Transjugular Intrahepatic Portosystemic Shunt Creation Research Articles

04:21 PM Abstract No. 277 Sex disparity in survival following transjugular intrahepatic portosystemic shunt creation in patients with hepatorenal syndrome

04:21 PM Abstract No. 277 Sex disparity in survival following transjugular intrahepatic portosystemic shunt creation in patients with hepatorenal syndrome

03:00 PM Abstract No. 169 Proton pump inhibitor use is a major risk factor for hepatic encephalopathy after transjugular intrahepatic portosystemic shunt creation

03:00 PM Abstract No. 169 Proton pump inhibitor use is a major risk factor for hepatic encephalopathy after transjugular intrahepatic portosystemic shunt creation

03:36 PM Abstract No. 173 Effect of shunt geometric parameters on transjugular intrahepatic portosystemic shunt patency

To assess the effect of shunt geometric parameters on transjugular intrahepatic portosystemic shunt (TIPS) patency and to quantitatively analyzed change of stent configuration. A database of patients who had TIPS performed from November 2011 to June 2015 was generated. The angiographic images during initial TIPS creation were reviewed independently by two observers. Stent-to-inferior venous cava distance (SIVCD), hepatic vein to stent angle (HVSA) and portal vein to stent angle (PVSA) was measured in two orthogonal planes. The patients meet the standard that SIVCD < 15mm, HVSA < 45° and PVSA < 45° were classified into the optimal position (OP) group, others classified into non-optimal position (NOP) group. To quantitatively compare the configuration change of stent-graft, the angle between vertical line and tangent of proximal end of stent (AVTP), distal end (AVTD) and stent bending angle (SBA) were measured in portographic images during TIPS creation and follow-up, respectively. Cox regression analysis was performed to assess these parameters on primary patency of TIPS, hepatic encephalopathy and survival. Among all 495 patients, 327 patients were enrolled in OP group. During the follow-up of mean 698 days, the TIPS dysfunction rate among the patients in OP group was 6.1%, compared with 30.0% among the patients in NOP group (P<0.001). Portogram was conducted in 40 patients during the follow-up period. AVTP was significantly decreased by 5.1±8.7° (P = 0.001) and SBA was significantly increased by 9.2±8.5° (P < 0.001). It suggested that stent had tendency to straighten, but the variation was not correlated with time (P = 0.342). The cumulative TIPS patency rates at 1, 2 and 4 years were 93%, 87% and 73%. A Cox multivariate analysis revealed that optimal position of stent (HR = 4.948; 95% CI: 2.929-8.358; P < 0.001) and splenectomy (HR = 2.410; 95% CI: 1.335-4.350; P = 0.004) was associated with TIPS dysfunction. Initial stent position is predictive of TIPS patency, with stent extending to the hepatocaval junction and reducing the angle with vessels. The stent-graft will gradually straighten after TIPS, thereby impacting the shunt patency.Tabled 1Comparison of Geometric Parameters and Prognosis Between the OP and NOP GroupsOP GroupNOP GroupP ValuePatients (n)327168SIVCD (mm)8.8±3.411.6±4.5mm0.002HVSA-a (°)30.2±8.635.1±11.60.042HVSA-l (°)17.7±7.217.1±7.50.203PVSA-a (°)30.2±8.734.9±10.00.014PVSA-l (°)17.0±8.427.7±18.60.001Diameter of stent-graft 10 mm297 (90.8%)147 (87.5%)0.265 8mm36 (9.2%)21 (12.5%)0.134Length of stent-graft 6cm279 (85.3%)136 (81.0%)0.098 8cm48 (14.7%)32 (19.0%)0.148Target portion of PV Right branch248 (75.8%)90 (53.6%)0.021 Left branch42 (12.9%)67 (39.9%)0.002 Bifurcation36 (11.0%)10 (5.9%)0.017 Trunk1 (0.3%)1 (0.6%)0.428PSG decrease (mm Hg)15.7±5.216.5±6.20.266TIPS dysfunction20 (6.1%)47 (30.0%)<0.001 Variceal rebleeding17 (5.2%)36 (21.4%) Ascites recurrence1 (0.3%)0 (0) No symptom2 (0.6%)11 (8.6%)Hepatic encephalopathy103 (31.5%)48 (28.6%)0.403 One time41 (12.5%)20 (11.9%) Two times and above62 (19.0%)28 (16.7%)Mortality43 (13.1%)30 (17.9%)0.118 GI bleeding4 (1.2%)5 (3.0%) Other reason39 (11.9%)25 (14.9%) Open table in a new tab

03:09 PM Abstract No. 170 Partially dilated transjugular intrahepatic portosystemic shunt (TIPS) stents with novel controlled expansion design improve survival of patients with decompensated liver cirrhosis

To investigate patient outcome after transjugular intrahepatic portosystemic shunt (TIPS) creation using the new controlled expansion Viatorr stent-graft (CE-VTS) in comparison to the regular self-expanding Viatorr stent-graft (VTS). 92 patients (m/f: 50/42, mean age 60 years, range 23-78 years) with decompensated liver cirrhosis underwent TIPS-creation and were prospectively enrolled into this case-control-study. 46 patients received TIPS-creation with a CE-VTS. 46 matched control patients received TIPS-creation with a VTS. Patients were matched according to sex, age, etiology of liver disease, indication for TIPS and MELD score. All stent-grafts (CE-VTS and VTS) had a nominal diameter of 10mm and were dilated to only 8mm during TIPS-creation. Primary endpoint of the study was one year overall survival; secondary endpoints were occurrence of hepatic encephalopathy, liver decompensation and hospital re-admissions. Patients receiving TIPS-creation with the CE-VTS showed a significantly lower rate of hepatic encephalopathy (HE) (hazard ratio [HR] 0.365; 95%-CI 0.181; 0.723) and ascites development (HR 0.282; 95%-CI 0.147; 0.541) leading to a significantly lower rate of hospital re-admissions. There was a more pronounced improvement of prognostic scores (MELD, MELD-Na, CLIF-C AD and CLIF-C ACLF) in the CE-VTS group compared to the VTS group. Right ventricular diameter and volume were significantly lower and left ventricular contractility was significantly better in patients treated with the CE-VTS. Overall the one-year survival rate was significantly higher in patients receiving TIPS-creation with the CE-VTS compared to those treated with the VTS (87% vs. 67%, p=0.03). TIPS-creation using a partially dilated controlled expansion Viatorr stent-graft is associated with improved clinical outcomes, less liver decompensations, less hospital re-admissions and improved patient survival one year after TIPS-creation. Lack of passive expansion of this type of stent-graft and improved cardiac parameters may be causes of improved outcomes.

03:27 PM Abstract No. 172 Transjugular intrahepatic portosystemic shunt (TIPS) creation to improve surgical candidacy prior to abdominal operation: a retrospective analysis

03:27 PM Abstract No. 172 Transjugular intrahepatic portosystemic shunt (TIPS) creation to improve surgical candidacy prior to abdominal operation: a retrospective analysis

03:27 PM Abstract No. 271 Transjugular intrahepatic portosystemic shunt (TIPS) creation, thrombolysis and thrombectomy in the management of severe, symptomatic portomesenteric venous thrombosis after bariatric surgery: retrospective review of patient outcomes

03:27 PM Abstract No. 271 Transjugular intrahepatic portosystemic shunt (TIPS) creation, thrombolysis and thrombectomy in the management of severe, symptomatic portomesenteric venous thrombosis after bariatric surgery: retrospective review of patient outcomes

TIPSS for variceal bleeding in patients with idiopathic non‐cirrhotic portal hypertension: comparison with patients who have cirrhosis

In patients with idiopathic non-cirrhotic portal hypertension (INCPH), the usual recommended strategy for management of variceal bleeding is the same as that in cirrhosis. However, this policy has been challenged by the different natural history between INCPH and cirrhosis. To compare outcomes after transjugular intrahepatic portosystemic shunt (TIPSS) between INCPH and cirrhotic patients admitted for variceal bleeding. Between March 2001 and September 2015, 76 consecutive patients with biopsy-proven INCPH undergoing TIPSS for variceal bleeding in a tertiary-care centre were included. 76 patients with cirrhotic portal hypertension receiving TIPSS for variceal bleeding, and matched for age, sex, Child-Pugh class, stent type and index year of TIPSS creation served as controls. Patients with INCPH, compared to those with cirrhosis, had significantly lower mortality (11% vs 36% at 5years, adjusted HR, 0.37; 95% CI 0.15-0.87, P=0.022), overt hepatic encephalopathy (16% vs 33% at 5years, adjusted HR, 0.35; 95% CI 0.16-0.75, P=0.007) and hepatic impairment, despite similar rates of further bleeding (33% vs 32% at 5years, adjusted HR, 0.72; 95% CI 0.36-1.44, P=0.358), and shunt dysfunction (35% vs 36% at 5years, adjusted HR, 0.84; 95% CI 0.41-1.72, P=0.627). These findings were consistent across different relevant subgroups. Patients with INCPH treated with TIPSS for variceal bleeding had similar progression of portal hypertension (further bleeding and shunt dysfunction) but fewer complications of liver disease (overt hepatic encephalopathy and hepatic insufficiency) and lower mortality rate compared with cirrhotic patients with comparable liver function.

Long-term patency and clinical outcome of the transjugular intrahepatic portosystemic shunt using the expanded polytetrafluoroethylene stent-graft.

BackgroundTransjugular intrahepatic portosystemic shunt (TIPS) creation is an established treatment option to management the complications of portal hypertension. Recent data on the long-term outcomes of TIPS are scarce.Materials and methodsIn this single-institution retrospective study, 495 patients underwent TIPS with the Fluency stent-grafts between December 2011 and June 2015 were evaluated. The cumulative rates of TIPS dysfunction, hepatic encephalopathy (HE), survival, and variceal rebleeding were determined using the Kaplan–Meier method. Cox regression analysis was used to assess the parameters on TIPS patency, occurrence of HE and all-cause mortality.ResultsTechnical success was 98.2%. TIPS-related complications occurred in 67 patients (13.5%) during the index hospital stay. TIPS creation resulted in an immediate decrease in mean portosystemic pressure gradient from 23.4 ± 7.1 mmHg to 7.6 ± 3.5 mmHg. The median follow-up period was 649 days. Primary TIPS patency rates were 93%, and 75.9% at 1 and 3 years, respectively. Previous splenectomy was associated with a higher risk of TPS dysfunction. The cumulative survival rates were 93.4% and 77.2% at 1 and 3 years, respectively. The 1- and 3-year probability of remaining free of variceal bleeding rates were 94.2% and 71.4%, respectively.ConclusionsThis retrospective single-center experience with TIPS using the Fluency stent-grafts demonstrates good long-term patency and favorable good clinical results. Previous splenectomy strongly predicts shunt dysfunction.

Adjuvant Transjugular Variceal Occlusion at Creation of a Transjugular Intrahepatic Portosystemic Shunt (TIPS): Efficacy and Risks of Bucrylate Embolization

The retrospective study evaluated 104 of 237 cirrhotic patients with TIPS for variceal bleeding who received adjuvant bucrylate embolization. For TIPS creation, bare stents were used in 35 patients (33.7%) and covered stents in 69 patients (66.3%) patients. Isolated gastric varices were seen in 10 patients (9.6%). Six patients (5.8%) rebled during a median follow-up time of 26months (1-57months). Rebleeding occurred in 14% (5/35) of patients with a bare stent but only in 1.4% (1/69) of patients with a covered stent. The 1- and 2-year rebleeding rates of all patients were 0.9 and 2.9% and of patients receiving a bare stent were 2.9 and 8.6%, respectively. Bucrylate migration was seen in 13 patients (12.5%). In 9 of these patients (8.7%), asymptomatic lung embolization occurred. This was rare in patients with esophageal varices (3.1%) but frequent (60%) in patients with isolated gastric varices and a spontaneous splenorenal shunt. Our results suggest that adjuvant embolization using bucrylate is effective and delays variceal rebleeding. The general use of covered stents, however, alleviates the utility of adjuvant bucrylate embolization which may be restricted to patients with a high risk of rebleeding indicated by large varices, active, acute or recent variceal bleeding and advanced cirrhosis. Bucrylate should not be used in isolated gastric varices because it bears a high risk of migration into the lungs.

Effect of Transjugular Intrahepatic Portosystemic Shunt Creation on Pulmonary Gas Exchange in Patients with Hepatopulmonary Syndrome: A Prospective Study

PurposeTo evaluate effect of transjugular intrahepatic portosystemic shunt (TIPS) creation on pulmonary gas exchange in patients with hepatopulmonary syndrome (HPS). Materials and MethodsAll patients with cirrhosis or Budd-Chiari syndrome undergoing elective TIPS creation at a single institution between June 2014 and June 2015 were eligible for inclusion. Twenty-three patients with HPS (age 55.0 y ± 14.4; 11 men; Model for End-Stage Liver Disease score 10.2 ± 2.7) who achieved technical success were included in the analysis. Diagnosis of HPS was established by contrast-enhanced echocardiography demonstrating intrapulmonary vascular dilatation and arterial blood gas analysis demonstrating arterial oxygenation defects. ResultsMean portosystemic gradient was reduced from 21.7 mm Hg ± 8.3 before TIPS creation to 10.8 mm Hg ± 5.1 after TIPS creation. Among the 5 (21.7%) patients who experienced dyspnea, 4 (80.0%) reported improvement after TIPS creation. This improvement was not maintained at 3 months after TIPS creation in 2 (50.0%) patients. Compared with before TIPS creation, mean change in alveolar-arterial oxygen gradient for patients with HPS was statistically significant at 1 month (−9.2 mm Hg ± 8.0; P < .001) after TIPS creation, but not at 2–3 days (−0.9 mm Hg ± 10.5; P = .678) or 3 months (−3.4 mm Hg ± 11.8; P = .179) after TIPS creation. ConclusionsTIPS creation can transiently improve pulmonary gas exchange in patients with HPS.

Psoas Muscle Density in Combination with Model for End-Stage Liver Disease Score Can Improve Survival Predictability in Transjugular Intrahepatic Portosystemic Shunts

PurposeTo examine the role of psoas muscle density (PD) measurement before transjugular intrahepatic portosystemic shunt (TIPS) creation in predicting survival when combined with Model for End-stage Liver Disease (MELD) score. Materials and MethodsThe medical records of 241 patients with cirrhosis who underwent TIPS creation between June 2005 and June 2015 were retrospectively reviewed. The patients were divided into 2 groups: those with variceal bleeding (VB; n = 113) and those with volume overload (VO; n = 128). The study included 149 men (62%), and mean patient age was 56 years ± 9.6 (range 24–83). Mean MELD score before TIPS creation was 11.8 ± 5.7. A threshold sensitivity of pre-TIPS PD for the assessment of mortality was calculated and then correlated with survival after TIPS creation. Receiver operating characteristic curves comparing 12-month mortality were used to assess the improvement in survival predictability after TIPS creation when the PD threshold was combined with MELD score vs MELD score alone. ResultsMean post-TIPS follow-up was 29.9 month ± 34.1 (range 1–3700 days). There was no significant difference in 3- or 12-month mortality rates between the VB and VO groups (32.7% vs 25.8% [P = .23] and 46% vs 46.1% [P = .99], respectively). The MELD score threshold for prediction of survival was 15 (P < .0001). There was no difference in the mean PD between VB and VO groups (34.2 HU ± 8.8 and 33.1 HU ± 10.3, respectively; P = .359). The increase in MELD score after TIPS creation was significant in both groups (VB, P = .0013; VO, P < .0001). The threshold of pre-TIPS PD for discrimination of survival was 29.4 HU (P < .0001), and PD measurements greater than this threshold were associated with a lower risk of mortality (hazard ratio, 0.27; 95% confidence interval, 0.13–0.57; P = .0006). Compared with the use of MELD score alone, the addition of PD measurement significantly increased the area under the curve from 0.61 to 0.68 (P = .0006). ConclusionsMeasurement of PD improved overall survival predictability in patients with cirrhosis undergoing TIPS creation when used in conjunction with MELD score. The best survival outcome was observed in patients with MELD score < 15 in combination with PD > 29.4 HU.

Technical Feasibility and Clinical Effectiveness of Transjugular Intrahepatic Portosystemic Shunt Creation in Pediatric and Adolescent Patients

PurposeTo examine the technical feasibility and clinical efficacy of transjugular intrahepatic portosystemic shunt (TIPS) creation in children and adolescents. Materials and MethodsRetrospective review was performed of 59 patients (mean age 12.6 y [range, 1.5–20 y], mean weight 47.5 kg [range, 11.4–112.2 kg], mean Model for End-stage Liver Disease/Pediatric End-stage Liver Disease score 12.5 [range, 6–33]) who underwent 61 TIPS attempts at 3 tertiary children’s hospitals from 2001 to 2017 for acute esophageal or gastroesophageal variceal bleeding, primary and secondary prevention of variceal bleeding, and refractory ascites. Pediatric liver disease etiologies included biliary atresia, cystic fibrosis, and ductal plate anomalies. Technical, hemodynamic, and clinical success and patency rates were reported at 1, 6, 12, and 24 months. Statistical analysis evaluated reasons for clinical failure. Kaplan-Meier analysis measured clinical success, patency, and transplant-free survival. ResultsTechnical success was 93.4% (57/61) in 59 consecutive patients. Most common TIPS indications were treating and preventing esophageal and gastroesophageal variceal bleeding (57/59; 96.6%). Hemodynamic success was 94% (47/50). Clinical success was 80.7% (45/56). Two-year clinical success for acute variceal bleeding and ascites was 94.1% and 100%, respectively. Overall patency at 1, 6, 12, and 24 months was 98.0%, 97.8%, 94.3%, and 91.3%. Two-year transplant-free survival was 88.8%. Overall and major complication rates were 21.2% (13/61) and 8.2% (5/61), with 3 mortalities. Gradient reduction < 12 mm Hg correlated with clinical success (P < .01). ConclusionsTIPS creation in pediatric patients is technically feasible and clinically efficacious for treatment and prevention of esophageal and gastroesophageal variceal hemorrhage. High 2-year clinical success, patency, and survival rates should encourage providers to consider portosystemic shunts as a bridge to liver transplantation.

Intravascular Ultrasound in the Creation of Transjugular Intrahepatic Portosystemic Shunts: Review of the Literature and Future Directions

Transjugular intrahepatic portosystemic shunt (TIPS) placement is a well-established interventional radiology procedure for treating sequelae of portal hypertension involving shunting portal blood flow to the hepatic vein bypassing the liver through a stent graft. Creating a TIPS can be a complex and radiation-intensive procedure due to the technically challenging step of cannulating the portal vein from the hepatic vein. As this is the most unpredictable step in TIPS creation, multiple techniques have been described for visualizing the portal vein to facilitate its access. The use of intravascular ultrasound (IVUS) has gained significant interest over the last few years due to reports of improved procedural metrics such as shortened procedural time and radiation dose. The purpose of this article is to review the literature and detail technical advances utilizing IVUS in TIPS creation. Intravascular ultrasound has been shown to be a safe and reproducible means of real-time image guidance for TIPS creation. The use of IVUS has been associated with improved procedural metrics including a decreased number of intrahepatic needle passes, shorter portal vein access times, decreased contrast usage, and a decrease in radiation dose. Due to technical advances and real-time portal vein visualization using IVUS, TIPS creation at our institution has dramatically changed. Our institutional practice has nearly completed shifted to the sole use of IVUS for portal vein access in TIPS creation due to significantly improved procedural metrics including radiation dose and contrast usage.

Ultrasonographic guidance for portal vein access during transjugular intrahepatic portosystemic shunt (TIPS) placement.

The purpose of our study was to retrospectively assess the safety and efficacy of percutaneous real-time ultrasound guidance for portal vein puncture during transjugular intrahepatic portosystemic shunt (TIPS) placement. Between January 2011 and November 2018, procedure details and outcome were retrospectively analyzed for 224 patients who underwent TIPS placement using real-time ultrasound guidance for portal vein puncture. There were 175 men and 49 women with a mean age of 52.7±10.6 (SD) years (range: 22-82 years). For each procedure, technical success, primary ultrasound guidance success, portosystemic pressure gradient, duration of the intervention, procedural complications, radiation exposure, mortality and morbidity rates at day 30 post-procedure were recorded for data analysis. Technical success rate was 100.0% with a success rate of the primary ultrasound guidance of 97.8% (219/224; 95% CI: 95.8-99.7). Mean duration of the procedure was 86.2±41.7 (SD) min (range: 22.0-267.0min). Mean dose-area product was 62.0±50.2 (SD) Gy.cm2 (range: 3.7-306.5Gy.cm2). Twelve complications (12/224; 5.4%) occurred in ten patients during TIPS procedures including 8 arterial punctures (3.6%) and 4 biliary punctures (1.8%). Four complications (4/224; 1.8%) were clinically significant. Mortality rate at day 30 after the procedure was 9.8% (22/224), without any patient dying from technical complications. Real-time ultrasound guidance is a safe technique to assist in the creation of TIPS and may allow for lower radiation exposure.

Proton Pump Inhibitor Use Is Associated with an Increased Frequency of New or Worsening Hepatic Encephalopathy after Transjugular Intrahepatic Portosystemic Shunt Creation

PurposeTo determine whether proton pump inhibitor (PPI) use increases the rate of new or worsening hepatic encephalopathy (HE) after transjugular intrahepatic portosystemic shunt (TIPS) creation. Materials and MethodsIn this retrospective study, 284 of 365 patients who underwent TIPS creation from January 1, 2005, to December 31, 2016, were analyzed (186 male, mean age 56 y, range 19–84 y). Dates of PPI use and dates of new or worsening HE, defined as hospitalization or escalation in outpatient medical management, were extracted from medical records. Mixed-effects negative binomial regression was used to test for an association between PPI usage and HE. ResultsAfter TIPS creation, among 168 patients on PPIs chronically, there were 235 episodes of new or worsening HE in 106,101 person-days (0.81/person-year). Among 55 patients never on PPIs, there were 37 episodes in 31,066 person-days (0.43/person-year). Among 61 patients intermittently taking PPIs, there were 78 episodes in 37,710 person-days while on PPIs (0.75/person-year) and 25 episodes in 35,678 person-days while off PPIs (0.26/person-year). In univariate regression, PPI usage was associated with a 3.34-fold increased rate of new or worsening HE (incidence rate ratio [IRR] 3.34; P < .001). In multivariate regression, older age (IRR 1.05; P < .001), male sex (IRR 1.58; P = .023), higher Model for End-Stage Liver Disease score (IRR 1.06; P = .015), previous HE or HE-preventive medication use (IRR 1.51; P = .029), and PPI use (IRR 3.19; P < .001) were significant risk factors. Higher PPI doses were associated with higher rates of HE (IRR 1.16 per 10 mg omeprazole equivalent; P = .046). ConclusionsPPI usage is associated with increased rates of new or worsening HE after TIPS creation.

Early-Recurrent Overt Hepatic Encephalopathy Is Associated with Reduced Survival in Cirrhotic Patients after Transjugular Intrahepatic Portosystemic Shunt Creation

PurposeTo investigate the role of early overt hepatic encephalopathy (OHE) as a clinical marker of prognosis in cirrhosis with a transjugular intrahepatic portosystemic shunt (TIPS) and to assess the relationship between recurrence of OHE and survival after TIPS. MethodsFrom January 2012 to December 2013, a retrospective study of consecutive patients with cirrhosis and a TIPS was performed at a single institution. A total of 304 patients (196 males; mean age, 52 years) were enrolled during the study period. The mean Model for End-Stage Liver Disease (MELD) score was 11.6. Time-dependent Cox regression was applied to estimate the predictive ability of early OHE (within 3 months after TIPS) and the effect of its frequency on survival. ResultsDuring a median follow-up of 28.3 months, 115 patients experienced OHE after the TIPS procedure; of these, 54 had at least 2 OHE episodes. Long-term survival worsened in patients with early OHE (hazard ratio [HR] = 2.75; 95% confidence interval [CI]: 1.75–4.32; P < .001). When early OHE was further divided into early-recurrent and single OHE, death was more common in patients with early-recurrent OHE (P < .001) than in patients with early-single OHE (P = .24). After adjustment by MELD score, ascites, serum albumin, indication for TIPS, and age, patients with early-recurrent OHE had a lower probability of survival (HR = 2.91; 95% CI: 1.04–4.89; P < .001). Furthermore, landmark and propensity score analyses confirmed the predictive value of early-recurrent OHE. ConclusionsEarly recurrence of OHE was associated with an increased risk of mortality for patients with cirrhosis who underwent TIPS.

No Increased Mortality After TIPS Compared with Serial Large Volume Paracenteses in Patients with Higher Model for End-Stage Liver Disease Score and Refractory Ascites

To compare survival after transjugular intrahepatic portosystemic shunt (TIPS) creation versus serial large volume paracenteses (LVP) in patients with refractory ascites and higher Model for End-Stage Liver Disease (MELD) scores. In this retrospective study, from 1/1/2013 to 10/1/2018, 478 patients (294 male; mean age 58, range 23-89) underwent serial LVP (n = 386) or TIPS (n = 92) for ascites. Propensity-matched cohorts were constructed based on age, MELD, Charlson comorbidity index, varices, and hepatic encephalopathy. Survival was analyzed using a Cox proportional hazards model in which MELD score and TIPS were treated as time-dependent covariates. An interaction term was used to assess the impact of TIPS versus serial LVP on survival as a function of increasing MELD. In the overall patient sample, higher MELD score predicted worse survival after either serial LVP or TIPS [hazard ratio (HR) = 1.13; p < 0.001], but there was no significant interaction between TIPS and higher MELD score conferring worse survival (HR = 1.01; p = 0.55). In 92 propensity-matched serial LVP and 92 TIPS patients, higher MELD score predicted worse survival after either serial LVP or TIPS (HR = 1.19; p < 0.001), but there was no significant survival interaction between TIPS and higher MELD (HR = 0.97; p = 0.22). In 30 propensity-matched serial LVP patients and 30 TIPS patients with baseline MELD greater than 18, TIPS did not predict worse survival (HR = 0.97; p = 0.94). Higher MELD predicts poorer survival after either serial LVP or TIPS, but TIPS creation is not associated with worse survival compared to serial LVP in patients with higher MELD scores LEVEL OF EVIDENCE: Level 4, case series.

Transjugular Intrahepatic Portosystemic Shunt (TIPS) Creation to Improve Surgical Candidacy Prior to Abdominal Operation: A Retrospective Analysis

Background and Hypothesis: TIPS creation is typically reserved for patients with refractory ascites or variceal hemorrhage. While TIPS have also been created prior to planned abdominal operation to decrease morbidity related to portal hypertension, there is little in the literature supporting its efficacy in that indication. The goal of this study was to determine if preoperative TIPS creation allows successful abdominal operation and improves outcomes. &#x0D; Experimental Design or Project Methods: A retrospective review of records of 22 patients who underwent preoperative TIPS creation between 2011 and 2016 was performed. Clinical and serologic data were obtained for 21 patients since one patient was completely lost to follow up after TIPS creation. The primary endpoint was whether patients underwent planned abdominal operation following TIPS. Operative outcomes and reasons that patients failed to undergo planned operation were examined as secondary endpoints. &#x0D; Results: The mean age was 56.4 ± 8.8 years, and the mean Child-Pugh and Model for End-Stage Liver Disease (MELD) scores were 7.2 ± 1.5 and 11.9 ± 4.3, respectively. Thirty-day mortality after TIPS creation was 9.5%. Eleven patients (52.4%) underwent planned abdominal operation and the thirty-day mortality rate was 0%. One of these 11 patients (9.1%) had surgical wound dehiscence and infection 53 days after operation. Reasons for failure to proceed to abdominal operation after TIPS were multifactorial. &#x0D; Conclusion and Potential Impact: In our population, TIPS allowed successful abdominal operation in the majority of patients, with thirty-day TIPS mortality of 9.5%, no perioperative mortality, and 9.1% major postoperative morbidity.

Changes in arterial oxygenation after portal decompression in Budd-Chiari syndrome patients with hepatopulmonary syndrome.

To evaluate the changes in arterial oxygenation after portal decompression in Budd-Chiari syndrome (BCS) patients with hepatopulmonary syndrome (HPS). From June 2014 to June 2015, all patients with BCS who underwent balloon angioplasty or transjugular intrahepatic portosystemic shunt (TIPS) creation at our institution were eligible for inclusion in this study. Arterial blood gas analysis was performed with the patient in an upright position and breathing room air at 2-3days and 1 and 3months after the procedure. Eleven patients with HPS and 14 patients without HPS were included in this study. The procedure was technically successful in 24 patients. One patient with HPS had technically unsuccessful TIPS creation. Reobstruction or TIPS dysfunction was not detected in any patient within 3months after the procedure. For patients with HPS, the alveolar-arterial oxygen gradient (A-aO2) remained comparable to baseline 2-3days after the procedure (-3.2 ± 11.9mmHg; p = .412), significantly improved 1month after the procedure (-11.7 ± 6.4mmHg; p < .001), and then returned to baseline 3months after the procedure (-1.3 ± 12.5mmHg; p = .757). For patients without HPS, the A-aO2 remained comparable to baseline at all three time points after the procedure (+1.4 ± 8.3mmHg, +3.5 ± 8.1mmHg, and +1.3 ± 8.2mmHg; p = .543, p = .137, and p = .565). Arterial oxygenation transiently improves after portal decompression in BCS patients with HPS. • Intrapulmonary vascular dilation and hepatopulmonary syndrome are common in patients with Budd-Chiari syndrome. • Arterial oxygenation transiently improves after portal decompression in Budd-Chiari syndrome patients with hepatopulmonary syndrome.

Transjugular Intrahepatic Portosystemic Shunt for the Treatment of Portal Hypertension-Induced Refractory Ascites Due to Metastatic Carcinomatous Liver Disease

Three patients with a medical history of breast carcinoma and metastatic carcinomatous liver disease associated with severe portal hypertension and refractory ascites are presented. Transjugular intrahepatic portosystemic shunt creation was considered as a palliative treatment option and a valuable alternative to regular paracenteses in these patients. In 2 of the 3 patients, the refractory ascites was controlled for several months without need for paracentesis, and subsequently transjugular intrahepatic portosystemic shunt may provide valuable palliation and ascites control in patients with refractory ascites due to breast cancer-induced pseudocirrhosis.