Transjugular Intrahepatic Portosystemic Shunt (TIPS) for Prevention of Variceal Rebleeding in Cirrhotic Patients With Portal Vein Thrombosis
Portal vein thrombosis (PVT) refers to an obstruction in the trunk of the portal vein. It can extend downstream to the portal branches, or upstream to the splenic and/or the mesenteric veins. The prevalence of PVT is 10-25% and incidence is about 16% in cirrhotic patients. Recent studies demonstrate that the presence of PVT is not only an independent predictor of failure to control active variceal bleeding and prevent variceal rebleeding, but also significantly associated with increased mortality in patients with liver cirrhosis.
However, in recent American Association of the Study of Liver Disease (AASLD) practice guidelines and Baveno V consensus on management of PVT in cirrhotic patients, no treatment strategies in cirrhotic patients with PVT was clearly recommended due to the absence of randomized controlled trials.
Portal Vein Thrombosis
Procedure: Transjugular intrahepatic portosystemic shunt (TIPS)
|Study Design:||Allocation: Randomized
Intervention Model: Parallel Assignment
Masking: Open Label
Primary Purpose: Treatment
|Official Title:||Transjugular Intrahepatic Portosystemic Shunt Versus Endoscopic Treatment Combined Anticoagulation and Propranolol for Prevention of Variceal Rebleeding in Cirrhotic Patients With Portal Vein Thrombosis: A Randomized Controlled Trial|
- Number of participants with variceal rebleeding [ Time Frame: 4 years ]Variceal rebleeding is the primary endpoint of this study. Cumulative variceal rebleeding rate is compared between the two groups.
- Number of death [ Time Frame: 4 years ]Death is a secondary endpoint of this study. Cumulative survival rate is compared between the two groups.
- Number of participants achieving portal vein recanalization [ Time Frame: 4 years ]Portal vein recanalization is a secondary endpoint of this study. Recanalization rate of thrombosed portal vein is compared between the two groups.
- Changes of degree of PVT in patients without portal vein recanalization [ Time Frame: 4 years ]We also observed changes of degree of portal vein thrombosis in patients without portal vein recanalization.
- Number of complications [ Time Frame: 4 years ]
TIPS-related complications: procedural complications, shunt dysfunction and hepatic encephalopathy.
Complications related to endoscopic and drug treatment.
|Study Start Date:||May 2011|
|Study Completion Date:||January 2015|
|Primary Completion Date:||January 2015 (Final data collection date for primary outcome measure)|
Active Comparator: ET+NSBB+AT
Endoscopic treatment(ET)- Endoscopic variceal ligation (EVL) and endoscopic injection.
Non-selective beta blocker(NSBB)-Propranolol.
Anticoagulation(AT)- Heparin followed by warfarin.
ET-Esophageal varices was treated by endoscopic variceal ligation (EVL). EVL was repeated at intervals of 3-4 weeks until the varices were obliterated or reduced to grade-I size. Gastric varices was treated by endoscopic injection using cyanoacrylate.
NSBB-Propranolol started at a dose of 20mg twice a day. The dose is adjusted to the maximal tolerated doses to heart rate (HR) of 55 bpm or to decrease the HR 25% from baseline.
AT-A continuously intravenous infusion of unfractionated heparin followed by oral warfarin is employed. Initially, heparin is administered intravenously at a starting dose of 1,000 U/h for 5 days. Subsequently, oral warfarin is prescribed at the dosage of 5 mg/d for 6 months and adjusted to maintain the INR at a target of 2.5 (range 2.0-3.0).
Active Comparator: TIPS
Transjugular intrahepatic portosystemic shunt(TIPS)- TIPS.
Procedure: Transjugular intrahepatic portosystemic shunt (TIPS)
Transjugular intrahepatic portosystemic shunt(TIPS)- TIPS was performed in a conventional fashion or in combination of percutaneous transhepatic or transsplenic approach. Postoperatively, intravenous heparin (8,000-12,000 u/d) for five days, warfarin for six months to one year and lifelong aspirin were routinely prescribed at dosages to achieve an international normalized ratio (INR) of up to two times the upper limit of normal for the prevention of shunt dysfunction. Intravenous arginine and branched-chain amino acids and antibiotics were administered for five days as prophylactics for encephalopathy and operation-related infection, respectively. TIPS revision was planned if any evidence of shunt dysfunction was seen; thereafter, long-term anticoagulation was prescribed.
Anticoagulation appears to be an effective first-line therapy for PVT in non-cirrhotic patients. However, anticoagulation is more complex in the setting of cirrhosis. The risk to benefit ratio of anticoagulation have never been fully confirmed in cirrhosis if there are a history of variceal bleeding or high-risk varices. Furthermore, the application of anticoagulation combined with non-selective beta-blockers and endoscopic variceal ligation is not completely advocated in cirrhotic patients with PVT due to the limited reports and the increased risk of bleeding.
Transjugular intrahepatic portosystemic shunt (TIPS)
TIPS is just regarded as the second-line therapy for the secondary prophylaxis of variceal bleeding in cirrhotic patients. However, this indication might be changed in the setting of PVT, given that an earlier decision of TIPS for PVT might achieve a higher recanalization rate. Certainly, an early decision of TIPS seemed to bring the risks of hepatic encephalopathy, liver failure, and procedural complications, although a high recanalization rate of thrombosed portal vein and prevention of variceal bleeding was achieved. Indeed, the risk to benefit ratio of TIPS in cirrhotic patients with PVT for the prevention of recurrent variceal bleeding has never been evaluated.
The aim of this study is to compare the efficacy and safety of TIPS and conventional therapy (endoscopic treatment, propranolol and anticoagulation) in decompensated cirrhosis patients with PVT and a history of variceal bleeding.
Please refer to this study by its ClinicalTrials.gov identifier: NCT01326949
|Xijing Hospital of Digestive Diseases, Fourth Military Medical University|
|Xi'an, Shaanxi, China, 710032|
|Principal Investigator:||Guohong Han||Xijing Hospital of Digestive Diseases, Fourth Military Medical University|