Targeted decrease of portal hepatic pressure gradient improves ascites control after TIPS

Covered TIPS Created with Viatorr Versus Fluency Stent-Grafts for the Refractory Ascites in Patients with Cirrhosis: An Observational Study

RATIONALE AND OBJECTIVES

To compare the long-term clinical efficacy and safety of transjugular intrahepatic portosystemic shunt (TIPS) created with Fluency versus Viatorr stent-grafts for the treatment of refractory ascites in patients with cirrhosis.

MATERIALS AND METHODS

A retrospective analysis was conducted on 118 cirrhotic patients with refractory ascites undergoing TIPS with Fluency stent-grafts (Fluency group, n=83) or Viatorr stent-grafts (Viatorr group, n=35) at two centers from January 2017 to December 2021. Competing risk analysis was used to compare the incidence of clinical outcomes between groups after adjusting for confounders.

RESULTS

During a median of 30.9 months follow-up, 31 patients (26.3%) developed portal hypertension complications (11 cases of recurrent ascites, 16 cases of variceal bleeding, and four cases of both ascites and variceal bleeding), 15 patients (12.7%) developed shunt dysfunction, 58 patients (49.15%) developed overt hepatic encephalopathy (OHE), and 74 patients (62.7%) died. After adjusting for confounding factors, the Viatorr stent was associated with a reduced OHE risk (38% vs 54% at 5 years, p=0.004) but a comparable incidence of portal hypertension complications (27% vs 27%, p=0.536), shunt dysfunction (14% vs 12%, p=0.401), and mortality (41% vs 37%; p=0.064) compared to the Fluency stents. These findings were consistent across most relevant subgroups.

CONCLUSION

In cirrhotic patients with refractory ascites undergoing TIPS, Viatorr stent-grafts were associated with lower risk of OHE while no significant differences in clinical efficacy compared to the Fluency stent-grafts.

Recompensation of Liver Cirrhosis by TIPS Reduces Epithelial Cell Death Markers, Translating Into Improved Clinical Outcome

BACKGROUND AND AIMS

Portal hypertension is the main pathophysiological driver of decompensation in patients with liver cirrhosis. Epithelial cell death markers, m30 and m65, correlate with hepatic injury and predict outcomes across various stages of liver disease. We aim (i) to evaluate whether portal hypertension itself contributes to liver outcome-relevant epithelial injury, and (ii) to analyse the capacity of m30/m65 to predict outcome in patients receiving a transjugular intrahepatic portosystemic shunt (TIPS) for refractory ascites.

METHODS

Sixty-six patients undergoing TIPS placement for refractory ascites and 20 patients with compensated cirrhosis as controls were prospectively enrolled in this monocentric cohort study. Epithelial cell death markers were analysed pre-TIPS, as well as 1-3 and 6-9 months post-TIPS. The capacity of baseline levels of m30/m65 in predicting six-month transplant-free survival rates was analysed by multivariable Cox proportional hazards regression.

RESULTS

Levels of m30 and m65 were higher in patients with decompensated cirrhosis (pre-TIPS) compared with compensated cirrhosis (controls). Following correction of portal hypertension by TIPS and recompensation, both markers decreased over time, reaching levels comparable to patients with compensated cirrhosis. On multivariable analysis, pre-TIPS baseline levels of m30 and m65 were not predictive for six-month survival.

CONCLUSION

Correction of portal hypertension via TIPS reduces levels of epithelial cell death markers, indicating that portal hypertension is a driver of outcome-relevant, hepatic cell death in patients with decompensated cirrhosis. Baseline m30/m65 values do not affect six-month survival rates, which suggests that TIPS placement overcomes the unfavourable spontaneous prognosis otherwise indicated by elevated baseline m30/65 levels.

Benefits of TIPS for Patients With Large Ascites Preceding Recurrent or Refractory ascites: A Multicenter Cohort Study

BACKGROUND AND AIM

Patients with recurrent or refractory ascites can benefit from transjugular intrahepatic portosystemic shunt (TIPS). However, the value of TIPS for patients with large ascites remains unclear.

METHODS

This retrospective multicenter study included patients who underwent TIPS or medicine plus large-volume paracentesis (medicine + LVP) for ascites between January 2014 and December 2022 at five centers. The primary endpoint was recurrence or worsening of ascites. The secondary endpoints were liver-related death, all-cause hemorrhage, overt hepatic encephalopathy (OHE), and shunt dysfunction.

RESULTS

Overall, 724 patients were evaluated, including 373 patients with large ascites preceding recurrent or refractory ascites received TIPS (the LA-TIPS group), 282 patients with recurrent and refractory ascites received TIPS (the RA-TIPS group), and 69 patients with large ascites preceding recurrent or refractory ascites received medicine + LVP (the LA-M group). Patients in the LA-TIPS group had significantly lower incidences of recurrence or worsening of ascites (37.4% vs. 45.3%, p < 0.001), liver-related death (44.8% vs. 62.0%, p < 0.001), and OHE (47.3% vs. 60.3%, p < 0.001) than those in the RA-TIPS group. Meanwhile, patients in the LA-TIPS group had significantly lower incidences of recurrence or worsening of ascites (37.4% vs. 44.6%, p = 0.006) and hemorrhage (38.3% vs. 47.2%, p = 0.042), but a higher incidence of OHE (34.2% vs. 4.5%, p < 0.001) than those in the LA-M group.

CONCLUSIONS

In terms of controlling ascites, the benefit of TIPS was greater in patients with large ascites preceding recurrent or refractory ascites, suggesting that TIPS might be considered in patients with large ascites before they progress to recurrent or refractory stages.

Which patients benefit the most? An update on transjugular intrahepatic portosystemic shunt

This is a narrative review in which the advances in technical aspects, the main indications, limitations and clinical results of the transjugular intrahepatic portosystemic shunt (TIPS) in portal hypertension (PH) are addressed. With the emergence of the coated prosthesis, a better shunt patency, a lower incidence of hepatic encephalopathy (HE) and better survival when compared to TIPS with the conventional prosthesis are demonstrated. The main indications for TIPS are refractory ascites, acute variceal bleeding unresponsive to pharmacological/endoscopic therapy and, lastly, patients considered at high risk for rebleeding preemptive TIPS (pTIPS). Absolute contraindications to the use of TIPS are severe uncontrolled HE, systemic infection or sepsis, congestive heart failure, severe pulmonary arterial hypertension, and biliary obstruction. The control of hemorrhage due to variceal rupture can reach up to 90%-100% of cases, and 55% in refractory ascites. Despite evidences regarding pTIPS in patients at high risk for rebleeding, less than 20% of eligible patients are treated. TIPS may also decrease the incidence of future decompensation in cirrhosis and increase survival in selected patients. In conclusion, TIPS is an essential treatment for patients with PH, but is often neglected. It is important for the hepatologist to form a multidisciplinary team, in which the role of the radiologist with experience in interventional procedures is prominent.

Optimal threshold of portal pressure gradient for patients with ascites after covered TIPS: a multicentre cohort study

BACKGROUND

Transjugular intrahepatic portosystemic shunt (TIPS) is recommended for treating recurrent and refractory ascites. However, determining the target portal pressure gradient (PPG) has been inconclusive. This multicentre cohort study explored the post-TIPS PPG potential range associated with improving survival.

METHODS

The study enrolled 276 patients, all of whom underwent covered TIPS for ascites treatment across four medical centers. The cumulative incidences of clinical outcomes were compared among groups categorized by potential PPG thresholds.

RESULTS

During the whole follow-up period with a medium follow-up of 21.6 (7.5, 41.6) months, 122 (44.2%) experienced liver-related death, and 73 (26.4%) patients experienced a recurrence of ascites. Multivariable analysis revealed PPG < 7 mmHg (p = 0.007) and the recurrence of ascites (p = 0.033) are independent risk factors for survival, while the PPG ≥ 11 mmHg was an independent risk factor for the recurrence of ascites (p = 0.012). Patients with ≥ 7 mmHg had a lower rate of liver-related death than patients with post-TIPS PPG < 7 mmHg (51.0% vs 66.6%, p = 0.004), while those with post-TIPS PPG ≥ 11 mmHg exhibited a higher cumulative incidence of ascites compared to those with post-TIPS PPG < 11 mmHg (44.6% vs 33.7%, p = 0.023). The robustness of the results was confirmed.

CONCLUSION

Our study highlighted the existence of an optimal post-TIPS PPG range in patients with recurrent and refractory ascites. Patients may experience improved survival and ascites control with a post-TIPS PPG of 7-11 mmHg.

Comparison of clinical outcomes in patients with refractory ascites treated with either TIPS, tunneled peritoneal catheter, or ascites pump

BACKGROUND

Refractory ascites (RA) remains a serious complication in patients with cirrhosis. Currently, the insertion of a TIPS is considered the standard of care in these patients. To achieve symptom control in those with TIPS contraindications, tunneled peritoneal catheters (PeCa) or ascites pumps were introduced. However, data comparing the available treatment options are scarce. This study aims to compare outcomes among patients with RA treated either with TIPS, PeCa, or ascites pump.

METHODS

All patients with RA and cirrhosis treated at Hannover Medical School between 2009 and 2023 were evaluated. Endpoints included mortality, acute kidney injury (AKI), hyponatremia, peritonitis, and rehospitalization rate. Propensity score matching was conducted to adjust for group differences.

RESULTS

First, 31 patients with ascites pump were compared to 62 patients with a PeCa after propensity score matching. There were no differences regarding mortality nor incidences of AKI, hyponatremia, or rehospitalization. However, incidences of peritonitis and explantation were lower in those with ascites pump (HR 0.32, 95% CI: 0.15-0.70, and HR 0.32, 95% CI: 0.14-0.71, respectively). Second, 35 ascites pump patients were matched with 70 individuals with TIPS. No differences regarding mortality or peritonitis incidence were observed. Ascites pump patients showed higher incidences of AKI (HR 4.55, 95% CI: 2.53-8.18) and hyponatremia (HR 4.13, 95% CI: 2.08-8.22). Last, 129 patients with TIPS were compared to 129 with PeCa. Mortality was comparable, while incidences of AKI (HR 5.01, 95% CI: 3.36-7.47), hyponatremia (HR 4.64, 95% CI: 3.03-7.12), and peritonitis (HR 2.19, 95% CI: 1.41-3.41) were higher in those with PeCa.

CONCLUSIONS

While ascites pump was associated with lower incidences of device infections and explantations, TIPS was associated with the lowest incidence of clinical complications in patients with RA.

Identification of optimal portal pressure decrease to control ascites while minimizing HE after TIPS: A multicenter study

BACKGROUND AND AIMS

Clinically significant portal hypertension in patients with liver cirrhosis can lead to refractory ascites. A TIPS treats clinically significant portal hypertension but may cause overt hepatic encephalopathy (oHE). Our aim was to determine the optimal reduction of the portal pressure gradient (PPG) through TIPS to control ascites without raising oHE risk.

APPROACH AND RESULTS

This multicenter study screened 1509 patients from 3 European centers (Hannover, Vienna, and Hamburg) undergoing TIPS implantation between 2000 and 2023. Patients with TIPS indications other than refractory ascites/hepatic hydrothorax, vascular liver disease, HCC, or insufficient PPG data were excluded. PPG was measured before and after TIPS insertion. Outcome data were assessed up to 1 year after TIPS insertion. Analyses were conducted utilizing a modern machine learning model, namely a competing-risk random survival forest, partial dependence plots, and competing risk analyses with liver transplantation/death as competitors. The cohort was divided into a 60% derivation and 40% validation cohort. Overall, 729 patients (median MELD: 13 [IQR 10-16], 66% male, 23% oHE before TIPS) were analyzed. The derivation cohort comprised 438 patients, and the validation cohort comprised 291 patients. The optimal PPG reduction, determined by maximally selected Gray statistic and PDP of the random survival forest, was 60%-80%. In this range, patients showed significantly fewer hepatic decompensations due to ascites (HDA) (subdistribution hazard ratio [sHR]: 0.7 [0.52-0.96]) with similar oHE incidences (sHR: 0.92 [0.67-1.27]). The PPG range was confirmed in the validation cohort (HDA: sHR: 0.66 [0.46-0.96]; oHE: sHR: 0.89 [0.61-1.32]).

CONCLUSIONS

A targeted PPG reduction of 60%-80% showed significantly reduced HDA without increased oHE risk. Therefore, PPG reduction within this range could be a valid reduction target.

Bayesian network-based survival prediction model for patients having undergone post-transjugular intrahepatic portosystemic shunt for portal hypertension

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.

Transjugular Intrahepatic Portosystemic Shunt: Devices Evolution, Technical Tips and Future Perspectives

Portal hypertension (PH) constitutes a pivotal factor in the progression of cirrhosis, giving rise to severe complications and a diminished survival rate. The transjugular intrahepatic portosystemic shunt (TIPS) procedure has undergone significant evolution, with advancements in stent technology assuming a central role in managing PH-related complications. This review aims to outline the progression of TIPS and emphasizes the significant influence of stent advancement on its effectiveness. Initially, the use of bare metal stents (BMSs) was limited due to frequent dysfunction. However, the advent of expanding polytetrafluoroethylene-covered stent grafts (ePTFE-SGs) heralded a transformative era, greatly enhancing patency rates. Further innovation culminated in the creation of ePTFE-SGs with controlled expansion, enabling precise adjustment of TIPS diameters. Comparative analyses demonstrated the superiority of ePTFE-SGs over BMSs, resulting in improved patency, fewer complications, and higher survival rates. Additional technical findings highlight the importance of central stent placement and adequate stent length, as well as the use of smaller calibers to reduce the risk of shunt-related complications. However, improving TIPS through technical means alone is inadequate for optimizing patient outcomes. An extensive understanding of hemodynamic, cardiac, and systemic factors is required to predict outcomes and tailor a personalized approach. Looking forward, the ongoing progress in SG technology, paired with the control of clinical factors that can impact outcomes, holds the promise of reshaping the management of PH-related complications in cirrhosis.