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Xu X, Yang Y, Tan X, Zhang Z, Wang B, Yang X, Weng C, Yu R, Zhao Q, Quan S. Hepatic encephalopathy post-TIPS: Current status and prospects in predictive assessment. Comput Struct Biotechnol J 2024; 24:493-506. [PMID: 39076168 PMCID: PMC11284497 DOI: 10.1016/j.csbj.2024.07.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2024] [Revised: 07/05/2024] [Accepted: 07/05/2024] [Indexed: 07/31/2024] Open
Abstract
Transjugular intrahepatic portosystemic shunt (TIPS) is an essential procedure for the treatment of portal hypertension but can result in hepatic encephalopathy (HE), a serious complication that worsens patient outcomes. Investigating predictors of HE after TIPS is essential to improve prognosis. This review analyzes risk factors and compares predictive models, weighing traditional scores such as Child-Pugh, Model for End-Stage Liver Disease (MELD), and albumin-bilirubin (ALBI) against emerging artificial intelligence (AI) techniques. While traditional scores provide initial insights into HE risk, they have limitations in dealing with clinical complexity. Advances in machine learning (ML), particularly when integrated with imaging and clinical data, offer refined assessments. These innovations suggest the potential for AI to significantly improve the prediction of post-TIPS HE. The study provides clinicians with a comprehensive overview of current prediction methods, while advocating for the integration of AI to increase the accuracy of post-TIPS HE assessments. By harnessing the power of AI, clinicians can better manage the risks associated with TIPS and tailor interventions to individual patient needs. Future research should therefore prioritize the development of advanced AI frameworks that can assimilate diverse data streams to support clinical decision-making. The goal is not only to more accurately predict HE, but also to improve overall patient care and quality of life.
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Affiliation(s)
- Xiaowei Xu
- Department of Gastroenterology Nursing Unit, Ward 192, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou 325000, China
| | - Yun Yang
- School of Nursing, Wenzhou Medical University, Wenzhou 325001, China
| | - Xinru Tan
- The First School of Medicine, School of Information and Engineering, Wenzhou Medical University, Wenzhou 325001, China
| | - Ziyang Zhang
- School of Clinical Medicine, Guizhou Medical University, Guiyang 550025, China
| | - Boxiang Wang
- The First School of Medicine, School of Information and Engineering, Wenzhou Medical University, Wenzhou 325001, China
| | - Xiaojie Yang
- Wenzhou Medical University Renji College, Wenzhou 325000, China
| | - Chujun Weng
- The Fourth Affiliated Hospital Zhejiang University School of Medicine, Yiwu 322000, China
| | - Rongwen Yu
- Wenzhou Institute, University of Chinese Academy of Sciences, Wenzhou 325000, China
| | - Qi Zhao
- School of Computer Science and Software Engineering, University of Science and Technology Liaoning, Anshan 114051, China
| | - Shichao Quan
- Department of Big Data in Health Science, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou 325000, China
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Chen R, Luo L, Zhang YZ, Liu Z, Liu AL, Zhang YW. Bayesian network-based survival prediction model for patients having undergone post-transjugular intrahepatic portosystemic shunt for portal hypertension. World J Gastroenterol 2024; 30:1859-1870. [PMID: 38659484 PMCID: PMC11036496 DOI: 10.3748/wjg.v30.i13.1859] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/29/2023] [Revised: 02/01/2024] [Accepted: 03/19/2024] [Indexed: 04/03/2024] Open
Abstract
BACKGROUND Portal hypertension (PHT), primarily induced by cirrhosis, manifests severe symptoms impacting patient survival. Although transjugular intrahepatic portosystemic shunt (TIPS) is a critical intervention for managing PHT, it carries risks like hepatic encephalopathy, thus affecting patient survival prognosis. To our knowledge, existing prognostic models for post-TIPS survival in patients with PHT fail to account for the interplay among and collective impact of various prognostic factors on outcomes. Consequently, the development of an innovative modeling approach is essential to address this limitation. AIM To develop and validate a Bayesian network (BN)-based survival prediction model for patients with cirrhosis-induced PHT having undergone TIPS. METHODS The clinical data of 393 patients with cirrhosis-induced PHT who underwent TIPS surgery at the Second Affiliated Hospital of Chongqing Medical University between January 2015 and May 2022 were retrospectively analyzed. Variables were selected using Cox and least absolute shrinkage and selection operator regression methods, and a BN-based model was established and evaluated to predict survival in patients having undergone TIPS surgery for PHT. RESULTS Variable selection revealed the following as key factors impacting survival: age, ascites, hypertension, indications for TIPS, postoperative portal vein pressure (post-PVP), aspartate aminotransferase, alkaline phosphatase, total bilirubin, prealbumin, the Child-Pugh grade, and the model for end-stage liver disease (MELD) score. Based on the above-mentioned variables, a BN-based 2-year survival prognostic prediction model was constructed, which identified the following factors to be directly linked to the survival time: age, ascites, indications for TIPS, concurrent hypertension, post-PVP, the Child-Pugh grade, and the MELD score. The Bayesian information criterion was 3589.04, and 10-fold cross-validation indicated an average log-likelihood loss of 5.55 with a standard deviation of 0.16. The model's accuracy, precision, recall, and F1 score were 0.90, 0.92, 0.97, and 0.95 respectively, with the area under the receiver operating characteristic curve being 0.72. CONCLUSION This study successfully developed a BN-based survival prediction model with good predictive capabilities. It offers valuable insights for treatment strategies and prognostic evaluations in patients having undergone TIPS surgery for PHT.
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Affiliation(s)
- Rong Chen
- Department of Infectious Diseases, Second Affiliated Hospital of Chongqing Medical University, Chongqing 400016, China
| | - Ling Luo
- Department of Infectious Diseases, Second Affiliated Hospital of Chongqing Medical University, Chongqing 400016, China
| | - Yun-Zhi Zhang
- Department of Infectious Diseases, Second Affiliated Hospital of Chongqing Medical University, Chongqing 400016, China
| | - Zhen Liu
- Department of Infectious Diseases, Second Affiliated Hospital of Chongqing Medical University, Chongqing 400016, China
| | - An-Lin Liu
- Department of Infectious Diseases, Second Affiliated Hospital of Chongqing Medical University, Chongqing 400016, China
| | - Yi-Wen Zhang
- Department of Infectious Diseases, Second Affiliated Hospital of Chongqing Medical University, Chongqing 400016, China
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Heller T, Herlemann DPR, Plieth A, Kröger JC, Weber MA, Reiner J, Jaster R, Kreikemeyer B, Lamprecht G, Schäffler H. Liver cirrhosis and antibiotic therapy but not TIPS application leads to a shift of the intestinal bacterial communities: A controlled, prospective study. J Dig Dis 2024; 25:200-208. [PMID: 38597371 DOI: 10.1111/1751-2980.13262] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/25/2023] [Revised: 02/20/2024] [Accepted: 03/05/2024] [Indexed: 04/11/2024]
Abstract
OBJECTIVES The gut-liver axis is discussed to play an important role in hepatic cirrhosis. Decompensated liver cirrhosis is associated with portal hypertension, which can lead to a variety of complications. Transjugular intrahepatic portosystemic shunt (TIPS) is an established treatment option for the complications of portal hypertension. In this study we focused on the effect of TIPS on intestinal microbial composition in cirrhotic patients. METHODS Thirty patients with liver cirrhosis were compared to 18 healthy adults. Seventeen patients with cirrhosis and portal hypertension received a TIPS. Clinical characteristics, including age, sex, and liver function measured with a Child-Pugh score and model for end-stage liver disease score, were obtained. Intestinal microbial composition was assessed via 16S rRNA gene amplicon sequencing from stool probes before and after TIPS. RESULTS TIPS led to a reduction of hepatic venous pressure gradient. However, TIPS did not cause a shift in the intestinal bacterial communities. Independent from the application of TIPS, antibiotic therapy was associated with a significant difference in the intestinal bacterial microbiota and also a reduced α-diversity. In addition, a significant difference was observed in the intestinal bacterial composition between patients with liver cirrhosis and healthy controls. CONCLUSION The presence of liver cirrhosis and the use of antibiotic therapy, but not the application of TIPS, were associated with a significant shift of the intestinal bacterial communities, showing a high impact on the microbiota of patients with liver cirrhosis.
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Affiliation(s)
- Thomas Heller
- Institute of Diagnostic and Interventional Radiology, Pediatric Radiology and Neuroradiology, University Medical Center Rostock, Rostock, Germany
| | - Daniel P R Herlemann
- Microbial Ecophysiology, Chair of Hydrobiology and Fisheries, Institute of Agricultural and Environmental Sciences, Estonian University of Life Sciences, Tartu, Estonia
- Leibniz Institute for Baltic Sea Research, Rostock, Germany
| | - Anabel Plieth
- Division of Gastroenterology and Endocrinology, Department of Medicine II, Rostock University Medical Center, Rostock, Germany
| | - Jens-Christian Kröger
- Institute of Diagnostic and Interventional Radiology, Pediatric Radiology and Neuroradiology, University Medical Center Rostock, Rostock, Germany
| | - Marc-André Weber
- Institute of Diagnostic and Interventional Radiology, Pediatric Radiology and Neuroradiology, University Medical Center Rostock, Rostock, Germany
| | - Johannes Reiner
- Division of Gastroenterology and Endocrinology, Department of Medicine II, Rostock University Medical Center, Rostock, Germany
| | - Robert Jaster
- Division of Gastroenterology and Endocrinology, Department of Medicine II, Rostock University Medical Center, Rostock, Germany
| | - Bernd Kreikemeyer
- Institute of Medical Microbiology, Virology and Hygiene, University Medical Center, Rostock, Germany
| | - Georg Lamprecht
- Division of Gastroenterology and Endocrinology, Department of Medicine II, Rostock University Medical Center, Rostock, Germany
| | - Holger Schäffler
- Division of Gastroenterology and Endocrinology, Department of Medicine II, Rostock University Medical Center, Rostock, Germany
- Department of Gastroenterology and Internal Medicine, Rems-Murr-Klinikum Winnenden GmbH, Winnenden, Germany
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Liao Y, Zhang L, Wang JT, Yue ZD, Fan ZH, Wu YF, Zhang Y, Dong CB, Wang XQ, Cui T, Meng MM, Bao L, Chen SB, Liu FQ, Wang L. A novel nomogram predicting overt hepatic encephalopathy after transjugular intrahepatic portosystemic shunt in portal hypertension patients. Sci Rep 2023; 13:15244. [PMID: 37709823 PMCID: PMC10502141 DOI: 10.1038/s41598-023-42061-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2023] [Accepted: 09/05/2023] [Indexed: 09/16/2023] Open
Abstract
We aim to develop a nomogram to predict overt hepatic encephalopathy (OHE) after transjugular intrahepatic portosystemic shunt (TIPS) in patients with portal hypertension, according to demographic/clinical indicators such as age, creatinine, blood ammonia, indocyanine green retention rate at 15 min (ICG-R15) and percentage of Portal pressure gradient (PPG) decline. In this retrospective study, 296 patients with portal hypertension who received elective TIPS in Beijing Shijitan Hospital from June 2018 to June 2020 were included. These patients were randomly divided into a training cohort (n = 207) and a validation cohort (n = 89). According to the occurrence of OHE, patients were assigned to OHE group and non-OHE group. Both univariate and multivariate analyses were performed to determine independent variables for predicting OHE after TIPS. Accordingly, receiver operating characteristic (ROC) curve, calibration curve, and decision curve analysis (DCA) were used to compare the accuracy and superiority of a novel model with conventional Child-Pugh and MELD scoring model. Age (OR 1.036, 95% CI 1.002-1.070, p = 0.037), Creatinine (OR 1.011, 95% CI 1.003-1.019, p = 0.009), Blood ammonia (OR 1.025, 95% CI 1.006-1.044, p = 0.011), ICG-R15 (OR 1.030, 95% CI 1.009-1.052, p = 0.004) and Percentage decline in PPG (OR 1.068, 95% CI 1.029-1.109, p = 0.001) were independent risk factors for OHE after TIPS using multifactorial analysis. A nomogram was constructed using a well-fit calibration curve for each of these five covariates. When compared to Child-Pugh and MELD score, this new nomogram has a better predictive value (C-index = 0.828, 95% CI 0.761-0.896). Consistently, this finding was reproduceable in validation cohort and confirmed with DCA. A unique nomogram was developed to predict OHE after TIPS in patients with PHT, with a high prediction sensitivity and specificity performance than commonly applied scoring systems.
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Affiliation(s)
- Yong Liao
- Department of Interventional Therapy, Beijing Shijitan Hospital, Capital Medical University, No. 10 Tie Yi Road, Yangfangdian, Haidian District, Beijing, 100038, China
- Department of Hepatobiliary Interventional Therapy, Beijing Tsinghua Changgung Hospital, Beijing, China
- School of Clinical Medicine, Tsinghua University, Beijing, 100038, People's Republic of China
- Department of Hepatobiliary Surgery, Xingtai People's Hospital of Hebei Medical University, Xingtai, 054001, Hebei, People's Republic of China
| | - Lin Zhang
- Department of Hepatobiliary Interventional Therapy, Beijing Tsinghua Changgung Hospital, Beijing, China
- School of Clinical Medicine, Tsinghua University, Beijing, 100038, People's Republic of China
| | - Ji-Tao Wang
- Department of Hepatobiliary Surgery, Xingtai People's Hospital of Hebei Medical University, Xingtai, 054001, Hebei, People's Republic of China
| | - Zhen-Dong Yue
- Department of Interventional Therapy, Beijing Shijitan Hospital, Capital Medical University, No. 10 Tie Yi Road, Yangfangdian, Haidian District, Beijing, 100038, China
| | - Zhen-Hua Fan
- Department of Interventional Therapy, Beijing Shijitan Hospital, Capital Medical University, No. 10 Tie Yi Road, Yangfangdian, Haidian District, Beijing, 100038, China
| | - Yi-Fan Wu
- Department of Interventional Therapy, Beijing Shijitan Hospital, Capital Medical University, No. 10 Tie Yi Road, Yangfangdian, Haidian District, Beijing, 100038, China
| | - Yu Zhang
- Department of Interventional Therapy, Beijing Shijitan Hospital, Capital Medical University, No. 10 Tie Yi Road, Yangfangdian, Haidian District, Beijing, 100038, China
| | - Cheng-Bin Dong
- Department of Interventional Therapy, Beijing Shijitan Hospital, Capital Medical University, No. 10 Tie Yi Road, Yangfangdian, Haidian District, Beijing, 100038, China
| | - Xiu-Qi Wang
- Department of Interventional Therapy, Beijing Shijitan Hospital, Capital Medical University, No. 10 Tie Yi Road, Yangfangdian, Haidian District, Beijing, 100038, China
| | - Ting Cui
- Department of Interventional Therapy, Beijing Shijitan Hospital, Capital Medical University, No. 10 Tie Yi Road, Yangfangdian, Haidian District, Beijing, 100038, China
| | - Ming-Ming Meng
- Department of Gastroenterology, Beijing Shijitan Hospital, Capital Medical University, Beijing, 100038, People's Republic of China
| | - Li Bao
- Department of Pharmacy, Beijing Shijitan Hospital, Capital Medical University, Beijing, 100038, People's Republic of China
| | - Shu-Bo Chen
- Department of Hepatobiliary Surgery, Xingtai People's Hospital of Hebei Medical University, Xingtai, 054001, Hebei, People's Republic of China
| | - Fu-Quan Liu
- Department of Interventional Therapy, Beijing Shijitan Hospital, Capital Medical University, No. 10 Tie Yi Road, Yangfangdian, Haidian District, Beijing, 100038, China.
| | - Lei Wang
- Department of Interventional Therapy, Beijing Shijitan Hospital, Capital Medical University, No. 10 Tie Yi Road, Yangfangdian, Haidian District, Beijing, 100038, China.
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Ushinsky A, Kim D, Darcy M, Kim SK. Impact of General Anesthesia on the Right Atrial Pressure During Transjugular Intrahepatic Portosystemic Shunt Creation: A Propensity Score Match Analysis. Cardiovasc Intervent Radiol 2023; 46:643-648. [PMID: 36977904 DOI: 10.1007/s00270-023-03410-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/02/2022] [Accepted: 02/28/2023] [Indexed: 03/30/2023]
Abstract
PURPOSE To evaluate the effect of general anesthesia on right atrial (RA) pressure measurements during transjugular intrahepatic portosystemic shunt (TIPS) placement using propensity score match analysis. MATERIALS A single-institution database was used to identify 664 patients who underwent TIPS creation under either conscious sedation (CS) or general anesthesia (GA) between 2009 and 2018. A propensity-matched cohort was created using logistic regression of sedation method on demographics, liver disease status, and indications. Paired analyses were performed using mixed models for RA pressure and Cox proportional hazards model with robust standard errors for mortality. RESULTS Of the 664 patients, 270 patients were matched based on similar characteristics (135 for GA and 135 for CS). Indications for TIPS creation included intractable ascites (n = 170, 63%), hepatic hydrothorax (n = 30, 11%), variceal bleeding (n = 43, 16%), and other (n = 27, 10%). Pre-TIPS RA pressure was greater in the matched GA group as compared to CS group by a mean of 4.2 mmHg (p < 0.0001). Similarly, post-TIPS RA pressure was greater in the matched GA group as compared to CS group by a mean of 3.3 mmHg (p < 0.0001). Pre- and post-procedure RA pressure was found to have no association with post-procedure mortality (0.8891, HR 1.077; p 0.917, HR 0.997; respectively). CONCLUSIONS Utilization of GA during TIPS creation raises the intra-procedural RA pressure compared to CS. However, this elevated intra-procedural RA pressure does not appear to be predictive of mortality post-TIPS creation.
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Affiliation(s)
- Alexander Ushinsky
- Interventional Radiology, Mallinckrodt Institute of Radiology, Washington University St. Louis School of Medicine, 510 S Kingshighway Boulevard, Campus, Box 8131, St Louis, MO, USA
| | - David Kim
- Interventional Radiology, Mallinckrodt Institute of Radiology, Washington University St. Louis School of Medicine, 510 S Kingshighway Boulevard, Campus, Box 8131, St Louis, MO, USA
- Radiology of Huntsville., Huntsville, AL, USA
| | - Michael Darcy
- Interventional Radiology, Mallinckrodt Institute of Radiology, Washington University St. Louis School of Medicine, 510 S Kingshighway Boulevard, Campus, Box 8131, St Louis, MO, USA
| | - Seung Kwon Kim
- Interventional Radiology, Mallinckrodt Institute of Radiology, Washington University St. Louis School of Medicine, 510 S Kingshighway Boulevard, Campus, Box 8131, St Louis, MO, USA.
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Posa A, Tenore L, Barbieri P, Mazza G, Sala E, Iezzi R. The Role of the Transjugular Intrahepatic Porto-Systemic Shunt in an Emergency Setting. Life (Basel) 2023; 13:life13040868. [PMID: 37109397 PMCID: PMC10146175 DOI: 10.3390/life13040868] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2023] [Revised: 03/14/2023] [Accepted: 03/23/2023] [Indexed: 04/29/2023] Open
Abstract
Transjugular intrahepatic porto-systemic shunt (TIPSS) is an interventional radiology procedure whose aim is to create artificial communication between the portal and the hepatic blood flow in order to reduce the pressure gradient in portal hypertension. The indications to perform a TIPSS procedure can be framed in an elective or emergency setting: refractory ascites to diuretic therapy and secondary prophylaxis of variceal hemorrhage are the most frequent reasons for executing a TIPSS in an election context, while acute uncontrolled variceal bleeding is the principal indication that a TIPSS needs to be performed in an emergency setting. In recent years, the role of the TIPSS has been redefined for several conditions, such as ectopic varices, portal vein thrombosis, Budd-Chiari syndrome, hepatic veno-occlusive disease, and many others. This review aims to perform a deep analysis of when and why a TIPSS procedure should be carried out in an emergency, pointing out the related most common technical difficulties and complications.
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Affiliation(s)
- Alessandro Posa
- Department of Diagnostic Imaging, Oncologic Radiotherapy and Hematology, A. Gemelli University Hospital Foundation IRCCS, L.go A. Gemelli 8, 00168 Rome, Italy
| | - Lorenzo Tenore
- Department of Diagnostic Imaging, Oncologic Radiotherapy and Hematology, A. Gemelli University Hospital Foundation IRCCS, L.go A. Gemelli 8, 00168 Rome, Italy
| | - Pierluigi Barbieri
- Department of Diagnostic Imaging, Oncologic Radiotherapy and Hematology, A. Gemelli University Hospital Foundation IRCCS, L.go A. Gemelli 8, 00168 Rome, Italy
| | - Giulia Mazza
- Department of Diagnostic Imaging, Oncologic Radiotherapy and Hematology, A. Gemelli University Hospital Foundation IRCCS, L.go A. Gemelli 8, 00168 Rome, Italy
| | - Evis Sala
- Department of Diagnostic Imaging, Oncologic Radiotherapy and Hematology, A. Gemelli University Hospital Foundation IRCCS, L.go A. Gemelli 8, 00168 Rome, Italy
- Istituto di Radiodiagnostica, Catholic University of the Sacred Heart, L.go F. Vito 1, 00168 Rome, Italy
| | - Roberto Iezzi
- Department of Diagnostic Imaging, Oncologic Radiotherapy and Hematology, A. Gemelli University Hospital Foundation IRCCS, L.go A. Gemelli 8, 00168 Rome, Italy
- Istituto di Radiodiagnostica, Catholic University of the Sacred Heart, L.go F. Vito 1, 00168 Rome, Italy
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Jain S, Parrotte S, Anyanwu C, Fairchild AH. Cirrhosis and Sarcopenia. Semin Intervent Radiol 2023; 40:3-8. [PMID: 37152802 PMCID: PMC10159715 DOI: 10.1055/s-0043-1764281] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/09/2023]
Abstract
Sarcopenia is a progressive muscle wasting syndrome involving loss in skeletal muscle mass, strength, and function. It is closely associated with cirrhosis and its complications with up to more than half of cirrhotic patients demonstrating imaging findings of sarcopenia. The pathogenesis of this syndrome remains complex, including multiple factors involved in skeletal muscle homeostasis, systemic inflammation, and energy dysregulation. Many modalities exist in assessing and measuring sarcopenia. The use of cross-sectional imaging, such as computed tomography and magnetic resonance imaging, with accurate and clinically proven assessment software should be considered the gold standard. Sarcopenia has become the focus of ongoing extensive research with initial findings highlighting increased mortality and complication rates in patient with cirrhosis and hepatocellular carcinoma. Additional studies have demonstrated reversal and improved survival in sarcopenic patients who have undergone transjugular intrahepatic portosystemic shunt placement. Thus, accounting for sarcopenia can help risk stratify patients prior to interventional procedures to allow for better outcomes and improved survival.
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Affiliation(s)
- Shivani Jain
- Department of Interventional Radiology, Louisiana State University Health Sciences Center, New Orleans, Louisiana
| | - Samantha Parrotte
- Department of Interventional Radiology, Louisiana State University Health Sciences Center, New Orleans, Louisiana
| | - Chikamuche Anyanwu
- Department of Interventional Radiology, Louisiana State University Health Sciences Center, New Orleans, Louisiana
| | - Alexandra H. Fairchild
- Department of Interventional Radiology, Louisiana State University Health Sciences Center, New Orleans, Louisiana
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Zhan PC, Li Z, Li X, Lv PJ, Zhang YY, Yu P, Ji K, Shi Y, Ye SW, Xie BC, Gao JB, Zhou PL, Wu G. A Nomogram to Predict the Risk of Stent Dysfunction After TIPS in Patients with Hepatitis B Cirrhosis. Acad Radiol 2022; 29:1532-1540. [PMID: 35216866 DOI: 10.1016/j.acra.2022.01.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2021] [Revised: 01/13/2022] [Accepted: 01/23/2022] [Indexed: 12/14/2022]
Abstract
RATIONALE AND OBJECTIVES To develop and validate a nomogram for the prediction of stent dysfunction after transjugular intrahepatic portosystemic shunt (TIPS) placement in patients with hepatitis B cirrhosis. MATERIALS AND METHODS From 2012 to 2020, 355 patients with hepatitis B cirrhosis who underwent TIPS placements were enrolled in this study. A multivariable logistic regression analysis was applied to determine independent risk factors for the nomogram construction. Discrimination, calibration, and clinical usefulness of the prediction model were assessed by using receiver operating characteristic curves, calibration scatter plots, and a decision curve analysis (DCA). RESULTS Independent factors for TIPS stent dysfunction included diabetes, previous splenectomy, the shunting branch of the portal vein, and stent position, which were used to construct the nomogram. The AUC values in the training and validation cohorts were 0.817 (95% CI: 0.731-0.903) and 0.804 (95% CI: 0.673-0.935), respectively, which suggested a good predictive ability. The calibration curves in both cohorts revealed good agreement between the predictions and actual observations. The DCA curve indicated that when the threshold probability ranged from 2% to 88%, the nomogram could provide clinical usefulness and a net benefit. CONCLUSION The nomogram that we developed could be conveniently used to predict TIPS stent dysfunction in patients with hepatitis B cirrhosis.
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Affiliation(s)
- Peng-Chao Zhan
- Department of Radiology, Zhengzhou University First Affiliated Hospital, Zhengzhou, China
| | - Zhen Li
- Department of Interventional Radiology, Zhengzhou University First Affiliated Hospital, No.1 Jianshe Road, Zhengzhou 450052, China.
| | - Xin Li
- Department of Interventional Radiology, Zhengzhou University First Affiliated Hospital, No.1 Jianshe Road, Zhengzhou 450052, China
| | - Pei-Jie Lv
- Department of Radiology, Zhengzhou University First Affiliated Hospital, Zhengzhou, China
| | - Yu-Yuan Zhang
- Department of Interventional Radiology, Zhengzhou University First Affiliated Hospital, No.1 Jianshe Road, Zhengzhou 450052, China
| | - Peng Yu
- Department of Interventional Radiology, Zhengzhou University First Affiliated Hospital, No.1 Jianshe Road, Zhengzhou 450052, China
| | - Kun Ji
- Department of Interventional Radiology, The First Affiliated Hospital of Zhejiang University, Hangzhou, China
| | - Yang Shi
- Department of Radiology, The Third Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Shu-Wen Ye
- Department of Interventional Radiology, Zhengzhou University First Affiliated Hospital, No.1 Jianshe Road, Zhengzhou 450052, China
| | - Bing-Can Xie
- Department of Interventional Radiology, Zhengzhou University First Affiliated Hospital, No.1 Jianshe Road, Zhengzhou 450052, China
| | - Jian-Bo Gao
- Department of Radiology, Zhengzhou University First Affiliated Hospital, Zhengzhou, China
| | - Peng-Li Zhou
- Department of Interventional Radiology, Zhengzhou University First Affiliated Hospital, No.1 Jianshe Road, Zhengzhou 450052, China
| | - Gang Wu
- Department of Interventional Radiology, Zhengzhou University First Affiliated Hospital, No.1 Jianshe Road, Zhengzhou 450052, China
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Hinojosa-Gonzalez DE, Tellez-Garcia E, Salgado-Garza G, Roblesgil-Medrano A, Bueno-Gutierrez LC, Villegas-De Leon SU, Espadas-Conde MA, Herrera-Carrillo FE, Flores-Villalba E. Intraoperative and postoperative impact of pretransplantation transjugular intrahepatic portosystemic shunts in orthotopic liver transplantations: A systematic review and meta-analysis. Turk J Surg 2022; 38:121-133. [PMID: 36483172 PMCID: PMC9714644 DOI: 10.47717/turkjsurg.2022.5702] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2022] [Accepted: 05/17/2022] [Indexed: 12/24/2022]
Abstract
OBJECTIVES Orthotopic liver transplantation (OLT) remains the definitive treatment for patients afflicted with end-stage liver disease (ESLD). Transjugular intrahepatic portosystemic shunts (TIPS) have been adapted as a bridge to transplantation, allowing partial normalization of portal pressure and associated symptom improvement. Conflicting evidence exists on TIPS' impact on operative procedures. This study aimed to analyze available evidence on patients who underwent OLT with prior TIPS compared to OLT alone with the intent to determine TIPS' impact on surgical outcomes. MATERIAL AND METHODS Following PRISMA guidelines, a systematic review was conducted, identifying studies comparing TIPS + OLT versus OLT alone in patients with ESLD. Data were analyzed using Review Manager 5.3. RESULTS Thirteen studies were included. Operative time, packed red blood cells transfusions, intensive care unit admission, length of stay, dialysis, serum creatinine levels, ascites, vascular complications, bleeding revisions, reintervention, and other complications rates were similar between both groups. Fresh frozen plasma transfusion -2.88 units (-5.42, -0.35; p= 0.03), was lower in the TIPS + OLT group. CONCLUSION Our study found TIPS can be safely employed without having detrimental impacts on OLT outcomes, furthermore, these findings also suggest TIPS does not increase bleeding or complications.
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Affiliation(s)
| | - Eduardo Tellez-Garcia
- School of Medicine and Health Sciences, Monterrey Institue of Technology, Monterrey, Mexico
| | - Gustavo Salgado-Garza
- School of Medicine and Health Sciences, Monterrey Institue of Technology, Monterrey, Mexico
| | | | | | | | | | | | - Eduardo Flores-Villalba
- School of Medicine and Health Sciences, Monterrey Institue of Technology, Monterrey, Mexico
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Department of Advanced Manufacturing, School of Engineering and Sciences, Monterrey Institue of Technology, Monterrey, Mexico
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Artru F, Moschouri E, Denys A. Direct intrahepatic portocaval shunt (DIPS) or transjugular transcaval intrahepatic portosystemic shunt (TTIPS) to treat complications of portal hypertension: Indications, technique, and outcomes beyond Budd-Chiari syndrome. Clin Res Hepatol Gastroenterol 2022; 46:101858. [PMID: 34999250 DOI: 10.1016/j.clinre.2022.101858] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/21/2021] [Revised: 12/27/2021] [Accepted: 01/03/2022] [Indexed: 02/04/2023]
Abstract
Transjugular intrahepatic portosystemic shunt (TIPS) is nowadays the benchmark treatment of severe portal hypertension complications. However, besides usual contraindication to the procedure (namely recurrent hepatic encephalopathy, severe liver dysfunction, right heart failure and/or pulmonary hypertension), TIPS appears regularly unfeasible due to abnormal and/or distorted anatomy. In this situation, the only non-surgical approaches to treat severe portal hypertension consist in the creation of an intrahepatic portocaval shunt from percutaneous (direct intrahepatic portocaval shunt - DIPS) or transjugular route (transjugular transcaval intrahepatic portosystemic shunt - TTIPS). These procedures have been rapidly adopted in patients with Budd-Chiari syndrome but are only poorly reported in patients with cirrhosis and without BCS. Considering the broadening landscape of TIPS indication in patients with cirrhosis within the last ten years, we aimed to describe the techniques, safety and efficacy of DIPS and TTIPS procedures as an alternative to TIPS in case of unfavourable anatomy.
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Affiliation(s)
- Florent Artru
- Service de gastroentérologie et d'hépatologie du Centre Hospitalier Universitaire Vaudois (CHUV), Lausanne, Vaud, Switzerland; Institute of Liver Studies, King's College Hospital, London, United Kingdom
| | - Eleni Moschouri
- Service de gastroentérologie et d'hépatologie du Centre Hospitalier Universitaire Vaudois (CHUV), Lausanne, Vaud, Switzerland
| | - Alban Denys
- Service radiodiagnostic et de radiologie interventionnelle du Centre Hospitalier Universitaire Vaudois (CHUV), Lausanne, Vaud, Switzerland.
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Mukund A, Rana S, Mohan C, Kalra N, Baijal SS. Indian College of Radiology and Imaging Evidence-Based Guidelines for Interventions in Portal Hypertension and Its Complications. Indian J Radiol Imaging 2022; 31:917-932. [PMID: 35136505 PMCID: PMC8817816 DOI: 10.1055/s-0041-1740235] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/10/2022] Open
Abstract
Portal hypertension is a complication of chronic liver disease. Various radiological interventions are being done to aid in the diagnosis of portal hypertension; further, an interventional radiologist can offer various treatments for the complications of portal hypertension. Diagnosis of portal hypertension in its early stage may require hepatic venous pressure gradient measurement. Measurement of gradient also guides in diagnosing the type of portal hypertension, measuring response to treatment and prognostication. This article attempts to provide evidence-based guidelines on the management of portal hypertension and treatment of its complications.
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Affiliation(s)
- Amar Mukund
- Department of Interventional Radiology, Institute of Liver and Biliary Sciences, New Delhi, India
| | - Shaleen Rana
- Department of Interventional Radiology, Institute of Liver and Biliary Sciences, New Delhi, India
| | - Chander Mohan
- Department of Interventional Radiology, BLK Superspecialty Hospital, New Delhi, India
| | - Naveen Kalra
- Department of Radiology, PGIMER, Chandigarh, India
| | - Sanjay Saran Baijal
- Department of Diagnostic and Interventional Radiology, Medanta—The Medicity, Gurugram, Haryana, India
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12
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Quantitative analysis of in-TIPS thrombosis in abdominal CT. Eur J Radiol Open 2022; 9:100405. [PMID: 35242887 PMCID: PMC8873550 DOI: 10.1016/j.ejro.2022.100405] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2021] [Revised: 02/11/2022] [Accepted: 02/14/2022] [Indexed: 11/24/2022] Open
Abstract
Purpose To identify transjugular intrahepatic portosystemic shunt (TIPS) thrombosis in abdominal CT scans applying quantitative image analysis. Materials and methods We retrospectively screened 184 patients to include 20 patients (male, 8; female, 12; mean age, 60.7 ± 8.87 years) with (case, n = 10) and without (control, n = 10) in-TIPS thrombosis who underwent clinically indicated contrast-enhanced and unenhanced abdominal CT followed by conventional TIPS-angiography between 08/2014 and 06/2020. First, images were scored visually. Second, region of interest (ROI) based quantitative measurements of CT attenuation were performed in the inferior vena cava (IVC), portal vein and in four TIPS locations. Minimum, maximum and average Hounsfield unit (HU) values were used as absolute and relative quantitative features. We analyzed the features with univariate testing. Results Subjective scores identified in-TIPS thrombosis in contrast-enhanced scans with an accuracy of 0.667 – 0.833. Patients with in-TIPS thrombosis had significantly lower average (p < 0.001), minimum (p < 0.001) and maximum HU (p = 0.043) in contrast-enhanced images. The in-TIPS / IVC ratio in contrast-enhanced images was significantly lower in patients with in-TIPS thrombosis (p < 0.001). No significant differences were found for unenhanced images. Analyzing the visually most suspicious ROI with consecutive calculation of its ratio to the IVC, all patients with a ratio < 1 suffered from in-TIPS thrombosis (p < 0.001, sensitivity and specificity = 100%). Conclusion Quantitative analysis of abdominal CT scans facilitates the stratification of in-TIPS thrombosis. In contrast-enhanced scans, an in-TIPS / IVC ratio < 1 could non-invasively stratify all patients with in-TIPS thrombosis. Quantitative image analyses of CT scans allow the diagnosis of in-TIPS thrombosis. Negative quantitative image analysis may reduce the necessity of an angiography. Unenhanced CT scans have no additional benefit for diagnosis of in-TIPS thrombosis.
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Han H, Yang J, Jin WK, Li X, Zhang F, Zhuge YZ, Wu M, Yang B. Diagnostic value of conventional ultrasound and shear wave elastography in detecting transjugular intrahepatic portosystemic shunt dysfunction. Acta Radiol 2021; 62:1575-1582. [PMID: 33251812 DOI: 10.1177/0284185120975183] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND Transjugular intrahepatic portosystemic shunt (TIPS) dysfunction can cause recurrent portal hypertension (PH)-related complications such as ascites and gastroesophageal variceal bleeding. Portography is invasive and costly limits its use as a screening modality. PURPOSE To assess the clinical value of conventional ultrasound in combination with point shear wave elastography (pSWE) to predict TIPS dysfunction. MATERIAL AND METHODS A total of 184 patients with cirrhosis scheduled for TIPS implantation were enrolled in this study and evaluated retrospectively. The splenoportal venous blood flow parameter, liver stiffness (LS), and spleen stiffness (SPS) were measured. Outcome measures included differences in portal vein velocity (PVV), splenic vein velocity (SPVV), LS, and SPS. The accuracy of change in PVV (ΔPVV), SPVV (ΔSPVV), and SPS (ΔSPS) to diagnose TIPS dysfunction was investigated. RESULTS TIPS dysfunction occurred in 28 of 184 patients (15.2%). Eighteen (64.3%) patients had shunt stenoses and 10 (35.7%) had shunt occlusion. Portal vein diameter (PVD), PVV, splenic vein diameter (SPVD), SPVV, LS, and SPS were not significantly different between the TIPS normal and TIPS dysfunction groups. Compared with the TIPS normal group, PVV and SPVV of the TIPS dysfunction group decreased significantly, whereas SPS increased significantly (P < 0.001). The values of areas under the receiver operating characteristic curves of ΔPVV, ΔSPVV, and ΔSPS for the diagnosis of TIPS dysfunction were 0.97, 0.96, and 0.87, respectively. CONCLUSION pSWE showed a diagnostic efficacy comparable to conventional ultrasound for diagnosing TIPS dysfunction and can be used routinely after TIPS procedures.
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Affiliation(s)
- Hao Han
- Department of Ultrasound, Nanjing Drum Tower Hospital Clinical College of Nanjing Medical University, Nanjing, PR China
| | - Jian Yang
- Department of Ultrasound, Nanjing Drum Tower Hospital, The Affiliated Hospital of Nanjing University Medical School, Nanjing, PR China
| | - Wei-kui Jin
- Department of Ultrasound, Nanjing Drum Tower Hospital, The Affiliated Hospital of Nanjing University Medical School, Nanjing, PR China
| | - Xia Li
- Department of Ultrasound, Nanjing Drum Tower Hospital, The Affiliated Hospital of Nanjing University Medical School, Nanjing, PR China
| | - Feng Zhang
- Department of Gastroenterology, Nanjing Drum Tower Hospital, The Affiliated Hospital of Nanjing University Medical School, Nanjing, PR China
| | - Yu-zheng Zhuge
- Department of Gastroenterology, Nanjing Drum Tower Hospital, The Affiliated Hospital of Nanjing University Medical School, Nanjing, PR China
| | - Min Wu
- Department of Ultrasound, Nanjing Drum Tower Hospital, The Affiliated Hospital of Nanjing University Medical School, Nanjing, PR China
| | - Bin Yang
- Department of Ultrasound, Jinling Hospital, Nanjing Medical University, Nanjing, PR China
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Husnain SMN, Shojaee S. Hepatic Hydrothorax and Congestive Heart Failure Induced Pleural Effusion. Clin Chest Med 2021; 42:625-635. [PMID: 34774170 DOI: 10.1016/j.ccm.2021.07.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
Abstract
Pleural effusions (PEs) are frequently encountered in routine clinical practice, affecting more than 3000 people per million population every year. Heart and liver failures are two of the most common causes of transudative PE. Because these effusions have nonmalignant etiologies, they are commonly referred to as benign effusions despite of the poor prognosis they foretell in their refractory stages. Like malignant effusions, symptom management is important and plays a significant role in palliation when these effusions become refractory to medical therapy.
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Affiliation(s)
| | - Samira Shojaee
- Department of Pulmonary and Critical Care Medicine, Section of Interventional Pulmonology, Virginia Commonwealth University Health System, 1200 East Broad Street, PO Box 980050, Richmond, VA 23298, USA.
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15
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Lu HL, Xuan FF, Luo YC, Qin X. Efficacy and safety of transjugular intrahepatic portosystemic shunt combined with transcatheter embolization/chemoembolization in hepatocellular carcinoma with portal hypertension and arterioportal shunt. Abdom Radiol (NY) 2021; 46:5417-5427. [PMID: 34302511 DOI: 10.1007/s00261-021-03214-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2021] [Revised: 07/11/2021] [Accepted: 07/12/2021] [Indexed: 11/09/2022]
Abstract
OBJECTIVES This study seeks to assess the efficacy and safety of transjugular intrahepatic portosystemic shunt (TIPS) combined with transarterial embolization/transarterial chemoembolization (TAE/TACE) in hepatocellular carcinoma (HCC) with portal hypertension and arterioportal shunt (APS). METHODS Consecutive hospitalized patients having HCC accompanied by portal hypertension and APS were retrospectively analyzed. A total of 103 patients were enrolled. Of them, 26 patients were in Group A and 77 patients were in Group B according to the treatment protocol (Group A: TIPS plus TAE/TACE; Group B: TAE/TACE alone). The clinical outcomes and survival rate were compared between the two groups. RESULTS The mean survival time in Group A and Group B were 14 mo and 9.9 mo, respectively, with statistical difference (p = 0.043). The immediate APS improvement rate was 95.2% in Group A and 91.9% in Group B, respectively, with no signficant difference (p = 1.000). However, the first follow-up consultation revealed that APS improvement rate in Group A was more obvious (66.7% vs 27.4%, p = 0.001). Objective response rate of HCC tended to be greater in Group A compared with Group B (65.4% vs 38.7%, p = 0.019). Liver function parameters significantly increased in Group A than those in Group B. After TIPS placement, the mean portal pressure gradient decreased from 32.61 ± 8.87 mmHg to 15.61 ± 8.15 mmHg, with significant difference (p = 0.000). The rate of absorption of ascites and control of variceal bleeding were statistically different between the two groups (p = 0.045 and 0.039, respectively). CONCLUSION Our research suggests that TIPS combined with TAE/TACE seems to be safe and efficacious in patients with HCC accompanied by portal hypertension and APS, albeit may be accompanied by liver function damage.
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Lower Ratio of Liver Volume and Body Weight Is a Negative Predictor of Survival after Transjugular Intrahepatic Portosystemic Shunt. J Pers Med 2021; 11:jpm11090903. [PMID: 34575680 PMCID: PMC8472540 DOI: 10.3390/jpm11090903] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2021] [Revised: 09/03/2021] [Accepted: 09/08/2021] [Indexed: 11/30/2022] Open
Abstract
Transjugular intrahepatic portosystemic shunt (TIPS) is the most effective measure to treat complications of portal hypertension. However, liver function may deteriorate after TIPS. Predictors of liver function and outcome after TIPS are therefore important for management of TIPS patients. The study aimed to evaluate the impact of liver volume on transplant-free survival (TFS) after TIPS, as well as the evolution of liver volume and its relationship with liver function after TIPS. A retrospective analysis of all consecutive patients who underwent TIPS in a tertiary care university liver center between 2012 and 2017 (n = 216) was performed; n = 72 patients with complete prior and follow-up (FU) computed tomography (CT) imaging studies were included in the study. Volumetry of the liver was performed by a semi-automatic 9-lobe image segmentation algorithm at baseline and FU (FU 1: 90–180 d; FU 2: 180–365 d; FU 3: 365–545 d; FU 4: 545–730 d; FU 5: >730 d). Output variables were total liver volume (TLV, cm3), left liver volume (LLV, cm3), right liver volume (RLV, cm3) and TLV/body weight ratio. CT derived liver volumes were correlated with liver function tests, portosystemic pressure gradient (PPG) measurements and survival. To assess predictors of liver volume change over time we fitted linear mixed models. Kaplan–Meier analysis was performed and validated by matched pair analysis followed by Cox regression to determine independent prognostic factors for survival. The median TLV at baseline was 1507.5 cm3 (773.7–3686.0 cm3). Livers with higher baseline liver volumes and larger TLV/weight ratios retained their volume after an initial loss while smaller livers continuously lost volume after TIPS. At the first follow-up period (90–180 d post-TIPS) lower liver volumes and TLV/weight ratios were associated with higher bilirubin levels. Within the final multivariable model containing time (days since TIPS), baseline INR and baseline TLV, the average loss of liver volume was 0.74 mL per day after TIPS. Twelve-month overall transplant-free survival was 89% and median overall TFS was 33 months. The median TFS for a baseline TLV/body weight ratio > 20 was significantly higher compared with ≤20 (40.0 vs. 27.0 months, p = 0.010) while there were no differences regarding the indication for TIPS or etiology of liver disease in the matched pair analysis. Lower TLV/weight ratios before TIPS were associated with shorter TFS and should therefore be critically considered when selecting patients for TIPS. In addition, this study provides first evidence of an effect of TIPS on subsequent liver volume change and associated liver function.
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Yeoh SW, Kok HK. Transjugular intrahepatic portosystemic shunts in portal vein thrombosis: A review. J Dig Dis 2021; 22:506-519. [PMID: 34323378 DOI: 10.1111/1751-2980.13035] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/17/2021] [Revised: 07/16/2021] [Accepted: 07/26/2021] [Indexed: 12/11/2022]
Abstract
The presence of portal vein thrombosis (PVT) has previously been considered a contraindication to the insertion of transjugular intrahepatic portosystemic shunts (TIPSS). However, patients with PVT may have portal hypertension complications and may thus benefit from TIPSS to reduce portal venous pressure. There is an increasing body of literature that discusses the techniques and outcomes of TIPSS in PVT. This review summarizes the techniques, indications and outcomes of TIPSS in PVT in published case reports, case series and comparative trials, especially regarding the reduction in portal hypertensive complications such as variceal bleeding. A comprehensive literature search was conducted using MEDLINE and PubMed databases. Manuscripts published in English between 1 January 1990 and 1 March 2021 were used. Abstracts were screened and data from potentially relevant articles analyzed. TIPSS in PVT has been reported with high levels of technical success, short-term portal vein recanalization and long-term PV patency and TIPSS patency outcomes. Several comparative studies, including randomized controlled trials, have shown favorable outcomes of TIPSS compared with non-TIPSS treatment of PVT complications. Outcomes of TIPSS with PVT appear similar to those in TIPSS without PVT. However, TIPSS may be more technically difficult in the presence of PVT, and such procedures should be performed in expert high-volume centers to mitigate the risk of procedural complications. The presence of PVT should no longer be considered a contraindication to TIPSS. TIPSS for PVT has been acknowledged as a therapeutic strategy in recent international guidelines, although further studies are needed before recommendations can be strengthened. KEY POINTS: Portal vein thrombosis (PVT) is no longer a contraindication to the insertion of transjugular intrahepatic portosystemic shunts (TIPSS) TIPSS often leads to the spontaneous dissolution of PVT, but can be combined with mechanical or pharmacological thrombectomy TIPSS reduces portal hypertensive complications of PVT, such as variceal bleeding, and can also facilitate liver transplantation where PVT may otherwise interfere with vascular anastomoses Studies have shown favorable long-term outcomes of TIPSS compared with TIPSS without PVT; as well as compared with non-TIPSS treatment of PVT complications TIPSS in PVT should be performed in high-volume specialist centers due to technical difficulties.
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Affiliation(s)
- Sern Wei Yeoh
- Department of Gastroenterology, Northern Health, Melbourne, Victoria, Australia.,School of Medical Education, University of Melbourne, Melbourne, Victoria, Australia
| | - Hong Kuan Kok
- Department of Radiology, Northern Health, Melbourne, Victoria, Australia.,School of Medicine, Deakin University, Melbourne, Victoria, Australia
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Enzymatic liver function measured by LiMAx is superior to current standard methods in predicting transplant-free survival after TIPS implantation. Sci Rep 2021; 11:13834. [PMID: 34226640 PMCID: PMC8257751 DOI: 10.1038/s41598-021-93392-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2021] [Accepted: 06/22/2021] [Indexed: 12/13/2022] Open
Abstract
Transjugular intrahepatic portosystemic shunt (TIPS) is one of the main treatment options in patients with decompensated liver cirrhosis but is still associated with partly severe complications. For adequate patient selection, prognostic parameters are of crucial importance. The liver maximum capacity (LiMAx) breath test measures enzymatic liver function and could potentially represent an efficient prognostic marker. We therefore aimed to assess the role of LiMAx in predicting survival of TIPS patients in a prospective analysis. LiMAx was performed for patients who underwent TIPS implantation between October 2016 and February 2018. Associations with transplant-free survival after 24 weeks were assessed by logistic regression. A total number of 30 patients were included, of whom seven received liver transplantation (N = 2) or died (N = 5) during follow-up. LiMAx values after (P = 0.01, OR = 1.24, 95% CI = 1.04-1.47) and before (P = 0.03, OR 1.21, 95% CI = 1.02-1.43) TIPS implantation and MELD score (P = 0.03, OR = 0.79, 95% CI = 0.63-0.98) were significantly associated with transplant-free survival according to univariate logistic regression. In AUROC analysis, LiMAx at day one after TIPS (sensitivity 85.7%, specificity 78.3%, AUROC 0.85, cut-off ≤ 165 µg/kg/h), LiMAx value at the day before TIPS (sensitivity 100%, specificity 73.9%, AUROC 0.82, cut-off ≤ 205 µg/kg/h) and MELD score (sensitivity 71.4%, specificity 73.9%, AUROC 0.82, cut-off ≥ 15) had the highest prognostic accuracy. LiMAx values prior and after TIPS procedure seem to be good prognostic parameters regarding prediction of transplant-free survival of patients undergoing TIPS implantation.
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Wang Z, Wu YF, Yue ZD, Zhao HW, Wang L, Fan ZH, Zhang Y, Liu FQ. Comparative study of indocyanine green-R15, Child-Pugh score, and model for end-stage liver disease score for prediction of hepatic encephalopathy after transjugular intrahepatic portosystemic shunt. World J Gastroenterol 2021; 27:416-427. [PMID: 33584073 PMCID: PMC7856842 DOI: 10.3748/wjg.v27.i5.416] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/23/2020] [Revised: 12/25/2020] [Accepted: 01/15/2021] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Hepatic encephalopathy (HE) remains an enormous challenge in patients who undergo transjugular intrahepatic portosystemic shunt (TIPS) implantation. The preoperative indocyanine green retention rate at 15 min (ICG-R15), as one of the liver function assessment tools, has been developed as a prognostic indicator in patients undergoing surgery, but there are limited data on its role in TIPS.
AIM To determine whether the ICG-R15 can be used for prediction of post-TIPS HE in decompensated cirrhosis patients with portal hypertension (PHT) and compare the clinical value of ICG-R15, Child-Pugh score (CPS), and model for end-stage liver disease (MELD) score in predicting post-TIPS HE with PHT.
METHODS This retrospective study included 195 patients with PHT who underwent elective TIPS at Beijing Shijitan Hospital from January 2018 to June 2019. All patients underwent the ICG-R15 test, CPS evaluation, and MELD scoring 1 wk before TIPS. According to whether they developed HE or not, the patients were divided into two groups: HE group and non-HE group. The prediction of one-year post-TIPS HE by ICG-R15, CPS and MELD score was evaluated by the areas under the receiver operating characteristic curves (AUCs).
RESULTS A total of 195 patients with portal hypertension were included and 23% (45/195) of the patients developed post-TIPS HE. The ICG-R15 was identified as an independent predictor of post-TIPS HE. The AUCs for the ICG-R15, CPS, and MELD score for predicting post-TIPS HE were 0.664 (95% confidence interval [CI]: 0.557-0.743, P = 0.0046), 0.596 (95%CI: 0.508-0.679, P = 0.087), and 0.641 (95%CI: 0.554-0.721, P = 0.021), respectively. The non-parametric approach (Delong-Delong & Clarke-Pearson) showed that there was statistical significance in pairwise comparison between AUCs of ICG-R15 and MELD score (P = 0.0229).
CONCLUSION The ICG-R15 has appreciated clinical value for predicting the occurrence of post-TIPS HE and is a choice for evaluating the prognosis of patients undergoing TIPS.
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Affiliation(s)
- Zhong Wang
- Department of Interventional Therapy, Beijing Shijitan Hospital, Capital Medical University, Beijing 100038, China
| | - Yi-Fan Wu
- Department of Interventional Therapy, Beijing Shijitan Hospital, Capital Medical University, Beijing 100038, China
| | - Zhen-Dong Yue
- Department of Interventional Therapy, Beijing Shijitan Hospital, Capital Medical University, Beijing 100038, China
| | - Hong-Wei Zhao
- Department of Interventional Therapy, Beijing Shijitan Hospital, Capital Medical University, Beijing 100038, China
| | - Lei Wang
- Department of Interventional Therapy, Beijing Shijitan Hospital, Capital Medical University, Beijing 100038, China
| | - Zhen-Hua Fan
- Department of Interventional Therapy, Beijing Shijitan Hospital, Capital Medical University, Beijing 100038, China
| | - Yu Zhang
- Department of Interventional Therapy, Beijing Shijitan Hospital, Capital Medical University, Beijing 100038, China
| | - Fu-Quan Liu
- Department of Interventional Therapy, Beijing Shijitan Hospital, Capital Medical University, Beijing 100038, China
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Early transjugular intrahepatic portosystemic shunt for acute variceal bleeding: a systematic review and meta-analysis. Eur Radiol 2021; 31:5390-5399. [PMID: 33409783 DOI: 10.1007/s00330-020-07525-x] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2020] [Revised: 10/23/2020] [Accepted: 11/16/2020] [Indexed: 12/18/2022]
Abstract
OBJECTIVES The alleged benefit of early placement of transjugular intrahepatic portosystemic shunt (TIPS) in patients with cirrhosis and acute variceal bleeding (AVB) remains controversial. This meta-analysis was conducted to evaluate the therapeutic effect of early TIPS on cirrhotic patients with AVB. METHODS MEDLINE, Embase, and Cochrane Central Register of Controlled Trials databases were searched for relevant literatures. Data from included studies were extracted, and random-effects meta-analyses were performed. RESULTS Three randomized control trials and six observational studies involving 2878 participants were included. Compared with those undergoing standard treatment, patients undergoing early TIPS had a significantly lower all-cause mortality (RR, 0.64; 95% CI, 0.52-0.79). Furthermore, early TIPS was associated with a significantly reduced incidence of failure to control bleeding (RR, 0.15; 95% CI, 0.07-0.29) and rebleeding (RR, 0.40; 95% CI, 0.23-0.71), without increasing the risk of hepatic encephalopathy (RR, 1.13; 95% CI, 0.92-1.38). In a stratification analysis based on Child-Pugh classification, the survival benefit was observed in Child-Pugh B patients with active bleeding (RR, 0.53; 95% CI, 0.31-0.93) and Child-Pugh C patients (RR 0.55, 95% CI, 0.37-0.82), but not in low-risk patients (Child-Pugh A and Child-Pugh B without active bleeding) (RR, 0.93; 95% CI, 0.55-1.57). CONCLUSION Early TIPS is a feasible therapeutic option for cirrhotic patients with AVB, especially benefiting high-risk patients in terms of improved survival. Given the current low utilization rate in clinical practice, this study favors the placement of early TIPS in a wider range of patients with cirrhosis and AVB, especially high-risk patients. KEY POINTS • Early TIPS is associated with improved survival in high-risk patients (Child-Pugh B plus active bleeding at endoscopy or Child-Pugh C 10-13) with cirrhosis and acute variceal bleeding. • Current utilization rate of early TIPS is low in clinical practice.
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Shunt-Induced Hepatic Encephalopathy in TIPS: Current Approaches and Clinical Challenges. J Clin Med 2020; 9:jcm9113784. [PMID: 33238576 PMCID: PMC7700586 DOI: 10.3390/jcm9113784] [Citation(s) in RCA: 31] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2020] [Revised: 11/19/2020] [Accepted: 11/20/2020] [Indexed: 12/11/2022] Open
Abstract
Transjugular intrahepatic portosystemic shunt (TIPS) is an established treatment tool in decompensated liver cirrhosis that has been shown to prolong transplant-free survival. Hepatic encephalopathy (HE) is a frequent complication of decompensated cirrhosis, eventually induced and/or aggravated by TIPS, that remains a clinical challenge especially in these patients. Therefore, patient selection for TIPS requires careful assessment of risk factors for HE. TIPS procedural parameters regarding stent size and invasive portosystemic pressure gradient measurements thereby have an important role. Endovascular shunt modification, in combination with a conservative medical approach, often results in a significant reduction of symptoms. This review summarizes HE molecular mechanisms and pathophysiology as well as diagnostic and therapeutic approaches targeting shunt-induced HE.
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Rostambeigi N, Farsad K, Young S, Shrestha P, Jahangiri Y, Liang KW, Cretcher M, Golzarian J. Lower-Extremity Edema Is Common after Transjugular Intrahepatic Portosystemic Shunt Creation and Is Associated with Lower Survival: A Two-Institution Study. Radiology 2020; 298:221-227. [PMID: 33201792 DOI: 10.1148/radiol.2020201690] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Background Transjugular intrahepatic portosystemic shunt (TIPS) creation is an accepted treatment of portal hypertension. Lower-extremity edema (LEE) is an underreported complication of TIPS creation. Purpose To assess the epidemiologic findings of LEE after TIPS creation and their association with patient survival. Materials and Methods The medical records of patients who underwent TIPS creation between January 2003 and April 2019 at Oregon Health and Science University and patients who underwent TIPS creation between January 2006 and December 2016 at University of Minnesota were retrospectively reviewed. Clinical, laboratory, and technical parameters, development and outcome of edema, and survival data were collected. LEE was defined as new-onset or worsened edema up to 1 year after TIPS creation. Cardiac ventricular function was evaluated with transthoracic echocardiography. Risk factors for LEE were evaluated with logistic regression analysis, and critical P values were additionally assessed by using the false discovery rate. Survival curves were compared by using the log-rank test. Results Three hundred thirty-four patients were included (mean age, 55 years ± 11 [standard deviation]; 208 men). TIPS creation was primarily performed for ascites (159 of 334 patients, 48%), gastrointestinal bleeding (127 of 334 patients, 38%), or a combination of bleeding and ascites (38 of 334 patients, 11%). One hundred seventy of the 334 patients (51%) developed LEE (new onset, 120; worsened edema, 50). Three of 170 patients (2%) had abnormal left ventricular ejection fraction. Multivariable analysis showed TIPS creation for ascites (odds ratio, 1.7; 95% CI: 1.04, 2.7; P = .03) and hepatic hydrothorax (odds ratio, 2.2; 95% CI: 1.1, 4.2; P = .02) was likely associated with LEE; however, it did not reach significance at a critical P value of .009. Among 164 patients with data on the outcome of LEE, LEE eventually improved in 94 (57%). The median survival of patients with LEE was lower than that of patients without LEE (38 months vs 71 months, respectively; P = .02). Conclusion Lower-extremity edema developed in more than 50% of study patients who underwent transjugular intrahepatic portosystemic shunt (TIPS) creation, regardless of left ventricular function. There was suggestion that TIPS creation for ascites might be an underlying risk factor. Lower-extremity edema portends worse survival. © RSNA, 2020 Online supplemental material is available for this article.
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Affiliation(s)
- Nassir Rostambeigi
- From the Mallinckrodt Institute of Radiology, Department of Vascular and Interventional Radiology, Washington University School of Medicine in St. Louis, 510 S Kingshighway Blvd, St Louis, MO 63110 (N.R.); Charles T. Dotter Department of Interventional Radiology, Oregon Health and Science University, Portland, Ore (K.F., Y.J., K.W.L., M.C.); and Department of Vascular and Interventional Radiology, University of Minnesota, Minneapolis, Minn (S.Y., P.S., J.G.)
| | - Khashayar Farsad
- From the Mallinckrodt Institute of Radiology, Department of Vascular and Interventional Radiology, Washington University School of Medicine in St. Louis, 510 S Kingshighway Blvd, St Louis, MO 63110 (N.R.); Charles T. Dotter Department of Interventional Radiology, Oregon Health and Science University, Portland, Ore (K.F., Y.J., K.W.L., M.C.); and Department of Vascular and Interventional Radiology, University of Minnesota, Minneapolis, Minn (S.Y., P.S., J.G.)
| | - Shamar Young
- From the Mallinckrodt Institute of Radiology, Department of Vascular and Interventional Radiology, Washington University School of Medicine in St. Louis, 510 S Kingshighway Blvd, St Louis, MO 63110 (N.R.); Charles T. Dotter Department of Interventional Radiology, Oregon Health and Science University, Portland, Ore (K.F., Y.J., K.W.L., M.C.); and Department of Vascular and Interventional Radiology, University of Minnesota, Minneapolis, Minn (S.Y., P.S., J.G.)
| | - Prashant Shrestha
- From the Mallinckrodt Institute of Radiology, Department of Vascular and Interventional Radiology, Washington University School of Medicine in St. Louis, 510 S Kingshighway Blvd, St Louis, MO 63110 (N.R.); Charles T. Dotter Department of Interventional Radiology, Oregon Health and Science University, Portland, Ore (K.F., Y.J., K.W.L., M.C.); and Department of Vascular and Interventional Radiology, University of Minnesota, Minneapolis, Minn (S.Y., P.S., J.G.)
| | - Younes Jahangiri
- From the Mallinckrodt Institute of Radiology, Department of Vascular and Interventional Radiology, Washington University School of Medicine in St. Louis, 510 S Kingshighway Blvd, St Louis, MO 63110 (N.R.); Charles T. Dotter Department of Interventional Radiology, Oregon Health and Science University, Portland, Ore (K.F., Y.J., K.W.L., M.C.); and Department of Vascular and Interventional Radiology, University of Minnesota, Minneapolis, Minn (S.Y., P.S., J.G.)
| | - Keng-Wei Liang
- From the Mallinckrodt Institute of Radiology, Department of Vascular and Interventional Radiology, Washington University School of Medicine in St. Louis, 510 S Kingshighway Blvd, St Louis, MO 63110 (N.R.); Charles T. Dotter Department of Interventional Radiology, Oregon Health and Science University, Portland, Ore (K.F., Y.J., K.W.L., M.C.); and Department of Vascular and Interventional Radiology, University of Minnesota, Minneapolis, Minn (S.Y., P.S., J.G.)
| | - Maxwell Cretcher
- From the Mallinckrodt Institute of Radiology, Department of Vascular and Interventional Radiology, Washington University School of Medicine in St. Louis, 510 S Kingshighway Blvd, St Louis, MO 63110 (N.R.); Charles T. Dotter Department of Interventional Radiology, Oregon Health and Science University, Portland, Ore (K.F., Y.J., K.W.L., M.C.); and Department of Vascular and Interventional Radiology, University of Minnesota, Minneapolis, Minn (S.Y., P.S., J.G.)
| | - Jafar Golzarian
- From the Mallinckrodt Institute of Radiology, Department of Vascular and Interventional Radiology, Washington University School of Medicine in St. Louis, 510 S Kingshighway Blvd, St Louis, MO 63110 (N.R.); Charles T. Dotter Department of Interventional Radiology, Oregon Health and Science University, Portland, Ore (K.F., Y.J., K.W.L., M.C.); and Department of Vascular and Interventional Radiology, University of Minnesota, Minneapolis, Minn (S.Y., P.S., J.G.)
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Banini BA, Alwatari Y, Stovall M, Ogden N, Gershman E, Shah RD, Strife BJ, Shojaee S, Sterling RK. Multidisciplinary Management of Hepatic Hydrothorax in 2020: An Evidence-Based Review and Guidance. Hepatology 2020; 72:1851-1863. [PMID: 32585037 DOI: 10.1002/hep.31434] [Citation(s) in RCA: 39] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/01/2020] [Revised: 05/08/2020] [Accepted: 06/04/2020] [Indexed: 12/12/2022]
Affiliation(s)
- Bubu A Banini
- Division of Gastroenterology, Hepatology and Nutrition, Department of Internal Medicine, Virginia Commonwealth University, Richmond, VA
| | - Yahya Alwatari
- Division of Cardiothoracic Surgery, Department of Surgery, Virginia Commonwealth University, Richmond, VA
| | - Madeline Stovall
- Division of Cardiothoracic Surgery, Department of Surgery, Virginia Commonwealth University, Richmond, VA
| | - Nathan Ogden
- Division of Interventional Radiology, Department of Radiology, Virginia Commonwealth University, Richmond, VA
| | - Evgeni Gershman
- Division of Pulmonary Disease and Critical Care Medicine, Department of Internal Medicine, Virginia Commonwealth University, Richmond, VA
| | - Rachit D Shah
- Division of Cardiothoracic Surgery, Department of Surgery, Virginia Commonwealth University, Richmond, VA
| | - Brian J Strife
- Division of Interventional Radiology, Department of Radiology, Virginia Commonwealth University, Richmond, VA
| | - Samira Shojaee
- Division of Pulmonary Disease and Critical Care Medicine, Department of Internal Medicine, Virginia Commonwealth University, Richmond, VA
| | - Richard K Sterling
- Division of Gastroenterology, Hepatology and Nutrition, Department of Internal Medicine, Virginia Commonwealth University, Richmond, VA
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TIPS Modification in the Management of Shunt-Induced Hepatic Encephalopathy: Analysis of Predictive Factors and Outcome with Shunt Modification. J Clin Med 2020; 9:jcm9020567. [PMID: 32092979 PMCID: PMC7073830 DOI: 10.3390/jcm9020567] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2020] [Revised: 02/13/2020] [Accepted: 02/16/2020] [Indexed: 02/07/2023] Open
Abstract
Purpose: To evaluate predictive parameters for the development of Hepatic Encephalopathy (HE) after Transjugular Intrahepatic Portosystemic Shunt (TIPS) placement and for success of shunt modification in the management of shunt-induced HE. Methods: A retrospective analysis of all patients with TIPS (n = 344) has been performed since 2011 in our university liver center. n = 45 patients with HE after TIPS were compared to n = 48 patients without HE after TIPS (case-control-matching). Of n = 45 patients with TIPS-induced HE, n = 20 patients received a reduction stent (n = 18) or TIPS occlusion (n = 2) and were differentiated into responders (improvement by at least one HE grade according to the West Haven classification) and non-responders (no improvement). Results: Older patient age, increased serum creatinine and elevated International Normalized Ratio (INR) immediately after TIPS placement were independent predictors for the development of HE. In 11/20 patients (responders, 55%) undergoing shunt modification, the HE grade was improved compared with nine non-responders (45%), with no relevant recurrence of refractory ascites or variceal bleeding. A high HE grade after TIPS insertion was the only positive predictor of treatment response (p = 0.019). A total of 10/11 responders (91%) survived the 6 months follow-up after modification but only 6/9 non-responders (67%) survived. Discussion: Older patient age as well as an increased serum creatinine and INR after TIPS are potential predictors for the development of HE. TIPS reduction for the treatment of TIPS-induced HE is safe, with particular benefit for patients with pronounced HE.
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