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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]

Patients with cirrhosis and ascites are at high risk of infections, which increase mortality and trigger acute-on-chronic liver failure (ACLF). To evaluate procalcitonin (PCT) as risk factor for 28- and 90-day mortality in patients with decompensated cirrhosis with or without ACLF hospitalized for suspected infection and treated with empiric antibiotic therapy. Two-hundred thirty-seven patients with ascites admitted at two Italian referral centers were prospectively evaluated. Risk factors for 28- and 90-day mortality were assessed by multivariate competing risks analysis, with liver transplant (LT) as competing event. Infection was confirmed in 83% of patients; 53% had ACLF; 88 (37%) died and 52 (22%) underwent LT within 90 days from admission. Creatinine [Hazard Ratio (HR)] 1.18, 95% Confidence Interval [95%CI] 1.01-1.38, p=0.039), grade III-IV hepatic encephalopathy (HR 2.32, 95%CI 1.15-4.65, p<0.018), septic shock (HR 2.77, 95%CI 1.39-5.53, p=0.004), baseline PCT>0.5 ng/mL (HR 4.10, 95%CI 1.24-13.38, p=0.021) or 48-hour PCT unfavorable course (HR 3.08, 95%CI 1.49-6.42, p=0.003) were risk factors for 28-day mortality by multivariate analysis (AUC 0.84). The same risk factors plus age (HR 1.03, 95%CI 1.01-1.05, p=0.001) were predictive for 90-day mortality (AUC 0.78). When ACLF was included in the multivariate model, instead of the single covariates, both ACLF and PCT (baseline levels and 48-hour course) were independently associated with 28- and 90-day mortality (AUC 0.83 and 0.72 respectively). When either baseline or 48-hour course PCT were combined with ACLF grade the prediction of 28- and 90- day mortality significantly increased. PCT both at baseline and 48-hour after starting empiric antibiotic treatment significantly predicts 28- and 90-day mortality in patients with decompensated cirrhosis presenting with or without ACLF at admission. Keywords : Decompensated cirrhosis, infections, empiric antibiotic treatment, ACLF, procalcitonin [ABSTRACT FROM AUTHOR]