Efficacy, feasibility and safety of TIPS in the treatment of recurrent portal hypertension with variceal bleeding after open splenectomy and esophagogastric devascularization.

To investigate the efficacy, feasibility, and safety of transjugular intrahepatic portosystemic shunt (TIPS) as a treatment for patients with recurrent portal hypertension with variceal bleeding (RPHVB) who have previously undergone open splenectomy and esophagogastric devascularization (OSED). The data were retrospectively retrieved from 39 cirrhotic RPHVB patients who had undergone OSED from August 2015 to December 2020. All patients were treated with TIPS using the Viabahn stent. Out of the 39 patients included in the study, TIPS was successfully performed in 38 patients with a success rate of 97.44%. One patient had a failed attempt due to cavernous transformation of the portal vein (CTPV). Among the 38 patients who underwent TIPS, 33 patients also underwent varicose vein embolization, while the remaining 5 patients only underwent TIPS procedure. A total of 39 Viabahn stents were implanted, with 5 patients receiving stents expanded to their nominal diameter of 8 mm and the remaining 33 patients having their shunt maintained at a diameter of 6 mm. The postoperative hemostasis rate was 97.37% (37/38). The portal vein pressure (PVP) and portal pressure gradient (PPG) decreased significantly from (31.28 ± 6.24) and (20.61 ± 5.14) mmHg to (19.58 ± 4.69) and (9.24 ± 3.07) mmHg, respectively (P < 0.001). During the follow-up period, the rebleeding rate was 6.09% (2/29), while the incidence of hepatic encephalopathy (HE) and shunt dysfunction was 13.79% (4/29) for each. Transjugular intrahepatic portosystemic shunt is an effective, feasible and safe treatment for RPHVB patients who have previously undergone OSED. A satisfactory clinical outcome could be achieved with a 6 mm-diameter shunt in most patients.

Wang Z ，Zhang Z ，Guo X ，Xu W ，Wei N ，Zhang Q ，Zu M ，Xu H ... -  《-》

Identifying the optimal measurement timing and hemodynamic targets of portal pressure gradient after TIPS in patients with cirrhosis and variceal bleeding.

The optimal timing of measurement and hemodynamic targets of portacaval pressure gradient (PPG) after transjugular intrahepatic portosystemic shunt (TIPS) placement remain unclear. This study aimed to identify the ideal moment for hemodynamic measurements and the optimal target of PPG in patients undergoing covered TIPS for variceal bleeding. Between May 2018 and December 2021, 466 consecutive patients with recurrent variceal bleeding treated with covered TIPS were prospectively included. Post-TIPS PPG was measured immediately (immediate PPG), 24-72 hours (early PPG), and again 1 month (late PPG) after TIPS placement. The agreement among PPGs measured at different time points was assessed by intra-class correlation coefficient (ICC) and Bland-Altman method. The unadjusted and confounder-adjusted effects of PPGs on clinical outcomes (portal hypertensive complications [PHCs], overt hepatic encephalopathy [OHE], further decompensation, and death) were assessed using Fine and Gray competing risk regression models. The agreement between early PPG and late PPG (ICC: 0.34) was better than that between immediate PPG and late PPG (ICC: 0.23, p <0.001). Early PPG revealed an excellent predictive value for PHCs (early PPG≥ vs. <12 mmHg: adjusted hazard ratio 2.17, 95% CI 1.33-3.55, p = 0.002) and OHE (0.40, 95% CI 0.17-0.91, p = 0.030), while immediate PPG did not. Late PPG showed a predictive value for PHC risk but not OHE. By targeting the lowest risk of further decompensation, we identified an optimal hemodynamic target with early PPG ranging from 11 to 14 mmHg that was associated with a decreased risk of OHE and effective prevention of PHC. PPG measured 24 to 72 hours after TIPS correlates with long-term PPG and clinical outcomes, and a hemodynamic target PPG of 11-14 mmHg is associated with reduced encephalopathy but not compromised clinical efficacy. The optimal timing of measurement and hemodynamic targets of portacaval pressure gradient (PPG) after transjugular intrahepatic portosystemic shunt (TIPS) remain unclear. Here we show that post-TIPS PPG measured at least 24 hours but not immediately after the procedure correlated with long-term PPG and clinical events. Thus, PPG measurements taken at least 24 hours after TIPS should be used to guide decision making in order to improve clinical outcomes. Targeting a post-TIPS PPG of 11-14 mmHg or a 20%-50% relative reduction from pre-TIPS baseline measured 24-72 hours after the procedure was associated with reduced encephalopathy but not compromised clinical efficacy. Thus, these criteria could be used to guide TIPS creation and revision in patients with cirrhosis and variceal bleeding undergoing covered TIPS. ClinicalTrials.gov, ID: NCT03590288.

Lv Y ，Wang Q ，Luo B ，Bai W ，Li M ，Li K ，Wang Z ，Xia D ，Guo W ，Li X ，Yuan J ，Zhang N ，Wang X ，Xie H ，Pan Y ，Nie Y ，Yin Z ，Fan D ，Han G ... -  《-》

Efficacy and safety of precision-guided transjugular extrahepatic portosystemic shunt (TEPS) in the management of cavernous transformation of the portal vein with portal hypertension: a case series.

Performing a Transjugular intrahepatic portal system shunt (TIPS) in patients with portal vein cavernous transformation (CTPV) poses significant challenges. As an alternative, transjugular extrahepatic portal vein shunt (TEPS) may offer a potential solution for these patients. Nonetheless, the effectiveness and safety of TEPS remain uncertain. This case series study aimed to evaluate the efficacy and safety of TEPS in treating patients with CTPV portal hypertension complications. The study encompassed a cohort of 22 patients diagnosed with CTPV who underwent TEPS procedures. Of these, 13 patients manifested recurrent hemorrhagic episodes subsequent to conventional therapies, 8 patients grappled with recurrent or refractory ascites, and 1 patient experienced acute bleeding but refused endoscopic treatment. Comprehensive postoperative monitoring was conducted for all patients to rigorously evaluate both the technical and clinical efficacy of the intervention, as well as long-term outcomes. The overall procedural success rate among the 22 patients was 95.5% (21/22).During the TEPS procedure, nine patients were guided by percutaneous splenic access, three patients were guided by percutaneous hepatic access, five patients were guided by transmesenteric vein access from the abdomen, and two patients were guided by catheter marking from the hepatic artery. Additionally, guidance for three patients was facilitated by pre-existing TIPS stents. The postoperative portal pressure gradient following TEPS demonstrated a statistically significant decrease compared to preoperative values (24.95 ± 3.19 mmHg vs. 11.48 ± 1.74 mmHg, p < 0.01).Although three patients encountered perioperative complications, their conditions ameliorated following symptomatic treatment, and no procedure-related fatalities occurred. During a median follow-up period of 14 months, spanning a range of 5 to 39 months, we observed four fatalities. Specifically, one death was attributed to hepatocellular carcinoma, while the remaining three were ascribed to chronic liver failure. During the follow-up period, no instances of shunt dysfunction were observed. Precision-guided TEPS appears to be a safe and efficacious intervention for the management of CTPV.

Zhang L ，Zhu YJ ，Wang XQ ，Wang RF ，Dong L ，Yin L ，Lv WF ，Cheng DL ，Zhou CZ ... -  《-》

Machine learning prediction of hepatic encephalopathy for long-term survival after transjugular intrahepatic portosystemic shunt in acute variceal bleeding.

Transjugular intrahepatic portosystemic shunt (TIPS) is an effective intervention for managing complications of portal hypertension, particularly acute variceal bleeding (AVB). While effective in reducing portal pressure and preventing rebleeding, TIPS is associated with a considerable risk of overt hepatic encephalopathy (OHE), a complication that significantly elevates mortality rates. To develop a machine learning (ML) model to predict OHE occurrence post-TIPS in patients with AVB using a 5-year dataset. This retrospective single-center study included 218 patients with AVB who underwent TIPS. The dataset was divided into training (70%) and testing (30%) sets. Critical features were identified using embedded methods and recursive feature elimination. Three ML algorithms-random forest, extreme gradient boosting, and logistic regression-were validated via 10-fold cross-validation. SHapley Additive exPlanations analysis was employed to interpret the model's predictions. Survival analysis was conducted using Kaplan-Meier curves and stepwise Cox regression analysis to compare overall survival (OS) between patients with and without OHE. The median OS of the study cohort was 47.83 ± 22.95 months. Among the models evaluated, logistic regression demonstrated the highest performance with an area under the curve (AUC) of 0.825. Key predictors identified were Child-Pugh score, age, and portal vein thrombosis. Kaplan-Meier analysis revealed that patients without OHE had a significantly longer OS (P = 0.005). The 5-year survival rate was 78.4%, with an OHE incidence of 15.1%. Both actual OHE status and predicted OHE value were significant predictors in each Cox model, with model-predicted OHE achieving an AUC of 88.1 in survival prediction. The ML model accurately predicts post-TIPS OHE and outperforms traditional models, supporting its use in improving outcomes in patients with AVB.

Liu DJ ，Jia LX ，Zeng FX ，Zeng WX ，Qin GG ，Peng QF ，Tan Q ，Zeng H ，Ou ZY ，Kun LZ ，Zhao JB ，Chen WG ... -  《-》

Transjugular Intrahepatic Portosystemic Shunt for Preventing Rebleeding of Esophageal Varices in Patients with Portal Cavernous Transformation.

Recurrent esophageal variceal bleeding and/or refractory ascites in patients with cavernous transformation of the portal vein (CTPV) is associated with a high fatality rate. Transjugular intrahepatic portosystemic shunt (TIPS) provides a treatment option for preventing esophageal variceal rebleeding and/or refractory ascites. This retrospective study evaluated the safety and efficacy of TIPS for the patients involved. The records of 41 consecutive patients with CTPV who underwent TIPS at our institution from January 2015 to May 2019 were reviewed. Among the 41 patients, 36 patients had variceal rebleeding only, and 5 patients exhibited both variceal rebleeding and refractory ascites. Ten of these patients underwent TIPS via a transjugular pathway alone; a combined transjugular/transhepatic pathway and a combined transjugular/transsplenic pathway were adopted for 21 and 3 patients, respectively; and the remaining 7 patients failed TIPS. TIPS succeeded in 34 of 41 (82.9%) patients. Four of 34 patients with CTPV were successfully cured with a thick collateral caval stent shunt operation. After TIPS, the mean portosystemic pressure gradient declined from 24.60 ± 6.15 mmHg to 15.89 ± 4.08 mmHg (P < 0.01). The occurrence rate of variceal rebleeding in the TIPS success group was lower than that in the TIPS failure group (11.8% vs 42.9%, P < 0.05). The occurrence rate of recurrent ascites in the TIPS failure group was greater than that in the TIPS success group (75% vs 15.8%, P < 0.05). TIPS patency was 76.5% (26 of 34 patients). During the follow-up time (median 12.64 months), the rate of hepatic encephalopathy was 5.9%, and the survival rate was 85.3%. TIPS is an effective and safe alternative therapy for preventing esophageal variceal rebleeding and/or refractory ascites in patients who exhibit CTPV, and these findings may be beneficial to clinical research.

Chen JW ，Chen PF ，Li J ，Duan XH ，Ren JZ ，Zhang WG ... -  《-》