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.

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 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.

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.

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.

Treatment of portosystemic shunt-borne hepatic encephalopathy in a 97-year-old woman using balloon-occluded retrograde transvenous obliteration:A case report

BACKGROUND Hyperammonemia and hepatic encephalopathy are common in patients with portosystemic shunts.Surgical shunt occlusion has been standard treatment,although recently the less invasive balloon-occluded retrograde transvenous obliteration(B-RTO)has gained increasing attention.Thus far,there have been no reports on the treatment of portosystemic shunts with B-RTO in patients aged over 90 years.In this study,we present a case of hepatic encephalopathy caused by shunting of the left common iliac and inferior mesenteric veins,successfully treated with B-RTO.CASE SUMMARY A 97-year-old woman with no history of liver disease was admitted to our hospital because of disturbance of consciousness.She had no jaundice,spider angioma,palmar erythema,hepatosplenomegaly,or asterixis.Her blood tests showed hyperammonemia,and abdominal contrast-enhanced computed tomography revealed a portosystemic shunt running between the left common iliac vein and the inferior mesenteric vein.She was diagnosed with hepatic encephalopathy secondary to a portosystemic shunt.The patient did not improve with conservative treatment:Lactulose,rifaximin,and a low-protein diet.B-RTO was performed,which resulted in shunt closure and improvement in hyperammonemia and disturbance of consciousness.Moreover,there was no abdominal pain or elevated levels of liver enzymes due to complications.The patient was discharged without further consciousness disturbance.CONCLUSION Portosystemic shunt-borne hepatic encephalopathy must be considered in the differential diagnosis for consciousness disturbance,including abnormal behavior and speech.

Application of transmesenteric vein extrahepatic portosystemic shunt in treatment of symptomatic portal hypertension with cavernous transformation of portal vein

Purpose:To evaluate the feasibility and efficacy of a transmesenteric vein extrahepatic portosystemic shunt(TmEPS)for the treatment of cavernous transformation of the portal vein(CTPV).Materials and methods:The clinical data of 20 patients with CTPV who underwent TmEPS between December 2020and January 2022 at Henan Provincial People’s Hospital were retrospectively collected.The superior mesenteric vein(SMV)trunk was patent or partially occluded in these patients.An extrahepatic portosystemic shunt between the inferior vena cava and the SMV was established using a stent graft through an infraumbilical median longitudinal mini-laparotomy.The technical success,efficacy,and complication rates were evaluated,and the preand postoperative SMV pressures were compared.Patients’clinical outcomes and shunt patency were assessed.Results:TmEPS was successfully performed in 20 patients.The initial puncture success rate of the balloon-assisted puncture technique is 95%.The mean SMV pressure decreased from 29.1±2.9 mmHg to 15.6±3.3 mmHg(p<0.001).All symptoms of portal hypertension resolved.No fatal procedural complications occurred.During the follow-up period,hepatic encephalopathy occurred in two patients.The remaining patients remained asymptomatic.All shunts were patent.Conclusions:TmEPS is a feasible,safe,and effective treatment option for patients with CTPV.

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.

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.

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.

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.

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.

Transjugular intrahepatic portosystemic shunt in cirrhosis: An exhaustive critical update

More than five decades after it was originally conceptualized as rescue therapy for patients with intractable variceal bleeding,the transjugular intrahepatic portosystemic shunt(TIPS)procedure continues to remain a focus of intense clinical and biomedical research.By the impressive reduction in portal pressure achieved by this intervention,coupled with its minimally invasive nature,TIPS has gained increasing acceptance in the treatment of complications of portal hypertension.The early years of TIPS were plagued by poor long-term patency of the stents and increased incidence of hepatic encephalopathy.Moreover,the diversion of portal flow after placement of TIPS often resulted in derangement of hepatic functions,which was occasionally severe.While the incidence of shunt dysfunction has markedly reduced with the advent of covered stents,hepatic encephalopathy and instances of early liver failure continue to remain a significant issue after TIPS.It has emerged over the years that careful selection of patients and diligent post-procedural care is of paramount importance to optimize the outcome after TIPS.The past twenty years have seen multiple studies redefining the role of TIPS in the management of variceal bleeding and refractory ascites while exploring its application in other complications of cirrhosis like hepatic hydrothorax,portal hypertensive gastropathy,ectopic varices,hepatorenal and hepatopulmonary syndromes,non-tumoral portal vein thrombosis and chylous ascites.It has also been utilized to good effect before extrahepatic abdominal surgery to reduce perioperative morbidity and mortality.The current article aims to review the updated literature on the status of TIPS in the management of patients with liver cirrhosis.

Percutaneous transhepatic intrahepatic portosystemic shunt for variceal bleeding: A series of six cases and literature review

Objectives:To present a case series of modified transjugular intrahepatic portosystemic shunts(TIPS) and percutaneous transhepatic intrahepatic portosystemic shunts(PTIPS) in cirrhotic patients with variceal bleeding(VB).In addition,the scientific literature pertaining to PTIPS was reviewed.Methods:This retrospective clinical case series included six cirrhotic patients with VB who were treated with PTIPS after the failure of endoscopic band ligation or endoscopic injection sclerotherapy combined with vasoactive drugs.The treatment was conducted between January 2017 and June 2019 at a single institution.Three patients suffered from severe atrophy of the right or left lobar of the liver as well as the main right or left branch of the portal vein.The remaining three patients showed severe atrophy of the whole liver and portal vein,resulting in widening of the liver fissure.A paired t-test was used to compare the changes in portal pressure gradient between before and after the PTIPS operation.The rebleeding rate,treatment efficacy,complications,and technical success rate were all assessed during follow-up.Results:All six PTIPS procedures were performed successfully,with no severe procedural-related complications observed.None of the patients experienced VB during a mean follow-up of 22.8(range,18.0-28.0) months.The mean portosystemic pressure gradient decreased from 28.3 ± 4.3 mmHg pre-procedure to 12.3 ± 2.6 mmHg immediately post-procedure(P <0.001).At follow-up,one patient was found to have developed grade 2 hepatic encephalopathy thrice during the first year,according to the West Haven criteria.However,this was resolved following medical treatment.Conclusions:When the patient’s portal venous anatomy is unconducive to the performance of TIPS using the transjugular approach,PTIPS can be considered as a safe,effective complementary surgical approach for patients with VB.

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.

Effect of initial stent position on patency of transjugular intrahepatic portosystemic shunt

AIM To evaluate the effect of initial stent position on transjugular intrahepatic portosystemic shunt(TIPS).METHODS We studied 425 patients from January 2004 to January 2015 with refractory ascites or variceal bleeding who required TIPS placement. Patients were randomly divided into group A(stent in hepatic vein, n = 57), group B(stent extended to junction of hepatic vein and inferior vena cava, n = 136), group C(stent in left branch of portal vein, n = 83) and group D(stent in main portal vein, n = 149). Primary unassisted patency was compared using Kaplan-Meier analysis, and incidence of recurrence of bleeding, ascites and hepatic encephalopathy(HE) were analyzed.RESULTS The mean primary unassisted patency rate in group B tended to be higher than in group A at 3, 6 and 12 mo(P = 0.001, 0.000 and 0.005), and in group D it tended to be lower than in group C at 3, 6 and 12 mo(P = 0.012, 0.000 and 0.028). The median shunt primary patency time for group A was shorter than for group B(5.2 mo vs 9.1 mo, 95%CI: 4.3-5.6, P = 0.013, logrank test), while for group C it was longer than for group D(8.3 mo vs 6.9 mo, 95%CI: 6.3-7.6, P = 0.025, log-rank test). Recurrence of bleeding and ascites in group A was higher than in group B at 3 mo(P = 0.014 and 0.020), 6 mo(P = 0.014 and 0.019) and 12 mo(P = 0.024 and 0.034. Recurrence in group D was higher than in group C at 3 mo(P = 0.035 and 0.035), 6 mo(P = 0.038 and 0.022) and 12 mo(P = 0.017 and 0.009). The incidence of HE was not significantly different among any of the groups(P = 0.965).CONCLUSION The initial stent position can markedly affect stent patency, which potentially influences the risk of recurrent symptoms associated with shunt stenosis or occlusion.

Transjugular intrahepatic portosystemic shunt for pyrrolizidine alkaloid-related hepatic sinusoidal obstruction syndrome

BACKGROUND Treatments for hepatic sinusoidal obstruction syndrome(HSOS)are limited.AIM To evaluate transjugular intrahepatic portosystemic shunting(TIPS)as a treatment for pyrrolidine alkaloid-related HSOS(PA-HSOS).METHODS This retrospective analysis included patients with PA-HSOS admitted to the First Affiliated Hospital of the University of Science and Technology of China(June 2015 to January 2019).Baseline clinical characteristics and follow-up data were extracted from the medical records.All patients included in this study experienced failure of initial therapy.Patients were divided into the TIPS and conservative treatment groups according to the therapy they received.Liver function,maximal ascites depth,imaging characteristics,pathology findings,and survival were compared between groups.RESULTS The TIPS group included 37 patients(28 males),and the conservative treatment group included 17 patients(11 males).Baseline characteristics were similar between groups.There were two deaths in the TIPS group and seven deaths in the conservative treatment group during follow-up(3-48 mo).The 3-,6-,12-and 24-mo survival rates were 94.6%,94.6%,94.6%and 94.6%,respectively,in the TIPS group and 70.6%,57.8%,57.8%and 57.8%,respectively,in the conservative treatment group.Kaplan-Meier analysis revealed significantly longer survival for the TIPS group than for the conservative treatment group(P=0.001).Compared with the pre-treatment value,maximal ascites depth was significantly lower at 1 wk,2 wk,1 mo,and 3 mo for the TIPS group(all P<0.05)but not in the conservative treatment group.Contrast-enhanced computed tomography demonstrated the disappearance of patchy liver enhancement after TIPS.Pathology showed that liver congestion and hepatocyte swelling improved with time after TIPS placement.CONCLUSION TIPS may achieve better outcomes than conventional symptomatic treatment in patients with PA-HSOS.

Transjugular intrahepatic portosystemic shunt for Budd-Chiari syndrome:A comprehensive review

Budd-Chiari syndrome(BCS)is a relatively rare clinical condition with a wide range of symptomatology,caused by the obstruction of the hepatic venous outflow.If left untreated,it has got an high mortality rate.Its management is based on a step-wise approach,depending on the clinical presentation,and includes different treatment from anticoagulation therapy up to Interventional Radiology techniques,such as transjugular intrahepatic portosystemic shunt(TIPS).TIPS is today considered a safe and highly effective treatment and should be recommended for BCS patients,including those awaiting orthotopic liver transplantation.In this review the pathophysiology,diagnosis and treatment options of BCS are presented,with a special focus on published data regarding the techniques and outcomes of TIPS for the treatment of BCS.Moreover,unresolved issues and future research will be discussed.