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1.
Eur J Gastroenterol Hepatol ; 36(8): 1010-1015, 2024 Aug 01.
Article in English | MEDLINE | ID: mdl-38808872

ABSTRACT

BACKGROUND: Sarcopenia is common in patients with cirrhosis and is a risk factor for increased mortality. Transjugular intrahepatic portosystemic shunt (TIPS) placement has been utilized in cirrhosis patients with decompensation . We investigated the role of sarcopenia in predicting mortality in patients undergoing TIPS. METHODS: We conducted a single-center retrospective study of 232 patients with cirrhosis who underwent TIPS between January 2010 and December 2015. Sarcopenia was defined by the psoas muscle index (PMI) cutoff value, calculated based on dynamic time-dependent outcomes using X-tile software. Kaplan-Meier analysis demonstrated the difference in survival in the sarcopenia group versus the non-sarcopenia group. . Univariate and multivariate analyses were used to identify the relationship between sarcopenia and post-TIPS mortality during a follow-up period of 1 year. RESULTS: For TIPS indications, 111 (47.84%) patients had refractory ascites, 69 (29.74%) patients had variceal bleeding, 12 (5.17%) patients had ascites, and 40 (17.24%) for other indications. The mean PMI was 4.40 ±â€…1.55. Sarcopenia was defined as a PMI value of <4.36 in males, and <3.23 in females. Sarcopenia was present in 96 (41.38%) of patients. . Kaplan-Meier analysis showed thatsarcopenia is associated with worse survival (log-rank P  < 0.01). Multivariate Cox regression analysis showed that sarcopenia is independently associated with worse survival during the 1-year follow-up period with an hazard ratio of 2.435 (95% CI 1.346-4.403) ( P  < 0.01), after adjusting for age, BMI, indications for TIPS, etiology for cirrhosis, and MELD score and stratified by sex. CONCLUSION: Sarcopenia is an independent risk factor for 1-year mortality in patients undergoing TIPS and should be considered when patients are evaluated as a candidate for TIPS.


Subject(s)
Kaplan-Meier Estimate , Liver Cirrhosis , Portasystemic Shunt, Transjugular Intrahepatic , Sarcopenia , Humans , Sarcopenia/mortality , Sarcopenia/complications , Portasystemic Shunt, Transjugular Intrahepatic/adverse effects , Portasystemic Shunt, Transjugular Intrahepatic/mortality , Male , Female , Retrospective Studies , Risk Factors , Middle Aged , Liver Cirrhosis/complications , Liver Cirrhosis/mortality , Liver Cirrhosis/surgery , Aged , Time Factors , Treatment Outcome , Multivariate Analysis , Adult , Proportional Hazards Models , Psoas Muscles/diagnostic imaging , Ascites/mortality , Ascites/etiology , Esophageal and Gastric Varices/surgery , Esophageal and Gastric Varices/mortality , Esophageal and Gastric Varices/etiology
2.
World J Gastroenterol ; 30(13): 1859-1870, 2024 Apr 07.
Article in English | MEDLINE | ID: mdl-38659484

ABSTRACT

BACKGROUND: Portal hypertension (PHT), primarily induced by cirrhosis, manifests severe symptoms impacting patient survival. Although transjugular intrahepatic portosystemic shunt (TIPS) is a critical intervention for managing PHT, it carries risks like hepatic encephalopathy, thus affecting patient survival prognosis. To our knowledge, existing prognostic models for post-TIPS survival in patients with PHT fail to account for the interplay among and collective impact of various prognostic factors on outcomes. Consequently, the development of an innovative modeling approach is essential to address this limitation. AIM: To develop and validate a Bayesian network (BN)-based survival prediction model for patients with cirrhosis-induced PHT having undergone TIPS. METHODS: The clinical data of 393 patients with cirrhosis-induced PHT who underwent TIPS surgery at the Second Affiliated Hospital of Chongqing Medical University between January 2015 and May 2022 were retrospectively analyzed. Variables were selected using Cox and least absolute shrinkage and selection operator regression methods, and a BN-based model was established and evaluated to predict survival in patients having undergone TIPS surgery for PHT. RESULTS: Variable selection revealed the following as key factors impacting survival: age, ascites, hypertension, indications for TIPS, postoperative portal vein pressure (post-PVP), aspartate aminotransferase, alkaline phosphatase, total bilirubin, prealbumin, the Child-Pugh grade, and the model for end-stage liver disease (MELD) score. Based on the above-mentioned variables, a BN-based 2-year survival prognostic prediction model was constructed, which identified the following factors to be directly linked to the survival time: age, ascites, indications for TIPS, concurrent hypertension, post-PVP, the Child-Pugh grade, and the MELD score. The Bayesian information criterion was 3589.04, and 10-fold cross-validation indicated an average log-likelihood loss of 5.55 with a standard deviation of 0.16. The model's accuracy, precision, recall, and F1 score were 0.90, 0.92, 0.97, and 0.95 respectively, with the area under the receiver operating characteristic curve being 0.72. CONCLUSION: This study successfully developed a BN-based survival prediction model with good predictive capabilities. It offers valuable insights for treatment strategies and prognostic evaluations in patients having undergone TIPS surgery for PHT.


Subject(s)
Bayes Theorem , Hypertension, Portal , Liver Cirrhosis , Portasystemic Shunt, Transjugular Intrahepatic , Humans , Hypertension, Portal/surgery , Hypertension, Portal/mortality , Hypertension, Portal/etiology , Hypertension, Portal/diagnosis , Portasystemic Shunt, Transjugular Intrahepatic/adverse effects , Portasystemic Shunt, Transjugular Intrahepatic/mortality , Middle Aged , Female , Male , Retrospective Studies , Prognosis , Liver Cirrhosis/surgery , Liver Cirrhosis/complications , Liver Cirrhosis/mortality , Treatment Outcome , Aged , Adult , Hepatic Encephalopathy/etiology , Hepatic Encephalopathy/surgery , Hepatic Encephalopathy/mortality , Risk Factors , Portal Pressure
3.
J Vasc Interv Radiol ; 35(5): 648-657.e1, 2024 May.
Article in English | MEDLINE | ID: mdl-38244917

ABSTRACT

PURPOSE: To investigate effects of baseline and early longitudinal body composition changes on mortality and hepatic encephalopathy (HE) after transjugular intrahepatic portosystemic shunt (TIPS). MATERIALS AND METHODS: This is a case-control study with analysis of a TIPS registry (1995-2020) including data from patients with cirrhosis with computed tomography (CT) scans obtained within 1 month before and 3 months after TIPS. Core muscle area (CMA), macroscopic subcutaneous adipose tissue (mSAT), macroscopic visceral adipose tissue (mVAT) area, and muscle adiposity index (MAI) on CT were obtained. Multipredictor Cox proportional hazards models were used to assess the effect of body composition variables on mortality or HE. RESULTS: In total, 280 patients (158 men; median age, 57.0 years; median Model for End-stage Liver Disease-sodium [MELD-Na] score, 14.0) were included. Thirty-four patients had post-TIPS imaging. Median baseline CMA was 68.3 cm2 (interquartile range, 57.7-83.5 cm2). Patients with higher baseline CMA had decreased risks of mortality (hazard ratio [HR]: 0.82; P = .04) and HE (HR: 0.82; P = .009). It improved prediction of mortality over MELD-Na and post-TIPS right atrial pressure alone (confidence interval = 0.729). An increase in CMA (HR: 0.60; P = .043) and mSAT (HR: 0.86; P = .022) or decrease in MAI (HR: 1.50; P = .049) from before to after TIPS was associated with a decreased risk of mortality. An increase in mSAT was associated with an increased risk of HE (HR: 1.11; P = .04). CONCLUSIONS: CMA on CT scan 1 month before TIPS placement predicts mortality and HE in patients with cirrhosis. Changes in body composition on CT measured 3 months after TIPS placement independently predict mortality and HE.


Subject(s)
Hepatic Encephalopathy , Liver Cirrhosis , Portasystemic Shunt, Transjugular Intrahepatic , Predictive Value of Tests , Registries , Humans , Portasystemic Shunt, Transjugular Intrahepatic/adverse effects , Portasystemic Shunt, Transjugular Intrahepatic/mortality , Male , Female , Middle Aged , Hepatic Encephalopathy/etiology , Hepatic Encephalopathy/mortality , Hepatic Encephalopathy/diagnostic imaging , Hepatic Encephalopathy/physiopathology , Risk Factors , Risk Assessment , Aged , Time Factors , Liver Cirrhosis/mortality , Liver Cirrhosis/diagnostic imaging , Treatment Outcome , Adiposity , Body Composition , Retrospective Studies , Tomography, X-Ray Computed , Case-Control Studies
4.
Med Sci Monit ; 28: e934057, 2022 Jan 15.
Article in English | MEDLINE | ID: mdl-35031594

ABSTRACT

BACKGROUND Psoas muscle density (PMD) as a nutritional indicator is a tool to evaluate sarcopenia, which is commonly diagnosed in patients with liver cirrhosis. However, there are limited data on its role in patients who have received a transjugular intrahepatic portosystemic shunt (TIPS). We aimed to determine the utility of PMD in predicting mortality of patients with TIPS implantation and to compare the clinical value of PMD, Child-Pugh score, model for end-stage liver disease (MELD) score, and MELD paired with serum sodium measurement (MELD-Na) score in predicting post-TIPS survival in 1 year. MATERIAL AND METHODS This retrospective study included 273 patients who met the criteria for study inclusion. All participants underwent computed tomography (CT) scans, Child-Pugh score evaluation, MELD-Na scoring, and MELD scoring. Post-TIPS survival time was estimated using the Kaplan-Meier survival curve. The prognostic values of scoring models such as the Child-Pugh score, MELD, MELD-Na, and PMD were evaluated using receiver operating characteristic curves. RESULTS During the 1-year follow-up period, 31 of 273 (11.36%) post-TIPS patients died. Multivariate analysis identified PMD as an independent protective factor. PMD showed a good ability to predict the occurrence of an endpoint within 1 year after TIPS. The area under the receiver operating characteristic curves for PMD, Child-Pugh score, MELD score, and MELD-Na for predicting mortality were, respectively, 0.72 (95% confidence interval [CI]: 0.663-0.773), 0.59 (95% CI: 0.531-0.651), 0.60 (95% CI: 0.535-0.655), and 0.58 (95% CI: 0.487-0.608). CONCLUSIONS PMD has appreciable clinical value for predicting the mortality of patients with TIPS implantation. In addition, PMD is superior to established scoring systems for identifying high-risk patients with a poor prognosis.


Subject(s)
Liver Cirrhosis/mortality , Portasystemic Shunt, Transjugular Intrahepatic/mortality , Psoas Muscles/diagnostic imaging , Sarcopenia/diagnostic imaging , Sarcopenia/mortality , Cohort Studies , Female , Follow-Up Studies , Humans , Liver/surgery , Liver Cirrhosis/complications , Male , Middle Aged , Retrospective Studies , Sarcopenia/etiology , Severity of Illness Index , Survival Analysis , Tomography, X-Ray Computed/methods
5.
J Gastroenterol Hepatol ; 37(3): 455-463, 2022 Mar.
Article in English | MEDLINE | ID: mdl-34665473

ABSTRACT

BACKGROUND AND AIM: A preemptive transjugular intrahepatic portosystemic shunt (p-TIPSS) after acute variceal bleeding (AVB) is advocated. However, when compared with the current standard of care, the survival benefit of p-TIPSS is questionable. We performed a systematic review, meta-analysis, and trial sequential analysis of randomized control trials (RCTs) to assess the survival benefit of p-TIPSS in patients with cirrhosis and AVB. METHODS: Comprehensive literature search of three bibliographic databases (MEDLINE, Embase, and Cochrane) was conducted from inception till May 2021. All study types evaluating the survival benefit of p-TIPSS in AVB were considered for inclusion. The relative risk (RR) of mortality and rebleeding at 6 weeks and mortality at 1 year with a random-effects model was computed. Trial sequential analysis was performed for the primary outcome of 6-week mortality. RESULTS: A total of nine studies (four RCTs and five cohort studies) comprising 2861 patients with AVB were included. The overall pooled risks of mortality at 6 weeks and 1 year were 17.9% (95% confidence interval [CI]: 16.5-19.3%) and 26.7% (95% CI: 25.0-28.3%), respectively. Although p-TIPSS was associated with lower 6-week rebleeding risk (RR = 0.20; 95% CI = 0.13-0.29, I2  = 0%), data from pooled RCTs showed no significant difference in mortality at 6 weeks (RR = 0.33; 95% CI = 0.08-1.36, I2  = 63%) or at 1 year (RR = 0.76; 95% CI = 0.51-1.14, I2  = 30%). Using trial sequential analysis, required sample size to detect a 20% relative risk reduction in mortality at 6 weeks with p-TIPSS was estimated to be 6317, which is beyond the total number of patients available for analysis. CONCLUSIONS: This meta-analysis found that the available data from RCTs are insufficient to confer 6-week mortality benefit with p-TIPSS compared with standard of care; thus, adequately powered RCTs are required.


Subject(s)
Esophageal and Gastric Varices , Gastrointestinal Hemorrhage , Liver Cirrhosis , Portasystemic Shunt, Transjugular Intrahepatic , Esophageal and Gastric Varices/surgery , Gastrointestinal Hemorrhage/etiology , Gastrointestinal Hemorrhage/mortality , Gastrointestinal Hemorrhage/surgery , Humans , Liver Cirrhosis/surgery , Portasystemic Shunt, Transjugular Intrahepatic/adverse effects , Portasystemic Shunt, Transjugular Intrahepatic/mortality , Randomized Controlled Trials as Topic , Risk Assessment
7.
Hepatology ; 74(4): 2085-2101, 2021 10.
Article in English | MEDLINE | ID: mdl-34018627

ABSTRACT

BACKGROUND AND AIMS: Data about the prognosis of salvage transjugular intrahepatic portosystemic shunt (TIPS) using covered stents for refractory variceal bleeding caused by portal hypertension are scarce. We aimed to assess survival and to identify predictors of mortality in these patients. APPROACH AND RESULTS: One hundred sixty-four patients with cirrhosis from five centers treated with salvage TIPS between 2007 and 2017 were retrospectively divided into a derivation cohort (83 patients) and a validation cohort (81 patients). Comparisons were performed using the Mann-Whitney and Fischer's exact test. Six-week overall survival (OS) was correlated with variables on the day of the TIPS using Kaplan-Meier curves with log-rank test and univariate/multivariate analyses using the Cox model. Eighty-three patients were included in the derivation cohort (male, 78%; age, 55 years, alcohol-associated cirrhosis, 88%; Model for End-Stage Liver Disease [MELD], 19 [15-27]; arterial lactate, 3.7 mmol/L [2.0-8.3]). Six-week OS rate was 58%. At multivariate analysis, the MELD score (OR, 1.064; 95% CI, 1.005-1.126; P = 0.028) and arterial lactate (OR, 1.063; 95% CI, 1.013-1.114; P = 0.032) were associated with 6-week OS. Six-week OS rates were 100% in patients with arterial lactate ≤2.5 mmol/L and MELD score ≤ 15 and 5% in patients with lactate ≥12 mmol/L and/or MELD score ≥ 30. The 81 patients of the validation cohort had similar MELD and arterial lactate level but lower creatinine level (94 vs 106 µmol/L, P = 0.008); 6-week OS was 67%. Six-week OS rates were 86% in patients with arterial lactate ≤2.5 mmol/L and MELD score ≤ 15 and 10% for patients with lactate ≥12 mmol/L and/or MELD score ≥ 30. In the overall cohort, rebleeding rate was 15.8% at 6 weeks, and the acute-on-chronic liver failure grade (OR, 1.699; 95% CI, 1.056-1.663; P = 0.040) was independently associated with rebleeding. CONCLUSIONS: After salvage TIPS, 6-week mortality remains high and can be predicted by MELD score and lactate. Survival rate at 6 weeks was >85% in patients with arterial lactate ≤2.5 mmol/L and MELD score ≤ 15, while mortality was >90% for lactate ≥12 mmol/L and/or MELD score ≥ 30.


Subject(s)
Esophageal and Gastric Varices , Gastrointestinal Hemorrhage , Hypertension, Portal , Lactic Acid/blood , Liver Cirrhosis/complications , Portasystemic Shunt, Transjugular Intrahepatic , Biomarkers/blood , End Stage Liver Disease/diagnosis , Esophageal and Gastric Varices/etiology , Esophageal and Gastric Varices/surgery , Female , France/epidemiology , Gastrointestinal Hemorrhage/etiology , Gastrointestinal Hemorrhage/physiopathology , Gastrointestinal Hemorrhage/surgery , Humans , Hypertension, Portal/etiology , Hypertension, Portal/physiopathology , Hypertension, Portal/surgery , Liver Cirrhosis/mortality , Male , Middle Aged , Organ Dysfunction Scores , Portasystemic Shunt, Transjugular Intrahepatic/adverse effects , Portasystemic Shunt, Transjugular Intrahepatic/methods , Portasystemic Shunt, Transjugular Intrahepatic/mortality , Predictive Value of Tests , Prognosis , Salvage Therapy/methods , Spain/epidemiology , Survival Analysis
8.
J Hepatol ; 74(6): 1362-1372, 2021 06.
Article in English | MEDLINE | ID: mdl-33508376

ABSTRACT

BACKGROUND & AIMS: Transjugular intrahepatic portosystemic shunt (TIPS) implantation is an effective and safe treatment for complications of portal hypertension. Survival prediction is important in these patients as they constitute a high-risk population. Therefore, the aim of our study was to develop an alternative prognostic model for accurate survival prediction after planned TIPS implantation. METHODS: A total of 1,871 patients with de novo TIPS implantation for ascites or secondary prophylaxis of variceal bleeding were recruited retrospectively. The study cohort was divided into a training set (80% of study patients; n = 1,496) and a validation set (20% of study patients; n = 375). Further, patients with early (preemptive) TIPS implantation due to variceal bleeding were included as another validation cohort (n = 290). Medical data and overall survival (OS) were assessed. A Cox regression model was used to create an alternative prediction model, which includes significant prognostic factors. RESULTS: Age, bilirubin, albumin and creatinine were the most important prognostic factors. These parameters were included in a new score named the Freiburg index of post-TIPS survival (FIPS). The FIPS score was able to identify high-risk patients with a significantly reduced median survival of 5.0 (3.1-6.9) months after TIPS implantation in the training set. These results were confirmed in the validation set (median survival of 3.1 [0.9-5.3] months). The FIPS score showed better prognostic discrimination compared to the Child-Pugh, MELD, MELD-Na score and the bilirubin-platelet model. However, the FIPS score showed insufficient prognostic discrimination in patients with early TIPS implantation. CONCLUSIONS: The FIPS score is superior to established scoring systems for the identification of high-risk patients with a worse prognosis following elective TIPS implantation. LAY SUMMARY: Implantation of a transjugular intrahepatic portosystemic shunt (TIPS) is a safe and effective treatment for patients with cirrhosis and clinically significant portal hypertension. However, risk stratification is a major challenge in these patients as currently available scoring systems have major drawbacks. Age, bilirubin, albumin and creatinine were included in a new risk score which was named the Freiburg index of post-TIPS survival (FIPS). The FIPS score can identify patients at high risk and may guide clinical decision making.


Subject(s)
Ascites/surgery , Esophageal and Gastric Varices/surgery , Gastrointestinal Hemorrhage/surgery , Liver Cirrhosis/surgery , Portasystemic Shunt, Transjugular Intrahepatic/adverse effects , Portasystemic Shunt, Transjugular Intrahepatic/mortality , Research Design , Age Factors , Aged , Bilirubin/blood , Clinical Decision-Making/methods , Creatinine/blood , Female , Humans , Male , Middle Aged , Prognosis , Retrospective Studies , Risk Factors , Secondary Prevention/methods , Serum Albumin, Human/analysis , Survival Rate , Treatment Outcome
9.
Rev. esp. enferm. dig ; 113(1): 23-27, ene. 2021. tab, graf
Article in Spanish | IBECS | ID: ibc-199884

ABSTRACT

OBJETIVO: el objetivo del presente estudio es conocer aspectos epidemiológicos, técnicos y clínicos en el uso de la derivación portosistémica intrahepática transyugular (TIPS) en España en las unidades de intervencionismo. Además, se compara el número de TIPS realizados en España con el de otros países. MATERIAL Y MÉTODOS: estudio retrospectivo aprobado por el Comité Ético de la Sociedad Española de Radiología Intervencionista (SERVE). Para la recolección de datos sobre el estado actual del TIPS en España, se preparó una encuesta con 31 ítems (datos demográficos, técnicos y clínicos). La encuesta fue enviada a los 49 hospitales que constaba en el registro de la SERVEI que en 2016 habían realizado TIPS. RESULTADOS: de los 49 centros encuestados, 33 (67,35 %) respondieron. Estos centros habían realizado 265 de los 415 TIPS realizados ese año en España. La indicación más frecuente fue el sangrado por varices gastroesofágicas (144, 54,33 %). El 62,26 % de los TIPS fueron realizados de forma urgente y el 37,7 %, de forma programada. El éxito técnico fue de 89,16 ± 20,9 %, resangrando entre ellos el 17,9 %. Sesenta y nueve pacientes (26,03 %) presentaron complicaciones (el 19,62 % menores y el 6,41 % mayores). La mortalidad a 30 días relacionada con la enfermedad fue del 14,33 %, mientras que a un año fue del 18,49 %. CONCLUSIÓN: de forma llamativa, en nuestro estudio, las complicaciones del TIPS no muestran una clara relación con el número de procedimientos realizados. En relación a otros países como Estados Unidos y Francia, el número de TIPS en España por millón de habitantes actualmente es sustancialmente menor, sin cambios significativos respecto al número realizado en 2013


No disponible


Subject(s)
Humans , Portasystemic Shunt, Transjugular Intrahepatic/methods , Digestive System Diseases/epidemiology , Minimally Invasive Surgical Procedures/methods , Portasystemic Shunt, Transjugular Intrahepatic/mortality , Spain/epidemiology , Portasystemic Shunt, Transjugular Intrahepatic/statistics & numerical data , Societies, Medical/ethics , Surveys and Questionnaires , Retrospective Studies
10.
J Vasc Interv Radiol ; 32(2): 211-219, 2021 02.
Article in English | MEDLINE | ID: mdl-33349507

ABSTRACT

PURPOSE: To evaluate safety and efficacy of segmental yttrium-90 (Y90) radioembolization for hepatocellular carcinoma (HCC) after transjugular intrahepatic portosystemic shunt (TIPS) placement. The hypothesis was liver sparing segmental Y90 for HCC after TIPS would provide high antitumor response with a tolerable safety profile. MATERIALS AND METHODS: This single-arm retrospective study included 39 patients (16 women, 23 men) with ages 49-81 years old who were treated with Y90. Child-Pugh A/B liver dysfunction was present in 72% (28/39) with a median Model for End-stage Liver Disease score of 18 (95% confidence interval, 16.4-19.4). Primary outcomes were clinical and biochemical toxicities and antitumor imaging response by World Health Organization (WHO) and European Association for the Study of the Liver (EASL) criteria. Secondary outcomes were orthotopic liver transplantation (OLT), time to progression (TTP), and overall survival (OS) estimates by the Kaplan-Meier method. RESULTS: The 30-day mortality was 0%. Grade 3+ clinical adverse events and grade 3+ hyperbilirubinemia occurred in 5% (2/39) and 0% (0/39), respectively. Imaging response was achieved in 58% (22/38, WHO criteria) and 74% (28/38, EASL criteria), respectively. Median TTP was 16.1 months for any cause and 27.5 months for primary index lesions. OLT was completed in 88% (21/24) of listed patients at a median time of 6.1 months (range, 0.9-11.7 months). Median OS was 31.6 months and 62.9 months censored and uncensored to OLT, respectively. CONCLUSIONS: Segmental Y90 for HCC appears safe and efficacious in patients after TIPS. Preserved transplant eligibility suggests that Y90 is a useful tool for bridging these patients to liver transplantation.


Subject(s)
Carcinoma, Hepatocellular/therapy , Embolization, Therapeutic , Liver Neoplasms/therapy , Portasystemic Shunt, Transjugular Intrahepatic , Radiopharmaceuticals/administration & dosage , Yttrium Radioisotopes/administration & dosage , Aged , Aged, 80 and over , Carcinoma, Hepatocellular/diagnostic imaging , Carcinoma, Hepatocellular/mortality , Databases, Factual , Disease Progression , Embolization, Therapeutic/adverse effects , Embolization, Therapeutic/mortality , Female , Humans , Liver Neoplasms/diagnostic imaging , Liver Neoplasms/mortality , Male , Middle Aged , Portasystemic Shunt, Transjugular Intrahepatic/adverse effects , Portasystemic Shunt, Transjugular Intrahepatic/mortality , Radiopharmaceuticals/adverse effects , Retrospective Studies , Time Factors , Treatment Outcome , Yttrium Radioisotopes/adverse effects
11.
J Vasc Interv Radiol ; 32(1): 61-69.e1, 2021 01.
Article in English | MEDLINE | ID: mdl-33218919

ABSTRACT

PURPOSE: To assess and compare the long-term outcomes of various endovascular interventions in patients with Budd-Chiari syndrome (BCS). MATERIALS AND METHODS: In this single-center retrospective study, 510 consecutive patients with BCS who had undergone a total of 618 endovascular procedures from January 2001 to December 2019 were included. Details of the type of endovascular intervention, technical success, clinical success, patency rate, complications, and survival outcomes were analyzed. RESULTS: The overall technical success rate was 96% (593 of 618 procedures; 500 in treatment-naïve patients and 93 repeat interventions for recurrent disease). Endovascular procedures included recanalization procedures (angioplasty and stent placement) in 355 patients (71%) and transjugular intrahepatic portosystemic shunt (TIPS) creation in 145 (29%). Major postprocedure complications occurred in 14 patients (2.8%). Vascular/stent restenosis occurred in 95 patients (19%), and successful repeat intervention was performed in 82 of those 95 (86.3%). An additional 11 of these 82 (13.4%) underwent a third intervention for restenosis. In the recanalization and TIPS groups, the 1- and 5-y cumulative patency rates were 87% and 74% and 95% and 68%, respectively. The 1- and 5-y survival rates were 96% and 89% and 90% and 76%, respectively. CONCLUSIONS: Endovascular interventions for BCS are feasible and safe in the majority of patients, with excellent short- and long-term patency and survival rates.


Subject(s)
Angioplasty , Budd-Chiari Syndrome/therapy , Portasystemic Shunt, Transjugular Intrahepatic , Adolescent , Adult , Aged , Angioplasty/adverse effects , Angioplasty/instrumentation , Angioplasty/mortality , Budd-Chiari Syndrome/diagnostic imaging , Budd-Chiari Syndrome/mortality , Budd-Chiari Syndrome/physiopathology , Female , Humans , Male , Middle Aged , Portasystemic Shunt, Transjugular Intrahepatic/adverse effects , Portasystemic Shunt, Transjugular Intrahepatic/instrumentation , Portasystemic Shunt, Transjugular Intrahepatic/mortality , Recurrence , Retrospective Studies , Risk Factors , Stents , Time Factors , Treatment Outcome , Vascular Patency , Young Adult
12.
Gastroenterol Hepatol ; 44(9): 620-627, 2021 Nov.
Article in English, Spanish | MEDLINE | ID: mdl-33249114

ABSTRACT

BACKGROUND AND AIMS: Transjugular intrahepatic portosystemic shunts (TIPS) are successfully used in the management of portal hypertension (PH)-related complications. Debate surrounds the diameter of the dilation. The aim was to analyse the outcomes of and complications deriving from TIPS in patients with cirrhosis and identify predictors of survival. METHODS: This was a retrospective single-centre study, which included patients with cirrhosis who had a TIPS procedure for PH from 2009 to October 2018. Demographic, clinical and radiological data were collected. The Kaplan-Meier method was used to measure survival and predictors of survival were identified with the Cox regression model. RESULTS: A total of 98 patients were included (78.6% male), mean age was 58.5 (SD±/-9.9) and the median MELD was 13.3 (IQR 9.5-16). The indications were refractory ascites (RA), variceal bleeding (VB) and hepatic hydrothorax (HH). Median survival was 72 months (RA 46.4, VB 68.5 and HH 64.7) and transplant-free survival was 26 months. Clinical and technical success rates were 70.5% and 92.9% respectively. Age (HR 1.05), clinical success (HR 0.33), sodium (HR 0.92), renal failure (HR 2.46) and albumin (HR 0.35) were predictors of survival. Hepatic encephalopathy occurred in 28.6% of patients and TIPS dysfunction occurred in 16.3%. CONCLUSIONS: TIPS with 10-mm PTFE-covered stent is an effective and safe treatment for PH-related complications in patients with cirrhosis. Age, renal failure, sodium, albumin and clinical success are independent predictors of long-term survival.


Subject(s)
Hypertension, Portal/complications , Liver Cirrhosis/complications , Portasystemic Shunt, Transjugular Intrahepatic/methods , Stents , Adult , Aged , Aged, 80 and over , Ascites/mortality , Ascites/surgery , Esophageal and Gastric Varices/complications , Esophageal and Gastric Varices/mortality , Esophageal and Gastric Varices/surgery , Female , Gastrointestinal Hemorrhage/etiology , Gastrointestinal Hemorrhage/mortality , Gastrointestinal Hemorrhage/surgery , Hepatic Encephalopathy/epidemiology , Hepatic Encephalopathy/mortality , Hepatic Encephalopathy/prevention & control , Hepatic Veins/diagnostic imaging , Hepatic Veins/surgery , Humans , Hydrothorax/mortality , Hydrothorax/surgery , Hypertension, Portal/mortality , Kaplan-Meier Estimate , Liver Cirrhosis/mortality , Male , Middle Aged , Polytetrafluoroethylene , Portasystemic Shunt, Transjugular Intrahepatic/adverse effects , Portasystemic Shunt, Transjugular Intrahepatic/mortality , Postoperative Complications/epidemiology , Postoperative Complications/mortality , Proportional Hazards Models , Prosthesis Design , Renal Insufficiency/mortality , Retrospective Studies , Serum Albumin , Sodium/blood , Treatment Outcome
13.
J Gastroenterol Hepatol ; 36(3): 775-781, 2021 Mar.
Article in English | MEDLINE | ID: mdl-32710679

ABSTRACT

BACKGROUND AND AIM: Nationwide data on readmissions after the transjugular intrahepatic portosystemic shunt (TIPS) procedure are lacking. We aimed to investigate the 30-day readmission rate after TIPS procedure, reasons, and predictors for readmissions and its impact on resource utilization and mortality in the USA. METHODS: We identified all adults who underwent an inpatient TIPS procedure between 2010 and 2014 using the National Readmission Database. Outcomes included all-cause 30-day readmission rate, reasons and predictors of readmissions, mortality rate, and mean hospitalization charges. RESULTS: Out of a total of 31 230 hospitalizations with TIPS procedure, 28 021 patients met the study criteria and were finally included. The mean age of patients was 56.90 years, and 63.84% were men. All-cause 30-day readmission rate was 27.81%. Hepatic encephalopathy with or without coma was the most common reason for readmissions in at least 36.43% patients. The in-hospital mortality for index hospitalization and 30-day readmission was 10.69% and 5.85%, respectively. The mean hospitalization charges for index hospitalization and readmissions were $153 357 and $45 751, respectively. Advanced age, Medicaid insurance, higher Charlson comorbidy index, ascites as indication of TIPS, and nonspecific or hepatitis C cirrhosis etiologies for cirrhosis were found to be independent predictors of 30-day readmissions after a TIPS procedure. CONCLUSIONS: Our study found a high rate of readmission for patients undergoing TIPS procedure, and the majority of these readmissions were related to hepatic encephalopathy. Further studies highlighting areas for improvement, particularly for patient selection and post-discharge care, are needed to reduce readmissions.


Subject(s)
Cost of Illness , Patient Readmission/statistics & numerical data , Portasystemic Shunt, Transjugular Intrahepatic , Female , Hepatic Encephalopathy/epidemiology , Hepatic Encephalopathy/etiology , Hepatitis C/complications , Hepatitis C/epidemiology , Hospital Mortality , Hospitalization/statistics & numerical data , Humans , Liver Cirrhosis/epidemiology , Liver Cirrhosis/etiology , Male , Middle Aged , Patient Acceptance of Health Care/statistics & numerical data , Patient Readmission/economics , Portasystemic Shunt, Transjugular Intrahepatic/economics , Portasystemic Shunt, Transjugular Intrahepatic/methods , Portasystemic Shunt, Transjugular Intrahepatic/mortality , Postoperative Care , Time Factors , Treatment Outcome , United States/epidemiology
14.
J Vasc Interv Radiol ; 31(9): 1382-1391.e2, 2020 09.
Article in English | MEDLINE | ID: mdl-32792277

ABSTRACT

PURPOSE: To investigate from a population health perspective the effects of transjugular intrahepatic portosystemic shunt (TIPS) creation on recurrent variceal bleeding and survival in patients with cirrhosis. MATERIALS AND METHODS: Patients with cirrhosis who presented to outpatient and acute-care hospitals in California (2005-2011) and Florida (2005-2014) with variceal bleeding comprised the study cohort. Patients entered the study cohort at their first presentation for variceal bleeding; all subsequent hospital encounters were then evaluated to determine subsequent interventions, complications, and mortality data. RESULTS: A total of 655,577 patients with cirrhosis were identified, of whom 42,708 (6.5%) had at least 1 episode of variceal bleeding and comprised the study cohort. The median follow-up time was 2.61 years. A TIPS was created in 4,201 (9.8%) of these patients. There were significantly greater incidences of coagulopathy (83.9% vs 72.8%; P < .001), diabetes (45.5% vs 38.8%; P < .001), and hepatorenal syndrome (15.3% vs 12.5%; P < .001) in TIPS recipients vs those without a TIPS. Following propensity-score matching, TIPS recipients were found to have improved overall survival (82% vs 77% at 12 mo; P < .001) and a lower rate of recurrent variceal bleeding (88% vs 83% recurrent bleeding-free survival at 12 months,; P < .001) than patients without a TIPS. Patients with a TIPS had a significant increase in encounters for hepatic encephalopathy vs those without (1.01 vs 0.49 per year; P < .001). CONCLUSIONS: TIPS improves recurrent variceal bleeding rates and survival in patients with cirrhosis complicated by variceal bleeding. However, TIPS creation is also associated with a significant increase in hepatic encephalopathy.


Subject(s)
Esophageal and Gastric Varices/therapy , Gastrointestinal Hemorrhage/prevention & control , Liver Cirrhosis/therapy , Portasystemic Shunt, Transjugular Intrahepatic , California/epidemiology , Comorbidity , Databases, Factual , Esophageal and Gastric Varices/diagnostic imaging , Esophageal and Gastric Varices/mortality , Female , Florida/epidemiology , Gastrointestinal Hemorrhage/diagnostic imaging , Gastrointestinal Hemorrhage/mortality , Hepatic Encephalopathy/epidemiology , Humans , Liver Cirrhosis/diagnosis , Liver Cirrhosis/mortality , Male , Portasystemic Shunt, Transjugular Intrahepatic/adverse effects , Portasystemic Shunt, Transjugular Intrahepatic/mortality , Recurrence , Risk Factors , Time Factors , Treatment Outcome
15.
Dig Liver Dis ; 52(9): 1017-1025, 2020 09.
Article in English | MEDLINE | ID: mdl-32653417

ABSTRACT

BACKGROUND/AIMS: Despite secondary-prophylaxis with ß-blockers and endoscopic-variceal-ligation rebleeding is frequent, particularly within the first-6-weeks. Early-rebleeding may have greater impact on death-risk than late rebleeding, which may affect therapy. We assessed whether the influence of rebleeding on long-term survival of patients on secondary-prophylaxis is greater in patients with early-rebleeding. METHODS: 369 patients with cirrhosis were consecutively included once recovered from first variceal-bleeding. The impact of rebleeding on survival was investigated according to whether it occurred within 6-weeks (early-rebleeding) or later (late-rebleeding). RESULTS: During 46-months of follow-up (IQR: 14-61), 45 patients (12%) had early-rebleeding, 74(20%) had late-rebleeding and 250(68%) had not rebleeding. Mortality risk was higher in early-rebleeding group vs. late-rebleeding (HR = 0.476, 95%CI = 0.318-0.712, p < 0.001) and was similar in late-rebleeding group vs. no-rebleeding (HR = 0.902, 95%CI = 0.749-1.086, p = 0.271). Adjusting for baseline risk-factors, early-rebleeding was independently associated with mortality-risk (HR = 1.58, 95%CI = 1.02-2.45; p = 0.04). Child-Pugh&MELD scores improved at 3rd-4th-week only in patients without early-rebleeding (p < 0.05). Presence of ascites or encephalopathy, MELD-score>12 and HVPG>20 mmHg identified patients at risk of early-rebleeding. CONCLUSIONS: Patients with early-rebleeding have higher risk of death than patients without rebleeding and even than those rebleeding later. Our results suggest that patients at risk of early rebleeding might benefit from preemptive therapies such as early-TIPS.


Subject(s)
Adrenergic beta-Antagonists/therapeutic use , Esophageal and Gastric Varices/therapy , Gastrointestinal Hemorrhage/mortality , Gastrointestinal Hemorrhage/prevention & control , Liver Cirrhosis/complications , Adult , Aged , Combined Modality Therapy , Esophageal and Gastric Varices/etiology , Esophageal and Gastric Varices/mortality , Esophageal and Gastric Varices/physiopathology , Female , Gastrointestinal Hemorrhage/etiology , Gastrointestinal Hemorrhage/physiopathology , Hepatic Encephalopathy/etiology , Humans , Ligation/methods , Liver Cirrhosis/mortality , Male , Middle Aged , Portasystemic Shunt, Transjugular Intrahepatic/adverse effects , Portasystemic Shunt, Transjugular Intrahepatic/mortality , Prospective Studies , Recurrence , Secondary Prevention , Severity of Illness Index , Spain/epidemiology , Survival Analysis , Time Factors , Treatment Outcome
16.
AJR Am J Roentgenol ; 215(1): 215-222, 2020 07.
Article in English | MEDLINE | ID: mdl-32432911

ABSTRACT

OBJECTIVE. The purpose of this study was to compare the ability of the model for end-stage liver disease (MELD) and sodium MELD (MELD-Na) scoring systems to predict outcomes after transjugular intrahepatic portosystemic shunt (TIPS) placement. MATERIALS AND METHODS. Two hundred and nineteen consecutive patients who underwent TIPS placement were retrospectively reviewed. The primary outcomes were death within 30 days and 90 days after TIPS placement (30- and 90-day mortality, respectively), and secondary outcomes included death within 365 days after TIPS placement (365-day mortality), length of hospital stay, and readmission to the hospital within 30 days of TIPS placement. RESULTS. Mortality rates within 30, 90, and 365 days after TIPS placement were 2.3% (5/219), 8.2% (17/207), and 21.7% (41/189), respectively. Logistic regression showed that the MELD score predicted 30-day mortality (odds ratio [OR], 1.13; 95% CI, 1.00-1.27; p = 0.04) and trended toward predicting 90-day mortality (OR, 1.09; 95% CI, 1.00-1.18; p = 0.06), whereas the MELD-Na score did not predict 30-day mortality (OR, 1.02; 95% CI, 0.97-1.06; p = 0.51) or 90-day mortality (OR, 1.01; 95% CI, 0.98-1.15; p = 0.44). In a comparison of the ROC AUCs for MELD and MELD-Na, MELD showed improved prediction of 30-day mortality (p = 0.06) but did not significantly vary in prediction of 90- and 365-day mortality (p = 0.80 and p = 0.76, respectively). When the maximal inflection point for MELD and MELD-Na was analyzed on the basis of 90-day mortality, a score of 23 was found to be most significant for both MELD (OR, 6.6; 95% CI, 1.5-29.1; p = 0.01) and MELD-Na (OR, 3.3; 95% CI, 1.1-9.6; p = 0.03). MELD and MELD-Na both accurately predicted the length of hospital stay after TIPS placement (p = 0.005 and p = 0.01, respectively). CONCLUSION. MELD is superior to MELD-Na for predicting 30-day and, perhaps, 90-day mortality after TIPS placement. At present, decisions regarding patient selection for TIPS placement should be made on the basis of the MELD score rather than the MELD-Na score.


Subject(s)
Liver Failure/etiology , Liver Failure/mortality , Portasystemic Shunt, Transjugular Intrahepatic/mortality , Female , Humans , Length of Stay/statistics & numerical data , Male , Middle Aged , Patient Readmission/statistics & numerical data , Predictive Value of Tests , Prognosis , Retrospective Studies , Severity of Illness Index
17.
J Vasc Interv Radiol ; 31(6): 1018-1024.e4, 2020 06.
Article in English | MEDLINE | ID: mdl-32376173

ABSTRACT

PURPOSE: To demonstrate that random forest models trained on a large national sample can accurately predict relevant outcomes and may ultimately contribute to future clinical decision support tools in IR. MATERIALS AND METHODS: Patient data from years 2012-2014 of the National Inpatient Sample were used to develop random forest machine learning models to predict iatrogenic pneumothorax after computed tomography-guided transthoracic biopsy (TTB), in-hospital mortality after transjugular intrahepatic portosystemic shunt (TIPS), and length of stay > 3 days after uterine artery embolization (UAE). Model performance was evaluated with area under the receiver operating characteristic curve (AUROC) and maximum F1 score. The threshold for AUROC significance was set at 0.75. RESULTS: AUROC was 0.913 for the TTB model, 0.788 for the TIPS model, and 0.879 for the UAE model. Maximum F1 score was 0.532 for the TTB model, 0.357 for the TIPS model, and 0.700 for the UAE model. The TTB model had the highest AUROC, while the UAE model had the highest F1 score. All models met the criteria for AUROC significance. CONCLUSIONS: This study demonstrates that machine learning models may suitably predict a variety of different clinically relevant outcomes, including procedure-specific complications, mortality, and length of stay. Performance of these models will improve as more high-quality IR data become available.


Subject(s)
Data Mining/methods , Machine Learning , Radiography, Interventional/adverse effects , Adolescent , Adult , Aged , Aged, 80 and over , Child , Child, Preschool , Databases, Factual , Female , Hospital Mortality , Humans , Iatrogenic Disease , Image-Guided Biopsy/adverse effects , Infant , Infant, Newborn , Inpatients , Length of Stay , Male , Middle Aged , Pneumothorax/etiology , Portasystemic Shunt, Transjugular Intrahepatic/adverse effects , Portasystemic Shunt, Transjugular Intrahepatic/mortality , Radiography, Interventional/mortality , Retrospective Studies , Risk Assessment , Risk Factors , Time Factors , United States , Uterine Artery Embolization/adverse effects , Young Adult
18.
Dig Dis Sci ; 65(11): 3378-3388, 2020 11.
Article in English | MEDLINE | ID: mdl-32062714

ABSTRACT

BACKGROUND: It has been reported that transjugular intrahepatic portosystemic shunting (TIPS) might be utilized as a salvage option for hepatorenal syndrome (HRS), while randomized controlled trials are pending and real-world contemporary data on inpatient mortality is lacking. METHODS: We conducted an observational retrospective cohort study from the National Inpatient Sample from 2005 to 2014. We included all adult patients admitted with HRS and cirrhosis, using ICD 9-CM codes. We excluded cases with variceal bleeding, Budd-Chiari, end-stage renal disease, liver transplant and transfers to acute-care facilities. TIPS' association with inpatient mortality was assessed using multivariable mixed-effects logistic regression, as well as exact-matching, thus mitigating for TIPS selection bias. The exact-matched analysis was repeated among TIPS-only versus dialysis-only patients. RESULTS: A total of 79,354 patients were included. Nine hundred eighteen (1.2%) underwent TIPS. Between TIPS and non-TIPS groups, mean age (58 years) and gender (65% males) were similar. Overall mortality was 18% in TIPS and 48% in dialysis-only cases (n = 10,379; 13.1%). Ninety six (10.5%) TIPS patients underwent dialysis. In-hospital mortality in TIPS patients was twice less likely than in non-TIPS patients (adjusted odds ratio [aOR] = 0.43, 95% CI 0.30-0.62; p < 0.001), with similar results in matched analysis [exact-matched (em) OR = 0.39, 95% CI 0.17-0.89; p < 0.024; groups = 96; unweighted n = 463]. Head-to-head comparison showed that TIPS-only patients were 3.3 times less likely to succumb inpatient versus dialysis-only patients (contrast aOR = 0.31, 95% CI 0.20-0.46; p < 0.001), with similar findings post-matching (emOR = 0.22, 95% CI 0.15-0.33; p < 0.001; groups = 54, unweighted n = 1457). CONCLUSIONS: Contemporary, real-world data reveal that TIPS on its own, and when compared to dialysis, is associated with decreased inpatient mortality when utilized in non-bleeders-HRS patients. Further randomized studies are needed to establish the long-term benefit of TIPS in these patients.


Subject(s)
Hepatorenal Syndrome/mortality , Hepatorenal Syndrome/surgery , Hospital Mortality , Portasystemic Shunt, Transjugular Intrahepatic/mortality , Female , Humans , Male , Middle Aged , Retrospective Studies , Salvage Therapy , United States
19.
J Vasc Interv Radiol ; 31(3): 409-415, 2020 Mar.
Article in English | MEDLINE | ID: mdl-31982313

ABSTRACT

PURPOSE: To compare the safety and efficacy of transarterial chemoembolization for hepatocellular carcinoma (HCC) in patients with and without transjugular intrahepatic portosystemic shunts (TIPS). MATERIALS AND METHODS: This single-institution study included a retrospective review of 50 patients who underwent transarterial chemoembolization for HCC between January 2010 and April 2017. Twenty-five patients had preexisting TIPS, and 25 patients were selected to control for age, sex, and target tumor size. Baseline median Model for End-Stage Liver Disease (MELD; 13 TIPS, 9 control; P < .001) and albumin-bilirubin (ALBI; 3 TIPS, 2 control; P < .001) differed between groups. Safety was assessed on the basis of Common Terminology Criteria for Adverse Events (CTCAE) and change in MELD and ALBI grade assessed between 3 and 6 months. Efficacy was assessed by tumor response and time to progression (TTP). RESULTS: There was 1 severe adverse event (CTCAE grade >2) in the TIPS group. There was no difference in the change in MELD or ALBI grade. Although there was no difference in tumor response (P = .19), more patients achieved a complete response in the control group (19/25, 76%) than in the TIPS group (13/25, 52%). There was no difference in TTP (P = .82). At 1 year, 2 patients in the control group and 3 patients in the TIPS group received a liver transplant. Seven patients died in the TIPS group. CONCLUSIONS: Transarterial chemoembolization is as safe and effective in patients with TIPS as in patients without TIPS, despite worse baseline liver function. Severe adverse events are rare and may be transient.


Subject(s)
Carcinoma, Hepatocellular/therapy , Chemoembolization, Therapeutic , Liver Neoplasms/therapy , Portasystemic Shunt, Transjugular Intrahepatic , Aged , Carcinoma, Hepatocellular/diagnostic imaging , Carcinoma, Hepatocellular/mortality , Chemoembolization, Therapeutic/adverse effects , Chemoembolization, Therapeutic/mortality , Disease Progression , Female , Humans , Liver Neoplasms/diagnostic imaging , Liver Neoplasms/mortality , Liver Transplantation , Male , Middle Aged , Portasystemic Shunt, Transjugular Intrahepatic/adverse effects , Portasystemic Shunt, Transjugular Intrahepatic/mortality , Retrospective Studies , Risk Factors , Time Factors , Treatment Outcome
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