Right versus Middle Hepatic Vein access and One-Year TIPS Outcomes.

Abstract

Background: This study evaluates one-year clinical outcomes of transjugular intrahepatic portosystemic shunt (TIPS) placement using a middle hepatic vein (MHV) versus right hepatic vein (RHV) access. Primary end points were shunt patency and one-year survival. Secondary outcomes included incidence of de novo hepatic encephalopathy (HE) and recurrence of portal hypertension related complications such as ascites, hepatic hydrothorax, and gastrointestinal bleeding. While prior studies have examined portal vein target selection, the clinical relevance of hepatic vein choice remains understudied.

Methods: A retrospective chart review of adult patients who underwent TIPS using a Viatorr stent graft between January 2014 and December 2022 was conducted. Patients were included if the procedure used either RHV or the MHV. Intracardiac echocardiography (ICE) was employed to select a direct path from hepatic to portal vein. Shunts were dilated to 8 or 10 mm to achieve a post-procedural portosystemic gradient (PSG) ≤ 12 mmHg or a 50% reduction from baseline. Clinical and imaging data was analyzed to assess outcomes, stratified by hepatic vein of access.

Results: One-year survival (84% MHV vs 75% RHV, p = 0.2) and overall one-year patency rates (96% MHV vs 87% RHV, p = 0.5) were similar between the groups. However, MHV access significantly reduced de novo hepatic encephalopathy (30% MHV vs 62% RHV, p = 0.008) and moderate to severe cases (16% MHV vs 42% RHV, p = 0.017). Despite more frequent use of smaller diameter shunts (8 mm: 72% MHV vs 47% of RHV, p < 0.001), MHV access achieved similar post-TIPS portosystemic gradient reductions (Average Pre-TIPS gradient: 17 mmHg MHV & 17 mmHg RHV, p = 0.8; Average Post-TIPS gradient: 8 mmHg MHV & 7.5 mmHg RHV, p = 0.12). Hepatic vein choice did not affect outcomes for ascites, hydrothorax, or gastrointestinal bleeding.

Conclusion: MHV and RHV access routes provided similar patency, survival, and TIPS indication outcomes, but MHV access had decreased incidence of hepatic encephalopathy and achieved similar portosystemic gradient reduction while using a smaller diameter shunt. MHV may be a preferred option for patients at higher risk of developing hepatic encephalopathy.