Transjugular Intrahepatic Portosystemic Shunt Insertion Research Articles

Cardiac dysfunction in patients with cirrhosis and acute decompensation.

The prevalence of cirrhotic cardiomyopathy (CCM) has been reported as high as 60%-70% in patients with liver cirrhosis and is associated with various negative outcomes. There has been a growing understanding of CCM over recent years. Indeed, the development of imaging techniques has enabled new diagnostic criteria to be proposed by the Cirrhotic Cardiomyopathy Consortium. However, important unanswered questions remain over pathophysiological mechanisms, optimal diagnostic modalities and potential treatment options. While there has been an increasing volume of literature evaluating CCM, there is a lack of clarity on its implications in acute decompensation, acute-on-chronic liver failure and following interventions such as transjugular intrahepatic portosystemic shunt insertion and liver transplantation. This review aims to summarise the literature in these challenging domains and suggest where future research should focus. We conclude that systemic inflammation and structural myocardial changes are likely to be crucial in the pathophysiology of the disease, but the relative contribution of different components remains elusive. Furthermore, future studies need to use standardised diagnostic criteria for CCM as well as incorporate newer imaging techniques assessing both myocardial structure and function. Finally, while specific treatments are currently lacking, therapeutics targeting systemic inflammation, microbial dysbiosis and bacterial translocation are promising targets and warrant further research.

High prevalence and clinical relevance of intrapulmonary vascular dilatations in patients undergoing TIPS implantation

Background and AimsConsiderate patient selection is vital to ensure best possible outcomes after transjugular intrahepatic portosystemic shunt (TIPS) insertion. However, data regarding the impact of intrapulmonary vascular dilatations (IPVD) or hepatopulmonary syndrome (HPS) on the clinical course after TIPS implantation is lacking. Hence, this study aimed to investigate the relevance of IPVD and HPS in patients undergoing TIPS implantation. MethodsContrast enhanced echocardiography and blood gas analysis were utilized to determine presence of IPVD and HPS. Multivariable competing risk analyses were performed to evaluate cardiac decompensation (CD), hepatic decompensation (HD) and liver transplant (LTx)-free survival within one-year of follow up. ResultsOverall, 265 patients were included, of whom 136 had IPVD and 71 fulfilled the HPS criteria. Patients with IPVD had lower Freiburg index of post-TIPS survival (FIPS) scores, lower creatinine and more often received a TIPS because of variceal bleeding. Presence of IPVD was associated with a significantly higher incidence of CD (HR: 1.756 95%CI: 1.011-3.048 p=0.046) and HD (HR: 1.841 95%CI: 1.255-2.701 p=0.002). However, LTx-free survival was comparable between patients with and without IPVD (HR: 1.081 95%CI: 0.630-1.855, p=0.780). Patients with HPS displayed a trend towards more CD (HR: 1.708 95%CI: 0.935-3.122, p=0.082) and HD (HR: 1.458 95%CI: 0.934-2.275, p=0.097) that failed to reach statistical significance. LTx-free survival did not differ in those with HPS compared to patients without HPS, respectively (HR: 1.052 95%CI: 0.577-1.921, p=0.870). ConclusionScreening for IPVD before TIPS implantation could help to further identify patients at higher risk of cardiac and hepatic decompensation.

Indications and outcomes of transjugular intrahepatic portosystemic shunt insertion in two regional Australian hepatology centres.

Transjugular intrahepatic portosystemic shunt (TIPS) is an important therapy for complications of portal hypertension but remains underutilised in regional settings. The aim of this study is to explore the demographics, indications, outcomes and complications in patients undergoing TIPS in two regional hepatology centres. Retrospective analysis was undertaken of all patients undergoing TIPS at two regional centres between January 2017 and March 2023. The primary outcome measures were efficacy and complications of TIPS. Patient demographics (such as age, baseline liver severity scores and aetiology of liver disease) and indications for TIPS are detailed. Forty-eight patients underwent TIPS. Median age was 56 years (interquartile range (IQR): 46-65). The most common indications for TIPS were refractory ascites (n = 17) and failure of secondary prophylaxis of variceal bleeding (n = 13). Cumulative survival at 3 months and 1 year was 93% and 77% respectively. There was no significant difference in outcomes based on TIPS indication. The median number of paracenteses in patients undergoing TIPS for refractory ascites 1 year pre- and post-TIPS were 10 (IQR: 4.5-16) and 2 (IQR: 0-4) respectively (P < 0.001). There were no procedure-related deaths. Inpatient management of liver disease complications had a mean cost of $32 874.67 (SEM: 7779) in 1 year pre-TIPS compared with $12 304.70 (SEM: 3531.1) in 1 year post-TIPS (P < 0.001). TIPS is a safe and effective treatment to reduce complications of portal hypertension and can be performed successfully in the regional setting.

Transjugular Intrahepatic Portosystemic Shunt in Nonmalignant Noncirrhotic Portal Vein Thrombosis and Portosinusoidal Vascular Disorder.

Transjugular intrahepatic portosystemic shunt (TIPS) emerges as a key treatment for portal hypertension (PH) complications. While international guidelines provide clear indications for its use in cirrhosis, empirical knowledge is notably scarcer in non-cirrhotic PH, particularly in nonmalignant noncirrhotic portal vein thrombosis (NNPVT) and in patients with portosinusoidal vascular disorder (PSVD). Patients afflicted by these rare diseases exhibit distinct clinical profiles compared to their cirrhotic counterparts, often characterized by a younger age, predominantly preserved hepatic functionality even in cases of severe PH, and a higher propensity for extensive splanchnic thrombosis, which intricately complicates TIPS placement, posing unique challenges for its creation. The objective of this review is to synthesize existing literature on the effectiveness, safety, specific indications, and clinical outcomes of TIPS in adult patients with NNPVT or PSVD, focusing also on the technical challenges of TIPS insertion in the presence of portal cavernoma.

Role of Transjugular Intrahepatic Portosystemic Shunt in the Liver Transplant Setting.

Liver transplantation is currently the only curative therapy for patients with liver cirrhosis. Not all patients in the natural course of the disease will undergo transplantation, but the majority of them will experience portal hypertension and its complications. In addition to medical and endoscopic therapy, a key role in managing these complications is played by the placement of a transjugular intrahepatic portosystemic shunt (TIPS). Some indications for TIPS placement are well-established, and they are expanding and broadening over time. This review aims to describe the role of TIPS in managing patients with liver cirrhosis, in light of liver transplantation. As far as it is known, TIPS placement seems not to affect the surgical aspects of liver transplantation, in terms of intraoperative bleeding rates, postoperative complications, or length of stay in the Intensive Care Unit. However, the placement of a TIPS "towards transplant" can offer advantages in terms of ameliorating a patient's clinical condition at the time of transplantation and improving patient survival. Additionally, the TIPS procedure can help preserve the technical feasibility of the transplant itself. In this context, indications for TIPS placement at an earlier stage are drawing particular attention. However, TIPS insertion in decompensated patients can also lead to serious adverse events. For these reasons, further studies are needed to make reliable recommendations for TIPS in the pre-transplant setting.

Transjugular intrahepatic portosystemic shunt for portal hypertension with chronic portal vein occlusion

PurposeThis study aims to evaluate the long-term patency of transjugular intrahepatic portosystemic shunt (TIPS) and determine the predictors of shunt dysfunction in patients with chronic portal vein occlusion (CPVO). MethodThis retrospective study was conducted from December 2010 to December 2020 in patients with portal hypertension and CPVO. Patients were followed up from initial TIPS insertion to December 2022 or death. Details of TIPS procedure, adverse events and clinical outcomes were recorded. The cumulative rate of shunt patency was calculated by the Kaplan-Meier method and compared by using the log-rank test. Independent predictors of shunt dysfunction were calculated with the Cox regression model. A nomogram comprising independent variables was developed to enhance the predictive accuracy of shunt patency. ResultsOne hundred six patients (mean age, 45.3 years ± 13.6; 71 males and 35 females) were enrolled in the study. TIPS procedure was technically successful in 100 of 106 patients (94.3 %). The primary shunt patency rates for all 100 patients were 78.9 %, 74.7 %, 67.2 %, and 62.4 % at 6, 12, 24, and 36 months, respectively, and the overall shunt patency rates were 88.9 %, 86.8 %, 83.6 %, and 81.2 % at 6, 12, 24, and 36 months, respectively. Independent predictor of shunt dysfunction were inadequate inflow from superior mesenteric vein or splenic vein (the maximum diameter < 8 mm) and platelet count ≥ 300 × 109/L. The developed nomogram is a simple tool for accurately predicting shunt patency. ConclusionsIn patients with CPVO, inadequate inflow and high platelet count are important factors for TIPS dysfunction.

Diastolic dysfunction is associated with cardiac decompensation after transjugular intrahepatic portosystemic shunt in patients with liver cirrhosis.

About 20% of patients develop cardiac decompensation within the first year after transjugular intrahepatic portosystemic shunt (TIPS) insertion. However, risk factors for cardiac decompensation remain poorly defined. We aimed to evaluate predictors of cardiac decompensation after TIPS insertion in a large, well-defined cohort of patients with liver cirrhosis. 234 cirrhotic patients who received a TIPS at Hannover Medical School were retrospectively followed up for one year to assess the incidence of cardiac decompensation. Echocardiographic parameters and established diagnostic criteria for cardiac impairment (e.g. by the American Society of Echocardiography/ European Association of Cardiovascular Imaging (ASE/EACVI)) were investigated for an association with cardiac decompensation in a competing risk analysis. Survival was analyzed using a multivariable cox regression analysis adjusting for Freiburg index of post-TIPS survival. Predominant TIPS indication was ascites (83%). Median age was 59years, median MELD-score 12% and 58% were male. Overall, 41 patients (18%) developed cardiac decompensation within one year after TIPS insertion. Diastolic dysfunction according to the ASE/EACVI was diagnosed in 26% of patients at baseline and was linked to a significantly higher risk for cardiac decompensation (p=0.025) after TIPS. When investigating individual echocardiographic baseline parameters, only pathological E/A (<0.8 or >2) was identified as a risk factor for cardiac decompensation (p=0.015). Mortality and liver transplantation (n=50) were significantly higher among patients who developed cardiac decompensation (HR=5.29, p<0.001) as well as in patients with a pathological E/A (HR=2.34, p=0.006). Cardiac high-risk status (44% of patients) was strongly linked to cardiac decompensation (HR=2.93, p=0.002) and mortality (HR=2.24, p=0.012). Cardiac decompensation after TIPS is a frequent and important complication and is associated with reduced survival. American Society of Echocardiography/EACVI criteria and E/A seem to be the best parameters to predict the cardiac risk in cirrhotic patients undergoing TIPS insertion.

Management of upper gastrointestinal bleeding in advanced hepatocellular carcinoma with portal hypertension and variceal bleeding during receiving tyrosine kinase inhibitors therapy: Beyond and known frontiers

AbstractHepatocellular carcinoma (HCC) poses a significant global burden, with most patients being diagnosed at an advanced stage, leading to poor prognosis due to the lack of systemic treatment. The approval of oral tyrosine kinase inhibitors (TKIs), immune checkpoint inhibitors, and anti‐angiogenic agents has rapidly expanded the treatment prospects for HCC. However, the use of these drugs has also increased the incidence of portal hypertension (PHT) and upper gastrointestinal variceal bleeding in HCC patients. The diagnosis, screening, emergency treatment, and secondary prevention of upper gastrointestinal variceal rebleeding in advanced HCC patients undergoing oral TKIs therapy have become clinically urgent and critical issues. This review provides an overview of the existing understanding regarding the uses and limitations of transjugular intrahepatic portosystemic shunt (TIPS) insertion for managing HCC in cirrhosis patients with PHT and variceal hemorrhage. Additionally, it explores the potential of TIPS in managing acute upper gastrointestinal bleeding and preventing rebleeding in advanced HCC patients undergoing TKIs therapy. The placement of TIPS within the treatment hierarchy is determined by the specific clinical environment and the individual attributes of the patient.

Predicting overt hepatic encephalopathy after TIPS: Value of three minimal hepatic encephalopathy tests

Hepatic encephalopathy (HE) is a frequent and severe complication in patients after transjugular intrahepatic portosystemic shunt (TIPS) insertion. However, risk factors for post-TIPS HE remain poorly defined. Minimal HE (mHE) is a well-known risk factor for overt HE in patients with cirrhosis without TIPS. We aimed to evaluate three tools frequently used for diagnosing mHE for their dynamic changes and their predictive value for overt HE after TIPS. We prospectively recruited 84 consecutive patients before TIPS insertion and monitored them for 180 days for post-TIPS HE. Before TIPS insertion, the patients underwent the portosystemic encephalopathy (PSE) syndrome test, the animal naming test (ANT), and the critical flicker frequency (CFF). Patients were retested after TIPS insertion. The majority of patients were male (67.9%), and the predominant indication for TIPS was refractory ascites (75%). Median age was 59 years, model for end-stage liver disease score was 12, and 66.3%, 64.6%, and 28.4% patients had evidence for mHE according to the PSE syndrome test, ANT, and CFF, respectively. Overall, 25 patients developed post-TIPS HE within 180 days after TIPS insertion. Post-TIPS incidence of overt HE was 22.2, 28.6, 45.5, and 55.6% in those with no, one, two, and three pathological tests at baseline, respectively. However, none of the three tests was significantly associated with post-TIPS HE. Of note, mean performance in all tests remained stable over time after TIPS insertion. PSE syndrome test, ANT and CFF, which are frequently used for diagnosing mHE have limited value for predicting HE after TIPS insertion. We could not find evidence that TIPS insertion leads to a psychometric decline in the long term. This prospective observational study compared three diagnostic tests for mHE and showed the limited value of these tests for predicting overt HE in patients with cirrhosis undergoing TIPS insertion. In addition, the results suggest that cognitive performance generally remains stable after TIPS insertion. These results are important for physicians and researchers involved in the management of patients with cirrhosis undergoing TIPS procedures. The study's findings serve as a starting point for further investigations on the development of more effective strategies for predicting and managing post-TIPS HE. ClinicalTrials.gov NCT04801290.

Transjugular intrahepatic portosystemic shunt insertion improves muscle mass but not muscle function or frailty measures.

Sarcopenia in cirrhosis is associated with poor outcomes. While transjugular intrahepatic portosystemic shunt (TIPS) insertion improves radiological measures of muscle mass, its impact on muscle function, performance and frailty has not been evaluated. Patients with cirrhosis referred for TIPS were prospectively recruited and followed for 6 months. L3 CT scans were used to calculate skeletal muscle and adipose tissue parameters. Handgrip strength, Liver Frailty Index and short physical performance battery were serially monitored. Dietary intake, insulin resistance, insulin-like growth factor (IGF)-1, and immune function using QuantiFERON Monitor (QFM) were measured. Twelve patients completed the study with a mean age of 58 ± 9 years and model for end-stage liver disease score of 16 ± 5. At 6 months post-TIPS, skeletal muscle area increased from 139.33 cm 2 ± 22.72 to 154.64 ± 27.42 ( P = 0.012). Significant increases were observed in the subcutaneous fat area ( P = 0.0076) and intermuscular adipose tissue ( P = 0.041), but not muscle attenuation or visceral fat. Despite marked changes in muscle mass, no improvements were observed in handgrip strength, frailty, or physical performance. At 6 months post-TIPS, IGF-1 ( P = 0.0076) and QFM ( P = 0.006) increased compared to baseline. Nutritional intake, hepatic encephalopathy measures, insulin resistance and liver biochemistry were not significantly impacted. Muscle mass increased following TIPS insertion as did IGF-1, a known driver of muscle anabolism. The lack of improvement in muscle function was unexpected and may relate to impairment in muscle quality and the effects of hyperammonaemia on muscle contractile function. Improvements in QFM, a marker of immune function, may suggest a reduction in infection susceptibility in this at-risk population and requires further evaluation.

WED-326 - Impact of intrapulmonary vascular dilatations and hepatopulmonary syndrome on the clinical course of patients after transjugular intrahepatic portosystemic shunt insertion

WED-326 - Impact of intrapulmonary vascular dilatations and hepatopulmonary syndrome on the clinical course of patients after transjugular intrahepatic portosystemic shunt insertion

SAT-551 - Impact of non-selective beta-blockers on first and further hepatic decompensation after transjugular intrahepatic portosystemic shunt insertion

SAT-551 - Impact of non-selective beta-blockers on first and further hepatic decompensation after transjugular intrahepatic portosystemic shunt insertion

The reproducibility of interventional radiology randomized controlled trials and external validation of a classification system.

The fragility index (FI) measures the robustness of randomized controlled trials (RCTs). It complements the P value by taking into account the number of outcome events. In this study, the authors measured the FI for major interventional radiology RCTs. Interventional radiology RCTs published between January 2010 and December 2022 relating to trans-jugular intrahepatic portosystemic shunt, trans-arterial chemoembolization, needle biopsy, angiography, angioplasty, thrombolysis, and nephrostomy tube insertion were analyzed to measure the FI and robustness of the studies. A total of 34 RCTs were included. The median FI of those studies was 4.5 (range 1-68). Seven trials (20.6%) had a number of patients lost to follow-up that was higher than their FI, and 15 (44.1%) had a FI of 1-3. The median FI, and hence the reproducibility of interventional radiology RCTs, is low compared to other medical fields, with some having a FI of 1, which should be interrupted cautiously.

A245 A TERTIARY CENTRE REVIEW OF PORTO-SYSTEMIC SHUNTS: AN INCREASINGLY IMPORTANT TOOL IN LIVER DISEASE MANAGEMENT

Abstract Background Portal hypertensive complications arising from chronic liver disease are increasingly prevalent. Radiologically placed porto-systemic shunts are used successfully to address complications such as ascites and recurrent variceal bleeding. Purpose We sought, with approval from ethics to electronically chart review the UHN experience for TIPSS (transjugular intrahepatic porto-systemic shunt) and DIPS (direct intrahepatic porto-caval shunt) over time. Method We employed a search strategy focused on radiologic databases, to identify UHN patients who had received a porto-systemic shunt insertion over three decades between January 1, 1990, to September 14, 2021. A total of 238 UHN patients that had a shunt imaged, re-assessed, or inserted were included in this retrospective electronic chart review. Demographic information was recorded at baseline. Data pertaining to clinical outcomes of portal hypertension such as refractory ascites, recurrent gastrointestinal bleeding and ESLD progression was recorded at baseline, 1 month, 3 months and 6 months post-shunt insertion. HVPG was recorded pre-shunt and post-shunt insertion. Transplant-free survival and post-operative complications was also assessed. Patients were followed until death or liver transplant. Result(s) Out of 238 patients confirmed, 219 had a TIPSS insertion and 19 a DIPS insertion. The average age at time of shunt was 55.1 ± 8.4 years. 53.7% (n=128) of patients were male. Indications for portosystemic shunt placement included refractory ascites (n=141), recurrent gastrointestinal bleeding (n=73), hydrothorax (n=10), hepatorenal syndrome (n=8), and portal vein thrombosis (n=4). Etiology of disease was categorized as alcohol-associated liver disease (n=107), non-alcohol associated fatty liver disease (n=36), viral hepatitis (n=27), autoimmune hepatitis (n=38) and vascular liver disease (n=20). Relevant events noted post procedure included hepatic encephalopathy (n=34), hydrothorax (n=17), vascular (including stent) thrombosis (n=17) and renal failure (n=4). 12 months post-shunt insertion 2.5% (n=6) of patients had died or received liver transplant; of these 1.7% (n=4) were transplanted. HPVG fell consistently post-procedure: 15.6 ± 1.5mmHg pre-shunt to 5.9 ± 1.2mmHg post-shunt. There was no observable increase in MELD-Na score in the first month post-shunt. Temporal trends showed that more patients aged 50 to 69, and more female patients, are now receiving shunt insertion than at the initiation of the chart review. Image Conclusion(s) Portosystemic shunt placement in the form of TIPSS or DIPS insertion is an increasingly common and effective treatment for portal hypertension in patents with advanced liver disease at UHN. Disclosure of Interest None Declared

Monitoring haemodynamic changes during transjugular portosystemic shunt insertion with electric cardiometry in sedated and spontaneous breathing patients. A diagnostic test accuracy study.

Transjugular intrahepatic portosystemic shunt (TIPS) allows a high blood volume into systemic circulation abruptly. The primary aim of the study was to investigate the effect of TIPS on systemic, portal hemodynamics, and electric cardiometry (EC) parameters in sedated and spontaneous breathing patients. Secondary aims?? Adult consecutive hepatic patients scheduled for elective TIPS were included. Patients were sedated with bispectral index-guided propofol infusion + fentanyl boluses. EC parameters, i.e., cardiac output (CO) and systemic vascular resistance (SVR) were noted. Noninvasive blood pressure, heart rate, central venous pressure (CVP, cmH2O), and portal venous pressure (PVP, cmH2O) were measured pre- and post-TIPS. Thirty-six people were enrolled (n = 25 included) from Aug 2018 to Dec 2019. Data (expressed in median (IQ)) were: age 33 (27-40) years, body mass index 24 (22.0-27) kg/m2, child A 60%, B 36%, and C 4%. Post-TIPS, PVP decreased (from 40 [37-45] to 34 [27-37] mmHg, P < 0.001), whereas CVP increased (from 7 [4-10] to 16 [10.0-19.0] mmHg, P < 0.001). The CO increased (P = 0.03) and SVR reduced (P = 0.012). The reduction in PVP following successful TIPS insertion elevated the CVP abruptly. EC was able to monitor an immediate increase in the CO and a reduction in SVR in association with the above PVP and CVP changes. The results of this unique study indicate that EC monitoring is promising; however, further evaluation in a larger population and in correlation with other gold-standard CO monitors is still indicated.

Emphasis on the prevention and treatment of hepatic vascular diseases

Portal hypertension, as a common and complex hepatic vascular disease, is a key pathophysiological link in many events of acute cirrhosis decompensation and the progression of multiple organ failure. The most effective measure to reduce portal hypertension is a transjugular intrahepatic portosystemic shunt (TIPS). Maintaining liver function, reducing complications, and improving patients' quality of life and survival time are positively impacted by early TIPS insertion. Patients with cirrhosis have a risk of portal vein thrombosis (PVT) that is 1 000 times higher than that of the normal population. Hepatic sinusoidal obstruction syndrome has a severe clinical course and a high mortality risk. The primary treatment approaches for PVT and HSOS are anticoagulation and TIPS. The innovative magnetic anastomosis vascular technique significantly shortens the anhepatic time and restores normal liver function in patients following liver transplantation.

Salvage transjugular intrahepatic portosystemic shunt in patients with cirrhosis and refractory variceal bleeding: Asystematic review with meta-analysis.

BackgroundTransjugular intrahepatic portosystemic shunt (TIPS) may be used as a salvage treatment in patients with cirrhosis and refractory variceal bleeding.AimTo synthesize the available evidence on the efficacy of TIPS in patients with cirrhosis and refractory variceal bleeding.MethodsMeta‐analysis of trials evaluating TIPS in patients with cirrhosis and refractory variceal bleeding, including subgroup analysis to assess the impact of recent changes in the management of variceal bleeding (i.e., the use of Polytetrafluoroethylene‐covered TIPS and the availability of pre‐emptive TIPS as a first‐line treatment for acute variceal bleeding).ResultsTwenty‐three studies with 1430 patients were included. The pooled estimate rates were 0.33 (95% CI = 0.29–0.37) for death at 1 month–6 weeks, 0.46 (95% CI = 0.40–0.52) for death at 1 year, and 0.09 (95% CI = 0.06–0.11) for death due to rebleeding in the follow‐up. The pooled estimate rates for death at 1 month or 6 weeks were similar in subgroup analyses including studies that did not use covered TIPS or that did not include patients after the pre‐emptive TIPS area compared to the ones that did (pooled estimate rate 0.33 [95% CI = 0.28–0.38] and 0.32 [95% CI = 0.25–0.39], respectively). The pooled estimate rates were 0.16 (95% CI = 0.13–0.18) for rebleeding, 0.25 (95% CI = 0.17–0.36) for occurrence of hepatic encephalopathy, and 0.08 (95% CI = 0.05–0.13) for access to liver transplantation after TIPS insertion.ConclusionsOne third of patients with cirrhosis and refractory variceal bleeding treated with salvage TIPS died within the first 6 weeks. Recent improvements in the management of variceal bleeding did not improve the survival of patients presenting with refractory variceal bleeding.

Natural history and outcomes of patients with liver cirrhosis complicated by hepatic hydrothorax.

BACKGROUNDHepatic hydrothorax (HH) is an uncommon and difficult-to-manage complication of cirrhosis with limited treatment options.AIMTo define the clinical outcomes of patients presenting with HH managed with current standards-of-care and to identify factors associated with mortality.METHODSCirrhotic patients with HH presenting to 3 tertiary centres from 2010 to 2018 were retrospectively identified. HH was defined as pleural effusion in the absence of cardiopulmonary disease. The primary outcomes were overall and transplant-free survival at 12-mo after the index admission. Cox proportional hazards analysis was used to determine factors associated with the primary outcomes.RESULTSOverall, 84 patients were included (mean age, 58 years) with a mean model for end-stage liver disease score of 29. Management with diuretics alone achieved long-term resolution of HH in only 12% patients. At least one thoracocentesis was performed in 73.8% patients, transjugular intrahepatic portosystemic shunt insertion in 11.9% patients and 33% patients received liver transplantation within 12-mo of index admission. Overall patient survival and transplant-free survival at 12 mo were 68% and 41% respectively. At multivariable analysis, current smoking [hazard ratio (HR) = 8.65, 95% confidence interval (CI): 3.43-21.9, P < 0.001) and acute kidney injury (AKI) (HR = 2.91, 95%CI: 1.21-6.97, P = 0.017) were associated with a significantly increased risk of mortality.CONCLUSIONCirrhotic patients with HH are a challenging population with a poor 12-mo survival despite current treatments. Current smoking and episodes of AKI are potential modifiable factors affecting survival. HH is often refractory of diuretic therapy and transplant assessment should be considered in all cases.

Reply.

We thank Luo et al. for the interest in our manuscript, although all answers to the raised concerns are found in the published manuscript. We agree that baseline liver function correlates with mortality, and we reported in detail no significant differences in baseline characteristics between groups; in particular, Model for End‐Stage Liver Disease, Child‐Pugh score, and age did not differ significantly, whereas albumin was higher in the groups with higher mortality (table 4). Moreover, Luo et al. stated that bilirubinemia >7 mg/dl is not a contraindication for transjugular intrahepatic portosystemic shunt (TIPS) insertion for ascites. This is a dangerous and misleading statement because studies so far have excluded those patients.1 There is evidence that bilirubin below 3 mg/dl is a good biomarker to predict outcome in patients with ascites.2 The strong association of bilirubin levels with post‐TIPS outcome reinforces the recommendation of guidelines for extreme caution for TIPS insertion for ascites if bilirubin >3–5 mg/dl.3,4 Although the quality of stents has improved over time, we included many patients and followed them over a long period of time. Indeed, we have reported the stent types used here (figure S7). Luo et al. raised an important issue of portal hepatic pressure gradient (PPG) variation and changes over time in our patients. It is very unlikely that in the real world outside of clinical trials longitudinal invasive measurements of PPG after TIPS are routinely performed. Ultrasound‐based assessment of patency is the routine follow‐up of choice. Therefore, we try to elaborate an easy‐to‐obtain surrogate marker at the time of TIPS insertion that is applicable for most cases in real‐life practice. Hereby, percentage decrease in PPG is a good marker for response to treatment in ascites control in our cohort. Finally, we agree that in recently compensated cases with ascites as the first decompensating event, the amount of ascites may be prognostic.5 However, all patients in our study received TIPS for therapy of recurrent and refractory ascites. Thus, the cited study does not apply to our patients and therefore the concern is unjustified. We thank again Luo et al. and hope that our answers could address their concerns and avoid confusion in further readers.

Evolution of Thoracic Duct Congestion after Portal Decompression by TIPS in Cirrhotic Patients.

To evaluate the thoracic duct (TD) diameter on CT scan in a population of cirrhotic patients before and after relief of portal hypertension by transjugular intrahepatic portosystemic shunt (TIPS) insertion. To evaluate the association between the initial TD diameters and the cirrhosis severity, the morphological signs of portal hypertension and the clinical success of TIPS. This retrospective monocentric study included 54 cirrhotic patients who underwent TIPS insertion between 2010 and 2020. Measurements of the TD were performed in CT scan at two distinct points: at the cisterna chyli (CC) and at the terminal TD near the lymphovenous junction. The mean diameter of the TD was 6.4 mm (± 2.9) at the CC and 6.9 mm (± 1.9) near the lymphovenous junction. After TIPS, the mean diameter decreased to 5.1 (± 2.1) at the CC (p < 0.001) and to 4.3 (± 1.5) at the terminal TD (p = 0.001). The initial TD diameter was associated with the presence of voluminous venous collaterals (p = 0.04 at CC and p = 0.04 junction). The initial terminal TD diameter was weakly associated with the largest axis of the spleen (r = 0.126, p = 0.03) and moderately associated with the azygos vein diameter (r = 0.511, p = 0.001). Initial TD diameter was not associated with Child-Pugh score (r = 0.276, p = 0.08 and r = 0.169, p = 0.7) or with clinical success of TIPS on ascites (p = 0.33 and 0.60) or on bleeding (p = 0.13 and 0.99). The diameter of the TD decreases after TIPS, but its initial diameter does not seem to be predictive of the clinical success of TIPS.