Portosystemic Shunt Research Articles

The Management of Shunt Dysfunction Caused by Stent Deviation During Transjugular Intrahepatic Portosystemic Shunt (TIPS) Surgery for Esophageal and Gastric Varices Bleeding

The Management of Shunt Dysfunction Caused by Stent Deviation During Transjugular Intrahepatic Portosystemic Shunt (TIPS) Surgery for Esophageal and Gastric Varices Bleeding

Portal Hypertensive Gastropathy and MELD-Na Score Predict Recurrent Gastrointestinal Bleeding After TIPSS: An ALTA Group Study.

Transjugular intrahepatic portosystemic shunt (TIPSS) is highly effective for treatment of variceal bleeding; however, factors contributing to rebleeding complications remain unclear. In this study, we aim to determine risk factors for recurrent portal hypertensive gastrointestinal bleeding following TIPSS. Utilising the Advancing Liver Therapeutic Approaches multicentre database, we retrospectively identified adult patients who underwent TIPSS for secondary prophylaxis of variceal bleeding and had a gastrointestinal rebleeding event within 1 year. We developed multivariable logistic regression models to identify clinical/procedural characteristics associated with rebleeding. We identified 476 patients, predominately middle-aged (mean age 57), male (62%) and White (65%), with mean MELD-Na 16. 16% (n = 77) had a rebleeding event; these patients were more likely to be male (p = 0.016), with higher serum creatinine (p = 0.005), MELD-Na (p = 0.0002), portal hypertensive gastropathy on pre-TIPSS upper endoscopy (p = 0.000) and with higher incidence of TIPSS revision (p = 0.000). There were no significant differences in type of TIPSS endoprosthesis, concurrent embolotherapy, and post-TIPSS pressure gradients between those who experienced rebleeding and those who did not. After adjusting for TIPSS revision, multivariable analysis revealed MELD-Na and presence of portal hypertensive gastropathy on pre-TIPSS endoscopy were independently associated with rebleeding. In this retrospective analysis of a multicentre, nationally representative database, we found that apart from TIPSS-related factors, high MELD-Na and portal hypertensive gastropathy on pre-TIPSS endoscopy were independent predictors of rebleeding within 1 year following TIPSS. These variables may be used to identify high-risk patients who may require additional monitoring following TIPSS.

Clinical Outcomes of Transjugular Intrahepatic Portosystemic Shunt Among Cirrhosis Patients With Recurrent Esophageal Variceal Bleeding

Clinical Outcomes of Transjugular Intrahepatic Portosystemic Shunt Among Cirrhosis Patients With Recurrent Esophageal Variceal Bleeding

Percutaneous thermal ablation in hepatocellular carcinoma patients with and without TIPS.

Managing hepatocellular carcinoma (HCC) in patients with a transjugular intrahepatic portosystemic shunt (TIPS) is becoming increasingly common. This study aimed to evaluate the safety and efficacy of percutaneous thermal ablation for treating HCC in patients with TIPS. This retrospective longitudinal study was conducted at Nantes University Hospital. The main inclusion criteria were patients undergoing percutaneous thermal ablation for HCC. Patients with a pre-existing TIPS were included in the 'TIPS group'. A 1:1 control group without TIPS, the 'n-TIPS group', was created for this case-control study. The primary endpoints were overall survival and progression-free survival over 12 months. Safety was assessed by comparing complications between the groups. Between 2008 and 2020, 371 patients underwent percutaneous thermal ablation for HCC. The 'TIPS group' included 34 patients (66 nodules), while 34 patients (84 nodules) were randomly assigned to the 'n-TIPS group.' Overall survival rates at 1 year were 97% and 94% respectively (p = 0.52). The progression-free survival rate was 68% and 57% respectively (p = 0.35). No deaths occurred within 30 days post-procedure. There were 3 immediate complications in the TIPS group and 4 in the n-TIPS group (p = 1), none of which were related to the TIPS, including thrombosis. Percutaneous thermal ablation for HCC in patients with TIPS appears to be as safe and effective as in TIPS-naïve patients. These results suggest that the presence of a TIPS should not be considered a contraindication for percutaneous thermal ablation in treating HCC.

Imaging of the Inferior Mesenteric Vasculature.

The inferior mesenteric artery (IMA) and inferior mesenteric vein (IMV) supply and drain blood from the distal colon and rectum, respectively. Routinely imaged at cross-sectional imaging of the abdomen and pelvis, these vessels play a vital role in gastrointestinal tract health but may be neglected due to their diminutive caliber relative to other mesenteric vessels and potential lack of inclusion in routine search patterns. The authors describe and illustrate normal and abnormal appearances of the IMA and IMV and findings that are diagnostic of primary vascular abnormalities or can offer diagnostic clues. After the embryologic features, normal anatomy, and anatomic variants of the IMA and IMV are reviewed, various manifestations of IMA and IMV abnormalities, such as aneurysm and pseudoaneurysm, stenosis, occlusion, dissection, hemorrhage, arteriovenous malformations and fistulas, tumoral invasion, vasculitis, and perivascular lymphatic dilatation, are explored with use of case examples. The role of the IMA and IMV as collateral vasculature, including the clinical scenarios of superior mesenteric arterial occlusion, aortic endoleak, and portosystemic venous shunt, are discussed. Finally, diagnostic clues that the inferior mesenteric vessels and adjacent soft tissues can provide, including mesenteric venous gas, compression or displacement from bowel volvulus or internal hernias, lymphadenopathy, and venous flow artifacts, are highlighted. The authors provide a comprehensive reference for radiologists who evaluate the IMA and IMV on cross-sectional images and shine a spotlight on these neglected but important vessels. ©RSNA, 2024 Supplemental material is available for this article.

The primary cause of markedly elevated aminotransferases in hospitalized patients with cirrhosis in ischemic hepatitis.

Marked elevation in aminotransferases (≥1000 IU/l) is typically associated with acute liver injury. Here, we hypothesized that the cause of elevation in aminotransferases ≥1000 in patients with cirrhosis is likely due to a limited number of disorders and may be associated with poor outcomes. We aimed to investigate the most common etiologies of acute elevations in aminotransferases in patients with cirrhosis, and to examine their associated outcomes. From May 2012 to December 2022, all hospitalized patients with cirrhosis and an aspartate aminotransferase or alanine aminotransferase ≥ 1000 IU/l were identified through Medical University of South Carolina's Clinical Data Warehouse. Complete clinical data were abstracted for each patient, and in-hospital mortality was examined. The cohort was made up of 152 patients, who were 57 ± 12 years old, with 51 (34%) women. Underlying liver disease included mainly hepatitis C cirrhosis, alcohol-related cirrhosis, metabolic dysfunction-associated steatohepatitis cirrhosis, autoimmune cirrhosis, primary sclerosing cholangitis cirrhosis, and cryptogenic cirrhosis. The most common cause of marked elevation in aminotransferases in cirrhotic patients was ischemic hepatitis (71%), followed by chemoembolization (7%), autoimmune hepatitis (6%), drug-induced liver injury (3%), post-transjugular intrahepatic portosystemic shunt placement (3%), rhabdomyolysis (3%), and hepatitis C (2%). During hospitalization and over a 1-month follow-up period, the mortality rate in patients with ischemic hepatitis was 73% (79/108), while that for other causes of liver injury was 20% (9/44). Ischemic hepatitis is the leading cause of marked elevation of aminotransferases in patients with cirrhosis, with distinctive clinical characteristics than other etiologies, and significantly poorer outcomes.

Evidence for preventing EVRB in cirrhotic patients: A systematic review.

Systematic strategies for preventing and treating esophagogastric variceal rebleeding (EVRB) are currently inadequate. This systematic review aimed to update this critical gap by searching contemporary studies from major guideline websites, databases, and professional associations focused on EVRB prevention in cirrhosis patients. Key findings highlight evaluation methods, risk management, preventive measures, health education, and follow-up strategies. Notably, a hepatic venous pressure gradient exceeding 18 mmHg is identified as a reliable predictor of gastroesophageal varices (GOV) rebleeding. Effective management of primary diseases is crucial, with methods including antiviral and anti-fibrotic therapies, alcohol avoidance, vaccination, and careful medication management. The combination of nonselective β-blockers (NSBBs) and endoscopic variceal ligation (EVL) is established as the gold standard for secondary EVRB prevention. For patients experiencing recurrent bleeding despite NSBBs and EVL, transjugular intrahepatic portosystemic shunt (TIPS) therapy is recommended. Surgical options, such as surgical shunt and devascularization, are advised for those unsuitable for endoscopic therapy or TIPS, particularly in Child-Pugh A and B patients unresponsive to treatment. Additionally, traditional Chinese medicine options, such as Fufang Biejia Ruangan Tablets, Fuzheng Huayu Capsules, and Anluo Huaxian Pills, have shown promise in improving hepatic fibrosis and GOV in cirrhotic patients. This review offers a comprehensive overview of current prevention and treatment strategies for EVRB, providing valuable insights for clinicians and healthcare professionals.

Congenital extrahepatic portosystemic shunt in a teenager: a case report

The congenital extrahepatic portosystemic shunt is a rare anomaly characterized by aplasia or hypoplasia of intrahepatic portal venous branches that generate complete or partial extrahepatic shunting of portal venous intra-systemic veins. The clinical presentation is variable, including nausea, abdominal pain, anorexia, and jaundice. This entity has been associated with other congenital anomalies, and the most common are the cardiovascular anomalies. Imaging studies are essential to confirm the diagnosis, establish pre-operative planning, and determine the surgical procedure to be performed. We presented the case of a 15-year-old adolescent who had abdominal symptoms and was found to have a portal venous vascular abnormality.

Outcome of 21 dogs treated for the portocaval subtype of extrahepatic portosystemic shunts.

To assess outcomes of dogs with side-to-side portocaval extrahepatic portosystemic shunts (PC-EHPSS) and poor portal perfusion to the liver treated with medical management alone (MM) or surgical attenuation (SA). Multi-institutional retrospective study. A total of 21 dogs with PC-EHPSS (14/21 MM and 7/21 SA). Medical records were reviewed, and data was collected on dogs <12 kg with PC-EHPSS treated with MM or SA between June 2008 to June 2021. Signalment, clinical signs, postoperative complications, bloodwork values, long-term clinical outcome, survival, and owner reported quality of life were recorded. Of 21 dogs included, 10 were mixed breeds and 14 were females. Median age at time of presenting clinical signs was 163 days. At final follow-up examination (median 1119 days), all SA and 6/14 MM dogs were alive, with a median survival time of 2138 days following treatment onset. In surviving MM dogs, outcome was fair in 3/6 and poor in 3/6. In SA dogs with long-term follow-up, outcome was fair in 5/6, and poor in 1/6. A greater proportion of SA dogs had improved bloodwork parameter values at final follow-up examination, and the mean relative change in final bloodwork values was higher when compared to MM dogs. These findings demonstrate that SA has improved clinical outcomes to MM for PC-EHPSS; however, SA clinical outcomes appear worse than those previously reported for other EHPSS. This information may have implications for expected outcomes in other EHPSS subtypes associated with severely diminished portal perfusion.

Beyond MELD Score: Association of Machine Learning-derived CT Body Composition with 90-Day Mortality Post Transjugular Intrahepatic Portosystemic Shunt Placement.

To determine the association of machine learning-derived CT body composition and 90-day mortality after transjugular intrahepatic portosystemic shunt (TIPS) and to assess its predictive performance as a complement to Model for End-Stage Liver Disease (MELD) score for mortality risk prediction. This retrospective multi-center cohort study included patients who underwent TIPS from 1995 to 2018 and had a contrast-enhanced CT abdomen within 9months prior to TIPS and at least 90 days of post-procedural clinical follow-up. A machine learning algorithm extracted CT body composition metrics at L3 vertebral level including skeletal muscle area (SMA), skeletal muscle index (SMI), skeletal muscle density (SMD), subcutaneous fat area (SFA), subcutaneous fat index (SFI), visceral fat area (VFA), visceral fat index (VFI), and visceral-to-subcutaneous fat ratio (VSR). Independent t-tests, logistic regression models, and ROC curve analysis were utilized to assess the association of those metrics in predicting 90-day mortality. A total of 122 patients (58 ± 11.8, 68% male) were included. Patients who died within 90 days of TIPS had significantly higher MELD (18.9 vs. 11.9, p < 0.001) and lower SMA (123 vs. 144.5, p = 0.002), SMI (43.7 vs. 50.5, p = 0.03), SFA (122.4 vs. 190.8, p = 0.009), SFI (44.2 vs. 66.7, p = 0.04), VFA (105.5 vs. 171.2, p = 0.003), and VFI (35.7 vs. 57.5, p = 0.02) compared to those who survived past 90 days. There were no significant associations between 90-day mortality and BMI (26 vs. 27.1, p = 0.63), SMD (30.1 vs. 31.7, p = 0.44), or VSR (0.97 vs. 1.03, p = 0.66). Multivariable logistic regression showed that SMA (OR = 0.97, p < 0.01), SMI (OR = 0.94, p = 0.03), SFA (OR = 0.99, p = 0.01), and VFA (OR = 0.99, p = 0.02) remained significant predictors of 90-day mortality when adjusted for MELD score. ROC curve analysis demonstrated that including SMA, SFA, and VFA improves the predictive power of MELD score in predicting 90-day mortality after TIPS (AUC, 0.84; 95% CI: 0.77, 0.91; p = 0.02). CT body composition is positively predictive of 90-day mortality after TIPS and improves the predictive performance of MELD score. Level 3, Retrospective multi-center cohort study.

Case Report: Management of a congenital intrahepatic portosystemic shunt with portal vein aneurysm in a child using 3D computer-assisted partial right hepatectomy

Congenital portosystemic shunts (CPSS) are rare pediatric vascular malformations characterized by abnormal development of the portal vein, which is attributed to incomplete embryonic remodeling of the hepatic and surrounding vasculature. CPSS manifests in two main forms: intrahepatic and extrahepatic. This study details the management of a pediatric patient diagnosed with Congenital Intrahepatic Portosystemic Shunt (CIPS) who was referred to our institution. By using a computer-assisted surgical system, the right hepatectomy was successfully performed, guided by precise intraoperative navigation based on three-dimensional reconstructions of enhanced CT imagery. The patient exhibited a favorable postoperative recovery trajectory, with the absence of complications or recurrence throughout the monitoring period.

Sleep disturbance in patients with cirrhosis and transjugular intrahepatic portosystemic shunt

BackgroundSleep disturbance (SD) is a common occurrence in individuals with cirrhosis and significantly impacts their quality of life. Datas regarding post transjugular intrahepatic portosystemic shunt (TIPS) SD are scarce. This study aimed to explore the incidence and outcomes of post-TIPS SD.MethodsFrom August 2018 to November 2019, 73 patients who underwent TIPS were prospectively recruited for the study. Sleep quality was evaluated via the Pittsburgh Sleep Quality Index (PSQI), and the presence of hepatic encephalopathy was evaluated according to the West Haven criteria before and after the TIPS procedure.ResultsNineteen patients (26%) experienced new-onset SD after TIPS, with a median latency of 67 (40–98) days from the procedure. The median time from TIPS creation to occurrence was 67 (40–98) days. Minimal hepatic encephalopathy (MHE) post-TIPS emerged as an independent predictor of SD, with an odds ratio of 3 (95% CI: 1.04–8.78, P = 0.046). Notably, five of the six (83%) patients with SD experienced improvement after being administered eszopiclone. Ten of the thirteen (77%) patients with SD improved spontaneously without treatment. Furthermore, the prevalence of MHE was significantly greater among patients with SD than among those without SD (58% vs. 31%, P = 0.04).ConclusionsSD is prevalent in patients who undergo TIPS. MHE is an independent risk factor for the development of SD post-TIPS. Eszopiclone may be a safe and effective treatment option for patients with SD after TIPS. The study was registered with ClinicalTrials.gov under the identifier NCT03685994, with a registration date of September 23, 2018.

Predicting Portal Pressure Gradient in Patients with Decompensated Cirrhosis: A Non-invasive Deep Learning Model.

A high portal pressure gradient (PPG) is associated with an increased risk of failure to control esophagogastric variceal hemorrhage and refractory ascites in patients with decompensated cirrhosis. However, direct measurement of PPG is invasive, limiting its routine use in clinical practice. Consequently, there is an urgent need for non-invasive techniques to assess PPG. To develop and validate a deep learning model that predicts PPG values for patients with decompensated cirrhosis and identifies those with high-risk portal hypertension (HRPH), who may benefit from early transjugular intrahepatic portosystemic shunt (TIPS) intervention. Data of 520 decompensated cirrhosis patients who underwent TIPS between June 2014 and December 2022 were retrospectively analyzed. Laboratory and imaging parameters were used to develop an artificial neural network model for predicting PPG, with feature selection via recursive feature elimination for comparison experiments. The best performing model was tested by external validation. After excluding 92 patients, 428 were included in the final analysis. A series of comparison experiments demonstrated that a three-parameter (3P) model, which includes the international normalized ratio, portal vein diameter, and white blood cell count, achieved the highest accuracy of 87.5%. In two distinct external datasets, the model attained accuracy rates of 85.40% and 90.80%, respectively. It also showed notable ability to distinguish HRPH with an AUROC of 0.842 in external validation. The developed 3P model could predict PPG values for decompensated cirrhosis patients and could effectively distinguish HRPH.

Comparison of outcomes for transjugular intrahepatic portosystemic shunt creation: Viatorr versus Fluency versus a bare stent/Fluency stent combination

PurposeTo compare clinical outcomes of transjugular intrahepatic portosystemic shunt (TIPS) created with the single covered-uncovered stent (Viatorr TIPS Endoprosthesis) versus covered stent (Fluency) versus a combination of covered and uncovered stent.Materials and methodsFrom May 2016 and July 2019, a total of 180 liver cirrhosis patients with recurrent variceal bleeding underwent TIPS creation with single covered-uncovered stent (n = 63) or covered stent (n = 41) or a covered and uncovered stent combination (n = 76). Shunt dysfunction, rebleeding, overt hepatic encephalopathy and mortality was estimated using the Kaplan–Meier method and compared with the log-rank test.ResultsThe difference of baseline characteristics among these three groups were not significant. The included patients had a median age of 51 years (IQR 43–61), and 101 (56.1%) were men. The 1-year and 2-year shunt dysfunction rates were 1.6% and 3.2% in the single covered-uncovered stent group, 7.3% and 7.3% in the covered stent group and 5.3% and 6.6% in the combination group, respectively. There was no significant difference among groups [Hazard Ratio (HR) (95%CI): 1 vs 2.29 (0.38 − 13.72) vs 2.10 (0.41 − 10.83); P = 0.913]. No significant differences in the incidence of all-cause rebleeding were observed between the groups at 1 year (Viatorr vs Fluency vs combination: 11.1% vs 17.1% vs 10.5%) as well as 2 years (15.9% vs 17.1% vs 11.8%), with the HR (95%CI) being 1 vs 1.27 (0.5—3.21) vs 0.74 (0.30–1.82); P = 0.475). The 1-year and 2-year incidence of overt hepatic encephalopathy were 30.2% and 30.2% in the single covered-uncovered stent group, 22.0% and 22.0% in the covered stent group and 25.0% and 25.0% in the combination group, respectively. However, there was no significant difference among these three groups (P = 0.402). In addition, there was no significant difference in the 1-year and 2-year mortality (6.3% and 7.9% vs. 4.9% and 9.8% vs. 6.6% and 9.2%, P = 0.606).ConclusionNo significant difference was observed among different stent groups. Fluency covered stent and the generic bare stent/Fluency covered stent was not an unreasonable alternative to the Viatorr stent for TIPS creation.

Mesenteric Vein to Gonadal Vein Shunt Embolization in Patients with Portal Hypertension: Technical Considerations and Clinical Outcomes.

To assess the technical and clinical outcomes of percutaneous embolization for high-flow mesenteric vein to gonadal vein (MGV) portosystemic shunts. In this HIPPA-compliant, review board-approved study, patients who underwent embolization of MGV shunts between 2011 and 2023 were included. Patient demographic data, embolization technique, clinical outcomes, and complications were retrieved from the electronic health records. Technical success was defined as complete occlusion of the shunt on follow-up imaging. Clinical outcomes assessed were resolution/improvement of hepatic encephalopathy, improvement in liver function, changes to liver volumes, and occurrence of adverse events. Eight patients (mean age 59.5, 75% female) with nine MGV shunts were included. The indications for shunt embolization included medically refractory hepatic encephalopathy, bleeding duodenal varices, and transplant liver dysfunction. The mean maximum shunt diameter was 23.3mm. Embolization was most commonly performed with a combination of coils and N-butyl cyanoacrylate or vascular plugs. Complete MGV shunt thrombosis was achieved in 7/9 shunts post-embolization, and symptom improvement was noted in 7/8 patients. Child-Pugh scores improved post-embolization in 6/9 patients by a median of 3 points. Liver volumes also increased by a mean of 20.8 ± 17.7% post-embolization. Minor adverse events included new onset ascites, partial mesenteric/portal vein thrombosis, and new gastroesophageal varices without bleeding in four patients. Embolization of MGV shunts is technically feasible and effective for treatment of hepatic encephalopathy and increasing hepatopetal portal perfusion. There was an improvement in Child-Pugh scores and an increase in liver volumes in the majority of patients post-embolization.

Transjugular intrahepatic portosystemic shunt in a private Mexican medical setting: Indications and hemodynamic and technical outcomes

Transjugular intrahepatic portosystemic shunt in a private Mexican medical setting: Indications and hemodynamic and technical outcomes

Preemptive Transjugular Intrahepatic Portosystemic Shunt in Variceal Bleeding: A Real-World Study in a Tertiary Hospital

Introduction: Several studies have highlighted the potential benefits of early prophylactic transjugular intrahepatic portosystemic shunt (preemptive TIPS) placement in reducing morbidity and mortality following variceal bleeding (VB). Baveno VII recommends its placement less than 72 h after VB (Child-Pugh class C <14 or class B >7 plus active bleeding). This study aimed to evaluate the effectiveness of preemptive TIPS compared to a control group in a referral center. Methods: The control group included cirrhotic patients with VB and Child-Pugh class C or B with active bleeding, retrospectively selected between 2016 and 2022 and divided into 2 subgroups: those that never underwent TIPS placement during the course of their illness (subgroup A) and those submitted to TIPS placement due to rebleeding (subgroup B). Additionally, patients who received preemptive TIPS placement between August 2022 and January 2024 were prospectively included into the preemptive transjugular intrahepatic portosystemic shunt (pTIPS) group. Results: A total of 47 patients were included, 19 (40.4%) in the pTIPS group and 28 (59.6%) in control group (17 in subgroup A). There were no differences in baseline characteristics between the groups, except hepatic encephalopathy that was significantly higher in the control group when compared to the pTIPS group: 19 (67.9%) versus 6 (31.6%), p = 0.014. Early rebleeding rates were significantly lower in the pTIPS group: 1 (5.3%) versus 13 (46.4%) (p = 0.002). There were no significant differences in 6-week survival between the groups: 25 (89.3%) versus 17 (89.5%), p = 0.683. Regarding hepatic encephalopathy, no significant differences were observed between the control and the pTIPS group: 6 (21.4%) versus 4 (21.1%), p = 0.632, even when comparing subgroup A (4, 23.5%) with the pTIPS group (p = 0.432). Conclusion: This real-world study highlights the potential benefits of preemptive TIPS placement in reducing early relapse of VB, thereby lowering morbidity and complications. The findings advocate for the proactive incorporation of preemptive TIPS into clinical practice to optimize patient outcomes following VB.

Sarcopenia Prevalence in Liver Cirrhosis Patients Using MRI and Handgrip Strength Measurements

Background: Cirrhosis, a leading cause of mortality worldwide, is histologically represented as formation of regenerative nodules encircled by fibrous bands caused by chronic liver injury. Nutritional status in cirrhotic patients is challenging to assess due to fluid accumulation resulting from impaired protein synthesis. Factors such as reduced food intake, malabsorption, and altered macronutrient metabolism negatively impact the nutritional status, leading to sarcopenia. The development of sarcopenia is multifactorial and is linked to lower survival rates. Aim: To assess sarcopenia prevalence in liver cirrhosis patients using MRI and handgrip strength measurements. Discussion: Impaired food intake in liver cirrhosis results from a combination of factors including loss of appetite, hormonal changes, early satiety, ascites, nausea, taste disturbances, and functional dyspepsia. Malabsorption can also occur due to portosystemic shunting, reduced bile production, chronic pancreatitis, and small intestinal bacterial overgrowth, all of which contribute to sarcopenia. It also arises from complex interactions involving impaired glycogen synthesis, inadequate nutrition, disrupted skeletal muscle protein synthesis and underlying hypermetabolism. Conclusion: MRI-based assessments indicate there is a significant occurrence of sarcopenia in individuals with cirrhosis. Our findings reveal that handgrip strength, when correlated with MRI results, is a reliable predictor of sarcopenia in these patients.

A mattress suture with pledgets can partially occlude intrahepatic shunts in 23 dogs: evaluation of long-term survival.

To explore the differences in outcomes between dogs with intrahepatic portosystemic shunts (IHPSSs) partially occluded with a mattress suture with pledgets or attenuated with cellophane banding. 74 dogs with IHPSSs were included in this retrospective study. Medical records between January 2000 and February 2020 were evaluated for information on dogs undergoing laparotomy with cellophane banding (group C) or mattress suture with pledgets (group P) for treatment of IHPSSs, including specific outcomes of survival time, persistence of clinical signs, and necessity of continued medical management. Primary veterinarians and owners were contacted for long-term follow-up. 51 dogs were entered in group C and 23 in group P. The duration of surgery was 154.6 minutes (136.3 to 170 minutes) for group C and 154.9 minutes (128.9 to 180.9 minutes) for group P. The short-term mortality rate was 2% for group C and 4% for group P. Dogs in group C had a median survival time of 3,537 days, while dogs in group P had a median survival time of 2,141 days. In the long term, dogs in group P received more medications than dogs in group C, but the distribution of the quality-of-life score was not different. Mattress suture with pledgets can be used as an alternative to cellophane banding. For dogs with IHPSSs where full surgical dissection for placement of cellophane band is not possible, partial occlusion of the shunt with a mattress suture with pledgets is a viable option with acceptable long-term outcomes.

Immediate and Long-Term Results of Portacaval Shunt Surgeries in Portal Hypertension: 10-Year Clinical Experience of a Regional Vascular Surgery Department

INTRODUCTION: The number of patients with liver cirrhosis (LC) makes 20–40 cases per 100 thousand populations and rises steadily. A five-year survival rate of patients with LC in the compensation stage is 50%–62%, in the decompensation stage — 11%–40%. In the overwhelming majority of patients (80%–90%), LC leads to the compensatory formation of esophageal and gastric varices (EV and GV, respectively), which is further complicated with a life-threatening bleeding in 30% of patients. AIM: To evaluate 5-year results of partial portacaval shunt surgeries. MATERIALS AND METHODS: The paper describes a 10-year clinical experience of the vascular surgery department of Yaroslavl Regional Clinical Hospital in surgical treatment of patients with LC with a clinical presentation of portal hypertension, with recorded esophageal and gastric variceal bleeding. The study included 26 patients (of them 11 men; the mean age 48 ± 7.3 years) with LC (A and B classes on Child-Pugh scale), who underwent planned reconstructive surgery on the portal system. By the type of anastomosis, the patients were divided into 3 groups: group 1 — mesocaval anastomosis (n = 6); group 2 — distal splenorenal anastomosis with preservation of spleen (n = 10); group 3 — splenorenal H-shaped shunt. The primary end points of the study were survival of the patients, rebleeding from EV, shunt patency. Secondary end points were dynamics of EV size, changes in the spleen size, dynamics of the portal and splenic veins size, blood flow directions in the portal system, the presence of hepatic encephalopathy. Postoperative mortality was 3.8%. RESULTS: Survival at 1, 3 and 5 years was 96%, 90% and 58, respectively, and patency of anastomoses was 96%, 96% and 91%, respectively. Rebleeding at 1 year made 4% (n = 1), at 3 years — 0, at 5 years — 17% (n = 2). Changes in the hemodynamics of the portal system were recorded after formation of all types of anastomoses: reduction of the diameter of the portal vein by on average 5 mm, of the splenic vein by 3 mm, of the spleen size by 210 cm3. Shunt thrombosis occurred in two of 26 patients (7.7%) at 1 year (splenorenal H-shaped shunt with use of prosthesis) and 4 years (splenorenal autovenous shunt), respectively. CONCLUSION: The formation of partial portacaval anastomoses in patients with portal hypertension and episodes of bleeding from esophageal varices is a reliable prevention of rebleeding. The first bleeding episode is an indication for an open surgery in case the transjugular intrahepatic stenting is impossible. Survival rate of patients after portacaval shunt surgeries is determined by the initial degree of hepatic failure and patency of the formed anastomoses.