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ObjectiveTo investigate the influencing factors for overt hepatic encephalopathy (OHE) in patients with hepatitis B cirrhosis after transjugular intrahepatic portosystemic shunt (TIPS), and to construct an individualized risk prediction model. MethodsA total of 302 patients with hepatitis B cirrhosis who underwent TIPS in Department of Gastroenterology, The General Hospital of Western Theater Command, from January 2017 to December 2021 were enrolled, and according to the presence or absence of OHE after surgery, they were divided into non-OHE group with 237 patients and OHE group with 65 patients. The two groups were compared in terms of general data, laboratory markers, Child-Turcotte-Pugh (CTP) score, MELD combined with serum sodium concentration (MELD-Na) score, and albumin-bilirubin (ALBI) score before surgery. The independent-samples t test or the Mann-Whitney U test was used for comparison of continuous data between two groups, and the chi-square test was used for comparison of categorical data between two groups. The univariate and multivariate logistic regression analyses were used to identify the influencing factors for OHE after TIPS in patients with hepatitis B cirrhosis, and independent influencing factors were used to construct a nomogram model. The receiver operating characteristic (ROC) curve analysis and the calibration curve analysis were used to evaluate the discriminatory ability and calibration of the model, and the decision curve analysis and the clinical impact curve (CIC) were used to evaluate the clinical effectiveness of the model . ResultsAge (odds ratio [OR]=1.035, 95% confidence interval [CI]: 1.004 — 1.066, P<0.05), white blood cell count (WBC)/platelet count (PLT) ratio (OR=33.725, 95%CI: 1.220 — 932.377, P<0.05), international normalized ratio (INR) (OR=5.149, 95%CI: 1.052 — 25.207, P<0.05), and pre-albumin (PAB) (OR=0.992, 95%CI: 0.983 — 1.000, P<0.05) were independent predictive factors for OHE after TIPS in patients with hepatitis B cirrhosis. The nomogram model constructed based on age, WBC/PLT ratio, INR, and PAB had an area under the ROC curve of 0.716 (95%CI: 0.649 — 0.781), with a sensitivity of 78.5% and a specificity of 56.1%. ConclusionThe nomogram model constructed based on age, WBC/PLT ratio, INR, and PAB can help to predict the risk of OHE after TIPS in patients with hepatitis B cirrhosis.
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Objective To compare the value of Child-Pugh score, Model for End-Stage Liver Disease (MELD) score, MELD combined with serum sodium concentration (MELD-Na) score, CLIF Consortium Acute Decompensation (CLIF-C AD) score, and Freiburg index of post-transjugular intrahepatic portosystemic shunt (TIPS) survival (FIPS) score in predicting the survival of patients undergoing TIPS. Methods A retrospective analysis was performed for the clinical data of 447 patients with liver cirrhosis who underwent TIPS in several hospitals in southwest China, among whom there were 306 patients in the survival group and 62 in the death group. The scores of the above five models were calculated, and a survival analysis was performed based on these models. The independent samples t -test was used for comparison of normally distributed continuous data between groups, and the non-parametric Mann-Whitney U test was used for comparison of non-normally distributed continuous data between groups; the Pearson chi-square test was used for comparison of categorical data between groups; a multivariate Cox regression analysis was used for correction analysis of known influencing factors with statistical significance which were not included in the scoring models; the Kaplan-Meier method was used to evaluate the discriminatory ability of each model in identifying risks in the surgical population, and the log-rank test was used for analysis. The area under the receiver operating characteristic curve (AUC), C-index at different time points, and calibration curve were used to evaluate the predictive ability of each scoring model. Results Compared with the death group, the survival group had significantly lower age ( Z =2.884, P < 0.05), higher albumin ( t =3.577, P < 0.05), and Na + ( Z =-3.756, P < 0.05) and significantly lower proportion of patients with alcoholic cirrhosis ( χ 2 =22.674, P < 0.05), aspartate aminotransferase ( Z =2.141, P < 0.05), prothrombin time ( Z =2.486, P < 0.05), international normalized ratio ( Z =2.429, P < 0.05), total bilirubin ( Z =3.754, P < 0.05), severity of ascites ( χ 2 =14.186, P < 0.05), and scores of the five models (all P < 0.05). Survival analysis showed that all scoring models effectively stratified the prognostic risk of the patients undergoing TIPS. Comparison of the C-index of each scoring model at different time points showed that Child-Pugh score had the strongest ability in predicting postoperative survival, followed by MELD-Na score, MELD score, and CLIF-C AD score, and FIPS score had a relatively poor predictive ability; in addition, the prediction efficiency of each score gradually decreased over time. Child-Pugh score had the largest AUC of 0.832 in predicting 1-year survival rate after surgery, and MELD-Na score had the largest AUC of 0.726 in predicting 3-year survival rate after surgery, but FIPS score had a poor ability in predicting 1- and 3-year survival rates. Conclusion All five scoring models can predict the survival of patients with liver cirrhosis after TIPS and can provide effective stratification of prognostic risk for such patients. Child-Pugh score has a better ability in predicting short-term survival, while MELD-Na score has a better ability in predicting long-term survival, but FIPS score has a relatively poor predictive ability in predicting both short-term and long-term survival.
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Transjugular intrahepatic portosystemic shunt (TIPS) is a safe and effective method for the treatment of portal hypertension complications in patients with decompensated liver cirrhosis. At present, there are many prognostic scoring tools for risk stratification of poor prognosis after TIPS. This article briefly introduces seven prognostic scoring tools commonly used for TIPS and summarizes the clinical research evidence of each scoring tool. The literature review shows that there is currently no sufficient research evidence to determine the optimal prognostic scoring tool after TIPS. Future clinical studies should comprehensively explore the advantages and disadvantages of different scoring tools in predicting short- and long-term adverse prognostic events after TIPS and develop new prognostic scoring tools in combination with new prognostic markers.
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Objective To investigate the long-term efficacy of transjugular intrahepatic portosystemic shunt (TIPS) in the treatment of primary biliary cholangitis (PBC) with portal hypertension. Methods A retrospective analysis was performed for 102 patients who received TIPS in Affiliated Drum Tower Hospital of Nanjing University Medical School from January 2015 to August 2021, and these patients were divided into PBC group with 41 patients and viral hepatitis cirrhosis group with 81 patients. Related indicators were collected, including routine blood test results, liver and renal function, coagulation function, portal vein thrombosis, hepatic encephalopathy, and etiology of TIPS treatment shortly after admission, preoperative portal venous pressure, and stents used in surgery, and Child-Pugh score was calculated. Follow-up data were collected and analyzed, including postoperative upper gastrointestinal rebleeding, stent dysfunction, hepatic encephalopathy, and the data on survival and prognosis. The independent samples t -test was used for comparison of normally distributed continuous data between two groups, and the Mann-Whitney U test was used for comparison of continuous data with skewed distribution between two groups; the chi-square test was used for comparison of categorical data between two groups. The Kaplan-Meier method was used for survival analysis, and the log-rank test was used for survival difference analysis. Results In the PBC group and the viral hepatitis cirrhosis group, the median percentage of reduction in portal venous pressure after surgery was 33.00% and 35.00%, respectively, and there was no significant difference between the two groups ( P > 0.05). At the end of follow-up, there were no significant differences between the PBC group and the viral hepatitis cirrhosis group in stent dysfunction rate (14.63% vs 24.69%, χ 2 =1.642, P > 0.05), upper gastrointestinal rebleeding rate (17.07% vs 24.69%, χ 2 =0.917, P > 0.05), the incidence rate of overt hepatic encephalopathy (12.20% vs 7.41%, χ 2 =0.289, P > 0.05), and disease-specific death rate (14.63% vs 9.88%, χ 2 =0.229, P > 0.05). Conclusion For PBC patients with portal hypertension, TIPS can achieve the same efficacy as the treatment of portal hypertension caused by viral hepatitis cirrhosis and can also effectively reduce portal hypertension without increasing the incidence rate of complications and disease-specific death rate. Therefore, it is a safe and effective treatment method.
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Transjugular intrahepatic portosystemic shunt (TIPS) is a procedure to establish a portosystemic shunt between the hepatic vein and the portal vein via the jugular approach, so as to reduce portal venous pressure and control acute esophagogastric variceal bleeding (EGVB). The prognosis of EGVB has been improved significantly over the past few decades, and endoscopic variceal ligation combined with drug therapy is now recommended as the first-line treatment regimen for this disease. The latest research advances in the management of EGVB over the past decade have focused on the relatively new concept of "early" or "pre-emptive" TIPS, that is to say, early TIPS (within 72 hours after admission, ideally within 24 hours) is recommended for patients with EGVB who are at a relatively high risk of failure in standard treatment. This article briefly introduces the effect of early TIPS on controlling bleeding, mortality rate, and hepatic encephalopathy, the high-risk population for early TIPS, timing of intervention, cost effectiveness, the applications of early TIPS in a real-world setting, and recommendations for early TIPS in international guidelines and consensus statements.
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Esophagogastric variceal bleeding (EGVB) is one of the main complications of decompensated portal hypertension, especially in patients with liver cirrhosis, and it often has a high mortality rate. Medication combined with endoscopy is the main prevention and treatment method for EGVB, while transjugular intrahepatic portosystemic shunt (TIPS) combined with variceal embolization can also be selected for some high-risk patients, and individualized diagnosis and treatment of portal hypertension based on hepatic venous pressure gradient should become the latest consensus and the main strategy. This article mainly reviews endoscopic therapy and TIPS for the prevention and treatment of EGVB patients with decompensated portal hypertension in terms of selection of indications, incidence rate of complications, and respective advantages and disadvantages.
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Refractory ascites is one of the common complications of portal hypertension in decompensated liver cirrhosis and is characterized by extremely poor prognosis and high mortality rate. Transjugular intrahepatic portosystemic shunt (TIPS) is recommended by several international and national guidelines as one of the treatment methods after failure of large volume paracentesis combined protein infusion therapy. TIPS can effectively control the recurrence of ascites, but it can increase the risk of hepatic encephalopathy, and there are still controversies over whether it can prolong survival time. With a deeper understanding of TIPS, the maturity of surgical techniques, and the update of stent materials, it is urgent to reevaluate the position of TIPS in the treatment of refractory ascites due to portal hypertension. This article reviews the current status and advances in TIPS for the treatment of refractory ascites due to portal hypertension.
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Sarcopenia is a common complication of liver cirrhosis and is significantly associated with poor prognosis. Transjugular intrahepatic portosystemic shunt (TIPS) is an important method for the treatment of portal hypertension and its complications. Based on current studies, this article analyzes the association between sarcopenia and the outcomes (hepatic encephalopathy and mortality) of patients with liver cirrhosis after TIPS and the value of improving the predictive ability of existing prognostic models for sarcopenia, as well as the improvement in sarcopenia after TIPS and its significance in the clinical management of patients with liver cirrhosis. A comprehensive analysis of existing reports show that baseline sarcopenia is associated with poor prognosis after TIPS, and it is thus recommended to evaluate nutritional status before TIPS based on radiological examination; TIPS can improve nutritional status and help to achieve reversal or improvement of sarcopenia to a certain extent, and it can also be translated into survival benefit. Therefore, for patients with sarcopenia and a relatively stable disease, TIPS can be performed as soon as possible after comprehensive evaluation.
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Objective:To investigate the feasibility and safety of endoscopic ultrasound (EUS)-guided intrahepatic portal vein puncture through jugular vein implantation in transjugular intrahepatic portosystemic shunt (TIPS).Methods:As research subjects, 5 beagle dogs were anesthetized, and EUS was placed through the jugular vein to observe the intrahepatic portal vein. Under real-time guidance, the portal vein was punctured and a stent was placed to complete the TIPS.Results:Among the 5 beagles, EUS was unable to be placed in 1 due to the small diameter of the external jugular vein, and it was implanted successfully in 4 others through the external jugular vein who underwent real-time guidance of portal vein puncture. Subsequent stent placement and balloon dilation were completed. All animals survived after the experiment.Conclusion:EUS-guided intrahepatic portal vein puncture through jugular vein implantation is safe and feasible in TIPS.
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Objective To observe the effectiveness and safety of Viatorr stent applicated in TIPS for treating primary hepatic carcinoma(PHC)complicated with liver cirrhosis and upper gastrointestinal hemorrhage.Methods Date of 20 PHC patients complicated with liver cirrhosis and upper gastrointestinal hemorrhage who underwent TIPS using Viatorr stent were retrospectively analyzed.The technical success rate of TIPS,clinical success rate,complications,recurrence of upper gastrointestinal hemorrhage and the patency of stent shunt 1,3,6 and 12 months after TIPS were recorded.Results TIPS was successfully completed in all 20 cases,and the technical success rate was 100%.The portal venous pressure was(37.58±7.26)mmHg before TIPS and(18.35±6.47)mmHg after TIPS,and the difference was significant(P<0.05).No active bleeding nor declined hemoglobin was found within 72 h after TIPS,and the clinical success rate was 100%(20/20).No severe complication such as intraperitoneal hemorrhage,hemorrhage caused by hepatic carcinoma rupture nor bile leakage occurred.During the follow-up period,hepatic encephalopathy occurred in 4 cases(4/20,20.00%)but alleviated after symptomatic treatments.Recurrence of upper gastrointestinal hemorrhage was noticed in 2 cases(2/20,10.00%),while 6 patients died(6/20,30.00%).One,3,6 and 12 months after TIPS,the patency of stent shunt was 100%(20/20),100%(20/20),100%(20/20)and 95.00%(19/20),respectively.Conclusion Viatorr stent applicated in TIPS was effective and safe for treating PHC complicated with liver cirrhosis and upper gastrointestinal hemorrhage.
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Objective:To investigate the value of age shock index (Age-SI) in predicting rebleeding and death in patients with liver cirrhosis complicated with acute portal vein thrombosis treated by transjugular intrahepatic portosystemic shunt (TIPS).Methods:A total of 134 patients with liver cirrhosis complicated with acute portal vein thrombosis treated in West China Hospital of Sichuan University from April 2019 to April 2021 were selected, all patients were treated with TIPS, the differences of clinical data between rebleeding and no rebleeding, death and survival were observed and analyzed.Results:The age, child Pugh grade C ratio, Age-SI and neutrophil lymphocyte ratio (NLR) of patients with rebleeding were (57.28±9.92)years, 42.11%, (54.68±7.8) and (4.40±0.92), respectively, which were significantly higher than those of patients without rebleeding ( P<0.05). The age of dead patients, the course of liver cirrhosis, Age-SI and NLR were (59.90±9.81)years, (60.86±9.82)months, (55.47±7.64) and (4.76±0.99), respectively, which were significantly higher than those of surviving patients ( P<0.05). Logistic regression analysis showed that age, Age-SI and NLR were the influencing factors of rebleeding ( P<0.05), and Age, course of liver cirrhosis and Age-SI were the influencing factors of death ( P<0.05). The area under the receiver operating characteristic (ROC) curve for predicting rebleeding by Age-SI was 0.862( P<0.05); The area under the ROC curve for predicting death by Age-SI was 0.854 ( P<0.05). Conclusions:Age-SI has high application value in predicting rebleeding and death in patients with liver cirrhosis complicated with acute portal vein thrombosis treated with TIPS, which is worthy of further study.
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Transjugular intrahepatic portosystemic shunt (TIPS) has been recommended as a treatment method for cirrhotic portal hypertension in domestic and foreign guidelines, but there is still uncertainty in its therapeutic efficacy. More and more studies have shown that TIPS combined with collateral vessel embolization (TIPS+E) has certain advantages in the treatment of gastroesophageal variceal bleeding in liver cirrhosis. This article reviews the major studies on TIPS+E in China and globally, summarizes related recommendations in guidelines and the current status of clinical application, and proposes the issues that need to be solved, such as indication, hemodynamic criteria, and selection of materials for embolization, and large-sample multicenter randomized controlled trials are needed for further clarification.
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Gastroesophageal variceal bleeding is the life-threating complication of cirrhotic portal hypertension, and transjugular intrahepatic portosystemic shunt (TIPS) is an effective therapy for portal hypertension-related complications. TIPS can be used for the prevention of first-time bleeding in patients with recurrent or intractable ascites. TIPS should be performed as early as possible for patients at a high risk of acute variceal bleeding (Child-Pugh class C 7 points with active bleeding on endoscopy or hepatic venous pressure > 20 mmHg). TIPS is an effective salvage therapy for acute variceal bleeding with failure after standard treatment, and is also a second-line option for preventing variceal rebleeding.
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Hepatic sinusoidal obstruction syndrome (HSOS) is a vascular liver disease characterized by varying degrees of liver injury and portal hypertension. HSOS in China is mostly associated with the intake of pyrrolizidine alkaloids. The step-up approach with anticoagulant therapy and transjugular intrahepatic portosystemic shunt (TIPS) as the core treatment methods is the therapy currently recommended for this disease. Subcutaneous injection of low-molecular-weight heparin is the first choice for anticoagulant therapy, and oral warfarin can be used in combination or sequentially to enhance anticoagulation. Patients with no response to anticoagulant therapy can switch to TIPS. The Drum Tower Severity Score (DTSS) system can be used during treatment to evaluate the severity of the disease, in order to identify high-risk patients earlier and switch to TIPS in time, thereby improving the prognosis of patients.
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Liver cirrhosis is the end stage of various chronic liver diseases, and portal hypertension is a main complication of liver cirrhosis. In this pathological state, spontaneous portosystemic shunt (SPSS), as the collateral circulation of the portal venous system, has not attracted enough attention in terms of occurrence mechanism and clinical value. The analysis shows that although SPSS is a natural shunt channel, further studies are still needed to clarify whether it can be used as a decompression method for portal hypertension, and a deeper understanding of SPSS will provide important guiding significance for the diagnosis and treatment of portal hypertension.
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Liver cirrhosis is the end stage of various chronic liver diseases, and portal hypertension is a main complication of liver cirrhosis. In this pathological state, spontaneous portosystemic shunt (SPSS), as the collateral circulation of the portal venous system, has not attracted enough attention in terms of occurrence mechanism and clinical value. The analysis shows that although SPSS is a natural shunt channel, further studies are still needed to clarify whether it can be used as a decompression method for portal hypertension, and a deeper understanding of SPSS will provide important guiding significance for the diagnosis and treatment of portal hypertension.
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Hepatic encephalopathy (HE) is a common complication after transjugular intrahepatic portosystemic shunt (TIPS), and there are still no systematic strategies for prevention and treatment at present. Based on recent studies in China and foreign countries, this article analyzes and summarizes the risk factors for HE after TIPS and the advances in treatment and prevention. It is pointed out that early diagnosis and prevention of covert HE should be emphasized in further research, and it is important to standardize the prevention strategies for HE after TIPS.
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Globally, the population living with liver cirrhosis is growing. There is the largest number of cirrhosis patients in China throughout the world. Acute-on-chronic liver failure (ACLF) is a clinical syndrome of sudden hepatic decompensations such as variceal bleeding, spontaneous bacterial peritonitis, hepatic encephalopathy and hepatorenal syndrome seen in patients with liver cirrhosis. ACLF leads to poor quality of life and high mortality. Portal hypertension is not only a consequence of the development of cirrhosis, but also a secondary or even superimposed attack to the development of cirrhosis. It is necessary to early reduce intrahepatic resistance by transjugular intrahepatic portosystemic shunt and drugs to improve the prognosis.
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Esophageal and gastric variceal bleeding (EGVB) is a serious complication of portal hypertension, and it is necessary to control the progression of esophageal and gastric varices in clinical practice and prevent and treat EGVB; however, the mortality rate associated with variceal rupture and bleeding remains high at present. As for clinical treatment, risk classification of patients should be performed based on clinical and hemodynamic features and individualized treatment should be adopted, taking into account the balance of "embolization, shunt, and perfusion" of portal hypertension, so as to improve the clinical outcome and prognosis of patients with liver cirrhosis.
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Sarcopenia is a common and insidious complication in patients with liver cirrhosis and is closely associated with the prognosis of patients with liver cirrhosis. Transjugular intrahepatic portosystemic shunt (TIPS) is an important method for the treatment of portal hypertension-related complications. More and more studies have shown that sarcopenia is associated with the prognosis of cirrhotic portal hypertension after TIPS. This article reviews the research on sarcopenia and its association with TIPS in China and globally, in order to explore the association between them and guide clinical treatment.