Individualized portal pressure gradient threshold based on liver function categories in preventing rebleeding after TIPS

BACKGROUND

The evidence in Portal pressure gradient (PPG) < 12 mmHg after transjugular intrahepatic portosystemic shunt (TIPS) for preventing rebleeding mostly comes from observations in uncovered stents era. Moreover, association between Child-Pugh classes and post-TIPS hepatic encephalopathy (HE) has indicated that tolerance of PPG reduction depends on liver function. This study aimed to investigate the optimal PPG for covered TIPS and explore the optimal threshold tailored to the Child-Pugh classes to find individualized PPG to balance rebleeding and overt HE.

METHODS

This multicenter retrospective study analyzed rebleeding, OHE, and mortality of patients associated with post-TIPS PPGs (8, 10, 12, and 14 mmHg) in the entire cohort and among different Child-Pugh classes. Propensity score matching (PSM) and competing risk analyses were performed for sensitivity analyses.

RESULTS

We included 2100 consecutively screened patients undergoing TIPS. In all patients, PPG < 12 mmHg reduced rebleeding after TIPS (p = 0.022). In Child-Pugh class A, none of the PPG thresholds were discriminative of clinical outcomes. In Child-Pugh class B, 12 mmHg (p = 0.022) and 14 mmHg (p = 0.037) discriminated rebleeding, but 12 mmHg showed a higher net benefit. In Child-Pugh class C, PPG < 14 mmHg had a lower rebleeding incidence (p = 0.017), and exhibited more net benefit than 12 mmHg.

CONCLUSION

Different PPG standards may be required for patients with different liver function categories. A PPG threshold < 12 mmHg might be suitable for patients in Child-Pugh class B, while < 14 mmHg might be optimal for patients in Child-Pugh class C.

Pre-transjugular-intrahepatic-portosystemic-shunt measurement of hepatic venous pressure gradient and its clinical application: A comparison study

BACKGROUND

It is controversial whether transjugular intrahepatic portosystemic shunt (TIPS) placement can improve long-term survival.

AIM

To assess whether TIPS placement improves survival in patients with hepatic-venous-pressure-gradient (HVPG) ≥ 16 mmHg, based on HVPG-related risk stratification.

METHODS

Consecutive variceal bleeding patients treated with endoscopic therapy + nonselective β-blockers (NSBBs) or covered TIPS placement were retrospectively enrolled between January 2013 and December 2019. HVPG measurements were performed before therapy. The primary outcome was transplant-free survival; secondary endpoints were rebleeding and overt hepatic encephalopathy (OHE).

RESULTS

A total of 184 patients were analyzed (mean age, 55.27 years ± 13.86, 107 males; 102 in the EVL+NSBB group, 82 in the covered TIPS group). Based on the HVPG-guided risk stratification, 70 patients had HVPG < 16 mmHg, and 114 patients had HVPG ≥ 16 mmHg. The median follow-up time of the cohort was 49.5 mo. There was no significant difference in transplant-free survival between the two treatment groups overall (hazard ratio [HR], 0.61; 95% confidence interval [CI]: 0.35-1.05; P = 0.07). In the high-HVPG tier, transplant-free survival was higher in the TIPS group (HR, 0.44; 95%CI: 0.23-0.85; P = 0.004). In the low-HVPG tier, transplant-free survival after the two treatments was similar (HR, 0.86; 95%CI: 0.33-0.23; P = 0.74). Covered TIPS placement decreased the rate of rebleeding independent of the HVPG tier (P < 0.001). The difference in OHE between the two groups was not statistically significant (P = 0.09; P = 0.48).

CONCLUSION

TIPS placement can effectively improve transplant-free survival when the HVPG is greater than 16 mmHg.

Comparison of long-term outcomes of splenectomy with periesophagogastric devascularization and transjugular intrahepatic portosystemic shunt in treating cirrhotic portal hypertension patients with recurrent variceal bleeding

PURPOSE

Transjugular intrahepatic portosystemic shunt (TIPS) and splenectomy with periesophagogastric devascularization (SPD) are widely used to treat cirrhotic portal hypertension (PH) and prevent variceal rebleeding. However, direct comparisons between these two approaches are rare. This study was designed to compare the long-term outcomes of TIPS and SPD in patients with cirrhotic PH and variceal rebleeding.

METHODS

The study included cirrhotic PH patients with a history of gastroesophageal variceal bleeding between 18 and 80 years of age who were admitted to the Third Affiliated Hospital of Sun Yat-sen University from January 2012 to January 2022. Patients were enrolled into two groups according to TIPS or SPD was performed. Baseline characteristics were matched using propensity score matching (PSM).

RESULTS

A total of 230 patients underwent TIPS, while 184 underwent SPD. PSM was carried out to balance available covariates, resulting in a total of 83 patients in the TIPS group and 83 patients in the SPD group. Patients in SPD group had better liver function during 60 months follow-up. Five-year overall survival rates in SPD group and TIPS group were 72 and 27%, respectively, at 2 years were 88 and 86%, respectively. The 2- and 5-year freedom from variceal rebleeding rates were 95 and 80% in SPD group and 80 and 54% in TIPS group.

CONCLUSIONS

SPD is clearly superior to TIPS in terms of OS and freedom from variceal rebleeding in patients with cirrhotic PH. In addition, SPD improved liver function in patients with cirrhotic PH.

Predictive power of portal pressure gradient remeasured shortly after transjugular intrahepatic portosystemic shunt

BACKGROUND AND AIMS

The portal pressure gradient (PPG) measured at the time of transjugular intrahepatic portosystemic shunt (TIPS) completion (immediate PPG) is easily disturbed by many factors. This study aimed to assess the diagnostic value of PPG remeasured 2-4 days after TIPS (delayed PPG) by comparison with immediate PPG.

METHODS

We retrospectively analyzed cirrhotic patients aged 18-75 years who received TIPS for preventing variceal rebleeding and pressure measurements at different time points.

RESULTS

Of 154 eligible patients, 60 (39.0%), 62 (40.3%), and 32 (20.8%) were categorized into group LL (both immediate and delayed PPG < 12 mmHg), LH (immediate PPG < but delayed PPG ≥ 12 mmHg) and HH (both immediate and delayed PPG ≥ 12 mmHg), respectively. Mean immediate and delayed PPG were 9.2 mmHg and 12.8 mmHg (p < 0.001). During a median follow-up of 22 months, the 1-year probability of variceal rebleeding was significantly lower in group LL (1.7%) compared to LH (9.8%, absolute risk difference [ARD]: - 8.2%, p = 0.028) and HH (12.6%, ARD: - 11.1%, p = 0.014), but was not significantly different between groups LH and HH (ARD: - 2.9%, p = 0.671). Delayed PPG (p < 0.001) was identified as an independent predictor of variceal rebleeding in multivariable Cox regression analysis. The area under curves of delayed and immediate PPG in predicting variceal rebleeding were 0.837 and 0.693 for all patients (p = 0.031), and 0.936 and 0.694 for patients without shunt dysfunction (p < 0.001).

CONCLUSIONS

In cirrhotic patients with variceal bleeding, delayed PPG has higher predictive power for variceal rebleeding than immediate PPG.

Number of endoscopic sessions to eradicate varices identifies high risk of rebleeding in cirrhotic patients

Background and aims

Risk stratification to identify patients with high risk of variceal rebleeding is particularly important in patients with decompensated cirrhosis. In clinical practice, eliminating gastroesphageal varices thoroughly after sequential endoscopic treatment reduces the rebleeding rate, however, no simple method has been build to predict high risk of variceal rebleeding. We conducted this study to explore the value of the number of endoscopic sessions required to eradicate gastroesphageal varices in identifying high risk of rebleeding.

Patients and methods

Consecutive cirrhotic patients received sequential endoscopic therapy between January 2015 and March 2020 were enrolled. Endoscopic treatment was performed every 1–4 weeks until the eradication of varices. The primary endpoint was variceal rebleeding.

Results

A total of 146 patients were included of which 60 patients received standard therapy and 86 patients underwent sequential endoscopic treatment alone. The cut-off value of the number of sequential endoscopic sessions is 3.5 times. Variceal rebleeding was significant higher in patients with endoscopic sessions > 3 times versus ≤ 3 times (61.5% vs. 17.5%, p < 0.001). Variceal rebleeding of patients with endoscopic sessions ≤ 3 times was significant lower than patients with > 3 times in group of standard therapy (19.6% vs. 88.9%, p < 0.001) and endoscopic therapy (15.9% vs. 47.1%, p = 0.028) respectively.

Conclusion

The number of sequential endoscopic sessions required to eradicate the varices is related to the risk of variceal rebleeding in patients with cirrhosis. If three times of endoscopic treatment can not eradicate the varices, a more aggressive treatment such as TIPS should be seriously considered.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12876-022-02283-0.

Transjugular Intrahepatic Portosystemic Shunt:The Impact of Portal Venous Pressure Declines on Shunt Patency and Clinical Efficacy

RATIONALE AND OBJECTIVES

Transjugular intrahepatic portosystemic shunt (TIPS) placement using the same-diameter covered stents can lead to differed declines of portal venous pressure declines (PVDs). This study aimed to compare the long-term shunt patency and clinical efficacy of TIPS placement that caused low PVDs (≤9 mmHg) and high PVDs (>9 mmHg).

MATERIALS AND METHODS

A total of 129 patients treated by TIPS placement with 8 mm-diameter polytetrafluoroethylene covered stents were included and analyzed retrospectively. They were stratified into group A with low PVDs (n = 69) and group B with high PVDs (n = 60).

RESULTS

The 6-year actuarial probabilities of remaining free of shunt dysfunction (47.2% vs 64.6%; p = 0.007) and variceal rebleeding (48.3% vs 63.9%; p = 0.038) were significantly lower in group A than in group B. The 6-year actuarial probability of remaining free of hepatic encephalopathy was significantly higher in group A than in group B (44.5% vs 32.5%; p = 0.010), though the 6-year cumulative survival rate was similar in both groups (A vs B: 65.5% vs 56.0%; p = 0.240). The baseline portal vein thrombosis (hazard ratio [HR]: 6.045, 95% confidence interval [CI]: 2.762-13.233; p = 0.000) and stent type (HR: 4.447, 95%CI: 1.711-11.559, p = 0.002) were associated with shunt dysfunction, whereas only ascites was associated with mortality (HR: 1.373, 95%CI: 1.114-3.215; p = 0.024).

CONCLUSION

High PVDs (>9 mmHg) were associated with higher shunt patency, lower incidence of variceal rebleeding, but higher frequency of hepatic encephalopathy and similar survival rate than low PVDs (≤9 mmHg) after TIPS placement.

Transjugular intrahepatic portosystemic shunt for the prevention of recurrent esophageal variceal bleeding in patients with cavernous transformation of portal vein

BACKGROUND

Treatment options for patients with cavernous transformation of portal vein (CTPV) are limited. This study aimed to evaluate the feasibility, efficacy and safety of transjugular intrahepatic portosystemic shunt (TIPS) to prevent recurrent esophageal variceal bleeding in patients with CTPV.

METHODS

We retrospectively analyzed 67 consecutive patients undergone TIPS from January 2011 to December 2016. All patients were diagnosed with CTPV. The indication for TIPS was a previous episode of variceal bleeding. The data on recurrent bleeding, stent patency, hepatic encephalopathy and survival were retrieved and analyzed.

RESULTS

TIPS procedure was successfully performed in 56 out of 67 (83.6%) patients with CTPV. TIPS was performed via a transjugular approach alone (n = 15), a combined transjugular/transhepatic approach (n = 33) and a combined transjugular/transsplenic approach (n = 8). Mean portosystemic pressure gradient (PSG) decreased from 28.09 ± 7.28 mmHg to 17.53 ± 6.12 mmHg after TIPS (P < 0.01). The probability of the remaining free recurrent variceal bleeding was 87.0%. The probability of TIPS patency reached 81.5%. Hepatic encephalopathy occurrence was 27.8%, and survival rate was 88.9% until the end of follow-up. Four out of 11 patients who failed TIPS died, and 4 had recurrent bleeding.

CONCLUSIONS

TIPS should be considered a safe and feasible alternative therapy to prevent recurrent esophageal variceal bleeding in patients with CTPV, and to achieve clinical improvement.

Secondary prophylaxis for esophageal variceal bleeding

Combination therapy with beta-blockers and endoscopic band ligation (EBL) is the standard prophylaxis of esophageal variceal rebleeding in cirrhosis. Beta-blockers are the backbone of combination therapy, since their benefit extend to other complications of portal hypertension. EBL carries the risk of post-banding ulcer bleeding, which explains why overall rebleeding is reduced when beta-blockers are added to EBL, and not when EBL is added to beta-blockers. TIPS is the rescue treatment, but it could be considered as first choice in patients that first bleed while on beta-blockers, those with contraindications to beta-blockers or with refractory ascites, and those with fundal varices.