Transjugular Intrahepatic Portosystemic Shunt Research Articles

Insights and future directions in studying intestinal microbiota post-transjugular intrahepatic portosystemic shunt for hepatitis B virus-related portal hypertension

The gut microbiota (GM) plays a major role in the progression and treatment response of liver diseases, with diverse compositions based on different etiologies. In China, hepatitis B virus (HBV) infection is the leading cause of cirrhosis and affects the GM composition in patients with cirrhosis-related portal hypertension (PH). However, a few studies have been conducted on GM alterations after transjugular intrahepatic portosystemic shunt (TIPS) in patients with HBV-related PH. A recent study investigated the changes in the GM in these patients after TIPS. This study found an increase in potentially pathogenic bacteria and a decrease in beneficial bacteria post-TIPS, particularly in patients with hepatic encephalopathy (HE), indicating the potential role of the GM in HE prediction and management post-TIPS. Nevertheless, the study had several limitations, including a small sample size, limited follow-up, a single time point for sample collection, and inadequate analysis of the correlation between intestinal flora, HBV infection status, and clinical parameters. Future research should address these limitations by expanding the sample size, prolonging the follow-up duration, collecting samples at multiple time points, and conducting comprehensive analyses to confirm the findings and evaluate the effectiveness of individualized microbiome-based therapies.

Transjugular intrahepatic portosystemic shunt (TIPS) with variceal embolization reduces rebleeding risk for patients with portal pressure gradient over 12 mmHg: A long-term follow-up study

ObjectiveThe consensus on whether Transjugular intrahepatic portosystemic shunt (TIPS) should be combined with variceal embolization in the treatment of portal hypertension-induced bleeding has not yet been reached. This study aimed to compare the difference in rebleeding incidence between TIPS and TIPS combined with variceal embolization and to analyze the optimal population for variceal embolization. MethodsClinical data of 721 patients undergoing TIPS were retrospectively collected. Patients were divided into two groups: TIPS alone (n = 155) and TIPS with embolization (TIPS+E, n = 251). Kaplan-Meier (KM) curves were used to analyze prognostic differences between the two groups, and subgroup analysis was conducted based on post-TIPS portal pressure gradient (PPG) exceeding 12 mmHg. ResultsAfter TIPS placement, the mean PPG significantly decreased for all patients. A total of 51 patients (12.6 %) experienced rebleeding, with 24 cases (15.9 %) in the TIPS group and 27 cases (10.6 %) in the TIPS+E group. There was no significant difference in cumulative rebleeding incidence between the TIPS+E and TIPS groups. In the subgroup with post-TIPS PPG greater than 12 mmHg, the cumulative rebleeding incidence was significantly lower in the TIPS+E group compared to the TIPS group (HR = 0.47, 95 %CI = 0.24–0.93, Log rank P = 0.026). No significant difference was found in patients with a post-TIPS PPG less than 12 mmHg. ConclusionFor patients with post-TIPS PPG exceeding 12 mmHg, simultaneous variceal embolization with TIPS placement significantly reduces the risk of rebleeding.

Gun-sight technique with dual hepatic vascular embolization for sigmoidal refractory biliary stricture after living-donor liver transplantation: A Case Report

BackgroundBiliary stricture is a common complication after living-donor liver transplantation (LDLT), but its management is challenging. We herein report a case of successful internal drainage achieved through combination of the gun-sight technique and dual hepatic vascular embolization (DHVE). Case presentationA 54-year-old woman with primary biliary cholangitis underwent ABO-incompatible LDLT with the right lobe. Duct-to-duct biliary anastomosis was performed, and V5 and V8 of the graft were reconstructed using a vein graft. However, 5 months after surgery, magnetic resonance cholangiopancreatography revealed stricture of the bile duct anastomosis. Endoscopic stenting could not be attempted because of the sigmoidal bending of the bile duct. Instead, percutaneous transhepatic cholangiographic drainage (PTCD) of the anterior and posterior branches was performed. We attempted to remove the PTCD tube by an endofistulization technique. We performed the gun-sight technique, originally employed for transjugular intrahepatic portosystemic shunt procedures, to create a pathway for internal drainage of the posterior segment. The anterior lobe was abandoned by applying DHVE, resulting in no external drainage tubes. ConclusionApplication of the gun-sight technique with DHVE for sigmoidal refractory biliary stricture after LDLT appears to be a feasible treatment.

Validating the prognostic value of muscle changes in patients with cirrhosis undergoing transjugular intrahepatic portosystemic shunt

Validating the prognostic value of muscle changes in patients with cirrhosis undergoing transjugular intrahepatic portosystemic shunt

Transjugular Intrahepatic Portosystemic Shunts for Acute and Chronic Portal Vein Thrombosis in Preparation for Liver Transplant

AbstractThe presence of portal vein thrombosis (PVT) in the pre-liver transplant patient can significantly impact waitlist, peri- and posttransplant outcomes, morbidity, and mortality. This article describes the pathophysiology of PVT and treatment options in patients with cirrhosis. It defines indications and rationale for placing transjugular intrahepatic portosystemic shunts, emphasizing technical details and risks in patients with nonneoplastic PVT awaiting liver transplantation.

Challenges and Opportunities in the Adoption of p-TIPS for Acute Variceal Bleeding: Insights from a US Tertiary Center.

Since the overwhelmingly positive results of the 'early use of TIPS' published in 2010, studies in Europe and Asia have confirmed early/pre-emptive transjugular intrahepatic portosystemic shunt (p-TIPS) in high-risk patients with acute variceal bleed (AVB) reduces treatment failure and mortality compared to standard of care (SOC). There are no studies evaluating p-TIPS in a US cohort. A review of patients with cirrhosis from June 2010 to June 2020 with AVB was conducted from a single large US center. Of 745 cirrhotic patients with AVB, 18% met criteria for p-TIPS. Alcohol and HCV accounted for 75% of etiology; 13% MASLD. The mean MELD-Na score in our cohort was 24, which is ten points higher than reported in the literature for over 600 p-TIPS cases. Only 9 patients underwent p-TIPS. Patients undergoing p-TIPS were less likely to have MASLD, more likely to be female and less likely to have PSE at baseline. One-year mortality in the SOC group (including patients undergoing 'rescue TIPS') was 53% versus 0% for p-TIPS (p = 0.01). Our observation suggests hesitancy among providers to recommend p-TIPS, likely due to concerns regarding a 'sicker' patient population. The current SOC in high-risk patients remain suboptimal. Limited data, including our own, suggest that p-TIPS may confer a survival benefit even in patients with high MELD. However, the recommendation of p-TIPS in such patients necessitates validation of its safety and efficacy. Consequently, we advocate for a RCT in the US to conclusively assess the utility of p-TIPS in this context. Until such evidence is established, it is likely that underutilization of this life-saving intervention will persist.

Percutaneous management of chronic total occlusion of the portal vein: a retrospective analysis of technical aspects and outcomes

BackgroundChronic total occlusion (CTO) of the portal vein is one of the main causes of portal hypertension, which may result in life-threatening complications often managed by interventional radiology (IR). The aim of this study is to report the innovative experience with percutaneous revascularization therapy in the management of portal vein CTO in paediatric and adult patients.Materials and methodsFrom January 2020 to December 2023 consecutive paediatric and adult patients with severe portal hypertension resulting from portal vein CTO who underwent attempts at percutaneous recanalization were retrospectively reviewed. Technical aspects including the percutaneous approach, portal vein stenting, transjugular intrahepatic portosystemic shunt (TIPS) creation, varices embolization and clinical outcomes including adverse events and control of portal hypertension were analyzed. Technical success was defined as at least partial restoration of the portal vein patency at the final angiogram. Clinical success was defined as the improvement of clinical-laboratory signs of portal hypertension and control for variceal bleeding.ResultsFifteen patients (median age = 21 years, range = 59 years; 10 males; 5 children) with portal vein CTO underwent a total of 25 percutaneous revascularization procedures. Nine patients (60%; 5 children, 4 adults) were liver transplant recipients. All patients except one had cavernous transformation of the extra-hepatic portal vein, involving the spleno-mesenteric confluence in 5 cases. Technical success was achieved in 13/15 (87%) patients of whom 8 had portal revascularization through the placement of an extra-hepatic stent; indeed, in six cases, a TIPS was performed to achieve sustained portal vein patency. Embolization of varices and/or cavernoma was performed in 12 patients. Adverse events occurred in 2/15 (splenic artery perforation and hemoperitoneum, one each) managed without sequelae. Technical success led to clinical success in all the 13/15 (87%) cases, with a median follow-up of 20 months (IQR 4–34 months).ConclusionCTO can be managed effectively by interventional radiology. Restored portal flow physiology alone is possible in most patients, while TIPS may be required in a small proportion of them, to prolong portal vein patency and control portal hypertension.

The Role of Vitamin D Deficiency in Hepatic Encephalopathy: A Review of Pathophysiology, Clinical Outcomes, and Therapeutic Potential

Hepatic encephalopathy (HE) is a neuropsychiatric condition frequently associated with cirrhosis and portosystemic shunting (PSS). It imposes a significant clinical and economic burden, with increasing attention toward identifying modifiable factors that could improve outcomes. Emerging evidence suggests that vitamin D deficiency (VDD), prevalent in patients with cirrhosis, may contribute to the development and severity of HE. This review explores the association between VDD and HE by analyzing the underlying pathophysiology, including oxidative stress, ammonia accumulation, and impaired hepatic function. Additionally, we summarize recent studies highlighting the correlation between low serum 25-hydroxy vitamin D (25-OHD) levels and worsening grades of HE. Despite strong observational data, interventional studies on vitamin D (VD) supplementation for HE remains limited. Current evidence suggests that VD’s antioxidant properties may alleviate oxidative stress in HE, with potential benefits in mitigating disease severity. Future research should focus on longitudinal studies and randomized controlled trials to evaluate the clinical impact of VD supplementation on HE outcomes and explore VD’s role in patients undergoing transjugular intrahepatic portosystemic shunt (TIPS) procedures. Understanding the therapeutic potential of VD could lead to improved management strategies for HE and cirrhotic patients at large.

TIPS insertion leads to sustained reversal of systemic inflammation in patients with decompensated liver cirrhosis.

Systemic Inflammation (SI) is considered a key mechanism in disease progression and development of complications in decompensated liver cirrhosis. SI is mainly driven by portal hypertension and bacterial translocation. Transjugular intrahepatic portosystemic shunt (TIPS)-insertion represents an effective treatment for portal hypertension. This study aims to investigate the impact of TIPS-insertion on SI and bacterial translocation. We prospectively included 59 cirrhotic patients undergoing TIPS-insertion. Blood samples were collected at TIPS-insertion and follow-up 1, 3, 6, and 12 months (FU) thereafter. At all time points, we performed a comprehensive analysis of SI including 43 soluble inflammatory markers (SIMs), and surrogates of bacterial translocation (sCD14, sCD163). To investigate long-term kinetics of SI, C-reactive protein (CRP) and white blood cells (WBC) were retrospectively analyzed in a cohort of 177 patients up to 3-years after TIPS-insertion. At TIPS-insertion, 30/43 SIMs, sCD14, and sCD163 measured significantly higher in cirrhotic patients compared to healthy controls. By FU6 25 SIMs and sCD14 measured at significantly lower levels compared to baseline. Interestingly, in patients with TIPS-indication refractory ascites IL-6 decreased to levels documented in earlier stages of cirrhosis. In long-term follow-up, CRP-levels significantly decreased after TIPS-insertion, which translated into improved liver-transplant-free survival in cox regression analysis (HR 0.968, p=0.042). Notably, patients with residual ascites post-TIPS showed significantly higher CRP- and IL-6 levels across all follow-ups compared to patients with resolved ascites. Decreasing portal hypertension via TIPS-insertion leads to a significant attenuation of SI and bacterial translocation over time.

Left-sided portal hypertension: what an interventional radiologist can offer?

Left-sided portal hypertension (LPH) refers to increased splenic venous pressure caused by splenic vein stenosis or occlusion. Pancreatitis is the leading cause of LPH. Typically, LPH remains asymptomatic, but it can lead to life-threatening hemorrhage from ruptured fundal varices in about 10% of patients. Further, it may be complicated by hypersplenism. Interventional radiology plays an essential role in LPH patients with failed endoscopic treatment. Variceal embolization is an effective salvage measure in bleeding gastric varices, but it carries a risk of recurrence and worsening of hypersplenism. Considering the pathophysiology, splenic vein recanalization (SVR) appears to be the best treatment; nevertheless, its lower technical success rate limits its utility only to a subgroup of LPH patients. Partial splenic embolization (PSE), a non-surgical alternative to splenectomy, reduces the splenic volume and venous outflow, thereby lowering variceal pressure. PSE is technically easier, which may explain its widespread use. Nonetheless, PSE can be complicated by life-threatening sepsis and portal vein thrombosis. Despite all attempts, some LPH patients eventually require a splenectomy. Importantly, the choice of therapy requires multidisciplinary discussion and is often influenced by availability, expertise, and clinical context. This article discusses various interventional strategies for managing LPH with the available evidence. KEY POINTS: Question Pressure within the main portal vein is normal in left-sided portal hypertension; thus, transjugular intrahepatic portosystemic shunt is ineffective. Findings Splenic vein stent placement can restore hepatopetal splenic blood flow and decompress splenic venous pressure. Clinical relevance Partial splenic embolization (PSE) is the most widely used interventional approach to manage left-sided portal hypertension-related complications.

Doppler velocities in patent transjugular intrahepatic portosystemic shunts: an analysis of 10 mm vs. 8 mm shunts

Doppler velocities in patent transjugular intrahepatic portosystemic shunts: an analysis of 10 mm vs. 8 mm shunts

CIRSE Standards of Practice on Transjugular Intrahepatic Portosystemic Shunts.

Proposed in the early 1980s as a solution for managing complications of portal hypertension, the percutaneous creation of transjugular intrahepatic portosystemic shunt has consistently gained a central role. Increasingly lower complication rates have been observed thanks to improvements in both technologies and the skills of interventional radiologists. This document is aimed at interventional radiologists and provides best practice recommendations for transjugular intrahepatic portosystemic shunt creation, describing patient selection, intraprocedural management and follow-up, in addition to recommendations in paediatric settings. The CIRSE Standards of Practice Committee established a writing group consisting of seven European clinicians with recognised expertise in the creation of transjugular intrahepatic portosystemic shunt. The writing group reviewed the existing literature performing a pragmatic evidence search using PubMed to select relevant publications in the English language and involving human subjects, preferably published from 2009 to 2024. The final recommendations were developed by consensus. TIPS creation has an established role in the successful management of portal hypertension and its complications. This Standards of Practice document provides up-to-date recommendations for patient selection, materials, its safe performance, and follow-up with complications management.

Analysis of independent risk factors for hepatic encephalopathy after transjugular intrahepatic portosystemic shunt in patients with cirrhosis combined with diabetes.

This study aimed to reveal the independent risk factors for overt hepatic encephalopathy (OHE) after transjugular intrahepatic portosystemic shunt (TIPS) in patients with decompensated cirrhosis complicated with diabetes. This study retrospectively analyzed 126 consecutive patients with cirrhosis combined with diabetes who underwent TIPS in our department from January 2016 to June 2022. The patients were divided into two groups according to the presence or absence of OHE after TIPS. Data were analyzed using the χ2-tests, unpaired t-tests, logistic regression, receiver operating characteristic curves, and Kaplan-Meier curves. Age and ascites were independent risk factors for OHE after TIPS in patients with cirrhosis and diabetes. Elder patients had a higher risk of postoperative OHE than younger patients [odds ratio (OR): 1.040; 95% confidence interval (CI): 1.003-1.079]. Compared with patients without ascites, patients with ascites were significantly more likely to develop OHE (OR: 3.757; 95% CI: 1.274-11.080; OR: 4.338; 95% CI: 1.069-17.603). Age and ascites are independent risk factors of post-TIPS OHE in cirrhotic patients with diabetes.

Post-TIPS Right Atrial Pressure and Left Atrial Volume Index Predict Heart Failure and Mortality: Dual Center Experience

Background: Heart failure (HF) after Transjugular Intrahepatic Portosystemic Shunt (TIPS) placement affects up to 20% of patients. Understanding factors associated with post-TIPS HF is critical. Cirrhotic Cardiomyopathy (CCM) is associated with adverse clinical outcomes. Aims: We aim to evaluate whether hemodynamic measurements and echocardiographic markers of CCM pre- and post-TIPS can predict post-TIPS HF and death. Methods: We performed a retrospective study of cirrhotic patients who underwent TIPS between 2010 and 2015 at two centers. Patients with cardiomyopathies other than CCM were excluded. A multivariable-adjusted time-to-event analysis assessed associations of clinical, hemodynamic, and echocardiographic parameters with post-TIPS HF and death during 2 years of follow-up. 180-day landmark analysis was used to assess association of echocardiographic changes with outcomes. Results: 360 patients met study criteria. 32 developed HF post-TIPS (8.8%). Right atrial pressure (RAP) measured intraprocedurally post-TIPS insertion was associated with increased risk for HF (adjusted HR 1.10 [1.04-1.17]), with a cut off of 22mm Hg associated with highest risk (multivariable HR 2.71, [1.22-6.02]. 92 patients died (25.5%). An increase in left atrial volume index (LAVI) within 180 days post-TIPS was associated with increased mortality (HR 1.08 [1.01-1.15]). Other echocardiographic CCM markers were not associated with HF or death. Conclusion: Increases in RAP and LAVI post-TIPS, but not CCM status, predict post-TIPS HF and death, respectively. Surveillance echocardiography may play a role in identifying those at highest risk of decompensation post-TIPS. Further prospective study of CCM and its markers in relation to TIPS outcomes is warranted.

TIPS, a Trick for Transcaval TEVAR Access.

We described an alternative access for thoracic endovascular aortic repair (TEVAR) deployment using a transjugular intrahepatic portosystemic shunt (TIPS) needle for gaining transcaval access to the abdominal aorta. A 63-year-old man presented with a penetrating atherosclerotic ulcer in the descending aorta. Traditional transfemoral and transaxillary access were not possible. A transcaval access was established using a TIPS needle to puncture from the caval vein to the aorta. Next, the access was gradually upsized until a 22 french large-bore transcaval access was achieved. Afterwards the thoracic endograft was positioned and deployed accustomed. The infrarenal aortocaval fistula was closed with a covered stent. When classic TEVAR access is not possible, transcaval access is a valuable and minimally invasive alternative access. We prefer the use of a TIPS needle for gaining access and use a covered stent for closing the aortic access site when possible instead of using electrified wires nor a transseptal occluder device. Preoperative planning remains key. We discribe a transcaval access with a TIPS needle and closing of the aortocaval fistula with a covered stent. We are one of fiew reports of transcaval puncturing instead of using an electrified wire and the first using a TIPS needle for gaining transcaval access. We hope this case and our comments help other surgeons, radiologists and patients when they are in need of a transcaval access and contribute to a successful procedure.

Psoas muscle index in sarcopenia following transjugular intrahepatic portosystemic shunt: A multicenter, retrospective study

AbstractAimsAlthough the skeletal muscle index at the third lumbar vertebra (L3‐SMI) is commonly utilized for the diagnosis of sarcopenia, the psoas muscle index at L3 (L3‐PMI) may serve as a reliable alternative indicator. This study aims to investigate the application of the PMI in patients who have undergone transjugular intrahepatic portosystemic shunt (TIPS).MethodsThis study included a cohort of 406 patients with cirrhosis who underwent TIPS between February 2016 and July 2022 across three medical centers in China. Clinical and imaging data, specifically L3‐SMI and L3‐PMI, were collected for these patients. The prognosis of the patients was assessed through re‐examinations and telephone follow‐ups, which extended up to 5 years. The diagnostic thresholds for sarcopenia, as defined by L3‐PMI and L3‐SMI, were established at 6.36 or 42.00 cm²/m² for males and 3.92 or 38.00 cm²/m² for females, respectively. Cox proportional hazards and Kaplan–Meier (K‐M) analyses were employed to evaluate patient survival.ResultsThe findings indicated that both L3‐PMI and L3‐SMI before TIPS were independent risk factors for mortality. The results of the paired t‐test demonstrated a significant increase in L3‐PMI 1 month post‐TIPS (5.11 ± 1.81 vs. 5.71 ± 1.90 cm²/m², p < 0.001), whereas L3‐SMI did not exhibit a significant increase until 6 months post‐TIPS (45.45 ± 9.41 vs. 48.59 ± 10.38 cm²/m², p < 0.001). Among these patients, 191 (47.0%) and 159 (39.2%) were diagnosed with sarcopenia according to the L3‐PMI and L3‐SMI models, respectively. Patients identified as sarcopenic by both indicators demonstrated a significantly lower survival rate (L3‐SMI model: hazard ratio [HR], 1.913; 95% confidence interval [CI], 1.094–3.410; log‐rank p = 0.020; L3‐PMI model: HR, 1.867; 95% CI, 1.059–3.290; log‐rank p = 0.030). In sarcopenic patients, the reversal of sarcopenia associated with improved survival occurred 1 month after TIPS in the L3‐PMI model (HR, 2.675; 95% CI, 1.245–5.735; log‐rank p = 0.012), while a similar effect was not observed until 6 months post‐TIPS in the L3‐SMI model (HR, 3.342; 95% CI, 1.477–7.560; log‐rank p = 0.004).ConclusionsL3‐PMI and L3‐SMI demonstrate comparable efficacy in diagnosing cirrhosis‐related sarcopenia. Furthermore, L3‐PMI has the capacity to identify improvements in sarcopenia as early as 1 month following TIPS, thereby providing earlier insights into patient survival outcomes.

Recompensation of Liver Cirrhosis by TIPS Reduces Epithelial Cell Death Markers, Translating Into Improved Clinical Outcome.

Portal hypertension is the main pathophysiological driver of decompensation in patients with liver cirrhosis. Epithelial cell death markers, m30 and m65, correlate with hepatic injury and predict outcomes across various stages of liver disease. We aim (i) to evaluate whether portal hypertension itself contributes to liver outcome-relevant epithelial injury, and (ii) to analyse the capacity of m30/m65 to predict outcome in patients receiving a transjugular intrahepatic portosystemic shunt (TIPS) for refractory ascites. Sixty-six patients undergoing TIPS placement for refractory ascites and 20 patients with compensated cirrhosis as controls were prospectively enrolled in this monocentric cohort study. Epithelial cell death markers were analysed pre-TIPS, as well as 1-3 and 6-9 months post-TIPS. The capacity of baseline levels of m30/m65 in predicting six-month transplant-free survival rates was analysed by multivariable Cox proportional hazards regression. Levels of m30 and m65 were higher in patients with decompensated cirrhosis (pre-TIPS) compared with compensated cirrhosis (controls). Following correction of portal hypertension by TIPS and recompensation, both markers decreased over time, reaching levels comparable to patients with compensated cirrhosis. On multivariable analysis, pre-TIPS baseline levels of m30 and m65 were not predictive for six-month survival. Correction of portal hypertension via TIPS reduces levels of epithelial cell death markers, indicating that portal hypertension is a driver of outcome-relevant, hepatic cell death in patients with decompensated cirrhosis. Baseline m30/m65 values do not affect six-month survival rates, which suggests that TIPS placement overcomes the unfavourable spontaneous prognosis otherwise indicated by elevated baseline m30/65 levels.

Optimal threshold of portal pressure gradient for patients with ascites after covered TIPS: a multicentre cohort study.

Transjugular intrahepatic portosystemic shunt (TIPS) is recommended for treating recurrent and refractory ascites. However, determining the target portal pressure gradient (PPG) has been inconclusive. This multicentre cohort study explored the post-TIPS PPG potential range associated with improving survival. The study enrolled 276 patients, all of whom underwent covered TIPS for ascites treatment across four medical centers. The cumulative incidences of clinical outcomes were compared among groups categorized by potential PPG thresholds. During the whole follow-up period with a medium follow-up of 21.6 (7.5, 41.6) months, 122 (44.2%) experienced liver-related death, and 73 (26.4%) patients experienced a recurrence of ascites. Multivariable analysis revealed PPG < 7mmHg (p = 0.007) and the recurrence of ascites (p = 0.033) are independent risk factors for survival, while the PPG ≥ 11mmHg was an independent risk factor for the recurrence of ascites (p = 0.012). Patients with ≥ 7mmHg had a lower rate of liver-related death than patients with post-TIPS PPG < 7mmHg (51.0% vs 66.6%, p = 0.004), while those with post-TIPS PPG ≥ 11mmHg exhibited a higher cumulative incidence of ascites compared to those with post-TIPS PPG < 11mmHg (44.6% vs 33.7%, p = 0.023). The robustness of the results was confirmed. Our study highlighted the existence of an optimal post-TIPS PPG range in patients with recurrent and refractory ascites. Patients may experience improved survival and ascites control with a post-TIPS PPG of 7-11mmHg.

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.