Davide Roccarina, Dario Saltini, Valentina Adotti, Martina Rosi, Marco Senzolo, Silvia Nardelli, Marcello Bianchini, Lara Biribin, Cristian Caporali, Falcini Margherita, Lucia Ragozzino, Tomas Guasconi, Federico Casari, Stefania Gioia, Claudia Campani, Francesco Prampolini, Angelica Ingravallo, Stefano Gitto, Silvia Aspite, Umberto Arena, Michele Citone, Melania Gaggini, Lorenzo Ridola, Giulio Barbiero, Salvatore De Masi, Oliviero Riggio, Manuela Merli, Fabrizio Fanelli, Sara Montagnese, Fabio Marra, Filippo Schepis, Francesco Vizzutti
{"title":"End-procedural adherence to recommended hemodynamic targets does not improve the outcome of elective tips in cirrhotic patients","authors":"Davide Roccarina, Dario Saltini, Valentina Adotti, Martina Rosi, Marco Senzolo, Silvia Nardelli, Marcello Bianchini, Lara Biribin, Cristian Caporali, Falcini Margherita, Lucia Ragozzino, Tomas Guasconi, Federico Casari, Stefania Gioia, Claudia Campani, Francesco Prampolini, Angelica Ingravallo, Stefano Gitto, Silvia Aspite, Umberto Arena, Michele Citone, Melania Gaggini, Lorenzo Ridola, Giulio Barbiero, Salvatore De Masi, Oliviero Riggio, Manuela Merli, Fabrizio Fanelli, Sara Montagnese, Fabio Marra, Filippo Schepis, Francesco Vizzutti","doi":"10.1097/hep.0000000000001224","DOIUrl":null,"url":null,"abstract":"Background & Aims: In clinical practice, the reduction of porto-caval pressure gradient (PCPG) following trans-jugular intra-hepatic porto-systemic shunt (TIPS) does not always meet the recommendation of current guidance. We evaluated the impact of different degrees of PCPG reduction, measured at the end of an elective TIPS, on ascites control, recurrence of portal hypertension-related bleeding (PHRB) and survival. Approach and Results: Cirrhotic patients receiving TIPS for refractory ascites (RA) or for the secondary prophylaxis of PHRB were consecutively enrolled. Reduction in PCPG was defined inadequate (IHR) in patients not achieving a PCPG <12 mm Hg for both secondary prophylaxis of PHRB and RA, or a reduction of at least 50% only for PHRB. Four-hundred-fifteen patients were analyzed. An adequate hemodynamic response (AHR) was achieved in 66%. Fifty percent of patients received an under-dilated (≤7 mm) endoprosthesis. No significant differences between patients with IHR and AHR were observed in rebleeding rate and ascites control, while overt hepatic encephalopathy was higher in AHR. Regardless of TIPS indication, survival was not significantly different between IHR and AHR, while advanced age and liver function before TIPS were significantly associated with a higher cumulative incidence of liver-related death. Notably, the cumulative incidence of liver-related mortality was higher in RA patients when AHR was defined as a post-TIPS PCPG <12 mm Hg or a reduction ≥50%. Conclusions: AHR measured at the end of an elective TIPS may not be essential to define the eventual outcome, while a marked drop in PCPG could negatively affect the prognosis of patients with RA.","PeriodicalId":177,"journal":{"name":"Hepatology","volume":"30 1","pages":""},"PeriodicalIF":12.9000,"publicationDate":"2025-01-07","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":"0","resultStr":null,"platform":"Semanticscholar","paperid":null,"PeriodicalName":"Hepatology","FirstCategoryId":"3","ListUrlMain":"https://doi.org/10.1097/hep.0000000000001224","RegionNum":1,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":null,"EPubDate":"","PubModel":"","JCR":"Q1","JCRName":"GASTROENTEROLOGY & HEPATOLOGY","Score":null,"Total":0}
引用次数: 0
Abstract
Background & Aims: In clinical practice, the reduction of porto-caval pressure gradient (PCPG) following trans-jugular intra-hepatic porto-systemic shunt (TIPS) does not always meet the recommendation of current guidance. We evaluated the impact of different degrees of PCPG reduction, measured at the end of an elective TIPS, on ascites control, recurrence of portal hypertension-related bleeding (PHRB) and survival. Approach and Results: Cirrhotic patients receiving TIPS for refractory ascites (RA) or for the secondary prophylaxis of PHRB were consecutively enrolled. Reduction in PCPG was defined inadequate (IHR) in patients not achieving a PCPG <12 mm Hg for both secondary prophylaxis of PHRB and RA, or a reduction of at least 50% only for PHRB. Four-hundred-fifteen patients were analyzed. An adequate hemodynamic response (AHR) was achieved in 66%. Fifty percent of patients received an under-dilated (≤7 mm) endoprosthesis. No significant differences between patients with IHR and AHR were observed in rebleeding rate and ascites control, while overt hepatic encephalopathy was higher in AHR. Regardless of TIPS indication, survival was not significantly different between IHR and AHR, while advanced age and liver function before TIPS were significantly associated with a higher cumulative incidence of liver-related death. Notably, the cumulative incidence of liver-related mortality was higher in RA patients when AHR was defined as a post-TIPS PCPG <12 mm Hg or a reduction ≥50%. Conclusions: AHR measured at the end of an elective TIPS may not be essential to define the eventual outcome, while a marked drop in PCPG could negatively affect the prognosis of patients with RA.
背景,目的:在临床实践中,经颈静脉肝内门静脉-腹腔分流术(TIPS)后门静脉-腔静脉压力梯度(PCPG)的降低并不总是符合当前指南的建议。我们评估了不同程度的PCPG降低(在选择性TIPS结束时测量)对腹水控制、门脉高压相关出血(PHRB)复发和生存的影响。方法和结果:连续纳入接受TIPS治疗难治性腹水(RA)或PHRB二级预防的肝硬化患者。对于PHRB和RA二级预防均未达到PCPG≤12 mm Hg的患者,或仅PHRB降低至少50%的患者,PCPG降低被定义为不充分(IHR)。对415名患者进行了分析。66%的患者获得了足够的血流动力学反应(AHR)。50%的患者接受了扩张不足(≤7mm)的假体植入。IHR和AHR患者在再出血率和腹水控制方面无显著差异,而AHR患者明显的肝性脑病更高。无论TIPS指征如何,IHR和AHR患者的生存率无显著差异,而TIPS前的高龄和肝功能与肝脏相关死亡的累积发生率较高显著相关。值得注意的是,当AHR被定义为tips后PCPG≤12 mm Hg或降低≥50%时,RA患者肝脏相关死亡率的累积发生率更高。结论:在选择性TIPS结束时测量AHR可能不是确定最终结果所必需的,而PCPG的显着下降可能会对RA患者的预后产生负面影响。
期刊介绍:
HEPATOLOGY is recognized as the leading publication in the field of liver disease. It features original, peer-reviewed articles covering various aspects of liver structure, function, and disease. The journal's distinguished Editorial Board carefully selects the best articles each month, focusing on topics including immunology, chronic hepatitis, viral hepatitis, cirrhosis, genetic and metabolic liver diseases, liver cancer, and drug metabolism.