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Transjugular intrahepatic portosystemic shunt (TIPS) can induce significant cardiovascular distress in patients with cirrhosis. Despite its therapeutic benefits, post-TIPS cardiac decompensation (CD) remains a serious concern, with early predictive factors still incompletely characterized. To identify reliable predictive factors of post-TIPS symptomatic CD (AHA stage C-D). We prospectively enrolled consecutive patients with cirrhosis undergoing TIPS between May 2022 and May 2024 at our tertiary referral center. Baseline clinical and biochemical parameters were recorded. Right-heart catheterization was performed at three time points: pre-TIPS, immediately post-TIPS, and one-month post-procedure. Liver stiffness measurement (LSM) by vibration-controlled transient elastography was performed at corresponding intervals. Among 53 patients treated with TIPS for secondary prophylaxis of variceal bleeding (59%) or refractory ascites (41%), with a median Child-Pugh score of 7 (IQR 3) and a MELD-Na score of 12 (IQR 6), CD developed in 20% of patients, with a median onset of 3.3 months (IQR 5.8). At univariable Cox regression analysis, factors associated with CD were advanced age (71 vs. 59 years; HR 1.10, p=0.010), presence of post-capillary pulmonary hypertension (pcPH) at one-month (82% vs. 26%; HR 6.33, p=0.018), and the evidence of increased LSM at one-month follow-up (73% vs. 19%; HR 6.42, p=0.006). The median LSM increased by +22% in patients who developed CD, in contrast to a -23% decrease observed in those who did not (p=0.012). Presence of pcPH and increase of LSM at one-month follow-up are strongly associated with the development of post-TIPS CD. This is the first demonstration that gold-standard diagnosis of pcPH few weeks after TIPS can predict evolution towards CD. Further studies are required to investigate the relationship between LSM changes and cardiac adaptation following TIPS. [ABSTRACT FROM AUTHOR]

Underdilated Transjugular Intrahepatic Portosystemic Shunt (udTIPS) effectively manages portal hypertension complications while minimizing shunt-related adverse events. Spleen Stiffness (SS) measured by vibration-controlled transient elastography has shown high accuracy in detecting clinically significant portal hypertension when compared to the gold standard hepato-venous pressure gradient. To evaluate SS as a non-invasive tool for identifying patients with Porto-Caval Pressure Gradient (PCPG) <12 mmHg after udTIPS. We prospectively enrolled patients with cirrhosis undergoing udTIPS at our referral center (January 2023–September 2024). Both invasive PCPG assessment and SS measurement with the spleen-dedicated 100Hz probe by FibroScan® were performed at three time-points: before TIPS, immediately post-TIPS, and one-month after the procedure. The study included 51 patients (mean age 62±12 years, 63% male) with preserved liver function [median Child-Pugh score 7 (IQR 3), MELD-Na 13 (IQR 6)]. TIPS indications were secondary prophylaxis for variceal bleeding (65%) and refractory ascites (35%). Median udTIPS dilation diameter was 6 (IQR 1) mm. PCPG progressively decreased from 22 (IQR 7) pre-TIPS to 15 (IQR 4) immediately post-TIPS and 11 (IQR 5) mmHg at one-month. Correspondingly, SS decreased from 74.5 (IQR 5) to 55.5 (IQR 21) and 41.6 (IQR 19) kPa. All SS measurements strongly correlated with PCPG values (ρ=0.72, p<0.0001). SS demonstrated an excellent diagnostic discrimination for PCPG <12 mmHg [AUC=0.90 (95% CI 0.84-0.96)]. The cut-off of <35 kPa accurately ruled in patients with post-TIPS PCPG <12 mmHg (97.8% specificity, 88.2% PPV, 21.3 positive likelihood ratio). SS measured with the spleen-dedicated 100Hz probe strongly correlates with PCPG over time and reliably identifies patients achieving PCPG <12 mmHg after udTIPS. If validated in larger cohorts, SS may become a non-invasive tool for tailoring invasive hemodynamic reassessments in post-TIPS monitoring protocols. [ABSTRACT FROM AUTHOR]

Transjugular intrahepatic portosystemic shunt (TIPS) has been demonstrated to be feasible in older adult patients (age ≥70 years), yet the selection criteria remain suboptimal. Sarcopenia, highly prevalent in elderly population, may be significantly associated with post-TIPS outcome. This study aimed at evaluating the impact of baseline sarcopenia on post-TIPS survival in older adults with cirrhosis. A retrospective analysis of the prospective Italian TIPS-Registry was conducted to identify patients ≥70 years who received TIPS from June 2015 to March 2023. The availability of baseline abdominal CT scan was a mandatory inclusion criterion. Skeletal muscle index (SMI) was evaluated at the L3-L4 level. Sarcopenia was defined as SMI <50 cm2/m2 for men and <39 cm2/m2 for women. Probability of liver-related death was evaluated by competing risks analysis. A prediction model for liver-related mortality was created. One-hundred and fifteen patients were included: median age 74 years (IQR 3.1), 62% male, median dry-BMI 25.7 (IQR 4.7), 60% prevalence of sarcopenia. The main etiologies were viral (40%), alcohol-associated cirrhosis (23%), and metabolic dysfunction-associated steatohepatitis (20%). Refractory ascites (57%) was the main indications for TIPS. During a mean follow up of 20 months (IQR 20), 40 (34.8%) patients died for liver-related causes and 16 (13.9%) for extrahepatic causes. Liver-related mortality was significantly higher in patients with sarcopenia than in those without (6-months: 25.0% vs. 2.2%; 1-year: 43.0% vs. 4.8%, respectively; p value <0.001). A predictive model including INR, creatinine, and sarcopenia was developed to estimate liver-related mortality. The model achieved good predictive performances with AUCs of 0.826, 0.788, and 0.712 at 6-month, 1-year, and 2-years, respectively. Due to its significant impact on survival, the evaluation of sarcopenia may improve the selection of older adults candidate to TIPS. The new predictive model for post-TIPS liver-related mortality deserves external validation. [ABSTRACT FROM AUTHOR]

Transjugular intrahepatic portosystemic shunt (TIPS) is a well-established treatment for refractory ascites (RA) in patients with cirrhosis. However, a major drawback is the development of post-procedural hepatic encephalopathy (HE), which results from the diversion of blood from the portal vein. According to the first-pass effect, this diversion reduces the liver's capacity to metabolize substances from the gut, leading to an accumulation of toxic compounds in the brain. Given that liver perfusion relies on arterial compensation (hepatic arterial buffer), it is plausible that effective compensation, which also depends on cardiac function, may reduce the risk of encephalopathy by detoxifying the blood during the second-pass metabolism. To evaluate by Dynamic Contrast Enhanced-Magnetic Resonance Imaging (DCE-MRI) the changes in liver perfusion induced by TIPS in patients with RA and their relationship with the risk of HE. Twenty-nine consecutive patients underwent DCE-MRI, cardiac and hepatic hemodynamic evaluation before and after TIPS. MRI images were processed by a homemade software using the Dual Input Dual Compartment (DIDC) model, focusing on perfusion parameters. The DIDC model showed that total hepatic perfusion decreased by 24% after TIPS (248 ml/min/100ml vs 189 ml/min/100ml, p 0.095). As expected, a significant reduction in portal perfusion (decreased by 67%; 128.6 ml/min/100ml vs 42.4 ml/min/100ml, p 0.004) and an increase in hepatic arterial fraction post-TIPS (48% vs 77%, p 0.001) was observed. Post-TIPS residual total hepatic perfusion inversely correlated with one-year HE risk: patients with perfusion ≤ 130 ml/min/100ml had a HE risk of 67.6% vs 36.4% for those > 130 ml/min/100ml (HR: 2.1, p 0.039). Perfusion MRI is able to elucidate the impact of TIPS on liver perfusion, quantifying the extent of hepatic perfusion and its correlation with the development of post-TIPS HE. [ABSTRACT FROM AUTHOR]

The use of small caliber (<8 mm) transjugular intrahepatic portosystemic shunt (TIPS) is a promising approach to reduce shunt-related complications. Its feasibility with the new controlled expansion endoprosthesis (GORE® VIATORR® CX 8-10 mm) has not yet been explored. To investigate whether GORE® VIATORR® CX self-expands over time at portal vein wall (PVW) and hepatic vein wall (HVW) when under-dilated to <8 mm at TIPS placement. We prospectively enrolled consecutive patients with cirrhosis who received under-dilated TIPS between June 2020 and September 2022 at our tertiary referral Center in Modena, Italy. All patients underwent hemodynamic measurements a) immediately before and after TIPS placement, b) 6-7 days and c) ≥1 month after the procedure. We measured average pressure values in different sites along the TIPS: portal-vein tract (PV), intra-parenchymal tract (IP), hepatic-vein tract (HV) and inferior vena cava (IVC). A subgroup of patients underwent serial CT scans within 24h (T0), at 6-7 days (T1) and at ≥1 month after TIPS (T2). Average maximal inner diameter of endoprosthesis was measured at 5 standard sites: PV, PVW, IP, HVW and distal HV. Sixty-four patients underwent hemodynamic assessments: 25, 29 and 10 received TIPS under-dilated to 5, 6 and 7 mm, respectively. A significant drop of pressure was observed while crossing PVW and HVW in all under-dilated groups (Figure 1A). Forty-three of these patients underwent CT scans: 17, 19 and 7 were dilated to 5, 6 and 7 mm, respectively. PVW and HVW sites maintained under-dilation overtime (Figure 1B). No TIPS dysfunction occurred during a mean follow up period of 363 days. Under-dilation TIPS strategy performed with GORE® VIATORR® CX is feasible. Evaluation of clinical outcomes after applying this strategy are awaited. [ABSTRACT FROM AUTHOR]