Intrahepatic Shunt Research Articles

Hepatic venous pressure gradient and rebleeding risk of patients with nonalcoholic steatohepatitis cirrhosis after variceal bleeding.

Hepatic venous pressure gradient (HVPG) has a strong predictive value for variceal rebleeding in cirrhotic patients, but the accuracy of HVPG may be compromised in nonalcoholic steatohepatitis (NASH) cirrhosis. This study aimed to evaluate the accuracy of HVPG and portal pressure gradient (PPG) for predicting rebleeding in NASH cirrhosis after acute variceal bleeding. Thirty-eight NASH cirrhosis patients and 82 hepatitis B virus (HBV) cirrhosis patients with acute variceal bleeding were included in this study. All patients recived transjugular intrahepatic portalsystemic shunt (TIPS). The prognostic value of HVPG and PPG for variceal rebleeding was evaluated. Compared with HBV cirrhosis, NASH cirrhosis demonstrated a lower HVPG (15.3 ± 3.8 vs. 18.0 ± 4.8; p = 0.003) and lower PPG (18.0 ± 3.7 vs. 20.0 ± 3.4; p = 0.005). HVPG (AUC = 0.82; p = 0.002) and PPG (AUC = 0.72; p = 0.027) had promising prognostic value among NASH cirrhosis patients. The optimal threshold of HVPG and PPG for predicting rebleeding in NASH cirrhosis was 17 mmHg and 20 mmHg. At multivariate analysis, HVPG ≥17 mmHg was a significant predictor of variceal rebleeding (HR 9.40; 95% CI 1.85-47.70; p = 0.007). In the patients with cirrhosis and vairceal bleeding, the levels of HVPG and PPG were found to be low in NASH cirrhosis than HBV cirrhosis. However, the prevalence of rebleeding was similar between two groups. HVPG measurement is still an accurate way to assess the risk of variceal rebleeding in NASH cirrhosis.

Intrahepatic portosystemic shunts, from prenatal diagnosis to postnatal outcome: a retrospective study

ObjectiveCongenital intrahepatic portosystemic shunts (IHPSS) are rare vascular malformations resulting in blood bypassing the liver to the systemic circulation. Previous studies included symptomatic patients diagnosed postnatally, but the outcome of...

Spectrum of Liver Pathology in Dyskeratosis Congenita.

Dyskeratosis congenita (DC) is a rare multisystemic disorder associated with defective telomere maintenance. Frequent clinical manifestations of DC include reticular skin pigmentation, dystrophic nails, oral leukoplakia, and bone marrow failure. Hepatic disturbances are reported to occur in 7% of DC patients. This study aimed to evaluate the histopathologic spectrum of hepatic involvement in this disorder. DC patients with liver tissue in the pathology database at Boston Children's Hospital from 1995 to 2022 were identified. Clinical and pathologic information was documented. Thirteen specimens from 11 DC patients were included (M:F = 7:4; median age at the time of liver tissue evaluation: 18y). DC-associated gene mutations were identified in 9 patients; TERF1-interacting nuclear factor 2 ( TINF2) was the most frequently represented gene mutation, seen in 4 patients. All patients had bone marrow failure, whereas dystrophic nails, cutaneous abnormal pigmentation, and oral leukoplakia were noted in 73%, 64%, and 55% of patients, respectively. Seven patients underwent bone marrow transplants before biopsy/autopsy (median interval of 45mo). Histologically, 3 of 4 patients who presented with portal hypertension showed noncirrhotic changes (nodular regenerative hyperplasia and/or obliterative portal venopathy), whereas prominent central and sinusoidal fibrosis was noted in patients with intrahepatic shunting and those showing features of chronic passive congestion. All cases showed hepatocyte anisonucleosis. One patient developed hepatic angiosarcoma, and another 1 had colorectal adenocarcinoma metastatic to the liver. DC patients show heterogeneous histologic findings in their liver. The findings of noncirrhotic portal hypertension, intrahepatic shunting, and angiosarcoma suggest vascular functional/structural pathology as a possible unifying etiology of hepatic manifestations of DC.

Adverse events after the transjugular intrahepatic portal shunt are linked to serum metabolomic changes following the procedure.

Background and Objective: Transjugular intrahepatic portal shunt (TIPS) insertion could promote weight gain and muscle and fat mass increase in patients with cirrhosis. However, few studies have focused on metabolic changes after TIPS. This study aims to explore metabolic changes after TIPS and potential biomarkers of adverse events. Methods: Peripheral and portal serum samples were collected before and after TIPS insertion. Untargeted metabolomics was performed using ultra-high-performance liquid chromatography-mass spectrometry. Spearman's correlation analysis was used to determine the relationship between metabolites and clinical parameters. Metabolite set enrichment analysis was performed to explore enriched pathways. The predictive value of the metabolites was calculated by receiver operating characteristic curve (ROC) analysis. Results: Metabolites in the peripheral and portal serum significantly changed early after TIPS. Some lipid metabolites were significantly correlated with liver function parameters. Both elevated and depleted metabolites were mainly enriched in amino acid metabolism. Nine and 12 portal metabolites have moderate predictive value in post-TIPS liver function decline and hepatic encephalopathy (HE), separately (area under curve >0.7). Conclusion: Metabolites in the peripheral and portal veins significantly changed after TIPS. Some metabolic changes might be ascribed to liver function decline early after TIPS. Nine and 12 portal metabolites might be potential biomarkers in prediction of liver function decline and HE, separately.

The Neglected Portal Intrahepatic Shunts.

1Department of Emergency, Taihe Hospital, HuBei University of Medicine, China. Correspondence: Heng Zhang, MD. E-mail: [email protected].

Transjugular intrahepatic collateral-systemic shunt is effective for cavernous transformation of the portal vein with variceal bleeding

BackgroundThe transjugular intrahepatic portal collateral-systemic shunt (transcollateral TIPS) is used to treat portal hypertension-related complications in patients with cavernous transformation of the portal vein (CTPV) and whose main portal vein cannot be recanalized. It is still not clear whether transcollateral TIPS can be as effective as portal vein recanalization–transjugular intrahepatic portosystemic shunt (PVR–TIPS). This study aimed to evaluate the efficacy and safety of transcollateral TIPS in the treatment of refractory variceal bleeding with CTPV.MethodsPatients with refractory variceal bleeding caused by CTPV were selected from the database of consecutive patients treated with TIPS in Xijing Hospital from January 2015 to March 2022. They were divided into the transcollateral TIPS group and the PVR–TIPS group. The rebleeding rate, overall survival, shunt dysfunction, overt hepatic encephalopathy (OHE) and operation-related complications were analyzed.ResultsA total of 192 patients were enrolled, including 21 patients with transcollateral TIPS and 171 patients with PVR–TIPS. Compared with the patients with PVR–TIPS, the patients with transcollateral TIPS had more noncirrhosis (52.4 vs. 19.9%, p = 0.002), underwent fewer splenectomies (14.3 vs. 40.9%, p = 0.018), and had more extensive thromboses (38.1 vs. 15.2%, p = 0.026). There were no differences in rebleeding, survival, shunt dysfunction, or operation-related complication rates between the transcollateral TIPS and PVR–TIPS groups. However, the OHE rate was significantly lower in the transcollateral TIPS group (9.5 vs. 35.1%, p = 0.018).ConclusionTranscollateral TIPS is an effective treatment for CTPV with refractory variceal bleeding.

Diagnosis and management of ascites, spontaneous bacterial peritonitis, and hepatorenal syndrome.

Ascites is the most common decompensation-associated complication of cirrhosis leading to reduced survival. Following significant development of antimicrobial resistance and studies comparing therapeutic options, the American Association for the Study of Liver Diseases released a new guidance providing an in-depth review of those studies and updated guidelines based on expert opinions and emerging data. We review salient 2021 guidance recommendations to provide brief pearls for diagnosis and management of ascites and relevant conditions associated with decompensated cirrhosis, such as hyponatremia, hepatic hydrothorax, spontaneous bacterial peritonitis, and hepatorenal syndrome, and use of transjugular intrahepatic shunt.

Major Pulmonary Arterial Hypertension Secondary to Congenital Portosystemic Intra Hepatic Shunt: A Case Report

Congenital portosystemic shunt, also known as Abernethy malformation, is a rare vascular malformation in which the portal blood drains towards the systemic circulation eluding the liver. These shunts arise through disturbances that intervene in the embryonic development of the splanchnic circulation, or when elements that are specific to the fetal circulation (especially those regarding the ductus venous) persist beyond the intrauterine life. We present the case of an 23 men years old, followed for ventricular septal defect (VSD) and pulmonary hypertension (PHA), who was addressed to our department to realize a Computed tomography pulmonary angiography (CTPA) for suspicion an acute pulmonary embolism (APE) due to a high d-dimer level. This examination does not show direct or indirect signs of pulmonary embolism but on the other hand objective a major pulmonary arterial hypertension associated with cardiomegaly secondary to a portosystemic intrahepatic shunt. An abdominal CT scan was requested in order to detail this vascular malformation and to objectify the presence of the portal trunk by the confluence of the spleno-mesaraic trunk and the inferior mesenteric vein with the demonstration of the communication of the right portal branch with inferior vena cava. Angio-CT should be the performed whenever a vascular malformation is suspected in order to establish a correct diagnosis, because portosystemic shunts carry a high risk of severe complications.

A245 A TERTIARY CENTRE REVIEW OF PORTO-SYSTEMIC SHUNTS: AN INCREASINGLY IMPORTANT TOOL IN LIVER DISEASE MANAGEMENT

Abstract Background Portal hypertensive complications arising from chronic liver disease are increasingly prevalent. Radiologically placed porto-systemic shunts are used successfully to address complications such as ascites and recurrent variceal bleeding. Purpose We sought, with approval from ethics to electronically chart review the UHN experience for TIPSS (transjugular intrahepatic porto-systemic shunt) and DIPS (direct intrahepatic porto-caval shunt) over time. Method We employed a search strategy focused on radiologic databases, to identify UHN patients who had received a porto-systemic shunt insertion over three decades between January 1, 1990, to September 14, 2021. A total of 238 UHN patients that had a shunt imaged, re-assessed, or inserted were included in this retrospective electronic chart review. Demographic information was recorded at baseline. Data pertaining to clinical outcomes of portal hypertension such as refractory ascites, recurrent gastrointestinal bleeding and ESLD progression was recorded at baseline, 1 month, 3 months and 6 months post-shunt insertion. HVPG was recorded pre-shunt and post-shunt insertion. Transplant-free survival and post-operative complications was also assessed. Patients were followed until death or liver transplant. Result(s) Out of 238 patients confirmed, 219 had a TIPSS insertion and 19 a DIPS insertion. The average age at time of shunt was 55.1 ± 8.4 years. 53.7% (n=128) of patients were male. Indications for portosystemic shunt placement included refractory ascites (n=141), recurrent gastrointestinal bleeding (n=73), hydrothorax (n=10), hepatorenal syndrome (n=8), and portal vein thrombosis (n=4). Etiology of disease was categorized as alcohol-associated liver disease (n=107), non-alcohol associated fatty liver disease (n=36), viral hepatitis (n=27), autoimmune hepatitis (n=38) and vascular liver disease (n=20). Relevant events noted post procedure included hepatic encephalopathy (n=34), hydrothorax (n=17), vascular (including stent) thrombosis (n=17) and renal failure (n=4). 12 months post-shunt insertion 2.5% (n=6) of patients had died or received liver transplant; of these 1.7% (n=4) were transplanted. HPVG fell consistently post-procedure: 15.6 ± 1.5mmHg pre-shunt to 5.9 ± 1.2mmHg post-shunt. There was no observable increase in MELD-Na score in the first month post-shunt. Temporal trends showed that more patients aged 50 to 69, and more female patients, are now receiving shunt insertion than at the initiation of the chart review. Image Conclusion(s) Portosystemic shunt placement in the form of TIPSS or DIPS insertion is an increasingly common and effective treatment for portal hypertension in patents with advanced liver disease at UHN. Disclosure of Interest None Declared

Congenital Portosystemic Shunts: Variable Clinical Presentations Requiring a Tailored Endovascular or Surgical Approach.

Congenital portosystemic shunts (CPSS) are rare developmental anomalies resulting in diversion of portal flow to the systemic circulation. These shunts allow intestinal blood to reach the systemic circulation directly, and if persistent or large, may lead to long-term complications. CPSS can have a variety of clinical presentations that depend on the substrate that is bypassing hepatic metabolism or the degree of hypoperfusion of the liver. Many intrahepatic shunts spontaneously close by 1 year of age, but extrahepatic and persistent intrahepatic shunts require intervention by a single session or staged closure with a multidisciplinary approach. Early detection and appropriate management are important for a good prognosis. The aim of this case series is to describe the varied clinical presentations, treatment approaches, and outcomes of 5 children with CPSS at our institution. Management of these patients should involve a multidisciplinary team, including interventional radiology, surgery, hepatology, and other medical services as the patient's clinical presentation warrants. Regardless of clinical presentation, if a CPSS persists past 1-2 years of age, closure is recommended.

Hepatobiliary and Pancreatic: Hepatic mass discovered incidentally with telangiectasia.

A 48-year-old woman with no history of alcohol use or medical history was referred to our hospital for abnormal endoscopic and liver sonography findings collected at another hospital. An gastric angiodysplasia (telangiectasia) on endoscopy and two suspicious liver echogenic masses in hepatic S4 and S6 were detected. Her laboratory tests, including liver function tests and tumor markers, were within the normal ranges and the viral markers were negative. Autoimmune antibodies related to autoimmune hepatitis were negative. As she had a severe allergic reaction to the computed tomography (CT) contrast agent, she underwent liver magnetic resonance imaging (MRI) for further evaluation. The liver MRI revealed dozens of hypervascular nodules of various sizes with a central scar and diffuse vascular abnormalities with peripheral vascular obliteration (Fig. 1a). She had experienced intermittent bleeding of the tongue and several telangiectasias were observed on her tongue (Fig. 1b). The differential diagnoses included hepatocellular adenoma and multiple focal nodular hyperplasia (FNH) syndrome with primary or secondary hepatic vascular abnormalities. Osler-Weber-Rendu disease (hereditary hemorrhagic telangiectasia [HHT]) was also possible considering the diffuse vascular abnormalities in the liver and the telangiectasia on the tongue. The pathology report based on the targeted liver biopsy described a hepatocellular nodular lesion composed of bland looking hepatocytes with sinusoidal dilatation and abnormal vessels, suggesting FNH or hepatocellular adenoma; however, immunohistochemical staining did not confirm either disease (Fig. 2). On the annual MRI follow up, innumerable hypervascular nodules, irregular heterogeneous enhancement of the liver (Fig. 3a), and diffuse vascular abnormalities with peripheral vascular obliteration (Fig. 3b) were the major findings, with no changes seen from the previous exam. Given that the pathology report did not definitively diagnose hepatocellular adenoma or multiple FNH syndrome, a hepatic vascular disorder such as HHT was considered in the differential diagnosis and genetic testing was performed. HHT is an autosomal dominant inherited disorder that affects the vasculature and is considered a rare disease, with a prevalence of 1 in 5000 or 1 in 10 000 births. The pathogenesis of HHT is a heterozygous mutation in the endoglin (ENG) gene or the activin receptor-like kinase type 1 gene, both of which are associated with the transforming growth factor-β superfamily signaling pathway, expressed mostly in the vascular endothelium. As 97% of patients with definite HHT carry a mutation in one of three genes, including ENG, a mutation in a locus mapped to chromosome 5, or an activin receptor-like kinase-1 (ACVRL1), we consulted the genetics department to evaluate the patient for HHT. HHT has traditionally been diagnosed based on clinical features (the Curacao criteria), but can now also be diagnosed by genetic testing. HHT is clinically suspected if two of the four Curacao criteria are met (family history of the disease, hemorrhage, telangiectasia, and visceral involvement) and definite if more than three of the criteria are met. The presence of intrahepatic shunts, disseminated intraparenchymal telangiectases, and other vascular lesions are the typical findings of hepatic involvement. In this patient, three (epistaxis, telangiectasia, and visceral involvement) of the four Curacao criteria were satisfied, leading to a definite diagnosis of HHT. Next-generation sequencing (NGS) panel performed also showed heterozygous mutation of the ACVRL1 (ALK1) gene, which is consistent with HHT type 2.

Agreement between Wedged Hepatic Venous Pressure and Portal Pressure in Hepatic Sinusoidal Obstruction Syndrome.

Wedge hepatic vein pressure (WHVP) accurately estimates the portal pressure (PP) in chronic sinusoidal portal hypertension patients. Whether this applies to patients with acute portal hypertension due to hepatic sinusoidal obstruction syndrome (HSOS) is unclear. Our aim was to assess the agreement between WHVP and PP in patients with HSOS by comparing them to decompensated cirrhosis patients. From December 2013 to December 2021, patients with pyrrolidine alkaloid-induced HSOS (PA-HSOS) receiving hepatic venous pressure gradient (HVPG) measurement and transjugular intrahepatic portosystem shunt (TIPS) were retrospectively collected and matched with those of patients with virus- or alcohol-related cirrhosis as a cirrhosis group. Pearson's correlation (R), intraclass correlation coefficient (ICC), scatter plots, and the Bland-Altman method were performed for agreement evaluation. A total of 64 patients were analyzed (30 PA-HSOS and 34 cirrhosis groups). The correlation between WHVP and PP was moderate in the PA-HSOS group (R: 0.58, p = 0.001; ICC: 0.68, p = 0.002) but good in the cirrhosis group (R: 0.81, p < 0.001; ICC: 0.90, p < 0.001). The percentage of patients with inconsistent WHVP and PP in the two groups was 13 (43.3%) and 15 (26.5%) (p = 0.156), respectively, and an overestimation of PP was more common in the PA-HSOS group (33.3% vs. 2.9%, p = 0.004). HVPG and portal pressure gradient (PPG) consistency was poor in both groups (R: 0.51 vs. 0.26; ICC: 0.65 vs. 0.41; p < 0.05). WHVP in patients with PA-HSOS did not estimate PP as accurately as in patients with virus- or alcohol-related cirrhosis, which was mainly due to PP overestimation.

Living donor liver transplantation in a pediatric patient having intrahepatic portocaval shunt with congenital absence of the intrahepatic portal vein

Living donor liver transplantation in a pediatric patient having intrahepatic portocaval shunt with congenital absence of the intrahepatic portal vein

Intrahepatic arterioportal shunt with portal-hypertension caused by liver biopsy after living-donor liver transplantation: a case report

Intrahepatic arterioportal shunt with portal-hypertension caused by liver biopsy after living-donor liver transplantation: a case report

Perinatal Outcomes According to the Type of Prenatally Diagnosed Umbilical-Portal-Systemic Venous Shunt

Background: The abnormal course of the umbilical vein and the absence or displacement of the portal vein or ductus venosus may suggest the presence of other shunts. In recent years, an in utero classification of umbilical-portal-systemic venous shunts (UPSVS) has been introduced. This study aims to report our experience with the prenatal diagnosis of UPSVS and to evaluate the perinatal outcomes of fetuses with different types of UPSVS. Methods: This was a retrospective study of fetuses prenatally diagnosed with UPSVS between January 2005 and September 2020 at Asan Medical Center. UPSVS was prenatally classified into three types according to the anatomical origin of the shunt: type I, umbilical-systemic shunt; type II, ductus venosus-systemic shunt; and type III, portal-systemic shunt. Type III was further divided into two subtypes: type IIIa, intrahepatic shunt; type IIIb, extrahepatic shunt. Postnatal ultrasonography or abdominal computed tomography (CT) was performed to confirm UPSVS. Results: Out of 18 fetuses prenatally diagnosed with UPSVS, four were excluded. All four patients were confirmed to have portal vein variations without a shunt. The median gestational age at the diagnosis of the remaining 14 fetuses was 30.3 weeks (range, 23.1–37.3). The median gestational age at birth was 37.2 weeks (range, 31.0–39.3), and the median birth weight was 2105 g (range, 1350–2870), including nine (64%) who had body weights below the 10th percentile. Eleven patients (79%) had combined anomalies; cardiomegaly and fetal hydrops were observed in eight (57%) and two (14%) patients, respectively. Among the 11 patients who underwent chromosomal analysis, three had abnormal results. Two infants with abnormal karyotypes died. The most common type was type I (8, 57%), followed by type IIIa (4, 29%), type II (1, 7%), and type IIIb (1, 7%). In type I, all but one patient had structural anomalies; five (63%) showed cardiomegaly and five (63%) were associated with growth restriction. Nevertheless, half of the patients survived without major anomalies. In type IIIa, three (75%) patients were associated with growth restriction, but they showed catch-up growth after birth. All patients had mild transient hyperammonemia. One type II patient was associated with cardiomegaly, fetal hydrops, and an abnormal karyotype. One type IIIb patient had multiple anomalies and an abnormal karyotype. No surgical correction was required because of the UPSVS. Conclusions: Prenatal diagnosis of UPSVS is feasible. When an abnormal course of the umbilical or portal vein is detected on the transverse abdominal view, UPSVS should be suspected. UPSVS is commonly associated with structural anomalies, chromosomal anomalies, growth restriction, and cardiomegaly. UPSVS without associated anomalies may have a favorable prognosis. Our study can help predict the prognosis of UPSVS and assist in prenatal counseling.

The change in the liver volume after direct intrahepatic portocaval shunt in patients with Budd-Chiari syndrome with diffuse hepatic vein occlusion.

To evaluate the changes in the liver volume and function after direct intrahepatic portocaval shunt (DIPS) in patients with Budd-Chiari syndrome (BCS) with diffuse hepatic vein (HV) occlusion. The clinical data of 29 patients with BCS who underwent DIPS for intractable ascites caused by diffuse hepatic vein occlusion in the Affiliated Hospital of Xuzhou Medical University were analysed retrospectively; the patients included 8 males and 21 females, with an average age of 33.3 ± 6.3years. The patients underwent abdominal CT scanning and liver function examinations before DIPS, and 1week, 3months, 6months and 12months after DIPS. The changes of the liver volume and liver function before and after DIPS were compared. All 29 patients underwent DIPS successfully. 28 patients survived during the follow-up of 12-33months, with a median follow-up of 16months. The patients' liver function were significantly improved at 3, 6 and 12months after the operation compared to before the operation (P < 0.05). The liver volumes measured before the operation and 1week, 3months, 6months and 12months after the operation were 2124.586 ± 420.889 cm3, 1926.263 ± 372.268 cm3, 1480.592 ± 183.061 cm3, 1461.904 ± 153.027 cm3 and 1469.286 ± 148.549 cm3, respectively. Compared with the preoperative liver volume, the liver volume had decreased significantly at 1week, 3months, 6months and 12months after the operation (P < 0.05). However, there was no significant difference in the liver volumes at 6 and 12months after the operation (P = 0.35). Direct intrahepatic portocaval shunt has achieved satisfactory clinical results in the treatment of BCS with diffuse hepatic vein occlusion. The congestive hepatomegaly was gradually reduced after the operation. The liver volume (which was defined as the clinical efficacy in this study) remained stable after 6months.

S3320 An Intrahepatic Portosystemic Shunt Masquerading as a Tumor

Introduction: Portosystemic shunts can be congenital or acquired and are divided into extrahepatic and intrahepatic shunts. Intrahepatic portosystemic venous shunts (IPSVSs) are abnormal intrahepatic connections that occur between branches of the portal vein (PV) and hepatic veins (HV) or IVC. Patients with IPSVSs can be symptomatic or asymptomatic as most of the cases are detected incidentally on imaging. However, they can potentially lead to long term complications by allowing bypass of mesenteric venous return into systemic circulation without going through the liver. We herein describe the case of a 58-year-old woman who was incidentally found to have an IPSVS on imaging for which she was recommended periodic surveillance imaging. Case Description/Methods: A 58-year-old woman was undergoing workup for weight loss and was noted to have a 2.3 x 2.0 cm hyperdense nodular lesion in the posterior segment of the right hepatic lobe suspicious for hemangioma or a hypervascular neoplasm on CT abdomen pelvis. She was referred to the hepatobiliary clinic and a CTA abdomen pelvis was then performed and showed a lobulated 2.2 x 2.1 x 2.9 cm lesion in segment 6 consistent with an intrahepatic portosystemic shunt (figure 1). The patient was otherwise asymptomatic and therefore was advised to continue with periodic imaging surveillance. Discussion: IPSVSs are divided into 4 types depending on their morphology. In type 1, a single large vessel connects the PV or its right branch to the IVC. Type 2 involves a localized peripheral shunt within one hepatic segment that has one or more communications between peripheral branches of the PV and HV. In type 3, an aneurysmal connection exists between PV and HV. And finally, multiple communications between PV and HV in multiple lobes are present in type 4. In patients without a history of liver disease or trauma, the origin of the IPSVS is presumed to be congenital. CT scan, MRI and even color Doppler sonograms should provide visualizations of the feeding portal vein and draining hepatic vein. For symptomatic IPSVSs, endovascular closure is the standard of care. However, no consensus exists for asymptomatic cases and surveillance is an appropriate option in asymptomatic patients.Figure 1.: Axial CTA abdomen venous phase showing aneurysmal communication (red arrow) between right portal vein (yellow arrow) and middle hepatic vein (green arrow) in segment 6 of the liver.

Hepatic venous pressure gradient (HVPG) predicts liver failure after transjugular intrahepatic portal shunt: a retrospective cohort study.

Esophagogastric variceal bleeding is a serious complication of decompensated cirrhosis. Transjugular intrahepatic portal shunt (TIPS) is a salvage treatment with clear hemostatic results. However, various complications may occur after TIPS, including postoperative liver failure, and the prognosis is very poor once occurs. Liver failure is a common symptom of severe liver disease with a high mortality rate. This study investigated the incidence of liver failure after TIPS treatment for varicose bleeding. We analyzed the data of patients admitted to the First Affiliated Hospital of Soochow University between January 2013 and December 2018 with portal hypertension with an episode of acute gastroesophageal variceal bleeding. A total of 121 patients were referred to the regional liver unit for TIPS. Hepatic venous pressure gradient (HVPG) and clinical data were collected. Patients with incomplete data were excluded, and 93 patients were ultimately enrolled in the study. Primary outcomes were morbidity and hospital mortality within 4 weeks of surgery. The data were retrospectively and consecutively collected and evaluated by univariate and multivariate analyses to identify risk factors of liver failure. The patients included 58 males (62.37%) and 35 females (37.63%), and the mean age was 58.43±11.85 years. The main cause was hepatitis B virus (HBV), which was found in 50.54% of patient. The overall surgical success rate was 83.87% (78/93). Of 15 treatment-failure patients, 9 (9.68%) died in hospital. Four patients died of liver failure, accounting for 44.44% of postoperative all-cause deaths. Univariate logistic regression analysis showed that only hepatic venous pressure gradient (HVPG) was an independent risk factor for post-TIPS morbidity [relative risk (RR) 1.156; 95% confidence interval (CI): 1.041 to 1.283; P=0.006]. In addition, HVPG was an independent risk factor for hospital mortality within 4 weeks (RR 1.133; 95% CI: 1.021 to 0.539; P=0.016). Post-TIPS liver failure is a serious complication in patients with cirrhosis. Pre-TIPS HVPG level may be used as a predictor of potential short-term postoperative adverse events.

S1181 Beta-Blockers Protective of Decompensated Congestive Heart Failure (dCHF) in Patients With Cirrhosis After Transjugular Intrahepatic Shunt (TIPSS)

S1181 Beta-Blockers Protective of Decompensated Congestive Heart Failure (dCHF) in Patients With Cirrhosis After Transjugular Intrahepatic Shunt (TIPSS)

Reduction of Hepatopulmonary and Intrahepatic Shunts after Treatment with Sorafenib in Hepatocellular Carcinoma Patients.

To investigate the reduction of elevated shunts after treatment with sorafenib in hepatocellular carcinoma (HCC) patients planned for transarterial radioembolization (TARE). Sixteen HCC patients treated with sorafenib were investigated. Shunts were evaluated by SPECT/CT after Technetium-99m Tc-macroaggregated albumin injection. All patients had high LSF (median 43.5%, range 28-86), and two (12.5%) of them had widespread intrahepatic shunts with concomitants elevated (36%) and acceptable (18%) lung shunt fraction (LSF). The mean duration of the sorafenib use was 134.4 ± 59.2days. While one patient (6.25%) developed hand-foot syndrome, minor side effects were seen in all patients. After sorafenib use, LSF fell below 20% in eight patients, and TARE was applied to all of them. There was strong negative correlation between the failure of shunt reduction and presence of macrovascular invasion (ρ = -0.775) and infiltrative tumour type (ρ = -0.775). Sorafenib use may be beneficial in some selected HCC patients with elevated shunts. Expected results may not be obtained in patients with infiltrative tumour type or macrovascular invasion, but patients with nodular tumour type with the absence of macrovascular invasion may be appropriate candidates for shunt reduction with ensuring subsequent TARE. Further investigations with sufficient patient population and standardized protocols of follow-up periods are needed to clarify the values for sorafenib use in HCC patients with evaluated shunts.