Doppler ultrasound surveillance of TIPS-patency in the era of covered stents – retrospective analysis of a large single-center cohort

Abstract

Purpose The purpose of this study was to determine accuracy and necessity of long-term Doppler ultrasound (DU) surveillance of transjugular intrahepatic portosystemic shunt (TIPS) patency after implantation of an ePTFE-covered stent-graft (Viatorr).

Methods This single-center retrospective study includes 228 consecutive cirrhotic patients with TIPS implantation due to portal hypertensive complications. Standardized DU surveillance was scheduled 3 – 5 days, 3 months, and 6 months after TIPS implantation and every 6 months thereafter. Portal venography was performed in case of DU findings suspicious of TIPS dysfunction, clinical signs of recurrent portal hypertension, or refractory hepatic encephalopathy.

Results During a mean follow-up of 16.6 ± 23.4 months, 866 DU examinations were performed. Twenty-two cases of TIPS dysfunction were observed in 16 patients with no first dysfunction more than 4 years after implantation. Routine DU in asymptomatic patients had little therapeutic impact (0.75 %). DU and venography were concordant in 39/46 (84.8 %) paired examinations, and 1-, 2-, and 5-year primary TIPS patency was 87.4 %, 83.7 %, and 79.97 %, respectively. Patients with TIPS dysfunction and subsequent successful revision during the first 2 years of follow-up had a significantly higher risk (p = 0.001) of new dysfunction compared to those without TIPS dysfunction. Cumulative 1-, 2-, and 5-year survival was 68.7 %, 61.3 %, and 42.7 %, respectively.

Conclusions Despite acceptable accuracy, scheduled DU surveillance proved to have minor therapeutic impact. Thus, detailed DU surveillance is not useful in asymptomatic patients after 2 years of unremarkable follow-up. In contrast, long-term DU surveilleance should be performed in patients after successful revision of TIPS dysfunction and patients with prothrombotic states (e. g., portal vein thrombosis, Budd-Chiari syndrome).

Zusammenfassung

Ziel Evaluation der diagnostischen Genauigkeit und Notwendigkeit einer langfristigen dopplersonografischen Überwachung der TIPS-Funktion nach Implantation eines ePTFE-beschichteten Stents (Viatorr).

Material und Methode In diese retrospektive monozentrische Studie wurden 228 Patienten eingeschlossen, die aufgrund portal hypertensiver Komplikationen einer Leberzirrhose eine TIPS-Anlage erhielten. Standardisierte dopplersonografische Kontrollen wurden 3 – 5 Tage, 3 Monate und 6 Monate nach TIPS-Implantation, sowie anschließend halbjährlich geplant. Eine Portografie erfolgte bei dopplersonografischem Verdacht einer TIPS-Dysfunktion sowie bei klinischen Zeichen einer erneuten portalen Hypertension oder einer refraktären hepatischen Encephalopathie.

Ergebnisse Während einer mittleren Nachbeobachtungszeit von 16.6 ± 23.4 Monaten wurden 866 Doppler-Kontrollen durchgeführt. Bei 16 Patienten wurden 22 Fälle einer TIPS-Dysfunktion beobachtet. Keine erstmalige Dysfunktion trat später als 4 Jahre nach TIPS-Implantation auf. Bei asymptomatischen Patienten hatten die Dopplerkontrollen nur selten eine therapeutische Konsequenz (0.75 %). Dopplersonografie und Portografie ergaben konkordante Ergebnisse bei 39/46 Untersuchungen (84.8 %). Die primäre 1-, 2- und 5- Jahres TIPS-Offenheit betrug 87.4 %, 83.7 % und 79.97 %. Patienten mit erfolgreicher Revision einer TIPS-Dysfunktion innerhalb der ersten zwei Jahre hatten ein signifikant höheres Risiko (p = 0.001) einer erneuten TIPS-Dysfunktion im Vergleich zu Patienten ohne TIPS-Dysfunktion in diesem Zeitraum. Das kummulative 1-, 2-und 5-Jahres Überleben betrug 68.7 %, 61.3 % und 42.7 %.

Schlussfolgerungen Trotz guter diagnostischer Genauigkeit hatte die Doppler-Surveillance nur selten eine therapeutische Konsequenz. Eine Fortführung regelmäßiger Dopplerkontrollen ist bei asymptomatischen Patienten nach unauffälliger Nachbeobachtung über zwei Jahre unnötig. Langfristige Dopplerkontrollen sollten hingegen nach erfolgreicher Revision einer TIPS-Dysfunktion sowie bei Patienten mit prothombotischen Erkrankungen (z. B. Pfortaderthrombose, Budd Chiari Syndrom) durchgeführt werden.

Schlüsselwörter

Doppler - Ultraschall - Überwachung - TIPS-Funktion - transjugulärer intrahepatischer portosystemischer Shunt

Key words

doppler - ultrasound - surveillance - TIPS-patency - transjugular intrahepatic portosystemic shunt

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