Transjugular intrahepatic portosystemic shunt for recompensating decompensated cirrhosis?

Transjugular intrahepatic portosystemic shunt(TIPS)is a medical procedure that has been used to manage variceal bleeding and ascites in patients with cirrhosis.It can prevent further decompensation and improve the survival of high-risk decompensated patients.Recent research indicates that TIPS could increase the possibility of recompensation of decompensated cirrhosis when it is combined with adequate suppression of the causative factor of liver disease.However,the results of the studies have been based on retrospective analysis,and further validation is required by conducting randomized controlled studies.In this context,we highlight the limitations of the current studies and emphasize the issues that must be addressed before TIPS can be recommended as a potential recompensating tool.

Bayesian network-based survival prediction model for patients having undergone post-transjugular intrahepatic portosystemic shunt for portal hypertension

BACKGROUND Portal hypertension(PHT),primarily induced by cirrhosis,manifests severe symptoms impacting patient survival.Although transjugular intrahepatic portosystemic shunt(TIPS)is a critical intervention for managing PHT,it carries risks like hepatic encephalopathy,thus affecting patient survival prognosis.To our knowledge,existing prognostic models for post-TIPS survival in patients with PHT fail to account for the interplay among and collective impact of various prognostic factors on outcomes.Consequently,the development of an innovative modeling approach is essential to address this limitation.AIM To develop and validate a Bayesian network(BN)-based survival prediction model for patients with cirrhosis-induced PHT having undergone TIPS.METHODS The clinical data of 393 patients with cirrhosis-induced PHT who underwent TIPS surgery at the Second Affiliated Hospital of Chongqing Medical University between January 2015 and May 2022 were retrospectively analyzed.Variables were selected using Cox and least absolute shrinkage and selection operator regression methods,and a BN-based model was established and evaluated to predict survival in patients having undergone TIPS surgery for PHT.RESULTS Variable selection revealed the following as key factors impacting survival:age,ascites,hypertension,indications for TIPS,postoperative portal vein pressure(post-PVP),aspartate aminotransferase,alkaline phosphatase,total bilirubin,prealbumin,the Child-Pugh grade,and the model for end-stage liver disease(MELD)score.Based on the above-mentioned variables,a BN-based 2-year survival prognostic prediction model was constructed,which identified the following factors to be directly linked to the survival time:age,ascites,indications for TIPS,concurrent hypertension,post-PVP,the Child-Pugh grade,and the MELD score.The Bayesian information criterion was 3589.04,and 10-fold cross-validation indicated an average log-likelihood loss of 5.55 with a standard deviation of 0.16.The model’s accuracy,precision,recall,and F1 score were 0.90,0.92,0.97,and 0.95 respectively,with the area under the receiver operating characteristic curve being 0.72.CONCLUSION This study successfully developed a BN-based survival prediction model with good predictive capabilities.It offers valuable insights for treatment strategies and prognostic evaluations in patients having undergone TIPS surgery for PHT.

Transjugular intrahepatic portosystemic shunt:A promising therapy for recompensation in cirrhotic patients

This is a retrospective study focused on recompensation after transjugular intrahepatic portosystemic shunt(TIPS)procedure.The authors confirmed TIPS could be a treatment for recompensation of patients with cirrhosis according to Baveno VII.The paper identified age and post-TIPS portal pressure gradient as independent predictors of recompensation in patients with decompensated cirrhosis after TIPS.These results need to be validated in a larger prospective cohort.

Milestones to optimize of transjugular intrahepatic portosystemic shunt technique as a method for the treatment of portal hypertension complications

This editorial describes the milestones to optimize of transjugular intrahepatic portosystemic shunt(TIPS)technique,which have made it one of the main methods for the treatment of portal hypertension complications worldwide.Innovative ideas,subsequent experimental studies and preliminary experience of use in cirrhotic patients contributed to the introduction of TIPS into clinical practice.At the moment,the main achievement in optimize of TIPS technique is progress in the qualitative characteristics of stents.The transition from bare metal stents to extended polytetrafluoroethylene–covered stent grafts made it possible to significantly prevent shunt dysfunction.However,the question of its preferred diameter,which contributes to an optimal reduction of portal pressure without the risk of developing post-TIPS hepatic encephalopathy,remains relevant.Currently,hepatic encephalopathy is one of the most common complications of TIPS,significantly affecting its effectiveness and prognosis.Careful selection of patients based on cognitive indicators,nutritional status,assessment of liver function,etc.,will reduce the incidence of post-TIPS hepatic encephalopathy and improve treatment results.Optimize of TIPS technique has significantly expanded the indications for its use and made it one of the main methods for the treatment of portal hypertension complications.At the same time,there are a number of limitations and unresolved issues that require further randomized controlled trials involving a large cohort of patients.

Efficacy of transjugular intrahepatic portosystemic shunts in treating cirrhotic esophageal-gastric variceal bleeding

BACKGROUND Esophageal-gastric variceal bleeding(EGVB)represents a severe complication among patients with cirrhosis and often culminates in fatal outcomes.Interven-tional therapy,a rapidly developing treatment modality over the past few years,has found widespread application in clinical practice due to its minimally inva-sive characteristics.However,whether transjugular intrahepatic portosystemic shunt(TIPS)treatment has an impact on patient prognosis remains controversial.METHODS A retrospective study was conducted on ninety-two patients presenting with cirrhotic EGVB who were admitted to our hospital between September 2020 and September 2022.Based on the different modes of treatment,the patients were assigned to the study group(TIPS received,n=50)or the control group(per-cutaneous transhepatic varices embolization received,n=42).Comparative ana-lyses were performed between the two groups preoperatively and one month postoperatively for the following parameters:Varicosity status;hemodynamic parameters[portal vein flow velocity(PVV)and portal vein diameter(PVD);platelet count(PLT);red blood cell count;white blood cell count(WBC);and hepatic function[albumin(ALB),total bilirubin(TBIL),and aspartate transaminase(AST)].The Generic Quality of Life Inventory-74 was utilized to assess quality of life in the two groups,and the 1-year postoperative rebleeding and survival rates were compared.RESULTS Following surgical intervention,there was an improvement in the incidence of varicosity compared to the preoperative status in both cohorts.Notably,the study group exhibited more pronounced enhancements than did the control group(P<0.05).PVV increased,and PVD decreased compared to the preoperative values,with the study cohort achieving better outcomes(P<0.05).PLT and WBC counts were elevated postoperatively in the two groups,with the study cohort displaying higher PLT and WBC counts(P<0.05).No differences were detected between the two groups in terms of serum ALB,TBIL,or AST levels either preoperatively or postoperatively(P<0.05).Postoperative scores across all dimensions of life quality surpassed preoperative scores,with the study cohort achieving higher scores(P<0.05).At 22.00%,the one-year postoperative rebleeding rate in the study cohort was significantly lower than that in the control group(42.86%;P<0.05);conversely,no marked difference was obser-ved in the 1-year postoperative survival rate between the two cohorts(P>0.05).CONCLUSION TIPS,which has demonstrated robust efficacy in managing cirrhotic EGVB,remarkably alleviates varicosity and improves hemodynamics in patients.This intervention not only results in a safer profile but also contributes significantly to a more favorable prognosis.

Correlation between serum markers and transjugular intrahepatic portosystemic shunt prognosis in patients with cirrhotic ascites

BACKGROUND Individuals with refractory ascites in the context of liver cirrhosis typically face an adverse prognosis.The transjugular intrahepatic portosystemic shunt(TIPS)is an efficacious intervention,but there is a lack of reliable tools for postoperative pro-gnosis assessment.Previously utilized clinical biochemical markers,such as the serum albumin concentration(Alb),sodium(Na+)concentration,and serum creatinine(Scr),have limited predictive value.Therefore,the quest for novel,specific biomarkers to evaluate the post-TIPS prognosis in patients with liver cirrhosis and refractory ascites holds significant practical importance.A retrospective analysis was conducted on 75 patients with liver cirrhosis and refractory ascites who underwent TIPS at our institution from August 2019 to August 2021.These patients were followed up regularly for two years,and the death toll was meticulously documented.The patients were allocated into a survival group(n=45 patients)or a deceased group(n=30 patients)based on their prognosis status.The clinical data of the two groups were collected,and Child-Pugh scores and MELD scores were calculated for analysis.Spearman correlation analysis was carried out to evaluate the correlation of prognosis with Child-Pugh grade,MELD score,and Cys C level.Additionally,a multiple-factor analysis utilizing the Cox proportional hazard model was used to identify independent risk factors affecting the post-TIPS prognosis of patients with liver cirrhosis and refractory ascites.The receiver operating characteristic curve(ROC)ascertained the predictive value of the Cys C concen-tration,Child-Pugh grade,and MELD score for the prognosis of liver cirrhosis with refractory ascites in post-TIPS patients.RESULTS During a 2-year follow-up period,among 75 patients with liver cirrhosis and refractory ascites who underwent TIPS treatment,30 patients(40.00%)passed away.The deceased cohort exhibited heightened aspartate aminotrans-ferase,alanine aminotransferase,total bilirubin,Scr,prothrombin time,Cys C,international normalized ratio,Child-Pugh,and MELD scores compared to those of the survival cohort,while Alb and Na+levels were attenuated in the deceased group(P<0.05).Spearman analysis revealed moderate to high positive correlations between prognosis and Child-Pugh score,MELD score,and Cys C level(r=0.709,0.749,0.671,P<0.05).Multivariate analysis using the Cox proportional hazard model demonstrated that the independent risk factors for post-TIPS prognosis in patients with liver cirrhosis and refractory ascites were Cys C(HR=3.802;95%CI:1.313-11.015),Child-Pugh(HR=3.030;95%CI:1.858-4.943),and MELD(HR=1.222;95%CI:1.073-1.393)scores.ROC analysis confirmed that,compared to those of the classic prognostic models for Child-Pugh and MELD scores,the predictive accuracy of Cys C for post-TIPS prognosis in patients with liver cirrhosis and refractory ascites was slightly lower.This analysis yielded sensitivity and specificity values of 83.33%and 82.22%,respectively.The area under the curve value at this juncture was 0.883,with an optimal cutoff value set at 1.95 mg/L.CONCLUSION Monitoring the serum Cys C concentration is valuable for assessing the post-TIPS prognosis in patients with liver cirrhosis and refractory ascites.Predictive models based on serum Cys C levels,as opposed to Scr levels,are more beneficial for evaluating the condition and prognosis of patients with ascites due to cirrhosis.

Development and validation of a predictive model for acute-onchronic liver failure after transjugular intrahepatic portosystemic shunt

BACKGROUND Transjugular intrahepatic portosystemic shunt(TIPS)is a cause of acute-onchronic liver failure(ACLF).AIM To investigate the risk factors of ACLF within 1 year after TIPS in patients with cirrhosis and construct a prediction model.METHODS In total,379 patients with decompensated cirrhosis treated with TIPS at Nanjing Drum Tower Hospital from 2017 to 2020 were selected as the training cohort,and 123 patients from Nanfang Hospital were included in the external validation cohort.Univariate and multivariate logistic regression analyses were performed to identify independent predictors.The prediction model was established based on the Akaike information criterion.Internal and external validation were conducted to assess the performance of the model.RESULTS Age and total bilirubin(TBil)were independent risk factors for the incidence of ACLF within 1 year after TIPS.We developed a prediction model comprising age,TBil,and serum sodium,which demonstrated good discrimination and calibration in both the training cohort and the external validation cohort.CONCLUSION Age and TBil are independent risk factors for the incidence of ACLF within 1 year after TIPS in patients with decompensated cirrhosis.Our model showed satisfying predictive value.

Development of a new Cox model for predicting long-term survival in hepatitis cirrhosis patients underwent transjugular intrahepatic portosystemic shunts

BACKGROUND Transjugular intrahepatic portosystemic shunt(TIPS)placement is a procedure that can effectively treat complications of portal hypertension,such as variceal bleeding and refractory ascites.However,there have been no specific studies on predicting long-term survival after TIPS placement.AIM To establish a model to predict long-term survival in patients with hepatitis cirrhosis after TIPS.METHODS A retrospective analysis was conducted on a cohort of 224 patients who un-derwent TIPS implantation.Through univariate and multivariate Cox regression analyses,various factors were examined for their ability to predict survival at 6 years after TIPS.Consequently,a composite score was formulated,encompassing the indication,shunt reasonability,portal venous pressure gradient(PPG)after TIPS,percentage decrease in portal venous pressure(PVP),indocyanine green retention rate at 15 min(ICGR15)and total bilirubin(Tbil)level.Furthermore,the performance of the newly developed Cox(NDC)model was evaluated in an in-ternal validation cohort and compared with that of a series of existing models.RESULTS The indication(variceal bleeding or ascites),shunt reasonability(reasonable or unreasonable),ICGR15,post-operative PPG,percentage of PVP decrease and Tbil were found to be independent factors affecting long-term survival after TIPS placement.The NDC model incorporated these parameters and successfully identified patients at high risk,exhibiting a notably elevated mortality rate following the TIPS procedure,as observed in both the training and validation cohorts.Additionally,in terms of predicting the long-term survival rate,the performance of the NDC model was significantly better than that of the other four models[Child-Pugh,model for end-stage liver disease(MELD),MELD-sodium and the Freiburg index of post-TIPS survival].CONCLUSION The NDC model can accurately predict long-term survival after the TIPS procedure in patients with hepatitis cirrhosis,help identify high-risk patients and guide follow-up management after TIPS implantation.

Impressive recompensation in transjugular intrahepatic portosystemic shunt-treated individuals with complications of decompensated cirrhosis based on Baveno VII criteria

BACKGROUND Transjugular intrahepatic portosystemic shunt(TIPS)is the standard second-line treatment option for individuals with complications of decompensated cirrhosis,such as variceal bleeding and refractory ascites.AIM To investigate whether recompensation existed in TIPS-treated patients with decompensated cirrhosis according to Baveno VII criteria.METHODS This retrospective analysis was performed on 64 patients who received TIPS for variceal bleeding or refractory ascites.The definition of recompensation referred to Baveno VII criteria and previous study.Clinical events,laboratory tests,and radiological examinations were regularly conducted during a preset follow-up period.The recompensation ratio in this cohort was calculated.Beyond that,univariate and multivariate regression models were conducted to identify the predictors of recompensation.RESULTS Of the 64 patients with a 12-mo follow-up,20(31%)achieved recompensation.Age[odds ratio(OR):1.124;95%confidence interval(CI):1.034-1.222]and postTIPS portal pressure gradient<12 mmHg(OR:0.119;95%CI:0.024-0.584)were identified as independent predictors of recompensation in patients with decompensated cirrhosis after TIPS.CONCLUSION The present study demonstrated that nearly one-third of the TIPS-treated patients achieved recompensation within this cohort.According to our findings,recompensation is more likely to be achieved in younger patients.In addition,postoperative portal pressure gradient reduction below 12 mmHg contributes to the occurrence of recompensation.

Contributory roles of sarcopenia and myosteatosis in development of overt hepatic encephalopathy and mortality after transjugular intrahepatic portosystemic shunt

BACKGROUND Skeletal muscle abnormalities,such as muscle mass depletion(sarcopenia)and fatty infiltration of the muscle(myosteatosis),are frequent complications in cirrhotic patients scheduled for transjugular intrahepatic portosystemic shunt(TIPS).AIM To investigate the association and predictive value of sarcopenia and myosteatosis for overt hepatic encephalopathy(HE)and mortality after TIPS.METHODS The records of cirrhotic patients who underwent the TIPS procedure at our hospital between January 2020 and June 2021 were retrospectively retrieved.The transversal psoas muscle thickness(TPMT)and psoas muscle attenuation(PMA)measured from the unenhanced abdominal computed tomography(CT)at the level of the third lumbar vertebrae were used to analyze the sarcopenia and myosteatosis,respectively.The area under curve(AUC)was used to evaluate the discriminative power of TPMT,PMA,and relevant clinical parameters.Furthermore,log-rank test was performed to compare the incidence of overt HE and survival between the different groups,and the association of risk factors with overt HE and mortality was analyzed using Cox proportional hazards regression models.RESULTS A total of 108 patients were collected.Among these patients,45.4%of patients developed overt HE after TIPS treatment.Furthermore,32.4%and 28.7%of these patients were identified to have myosteatosis and sarcopenia,respectively.Myosteatosis(51.0%vs 16.9%,P<0.001)and sarcopenia(40.8 vs 18.6%,P=0.011)were found to be more frequent in patients with overt HE,when compared to patients without overt HE.The receiver operating characteristics analysis indicated that the predictive power of TPMT and PMA in overt HE(AUC=0.713 and 0.778,respectively)was higher when compared to the neutrophil lymphocyte ratio(AUC=0.636).The cumulative incidence of overt HE was the highest in patients with concomitant sarcopenia and myosteatosis,followed by patients with myosteatosis or sarcopenia,while this was the lowest in patients without sarcopenia and myosteatosis.In addition,sarcopenia and myosteatosis were independently associated with overt HE and mortality after adjusting for confounding factors in post-TIPS patients.CONCLUSION CT-based estimations for sarcopenia and myosteatosis can be used as reliable predictors for the risk of developing overt HE and mortality in cirrhotic patients after TIPS.

Prevention and treatment of hepatic encephalopathy during the perioperative period of transjugular intrahepatic portosystemic shunt

Transjugular intrahepatic portosystemic shunt(TIPS)is an established procedure for treating the complications of portal hypertension in liver cirrhosis.While the pathogenesis of postoperative TIPS-related hepatic encephalopathy(HE)has yet to be fully understood,intraoperative portosystemic shunts may provide a pathological basis for the occurrence of postope-rative HE in patients with liver cirrhosis.Studies at home and abroad have expressed mixed opinions about TIPSrelated HE.This study presents a literature review on the risk factors for and prevention and treatment of perioperative TIPS-related HE in patients with liver cirrhosis,aiming to optimize the procedure and reduce the incidence of postoperative HE.

Prognosis after splenectomy plus pericardial devascularization vs transjugular intrahepatic portosystemic shunt for esophagogastric variceal bleeding

BACKGROUND Portal hypertension combined with esophagogastric variceal bleeding(EGVB)is a serious complication in patients with hepatitis B virus(HBV)-related cirrhosis in China.Splenectomy plus pericardial devascularization(SPD)and transjugular intrahepatic portosystemic shunt(TIPS)are effective treatments for EGVB.However,a comparison of the effectiveness and safety of those methods is lacking.AIM To compare the prognosis after SPD vs TIPS for acute EGVB after failure of endoscopic therapy or secondary prophylaxis of variceal rebleeding(VRB)in patients with HBV-related cirrhosis combined with portal hypertension.METHODS This retrospective cohort study included 318 patients with HBV-related cirrhosis and EGVB who underwent SPD or TIPS at West China Hospital of Sichuan University during 2009-2013.Propensity score-matched analysis(PSM),the Kaplan-Meier method,and multivariate Cox regression analysis were used to compare overall survival,VRB rate,liver function abnormality rate,and hepatocellular carcinoma(HCC)incidence between the two patient groups.RESULTS The median age was 45.0 years(n=318;226(71.1%)males).During a median follow-up duration of 43.0 mo,18(11.1%)and 33(21.2%)patients died in the SPD and TIPS groups,respectively.After PSM,SPD was significantly associated with better overall survival(OS)(P=0.01),lower rates of abnormal liver function(P<0.001),and a lower incidence of HCC(P=0.02)than TIPS.The VRB rate did not differ significantly between the two groups(P=0.09).CONCLUSION Compared with TIPS,SPD is associated with higher postoperative OS rates,lower rates of abnormal liver function and HCC,and better quality of survival as acute EGVB treatment after failed endoscopic therapy or as secondary prophylaxis of VRB in patients with HBV-related cirrhosis combined with portal hypertension.There is no significant between-group difference in VRB rates.

Reduction of portosystemic gradient during transjugular intrahepatic portosystemic shunt achieves good outcome and reduces complications

BACKGROUND Transjugular intrahepatic portosystemic shunt(TIPS)is placed important role in the therapy of complications of portal hypertension,there is still no suitable criterion for a reduction in portosystemic gradient(PSG),which can both reduce PSG and maximize clinical results and minimize hepatic encephalopathy(HE).AIM To compare the clinical outcomes and incidence of HE after one-third PSG reduction during TIPS in patients with variceal bleeding and refractory ascites.METHODS A total of 1280 patients with portal-hypertension-related complications of refractory ascites or variceal bleeding who underwent TIPS from January 2016 to January 2019 were analyzed retrospectively.Patients were divided into group A(variceal hemorrhage and PSG reduced by one third,n=479);group B(variceal hemorrhage and PSG reduced to<12 mmHg,n=412);group C(refractory ascites and PSG reduced by one third,n=217);and group D(refractory ascites and PSG reduced to<12 mmHg of PSG,plus medication,n=172).The clinical outcomes were analyzed.RESULTS By the endpoint of follow-up,recurrent bleeding was no different between groups A and B(χ^(2)=7.062,P=0.374),but recurrent ascites did differ significantly between groups C and D(χ^(2)=14.493,P=0.006).The probability of total hepatic impairment within 3 years was significantly different between groups A and B(χ^(2)=11.352,P=0.005)and groups C and D(χ^(2)=13.758,P=0.002).The total incidence of HE differed significantly between groups A and B(χ^(2)=7.932,P=0.016),groups C and D(χ^(2)=13.637,P=0.007).There were no differences of survival rate between groups A and B(χ^(2)=3.376,P=0.369,log-rank test),but did differ significantly between groups C and D(χ^(2)=13.582,P=0.014,log-rank test).CONCLUSION The PSG reduction by one third may reduce the risk of HE,hepatic function damage and achieve good clinical results.

Predicting disease progression in cirrhotic patients after transjugular intrahepatic portosystemic shunt implantation:A sexstratified analysis

BACKGROUND Transjugular intrahepatic portosystemic shunt(TIPS)has been extensively used to treat portal hypertension-associated complications,including cirrhosis.The prediction of post-TIPS prognosis is important for cirrhotic patients,as more aggressive liver transplantation is needed when the post-TIPS prognosis is poor.AIM To construct a nutrition-based model that could predict the disease progression of cirrhotic patients after TIPS implantation in a sex-dependent manner.METHODS This study retrospectively recruited cirrhotic patients undergoing TIPS implantation for analysis.Muscle quality was assessed by measuring the skeletal muscle index(SMI)by computed tomography.Multivariate Cox proportional hazard models were utilized to determine the association between SMI and disease progression in cirrhotic patients after TIPS implantation.RESULTS This study eventually included 186 cirrhotic patients receiving TIPS who were followed up for 30.5±18.8 mo.For male patients,the 30-mo survival rate was significantly lower and the probability of progressive events was higher(3.257-fold)in the low-level SMI group than in the high-level SMI group.According to the multivariate Cox analysis of male patients,SMI<32.8 was an independent risk factor for long-term adverse outcomes after TIPS implantation.A model was constructed,which involved creatinine,plasma ammonia,SMI,and acute-on-chronic liver failure and hepatic encephalopathy occurring within half a year after surgery.This model had an area under the receiver operating characteristic curve of 0.852,sensitivity of 0.926,and specificity of 0.652.According to the results of the DeLong test,this model outperformed other models(Child-Turcotte-Pugh,Model for End-Stage Liver Disease,and Freiburg index of post-TIPS survival)(P<0.05).CONCLUSION SMI is strongly associated with poor long-term outcomes in male patients with cirrhosis who underwent TIPS implantation.

Stent fracture after transjugular intrahepatic portosystemic shunt placement using the bare metal stent/stent-graft combination technique

BACKGROUND A transjugular intrahepatic portosystemic shunt(TIPS)is widely placed to treat portal hypertension.Because the Viatorr®stent(W.L.Gore and Associates,Flagstaff,AZ,United States)is not available in all hospitals in China,the bare metal stent(BMS)/stent-graft combination technique is still popular for TIPS construction.Stent fracture is a complication after TIPS placement using this technique,with limited available literature focusing on it.AIM To assess the incidence of stent fracture after TIPS placement using the BMS/stent-graft combination technique and to identify the risk factors for stent fracture.We proposed technique modifications to improve the clinical results of TIPS placement with the BMS/stent-graft combination technique.METHODS We retrospectively analyzed the computed tomography(CT)data of all patients with portal hypertension who underwent the TIPS procedure between June 2011 and December 2021 in a single center.Patients implanted with the BMS/stent graft and had follow-up imaging data available were included.We identified patients with stent fracture and analyzed their characteristics.Multivariable logistic regression was applied to identify the potential predictors of stent fracture.RESULTS Of the 68 included patients,stent fracture occurred in seven(10.3%)patients.Based on CT images,the stent fractures were categorized into three types.Our study consisted of four(57.1%)type I fractures,one(14.3%)type II fracture,one(14.3%)type IIIa fracture,and one(14.3%)type IIIb fracture.After adjusting for covariates,multivariable logistic regression revealed that the risk factors for stent fracture were the implantation of a greater number of stents[adjusted odds ratio(aOR)=22.2,95%confidence interval(CI):1.2-415.4,P=0.038]and a larger proximal sagittal stent bending angle(aOR=1.1,95%CI:1.0-1.3,P=0.020).CONCLUSION Stent fracture occurred in approximately 10%of patients with portal hypertension who underwent TIPS with the BMS/stent-graft combination technique.The number of implanted stents and stent bending angle at the inferior vena cava end were predictors of stent fracture,which suggests that the incidence of stent fracture could potentially be reduced by procedural modifications.

Novel CABIN score outperforms other prognostic models in predicting in-hospital mortality after salvage transjugular intrahepatic portosystemic shunting

BACKGROUND Transjugular intrahepatic portosystemic shunt(TIPS)is now established as the salvage procedure of choice in patients who have uncontrolled or severe recurrent variceal bleeding despite optimal medical and endoscopic treatment.AIM To analysis compared the performance of eight risk scores to predict in-hospital mortality after salvage TIPS(sTIPS)placement in patients with uncontrolled variceal bleeding after failed medical treatment and endoscopic intervention.METHODS Baseline risk scores for the Acute Physiology and Chronic Health Evaluation(APACHE)II,Bonn TIPS early mortality(BOTEM),Child-Pugh,Emory,FIPS,model for end-stage liver disease(MELD),MELD-Na,and a novel 5 category CABIN score incorporating Creatinine,Albumin,Bilirubin,INR and Na,were calculated before sTIPS.Concordance(C)statistics for predictive accuracy of inhospital mortality of the eight scores were compared using area under the receiver operating characteristic curve(AUROC)analysis.RESULTS Thirty-four patients(29 men,5 women),median age 52 years(range 31-80)received sTIPS for uncontrolled(11)or refractory(23)bleeding between August 1991 and November 2020.Salvage TIPS controlled bleeding in 32(94%)patients with recurrence in one.Ten(29%)patients died in hospital.All scoring systems had a significant association with in-hospital mortality(P<0.05)on multivariate analysis.Based on in-hospital survival AUROC,the CABIN(0.967),APACHE II(0.948)and Emory(0.942)scores had the best capability predicting mortality compared to FIPS(0.892),BOTEM(0.877),MELD Na(0.865),Child-Pugh(0.802)and MELD(0.792).CONCLUSION The novel CABIN score had the best prediction capability with statistical superiority over seven other risk scores.Despite sTIPS,hospital mortality remains high and can be predicted by CABIN category B or C or CABIN scores>10.Survival was 100%in CABIN A patients while mortality was 75%for CABIN B,87.5%for CABIN C,and 83%for CABIN scores>10.

Comparison of embolic agents for varices during transjugular intrahepatic portosystemic shunt for variceal bleeding: Tissue gel or coil?

Purpose:We aimed to compare treatment efficacy,safety and material cost between tissue gel and coil regarding variceal embolization during transjugular intrahepatic portosystemic shunt(TIPS).Materials&Methods:This retrospective study including cirrhotic patients with variceal bleeding treated with TIPS combined with variceal embolization between January 2016 and August 2017.Patients were divided into three groups according to embolic agents used in variceal embolization:tissue gel group(Group A),combination group(Group B),and coil group(Group C).The primary endpoint was 1-year rebleeding rate after TIPS creation.The secondary endpoints included shunt dysfunction,overt hepatic encephalopathy,liver function,and embolic agents-related expense.Results:A total of 60 patients(30,10,and 20 in Group A,B,and C)were included.Variceal rebleeding occurred in3(10%),0(0%),and 4(20%)patients within one year after TIPS creation in Group A,B,and C,respectively.Stent dysfunction occurred in 2(3.3%)patients and 9(15.0%)patients experienced overt hepatic encephalopathy.No significant differences were observed between three groups regarding primary and secondary endpoints except embolic agents-related expense,with a significantly lower cost in Group A when compared to the other two groups.Stent dysfunction occurred in two patients,with one patient in Group A developed acute occlusion caused by thrombus and another patient in Group C underwent stent stenosis during follow-up.Conclusions:Compares to coil alone or combines with coil,tissue gel has similar treatment efficacy and safety,but with significantly lower cost for variceal bleeding during TIPS.

Early Hepatic Encephalopathy after a Transjugular Intrahepatic Portosystemic Shunt Procedure: Case Report

Patients with decompensated hepatic cirrhosis may present systemic alterations and dysfunction of multiple organs. Ascites, portal hypertension, esophageal varices, and hepatic encephalopathy are common complications arising from cirrhosis. The aim of this paper is to report a case of a patient with liver cirrhosis and the complications of a transjugular intrahepatic portosystemic shunt. Male, elderly, and ex-alcoholic, diagnosed with liver cirrhosis, ascites, and esophageal varices. He underwent transjugular intrahepatic portosystemic shunt due to portal hypertension and returned to the hospital after 24 hours with agitation and mental confusion. He had a bowel movement stop, neurological worsening, loss of renal function, hepatic hydrothorax, hepatic encephalopathy, hypernatremia, hypocalcemia, and hypophosphatemia. He underwent a new procedure to occlude the transjugular intrahepatic portosystemic shunt, showing improvement of the mental status and ascites. However, continued with decompensation and hydro-electrolytic disorders. He evolved with worsening of the ventilatory pattern, and neurological and renal function, with a fatal outcome. Esophageal varices due to portal hypertension can be corrected with the transjugular intrahepatic portosystemic shunt. However, complications such as hypernatremia, hepatic hydrothorax, and hepatic encephalopathy may occur. Therefore, there is a need for reintervention to shunt or reduce its caliber. Thus, for patients with advanced age and decompensated cirrhosis, the potential risks and benefits of this procedure should be carefully evaluated due to the risk of complications and death.

Clinical outcomes of transcatheter selective superior mesenteric artery urokinase infusion therapy vs transjugular intrahepatic portosystemic shunt in patients with cirrhosis and acute portal vein thrombosis

AIM To compare the outcomes of transcatheter superior mesenteric artery(SMA) urokinase infusion and transjugular intrahepatic portosystemic shunt(TIPS) for acute portal vein thrombosis(PVT) in cirrhosis.METHODS From January 2013 to December 2014, patients with liver cirrhosis and acute symptomatic PVT who met the inclusion criteria were randomly assigned to either an SMA group or a TIPS group. The two groups accepted transcatheter selective SMA urokinase infusion therapyand TIPS, respectively. The total follow-up time was24 mo. The primary outcome measure was the change in portal vein patency status which was evaluated by angio-computed tomography or Doppler ultrasound.Secondary outcomes were rebleeding and hepatic encephalopathy.RESULTS A total of 40 patients were enrolled, with 20 assigned to the SMA group and 20 to the TIPS group. The symptoms of all patients in the two groups improved within 48 h. PVT was improved in 17(85%) patients in the SMA group and 14(70%) patients in the TIPS group. The main portal vein(MPV) thrombosis was significantly reduced in both groups(P < 0.001), and there was no significant difference between them(P= 0.304). In the SMA group, superior mesenteric vein(SMV) thrombosis and splenic vein(SV) thrombosis were significantly reduced(P = 0.048 and P = 0.02),which did not occur in the TIPS group. At 6-, 12-,and 24-mo follow-up, in the SMA group and the TIPS group, the cumulative rates free of the first episode of rebleeding were 80%, 65%, and 45% vs 90%, 80%,and 60%, respectively(P = 0.320); the cumulative rates free of the first episode of hepatic encephalopathy were 85%, 80%, and 65% vs 50%, 40%, and 35%,respectively(P = 0.022).CONCLUSION Transcatheter selective SMA urokinase infusion and TIPS are safe and effective for acute symptomatic PVT in cirrhosis.

Transjugular intrahepatic portosystemic shunt versus open splenectomy and esophagogastric devascularization for portal hypertension with recurrent variceal bleeding

BACKGROUND： Transjugular intrahepatic portosystemic shunt（TIPS） and open splenectomy and esophagogastric devascularization（OSED） are widely used to treat patients with portal hypertension and recurrent variceal bleeding（PHRVB）. This study aimed to compare the effectiveness between TIPS and OSED for the treatment of PHRVB.METHODS： The data were retrospectively retrieved from 479 cirrhotic patients（Child-Pugh A or B class） with PHRVB, who had undergone TIPS（TIPS group） or OSED（OSED group） between January 1, 2010 and October 31, 2014.RESULTS： A total of 196 patients received TIPS, whereas 283 underwent OSED. Within one month after TIPS and OSED, the rebleeding rates were 6.1% and 3.2%, respectively（P=0.122）. Significantly lower incidence of pleural effusion,splenic vein thrombosis, and pulmonary infection, as well as higher hepatic encephalopathy rate, shorter postoperative length of hospital stay, and higher hospital costs were observed in the TIPS group than those in the OSED group. During the follow-up periods（29 months）, significantly higher incidences of rebleeding（15.3% vs 4.6%, P=0.001） and hepatic encephalopathy（17.3% vs 3.9%, P=0.001） were observed in the TIPS group than in the OSED group. The incidence of instent stenosis was 18.9%. The survival rates were 91.3% in the TIPS group and 95.1% in the OSED group. The long-term liver function did not worsen after either TIPS or OSED.CONCLUSION： For the patients with liver function in the Child-Pugh A or B class, TIPS is not superior over OSED in terms of PHRVB treatment and rebleeding prevention.