Transjugular Intrahepatic Portosystemic Research Articles

Safety and Efficacy of Overdilation of 10 mm Viatorr Transjugular Intrahepatic Portosystemic Shunt Stents Using 12 mm Balloons

Safety and Efficacy of Overdilation of 10 mm Viatorr Transjugular Intrahepatic Portosystemic Shunt Stents Using 12 mm Balloons

Intravascular Ultrasound Guidance for Transjugular Intrahepatic Portosystemic Shunt Creation Reduces Laboratory Markers of Acute Liver Injury

PurposeTo compare the laboratory markers of acute liver injury after transjugular intrahepatic portosystemic shunt (TIPS) creation performed using intravascular ultrasound (IVUS) guidance with those using other techniques. Materials and MethodsThis single-center, retrospective study examined 293 TIPS procedures performed between 2014 and 2022 (160 men; mean age, 57.4 years; 71.7% with ascites, 158 with IVUS). Laboratory changes on postprocedural day (PPD) 1 were classified based on Common Terminology Criteria for Adverse Events (CTCAE) grades and were compared between IVUS and non-IVUS cases. ResultsIVUS cases had a lower baseline Model for End-Stage Liver Disease (MELD) score (12.5 vs 13.7, P = .016), higher pre- (16.8 vs 15.2, P = .009), and post-TIPS (6.6 vs 5.4 mm Hg, P < .001) pressure gradient, smaller stent diameter (9.2 vs 9.9 mm, P < .001), and fewer needle passes (2.4 vs 4.2, P < .001). IVUS predicted a lower PPD 1 CTCAE grade for aspartate transaminase (8.0% vs 22.2% grade ≥ 2, P = .010), alanine transaminase (ALT) (2.2% vs 7.1%, P = .017), and bilirubin (9.4% vs 26.2%, P < .001), findings confirmed using multivariable regression and propensity score analysis. IVUS predicted fewer adverse events (1.3% vs 8.1%, P = .008) and an increased likelihood of PPD 1 discharge (81% vs 59%, P = .004). IVUS was not associated with differences in PPD 30 MELD scores or 30-day survival; however, higher PPD 1 ALT (β = 1.96, P = .008) and bilirubin levels (β = 1.38, P = .004) predicted larger PPD 30 MELD score increase. Higher increases in ALT level predicted worse 30-day survival (hazard ratio, 1.93; P = .021). ConclusionIVUS resulted in less laboratory evidence of acute liver injury immediately following TIPS creation.

Viatorr Stent Migration and Retrieval during Transjugular Intrahepatic Portosystemic Shunt Revision.

Transjugular intrahepatic portosystemic shunt (TIPS) is an important interventional option for the treatment of complications related to cirrhosis and portal hypertension. Emergent TIPS placement can be a life-saving measure in patients with uncontrolled variceal hemorrhage. After TIPS placement, patients may benefit from additional interventions for clinical optimization including stent dilation, stent extension, and embolization of varices. Here, we describe a case of emergent TIPS placement and revision which resulted in TIPS stent migration requiring stent removal and replacement. We discuss our technique and review previously reported methods for the management of migrated TIPS stents.

The Use of Intracardiac Echocardiography in Transjugular Intrahepatic Portosystemic Shunt Procedure.

Transjugular intrahepatic portosystemic shunt (TIPS) is a complex intervention with a steep learning curve that requires centers of expertise to improve technical success and reduce complications. Portal venous access is the most challenging step of the procedure and requires planning and image guidance strategies to prevent vascular or bile duct injury and further complications. Intracardiac echocardiography (ICE) has been reported to be a safe and accurate tool that provides images of the portal vein anatomy in real time. The use of ICE has become the standard of care in several centers. It is now frequently used to target the portal vein in complex TIPS procedures. This review article describes some technical aspects and indications of ICE-guided TIPS.

Advanced Techniques for Accessing the Portal Vein during Transjugular Intrahepatic Portosystemic Shunt Creation.

Transjugular portosystemic shunt (TIPS) placement is a widely accepted method for reducing portal pressures in conditions including symptomatic varices, refractory ascites, hepatic hydrothorax, portomesenteric thrombosis, and Budd-Chiari syndrome. The traditional method for performing TIPS involves "blind" access into a portal vein branch from a hepatic vein, typically right portal vein to right hepatic vein, using preoperative imaging and intraoperative wedged portography for guidance. However, standard access technique may not always be feasible due to occluded portal or hepatic veins, distorted anatomy, or prior TIPS. In this article we discuss alternative techniques for accessing the portal vein for TIPS placement when standard methods are not sufficient.

Agreement between Wedged Hepatic Venous Pressure and Portal Pressure in Hepatic Sinusoidal Obstruction Syndrome.

Wedge hepatic vein pressure (WHVP) accurately estimates the portal pressure (PP) in chronic sinusoidal portal hypertension patients. Whether this applies to patients with acute portal hypertension due to hepatic sinusoidal obstruction syndrome (HSOS) is unclear. Our aim was to assess the agreement between WHVP and PP in patients with HSOS by comparing them to decompensated cirrhosis patients. From December 2013 to December 2021, patients with pyrrolidine alkaloid-induced HSOS (PA-HSOS) receiving hepatic venous pressure gradient (HVPG) measurement and transjugular intrahepatic portosystem shunt (TIPS) were retrospectively collected and matched with those of patients with virus- or alcohol-related cirrhosis as a cirrhosis group. Pearson's correlation (R), intraclass correlation coefficient (ICC), scatter plots, and the Bland-Altman method were performed for agreement evaluation. A total of 64 patients were analyzed (30 PA-HSOS and 34 cirrhosis groups). The correlation between WHVP and PP was moderate in the PA-HSOS group (R: 0.58, p = 0.001; ICC: 0.68, p = 0.002) but good in the cirrhosis group (R: 0.81, p &lt; 0.001; ICC: 0.90, p &lt; 0.001). The percentage of patients with inconsistent WHVP and PP in the two groups was 13 (43.3%) and 15 (26.5%) (p = 0.156), respectively, and an overestimation of PP was more common in the PA-HSOS group (33.3% vs. 2.9%, p = 0.004). HVPG and portal pressure gradient (PPG) consistency was poor in both groups (R: 0.51 vs. 0.26; ICC: 0.65 vs. 0.41; p &lt; 0.05). WHVP in patients with PA-HSOS did not estimate PP as accurately as in patients with virus- or alcohol-related cirrhosis, which was mainly due to PP overestimation.

Clinical Presentation, Risk Factors and Outcome of Splanchnic Venous Thrombosis: A Report on 305 Cases

Background and Aims: Splanchnic vein thrombosis (SVT) is a manifestation of unusual site venous thromboembolism. Most common predisposing factors for SVT include liver cirrhosis, solid abdominal cancer, myeloproliferative neoplasms (MPN), and abdominal infection or inflammatory diseases. Complex balance between bleeding risk and the risk of thrombus extension or recurrence makes the management of SVT a clinical challenge. In this study, we reported clinical presentation and outcome data of patients with SVT followed in our center from January 2000 to December 2021, with a focus on MPN and cirrhotic patients. Methods: We performed a retrospective review of clinical reports of 305 SVT patients. According to PLT count in patients with no active bleeding, anticoagulation treatment was started as soon as possible with: no treatment for a platelet count <30.000/μl; prophylactic dose of LMWH or related drugs for a platelet count range 30.000 -50.000/μl and therapeutic dose low-molecular-weight heparin (LMWH) followed by early initiation of vitamin-K antagonist (VKA; INR range 1.8-2.5) for a platelet count >50.000/μl. Moreover, cytoreductive therapy was administered in MPN patients and prophylaxis with beta-blockers and endoscopic therapies were applied in cirrhotic SVT. Cox regression analysis was used to identify independent predictors of recanalization and overall survival. The Kaplan-Meier method was performed to estimate the overall survival and the time to reach vessel recanalization. Results: In a median follow up of 16.1 months (range, 1-346), 305 patients experienced a SVT (median age 59 years; 68.2% males). Isolated portal vein thrombosis was the most common site of thrombosis (55.1%), followed by multiple venous involvement (28.9%). Six patients developed a Budd-Chiari syndrome. SVT were associated to chronic liver disease, solid cancer and abdominal infections in 212 (69.5%), 100 (32.8%) and 34 (11.5%) patients, respectively. Ninety-seven patients had splenomegaly. MPN was identified in 38 (12.5%) patients. Among these patients, JAK2 and CALR mutation were detected in 81.6% and 13.2%, respectively, and abnormal karyotype in 10.5%. Ascites and esophageal varices were present in 47.5% and 48.8% of patients, respectively. Therapeutic decisions were taken as a multidisciplinary team, involving the use of VKA and LMWH in 70 and 163 patients, respectively. In addition, trans-jugular intrahepatic portosystemic (TIPS) or other surgical shunting was undertaken in 12% and variceal banding in 11%. In a median duration therapy of 9.6 months, bleeding complications and recanalization were reported in 9.5% and 35.4% of patients, respectively. At univariate analysis, VKA exposure was associated with a significantly lower risk of bleeding events compared to LMWH (p=0.039), while esophageal varices (p=0.049), leukocytosis at time of thrombosis (p=0.048), liver cirrhosis (p=0.010) and solid tumor (p=0.021) were associated with lack of recanalization. Only one death was attributed to fatal bleeding, whereas 76 patients died for causes not related to anticoagulation (cirrhosis, cancer, MPN evolution) with a median OS was not reached (range, 107,89-NR). Factors associated with poor survival included age (p<0.001), MPN (p=0.047), recurrent thrombosis (p=0.041), alkaline phosphatase (p=0.013), gamma-GT (p<0.001), albumin (p=0.021), MELD score (p=0.004), lack of recanalization (p<0.001), bleeding event (p=0.043), ascites (p=0.009), and antithrombotic therapy (p=0.006, Figure 1). Among MPN patients, poor survival outcome was also associated with driver mutations (p=0.034), hemoglobin level at thrombosis (p<0.001), splenomegaly (p=0.019), and cytoreductive therapy (p=0.019). Conclusions: Outcome in SVT patients mostly depends on the presence of an underlying MPN, liver failure, active bleeding, recurrence and recanalization rate. Moreover, the anticoagulant treatment was associated with a low bleeding incidence also in patients with major risk factors for bleeding (i.e. liver cirrhosis, cancer or esophageal varices). Figure 1View largeDownload PPTFigure 1View largeDownload PPT Close modal

Coaxial Stent Graft inside a Constraining Stent for Transjugular Intrahepatic Portosystemic Shunt Reduction

A technique to create a coaxial, self-expanding stent graft inside a constraining, bare-metal, balloon-expandable stent for transjugular intrahepatic portosystemic shunt (TIPS) reduction is described. The key steps are performed on a back table rather than inside the patient, and the resulting construct is deployed using standard unsheathing maneuvers. The construct was used in 4 patients to make 6 TIPS diameter reductions (mean postreduction diameter, 6 mm; range, 0–8 mm), all resulting in increases in the portosystemic pressure gradient (mean increase, 6 mm Hg; range, 1–19 mm Hg). On average, hepatic encephalopathy improved 1 point on the West Haven scale (range, 0–2).

Change of Left Ventricular Myocardial Contractility in Speckle Tracking Echocardiography After Transjugular Intrahepatic Portosystemic Shunt Predicts Survival

BackgroundLeft ventricular global longitudinal strain (LV-GLS) has been shown to better reflect the left cardiac contractility in cirrhosis than other investigations and might bear prognostic value. The aim of this study was to investigate the evolution of myocardial contractility assessed by speckle tracking echocardiography (STE) after transjugular intrahepatic portosystemic shunt (TIPS) placement and its prognostic value in outcome.MethodsIn this study, 206 (126 males) patients with liver cirrhosis receiving TIPS were included. In all study patients, conventional transthoracic echocardiography (TTE) was performed before and in the first weeks after TIPS placement to assess left and right ventricular volume, planar and functional parameters. Also, LV-GLS was measured by STE to assess left ventricular contractility as surrogate for myocardial dysfunction. Hemodynamic and clinical parameters were assessed before TIPS and during follow-up.ResultsAs expected, most conventional parameters of TTE showed a significant change after TIPS placement. However, neither the absolute values, nor the changes of conventional cardiac parameters of TTE before and after TIPS insertion were associated with survival. By contrast, an increase in contractility of more than 20% using STE after TIPS was an independent predictor of mortality.ConclusionThese results demonstrate that an increase of left ventricular contractility of more than 20% after TIPS insertion is an independent predictor of survival and this may identify patients at risk and in need of closer follow-up care.

Combination of Model for End-Stage Liver Disease and Lactate Predicts Death in Patients Treated With Salvage Transjugular Intrahepatic Portosystemic Shunt for Refractory Variceal Bleeding.

Data about the prognosis of salvage transjugular intrahepatic portosystemic shunt (TIPS) using covered stents for refractory variceal bleeding caused by portal hypertension are scarce. We aimed to assess survival and to identify predictors of mortality in these patients. One hundred sixty-four patients with cirrhosis from five centers treated with salvage TIPS between 2007 and 2017 were retrospectively divided into a derivation cohort (83 patients) and a validation cohort (81 patients). Comparisons were performed using the Mann-Whitney and Fischer's exact test. Six-week overall survival (OS) was correlated with variables on the day of the TIPS using Kaplan-Meier curves with log-rank test and univariate/multivariate analyses using the Cox model. Eighty-three patients were included in the derivation cohort (male, 78%; age, 55years, alcohol-associated cirrhosis, 88%; Model for End-Stage Liver Disease [MELD], 19 [15-27]; arterial lactate, 3.7mmol/L [2.0-8.3]). Six-week OS rate was 58%. At multivariate analysis, the MELD score (OR, 1.064; 95% CI, 1.005-1.126; P=0.028) and arterial lactate (OR, 1.063; 95% CI, 1.013-1.114; P=0.032) were associated with 6-week OS. Six-week OS rates were 100% in patients with arterial lactate ≤2.5mmol/L and MELD score≤15 and 5% in patients with lactate ≥12mmol/L and/or MELD score≥30. The 81 patients of the validation cohort had similar MELD and arterial lactate level but lower creatinine level (94vs 106µmol/L, P=0.008); 6-week OS was 67%. Six-week OS rates were 86% in patients with arterial lactate ≤2.5mmol/L and MELD score≤15 and 10% for patients with lactate ≥12mmol/L and/or MELD score≥30. In the overall cohort, rebleeding rate was 15.8% at 6weeks, and the acute-on-chronic liver failure grade (OR, 1.699; 95% CI, 1.056-1.663; P=0.040) was independently associated with rebleeding. After salvage TIPS, 6-week mortality remains high and can be predicted by MELD score and lactate. Survival rate at 6weeks was >85% in patients with arterial lactate ≤2.5mmol/L and MELD score≤15, while mortality was >90% for lactate ≥12mmol/L and/or MELD score≥30.

High Prevalence of Transjugular Intrahepatic Portosystemic Shunt Creation Without Prior Endoscopy During Acute Variceal Bleeding Hospitalization in the United States.

Current clinical guidelines by both American Association for the Study of Liver Disease and European Association for the Study of the Liver recommend endoscopy in all patients admitted with acute variceal bleeding within 12 hours of admission. Transjugular intrahepatic portosystemic shunt (TIPS) creation may be considered in patients at high risk if hemorrhage cannot be controlled endoscopically. We conducted a cross‐sectional observational study to assess how frequently TIPS is created for acute variceal bleeding in the United States without preceding endoscopy. Adult patients undergoing TIPS creation for acute variceal bleeding in the United States (n = 6,297) were identified in the last 10 available years (2007‐2016) of the National Inpatient Sample. Hierarchical logistic regression was used to examine the relationship between endoscopy nonutilization and hospital characteristics, controlling for patient demographics, income level, insurance type, and disease severity. Of 6,297 discharges following TIPS creation for acute variceal bleeding in the United States, 31% (n = 1,924) did not receive first‐line endoscopy during the same encounter. Rates of “no endoscopy” decreased with increasing population density of the hospital county (nonmicropolitan counties 43%, n = 114; mid‐size metropolitan county 35%, n = 513; and central county with >1 million population 23%, n = 527) but not by hospital teaching status (n = 1,465, 32% teaching vs. n = 430, 26% nonteaching; P = 0.10). Higher disease mortality risk (odds ratio, 0.42; 95% confidence interval, 0.22‐0.80; P = 0.02) was associated with lower odds of noncompliance. Conclusion: One third of all patients undergoing TIPS creation for acute variceal bleeding in the United States do not receive first‐line endoscopy during the same encounter. Patients admitted to urban hospitals are more likely to receive guideline‐concordant care.

Splanchnic Vein Thrombosis in Overt Myeloproliferative Neoplasms: The Mayo Clinic Experience with 107 Unselected Consecutive Cases

Background:Splanchnic vein thrombosis (SVT) is a characteristic feature of JAK2 mutation-enriched myeloproliferative neoplasms (MPN). MPN constitutes the most frequent cause of Budd-Chiari syndrome (BCS) and non-malignant, non-cirrhotic portal vein thrombosis (Blood. 2012;120:4921). Reported risk factors for recurrent SVT included BCS, thrombosis history, splenomegaly, leukocytosis and absence of warfarin therapy (Blood Cancer J. 2016;6:e493). The main objective of the current study was to share the experience from a single tertiary center.Methods:Study patients were selected from institutional databases, with additional cases identified through Advanced Cohort Explorer Tool. Conventional diagnostic criteria were utilized (Blood 2016;127:2391) Diagnosis of SVT in all cases was confirmed by imaging studies. Cases with latent MPN (MPN-U) or evidence of other cancer were excluded. All analyses considered clinical and laboratory parameters obtained at time of SVT.Results:i) Presenting features107 patients (median age 56 years; range 22-84; 62% females) were considered; specific MPN diagnosis was primary myelofibrosis (PMF) 36%, polycythemia vera (PV) 29%, essential thrombocythemia (ET) 29%, post-PV 6% and post-ET myelofibrosis (MF) 1%. Among evaluable cases, JAK2 mutation was detected in 85% and abnormal karyotype in 33%. At the time of SVT, 80% were not receiving aspirin (ASA) therapy and 4% had history of OCP use. Thrombosis history was recorded in 51% and included history of SVT in 38%. 39 (36%) patients had pre-SVT history of splenectomy, including 16 (15%) in the month before. Presentation included abdominal pain 62%, ascites 31% and GI bleed 15%.ii) Type of SVT and clinical correlatesSVT types included BCS ± other vessels (n=9; 6 PV, 2 ET and 1MF), portal ± splenic (n=73; 38 MF, 20 PV, 15 ET), portal + mesenteric ± splenic (n=23; 14 ET, 5 MF and 4 PV). Comparison of these three SVT categories disclosed significant associations with MPN sub-category (p<0.01; BCS with PV and “portal + mesenteric” with ET), abdominal pain (p=0.02; with BCS and “portal + mesenteric”) and ascites (p=0.007; with BCS).iii) Initial management of SVTInitial treatment included systemic anticoagulation (SA) only in 39% of the patients, SA + ASA 4%, SA + cytoreductive drug 21%, SA + ASA + cytoreductive drug 4%, and no SA 33%. In addition, trans-jugular intrahepatic portosystemic (TIPS) or other surgical shunting was undertaken in 13% and variceal banding in 14%.iv) Post-SVT survival, causes of death and prevalence of liver failureAt median post-SVT follow up of 2.6 years (range .02-17.5), 35 (33%) deaths and 5 (5%) leukemic transformations were noted; the corresponding percentages for PV/ET vs MF were 18% vs 53% and 1.6% vs 9%. Causes of death were unrelated to SVT in 17 instances, unknown in 6, liver failure in 5 (all MF), upper gastrointestinal bleed in 4 (3 MF 1 PV), AML in 2 MF cases and thrombosis in one ET patient.v) Risk factors for post-SVT survival and recurrent SVTAs expected, post-SVT survival was significantly shorter in patients with MF vs PV/ET (HR 4.6, 95% CI 2.2-9.6). In multivariable analysis, older age (p<0.01), MF diagnosis (vs PV/ET) (HR 4.0; 95% CI 1.9-8.4) and presentation with ascites (HR 2.7, 95% CI 1.3-5.8) were independently associated with shorter survival; the latter was also associated with post-SVT complications (p=0.01). When analysis was restricted to the 62 patients with PV/ET, median post-SVT survival was not reached and advanced age was the only predictor of shortened survival (p<0.01), while associations of BCS with PV and “portal + mesenteric” with ET were confirmed (p<0.01). Seven of 8 BCS cases occurred in patients younger than age 60 (p=0.07) and 7 of 8 BCS presented with ascites (p<0.01). The only predictor of SVT relapse was male sex (p<0.01). In general, post-SVT survival and recurrence rate were not affected by type of SVT or initial treatment strategy.Conclusions:Outcome in MPN-associated SVT mostly depends on the underlying MPN type, with limited influence from SVT-directed treatment strategies; importantly, there was no overt evidence of adverse effect, from SVT, on overall or leukemia-free survival in PV or ET; liver failure and GI bleed were relatively frequent causes of death in MF-associated SVT. Other noteworthy observations from the current study included association of BCS with PV, ascites and younger age; and recurrent SVT with male sex. DisclosuresNo relevant conflicts of interest to declare.

Combined Transjugular Intrahepatic Portosystemic Shunt Plus Variceal Obliteration versus Transjugular Intrahepatic Portosystemic Shunt Alone for the Management of Gastric Varices: Comparative Single-Center Clinical Outcomes

PurposeTo compare the safety and clinical outcomes of combined transjugular intrahepatic portosystemic shunt (TIPS) plus variceal obliteration to those of TIPS alone for the treatment of gastric varices (GVs). Materials and MethodsA single-center, retrospective study of 40 patients with bleeding or high-risk GVs between 2008 and 2019 was performed. The patients were treated with combined therapy (n = 18) or TIPS alone (n = 22). There were no significant differences in age, sex, model for end-stage liver disease score, or GV type between the groups. The primary outcomes were the rates of GV eradication and rebleeding. The secondary outcomes included portal hypertensive complications and hepatic encephalopathy. ResultsThe mean follow-up period was 15.4 months for the combined therapy group and 22.9 months for the TIPS group (P = .32). After combined therapy, there was a higher rate of GV eradication (92% vs 47%, P = .01) and a trend toward a lower rate of GV rebleeding (0% vs 23%, P = .056). The estimated rebleeding rates were 0% versus 5% at 3 months, 0% versus 11% at 6 months, 0% versus 18% at 1 year, and 0% versus 38% at 2 years after combined therapy and TIPS, respectively (P = .077). There was no difference in ascites (13% vs 11%, P = .63), hepatic encephalopathy (47% vs 55%, P = .44), or esophageal variceal bleeding (0% vs 0%, P > .999) after the procedure between the groups. ConclusionsThe GV eradication rate is significantly higher after combined therapy, with no associated increase in portal hypertensive complications. This translates to a clinically meaningful trend toward a reduction in GV rebleeding. The value of a combined treatment strategy should be prospectively studied in a larger cohort to determine the optimal management of GVs.

New Techniques and Devices in Transjugular Intrahepatic Portosystemic Shunt Placement.

Recently, new techniques and devices in transjugular intrahepatic portosystemic shunt (TIPS) placement have emerged that can improve upon the standard procedure. Ultrasound guidance during TIPS with intracardiac echocardiography (ICE), placement of controlled expansion (CX) stents, and portal vein recanalization (PVR) via transsplenic access are three techniques with new data supporting their implementation. ICE guidance can improve the technical success of difficult cases, decrease procedure time, and decrease complications such as capsular puncture, hemobilia, and hepatic artery injury. CX stents offer the operator better control over the final portosystemic gradient, which is particularly useful in patients with a high risk of post-TIPS hepatic encephalopathy. Finally, transsplenic access provides a stable, antegrade route for PVR, which can be used to optimize transplant candidacy as well as treat the sequelae of portal hypertension in patients with portal vein thrombosis. This article will describe the benefits, technical parameters, and patient selection criteria for each of these new techniques.

Race and Gradient Difference Are Associated with Increased Risk of Hepatic Encephalopathy Hospital Admission After Transjugular Intrahepatic Portosystemic Shunt Placement

Hepatic encephalopathy (HE) is a well-recognized complication of transjugular intrahepatic portosystemic shunt (TIPS) placement. The aim of this investigation was to evaluate incidence and predictors of post-TIPS HE necessitating hospital admission in a non-clinical trial setting. We performed a retrospective cohort study identifying 273 consecutive patients undergoing TIPS from 2010 to 2015 for any indication; 210 met inclusion/exclusion criteria. The primary endpoint was incidence of post-TIPS HE defined as encephalopathy with no other identifiable cause requiring hospitalization within 90 days of TIPS. Clinical demographics and procedural variables were collected and analyzed to determine predictors of readmission for post-TIPS HE. Categorical variables were analyzed using Fisher's exact test; continuous variables were compared using Levene's t-test and student's t-test; P<0.05, significant. Forty-two of 210 patients (20%) developed post-TIPS HE requiring hospitalization within 90 days. On analysis of cohorts (post-TIPS HE vs. no post-TIPS HE): non-white race (31.0% vs. 17.5%, P=0.022) and increased hepatic venous pressure gradient (HVPG) difference during TIPS (10.5 vs. 8.9mmHg, P=0.030) were associated with an increased incidence of HE requiring readmission within 90 days. HE remains a common complication of TIPS. Non-Caucasian race is a significant clinical demographic associated with increased risk for readmission. Independent of initial or final HVPG, HVPG difference appears to be a significant modifiable technical risk factor. In the absence of clear preventative strategies for post-TIPS encephalopathy, non-Caucasians with HVPG reductions >9mmHg may require targeted follow up evaluation to prevent hospital readmission.

Treatment for Gynura segetum caused hepatic vein occlusive disease: a single-center retrospective study

Objective To explore the effects of different treatments on prognosis of patients with Gynura segetum caused hepatic vein occlusion disease (HVOD). Methods From July 2008 to January 2016, 85 patients with Gynura segetum caused HVOD were enrolled and received treatment of liver function protection and microcirculation improvement. According to different treatment options, patients were divided into non-anticoagulation group, non-anticoagulation transfered to transjugular intrahepatic portosystem stent-shunt (TIPS) group, anticoagulation group, anticoagulation transfered to TIPS group and anticoagulation-TIPS step-by-step treatment group. The efficacy of each group was observed. Chi-square test was performed for statistical analysis. Results Among 22 patients who received non-anticoagulation treatment, six (27.3%) patients were cured and 14(63.6%) patients died during the treatment period; besides two (9.1%) patients received TIPS because of ineffective treatment and achieved long-term survival. Among 63 patients treated with combination of low-molecular-weight heparin and warfarin, six (9.5%) patients died and 36(57.1%) patients were cured. The cure rate was higher than that of non-anticoagulation group (χ2=5.820, P=0.016). Other 21 patients received TIPS treatment, achieved long-term survival except one patient died from surgical complications. The cure rate of anticoagulation-TIPS step treatment group was 88.9% (56/63) which was higher than that of non-anticoagulation group, and the difference was statistically significant (χ2=31.350, P<0.01). Conclusions Compared to conventional liver function protection treatment and symptomatic treatment, anticoagulation therapy significantly increases the cure rate of patients with Gynura segetum caused HVOD. Anticoagulation-TIPS step-by-step treatment further improves the cure rate. Key words: Gynura segetum; Hepatic veno-occlusive disease; Heparin, low-molecular-weight; Warfarin; Portasystemic shunt, transjugular intrahepatic

Risk factors of hepatic myelopathy after transjugular intrahepatic portosystem stent-shunt

Objective To investigate risk factors of hepatic myelopathy (HM) after transjugular intrahepatic portosystem stent-shunt (TIPS), and to explore the correlation between HM after TIPS and long term survival. Methods From January 2005 to September 2014, patients with liver cirrhosis received TIPS treatment because of complications associated with portal hypertention were collected. After operation, all patients were followed up by telephone at one, three, six months and later every six months, and the follow-up stopped until death or September 2015. Univariate and multivariate Logistic regression analysis was performed to screen risk factors of HM, and the survival of patients was compared and analyzed. Results A total of 1 101 patients with liver cirrhosis and successfully treated by TIPS were enrolled, and they were divided into HM group (n=80) and non-HM group (n=1 021). The median follow-up time was 44.77 months (range, 2.87-129.80 months). Male (hazard ratio (HR)=2.825, 95%CI:1.454-5.179), splenectomy history (HR=1.829, 95%CI:1.024-3.265) and post-TIPS hepatic encephalopathy (HE) (HR=5.057, 95%CI:2.824-9.055) were risk factors of HM by multivariate Logistic regression analysis (all P<0.05). The median survival time of HM group and non-HM group was 69.93 and 58.43 months, respectively. There was no statistically significant difference in survival time between two groups (P=0.208). The one, three and five years cumulative survival rates of the above two groups were 96.25%, 73.28%, 61.13% and 81.36%, 64.28%, 49.11%, respectively. Conclusion The risk of HM after TIPS is increased in male liver cirrhosis patients with splenectomy. To reduce the risk of HM, a positive prevention of HE after TIPS is recommended. Key words: Portasystemic shunt, transjugular intrahepatic; Hepatic encephalopathy; Spinal cord diseases; Risk factor

Splanchnic vein thrombosis secondary to severe acute pancreatitis treated with regional anticoagulation via transjugular intrahepatic portosystem stent-shunt

s / Pancreatology S12 who received the plasma exchange treatment.We then compared the level of triglycerides before and after the treatment. We also compared the mortality and morbidity rates. Lastly, we compared the results of TG levels, hospital length of stay, and mortality rates in subgroups which received the plasma exchange therapy within 24 h and after 24 h. Result: 1. Statistically significant difference in TG levels between the PE and NPE treatment was found. 2. There was a statistically significant difference in AMY level between patients who received PE treatment and those who did not after a week. 3. There was statistically significant difference in intensive care unit length of stay, system complication incidence, recurrence rate, and mortality rate between patients with severe pancreatitis (Ranson scores 3) who received the PE treatment and thosewho did notwhile no statistically significant difference was found in HLOS, local complication incidence. 4. There was no statistically significant difference in triglycerides level within 24 and after 24 hours of treatment but the difference between HLOS and mortality rate was statistically significant. Conclusion: Plasma exchange is associated with a higher rate of recovery in patients with severe hyperlipidemia pancreatitis complications as PE significantly lowers the level of triglyceride. Furthermore, early PE treatment could reduce HLOS and mortality rate.

Mo1016 Evaluation of Sarcopenia As a Predictor of Hepatic Encephalopathy Following Transjugular Intrahepatic Portosystemic (TIPS) Shunt Placement

A S L D A b st ra ct s subcutaneous fat (SF) were calculated in cm2 using the CT slice at the level of L 4 vertebra with Adobe Photoshop. We assessed differences in subcutaneous fat between compensated (Cc) and decompensated cirrhosis (Dc) and its determinants by multivariable linear regression. Results:We had complete data on 144 patients (44 compensated, 100 decompensated). Demographic characteristics were not significantly different between the two groups. The average MELD score was higher (18.4 in Dc vs. 14 in Cc; p<0.01). The average SMM was lower in Dc compared to Cc although this difference was not statistically significant (127 vs. 138 cm2, p=0.08). However, in males, SMM was significantly lower in Dc vs. Cc even after adjusting for race; age, serum albumin and MELD score (Coefficient of -16.1; 95% Confidence Interval -32.2 to -0.1; p=0.04). [Table 1]. Conversely in females, sf was lower in Dc vs. Cc when adjusted for above confounders with a trend towards significance (Coefficient of -127.3; 95% Confidence Interval -258.9 to 3.3; p=0.057). There was no difference in SF between Dc and Cc males and SMM between Dc and Cc females respectively. Conclusions: Skeletal muscle is reduced to a greater extent in males and subcutaneous fat is reduced to a greater extent in females as cirrhosis becomes decompensated, as seen in other chronic diseases These changes in decompensated cirrhosis may depend on pre morbid body composition with females losing more fat due to higher baseline body fat percentage and males losing more lean muscle mass for the same reasons. Further investigation into these mechanisms is warranted. Univariable and multivariable linear regression of SMM and SF in males and females

Short-Term Rebleeding Rates for Isolated Gastric Varices Managed by Transjugular Intrahepatic Portosystemic Shunt versus Balloon-Occluded Retrograde Transvenous Obliteration

PurposeTo assess the short-term rebleeding rate associated with the use of a transjugular intrahepatic portosystemic shunt (TIPS) compared with balloon-occluded retrograde transvenous obliteration (BRTO) for management of gastric varices (GV). Materials and MethodsA single-center retrospective comparison of 50 patients with bleeding from GV treated with a TIPS or BRTO was performed. Of 50 patients, 27 (17 men and 10 women; median age, 55 y; range, 31–79 y) received a TIPS with covered stents, and 23 (12 men and 11 women; median age, 52 y; range, 23–83 y) underwent a BRTO procedure with a foam sclerosant. All study subjects had clinical and endoscopic evidence of isolated bleeding GV and were hemodynamically stable at the time of the procedure. Clinical and endoscopic follow-up was performed. Kaplan-Meier analysis was used to evaluate rebleeding rates from the GV. ResultsThe technical success rate was 100% in the TIPS group and 91% in the BRTO group (P = .21). Major complications occurred in 4% of the patients receiving TIPS and 9% of patients the undergoing BRTO (P = .344). Encephalopathy was reported in 4 of 27 (15%) patients in the TIPS group and in none of the patients in the BRTO group (0%; P = .12). At 12 months, the incidence of rebleeding from a GV source was 11% in the TIPS group and 0% in the BRTO group (P = .25). ConclusionsBRTO appears to be equivalent to TIPS in the short-term for management of bleeding GV. Further comparative studies are warranted to determine optimal management strategies in individual patients.