Liver stiffness measured by transient elastography as predictor of prognoses following portosystemic shunt occlusion

Non-variceal Extrahepatic Portosystemic Shunts: A Review of Pathogenesis, Diagnosis, and Treatment

Extrahepatic portosystemic shunts (EPS) are abnormal connections between the portal and systemic circulations. Acquired EPS occur most commonly in adults and are usually associated with portal hypertension due to cirrhosis. Acquired EPS cases can be further subdivided into two types: variceal (pre-existing) EPS and non-variceal EPS (NVEPS). Variceal EPS arise from originally small vessels with pre-existing dual portal and systemic drainage. Due to elevated portal pressure, these vessels dilate and undergo a reversal of flow, sending blood back to the systemic circulation. A much less common and, therefore, underappreciated subset of acquired EPS is NVEPS, which consists of aberrant connections that did not previously exist between the portal vein and large systemic vessels, usually in the presence of portal hypertension. Neoangiogenesis results in the development of abnormal anastomoses between the portal vein and other large veins, resulting in splenorenal, gastrorenal, portocaval, and mesocaval shunts. While not uncommon, they are frequently overlooked in the diagnosis and treatment of portal hypertension and can pose significant diagnostic and therapeutic challenges. Because the treatment of variceal EPS and NVEPS can differ markedly, it is important to correctly diagnose NVEPS and institute appropriate management. The aim of this article was to review acquired EPS, with particular attention to NVEPS, updating the pathogenesis, diagnosis, and treatment.

Coil or plug-assisted retrograde transvenous obliteration (CARTO/PARTO) for treating portal hypertensive variceal bleeding: A multicenter, real-world 10-year retrospective study

BACKGROUND AND AIMS

Coil-assisted retrograde transvenous obliteration (CARTO) and plug-assisted retrograde transvenous obliteration (PARTO) are well-accepted treatments for gastric variceal bleeding. However, long-term (>2 y) clinical outcomes have yet to be studied. In this study, we investigated long-term clinical outcomes, including overall survival (OS) in 10 years.

APPROACH AND RESULTS

We performed a multinational, multicenter, retrospective study of CARTO/PARTO in gastric varices treatments between May 2012 and July 2024. The primary study outcomes were a long-term OS and prognostic factors of CARTO/PARTO. The secondary outcomes were long-term clinical/technical success, complications, and clinical changes including portal hypertensive symptoms. A total of 311 patients (41% female; 69% CARTO) from 13 centers in 5 countries were included. The cumulative 1-, 3-, 5-, 7-, and 10-year OS rates were 98%, 80%, 68%, 52%, and 33%, respectively, with a median OS of 99 months. Prophylactic CARTO/PARTO showed a better OS than CARTO/PARTO for active bleeding ( p =0.00035). The independent prognostic factors of OS were having high pre-MELD, concurrent HCC, treating GOV2, history of esophageal variceal bleeding, high pre-TBili, and ammonia levels. Notably, a high pre-MELD score >27 had a significantly higher mortality rate (92.6%) than a lower pre-MELD score ( p <0.001). The overall cumulative 1-, 3-, 5-, 7-, and 10-year recurrent gastric varices bleeding rates were 0.9%, 3.2%, 4.0%, 4.5%, and 5.4%, respectively. The overall technical and clinical success rates were 96.5% and 95.3%, respectively, with a 4.5% major complication rate over 10 years.

CONCLUSIONS

CARTO and PARTO have excellent long-term survival and clinical outcomes. However, these are negatively affected by high MELD scores, concomitant HCC, and coexisting esophageal varices.

A model for predicting poor survival in patients with cirrhosis undergoing portosystemic shunt embolization

BACKGROUND AND AIM

Portosystemic shunt embolization (PSSE) is a promising treatment for hepatic encephalopathy (HEP) and gastric varix (GV) in cirrhotic patients with a spontaneous portosystemic shunt. However, PSSE may worsen portal hypertension causing hepatorenal syndrome, liver failure, and mortality. This study aimed to develop and validate a prognostic model that helps identify patients with a risk of poor short-term survival after PSSE.

METHODS

We included 188 patients who underwent PSSE for recurrent HEP or GV at a tertiary center in Korea. To develop a prediction model for 6-month survival after PSSE, Cox proportional-hazard model was used. The developed model was validated in a separate cohort of 184 patients from two other tertiary centers.

RESULTS

In multivariable analysis, the 1-year overall survival after PSSE was significantly associated with baseline levels of serum albumin, total bilirubin, and international normalized ratio (INR). We therefore developed the albumin-bilirubin-INR (ABI) score by assigning 1 point each for albumin < 3.0 g/dL, total bilirubin ≥ 1.5 mg/dL, and INR ≥ 1.5. Time-dependent areas under the curve of the ABI score for predicting 3-month and 6-month survival were 0.85 and 0.85 in the development cohort and 0.83 and 0.78 in the validation cohort, indicating good discrimination performance. The ABI score showed a better discrimination and calibration performance than the model for end-stage liver disease and the Child-Pugh scores, especially in high-risk patients.

CONCLUSIONS

The ABI score is a simple prognostic model that helps decide whether to proceed with PSSE for the prevention of HEP or GV bleeding in patients with spontaneous portosystemic shunt.

A combination of liver stiffness and international normalized ratio is an ideal prognostic predictor of portosystemic shunt occlusion in patients with portal hypertension

BACKGROUND

We previously reported liver stiffness (LS) as a prognostic predictor of portosystemic shunt (PSS) occlusion. This study aims to reinvestigate the predictive factors of the model for end-stage liver disease-sodium (MELD-Na) score amelioration following balloon-occluded retrograde transvenous obliteration (BRTO) and to evaluate the postoperative prognoses of patients with portal hypertension by using newly identified factors.

METHODS

Seventy-five patients who underwent BRTO between 2008 and 2021 were retrospectively enrolled. The MELD-Na scores were calculated preoperatively and one month postoperatively. We monitored long-term outcomes and analyzed postoperative survival.

RESULTS

At one month postoperatively, the MELD-Na score decreased in 46 (61.3%) patients. Univariate analyses revealed a significant association of the score amelioration with nine factors, including lower LS levels and a higher international normalized ratio (INR). A multivariate logistic regression analysis with receiver operating characteristic curve analyses identified preoperative LS levels and INR as significant independent predictors of the postoperative MELD-Na score amelioration, with optimal cutoffs of 28.1 kPa and 1.06, respectively. The combination of LS < 28.1 kPa and INR ≥ 1.06 showed a sensitivity and specificity of 84.8% and 75.9% for the prediction of the score amelioration, respectively. For the propensity score model, we matched 24 patients with similar age, sex, MELD-Na score, and concomitant hepatocellular carcinoma. Kaplan-Meier analysis determined significantly higher cumulative survival rates in patients with LS < 28.1 kPa and INR ≥ 1.06 than in other populations.

CONCLUSIONS

A combination of LS and INR can predict the MELD-Na score amelioration and prognosis improvement following PSS occlusion.

Identification of reversed portal flow on 4DCT and of factors contributing to reversed portal flow in patients with liver cirrhosis and portosystemic shunt before interventional radiology procedures

AIM

Patients with liver cirrhosis and portosystemic shunt occasionally develop reversed portal flow in the portal venous system. The factors contributing to reversed portal flow in these patients remain unclear. The aim of this study was to identify factors contributing to reversed portal flow in patients with portosystemic shunts based on four-dimensional computed tomography (4DCT), which visualized flow dynamics in the portal venous system.

METHODS

Data from 34 consecutive patients with portosystemic shunts who had undergone 4DCT before interventional radiology procedures were retrospectively investigated in this study. Uni- and multivariate analyses were performed to identify factors contributing to reversed portal flow.

RESULTS

Flow dynamics could be visualized on 4DCT in 32 of the 34 patients. Fifteen patients had forward portal flow; 17 had reversed portal flow. The main portal, splenic, and superior mesenteric veins displayed reversed portal flow in five, 12, and five vessels, respectively. Portosystemic shunt originating from splenic and superior mesenteric veins, worse albumin-bilirubin score, and small main portal vein diameter were significant factors contributing to reversed portal flow in both univariate (p = 0.049, p = 0.027, and p = 0.002) and multivariate (odds ratio [OR] 6.345, p = 0.012; OR 4.279, p = 0.039; and OR 5.516, p = 0.019) analyses.

CONCLUSIONS

The reversed portal flow was visualized on 4DCT. Portosystemic shunt originating distant to the liver, worse albumin-bilirubin score, and small diameter of the main portal vein were factors contributing to reversed flow in the portal venous system.

Hepatic venous pressure gradient after balloon-occluded retrograde transvenous obliteration and liver stiffness measurement predict the prognosis of patients with gastric varices

BACKGROUND

Balloon-occluded retrograde transvenous obliteration (BRTO) is a treatment option for patients with gastric varices (GVs). This study aimed to clarify the clinical significance of portal hypertension estimated by the hepatic venous pressure gradient (HVPG), subsequent exacerbation of esophageal varices (EVs), and prognosis of patients who underwent BRTO for GVs.

METHODS

Thirty-six patients with GVs treated with BRTO were enrolled in this study, and their HVPG was measured before (pre-HVPG) and on the day after BRTO (post-HVPG). After BRTO, patients were followed-up for a median interval of 24.5 (3-140) months. Clinical factors related to EVs exacerbation and prognosis after BRTO were retrospectively analyzed.

RESULTS

Post-HVPG increased compared to pre-HVPG in 21 out of 36 patients (58%), and post-HVPG was overall significantly higher compared to pre-HVPG (P = 0.009). During the observation period, 19 patients (53%) developed EVs exacerbation, and the cumulative EVs exacerbation rates at 1, 3 and 5 years after BRTO were 27%, 67%, and 73%, respectively. Pre-HVPG was not related to EVs exacerbation, although elevation of post-HVPG to ≥ 13 mmHg (P < 0.01) and high level of serum aspartate aminotransferase (P < 0.05) were significant independent risk factors for EVs exacerbation after BRTO. Fourteen patients (38.9%) died during the observation period. An elevated value of liver stiffness measurement (LSM) of ≥ 21 kPa was a significant independent risk factor for poor prognosis after BRTO (P < 0.05).

CONCLUSIONS

HVPG increases after BRTO. HVPG after BRTO has greater predictive ability for subsequent EVs exacerbation than HVPG before BRTO. LSM is a potential prognostic parameter in patients who undergo BRTO.

Drastic Improvement in Hepatitis B/C Virus-induced Decompensated Liver Cirrhosis Treated by Total Management Consisting of Interventional Radiology, Endoscopy, and Pharmacotherapy

Recent advances in antiviral therapy have enabled control of the hepatitis virus; however, these do not completely eliminate the pathological condition of liver disease, and portal hypertension remains a clinical problem. We herein report a case of hepatitis B virus/hepatitis C virus (HBV/HCV)-induced decompensated liver cirrhosis for which total management consisting of interventional radiology and endoscopy, based on the evidence of our clinical studies, followed by antiviral therapy for co-infection with HBV and HCV was successful. This case clearly indicates the effective timing of total management, suggesting that it prolongs the vital prognosis in addition to improving the hepatic function.

Liver and spleen stiffness on ultrasound elastography are predictors of the occurrence of esophagogastric varices after balloon-occluded retrograde transvenous obliteration

BACKGROUND

Balloon-occluded retrograde transvenous obliteration (BRTO) is an effective treatment for gastric varices, but predictors associated with overall survival rate (OS) and occurrence of esophagogastric varices (EGV) have not yet been clarified. In this study, we clarified these predictors by performing ultrasound elastography and blood tests at various time points.

METHODS

A total of 34 patients were enrolled. The primary endpoint was to identify predictors associated with OS and EGV occurrence by univariate and multivariate analyses. Secondary endpoints were to extract the cut-off values for OS and EGV occurrence, and to clarify chronological changes in liver stiffness (LS), spleen stiffness (SS), spleen index (SI), and portal vein flow volume (PVF). Time points were set as before BRTO (Bf), and 1 day (D1), 7 days (D7), 1 month (1M), 3 months (3M), and 6 months (6M) after BRTO.

RESULTS

Albumin-bilirubin score Bf, fibrin-4 index change 6M, and branched chain amino acids tyrosine molar ratio (BTR) 1M were predictors of OS on univariate analysis (P = .021, .033, and .019, respectively) but were not extracted by multivariate analysis. The factors of LS 6M > 19.9 kPa and SS D7 > 21.7 kPa were predictors of the occurrence of EGV on multivariate analysis (P = .029 and .025, respectively). PVF significantly increased with time after BRTO.

CONCLUSION

Albumin-bilirubin score and BTR had the possibility to associate with OS, and the predictors of reduced occurrence of EGV were LS < 19.9 and SS < 21.7.

Spontaneous portosystemic shunt embolization in liver transplant recipients with recurrent hepatic encephalopathy

INTRODUCTION AND OBJECTIVES

Spontaneous portosystemic shunts (SPSS) are a common cause of recurrent hepatic encephalopathy (HE). Shunt occlusion is an effective and safe procedure when performed in patients with cirrhosis and preserved liver function. We aimed to describe our experience with SPSS embolization after liver transplantation (LT).

PATIENTS

We identified five patients who underwent SPSS embolization after LT. Clinical, biochemical and technical procedure data were collected.

RESULTS

At presentation, all patients had developed graft cirrhosis and HE after LT. Median Model for End-stage Liver Disease (MELD) at embolization was 9 (range 7-12), median Child-Pugh was 8 (range 7-9). Splenorenal and mesocaval shunt were the most frequent types of SPSS found. Three patients have been completely free of HE. Of the two patients who had HE recurrence after embolization, one patient had two episodes of HE which was controlled well with medications. The other patient required three embolizations because of recurrent HE. Median follow-up was 4.4 years (range 1.0-5.0) and MELD score at last follow up was 13 (range 10-18) and median Child-Pugh score B, 7 points (range 5-12).

CONCLUSIONS

SPSS can be considered as a cause of HE after LT. SPSS embolization is feasible and safe in LT recipients.

Prognostic and recurrence factors after endoscopic injection sclerotherapy for esophageal varices: Multivariate analysis with the propensity score matching: Multivariate analysis with propensity score matching

BACKGROUND

Peri-esophageal collateral veins have been reported to be associated with the recurrence of esophageal varices (EVs). In this study, we retrospectively analyzed whether endoscopic ultrasonography (EUS) findings obtained just before endoscopic injection sclerotherapy (EIS) are associated with the success rate of intravariceal injection, recurrence rate of EVs, and overall survival rate (OS) of patients. Furthermore, we investigated the independent predictors associated with these factors by multivariate analysis.

METHODS

A total of 91 patients with risky EVs treated by EIS were analyzed. The primary endpoint was to identify independent predictors associated with the success rate of intravariceal injection, recurrence rate, and OS by multivariate analysis, to confirm the usefulness of EUS examination. The secondary endpoint was to clarify differences in recurrence rate and OS between patients who underwent additional argon plasma coagulation (APC) and those who did not, by the propensity score matching method.

RESULTS

Luminal diameter of EVs and F factor were predictors of the success rate of intravariceal injection. APC was predictor of OS and recurrence of EVs. EUS findings were not associated with these factors. Propensity score matching (APC, 23; without APC, 23) showed that recurrence rate was significantly improved in the APC group (P = 0.050) and that OS had the tendency to be higher in the APC group (P = 0.068).

CONCLUSION

Endoscopic ultrasonography findings before EIS were associated with successful intravariceal injection but were not associated with recurrence rate or OS. Additional APC could improve OS and reduce the recurrence of EVs.

The First Case of Coil Embolization for Left Gastric Vein Aneurysm with Liver Cirrhosis: A Case Report and Review of the Literature

We herein report the first case of interventional radiology for a left gastric vein aneurysm with a gastrorenal shunt. The etiology of the aneurysm was considered secondary to portal hypertension and liver cirrhosis due to hepatitis B virus infection. As the aneurysm was asymptomatic but had a tendency to expand, we successfully performed coil embolization for the aneurysm through a gastrorenal shunt.

Friend or Foe? Spontaneous Portosystemic Shunts in Cirrhosis-Current Understanding and Future Prospects

Portal hypertension (PHT) in cirrhosis results from increased resistance to splanchnic blood flow secondary to parenchymal and vascular changes within the liver. In an attempt to counteract the increased portal pressure, two mechanisms simultaneously occur: splanchnic vasodilatation and formation of spontaneous portosystemic shunts (SPSS). Long considered to be a compensatory mechanism to decompress the portal venous system, it is now well established that SPSS are not only inefficient in decreasing the portal pressure but also contribute to reduced hepatocyte perfusion and increased splanchnic blood flow and resistance, associated with worsening PHT. Recent studies have described a high prevalence of SPSS in cirrhosis patients, increasing with liver dysfunction, and observed an association between the presence of SPSS and worse clinical outcomes. In cirrhosis patients with preserved liver functions, the presence of SPSS independently increases the risk of hepatic encephalopathy, variceal bleeding, and ascites, and reduces transplant-free survival. Moreover, the presence of SPSS in patients undergoing transjugular intrahepatic portosystemic shunting and liver transplant has been shown to variably affect the postprocedural outcome. This article provides an overview of the current understanding of the role of SPSS in the natural history of liver cirrhosis and their status as a therapeutic target and an imaging biomarker to identify patients at higher risk of developing complications of PHT.

Viral elimination is essential for improving surgical outcomes of hepatitis C virus-related hepatocellular carcinoma: Multicenter retrospective analysis

AIM

The impact of sustained virologic response (SVR) on surgical outcomes for patients with hepatitis C virus (HCV)-related hepatocellular carcinoma (HCC) remains controversial. This study aimed to evaluate the influence of SVR on long-term surgical outcomes after hepatectomy.

METHODS

This multicenter study included 504 patients who underwent curative resection for HCV-related HCC. Patients with a history of HCC treatment, HBV infection, poor liver function, and tumor with major vascular invasion were excluded. Long-term surgical outcomes (overall survival [OS] and recurrence-free survival [RFS]) among patients who achieved SVR before hepatectomy (Pre-SVR group: 58 patients), after hepatectomy (Post-SVR group: 54 patients), and without SVR (Non-SVR group: 186 patients) were compared after adjusting for 13 confounding factors. Using the surgically resected specimens, comparison of the pathological changes in liver fibrosis between the first and second hepatectomy were analyzed.

RESULTS

Patients with SVR were younger, had better liver function, and less liver fibrosis compared to patients without SVR. Propensity score-matched OS and RFS were significantly better in Pre-SVR group than Non-SVR group (P = .029 and P = .009, respectively). Inverse probability-weighted OS and RFS were also significantly better in the Post-SVR group (P = .001 and P = .021, respectively) than in the Non-SVR group. Histopathological evaluation revealed that only the patients with SVR had regression of liver fibrosis (P < .05).

CONCLUSION

Achievement of SVR before or after hepatectomy is essential for improving long-term surgical outcomes in patients with HCV-related HCC.

Significant improvement in portal-systemic liver failure symptoms and successful management of portal-splenic venous hemodynamics by the combination of interventional radiology and pharmacotherapy

This study describes a case of hepatitis C virus-related decompensated cirrhosis with portal-systemic liver failure and refractory encephalopathy. It was successfully managed with a combination of interventional radiology and pharmacotherapy, to improve hepatic function, including hyperammonemia and to control portal-splenic venous hemodynamics with hepatic venous pressure gradient (HVPG) monitoring. A man in his late 50s presented with a Child-Pugh score of 13, Model for End-Stage Liver Disease-sodium (MELD-Na) score of 19 and blood ammonia level of 185 μg/dL. He underwent balloon-occluded retrograde transvenous obliteration (BRTO) followed by partial splenic embolization (PSE) and non-selective beta-blocker (NSBB) administration. BRTO induced drastic changes in the portal-splenic venous hemodynamics, resulting in dramatically improved hepatic function and reduced hyperammonemia. However, the procedure resulted in increased HVPG from 13.6 mmHg at baseline to 23.5 mmHg at 1-month post-BRTO, accompanied by ascites retention and development of portal hypertensive gastropathy. Thereafter, PSE was performed, followed by NSBB administration, to control the elevated portal venous pressure following BRTO. Postoperatively, the patient's ascites and portal hypertensive gastrophy improved after splenic artery embolization, which eventually disappeared after the additional administration of NSBBs 1 month later. The HVPG finally decreased to 16.9 mmHg; the Child-Pugh score, MELD-Na score and blood ammonia level improved to 7, 11 and 22 μg/dL, respectively, after all therapies. BRTO significantly improved the symptoms of portal-systemic liver failure with refractory encephalopathy. PSE and NSBB administration could contribute to additional amelioration of hepatic function and successful management of complications induced by portal hemodynamic changes following BRTO.

Spontaneous portosystemic shunts in liver cirrhosis: new approaches to an old problem

Portal hypertension is the main consequence of liver cirrhosis, leading to severe complications such as variceal hemorrhage, ascites or hepatic encephalopathy. As an attempt to decompress the portal venous system, portal flow is derived into the systemic venous system through spontaneous portosystemic shunts (SPSSs), bypassing the liver. In this review, we aim to provide an overview of the published reports in relation to the prevalence and physiopathology behind the appearance of SPSS in liver cirrhosis, as well as the complications derived from its formation and its management. The role of SPSS embolization is specifically discussed, as SPSSs have been assessed as a therapeutic target, mainly for patients with recurrent/persistent hepatic encephalopathy and preserved liver function. Furthermore, different aspects of the role of SPSS in liver transplantation, as well as in candidates for transjugular intrahepatic portosystemic shunt are reviewed. In these settings, SPSS occlusion has been proposed to minimize possible deleterious effects, but results are so far inconclusive.

Transcatheter Embolization of Renal-Splenic Shunt to Treat Hematemesis

Although sequelae of chronic liver disease are the most common causes of altered pressure dynamics in the portal and splanchnic circulations, there are other mechanisms resulting in increased venous pressures with subsequent development of splenic and gastric varices. We report a case of a patient without portal hypertension, but with bleeding gastric varices with a presumed splenorenal shunt (SRS) on CT. Venography revealed flow reversal through the shunt (directed from the renal vein, into the splenic vein and out the portal vein; a renal-splent shunt (RSR)) and thus an anatomically similar but functionally distinct systemic to mesenteric variant. While being anatomically similar to the well-known SRS, the different flow dynamics necessitate a different approach for treatment and important considerations for the use of any liquid embolic.

Improved Hepatic Reserve and Fibrosis in a Case of "Portal-Systemic Liver Failure" by Portosystemic Shunt Occlusion

Patient: Female, 67-year-old

Final Diagnosis: Portal-systemic liver failure

Symptoms: None (second opinion)

Medication: None

Clinical Procedure: Balloon-occluded retrograde transvenous obliteration (BRTO) Specialty: Radiology