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

Interventional embolisation for patients with cirrhosis and recurrent or persistent hepatic encephalopathy related to spontaneous portosystemic shunts: protocol for a prospective, non-randomised controlled study

INTRODUCTION

The presence of spontaneous portosystemic shunts (SPSS) has been identified to be associated with hepatic encephalopathy (HE) in patients with cirrhosis. Nevertheless, the role of interventional embolisation in managing such patients remains poorly defined. Consequently, this prospective controlled study aims to assess the efficacy and safety of interventional embolisation as a therapeutic approach for patients with cirrhosis and recurrent or persistent HE related to SPSS.

METHODS AND ANALYSIS

Cirrhotic patients diagnosed with recurrent or persistent HE associated with SPSS will be recruited for this study, and assigned to either the interventional embolisation group or the standard medical treatment group. The efficacy endpoints encompass the evaluation of postoperative alleviation of HE symptoms and the incidence of overt HE recurrence during the follow-up period, as well as the duration and frequency of hospitalisations for HE, alterations in liver function and volume, and overall survival. The safety endpoints encompass both immediate and long-term postoperative complications.

ETHICS AND DISSEMINATION

This study will be conducted in strict adherence to the principles of good clinical practice and the guidelines outlined in the Declaration of Helsinki. Ethical approval for the trial has been obtained from the Ethics Committee of Mengchao Hepatobiliary Hospital of Fujian Medical University (2023_013_02). Written informed consent will be obtained from all the participants by the treating physician for each patient prior to their enrolment. The documented informed consent forms will be retained as part of the clinical trial records for future reference. The study findings will be disseminated through publication in peer-reviewed journals and will be presented at international conferences.

TRIAL REGISTRATION NUMBER

ChiCTR2300072189.

Evolution of spontaneous portosystemic shunts over time and following aetiological intervention in patients with cirrhosis

Background & Aims

Spontaneous portosystemic shunts (SPSS) develop frequently in cirrhosis. Changes over time and the effect of aetiological interventions on SPSS are unknown, so we aimed to explore the effect of these variables on SPSS evolution.

Methods

Patients with cirrhosis from the Baveno VI-SPSS cohort were selected provided a follow-up abdominal CT or MRI scan was available. Clinical and laboratory data were collected at baseline and follow-up. Imaging tests were reviewed to evaluate changes in the presence and size of SPSS (large (L)-SPSS was ≥8 mm) over time. Regarding alcohol- or HCV-related cirrhosis, two populations were defined: cured patients (abstinent from alcohol or successful HCV therapy), and non-cured patients.

Results

A total of 617 patients were included. At baseline SPSS distribution was 22% L-SPSS, 30% small (S)-SPSS, and 48% without (W)-SPSS. During follow-up (median follow-up of 63 months), SPSS distribution worsened: L-SPSS 26%, S-SPSS 32%, and W-SPSS 42% (p <0.001). Patients with worse liver function during follow-up showed a simultaneous aggravation in SPSS distribution. Non-cured patients (n = 191) experienced a significant worsening in liver function, more episodes of liver decompensation and lower transplant-free survival compared to cured patients (n = 191). However, no differences were observed regarding SPSS distribution at inclusion and at follow-up, with both groups showing a trend to worsening. Total shunt diameter increased more in non-cured (52%) than in cured patients (28%). However, total shunt area (TSA) significantly increased only in non-cured patients (74 to 122 mm2, p <0.001).

Conclusions

The presence of SPSS in cirrhosis increases over time and parallels liver function deterioration. Aetiological intervention in these patients reduces liver-related complications, but SPSS persist although progression is decreased.

Impact and implications

There is no information regarding the evolution of spontaneous portosystemic shunts (SPSS) during the course of cirrhosis, and especially after disease regression with aetiological interventions, such as HCV treatment with direct-acting antivirals or alcohol abstinence. These results are relevant for clinicians dealing with patients with cirrhosis and portal hypertension because they have important implications for the management of cirrhosis with SPSS after disease regression. From a practical point of view, physicians should be aware that in advanced cirrhosis with portal hypertension, after aetiological intervention, SPSS mostly persist despite liver function improvement, and complications related to SPSS may still develop.

Repeated rough coiling technique of portosystemic shunt: A novel treatment for hepatic encephalopathy

Hepatic encephalopathy (HE) usually occurs in the end stages of cirrhosis. During these stages, portosystemic shunt (PSS) is one cause of severe HE. Previous reports have demonstrated that shunt embolization is effective in cases involving a large PSS. However, embolization is risky in some patients because severe ascites and esophageal varices may result from aggravation of portal hypertension. Herein, we report a case in which intentional flow reduction was repeatedly performed for spleno-renal shunt using 2 flow reduction methods, debranching and the rough coiling technique, for a patient with severe HE for whom embolization of the whole PSS pathway was risky. Complete embolization was finally achieved by repeated flow reduction over 5 sessions. The patient tolerated treatment well with no ascites for 4 years after total embolization. If embolization of the whole PSS puts the patient at risk for refractory HE, repeatable flow reduction might provide a good alternative path to single-step embolization.

Prevalence, clinical characteristics, and outcomes of spontaneous portosystemic shunt in patients with hepatitis B-related cirrhosis: A multicenter study from China

BACKGROUND

The impact of spontaneous portosystemic shunt (SPSS) on decompensated events and mortality for patients with hepatitis B-related cirrhosis remains poorly investigated.

AIMS

To evaluate the prevalence, clinical characteristics, and outcomes of SPSS among patients with hepatitis B-related cirrhosis.

METHODS

Patients who were diagnosed with hepatitis B-related cirrhosis were retrospectively recruited. All eligible patients were classified into SPSS and non-SPSS groups and their clinical characteristics and outcomes were compared and analyzed.

RESULTS

Of the 1282 patients included in this study, SPSS was identified in 488 patients (38.1%). SPSS group had more severe liver function impairment, higher prevalence and severity of esophageal and gastric varices (EGV), and a higher prevalence of EGV bleeding (EGVB), portal vein thrombosis (PVT), hepatic encephalopathy (HE), ascites, and hepatocellular carcinoma (HCC, all P<0.05). During the follow-up period, SPSS group experienced a significantly higher incidence of EGVB, PVT, and HE (all P<0.05); however, there was no significant difference in the incidence of ascites, HCC, and mortality between the two groups (all P>0.05).

CONCLUSION

With hepatitis B-related cirrhosis, SPSS was common and characterized by severe liver damage and a high prevalence of decompensated events. Moreover, patients with SPSS had higher risks of EGVB, PVT, and HE.

Urine-based Detection of Congenital Portosystemic Shunt in C57BL/6 Mice

Sporadic occurrence of congenital portosystemic shunt (PSS) at a rate of ∼1 out of 10 among C57BL/6 J mice, which are widely used in biomedical research, results in aberrancies in serologic, metabolic, and physiologic parameters. Therefore, mice with PSS should be identified as outliers in research. Accordingly, we sought methods to, reliably and efficiently, identify PSS mice. Serum total bile acids ≥ 40 µm is a bona fide biomarker of PSS in mice but utility of this biomarker is limited by its cost and invasiveness, particularly if large numbers of mice are to be screened. This led us to investigate if assay of urine might serve as a simple, inexpensive, noninvasive means of PSS diagnosis. Metabolome profiling uncovered that Krebs cycle intermediates, that is, citrate, α-ketoglutarate, and fumarate, were strikingly and distinctly elevated in the urine of PSS mice. We leveraged the iron-chelating and pH-lowering properties of such metabolites as the basis for 3 urine-based PSS screening tests: urinary iron-chelation assay, pH strip test, and phenol red assay. Our findings demonstrate the feasibility of using these colorimetric assays, whereby their readout can be assessed by direct observation, to diagnose PSS in an inexpensive, rapid, and noninvasive manner. Application of our urinary PSS screening protocols can aid biomedical research by enabling stratification of PSS mice, which, at present, likely confound numerous ongoing studies.

Spontaneous portosystemic shunts outside the esophago-gastric region: Prevalence, clinical characteristics, and impact on mortality in cirrhotic patients: A systematic review and meta-analysis

BACKGROUND

Spontaneous portosystemic shunt (SPSS) other than esophago-gastric varices is one of the consequences of cirrhosis-induced portal hypertension (PHT), but its role is not fully understood. Therefore, we conducted a systematic review and meta-analysis to determine the prevalence and clinical characteristics of SPSS (excluding esophago-gastric varices) and its impact on mortality in patients with cirrhosis.

METHODS

Eligible studies were identified from MedLine, PubMed, Embase, Web of Science, and Cochrane Library between Jan 1, 1980 and Sep 30, 2022. Outcome indicators were SPSS prevalence, liver function, decompensated events, and overall survival (OS).

RESULTS

Totally, 2015 studies were reviewed, of which 19 studies recruiting 6884 patients were included. On pooled analysis, the prevalence of SPSS was 34.2% (26.6%∼42.1%). SPSS patients had significantly higher Child-Pugh scores and grades and Model for End-stage Liver Disease scores (all P<0.05). Moreover, SPSS patients experienced a higher incidence of decompensated events, including hepatic encephalopathy, portal vein thrombosis, and hepatorenal syndrome (all P<0.05). Additionally, SPSS patients had significantly shorter OS than the non-SPSS group (P<0.05).

CONCLUSIONS

In patients with cirrhosis, SPSS outside the esophago-gastric region is common, characterized by severe impairment of liver function, high rates of decompensated events, including HE, PVT, and hepatorenal syndrome, as well as a high mortality rate.

Treatment of refractory hepatic encephalopathy induced by spontaneous portosystemic shunt: Selective splenic vein embolization versus shunt embolization

BACKGROUND AND AIMS

Spontaneous portosystemic shunt (SPSS) can cause refractory hepatic encephalopathy (HE) in cirrhotic patients. The embolization of the shunt (ES) can resolve the HE, while the selective embolization of the splenic vein (SESV) can treat splenorenal shunts related HE. The aim of this study was to compare the clinical outcomes of ES and SESV when applied for the treatment of SPSS-induced refractory HE in cirrhotic patients.

METHODS

Patients with refractory HE who were treated with ES or SESV were retrospectively identified. The clinical outcomes were compared and analyzed.

RESULTS

The 6-month mortality after the ES procedure was significantly higher than that after the SESV procedure. During the 6-month follow-up, both the white blood cell and the platelet counts were significantly lower after the ES procedure than after the SESV procedure. There was a significant increase in aspartate aminotransferase levels after ES. However, the albumin levels as well as the Child-Pugh score and grade were found to be significantly improved at 6 months after the undertaking of an SESV (as compared with baseline).

CONCLUSION

The 6-month mortality was improved after SESV (as compared with ES) in the treatment of SPSS-induced refractory HE. A prospective multicenter study for validation is warranted.

Esophageal and stomach varices: physiological and anatomical features of formation

Esophageal and stomach varices: physiological and anatomical features of formation

Enterohepatic Shunt-Driven Cholemia Predisposes to Liver Cancer

BACKGROUND & AIMS

Pathogenesis of hepatocellular carcinoma (HCC), which kills millions annually, is poorly understood. Identification of risk factors and modifiable determinants and mechanistic understanding of how they impact HCC are urgently needed.

METHODS

We sought early prognostic indicators of HCC in C57BL/6 mice, which we found were prone to developing this disease when fed a fermentable fiber-enriched diet. Such markers were used to phenotype and interrogate stages of HCC development. Their human relevance was tested using serum collected prospectively from an HCC/case-control cohort.

RESULTS

HCC proneness in mice was dictated by the presence of congenitally present portosystemic shunt (PSS), which resulted in markedly elevated serum bile acids (BAs). Approximately 10% of mice from various sources exhibited PSS/cholemia, but lacked an overt phenotype when fed standard chow. However, PSS/cholemic mice fed compositionally defined diets, developed BA- and cyclooxygenase-dependent liver injury, which was exacerbated and uniformly progressed to HCC when diets were enriched with the fermentable fiber inulin. Such progression to cholestatic HCC associated with exacerbated cholemia and an immunosuppressive milieu, both of which were required in that HCC was prevented by impeding BA biosynthesis or neutralizing interleukin-10 or programmed death protein 1. Analysis of human sera revealed that elevated BA was associated with future development of HCC.

CONCLUSIONS

PSS is relatively common in C57BL/6 mice and causes silent cholemia, which predisposes to liver injury and HCC, particularly when fed a fermentable fiber-enriched diet. Incidence of silent PSS/cholemia in humans awaits investigation. Regardless, measuring serum BA may aid HCC risk assessment, potentially alerting select individuals to consider dietary or BA interventions.

Closing spontaneous portosystemic shunts in cirrhosis: Does it make sense? Does it work? What does it take?

Spontaneous portosystemic shunts (SPSS) are an often neglected cause of hepatic encephalopathy associated with cirrhosis. Nowadays, SPSS are considered as radiological biomarkers of clinically significant portal hypertension rather than the previous dogmatic perceived decompressive vessels. SPSS are not rare as they can be diagnosed in over 60% of the patients with cirrhosis by mere contrast-enhanced CT. Moreover, they are clinically relevant since they impact on all portal hypertensive related complications, in particular medically refractory HE, and represent an independent predictor of decompensation and mortality in cirrhosis, irrespective of the type of SPSS. Taken together, these elements warrant strategies to target these shunts directly which is currently is achieved via interventional radiology embolization. In this review, we discuss why it makes sense to tackle SPSS, how to do it and what it takes to do it right based on aggregated literature.

Splenic vein embolization as a feasible treatment for patients with hepatic encephalopathy related to large spontaneous splenorenal shunts

INTRODUCTION AND OBJECTIVES

Although splenic vein embolization (SVE) has been performed for the management of patients with hepatic encephalopathy (HE) related to large spontaneous splenorenal shunts (SSRS) in recent years, its role remains poorly defined. In this study, we aimed to explore the safety and efficacy of SVE for HE patients with large SSRS.

MATERIALS AND METHODS

Data from cirrhotic patients who were confirmed to have recurrent or persistent HE related to large SSRS and underwent SVE from January 2017 to April 2021 were retrospectively collected and analyzed at our center. The primary endpoints were the change of HE severity at 1 week after embolization and the recurrence of HE during the follow-up period. The secondary endpoints were procedure-related complications and changes in laboratory indicators and hepatic function (Child-Pugh score/grade and model for end-stage liver disease score).

RESULTS

Of the eight cirrhotic patients included in the study, six were diagnosed with recurrent HE, and the others were diagnosed with persistent HE. Embolization success was achieved for all patients (100%), and no immediate procedure-related complications, de novo occurrence, or aggravation of symptoms related to portal hypertension were observed during the long-term follow-up. HE status was assessed at 1 week after embolization. The results demonstrated that the symptoms were mitigated in three patients and resolved completely in five patients. During the follow-up period, all patients were free of HE within 1 month after embolization, but one patient experienced the recurrence of HE within 6 months and another one experienced the recurrence of HE within 1 year. Compared with the preoperative parameters, the Child-Pugh score and grade were significantly improved at 1 week and 1 month after embolization (all P<0.05), and the serum ammonia level was significantly lower at 1 month after embolization (P<0.05).

CONCLUSIONS

SVE could be considered as a feasible treatment for patients with HE related to large SSRS, but further validation is required.

Concurrent large spontaneous portosystemic shunt embolization for the prevention of overt hepatic encephalopathy after TIPS: A randomized controlled trial

BACKGROUND AND AIMS

Large spontaneous portosystemic shunt (SPSS) is associated with increased risk of HE in patients undergoing transjugular intrahepatic portosystemic shunt (TIPS). This study aimed to evaluate whether prophylactic embolization of large SPSS at the time of TIPS creation could reduce the incidence of post-TIPS HE in patients with cirrhosis and variceal bleeding.

APPROACH AND RESULTS

From June 2014 to August 2017, 56 patients with cirrhosis and large SPSS planning to undergo TIPS for the prevention of variceal bleeding were randomly assigned (1:1) to receive TIPS alone (TIPS group, n = 29) or TIPS plus simultaneous SPSS embolization (TIPS+E group, n = 27). The primary endpoint was overt HE. TIPS placement and SPSS embolization was successful in all patients. During a median follow-up of 24 months, the primary endpoint was met in 15 patients (51.7%) in the TIPS group and six patients (22.2%) in the TIPS+E group (p = 0.045). The 2-year cumulative incidence of overt HE was significantly lower in the TIPS+E group compared with the TIPS group (21.2% vs. 48.3%; HR, 0.38; 95% CI, 0.15-0.97; p = 0.043). The 2-year incidence of recurrent bleeding (TIPS+E vs. TIPS, 15.4% vs. 25.1%; p = 0.522), shunt dysfunction (12.3% vs. 18.6%, p = 0.593), death (15.0% vs. 6.9%, p = 0.352), and other adverse events was not significantly different between the two groups.

CONCLUSIONS

In patients with cirrhosis treated with TIPS for variceal bleeding, concurrent large SPSS embolization reduced the risk for overt HE without increasing other complications. Concurrent large SPSS embolization should therefore be considered for prophylaxis of post-TIPS HE.

Filter-Assisted Shunt Embolization of Large Portosystemic Shunts: Technical Feasibility, Safety, and Outcomes

PURPOSE

To describe the feasibility and outcomes of filter-assisted shunt embolization in patients with acquired large portosystemic shunts.

METHODS

Two-center HIPAA compliant retrospective study of all patients who underwent filter-assisted shunt embolization between 03/2015-03/2021. Initial clinical evaluation, including demographic information, shunt sizing, and procedural details, was reviewed. Technical success was defined as successful occlusion of the targeted shunt.

RESULTS

Eight patients (55 ± 10 years/88% male) had a large acquired portosystemic shunt which was suitable for filter-assisted shunt embolization. Indications for the procedure: 3 = pre-transplantation optimization, 2 = overt hepatic encephalopathy (HE), 1 = post-transplant thrombosis, 1 = portal vein thrombosis and encephalopathy, 1 = encephalopathy and variceal bleeding. Portosystemic shunts occurred between splenic and renal veins, inferior mesenteric and gonadal veins, and coronary veins. Mean shunt diameter was 27 ± 5 mm. The technical success of the procedure was 8/8 (100%). In 7 patients, a transjugular intrahepatic portosystemic shunt (TIPS) was also placed at the time of the shunt embolization due to either pre-transplant indication or sluggish portal flow. There were no intraprocedural complications from filter placement.

OUTCOMES

3 = currently listed for transplant, 2 = resolution of HE, 1 = made CMO, 1 patient with patent post-transplant vasculature. 1 = died as a complication related to TIPS placement (SIR Class F Complication).

CONCLUSION

Filter-assisted shunt embolization is a technically feasible and safe technique to reduce or embolize large portosystemic shunts.

Management of spontaneous portosystemic shunts at the time of liver transplantation: treatment or observation? Results of a systematic review

BACKGROUND

Optimal treatment of spontaneous portosystemic shunts (SPSS) during liver transplantation (LT) remains debated. We systematically reviewed the literature on definitions, treatment and outcomes of patients presenting SPSS undergoing LT.

METHODS

According to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, we used PubMed to retrieve all studies dealing with SPSS and LT between January 1987 and January 2020. The primary endpoints were definitions and outcomes according to the management of SPSS (treatment vs observation).

RESULTS

Thirteen studies detailing the management of 962 SPSS were retrieved. Hemodynamically significant SPSS were defined as those having diameter ≥ 10 mm in 41% (n = 395) of patients. SPSS were splenorenal (42%), cavo-gastric (15.2%), umbilical (7.4%), mesenterico-caval (n = 31; 3.2%), mesenterico-renal (0.1%) and unreported (31.9%), respectively. At the time of LT 372 shunts (38.7%) were treated while 590 were observed (61.3%). During a follow-up time ranging from 4 months to 5 years, the reported overall survival (OS) at 1 year was not significantly different except for one study. Portal vein anastomosis complications (i.e. reduced flow, stenosis or thrombosis) were similarly reported in observed [n = 26 (4%)] and ligated SPSS [n = 10 (2%)] (p = 0.22) but the rate of relaparotomy was significantly higher in observed SPPS (16 vs 2; p = 0.01) to rescue post LT portal vein thrombosis (n = 6) and reduced portal flow and graft dysfunction (n = 10).

CONCLUSIONS

There was a heterogeneous management of SPSS during LT in the literature. Ligation of SPPS did not reduce vascular complications neither improved survival. A randomized prospective study might contribute to identify best management of SPSS at time of LT.

Hepatic Encephalopathy: Current and Emerging Treatment Modalities

Hepatic encephalopathy (HE) is a potentially reversible neurocognitive complication of cirrhosis. It has been reported in at least 30% of patients with cirrhosis and imposes a significant economic burden on caregivers and the healthcare system. Ammonia has been recognized as the culprit in HE development, and all the currently approved treatments mostly act on this toxin to help with HE resolution. After a brief overview of HE characteristics and pathophysiology, this review explores the current accepted treatments for this debilitating complication of cirrhosis. This is followed by an overview of the novel available therapies and a brief focus on future treatment modalities for HE.

Computed Tomography Images of Spontaneous Portosystemic Shunt in Liver Cirrhosis

Spontaneous portosystemic shunt (SPSS) refers to collateral vessels that communicate between the portal vein system and systemic circulation. SPSS mainly includes esophageal varices, gastric varices, left gastric vein, recanalized paraumbilical vein, abdominal wall varices, and spontaneous splenorenal shunt. SPSS contributes to the development of hepatic encephalopathy caused by portal vein inflow bypassing and carries a higher risk of death in liver cirrhosis. Abdominal contrast-enhanced computed tomography is a major imaging approach to establish a diagnosis of SPSS and evaluate its location and feature. This review primarily describes the main contrast-enhanced CT features of SPSS in liver cirrhosis.

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.

Spontaneous portosystemic shunt diameter predicts liver function after balloon‐occluded retrograde transvenous obliteration

Background and Aim

Recently, balloon‐occluded retrograde transvenous obliteration (BRTO), performed for spontaneous portosystemic shunts (SPSS), has been receiving attention as a measure to improve liver function in cirrhotic patients with portal hypertension. However, it is unclear whether SPSS diameter is associated with changes in hepatic venous pressure gradient (HVPG) and liver function after BRTO.

Methods

In 34 cirrhotic patients receiving BRTO for hepatic encephalopathy/gastric varices, the association of SPSS diameter with liver function at baseline and 6 months after BRTO and the accompanying changes in HVPG were investigated.

Results

Patients had Child–Pugh (CP) scores of A/B/C (7/19/8), SPSS diameters of ≤10 mm/11–20 mm/<20 mm (8/21/5), and an average observation period of 3.2 (0.3–8.5) years. SPSS diameter was significantly associated with male sex, alcohol use, and values of albumin, prothrombin time (PT%), and NH₃ at baseline. Moreover, the SPSS diameter was significantly correlated with the changes in HVPG observed upon BRTO (r = 0.55, P = 0.005), and a large shunt diameter was significantly associated with a greater increase in HVPG. At 6 months, significant improvements in albumin, PT%, bilirubin, and NH₃ were observed overall, but the improvement was marked in those with larger shunt diameters if they had CP A/B.

Conclusion

SPSS diameter was strongly associated with liver function at baseline and after BRTO and also with changes in HVPG, indicating that SPSS diameter is an important predictor of BRTO outcome.

Size and location of spontaneous portosystemic shunts predict the risk of decompensation in cirrhotic patients

BACKGROUND

The prognostic role of spontaneous portosystemic shunts (SPSS) has been poorly investigated.

AIMS

To evaluate the impact of the presence of SPSS, as well as their characteristics, on the risk of decompensation.

METHODS

This is a retrospective cohort study of 235 advanced chronic liver disease (ACLD) patients with available imaging examination, transient elastography, and upper endoscopy. ACLD was defined as liver stiffness measurement (LSM) >10 kPa. Competitive risk analyses were performed to identify the factors associated with the main outcome.

RESULTS

SPSS were reported in 141 (60%) of the patients. Non-viral etiology was independently associated with SPSS presence [Odds-Ratio (OR): 2.743;95%-Interval-of-Confidence (IC):1.129-6.664]. During a follow-up of 37 (20-63) months, SPSS were found predictors of any decompensation type [Subhazard Ratio (SHR):2.264; 95%-IC:1.259-4.071], independently from a history of decompensation or high-risk-varices presence. The risk of complications was higher in patients with large (SHR: 3.775; 95%-IC: 2.016-7.070) and multiple (SHR:3.832; 95%-IC: 2.004-7.330) shunts, and in those with gastrorenal shunts (SHR:2.636; 95%-IC:1.521-4.569).

CONCLUSIONS

The presence, size, and number of SPSS predict not only the risk of hepatic encephalopathy but that of any type of decompensation across all stages of cirrhosis. Future studies should explore the possibility of treating shunts to prevent decompensation.

Validation of a standardized CT protocol for the evaluation of varices and porto-systemic shunts in cirrhotic patients

PURPOSE

The aim of the present study was to propose and validate a standardized CT protocol for evaluating all the types of portosystemic collaterals (P-SC), including gastroesophageal varices and spontaneous portosystemic shunts (SPSS), and to evaluate the prognostic role of portal hypertension CT features for the prediction of the hepatic decompensation risk in cirrhotic patients.

METHODS

A retrospective cohort study of 184 advanced chronic liver disease who underwent CT scan between January 2014 and December 2017. Patients with an interval > 6 months between the imaging, elastometric, endoscopic and biochemical evaluation were excluded, as well as patients with previous transjugular intrahepatic portosystemic shunt (TIPS), liver transplantation (LT) or terminal medical conditions. Data on liver disease history, co-morbidities, endoscopic and radiologic findings were collected. The incidence of hepatic decompensation and other events, such as portal vein thrombosis, HCC, TIPS placement, LT, death, and its cause, were also recorded. The procedure was performed at baseline and after the administration of contrast agent using a multiphasic technique and bolus tracking. Two senior radiologists working in different centres and a non-expert radiologist reviewed all CT examinations, to evaluate both intra-observer and inter-observer variability of the CT protocol and to obtain an external validation. The radiological variables were evaluated using both univariate and adjusted multivariate competing risk regression models.

RESULTS

Both intra-observer and inter-observer agreement were excellent in detection and measurement of almost all types of P-SC. The presence of SPSS, a spleen diameter > 16 cm, a portal vein diameter > 17 mm and the presence of ascites resulted independent predictors of decompensation-free survival for cirrhotic patients and were incorporated in an easy-to-use score (AUROC = 0.799, p-value = 0.732) which can the risk of decompensation at 5 years, ranking it as low (11.3%), moderate (35.6%) or high (70.8%).

CONCLUSIONS

The CT protocol commonly performed during the HCC surveillance program for cirrhotic patients is valid for detecting all types of P-SC. The radiological score identified to predict the decompensation-free survival for cirrhotic patients could be an easy-to-use clinical tool.

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.

Successful control of portal hypertension-related complications after two embolization procedures for multiple and large spontaneous portosystemic shunts in a patient with liver cirrhosis

Liver cirrhosis is frequently complicated by spontaneous portosystemic shunt (SPSS) due to portal hypertension. Shunt embolization is considered when symptoms related to SPSSs are refractory to endoscopic and/or medical therapies. However, little information is available on the treatment of patients with multiple and large SPSS. We report a successfully managed case in which patient with such SPSS received two embolization procedures within 6 months. A 57-year-old man with alcoholic liver cirrhosis was transferred to our hospital due to a ruptured gastric varix. CT examination showed gastrorenal and splenorenal shunts of 8 mm and 11 mm in diameter, respectively. In addition, multiple hepatocellular carcinomas (HCCs) were noted. First, balloon-occluded retrograde transvenous obliteration (BRTO) was performed for the gastrorenal shunt, resulting in the disappearance of the varix, followed by transcatheter arterial chemoembolization (TACE) for HCCs. However, the hepatic encephalopathy worsened after the BRTO and TACE, and the splenorenal shunt enlarged to 18 mm in diameter. Although the shunt was tortuous and had another drainage vein, we completed the embolization for the shunt using metallic coils without any events. The patient's hepatic encephalopathy and hepatic function were ameliorated after embolization for the splenorenal shunt, and the patient was free from hepatic encephalopathy.

Prevention of variceal rebleeding in cirrhotic patients with spontaneous portosystemic shunts: transjugular intrahepatic portosystemic shunt versus endoscopic treatment

BACKGROUND

Spontaneous portosystemic shunts(SPSSs) in cirrhotic patients indicate higher incidence of gastric varices, which increases the risk for bleeding and death. However, few studies compared endoscopic therapy with transjugular intrahepatic portosystemic shunt (TIPS) in preventing variceal rebleeding in cirrhotic patients with SPSSs. This research aims to evaluate the effectiveness of the two methods in this group of patients.

METHODS

We reviewed consecutive cirrhotic patients with SPSSs who underwent either TIPS or endoscopic treatment to prevent variceal rebleeding between January 2015 and December 2018 in our institution. Outcomes including rebleeding, overt hepatic encephalopathy (OHE), complications and survival were compared. Meanwhile, subgroup analyses were conducted to screen relevant factors affecting the results.

RESULTS

A total of 97 patients were included in the study. The TIPS arm contained 50 patients and the endoscopy arm contained 47 patients. Rebleeding rate in TIPS group was statistically lower than endoscopic group [16.0 vs 38.3%, hazard ratio (HR) = 0.37, 95% confidence interval (CI): 0.16-0.84, P = 0.01], while OHE was more frequent (16.0 vs 2.1%, HR = 7.59, 95% CI: 0.94-61.2, P = 0.025), the survival rate (92 vs 89.4%, HR = 0.88, 95% CI: 0.22-3.60, P = 0.87) and frequency of complications were comparable between two groups. In the subgroups of GOV2/IGV1 and splenorenal shunt/gastrorenal shunt, compared with endoscopic treatments, TIPS reduced the rate of rebleeding without significantly increasing overt hepatic encephalopathy; however, it did not improve survival rate.

CONCLUSIONS

For cirrhotic patients with SPSSs, TIPS brought a lower rebleeding rate but a higher incidence of OHE. However, in the subgroups of GOV2/IGV1 and splenorenal shunt/gastrorenal shunt, TIPS was considered more reasonable due to the lower rebleeding rate and comparable OHE incidence.

Transportal Technetium-99m Labeled Macroaggregated Albumin Scintigraphy to Quantify Occult Intrahepatic Microvascular Portosystemic Shunting

Nodular regenerative hyperplasia (NRH) of the liver may lead to noncirrhotic portal hypertension with subsequent development of portosystemic shunts. While extrahepatic and macrovascular shunts are readily visualized with imaging or endoscopy, there is no standard technique to detect intrahepatic microvascular portosystemic shunting and quantitatively assess shunt burden. We present a case of a 53-year-old female with suspected NRH and hepatopulmonary syndrome with inconclusive liver biopsies and absent portosystemic shunts per abdominal imaging. A percutaneous transportal infusion of Technetium-99m labeled macroaggregated albumin (99mTc-MAA) successfully identified intrahepatic microvascular portosystemic shunting and quantified a lung shunt fraction of more than 30%. NRH was subsequently confirmed with a surgical wedge biopsy and the patient was successfuly treated with a liver transplant. Transportal 99mTc-MAA could be used to both identify and quantify otherwise occult microvascular portosystemic shunts in patients with clinical sequelae of portal hypertension.