Intrahepatic Shunt Research Articles

Agenesis of Ductus Venosus: A Case Series

Ductus venosus agenesis is a rare anomaly which is significantly associated with cardiac, extracardiac and chromosomal anomalies. The prognosis depends on its association with other congenital abnormalities independent of the type of shunt. The aim of this study was to evaluate the ductus venosus in 2nd trimester scans and to evaluate associated congenital malformations associated with agenesis of the ductus venosus and its feto-neonatal outcome. We performed a retrospective study for a 5 year period from November 2015 to November 2019. Of the 8 cases seen, 2 (25%) had an intrahepatic shunt and 6 (75%) presented with extrahepatic umbilical venous drainage. Agenesis of ductus venosus was associated in 5 cases (62%) with cardiac abnormalities, 6 cases (75%) with extracardiac anomalies and 3 (37%) cases with chromosomal abnormality. Our study showed poorer outcome in fetuses associated with both cardiac and extracardiac anomalies accounting for 75% of all cases whereas intrahepatic type with mild cardiomegaly had favourable pregnancy outcome. Agenesis of ductus venosus is significantly associated with fetal cardiac and extracardiac abnormalities independent of the type of umbilical venous drainage. Extrahepatic umbilical venous drainage even if isolated has the significant risk of congestive heart failure, hydrops and/or intrahepatic portal venous system anomalies. The intrahepatic type has better prognosis if associated with no or minor abnormality.

Role of Endoscopic Ultrasound to Assess and Manage Portal Hypertension

AbstractPortal hypertension leads to the development of varices along the gastrointestinal tract. Endoscopy plays an important role in the diagnosis and management of varices. Endosonography (EUS) enables visualization and permits access to varices and veins outside the gastrointestinal tract. EUS has emerged as an important tool, with the ability to identify vascular changes, treat gastric and ectopic varices, perform portal pressure measurements, portal venography, and intrahepatic shunt placement. This review discusses the role of endoscopy and the emerging role of EUS in evaluation and management of portal hypertension.

Liver resection for a congenital intrahepatic portosystemic shunt in a child with hyperammonemia and hypermanganesemia: a case report

BackgroundCongenital portosystemic shunt (CPSS) is a rare malformation that leads to hyperammonemia, hypermanganesemia, and various symptoms. CPSSs are divided into intrahepatic and extrahepatic shunts. In patients with persistent CPSS including an intrahepatic portosystemic shunt (IPSS), early intervention to occlude the shunt reverses the associated complications.Case presentationThe patient was a 1-year-and-7-month-old girl. She presented with hypergalactosemia and elevation of blood ammonia level (75 μg/dL) and total bile acid levels (68.2 μmol/L) during the neonatal period. Two IPSSs were detected using ultrasound and enhanced computerized tomography. Magnetic resonance imaging (MRI) at 1 year and 3 months of age showed abnormally high signal intensity in the pallidum of her brain. Spontaneous closure was not observed. We performed a right hepatectomy at 1 year and 7 months of age. The portal vein pressure was 16 mmHg after temporary occlusion of the right portal vein. Blood ammonia and serum manganese levels decreased immediately after the operation. The abnormal signal on brain MRI disappeared. She had a favorable course with no sign of recurrence of IPSS 5 years postoperatively.ConclusionLiver resection for an IPSS to control the symptoms of a portosystemic shunt is reasonable in a child for whom interventional radiological treatment is not indicated.

Clinical application and efficacy of TIPS combined with AngioJet mechanical thrombectomy for liver cirrhosis with extensive portal vein thrombosis

Objective: To assess the safety and efficacy of transjugular intrahepatic portosystemic shunt (TIPS) combined with AngioJet mechanical thrombectomy for liver cirrhosis with extensive portal vein thrombosis. Methods: From March 2018 to April 2019, a total of 11 patients with liver cirrhosis and extensive portal vein thrombosis were treated by TIPS combined with AngioJet mechanical thrombectomy, including 6 males and 5 females, with the age of 37-71 (46±9) years old, 3 cases of Child-Pugh grade A, 8 cases of grade B and 0 cases of grade C. The intraoperative immediate thrombus clearance rate, perioperative complication rate, postoperative thrombus recurrence rate, rebleeding rate, the incidence of hepatic encephalopathy and the rate of stent patency of all cases were collected and analyzed. Results: All the patients were treated successfully. The immediate complete thrombus clearance (grade Ⅲ) rate of portal vein trunk was 9/11, and grade Ⅱ was 2/11, The average dose of urokinase was 30-60 (40±5) ten thousand U, slight puncture point bleeding occurred in 3 cases, and recurrence of PVT in portal vein trunk occurred in 1 case with Ⅱ grade clearance rate after operation, rebleeding occurred in 1 case, hepatic encephalopathy occurred in 2 cases, the primary patency rate of stents was 9 cases. Conclusion: TIPS combined with AngioJet mechanical thrombectomy can treat the liver cirrhosis with extensive portal vein thrombosis effectively and safely, and postoperative portal vein patency rate and intrahepatic shunt patency rate are high.

3:45 PM Abstract No. 252 Retrospective review of the safety and efficacy of 12-mm-diameter PTFE-covered stents in transjugular intrahepatic portosystemic shunt creation: a single institution’s experience

The objective of this study is to evaluate the efficacy, complications, and 30-day mortality of transjugular intrahepatic portosystemic shunt (TIPS) creation performed using 12 mm internal diameter polytetrafluoroethylene (PTFE)-covered stents in patients with portal hypertension and variceal hemorrhage. We retrospectively reviewed the medical records of 27 patients who underwent transjugular intrahepatic porsosytemic shunt (TIPS) creation from March of 2014 to December of 2016, using 12 mm PTFE covered stents (VIATORR, Gore Medical, AZ) for variceal hemorrhage. Patient demographics, porto-systemic gradients, clinical follow-up, including rate of variceal hemorrhage and hepatic encephalopathy were reviewed. A total of 27 patients were identified (mean age, 50.5 years [± 9.2]; 17 male). Of the 27 patients, 2 were lost to follow-up. Most common underlying etiologies of cirrhosis were alcohol use (41%), HCV (19%), and non-alcoholic steatohepatitis (NASH, 19%). Other etiologies included autoimmune hepatitis, primary biliary cirrhosis, and Budd-Chiari syndrome. The mean portosystemic gradient before TIPS was 18.5 mm Hg (± 8.9, CI 15.0 – 22.1). Mean portosystemic gradient after TIPS was 4.1 mm Hg (± 2.6, CI 3.2–5.1). During a mean follow-up period of 35 months, rate of recurrent variceal hemorrhage was 4.5% (1 of 22 patients). Rate of new-onset hepatic encephalopathy after TIPS was 34% (9 of 24 patients). 30-day post procedure mortality rate was 15% (4 of 27 patients). Three of the four deaths were a result of cardiac arrest, which happened prior to TIPS deployment in an emergent setting. No instances of repeat intervention were recorded in the follow-up period. The placement of a 12 mm PTFE-covered stent during TIPS creation in cirrhotic patients with variceal bleeding appears more efficacious without increased complication rate compared to published literature for 8 and 10 mm diameter stents.

Abstract No. 645 Clinical experience with transjugular intrahepatic portosystemic shunt downsizing in patients with severe hepatic encephalopathy

The purpose of this study was to evaluate the outcomes of Transjugular Intrahepatic Shunt (TIPS) downsizing in the setting of severe hepatic encephalopathy. Data regarding outcomes and factors influencing these outcomes is relatively scarce. This follows a cohort of patients at a tertiary care center who underwent TIPS revision, in an effort to determine the efficacy and complication rate of the intervention. A list of patients with underlying cirrhosis undergoing TIPS procedures between 2013-2019 at a large volume tertiary care center was obtained. Data collected included patient demographics, reason for TIPS, whether downsizing occurred, reason for downsizing, frequency of paracentesis prior to and after downsizing, grade of hepatic encephalopathy prior to and after downsizing, MELD labs prior to and after downsizing, IR technique used for downsizing, whether patients were liver transplant candidates and/or underwent transplantation, and mortality. A total of 195 patients underwent TIPS placement between 2013-2019. Of those, 16 patients required TIPS downsizing using a balloon-expandable covered stent. The mean MELD was 18.4 just prior to downsizing and 17.6 one week after downsizing. The mean portosystemic gradient was 10.5 mm Hg before downsizing and 22.8 mm Hg after downsizing. TIPS downsizing was successful in decreasing the degree of hepatic encephalopathy from an average of grade 2.8 to grade 0.8 encephalopathy. Nine patients died with post-downsizing gradients of 28-29 mm Hg being among the highest. The two patients who survived to transplant within 8 months of their TIPS had pre and post-downsizing MELD scores of 15 or less. The results of the study suggest TIPS downsizing is effective in reducing hepatic encephalopathy. Most patients who were considered transplant candidates undergoing TIPS downsizing did not survive to transplant unless they were transplanted relatively shortly after TIPS, suggesting that TIPS/downsizing served more as short-term bridge to transplant in these patients. Those that died expectedly had higher MELD scores and post-downsizing portosystemic gradients. Limitations of this study are the small patient size and that it was single center.

Anesthetic Considerations in Hepatic Transplant in a Patient With Rendu-Osler-Weber Syndrome: A Case Report

Hereditary hemorrhagic telangiectasia (HHT), or Rendu-Osler-Weber syndrome, is an autosomal dominant vascular disorder with low prevalence that presents a wide variety of clinical manifestations due to multiple vascular lesions in a wide variety of organs and tissues. Orthotopic liver transplantation is the only treatment option for arteriovenous malformation in HHT. These patients require complicated anesthetic management. We present the case of a 63-year-old woman with HHT of 18 years’ evolution, intrahepatic portal systemic shunts, and severe pulmonary hypertension, with dyspnea at minimum effort.

Clinical value of portal venous pressure based on three dimensional reconstruction model of portal vein combined with finite element analysis in patients with portal hypertension

Objective To study the clinical value of three-dimensional CT reconstruction model of portal venous system combined with finite element analysis to measure portal venous pressure in patients with portal hypertension. Methods A retrospective study was conducted on 27 patients who were diagnosed to have portal hypertension at the Second Affiliated Hospital of Kunming Medical University from May 2016 to May 2018. There were 17 males and 10 females, with ages ranging from 34 to 77 years (mean 56 years). All these patients underwent transjugular intrahepatic portal venous shunt (TIPS) during which the portal venous pressure was measured. The imaging data was imported into the three-dimensional software of medical imaging to reconstruct the three dimensional model of portal vein, and the finite element analysis software of ANSYS was used to calculate the portal venous pressure by calculation with given boundary conditions. Pearson correlation was used to analyze the correlation between the actual measurement of portal venous pressure and the predicted value. Results The actual measured value of portal vein pressure before TIPS in 27 patients with portal hypertension was (3 783±930) Pa, and the predicted value was (4 238±1 218) Pa. There was no significant difference (P>0.05). The predicted value of portal venous pressure was positively correlated with the actual measured value (r=0.402, 95%CI: 0.026-0.678, P<0.05). Conclusion Non-invasive measurement of portal venous pressure based on three-dimensional portal venous reconstruction combined with finite element analysis correlated with actual portal venous pressure in patients with portal hypertension. Key words: Hypertension, portal; Imaging, three-dimensional; Multislice spiral computerized tomography; Correlation

Outcome of non-surgical dietary treatment with or without lactulose in dogs with congenital portosystemic shunts

Background Congenital portosystemic shunts (CPSS) are vascular anomalies, allowing portal blood to bypass the hepatic parenchyma, thereby accumulating toxic substances such as ammonia in the systemic circulation resulting in hepatic encephalopathy. Aim To evaluate the outcome of non-surgically treated dogs with a CPSS. Methods Case records of 78 dogs with a single congenital CPSS confirmed by ultrasound and/or computed tomography between September 2003 and February 2015 were reviewed. Median age at diagnosis of CPSS in dogs was 10.8 months (range 2–133 months). Non-surgical treatment was started as an adjusted diet (a diet restricted in protein) with or without lactulose. Owners were contacted by telephone to determine survival time and presumed cause of death, if applicable. In addition, a questionnaire was used to retrospectively assess quality of life (QoL) and CPSS scores in 37 dogs before and during non-surgical treatment. Differences between Kaplan–Meier curves were tested by a Log rank test. Results Overall estimated median survival time (EMST) was 38.5 months (range 1 day − 91 months; 78 dogs). No significant differences between EMSTs were found between dogs with extra- (n = 48) or intrahepatic (n = 29) shunts, nor between treatment with only an adjusted diet, or an adjusted diet combined with lactulose. During non-surgical treatment, significant improvement in perceived QoL and CPSS scores were found (P < 0.01). Conclusion Our study demonstrated that an overall median EMST of 3.2 years was reached and that owners retrospectively perceived that non-surgical treatment resulted in an improved QoL and clinical performance, irrespective of intrahepatic or extrahepatic CPSS location.

Transjugular intrahepatic portal shunt in the treatment of portal hypertension due to cirrhosis: single center experience

AimTo investigate clinical efficacy of transjugular intrahepatic portal shunt (TIPS) for the treatment of cirrhotic portal hypertension.Methods71 cases of patients with cirrhotic portal hypertension and esophageal and gastric variceal bleeding hospitalized from January 2014 to June 2017 were enrolled and treated with TIPS. The change of portal pressure and serum biochemical indexes before and after TIPS were compared, and re-hemorrhage rate, ascites incidence, complications, and survival rate were calculated.Results71 patients (male/female 47/24, aged 29–77 years, average 48.9 ± 9.8 years) with cirrhotic portal hypertension received TIPS. The success rate of TIPS was 93% (66/71). During 1–24 months (mean 12.5 ± 7 months) follow-up of 66 patients, 61 cases survived and 5 cases died. The portal pressure decreased significantly from 40.48 ± 3.15 cmH2O to 23.59 ± 4.41 cmH2O after TIPS (P < 0.05). During the follow-up, the incidence of hepatic encephalopathy was 12.1%, the incidence of re-hemorrhage was 18.2%, and there were 4 cases of stent dysfunction, with 1 case of bare stent and 3 cases of dual stent.ConclusionTIPS is an effective procedure for the treatment of cirrhotic portal hypertension complications, since it can reduce portal pressure and significantly alleviate ascites. Liver function is impaired in short-term after TIPS, but TIPS has no significant effect on liver function in middle-term.

Predictive Power of Liver Maximum Function Capacity Test in Transjugular Intrahepatic Portosystemic Shunt Patients: A Pilot Study

Background: Transjugular intrahepatic shunt (TIPSS) is placed in patients with variceal bleeding, refractory ascites, and for other indications. Postprocedural liver function-associated complications (LFAC), including hepatic encephalopathy (HE) and liver failure, represent a major setback. Current methods to predict complications are insufficient. Objectives: We investigated in a pilot study of patients prior TIPSS placement whether the risk of LFAC correlates with the functional reserve of the liver, as assessed by liver maximum function capacity (LiMAx) test. Methods: Prospectively we included patients prior TIPSS placement between June 2016 and November 2017 at Saarland University Medical Center. LiMAx was conducted before and after TIPSS placement. Patients with HE prior TIPSS, as well as other factors predisposing to HE, including concomitant sedative drugs, current bacterial infections and sepsis, were excluded. Overt HE (OHE), LiMAx, and laboratory values were assessed before and after TIPSS placement. Data were analyzed in multivariate regression and AUROC models. Results: Mean age was 60 ± 8 years. Patients (n = 20) were mainly men (65%), and presented predominantly with Child-Pugh class B (90%). Indications for TIPSS were most commonly refractory ascites or recurrent variceal bleeding. In total, 40% of the patients developed LFAC after TIPSS placement. Expectedly, LiMAx decreased and serum bilirubin increased after TIPSS. LiMAx drop ≥20% was the only parameter predicting the development of LFAC after TIPSS in multivariate regression and AUROC analysis. Conclusions: In multivariate regression models and AUROC analysis, a drop in LiMAx predicted the development of LFAC after TIPSS placement. Additional larger studies assessing OHE and early liver failure separately are warranted.

2428 Direct Intrahepatic Portocaval Shunt (DIPS) as a Therapeutic Option in Acute Variceal Hemorrhage

INTRODUCTION: Direct Intrahepatic Portocaval Shunt (DIPS) is a modified transjugular intrahepatic portosystemic shunt (TIPS) procedure, in which a stent is placed across the inferior vena cava directly into the portal vein under intravascular ultrasound guidance. DIPS is a recognized salvage therapy for acute variceal hemorrhage, but not commonly utilized. Indications for DIPS include patients with hepatic venous anomalies not amenable to TIPS, distorted post-surgical vascular anatomy of the liver, intrahepatic portal venous thrombus, or a prior failed TIPS. CASE DESCRIPTION/METHODS: A 73-year-old male with a history of cirrhosis from alcohol and hepatitis C virus and right lobe hepatocellular carcinoma status-post laparoscopic microwave ablation presented with hematemesis. An EGD revealed a gastric varix (Figure 1), which was deemed too large for treatment with cyanoacrylate glue deposition. A TIPS was attempted but failed due to hepatic venous anomalies. Subsequently, the varix was treated with a balloon-occluded antegrade transvenous obliteration (BATO) and a balloon occluded retrograde transvenous obliteration (BRTO). Figure 2 demonstrates the BATO, which coiled the afferent vessels to the varix (red arrow), and the BRTO, which coiled the efferent gastro-renal shunt of the varix (blue arrow). Two days after the BATO/BRTO, the patient had recurrent melena and anemia. An EGD doppler-guided glue deposition into the gastric varix was attempted but failed. A TIPS was not a viable option as an ultrasonography revealed a new portal vein thrombus extending into the anterior and posterior branches of the right portal vein. Thus, a DIPS was performed. Under intravascular ultrasound guidance, a catheter (red arrows) was advanced from the IVC directly to the left portal vein creating a shunt with stent placement as seen in Figure 3. The pre-procedure portosystemic gradient was 18 mm Hg, and post-procedure portosystemic gradient was 5 mm Hg with a reduction in the gastric varix. The patient is well three-months post-procedure without recurrent melena or anemia. DISCUSSION: This case demonstrates the successful utilization of DIPS in a patient where TIPS was not feasible due to hepatic venous anomalies and a portal vein thrombus. Furthermore, DIPS was successful in the treatment of a variceal hemorrhage when other therapies such as cyanoacrylate glue deposition, BATO, and BRTO failed. Therefore, DIPS should be utilized in challenging cases of variceal hemorrhage when performed by an experienced interventional radiologist.

2215 An Interesting Case of Intrahepatic Porto-Hepatic Shunt as a Cause of Unexplained Encephalopathy

INTRODUCTION: Congenital portosystemic shunts or Abernethy malformations are rare anatomical abnormalities shunting blood from the portal venous system to the systemic venous system, thereby bypassing passage through the hepatic acinus. The presentation may range from incidental finding on imaging to hepatic encephalopathy and liver failure depending on the degree and type of shunt. Here, we describe an interesting case of unexplained encephalopathy in a patient without liver cirrhosis found to have congenital intrahepatic Type II Abernethy malformation. CASE DESCRIPTION/METHODS: A 73-year-old female with a past medical history of Rheumatoid arthritis and Gilbert syndrome was admitted to hospital with clinical evidence of encephalopathy. Vitals were stable and physical examination was unremarkable except for encephalopathy. Laboratory investigations were unremarkable except for elevated ammonia levels (165 µmol/L). Computed tomography (CT) of the brain was unremarkable. Abdominal ultrasonography revealed the normal size and echotexture of the liver. Abdominal CT angiography showed the presence of dilated portal vein measuring up to 1.8 cm at the porta-hepatis along with dilated superior mesenteric and splenic veins. Multiple dilated vascular channels were seen within the right hepatic lobe. An intrahepatic portosystemic shunt between an enlarged middle hepatic vein and 2 separate branches of the right portal vein was visualized. Pressure gradients were measured and were normal. She received conservative management with lactulose and rifaximin and discharged on day 6 after the resolution of encephalopathy. DISCUSSION: Encephalopathy associated with portal-systemic bypass and no intrinsic hepatocellular disease is often referred to as Type B hepatic encephalopathy as was in our patient. Ammonia which is the culprit for the neuropsychiatric manifestation is usually metabolized by the liver in normal conditions, however in cases of portosystemic shunting, whether congenital or not, ammonia bypasses the liver and enters the systemic circulation and directly reaches the brain. The degree of symptomatology associated with these venous shunts depends on the shunt ratio and patient age. Treatment options include medical management including use of lactulose and non-absorbable antibiotics or endovascular shunt closure. Our patient was managed medically with the plan to refer her for shunt closure if she continues to have recurrent episodes.

2270 The Path to Encephalopathy: A Case of Spontaneous Portosystemic Shunt Embolization

INTRODUCTION: Hepatic encephalopathy (HE) is a debilitating complication of cirrhosis that can lead to alterations in consciousness, behavior, and overall functional decline. It has been suggested that up to 70% of patients with HE refractory to medical treatment have evidence of spontaneous portosystemic shunts (SPSS). While this is a relatively well-known sequela of longstanding cirrhosis, and current guidelines recommend at least consideration of closure of SPSS if found, the literature is limited regarding procedural occlusion of these potentially harmful vascular phenomena. CASE DESCRIPTION/METHODS: We present the case of a 70-year-old female with cirrhosis secondary to non-alcoholic steatohepatitis and progressive ascites requiring repeated therapeutic paracentesis. Over a short period, her need for paracentesis inexplicably declined and her HE simultaneously worsened, despite appropriately titrated lactulose. Imaging at this point revealed spontaneous splenosystemic and intrahepatic shunts. At the time of presentation, the patient’s Model for End-Stage Liver Disease (MELD) score was 14. Despite optimization of medical therapy and shunt embolization, the patient’s mental status did not improve. Upon further review of post-embolization imaging, there was evidence of shunt collateralization that still appeared to be patent. This patient’s lack of clinical improvement may have been due to several factors, but incomplete embolization of known shunts or presence of additional undiagnosed shunts seem most likely. DISCUSSION: As hepatic fibrosis progresses, portal hypertension rises steadily to the point where otherwise insignificant portosystemic microvasculature can engorge to sizes greater than 1 centimeter. This phenomenon can relieve portal hypertension at the expense of releasing higher levels of ammonia and other neurotoxins into systemic circulation, resulting in more pronounced HE. While the decision to pursue embolization should be individualized, the presence of SPSS should always be considered in the setting of refractory HE. A MELD score of 11 or less may be associated with more favorable outcomes following embolization of SPSS and a majority of patients show rapid clinical improvement of HE following successful shunt closure. Dedicated post-embolization imaging should be obtained, especially if a patient’s HE remains refractory after intervention.

Double-Balloon-Assisted N-Butyl-2-Cyanoacrylate Embolization of Nontumorous Intrahepatic Arterioportal Shunts

This report describes the safety and efficacy of double-balloon-assisted N-butyl-2-cyanoacrylate embolization of nontumorous intrahepatic arterioportal shunts in 5 consecutive, previously untreated patients. A proximal balloon was used for flow control and a coaxial microballoon was used to control the delivery of N-butyl-2-cyanoacrylate. Complete occlusion was achieved in 3 patients and shunt flow decreased in 2 patients, without complications. In the latter 2 patients, pre-embolization shunt flow was lower than that in patients with complete occlusion. Our results suggest that this coaxial double-balloon-assisted technique may be safe and effective for the embolization of nontumorous intrahepatic arterioportal shunts, especially in high-flow shunts.

Analysis of the medium-term curative effect of transjugular intrahepatic portosystemic shunt through jugular vein with covered Viatorr stent

Objective: To investigate the medium-term curative effect of transjugular intrahepatic portosystemic shunt (TIPS) through jugular vein with covered Viatorr stent. Methods: Data of 105 consecutive patients with covered Viatorr stent of our hospital was retrospectively analyzed. Follow-up was performed after surgery, and color Doppler was reviewed to evaluate the efficacy of TIPS. Results: Transjugular intrahepatic shunt was successfully established in all patients. The pressure gradients of portal vein before and after operation were 22.33 ± 6.4 mmHg and 9.78 ± 4.9 mmHg, respectively,P< 0.01, and the difference was statistically significant. The follow-up period ranged from 12.7 to 15.6 months, with an average of 13.09 ± 1.4 month. Total bilirubin and coagulation time increased after operation, but there was no significant difference in total bilirubin and coagulation time at 1, 3, 6 and 12 months after operation. The patency rate of shunt was 100%, 99.05%, 99.05% and 99.05% at 1, 3, 6 and 12 months after operation. The incidence of hepatic encephalopathy was 34.2%, 29.5%, 19.1% and 14.3% respectively. The recurrence rate of symptoms was 0%. Conclusion: Patients with cirrhotic portal hypertension who underwent TIPS with covered Viatorr stent had a lower rate of restenosis, improved liver function, and a lower incidence of severe hepatic encephalopathy. However, the long-term efficacy needs further observation.

TIPS Is Not Associated with a Higher Risk of Developing HCC in Cirrhotic Patients: A Systematic Review and Meta-analysis.

Background and Aims: The association between portal-systemic shunt and hepatocellular carcinoma (HCC) development in patients who have cirrhosis is still controversial. This systematic review with meta-analysis was performed to systematically clarify the potential role of portal-systemic shunt in the development of HCC.Methods: The PubMed, Embase, and Cochrane Library databases were searched for potentially eligible literature. Meta-analysis with random-effects model was performed to combine the incidence rates of HCC after portal-systemic shunt. Finally, seven studies were included. In the present review, we mainly focused on 859 patients (365 in the transjugular intrahepatic portal-systemic shunt (TIPS) group and 494 in the non-TIPS group) from five studies to analyze incidence rates after TIPS.Results: At the end of follow-up, there were 66 (18%, 66/365) patients who developed HCC after TIPS intervention and 63 (13%, 63/494) patients who developed HCC after non-TIPS treatments. Pooled estimates with random-effects model did not demonstrate a significant increase of incidence of HCC after TIPS (risk ratio: 1.37 [confidence interval (CI): 0.96 to 1.97]; p = 0.08) compared with non-TIPS treatments. Subgroup analyses for those patients with transplanted liver also did not detect a significant difference between the TIPS group and non-TIPS group (risk ratio: 1.10 [CI: 0.59 to 2.07]; p = 0.75).Conclusions: Current evidence suggests that portal-systemic shunt is not associated with a higher risk of HCC development in cirrhotic patients.

SAT-098-Transjugular intrahepatic portosystematic shunt with 7 mm covered stent reduces hepatic encephalopathy without losing shunt function for prevention of portal hypertensive rebleeding

SAT-098-Transjugular intrahepatic portosystematic shunt with 7 mm covered stent reduces hepatic encephalopathy without losing shunt function for prevention of portal hypertensive rebleeding

SAT-099-Portal pressure gradient measured immediately after transjugular intrahepatic portosystematic shunt placement: Poor in predicting rebleeding in patients with portal hypertension

SAT-099-Portal pressure gradient measured immediately after transjugular intrahepatic portosystematic shunt placement: Poor in predicting rebleeding in patients with portal hypertension

03:18 PM Abstract No. 270 Parallel TIPS versus DIPS for second percutaneous portosystemic shunt placement in cirrhotic patients with an existing TIPS

A second portosystemic shunt (sPSS) may be needed in patients with recurrent variceal bleeding or persistent ascites despite an existing transjugular intrahepatic portosystemic shunt (TIPS) due to insufficient portal decompression or shunt occlusion refractory to recanalization. There is no consensus on the best method for sPSS creation. The goal of this study was to compare the technical and clinical outcomes of placing a parallel TIPS (pTIPS) versus direct intrahepatic portocaval shunt (DIPS) as the sPSS. From 2002-2017, a pTIPS (n = 12; median age 62 y, MELD 13) or DIPS (n = 8; 57 y, 12) was placed in 20 patients with an existing TIPS and recurrent symptoms. sPSS indication, procedure details, technical and clinical success rates, and complications were retrospectively reviewed and compared. A sPSS was indicated for persistent ascites or recurrent variceal bleeding in 6 and 6 patients, respectively, in the pTIPS group and 6 and 2 patients in the DIPS group. The existing TIPS was patent in 5/12 patients in the pTIPS group and 4/8 in the DIPS group; the rest were chronically occluded. DIPS was specifically chosen in 5 cases due to anatomical limitations posed by the existing TIPS. In one pTIPS procedure, the existing occluded TIPS prevented full expansion of the new pTIPS, requiring balloon expandable stent placement. Stent-grafts were used in all cases (pTIPS: diameter 10 mm n=8, 8 mm n=4; DIPS: 10 mm n=5, 8 mm n=3, 7 mm n=1). Technical success was 100% in both groups. Mean procedure time for DIPS trended towards shorter versus pTIPS (73±22 vs 97±63 min, p=0.35) with a wider range in pTIPS procedure times (50-101 vs 72-262 min). Mean portosystemic gradient reductions after pTIPS (14.8±4.3 to 6.6±2.6 mm Hg) and DIPS (12.4±3.8 to 5.6±2.9) were similar. Ascites improved and variceal bleeding resolved in all patients. Hepatic encephalopathy worsened in 2 pTIPS and 1 DIPS patients. No acute liver failure occurred. Two pTIPS patients died within 30 days due to sepsis and lung cancer. Technical and clinical outcomes were similar between pTIPS and DIPS for sPSS creation. DIPS may be technically preferable due to anatomical issues in some patients with an existing TIPS.