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Purpose: This study evaluates a deep learning-based denoising algorithm to improve the trade-off between radiation dose, image noise, and motion artifacts in TIPSS procedures, aiming for shorter acquisition times and reduced radiation with maintained diagnostic quality. Methods: In this retrospective study, TIPSS patients were divided based on CBCT acquisition times of 6 s and 3 s. Traditional weighted filtered back projection (Original) and an AI denoising algorithm (AID) were used for image reconstructions. Objective assessments of image quality included contrast, noise levels, and contrast-to-noise ratios (CNRs) through place-consistent region-of-interest (ROI) measurements across various critical areas pertinent to the TIPSS procedure. Subjective assessments were conducted by two blinded radiologists who evaluated the overall image quality, sharpness, contrast, and motion artifacts for each dataset combination. Statistical significance was determined using a mixed-effects model (p ≤ 0.05). Results: From an initial cohort of 60 TIPSS patients, 44 were selected and paired. The mean dose-area product (DAP) for the 6 s acquisitions was 5138.50 ± 1325.57 µGy·m2, significantly higher than the 2514.06 ± 691.59 µGym2 obtained for the 3 s series. CNR was highest in the 6 s-AID series (p < 0.05). Both denoised and original series showed consistent contrast for 6 s and 3 s acquisitions, with no significant noise differences between the 6 s Original and 3 s AID images (p > 0.9). Subjective assessments indicated superior quality in 6 s-AID images, with no significant overall quality difference between the 6 s-Original and 3 s-AID series (p > 0.9). Conclusions: The AI denoising algorithm enhances CBCT image quality in TIPSS procedures, allowing for shorter scans that reduce radiation exposure and minimize motion artifacts.
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Hepatic recompensation is firstly described in the Baveno VII criteria, which requires the fulfillment of strict criteria. First, a primary cause of cirrhosis must be addressed, suppressed, or cured. Second, complications of liver cirrhosis, including ascites, encephalopathy, and variceal hemorrhage, must disappear without any intervention. Finally, liver function indicators must be improved. Moreover, without addressing/suppressing/curing cirrhosis and improvement in liver synthetic function, complications, including ascites and variceal hemorrhage can be improved by a transjugular intrahepatic portosystemic shunt (TIPS), which is not evidence of hepatic recompensation. Therefore, on the basis of the definition of hepatic recompensation, TIPS does not achieve hepatic recompensation.
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Liver cirrhosis has long been considered a point of no return, with limited hope for recovery. However, recent advancements, particularly the Baveno VII criteria and the utilization of transjugular intrahepatic portosystemic shunt (TIPS), have illuminated the concept of hepatic recompensation. In this editorial we comment on the article by Gao et al published in the recent issue. This editorial provides a comprehensive overview of the evolution of understanding cirrhosis, the criteria for recompensation, and the efficacy of TIPS in achieving recompensation. We discuss key findings from recent studies, including the promising outcomes observed in patients who achieved recompensation post-TIPS insertion. While further research is needed to validate these findings and elucidate the mech-anisms underlying recompensation, the insights presented here offer renewed hope for patients with decompensated cirrhosis and highlight the potential of TIPS as a therapeutic option in their management.
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Cirrosis Hepática , Derivación Portosistémica Intrahepática Transyugular , Derivación Portosistémica Intrahepática Transyugular/métodos , Derivación Portosistémica Intrahepática Transyugular/efectos adversos , Humanos , Cirrosis Hepática/cirugía , Cirrosis Hepática/complicaciones , Resultado del Tratamiento , Hipertensión Portal/cirugía , Hipertensión Portal/etiología , Hipertensión Portal/diagnóstico , Encefalopatía Hepática/etiología , Encefalopatía Hepática/cirugíaRESUMEN
INTRODUCTION: The recently developed Freiburg Index of Post-TIPS Survival (FIPS) allows improved risk classification of patients with decompensated cirrhosis allocated to transjugular intrahepatic portosystemic shunt (TIPS) implantation. This study investigated the prognostic value of the FIPS in patients hospitalized with acute decompensation of cirrhosis (AD), outside the setting of TIPS implantation. METHODS: A total of 1133 patients with AD were included in a retrospective, multi-centre study. Ninety-day, 180-day and 1-year mortality were recorded and the FIPS' performance in predicting mortality at these time points was analysed using ROC analyses. RESULTS: Ninety-day, 180-day and 1-year mortality were 17.7%, 24.4% and 30.8%. Uni- and multivariable Cox regression models showed that the FIPS independently predicted 1-year mortality in the study cohort (HR 1.806, 95% CI 1.632-1.998, p < .0001). In ROC analyses, the FIPS offered consistently high performance in the prediction of mortality within 1 year after AD (area under the receiver operator characteristic [AUROC]: 1-year mortality .712 [.679-.746], 180-day mortality .740 [.705-.775] and 90-day mortality .761 [.721-.801]). In fact, in the subgroup of patients presenting with variceal bleeding, the FIPS even showed significantly improved discriminatory performance in the prediction of long-term mortality (AUROC 1-year mortality: .782 [.724-.839]) in comparison with established prognostic scores, such as the CLIF-C AD score (.724 [.660-.788], p = .0071) or MELD 3.0 (.726 [.662-.790], p = .0042). CONCLUSIONS: The FIPS accurately predicts mortality in patients with AD and seems to offer superior prognostication of long-term mortality in patients with variceal bleeding.
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PURPOSE: To report antegrade transvenous obliteration, with or without concurrent portosystemic shunt creation, for the treatment of hemorrhagic rectal varices. MATERIALS AND METHODS: Eight patients, including five (62.5%) females and three (37.5%) males, with mean age of 55.8 ± 13.8 years (range: 30-70 years), underwent transjugular-approach antegrade transvenous obliteration of rectal varices, with or without portosystemic shunt creation. Demographic data, procedural details, technical success of variceal obliteration, clinical success, adverse events, and follow-up outcomes were retrospectively recorded. Clinical success was defined as resolution of rectal hemorrhage. RESULTS: Portal venous access was achieved via a transjugular intrahepatic approach in all patients. The inferior mesenteric vein was selected, and foamy sclerosant (1:2:3 mixture by volume of ethiodized oil: sodium tetradecyl sulfate: air) was injected into the rectal varices with antegrade balloon occlusion in seven (87.5%) and without balloon occlusion in one (12.5%). Five of eight (62.5%) patients underwent concomitant transjugular intrahepatic portosystemic shunt (TIPS) creation (mean diameter 8.4 ± 0.9-mm) immediately following transvenous obliteration. Technical success of variceal obliteration was achieved in all patients. There were no immediate post-procedural adverse events. There were no reported occurrences of rectal ischemia, perforation, or stricture following obliteration. Two (40%) of the patients who underwent concomitant TIPS creation developed hepatic encephalopathy within 30 days of the procedure, which was medically managed. Clinical resolution of hemorrhage was achieved in all patients with no recurrent rectal variceal hemorrhage during mean follow-up of 666 ± 396 days (range: 14 - 1,224 days). CONCLUSION: Transvenous obliteration, with or without concurrent TIPS creation, is feasible with promising results for the management of rectal variceal hemorrhage.
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OBJECTIVE: Non-cirrhotic porto-mesenteric vein thrombosis (NC-PMVT) is a rare but severe clinical condition. The study aims to assess the effectiveness and safety of transjugular intrahepatic portosystemic shunt (TIPS) coupled with dual-access thrombolysis in patients with acute severe NC-PMVT. METHODS: From January 2018 to February 2023, a total of 25 patients with acute severe NC-PMVT who were treated with TIPS in conjunction with mechanical thrombectomy and dual-access thrombolysis. The period of thrombolysis was determined by the improvement of clinical symptoms and vascular recanalization. The technical success, recanalization rate, clinical success, and procedure-related complications were analyzed. RESULTS: The technical success rate was 100 %. The median duration for thrombolytic catheter removal was 5 (IQR 3.5 - 7) days. Full and partial recanalization were accomplished in 10 (40 %) and 15 (60 %) patients respectively before discharge. No significant procedure-related complications were reported. The clinical success rate was 88 %, with a mortality rate of 12 %. Over a median follow-up of 8 months, 3/22 (13.64 %) patients had a recurrence of thrombosis; 1/22 (4.54 %) patients underwent partial intestinal resection one and a half months post-discharge; the remaining patients did not experience any portal hypertensive complications. CONCLUSION: The combination of TIPS and dual-access thrombolysis appears to be safe and effective for patients with acute severe NC-PMVT.
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OBJECTIVE: The consensus on whether Transjugular intrahepatic portosystemic shunt (TIPS) should be combined with variceal embolization in the treatment of portal hypertension-induced bleeding has not yet been reached. This study aimed to compare the difference in rebleeding incidence between TIPS and TIPS combined with variceal embolization and to analyze the optimal population for variceal embolization. METHODS: Clinical data of 721 patients undergoing TIPS were retrospectively collected. Patients were divided into two groups: TIPS alone (n = 155) and TIPS with embolization (TIPS+E, n = 251). Kaplan-Meier (KM) curves were used to analyze prognostic differences between the two groups, and subgroup analysis was conducted based on post-TIPS portal pressure gradient (PPG) exceeding 12 mmHg. RESULTS: After TIPS placement, the mean PPG significantly decreased for all patients. A total of 51 patients (12.6 %) experienced rebleeding, with 24 cases (15.9 %) in the TIPS group and 27 cases (10.6 %) in the TIPS+E group. There was no significant difference in cumulative rebleeding incidence between the TIPS+E and TIPS groups. In the subgroup with post-TIPS PPG greater than 12 mmHg, the cumulative rebleeding incidence was significantly lower in the TIPS+E group compared to the TIPS group (HR = 0.47, 95 %CI = 0.24-0.93, Log rank P = 0.026). No significant difference was found in patients with a post-TIPS PPG less than 12 mmHg. CONCLUSION: For patients with post-TIPS PPG exceeding 12 mmHg, simultaneous variceal embolization with TIPS placement significantly reduces the risk of rebleeding.
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Cirrhosis is often characterized by decreased liver function, ranging from a compensated, typically asymptomatic phase to a decompensated phase characterized by the appearance of ascites or variceal bleeding, and ultimately hepatorenal syndrome (HRS) or hepatopulmonary syndrome (HPS). The latter two complications are associated with a poor prognosis and limited treatment efficacy. In cases of ascites or variceal bleeding resistant to medical therapy, transjugular intrahepatic portosystemic shunt (TIPS) is effective and safe. Shunting blood by TIPS diverts portal blood to the systemic circulation, potentially increasing systemic blood volume and benefiting renal function. However, TIPS could also divert nitric oxide to the systemic circulation, potentially worsening systemic hypotension and perfusion, which could be detrimental to renal function. Available evidence indicates that TIPS often improves renal function in patients with portal hypertension, with or without HRS. No studies have shown persistently decreased renal function after TIPS. However, these data are insufficient to support a recommendation for the use of TIPS specifically for HRS. In patients without pre-existing HPS, TIPS does not appear to significantly affect pulmonary gas exchange. Results of TIPS in HPS have been inconsistent; some studies have shown improvement, but effects were transient. No studies have shown a persistent decline in pulmonary function after TIPS. The evidence supports the need for large randomized controlled trials to investigate the beneficial effects of TIPS for HRS. Similar pulmonary function data are less clear regarding TIPS for HPS. The aim of the current report was to review the literature regarding the effects of TIPS on renal and pulmonary function in hepatic decompensation, with or without the development of HRS or HPS.
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BACKGROUND AND AIMS: It has been described that recompensation can improve prognosis in patients with cirrhosis. However, recompensation after transjugular intrahepatic portosystemic shunt (TIPS) has not been studied. We evaluated the impact of recompensation after TIPS on the risk of hepatocellular carcinoma (HCC) and death, and we compared it with compensated cirrhosis patients. METHODS: An observational study of consecutive patients with cirrhosis undergoing TIPS between 2008 and 2022 was performed. Baveno VII definition of recompensation was used including patients with or without diuretics/Hepatic encephalopathy prophylaxis. A prospective cohort of consecutive compensated cirrhosis patients was used for comparison. RESULTS: Overall, 208 patients with cirrhosis were included, 92 compensated and 116 decompensated who underwent TIPS. After 1 year, 24% achieved recompensation. Liver function (MELD 12 ± 5 vs. 15 ± 6; p = .049), LDL-cholesterol (97 mg/dL vs. 76 mg/dL, p = .018), white cell count (7.96 × 109/dL vs. 6.24 × 109/dL, p = .039) and platelets (129 × 109/dL vs. 101 × 109/dL, p = .039) were associated with recompensation. Recompensation was associated with a reduction in the risk of HCC (p = .020). Multivariable analysis showed that this risk was significantly higher in non-recompensated patients (p = .003) but no differences were observed in recompensated compared with compensated patients (p = .816). Similarly, decompensated patients presented lower survival rates (p = .011), while no differences were observed between recompensated and compensated patients (p = .677). CONCLUSIONS: Recompensation after TIPS has a clear impact on the incidence of HCC and death, with a similar prognosis than patients with compensated cirrhosis. Liver function is associated with recompensation, suggesting the importance of considering early TIPS in patients with indication.
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BACKGROUND: Gut microbiota (GM) affects the progression and response to treatment in liver diseases. The GM composition is diverse and associated with different etiologies of liver diseases. Notably, alterations in GM alterations are observed in patients with portal hypertension (PH) secondary to cirrhosis, with hepatitis B virus (HBV) infection being a major cause of cirrhosis in China. Thus, understanding the role of GM alterations in patients with HBV infection-related PH is essential. AIM: To evaluate GM alterations in patients with HBV-related PH after transjugular intrahepatic portosystemic shunt (TIPS) placement. METHODS: This was a prospective, observational clinical study. There were 30 patients (with a 100% technical success rate) recruited in the present study. Patients with esophagogastric variceal bleeding due to HBV infection-associated PH who underwent TIPS were enrolled. Stool samples were obtained before and one month after TIPS treatment, and GM was analyzed using 16S ribosomal RNA amplicon sequencing. RESULTS: One month after TIPS placement, 8 patients developed hepatic encephalopathy (HE) and were assigned to the HE group; the other 22 patients were assigned to the non-HE group. There was no substantial disparity in the abundance of GM at the phylum level between the two groups, regardless of TIPS treatment (all, P > 0.05). However, following TIPS placement, the following results were observed: (1) The abundance of Haemophilus and Eggerthella increased, whereas that of Anaerostipes, Dialister, Butyricicoccus, and Oscillospira declined in the HE group; (2) The richness of Eggerthella, Streptococcus, and Bilophila increased, whereas that of Roseburia and Ruminococcus decreased in the non-HE group; and (3) Members from the pathogenic genus Morganella appeared in the HE group but not in the non-HE group. CONCLUSION: Intestinal microbiota-related synergism may predict the risk of HE following TIPS placement in patients with HBV-related PH. Prophylactic microbiome therapies may be useful for preventing and treating HE after TIPS placement.
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Microbioma Gastrointestinal , Encefalopatía Hepática , Virus de la Hepatitis B , Hipertensión Portal , Derivación Portosistémica Intrahepática Transyugular , Humanos , Derivación Portosistémica Intrahepática Transyugular/efectos adversos , Masculino , Femenino , Persona de Mediana Edad , Hipertensión Portal/etiología , Hipertensión Portal/diagnóstico , Hipertensión Portal/microbiología , Estudios Prospectivos , Encefalopatía Hepática/etiología , Adulto , Virus de la Hepatitis B/aislamiento & purificación , Heces/microbiología , Cirrosis Hepática/virología , Cirrosis Hepática/microbiología , Cirrosis Hepática/cirugía , China/epidemiología , Resultado del Tratamiento , Hepatitis B/complicaciones , Hepatitis B/diagnóstico , Hepatitis B/virología , Várices Esofágicas y Gástricas/etiología , Várices Esofágicas y Gástricas/diagnóstico , Várices Esofágicas y Gástricas/microbiología , Várices Esofágicas y Gástricas/virología , Hemorragia Gastrointestinal/etiología , ARN Ribosómico 16S/genética , Disbiosis/etiología , Anciano , Bacterias/aislamiento & purificación , Bacterias/genéticaRESUMEN
BACKGROUND: This study aims to explore racial disparities in immediate outcomes of Transjugular Intrahepatic Portosystemic Shunt (TIPS) among Native Americans, a group that have higher prevalence of liver cirrhosis but were the "invisible group" in previous TIPS studies due to their small population size. METHODS: The study identified Native Americans and Caucasians who underwent TIPS in National/Nationwide Inpatient Sample (NIS) database from Q4 2015-2020. Preoperative factors, including demographics, indications for TIPS, comorbidities, etiologies for liver disease, primary payer status, and hospital characteristics, were matched by 1:5 propensity score matching. In-hospital post-TIPS outcomes were then compared between the two cohorts. RESULTS: There were 6,658 patients who underwent TIPS, where 101 (1.52%) were Native Americans and 4,574 (68.70%) were Caucasians. Native Americans presented as younger, with a lower socioeconomic status, and displayed higher rates of alcohol abuse and related liver diseases. After propensity-score matching, Native Americans had comparable in-hospital post-TIPS outcomes including mortality (8.33% vs 9.09%, p = 1.00), hepatic encephalopathy (18.75% vs 25.84%, p = 0.19), acute kidney injury (28.13% vs 30.62%, p = 0.71), and other adverse events. Native Americans also had similar wait from admission to operation (2.15 ± 0.30 vs 2.87 ± 0.21 days, p = 0.13), hospital length of stay (7.43 ± 0.63 vs 8.62 ± 0.47 days, p = 0.13), and total costs (158,299 ± 14,218.2 vs 169,425 ± 8,600.7 dollars, p = 0.50). CONCLUSION: Native Americans had similar immediate outcomes after TIPS compared to their propensity-matched Caucasians. While these results underscore effective healthcare delivery of TIPS to Native Americans, it is imperative to pursue further research for long-term post-procedure outcomes.
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Background and Aims: The objective of this study was to investigate the effect of neutrophil-to-lymphocyte ratio (NLR) on the survival of cirrhotic patients with esophagogastric variceal bleeding (EGVB) treated with transjugular intrahepatic portosystemic shunt (TIPS). Methods: A total of 293 patients treated with TIPS were included. The receiver operator characteristic curve (ROC) was used to calculate the optimal cut-off values of parameters such as NLR. The Kaplan-Meier curve and Cox proportional risk model were used to evaluate the effects of NLR and other variables on 2-year all-cause mortality. Results: The area under the ROC for NLR was 0.634, with an optimal cutoff value of 4.9. Two-year mortality rates for patients with high (≥4.9) and low (<4.9) NLR were 22.1% and 9.3%, respectively (Log rank test: P = 0.002). After correcting for confounders, multivariate analysis demonstrated that NLR ≥ 4.9 (HR = 2.741, 95% CI 1.467-5.121, P = 0.002), age ≥ 63 (HR = 3.403, 95% CI 1.835-6.310, P < 0.001), and gender (male) (HR = 2.842, 95% CI 1.366-5.912, P = 0.001) were independent risk factors for the mortality outcome. Considering the stratification of early and selective TIPS treatment, high NLR still significantly increased the risk of mortality for patients (Log rank test: P = 0.007, HR = 2.317, 95% CI 1.232-4.356). Conclusion: NLR can help to predict survival in EGVB patients after TIPS, and the type of TIPS should also be considered in practical applications.
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OBJECTIVES: This study aimed to evaluate the feasibility, safety, and efficacy of the transjugular mesenteric-caval shunt (TMCS) as a treatment for the cavernous transformation of the portal vein (CTPV) and recurrent variceal bleeding. METHODS: This retrospective case series was conducted with approval from the institutional review board. It involved seven patients diagnosed with CTPV and recurrent variceal bleeding who underwent the TMCS procedure. We analyzed the rate of procedural complications, incidents of rebleeding, stent stenosis, hepatic encephalopathy, and overall survival to assess treatment outcomes. RESULTS: The TMCS was successfully performed in all seven patients without any life-threatening complications. Postoperatively, one patient developed a lung infection and pleural effusion, which resolved with appropriate treatment. Additionally, two patients experienced an increase in total bilirubin levels, but there was no further deterioration in liver function. The median portal pressure gradient significantly decreased from a preoperative value of 27 mmHg (range 20-36 mmHg) to a postoperative value of 6 mmHg (range 4-11 mmHg). A notable improvement was observed in one cirrhotic patient, with liver function progressing from Child-Pugh class B (score 9) to class A (score 6). Over a median follow-up period of 14 months (range 7-18 months), none of the patients encountered rebleeding, stent stenosis, hepatic encephalopathy, or mortality. CONCLUSION: The TMCS appears to be a viable and effective alternative for managing CTPV with recurrent variceal bleeding. Its long-term outcome requires further evaluation. CLINICAL RELEVANCE STATEMENT: TMCS provides a promising treatment for patients with life-threatening CTPV complications when occluded portal vein cannot be recanalized and portal vein recanalization TIPS is not an option. KEY POINTS: Performing TIPS in patients with portal vein cavernoma is complex due to the requirement for recanalization of the occluded portal vein. Creating a mesenteric-caval shunt through a transjugular approach is a feasible technique. Establishing a TMCS provides a means to manage life-threatening complications arising from portal vein cavernoma.
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PURPOSE: To determine the relationship between clinical, procedural, hospital, and physician characteristics with the duration of the transjugular intrahepatic portosystemic shunt (TIPS) procedure. METHODS: This retrospective study included patients over 18 years of age who underwent an initial TIPS procedure between January 2005 and August 2020. Exclusion criteria were TIPS performed outside the institution and failed TIPS placement. A total of 154 records were included. Regression analyses were used to identify predictors of procedural duration. RESULTS: The mean age at TIPS placement was 57 years. Seventy percent of patients were male and non-Hispanic whites (80.5%). The mean duration of the TIPS procedure was 169 minutes (SD: 78). Procedural duration was shorter when the etiology of cirrhosis was viral (mean: 144 min, SD: 84, p=0.008); the reason for TIPS was ascites (152, SD: 66, p=0.01); and the procedure did not require additional access (153 min, SD: 67, p=<.0001). The main clinical predictor of procedural duration was baseline bilirubin (Beta coefficient (ß): 5.6 min, p=0.0007). In multivariable linear models, in those patients that did not require additional access, bilirubin (ß: 4.9 min, p=0.005), etiology of cirrhosis, and physician experience were the main predictors of TIPS procedure duration. The effect of baseline bilirubin on procedural duration increased in the ascites group (ß: 19.5 minutes, p=0.006), especially when additional access was not required. CONCLUSIONS: The study demonstrates an association between baseline bilirubin, etiology of cirrhosis, and physician experience with the duration of the TIPS procedure. The mechanism underlying the positive association between baseline bilirubin and procedural time is possibly related to the degree of liver fibrosis.
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BACKGROUND & AIMS: The optimal timing of measurement and hemodynamic targets of portacaval pressure gradient (PPG) after TIPS remains inconclusive. This study aimed to identify the ideal moment of hemodynamic measurements and the optimal target of PPG in patients undergoing covered TIPS for variceal bleeding. METHODS: Between May 2018 and December 2021, 466 consecutive patients with recurrent variceal bleeding treated with covered TIPS were prospectively included. Post-TIPS PPG were measured immediately (immediate PPG), 24-72 hours (early PPG), and again 1 month (late PPG) after TIPS placement. The agreement among PPGs measured at different time points was assessed by intra-class correlation coefficient (ICC) and Bland-Altman method. The unadjusted and confounder-adjusted effects of PPGs on the clinical outcomes (portal hypertension complications [PHC], overt hepatic encephalopathy [OHE], further decompensation, and death) were assessed using Fine and Gray competing risk regression models. RESULTS: The agreement between early PPG and late PPG (ICC: 0.34) was better than that between immediate PPG and late PPG (ICC: 0.23, p<0.001). Early PPG revealed an excellent predictive value for PHC risk (early PPG ≥ vs <12 mmHg: adjusted HR [95%CI]: 2.17 [1.33-3.55], p=0.002) as well as OHE (0.40 [0.17-0.91], p=0.030) while immediate PPG did not. Late PPG showed a predictive value for PHC risk but not OHE. By targeting the lowest risk of further decompensation, we identified an optimal hemodynamic target with early PPG ranging 11 to 14 mmHg that was associated with a decreased risk of OHE while effectively preventing PHC. CONCLUSIONS: PPG measured 24 to 72 hours after TIPS correlates with long term PPG and clinical outcomes, and hemodynamic target with a PPG 11-14 mmHg reduced encephalopathy but not compromised clinical efficacy. IMPACT AND IMPLICATIONS: The optimal timing of measurement and hemodynamic targets of portacaval pressure gradient (PPG) after transjugular intrahepatic portosystemic shunt (TIPS) remains inconclusive. Here we show that post-TIPS PPG measured at least 24 hours but not immediately after the procedure correlated with long-term PPG and clinical events, therefore should be used for decision making in order to improve clinical outcomes. Targeting post-TIPS PPG at 11-14 mmHg or 20%-50% relative reduction from pre-TIPS baseline that measured 24-72 hours after procedure reduced encephalopathy but not compromised clinical efficacy, therefore could be used to guide TIPS creation and revision in patients with cirrhosis and variceal bleeding undergoing covered TIPS. CLINICAL TRIAL REGISTRATION NUMBER: ClinicalTrials.gov, ID: NCT03590288.
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OBJECTIVES: Transjugular intrahepatic portosystemic shunt (TIPS) is a catheter-based, minimally invasive procedure to reduce portal hypertension. The aim of the study was to investigate dysfunction and mortality after TIPS and to identify factors associated with these events. METHODS: A retrospective analysis of 834 patients undergoing TIPS implantation in a single center from 1993-2018 was performed. Cumulative incidence curves were estimated, and frailty models were used to assess associations between potentially influential variables and time to dysfunction or death. RESULTS: 1-, 2-, and 5-year mortality rates were 20.9% (confidence interval (CI) 17.7-24.1), 22.5% (CI 19.1-25.8), and 25.0% (CI: 21.1-28.8), 1-year, 2-year, and 5-year dysfunction rates were 28.4% (CI 24.6-32.3), 38.9% (CI 34.5-43.3), and 52.4% (CI 47.2-57.6). The use of covered stents is a protective factor regarding TIPS dysfunction (hazard ratio (HR) 0.47, CI 0.33-0.68) but does not play a major role in survival (HR 0.95, CI 0.58-1.56). Risk factors for mortality are rather TIPS in an emergency setting (HR 2.78, CI 1.19-6.50), a previous TIPS dysfunction (HR 2.43, CI 1.28-4.62), and an increased Freiburg score (HR 1.45, CI 0.93-2.28). CONCLUSION: The use of covered stents is an important protective factor regarding TIPS dysfunction. Whereas previous TIPS dysfunction, emergency TIPS implantation, and an elevated Freiburg score are associated with increased mortality. Awareness of risk factors could contribute to a better selection of patients who may benefit from a TIPS procedure and improve clinical follow-up with regard to early detection of thrombosis/stenosis. CRITICAL RELEVANCE STATEMENT: The use of covered stents reduces the risk of dysfunction after transjugular intrahepatic portosystemic shunt (TIPS). TIPS dysfunction, emergency TIPS placement, and a high Freiburg score are linked to higher mortality rates in TIPS patients. KEY POINTS: The risk of dysfunction is higher for uncovered stents compared to covered stents. Transjugular intrahepatic portosystemic shunt dysfunction increases the risk of instantaneous death after the intervention. A higher Freiburg score increases the rate of death after the intervention. Transjugular intrahepatic portosystemic shunt implantations in emergency settings reduce survival rates.
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BACKGROUND: Histopathological characterization obtained by transjugular liver biopsy (TJLB) may theoretically contribute to clarification of the exact aetiology of acute liver failure (ALF). It's unclear whether the histopathological information from TJLB, due to the small specimen size, significantly contributes to diagnosing ALF causes, guiding therapy decisions, or predicting overall prognosis. This retrospective study aimed to analyse safety and clinical significance of TJLB in patients with ALF. METHODS: This retrospective, monocentric study investigated safety and efficacy of TJLB in patients with ALF over a ten-year period at a tertiary care transplant-center. The predictive value of various clinical and laboratory characteristics as well as histopathological findings obtained by TJLB on 28-day liver-transplant-free survival were evaluated by calculating uni- and multivariate Cox-proportional hazard regression models. Additional univariate logistic regression analyses were performed to explore the influence of degree of intrahepatic necrosis on the secondary endpoints intensive-care-unit (ICU) admission, need for endotracheal intubation, renal replacement therapy and high-urgency listing for LTX. RESULTS: A total of 43 patients with ALF receiving TJLB were included into the study. In most cases (n = 39/43 cases) TJLB confirmed the initially already clinically presumed ALF aetiology and the therapeutic approach was unchanged by additional histological examination in the majority of patients (36/43 cases). However, in patients with a high suspicion for aetiologies potentially treatable by medical immunosuppression (e.g. AIH, GvHD), TJLB significantly influenced further treatment planning and/or adjustment. While the degree of intrahepatic necrosis showed significance in the univariate analysis (p = 0.04), it did not demonstrate a significant predictive effect on liver transplant-free survival in the multivariate analysis (p = 0.1). Only consecutive ICU admission was more likely with higher extent of intrahepatic necrosis (Odds ratio (OR) 1.04 (95% CI 1-1.08), p = 0.046). CONCLUSIONS: Performance of TJLB in ALF led to a change in suspected diagnosis and to a significant change in therapeutic measures only in those patients with a presumed high risk for aetiologies potentially responsive to immunosuppressive therapy. Clinical assessment alone was accurate enough, with additional histopathological examination adding no significant value, to predict overall prognosis of patients with ALF.
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Fallo Hepático Agudo , Trasplante de Hígado , Hígado , Humanos , Estudios Retrospectivos , Femenino , Masculino , Fallo Hepático Agudo/patología , Fallo Hepático Agudo/etiología , Fallo Hepático Agudo/diagnóstico , Persona de Mediana Edad , Hígado/patología , Adulto , Biopsia , Venas Yugulares/patología , Pronóstico , Modelos de Riesgos Proporcionales , Valor Predictivo de las Pruebas , Relevancia ClínicaRESUMEN
BACKGROUND: Portal shunt and immune status related to the spleen are related to the occurrence of hepatic encephalopathy (HE). It is unknown whether spleen volume before transjugular intrahepatic portosystemic shunt (TIPS) is related to postoperative HE. AIM: To investigate the relationship between spleen volume and the occurrence of HE. METHODS: This study included 135 patients with liver cirrhosis who underwent TIPS, and liver and spleen volumes were elevated upon computed tomography imaging. The Kaplan-Meier curve was used to compare the difference in the incidence rate of HE among patients with different spleen volumes. Univariate and multivariate Cox regression analyses were performed to identify the factors affecting overt HE (OHE). Restricted cubic spline was used to examine the shapes of the dose-response association between spleen volumes and OHE risk. RESULTS: The results showed that 37 (27.2%) of 135 patients experienced OHE during a 1-year follow-up period. Compared with preoperative spleen volume (901.30 ± 471.90 cm3), there was a significant decrease in spleen volume after TIPS (697.60 ± 281.0 cm3) in OHE patients. As the severity of OHE increased, the spleen volume significantly decreased (P < 0.05). Compared with patients with a spleen volume ≥ 782.4 cm3, those with a spleen volume < 782.4 cm3 had a higher incidence of HE (P < 0.05). Cox regression analysis showed that spleen volume was an independent risk factor for post-TIPS OHE (hazard ratio = 0.494, P < 0.05). Restricted cubic spline model showed that with an increasing spleen volume, OHE risk showed an initial increase and then decrease (P < 0.05). CONCLUSION: Spleen volume is related to the occurrence of OHE after TIPS. Preoperative spleen volume is an independent risk factor for post-TIPS OHE.
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Individuals with Philadelphia chromosome-negative myeloproliferative neoplasms (MPNs) such as polycythemia vera and essential thrombocythemia (ET) demonstrate an increased thrombotic risk associated with JAK2 mutations. Physicians must take heed when treating these patients, to mitigate this pro-thrombotic state as much as possible. Failure to do so, or exacerbating the state, can lead to dire consequences. We present the case of a 27-year-old female with a history of ulcerative colitis (UC) and ET, currently taking estrogen-containing oral contraceptive pills (OCPs). She presented to the emergency department with rapid weight gain, jaundice, nausea, and diarrhea and was found to have obstructive jaundice and thrombotic burden that extended into the portal, mesenteric, splenic, and hepatic veins. On the second attempt, a successful transjugular intrahepatic portosystemic shunt procedure was performed, resulting in improved venous flow. This case underscores the importance of cautious medication use, especially OCPs, in patients with hypercoagulable states due to JAK2 mutations, for example, the V617F mutation in JAK2. It emphasizes the need for vigilant monitoring, individualized management, and a multidisciplinary approach to mitigate thrombotic complications. Increased awareness and continued research are crucial for optimizing treatment strategies for patients with MPNs and associated genetic mutations.