Transjugular intrahepatic portosystemic shunt (TIPS) placement is used to treat complications of portal hypertension. This study aimed to evaluate the prognostic value of von Willebrand factor antigen (VWF) dynamics following TIPS placement. Patients with TIPS placement at the Medical University of Vienna (2018-2025) and University Medical Center Mainz (2022-2025) with available VWF at baseline (BL) were included. Patients from both cohorts with available VWF after 3 months (M3) were included in the combined longitudinal cohort (CLC). Meaningful VWF decrease (VWF-Response) was defined as a relative VWF change (ΔVWF) of at least -5% at M3. Patients were stratified by presence of VWF-Response and interleukin-6 decrease (IL6-Response) into three groups: both (R2), either/or (R1), and neither (R0). Overall, 113 and 86 patients were included in the Vienna and Mainz cohorts, respectively. BL VWF was not associated with mortality in both cohorts. 118 patients constituted the CLC, which showed median BL VWF of 313.0% that decreased to 262.0% at M3 (p = 0.007). Fifty-three patients (44.9%) achieved VWF-Response. Both, VWF change (ΔVWF; asHR: 2.75; 95% CI: 1.07-7.11; p = 0.037) and VWF-Response (asHR: 0.24; 95% CI: 0.09-0.61; p = 0.003) were independently associated with survival. According to VWF and IL6 responses, patients were stratified as low-risk (R2), versus intermediate-risk (R1) versus high-risk (R0) with a cumulative incidence of death at 2 years of follow-up of R2: 10.6% versus R1: 23.1% versus R0: 46.7%, respectively. After TIPS placement, VWF-Response identifies patients with a favourable prognosis and can be combined with IL6-Response for risk stratification regarding mortality.

Robotic recipient liver transplantation worldwide: a systematic review and meta-analysis of the first 93 patients, from feasibility to early outcomes.

Post-TIPS overt hepatic encephalopathy (OHE) and variceal rebleeding (VRB) remain serious complications with limited predictive tools. This study investigates whether the inherent preoperative three-dimensional portal venous geometry (3D-PVG) serves as an independent prognostic biomarker for 1year OHE and VRB in patients undergoing transjugular intrahepatic portosystemic shunt (TIPS). In this multicenter retrospective study, 579 cirrhotic patients undergoing successful TIPS were enrolled. We extracted 3D-PVG features from routine computed tomography angiography (CTA) images before TIPS, quantifying bifurcation angles ('Near') and vessel segment tortuosity ('Far'). Cox regression identified predictors for 1-year OHE and VRB. Model performance was evaluated using Harrell's C-index, comparing clinical models against integrated clinical-geometric models (3D-CGM). For 1-year OHE, increased age (HR 1.458, p < 0.001), higher BUN (HR 1.171, p = 0.019), and extremely flat bifurcations (near_bin_87: 172°-174°; HR 1.104, p = 0.039) were independent risk factors. For 1-year VRB, first bleeding (HR 2.347, p = 0.027), elevated Cr (HR 1.244, p = 0.012), relatively flat bifurcations (near_bin_74: 146°-148°; HR 1.432, p = 0.001), and very straight vessel segments (far_bin_2: 2°-4°; HR 1.467, p = 0.013) were risk factors, while use of covered stents (HR 0.197, p = 0.013) and gently curved vessel segments (far_bin_27: 52°-54°; HR 0.262, p = 0.018) were protective factors. Integrating 3D-PVG features significantly improved predictive performance: the 3D-CGM achieved C-indices of 0.801 for OHE and 0.792 for VRB, surpassing clinical models (0.715 and 0.686, respectively). The inherent portal venous geometry may serve as an independent imaging biomarker for post-TIPS outcomes. The 3D-CGM markedly enhances risk prediction, providing a non-invasive approach for prognosis assessment in portal hypertension.

Serial thoracentesis is an established management strategy for hepatic hydrothorax (HH) patients who are intolerant to diuretics or not candidates for transjugular intrahepatic portosystemic shunt (TIPS) placement, but it carries a risk of complications. The role of indwelling pleural catheters (IPCs) in HH management remains controversial. This study aims to evaluate the safety and efficacy of IPCs compared with serial thoracentesis in patients with HH. We conducted a retrospective, propensity-matched cohort study using US population-based data, aged 18 to 89 years with HH secondary to cirrhosis of any etiology. Exclusion criteria included malignancy, congestive heart failure, nephrotic syndrome, chronic kidney disease, TIPS placement, or pleural effusions due to causes other than hepatic hydrothorax. Patients were stratified into 2 cohorts: (1) HH managed with IPCs placement and (2) HH managed with serial thoracentesis. After 1:1 propensity score matching, multivariate regression analysis was performed to evaluate primary and secondary outcomes over 18 months following the index intervention. All-cause mortality at 18 months was comparable between the IPCs and serial thoracentesis cohorts (odds ratio [OR]: 0.662, 95% CI: 0.434-1.108). However, patients in the serial thoracentesis group demonstrated higher odds of emergency room visits (OR: 2.273, 95% CI: 1.423-3.631), urgent care visits (OR: 1.581, 95% CI: 1.464-2.531), hepatic encephalopathy (OR: 2.351, 95% CI: 1.354-4.084), pneumonia (OR: 1.889, 95% CI: 1.075-3.320), liver transplantation (OR: 2.744, 95% CI: 1.276-5.897), and hypokalemia (OR: 2.028, 95% CI: 1.136-3.619) compared with the IPCs cohort. IPCs placement was associated with a lower risk of emergency room and urgent care visits, hepatic encephalopathy, pneumonia, hypokalemia, and reduced need for liver transplantation compared with serial thoracentesis in patients with HH.

Oxaliplatin-based neoadjuvant therapy (NAT) is increasingly being used in patients undergoing curative-intent surgery for pancreatic ductal adenocarcinoma (PDAC). Liver toxicity, notably through the development of chemotherapy-associated liver injury (CALI), has been shown in patients with colorectal liver metastases. However, its impact on postoperative complications after pancreaticoduodenectomy (PD) is not known. The study aimed to assess the hepatic changes on computed tomography (CT) imaging after oxaliplatin-based NAT and to identify markers predictive of postoperative complications. CT scans were retrospectively analyzed before and after oxaliplatin-based NAT of consecutive patients undergoing PD for PDAC between 2017 and 2020. The appearance of qualitative and quantitative features of CALI, such as liver attenuation, liver surface nodularity, hepatic and splenic volumetry, liver enhancement patterns, and features of portal hypertension, were derived from CT images, and their association with postoperative complications were analyzed. A total of 122 patients were analyzed (58 women; median age, 65 years [IQR,57-69]). Most patients received FOLFIRINOX protocol (n = 107, 87.7%). After chemotherapy, the splenic volume, heterogeneity of hepatic parenchymal enhancement, and portosystemic shunts significantly increased (p < 0.001). Preoperative low liver attenuation on unenhanced CT and heterogeneity of the liver parenchyma on contrast-enhanced CT were significantly associated with severe postoperative complications (p < 0.001). Liver attenuation value on unenhanced CT was inversely correlated with the Comprehensive Complication Index score (correlation coefficient -0.329, p < 0.001). After oxaliplatin-based NAT for pancreatic ductal adenocarcinoma, imaging-based signs of CALI were associated with severe complications after pancreaticoduodenectomy.

Clostridium butyricum reduces the incidence of overt hepatic encephalopathy in patients with liver cirrhosis after transjugular intrahepatic portosystemic shunt (TIPS).

The VIATORR Controlled Expansion (VCX) stent-graft was developed to allow more precise control of shunt diameter during transjugular intrahepatic portosystemic shunt (TIPS) creation. However, real-world data on its actual in vivo expansion behavior and short-term clinical implications remain limited. This study aimed to provide fluoroscopic quantitative assessment of early in vivo expansion of VCX stent-grafts and to assess its association with short-term overt hepatic encephalopathy (OHE). This single-center retrospective cohort included consecutive patients with cirrhosis who underwent TIPS using either a legacy 8-mm VIATORR TIPS stent-graft (VTS) or a VCX stent-graft. In the VCX group, stents were initially dilated to 8mm and further dilated to 10mm only when post-procedural portal pressure gradient (PPG) remained > 12 mmHg or decreased by < 50% from baseline. Propensity score matching (PSM) was performed to compare short-term clinical outcomes between the VCX and VTS groups. The primary imaging outcome was early in vivo expansion of the VCX controlled mid-segment, assessed by fluoroscopic diameter measurements at implantation and 3-month follow-up. The main clinical safety outcome was new-onset OHE within 6 months after TIPS. A total of 177 patients were included (108 VTS and 69 VCX). Among VCX patients with paired imaging follow-up, the mid-segment diameter increased from 8.0mm at implantation to a mean of 8.65mm at 3 months (range 8.2-9.1mm; p < 0.001). Mean post-TIPS PPG increased from 7.7 mmHg immediately after TIPS to 11.6 mmHg at 3 months (p < 0.001), with no significant correlation between diameter change and PPG change. After PSM, 132 patients were analyzed. The cumulative 6-month incidence of OHE was numerically higher in the VCX group but did not reach statistical significance compared with VTS (HR 11.74, 95% CI 0.73-4.16; log-rank p = 0.204). VCX stent-grafts exhibit measurable early self-expansion after implantation, indicating that the controlled-expansion segment may not remain fixed at the intended 8-mm diameter during early follow-up. While the incidence of OHE did not differ significantly between the VCX group and the VTS group after PSM, the observed expansion underscores the dynamic nature of post-TIPS stent behavior and supports imaging-based follow-up of shunt configuration and hemodynamic status.

Prognostic Factors for Post Transjugular Intrahepatic Portosystemic Shunt Creation Liver Failure and Death.

Portal hypertension leads to the development of a complex and heterogeneous network of portosystemic collateral pathways, which represent adaptive responses to increased portal pressure. Although traditionally considered compensatory mechanisms, growing evidence indicates that Spontaneous Portosystemic Shunts (SPSS) are ineffective in normalizing portal pressure and may contribute to adverse clinical outcomes. In patients with cirrhosis, particularly those with preserved liver function, the presence and extent of SPSS are independently associated with hepatic encephalopathy, variceal bleeding, portal vein thrombosis, and reduced transplant-free survival, highlighting their prognostic relevance. Cross-sectional imaging with computed tomography (CT) and magnetic resonance imaging (MRI) plays a central role in the noninvasive assessment of portal hypertension by enabling comprehensive mapping of collateral circulation, including shunt size, anatomical course, and drainage pathways. These imaging characteristics are key determinants of clinical impact and therapeutic planning. This pictorial review illustrates the major portosystemic collateral pathways encountered in portal hypertension using representative clinical cases, emphasizing key imaging features and common diagnostic pitfalls, as well as highlighting the clinical significance in each context. Accurate recognition and standardized reporting of SPSS are essential to optimize risk stratification, guide management decisions, and improve outcomes in patients with portal hypertension.

Liver cirrhosis is a leading cause of global liver-related morbidity and mortality, with hepatocellular carcinoma (HCC) being the most common and fatal complication. Transjugular intrahepatic portosystemic shunt (TIPS) is a minimally invasive treatment for ascites and gastrointestinal bleeding in patients with cirrhosis. Whether transjugular intrahepatic portalsystemic shunt (TIPS) increases the incidence of hepatocellular carcinoma (HCC) in patients with cirrhosis remains controversial. This study aimed to explore the association between TIPS and the development of HCC. We systematically researched PubMed, Embase, Cochrane Library, and Web of Science databases from their inception until March 7, 2023, to identify eligible studies. The incidence of HCC was extracted and analyzed using a random-effects in RevMan. The primary outcome was the cumulative incidence of HCC, and secondary outcomes included subgroup HCC risk by etiology, stent type, follow-up duration, and overall survival. This study was registered with PROSPERO (CRD42023442262). Ten studies comprising 2753 patients were included. Among the 1070 patients who received TIPS, 11.31% (121/1070 ) developed HCC, compared with 8.85% (149/1683) developed HCC (8.85%) in 1683 non-TIPS patients. TIPS did not increase the incidence of HCC [OR = 1.16, 95%CI (0.76,1.77), P = 0.51, I²=50%]. We then performed the analysis according to etiology and stent type. In studies primarily focused on alcoholic liver disease, TIPS did not increase the incidence of HCC [OR = 1.07 95% CI (0.61,1.88), P = 0.82, I²=67%]. Comparable results were observed in studies predominantly using bare stents [OR = 1.52, 95% CI (0.98,2.37), P = 0.06, I²=12%]. Furthermore, TIPS did not increase the cumulative incidence of cancer in 1 year [OR = 0.73 95%CI (0.20,2.69), P = 0.63, I²=74%] and 5 years [OR = 0.99 95% CI (0.52,1.87), P = 0.96], nor did it affect the survival rate [OR = 1.22,95% CI (0.65,2.32), P = 0.53, I²=44%]. TIPS is not associated with an increased risk of HCC development in cirrhosis patients. Clinicians can safely select TIPS as a treatment option for cirrhotic patients with portal hypertension, without excessive concern about an elevated risk of HCC associated with the procedure.

Standardized perioperative pathways for pediatric non-cirrhotic portal hypertension (PHT) requiring complex portosystemic shunt surgery remain scarce. Enhanced Recovery After Surgery (ERAS) protocols aim to reduce surgical stress and optimize postoperative recovery. This study evaluates the impact of ERAS implementation on outcomes in children undergoing shunt procedures for PHT. A retrospective cohort study was conducted over 18 years. Patients were divided into two groups: Group I (pre-ERAS,2006-2016) and Group II (post-ERAS,2016-2024). Demographics, surgical type, time to oral feeding, mobilization, drain usage, ICU stay, hospital stay, and 30-day readmissions were analyzed. A total of 103 patients (M/F: 50/53; mean age 8.4 ± 5 years) underwent shunt surgery. Fifty-one were treated before and 52 after ERAS implementation. Distal splenorenal shunt was most common (n = 74), followed by Rex shunt (n = 20) and other procedures (n = 9). ERAS was associated with significantly earlier oral feeding (1.1 vs.1.6 days, p = 0.007), earlier mobilization (1.15 vs.1.6 days, p = 0.046), markedly reduced drain use (1.9% vs. 23.5%, p = 0.001), shorter ICU stay (1.48 vs.1.9 days, p = 0.03), and nearly halved hospital stay (4.6 vs.8.5 days, p = 0.001). Thirty-day readmissions were similar. ERAS implementation in pediatric PHT surgery is feasible, safe, and associated with substantially improved recovery and standardized perioperative care.

Malformation of the ductus arteriosus (DA) is uncommon in otherwise healthy newborns. We report an extremely rare aneurysmal DA with bifurcation, in which the superior branch connects at the typical location on the roof of the main pulmonary artery, while the inferior branch connects to the left aspect of the left pulmonary artery origin. This unusual DA configuration is associated with an intrahepatic congenital portosystemic shunt.

To compare the incidence of hepatic encephalopathy (HE) after transjugular intrahepatic portosystemic shunt (TIPS) using two types of expanded polytetrafluoroethylene (ePTFE)-covered stents: dedicated stent-graft (DSG; Viatorr) versus generic stent-graft (GSG; Fluency) in patients with cirrhosis. We conducted a retrospective analysis of cirrhotic patients who underwent TIPS using DSGs or GSGs between January 2012 and March 2024. Propensity score matching (PSM) was used to adjust for baseline differences between the two groups. The primary outcome was overt hepatic encephalopathy (OHE). Secondary outcomes included shunt dysfunction and transplant-free overall survival (TF-OS). After matching, 320 patients were included in each group. The cumulative incidence of OHE at 1, 2, and 3years was lower in the DSG group than in the GSG group (16.1%, 21.9%, and 26.3% vs. 26.6%, 31.3%, and 33.7%; p = 0.013). After adjustment for confounders, DSGs were independently associated with a lower risk of OHE (subdistribution hazard ratio [sHR], 0.68; 95% CI, 0.51-0.91). Shunt dysfunction was also less frequent in the DSG group (2.9%, 5.2%, and 6.8% vs. 9.8%, 18.2%, and 23.7%; p < 0.001), with DSGs independently associated with a reduced risk (sHR, 0.29; 95% CI, 0.18-0.48). TF-OS did not differ significantly between the DSG and GSG groups (88.8%, 82.5%, and 76.8% vs. 90.3%, 83.1%, and 76.1%; p = 0.979). DSGs were associated with a lower risk of OHE and improved shunt patency compared with GSGs, supporting their preferential use in TIPS creation.

To evaluate the feasibility, safety, and clinical efficacy of transmesenteric extrahepatic portosystemic shunt in patients with cavernous transformation of the portal vein complicated by superior mesenteric vein occlusion. Twenty-one consecutive patients underwent transmesenteric extrahepatic portosystemic shunt, including 13 men (62%), with a median age of 50years (interquartile range, 43.5-56.5years). As a hybrid procedure, the superior mesenteric vein was accessed through a mini-laparotomy and recanalized when feasible. A direct extrahepatic portosystemic shunt was then created by puncturing the inferior vena cava, and mechanical thrombectomy with catheter-directed thrombolysis was performed for recent thrombus when indicated. Technical success, clinical outcomes, complications, and stent patency were systematically evaluated during follow up. The technical success rate of transmesenteric extrahepatic portosystemic shunt was 95.2% (20/21). The balloon assisted puncture technique achieved a 100% success rate (20/20), with successful puncture on the first attempt in 85% of patients (17/20). The mean superior mesenteric vein pressure significantly decreased from 29.9 ± 5.92mmHg to 17.5 ± 2.50mmHg (p = 0.003). No intra-abdominal hemorrhage occurred. The median follow-up duration was 18months (interquartile range, 11-30months). At 48months, the cumulative stent patency rate was 75%, and the overall survival rate was 89.6%. Transmesenteric extrahepatic portosystemic shunt may represent a complementary extrahepatic shunting option for carefully selected patients with cavernous transformation of the portal vein and extensive mesenteric venous occlusion, particularly when conventional intrahepatic shunt techniques are technically unfeasible or associated with high procedural risk.

ABSTRACTBackground & AimsTransjugular intrahepatic portosystemic shunt (TIPS) improves survival in refractory ascites. A careful patient's selection is mandatory as TIPS can lead to complications. Liver volumetry is predictive of outcomes before hepatic surgery, but data on its role before TIPS placement are scarce. We aimed to evaluate whether liver and spleen volume measurements are associated with prognosis after TIPS placement in patients with ascites.MethodsWe analysed data from three French centers, treated with TIPS between 2017 and February 2022. Inclusion criteria encompassed a TIPS placement for refractory or recurrent ascites and availability of cross‐sectional imaging. Exclusion criteria included non‐cirrhotic portal hypertension, other indications for TIPS, hepatocellular carcinoma beyond Milan criteria, and extrahepatic malignancy. Liver and spleen volumes were measured using pre‐TIPS CT or MRI scans. The primary endpoint was 1‐year transplant‐free survival (TFS). Secondary endpoints were overt hepatic encephalopathy (HE), recurrence of ascites, acute variceal bleeding, and jaundice.ResultsThe 160 patients were included (median age 60 years, male gender 83.8%, alcohol‐related cirrhosis 58.8%, with active alcohol consumption in 25.6%, Child‐Pugh B cirrhosis in 81.2%, median MELD score was 12). The 1‐year TFS was 60.1%. Multivariate analysis identified serum creatinine (HR = 1.01 95% CI [1.00–1.01], p = 0.04), total bilirubin (HR = 1.02 95% CI [1.02–1.04], p = 0.004), and portal pressure gradient (HR = 1.09 95% CI [1.01–1.18], p = 0.03) as independent factors associated with TFS. Neither liver‐to‐spleen volume ratios (LSVR) (p = 0.36) nor liver volume index (p = 0.92) were significantly associated with death or LT. Overall, 38.1% of patients developed overt HE after TIPS, with lower platelet count (HR = 1.01 95% CI [1.00–1.01], p = 0.04) emerging as an independent predictor. No radiological characteristics were associated with the recurrence of ascites.ConclusionsIn this multicenter study, liver and spleen volumes were not associated with transplant‐free survival or liver‐related outcomes in patients undergoing TIPS for ascites. These findings suggest that liver volumetry should not be a determining factor in patient selection for TIPS placement.

Acute kidney injury is a common and prognostically significant complication of cirrhosis, with hepatorenal syndrome (HRS) representing its most severe clinical manifestation. Traditionally viewed as a functional renal disorder driven by splanchnic vasodilation and neurohormonal activation, HRS has been increasingly recognized as part of a more complex, multisystem circulatory disturbance. Growing evidence implicates impaired cardiac reserve, hemodynamic derangements, and systemic inflammation as key contributors to renal dysfunction in advanced liver disease, supporting a unified hepato-cardio-renal syndrome framework. Herein, we synthesize emerging mechanistic insights linking hepatic, cardiac, and renal dysfunction in cirrhosis, with particular emphasis on circulatory derangements, cirrhotic cardiomyopathy, congestive nephropathy, and inflammatory mediators. We discuss evolving diagnostic paradigms, highlighting the role of point-of-care ultrasonography for bedside hemodynamic phenotyping beyond traditional clinical assessment. Therapeutic implications are reviewed through a cardiorenal lens, including the nuanced use of albumin, vasoconstrictors, and transjugular intrahepatic portosystemic shunting. Finally, we explore the impact of hepato-cardio-renal syndrome on liver transplant evaluation, perioperative management, and decisions regarding combined organ transplantation.

ABSTRACTBackground and AimsThe role of transjugular intrahepatic portosystemic shunt (TIPS) in older adults remains controversial because of limited risk‐stratification tools. We aimed to assess whether sarcopenia and myosteatosis are independently associated with post‐TIPS mortality and overt hepatic encephalopathy (OHE) in patients aged ≥ 70 years, and whether adding sarcopenia to established prognostic scores improves discrimination for post‐TIPS mortality.MethodsThis multicenter retrospective study included 115 consecutive patients with cirrhosis aged ≥ 70 years undergoing TIPS for refractory ascites or secondary prophylaxis of variceal bleeding. Sarcopenia and myosteatosis were assessed by computed tomography at L3. Post‐TIPS mortality and time to first OHE episode were analysed using Kaplan–Meier and Cox regression. Sarcopenia was integrated into established prognostic scores, and predictive performance was evaluated using time‐dependent ROC analyses.ResultsSarcopenia and myosteatosis were present in 60% and 80% of patients, respectively. During follow‐up, 49% died and 45% developed OHE. Sarcopenia was independently associated with both mortality and OHE, whereas myosteatosis and adipose‐tissue indices were not. Incorporating sarcopenia improved the discriminative performance of all scores, with MELD 3.0–sarcopenia showing the highest accuracy (AUC 0.845). Predicted survival probabilities clearly separated patients across MELD 3.0 categories according to sarcopenia status. For OHE, sarcopenia increased the risk while underdilated TIPS was protective, defining four distinct risk profiles.ConclusionsSarcopenia is highly prevalent and independently predicts both mortality and OHE after TIPS in older adults. Its integration into prognostic tools enhances risk stratification and supports individualised decision‐making in this vulnerable population.

Feasibility and Effectiveness of Cyanoacrylate-Assisted BRTO for Gastric Varices and Splenorenal Shunts.

"Cingulate Island" Sign in a Patient with Reversible Parkinsonism due to a Portosystemic Shunt.

A 72-year-old male with a history of heavy alcohol consumption was referred for evaluation and treatment of hepatic lesions. Imaging examinations revealed two masses in liver segments III and VIII, consistent with hepatocellular carcinoma (HCC). Despite normal liver enzyme and tumor marker levels, fasting serum bile acid was markedly elevated (89.7µmol/L). Contrast-enhanced computed tomography (CT) identified a major portosystemic shunt (PSS) between the left gastric and renal veins. Although the indocyanine green (ICG) retention rate at 15min was elevated at 51.4%, we attributed the abnormal ICG result to the large PSS rather than cirrhosis. Therefore, partial hepatectomy with shunt ligation was planned. Intraoperative portal pressure remained below 20 cmH₂O both before and after shunt clamping. The patient underwent successful resection and shunt ligation. Postoperatively, liver function normalized, bile acid levels decreased, and ICG retention improved to 12.1%. The patient recovered uneventfully, and follow-up CT at four months showed no recurrence and disappearance of the shunt. This case highlights the importance of intraoperative portal pressure monitoring and functional assessment in patients with major PSS. Shunt ligation can improve hepatic functional reserve and prevent complications such as hepatic encephalopathy. The decision-making process for such cases should integrate preoperative functional assessments with intraoperative hemodynamic findings.