopathy incidence. Since splenic venous flow contributes to portal hypertension, we assessed if combining small-diameter TIPS with splenic artery embolization could improve ascites while minimizing encephalopathy. 

METHODS
Fifty-five patients underwent TIPS creation for refractory ascites. Subjects underwent creation of 8 mm TIPS followed by proximal splenic artery embolization (group A, n=8), or of 8 mm (group B, n=6) or 10 mm TIPS (group C, n=41) without splenic embolization. Data were retrospectively reviewed.

RESULTS
In group A, median portosystemic gradient decreased from 19 mmHg to 9 mmHg after TIPS, and 8 mmHg after subsequent splenic artery embolization. In groups B and C, gradient decreased from 15 mmHg to 8 mmHg and 16 mmHg to 6 mmHg. All patients except for one in group A and two in C had greater than 50% reduction in the number of paracenteses in 3 months. Any postprocedural encephalopathy incidence was 62%, 50%, 83% in groups A, B, and C, respectively. Overall, 20% of subjects with 10 mm TIPS required TIPS reduction/closure compared to 7% of subjects with 8 mm TIPS.

CONCLUSION
We found that 8 mm diameter TIPS provided similar ascites control compared to 10 mm TIPS regardless of splenic embolization. While more patients with 10 mm TIPS required reduction/closure for severe encephalopathy, the study was underpowered for definitive assessment. Splenic embolization might have the potential to further decrease portosystemic gradient and ascites as an alternative to dilation of TIPS to 10 mm minimizing the risk of encephalopathy, but larger studies are warranted.

You may cite this article as: Frenk NE, Bochnakova T, Ganguli S, et al. Small-diameter TIPS combined with splenic artery embolization in the management of refractory ascites in cirrhotic patients. Diagn Interv Radiol 2021; 27: 232–237

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