Non-invasive laboratory-based models have been proposed to estimate portal hypertension severity in patients with compensated advanced chronic liver disease (cACLD), but external validation in diverse populations remains limited. We aimed to externally validate two such models, originally developed in European cohorts, for predicting clinically significant portal hypertension (CSPH; hepatic venous pressure gradient [HVPG] ≥ 10mmHg) and severe portal hypertension (HVPG ≥ 16mmHg) in a U.S.-based cACLD cohort. We conducted a retrospective single-center study of adults with cACLD who underwent HVPG measurement between 2014 and 2024. Patients with active hepatic decompensation, hepatocellular carcinoma, or prior transjugular intrahepatic portosystemic shunt were excluded. Model performance of the Vienna laboratory-based model and the FIB-4 plus albumin (FIB4 +) model was evaluated using discrimination (area under the receiver operating characteristic curve [AUROC]) and calibration metrics, including calibration intercepts, slopes, and Brier scores. The cohort included 143 patients (median age 56years; 54% female), predominantly with metabolic dysfunction-associated steatotic liver disease or alcohol-related liver disease. Median HVPG was 7mmHg, with CSPH present in 33% and HVPG ≥ 16mmHg in 11%. Discrimination was modest for both models. The Vienna model achieved AUROCs of 0.71 for HVPG ≥ 10mmHg and 0.77 for HVPG ≥ 16mmHg, while the FIB4 + model achieved AUROCs of 0.69 and 0.71, respectively. Both models systematically overestimated risk, demonstrating poor calibration across thresholds. Negative predictive values for HVPG ≥ 16mmHg exceeded 95% for both models. Predictive performance was weaker in non-viral etiologies. In this U.S.-based external validation, laboratory-based models for portal hypertension showed modest discrimination and poor calibration, with systematic risk overestimation. While high negative predictive values suggest potential utility as rule-out tools for severe portal hypertension, recalibration and prospective validation are required before clinical implementation.

Porto-sinusoidal vascular disorder (PSVD) was defined by the Vascular Liver Disease Interest Group in 2019 and encompasses conditions that cause portal hypertension in patients without cirrhosis. Nodular regenerative hyperplasia (NRH) is a pathological finding associated with PSVD. We encountered a patient with refractory ascites who underwent transjugular liver biopsy and was diagnosed with PSVD. The patient subsequently underwent transjugular intrahepatic portosystemic shunt (TIPS) placement for refractory ascites and recurrent variceal bleeding caused by portal hypertension, which resolved the ascites and improved the varices. Post-procedural complications, including hepatic ischemia, portal vein thrombosis, and hepatic encephalopathy, were observed but improved with conservative treatment. TIPS can be a feasible treatment option for patients with portal hypertension associated with non-cirrhotic conditions such as PSVD.

Transjugular intrahepatic portosystemic shunt (TIPS) and plug-assisted retrograde transvenous obliteration (PARTO) are the standard of care for managing portal hypertension-related complications. However, the role of peri-procedural antibiotics in preventing infections during these interventions remains unclear because of limited evidence, and this study aimed to address this gap. In this single-centre, double-blind, placebo-controlled, randomised trial, adult patients with portal hypertension were randomised to receive ceftriaxone (1 g twice daily until discharge) or placebo. The primary outcome was the incidence of clinically significant infection defined as fever and a quick Sequential Organ Failure Assessment (qSOFA) score ≥ 2, and secondary outcomes were hospital stay duration, in-hospital mortality and adverse events. Of the 70 patients, 35 received placebo and 35 received ceftriaxone (antibiotic). Twenty-one patients in the placebo arm and 22 in the antibiotic arm underwent PARTO, and the rest underwent TIPS or direct intrahepatic portocaval shunt. On Kaplan-Meier analysis, the risk of clinically significant infection (fever and qSOFA ≥ 2) was 17.1% in the placebo arm and 8.6% in the antibiotic arm (P = 0.31). Fever rates were similar (20% in the placebo arm compared with 22.9% in the antibiotic arm, P = 0.77). Hospital stay duration (4.4 ± 1.7 days in the placebo arm compared with 4.1 ± 2.2 days in the antibiotic arm, P = 0.47) and in-hospital mortality (one death per arm) were comparable. One patient in the placebo arm experienced an injection-site rash. No significant predictors of infection were identified due to the small sample size. Peri-procedural ceftriaxone did not significantly reduce infection rates in patients undergoing elective TIPS or PARTO.

BACKGROUND The effect of post-transjugular intrahepatic portosystemic shunt (TIPS) rebleeding on liver-related mortality remains uninvestigated. AIM To investigate the relationship between post-TIPS rebleeding and liver-related mortality in patients with cirrhosis and to conduct subgroup analyses based on liver function. METHODS This study included 1782 patients who underwent covered TIPS at seven medical centers to prevent rebleeding. The primary endpoints were liver-related death and all-cause rebleeding. Propensity score matching, adjusted survival curves, and competing risk analyses based on liver transplantation and non-liver death were performed to ensure the robustness of the results. RESULTS During a median follow-up period of 32.25 months, 346 patients (19.4%) developed post-TIPS rebleeding, and 429 (24.1%) died from liver-related causes. Chronic HBV infection was the predominant cirrhosis etiology. Multivariable analysis identified older age, higher Child-Pugh and model for end-stage liver disease-Na scores, and post-TIPS rebleeding as independent predictive factors for liver-related mortality. Liver-related mortality increased by approximately 49.4% in the rebleeding group compared with the no-bleeding group. These findings remained consistent after propensity score matching, survival curve adjustment, and competing risk assessment. Similar findings were observed across different liver function subgroups. CONCLUSION Post-TIPS rebleeding was significantly associated with higher mortality in patients with cirrhosis and variceal bleeding irrespective of liver function category.

Hepatic myelopathy is a rare but underrecognized complication of chronic liver disease characterized by pure motor, symmetric and spastic paraparesis without sphincter involvement. We report the case of a 39-year-old female with Child Pugh A alcohol-related cirrhosis presenting with progressive spastic paraparesis 2 months after transjugular intrahepatic portosystemic shunt (TIPS) placement for recurrent oesophageal variceal bleed. TIPS occlusion achieved partial neurological recovery but significant functional improvement. She had no further presentations of decompensation with variceal bleeding or hepatic encephalopathy. Early recognition and multidisciplinary input are essential in preserving functional outcome, especially when liver transplant is not indicated.LEARNING POINTSThe onset of symmetric, pure motor spastic paraparesis following a transjugular intrahepatic portosystemic shunt procedure in cirrhosis should prompt clinical suspicion for hepatic myelopathy.Hepatic myelopathy can be reversible with timely shunt occlusion/modification, especially when a liver transplant is not indicated.Recognizing liver cirrhosis as a systemic syndrome and adopting early multi-disciplinary input improve patient outcomes.

Association of Hemostatic Blood Product Transfusion With Clinical Outcomes in Esophageal Variceal Bleeding.

Asialoglycoprotein receptor-bound PLGA nanoparticles loaded with Riociguat targetedly ameliorate portal hypertension in liver cirrhosis.

Transvenous Extrahepatic Portosystemic Shunts (TEPS): Intravascular Ultrasound-Guided Creation of Portocaval, Mesocaval, and Splenorenal Shunts.

Hepatic venous pressure gradient (HVPG) is the gold standard for diagnosing clinically significant portal hypertension in patients with viral- and alcohol-related cirrhosis, but its accuracy is limited in other aetiologies. This study aimed to evaluate the correlation of portal venous pressure measurements in patients with non-alcoholic, non-viral-related decompensated cirrhosis, using fine-needle puncture (FN-PVP), direct portal vein catheterisation (D-PVP) and wedged hepatic vein balloon occlusion (WHVP). This study retrospectively included patients from the author's centre who simultaneously underwent FN-PVP, HVPG and transjugular intrahepatic portosystemic shunt (TIPS) placement for variceal bleeding or refractory ascites. The Spearman correlation coefficient (r), linear regression coefficient (R2), intraclass correlation coefficient (ICC) and the Bland-Altman method were used to assess the correlation and consistency between the pressure measurements obtained by the different methods. Seventy-one patients were included, all undergoing FN-PVP measurements without procedure-related complications. The correlation and consistency between WHVP and D-PVP were moderate (r = 0.487, R2 = 0.25), while FN-PVP demonstrated excellent correlation and consistency with D-PVP (r = 0.945, R2 = 0.914). Similar patterns were observed when comparing HVPG and direct portal pressure gradient (D-PPG), fine-needle portal pressure gradient (FN-PPG) and D-PPG (r: 0.558 vs. 0.918; R2: 0.302 vs. 0.87). In patients without intrahepatic venovenous shunts (IHVS), the correlation and consistency between WHVP and D-PVP showed slight improvement (r = 0.609, ICCa = 0.523, ICCc = 0.620). Using D-PPG as the benchmark, FN-PPG demonstrated excellent classification accuracy, significantly outperforming HVPG. In patients with non-alcoholic, non-viral-related PHT, HVPG may underestimate the true PPG, regardless of the presence of IHVS. In contrast, FN-PVP can safely and accurately reflect portal pressure and serves as an effective alternative for direct portal pressure measurement.

Budd-Chiari syndrome represents a rare vascular disorder defined by obstruction of hepatic venous outflow which, without timely intervention, may progress to portal hypertension, cirrhosis, and liver failure. Primary Budd-Chiari syndrome refers to intrinsic venous obstruction, which is most commonly associated with underlying prothrombotic states that predispose individuals to venous thrombosis. Interventional procedures are often required as a therapeutic modality when medical therapy alone is insufficient. Transjugular intrahepatic portosystemic shunt (TIPS) is commonly used to reduce portal hypertension in Budd-Chiari syndrome; however, it may not be feasible in the presence of hepatic vein thrombosis where cannulation of the hepatic vein, and thus, shunt creation may not be possible. In such cases, direct intrahepatic portosystemic shunt (DIPS) may provide an alternative route for portal decompression through the creation of a shunt directly between the inferior vena cava and the portal venous system. We describe a 34-year-old female presenting with autoimmune hepatitis and primary Budd-Chiari syndrome who underwent a successful ultrasound-guided direct intrahepatic portocaval shunt creation between the portal vein and the intrahepatic inferior vena cava, resulting in a significant reduction in portal venous pressure gradient and improved portal venous flow. This case highlights the feasibility of DIPS in a tertiary hospital setting and supports its role as an alternative endovascular approach for managing portal hypertension in Budd-Chiari syndrome.

To evaluate the efficacy of trans-jugular intrahepatic portosystemic shunt (TIPS) in patients with liver cirrhosis with hepatorenal syndrome non-acute kidney injury (HRS-NAKI) and refractory ascites who are not candidates for liver transplantation. We retrospectively analyzed cirrhotic patients with refractory ascites and HRS-NAKI treated with TIPS (n = 35) and those receiving standard medical therapy alone (n = 134). Propensity score matching (1:1) was performed using age, sex, model for end-stage liver disease (MELD) score, Child-Turcotte-Pugh (CTP) score, serum bilirubin, serum creatinine, serum sodium and ascites severity, yielding 35 matched controls. Laboratory and clinical parameters at one, three and sixmonths were recorded and comparisons were made between both groups using appropriate statistical tests. At sixmonths, TIPS patients demonstrated improvement in serum creatinine (1.72 ± 0.31 to 1.41 ± 0.28mg/dL) and urea (78.6 ± 21.4 to 52.3 ± 18.9mg/dL), while controls showed deterioration. Urinary sodium increased significantly after TIPS (14.0 ± 6.9 to 55.5 ± 25.0mmol/L at three months, p = 0.001). Mean large-volume paracentesis frequency was lower in TIPS patients (0.52 vs. 1.16 per month, p = 0.002). Plasma renin activity declined after TIPS (13.9 ± 1.5 to 4.8 ± 1.2ng/mL/h at sixmonths). Hepatic encephalopathy occurred in 35.1%, liver failure in 5.7% and heart failure in 5.7%. Six-month mortality was 11.4% in the TIPS group and 20% in the control. TIPS improves renal function, neuro-hormonal activation and ascites control in patients with HRS-NAKI and refractory ascites who are not transplant candidates. However, it is associated with significant adverse events including hepatic encephalopathy, liver failure and cardiac decompensation. Larger prospective studies are required to identify patients who derive maximal benefit.

This study investigated the incidence, risk factors, and prognostic implications of acute kidney injury (AKI) after transjugular intrahepatic portosystemic shunt (TIPS). This multicenter retrospective study included patients who underwent TIPS at three hospitals in China. AKI risk factors were identified using multivariate logistic regression in the overall cohort. Propensity score matching was performed to balance baseline covariates. Survival differences were assessed using the Kaplan-Meier method, and the association between AKI and mortality was evaluated using stratified Cox regression models. A total of 995 patients were included, of whom 4.92% developed postoperative AKI. Multivariable analysis identified older age (OR: 1.07, 95% CI: 1.04–1.10), higher preoperative neutrophil percentage (OR: 1.05, 95% CI: 1.02–1.08), elevated preoperative creatinine (OR: 1.01 [per μmol/L], 95% CI: 1.00–1.01), and an increased Child-Pugh score (OR: 1.27, 95% CI: 1.01–1.59) as independent risk factors for AKI. AKI was strongly associated with increased overall mortality (p < 0.001). In the propensity score-matched cohort, postoperative AKI remained an independent predictor of worse long-term survival (HR: 4.09, 95% CI: 1.97–8.50). In conclusion, age, preoperative neutrophil percentage, creatinine level, and Child-Pugh score were independent risk factors for AKI following TIPS, and the development of AKI is strongly associated with a poor prognosis in these patients.

The transjugular intrahepatic portosystemic shunt (TIPS) is a cornerstone intervention for complications of portal hypertension, including variceal bleeding and refractory ascites. As the population with cirrhosis ages, clinicians increasingly face the question of whether and how to perform TIPS safely in older adults. We reviewed observational cohorts, registry analyses, and systematic reviews/meta-analyses. Existing evidence does not support chronological age as an absolute contraindication; however, multiple studies suggest that advanced age is associated with higher rates of post-TIPS hepatic encephalopathy (HE), early mortality, and readmissions. These findings underscore the need to shift from a binary "eligible vs. ineligible" paradigm to a structured, actionable framework that addresses modifiable risks and anticipates age-related vulnerabilities. Recent clinical practice guidance emphasizes comprehensive pre-TIPS assessment and vigilant post-procedure care, with specific attention to HE risk factors (e.g., prior HE, hyponatremia, renal dysfunction, sarcopenia) and cardiopulmonary reserve. In this narrative review, we propose an elderly-focused clinical pathway built around a four-domain assessment (Liver-Brain-Body-Heart/Kidney) and a traffic-light risk tiering system to guide patient selection, procedural strategy, follow-up scheduling, and triggered management of HE, cardiac decompensation, and renal dysfunction. This pathway aims to preserve the benefits of portal decompression while reducing preventable complications and improving outcomes that are meaningful to older patients, including functional status and quality of life. This narrative review emphasizes that outcomes after TIPS in older adults are determined not by chronological age alone but by multidomain physiological reserve. The proposed pathway informs patient selection, procedural planning, and early post-discharge monitoring in older adults.

Hepatic encephalopathy (HE) remains a major complication following transjugular intrahepatic portosystemic shunt (TIPS) placement. The objective of this study was to systematically evaluate and quantify risk factors for HE after TIPS through a meta-analysis. A comprehensive search of multiple databases was conducted from inception until December 16, 2025 to identify observational studies (cohort or case-control designs) investigating risk factors for HE in adult patients after TIPS. Literature screening, data extraction, and quality assessment using the Newcastle-Ottawa Scale (NOS) were performed independently by two reviewers. Meta-analyses were conducted using Stata software. Odds ratios (ORs) or mean differences (MD) with 95% confidence intervals (CIs) were pooled for 26 potential risk factors. not applicable. Twenty-seven studies (total 3,934 patients, 862 HE cases) were included. The overall methodological quality was moderate to high. Significant predictors of post-TIPS HE included advanced age (MD = 4.12 years, 95% CI: 2.68 to 5.56), Child-Pugh class C (OR = 2.87, 95% CI: 1.89 to 4.36), prior history of HE (OR = 3.28, 95% CI: 1.92 to 5.61), preoperative hyperammonemia (MD = 8.02 µmol/L, 95% CI: 4.15 to 11.89), hyponatremia (MD = -3.85 mmol/L, 95% CI: -4.72 to -2.98), significant pleural effusion (OR = 2.45, 95% CI: 1.28 to 4.68), and insufficient portal pressure gradient (PPG) reduction (MD = 2.31 mmHg, 95% CI: 1.15 to 3.47). Child-Pugh class A (OR = 0.45, 95% CI: 0.32 to 0.63) and the use of stents with a diameter ≥ 8mm (OR = 0.58, 95% CI: 0.39 to 0.86) were protective factors. This meta-analysis identifies post-TIPS hepatic encephalopathy as a multifactorial condition determined by the interplay of hepatic functional reserve (Child-Pugh score, ammonia), patient characteristics (age, prior HE), electrolyte balance (sodium), hemodynamic response (PPG reduction), and procedural factors (stent diameter). The quantification of 26 distinct factors underscores the necessity of a comprehensive, multidimensional risk assessment that integrates metabolic, neurological, and hemodynamic profiles.

Neutrophils guarantee a prompt and robust host response to pathogens. Yet, overshooting neutrophil activation leads to tremendous collateral damage in tissues. In advanced chronic liver disease (ACLD), neutrophils are exposed to the highly immunogenic milieu of the portal circulation prior to entering the liver sinusoids. In alcohol-related liver disease (ALD), neutrophils occupy a central role and therefore mechanisms regulating neutrophil activity pose a possible therapeutic target. Evaluate the impact of the portal milieu on neutrophils in ACLD with portal hypertension. We conducted a prospective study of patients undergoing transjugular intrahepatic portosystemic shunt placement. Paired blood samples were obtained from the portal vein (PV) and superior vena cava (SVC); the neutrophil phenotype was assessed by spectral flow cytometry; plasma was analysed by cytokine quantification, reporter assays and metabolomics. Effects of tryptophan supplementation on neutrophil function and phenotype were tested in isolated neutrophils. Patients with ALD but not non-ALD showed highly activated CD10highCD11bhigh neutrophils in the portal circulation. PV plasma induced this phenotype in SVC neutrophils. Analysis of portal plasma revealed no differences in cytokines or toll-like receptor (TLR)/nucleotide-binding oligomerisation domain-containing protein (NOD) ligands but decreased local tryptophan concentrations in patients with ALD. In vitro supplementation of tryptophan ameliorated activation of isolated neutrophils. Our findings identify portal tryptophan as a local regulator of neutrophil activation in ACLD. The link between low tryptophan levels and heightened neutrophil reactivity, especially in ALD, underscores the role of the gut-liver metabolic crosstalk in immune modulation and highlights a potential therapeutic target for mitigating neutrophil-driven liver injury.

Transjugular intrahepatic portosystemic shunt (TIPS) is utilized to manage portal hypertensive complications in patients with decompensated cirrhosis. However, its effects on transplant candidacy and peri-operative outcomes remain unclear. We hence aimed to evaluateperi-transplant outcomes andimplications of TIPS in liver transplant (LT) candidates. We conducted a retrospective cohort study of adult LT candidates listed in the United Network for Organ Sharing (UNOS) database from January 1, 2000 to January 3, 2025. Waitlist outcomes include development of portal hypertension-related complications, time-to-transplant and waitlist survival. Post-transplant outcomes include graft survival and overall post-transplant survival. These outcomes were compared between patients with and without TIPS, and across disease etiologies among TIPS recipients. Among 169,681 waitlist registrants (19,940 with TIPS, 149,741 without TIPS), TIPS was associated with higher odds of portal vein thrombosis during waitlist (OR: 1.365, 95% CI: 1.270 to 1.467, p < 0.001) and lower odds of ascites during waitlist (OR: 0.874, 95% CI: 0.818 to 0.934, p < 0.001). TIPS recipients had significantly higher 90-day and 1-year time-to-transplant and waitlist survival, with minimal differences in graft survival and overall post-transplant survival. Among TIPS recipients, patients with alcohol-associated liver disease and metabolic dysfunction-associated steatotic liver disease had significantly lower 90-day and 1-year time-to-transplant and higher 1-year waitlist survival compared to patients with hepatitis C. TIPS is associated with improved waitlist survival and timely transplantation without negatively impacting post-transplant outcomes. These findings support the use of TIPS in a select group of patients with high burden of portal hypertensive complications.

Background: Non-invasive scoring systems for predicting the hepatic venous pressure gradient (HVPG) and, thus, clinically significant portal hypertension (CSPH) have been proposed; the aim of this study was to evaluate the accuracy of these scores in a cohort of patients undergoing transjugular intrahepatic portosystemic shunt (TIPS) placement and to further analyze patients without a markedly elevated portosystemic gradient (PSG) at the time of the procedure. Methods: We retrospectively analyzed 314 patients who underwent TIPS implantation at our tertiary care center between 2010 and 2022. The diagnostic performance of CT-based scoring systems by Iranmanesh (Score 1) and Kihira (Score 2), as well as laboratory-based scores including MELD (Score 3), FIB-4 (Score 4), and APRI (Score 5), was assessed for detecting a markedly elevated PSG (PSG > 10 mmHg). Additionally, we evaluated whether incorporating the inferior vena cava (IVC) diameter as a surrogate marker of central venous pressure (CVP) improves the accuracy of CT-based scores. Results: Both Scores 1 and 2 showed high sensitivity (89-87%) but low specificity (33-27%). ROC analysis revealed AUC values between 0.65 and 0.62. Laboratory-based scores (Score 3-5) performed poorly with AUCs of 0.57-0.54. Adding IVC diameter as an estimator for CVP to Scores 1 and 2 significantly increased the AUC to 0.74 and 0.76. In Lasso regression, IVC diameter was selected as a significant variable for PSG estimation. Conclusions: CT-based scoring systems showed promise in assessing markedly elevated PSG, but their specificity was low. Including the IVC diameter improved accuracy in detecting elevated PSG in TIPS patients. Future scoring systems should incorporate CVP estimators like the IVC diameter.

Mortality following transjugular intrahepatic portosystemic shunt (TIPS) placement remains a critical concern. Traditional scoring systems, such as the Model for End-Stage Liver Disease (MELD) and MELD-Na, as well as the newer Modified TIPS-Score (MOTS) and Freiburg Index of Post-TIPS Survival (FIPS), have shown potential for refining risk stratification. To externally validate prognostic scores for predicting 30- and 90-day mortality following TIPS. This retrospective study, conducted at Austin Health, Australia, included 117 patients who underwent TIPS with ≥90 days of follow-up between 2011 and 2024. Prognostic scores were calculated using pre-TIPS clinical and laboratory data. Discrimination and calibration were assessed and prognostic accuracy evaluated at established thresholds for MELD ≥ 18, MELD-Na ≥ 20, MOTS > 1, FIPS ≥ 0.92 and additional scores. TIPS indications included ascites and/or hepatic hydrothorax (56.4%), variceal haemorrhage (34.2%), Budd-Chiari syndrome (6.0%) and other indications (3.4%). Mortality occurred in 13 (11.1%) and 21 patients (17.9%) by 30 and 90 days respectively. MELD demonstrated the best discrimination for 30-day mortality (area under the curve (AUC) = 0.82), followed by MOTS (0.80), FIPS (0.76) and MELD-Na (0.73), with similar trends at 90 days. MOTS was best calibrated, followed by FIPS and MELD. FIPS ≥ 0.92 had excellent specificities (94% and 95%) and negative predictive values (94% and 88%) for 30- and 90-day mortality, marginally outperforming MELD and MOTS. MELD-Na and other scores performed less well. MOTS, MELD and FIPS demonstrated robust discriminative performance for early post-TIPS mortality and outperformed other models. Further research is required to establish optimum risk thresholds for these tools and support these findings.

The ileal conduit is one of the most commonly performed urinary diversion procedures for muscle-invasive bladder cancer, and among the various complications, bleeding from an ileal conduit is rare. In patients with recurrent stomal haemorrhage, one must consider the possibility of atypical varices and assess for liver cirrhosis if it has not been previously established. Here, we describe a case of bleeding ectopic varices at the ileal conduit site in a patient in his 50s who underwent surgery for urinary bladder carcinoma, which was successfully managed through percutaneous transhepatic glue embolisation. Selective embolisation of these ectopic varices with coils or glue produces impressive results, offering the benefit of being minimally invasive, and can be considered an initial treatment option for stomal variceal bleeding. Other techniques, such as transjugular intrahepatic portosystemic shunt or antegrade and retrograde variceal occlusion using balloon or plug assistance, can also be attempted to eliminate varices.

Abstract No. 243 Association Between Modified Frailty Index (mFI-5) and Postoperative Outcomes of Transjugular Intrahepatic Portosystemic Shunt (TIPS) Procedures