Gastroesophageal Variceal Filling and Drainage Pathways: An Angiographic Description of Afferent and Efferent Venous Anatomic Patterns.

Varices commonly occur in liver cirrhosis patients and are classified as esophageal (EV), gastroesophageal (GEV), or isolated gastric (IGV) varices. These vessels may be supplied and drained by several different afferent and efferent pathways. A working knowledge of variceal anatomy is imperative for Interventional Radiologists performing transjugular intrahepatic portosystemic shunt and embolization/obliteration procedures. This pictorial essay characterizes the angiographic anatomy of varices in terms of type and frequency of venous filling and drainage, showing that different varices have distinct vascular anatomy. EVs typically show left gastric vein filling and "uphill" drainage, and GEVs and IGVs exhibit additional posterior/short gastric vein contribution and "downhill" outflow. An understanding of these variceal filling and drainage pathways can facilitate successful portal decompression and embolization/obliteration procedures.

Characterization of liver function parameter alterations after transjugular intrahepatic portosystemic shunt creation and association with early mortality.

OBJECTIVE: The purpose of this article is to characterize the temporal evolution and clinical impact of laboratory liver function parameters after transjugular intrahepatic portosystemic shunt (TIPS) creation. MATERIALS AND METHODS: In this single-institution retrospective study, 157 patients (98 men and 59 women; median age, 55 years) underwent TIPS between 2000 and 2012 and had 1-month hepatobiliary laboratory follow-up. Medical record review was used to compare baseline, peak, and low bilirubin, aspartate aminotransferase (AST), alanine aminotransferase (ALT), alkaline phosphatase, and international normalized ratio (INR) levels within 30 days after TIPS in surviving and dying patients to assess laboratory responses to shunt creation. RESULTS: TIPSs were created with a hemodynamic success rate of 98%, with median pressure gradient reduction of 13 mm Hg. Ninety-day mortality was 21%. Hepatobiliary laboratory values showed significant increases in the days after TIPS compared with baseline levels (bilirubin, 1.6 vs 3.5 mg/dL; AST, 49 vs 149 U/L; ALT, 26 vs 90 U/L; alkaline phosphatase, 97 vs 177 U/L; and INR, 1.5 vs 2.0; p<0.05 in all cases). Patients surviving to 90 days experienced statistically significant but transient laboratory value elevations-up to twofold over baseline-within days of TIPS, whereas patients dying within 90 days experienced three-to fourfold increases over a longer period that did not return to baseline. Differences in laboratory evolution were statistically significant in surviving versus dying patients. CONCLUSION: TIPS results in acute transient elevation of hepatobiliary enzymes, which may be more pronounced in patients with early mortality. An exaggerated laboratory elevation in excess of threefold greater than baseline or a prolonged increase exceeding 1 week may herald poorer clinical outcome.

Within-patient temporal variance in MELD score and impact on survival prediction after TIPS creation.

BACKGROUND: To assess within-patient temporal variability in Model for End Stage Liver Disease (MELD) scores and impact on outcome prognostication after transjugular intrahepatic portosystemic shunt (TIPS) creation. MATERIAL AND METHODS: In this single institution retrospective study, MELD score was calculated in 68 patients (M:F = 42:26, mean age 55 years) at 4 pre-procedure time points (1, 2-6, 7-14, and 15-35 days) before TIPS creation. Medical record review was used to identify 30- and 90-day clinical outcomes. Within-patient variability in pre-procedure MELD scores was assessed using repeated measures analysis of variance, and the ability of MELD scores at different time points to predict post-TIPS mortality was evaluated by comparing area under receiver operating characteristic (AUROC) curves. RESULTS: TIPS were successfully created for ascites (n = 30), variceal hemorrhage (n = 29), hepatic hydrothorax (n = 8), and portal vein thrombosis (n = 1). Pre-TIPS MELD scores showed significant (P = 0.032) within-subject variance that approached ± 18.5%. Higher MELD scores demonstrated greater variability in sequential scores as compared to lower MELD scores. Overall 30- and 90-day patient mortality was 22% (15/67) and 38% (24/64). AUROC curves showed that most recent MELD scores performed on the day of TIPS had superior predictive capacity for 30- (0.876, P = 0.037) and 90-day (0.805 P = 0.020) mortality compared to MELD scores performed 2-6 or 7-14 days prior. CONCLUSIONS: In conclusion, MELD scores show within-patient variability over time, and scores calculated on the day of TIPS most accurately predict risk and should be used for patient selection and counseling.

Older patient age may predict early mortality after transjugular intrahepatic portosystemic shunt creation in individuals at intermediate risk.

PURPOSE: To identify prognostic factors for early mortality among patients with intermediate-risk Model for End-stage Liver Disease (MELD) scores undergoing transjugular intrahepatic portosystemic shunt (TIPS) creation. MATERIALS AND METHODS: In this single-institution retrospective study, 47 patients (31 men; mean age, 54 y) with intermediate MELD scores (ie, 18-25) underwent TIPS creation between 1999 and 2012. Medical records were reviewed to identify demographic (age, sex), liver disease (Child-Pugh, MELD), and procedure data (indication, urgency, stent type, portosystemic pressure gradient reduction, complications), and the influence of these parameters on 90-day mortality was assessed by multivariate binary logistic regression analysis. RESULTS: TIPSs were successfully created for variceal hemorrhage (n = 24), ascites (n = 17), hydrothorax (n = 5), and portal vein thrombosis (n = 1). Hemodynamic success rate was 94% (44 of 47), and mean portosystemic pressure gradient reduction was 13 mm Hg. The 90-day mortality rate was 36% (17 of 47). Patient age (P = .026) was significantly associated with 90-day mortality. Mean ages of living versus dead patients were 51 and 60 years, and mortality rates in patients aged 54 years or younger versus 55 years or older were 21% (five of 24) and 52% (12 of 23), respectively. There was no difference in MELD scores between these age groups (20.6 vs 21.0; P = .600), and MELD score was not a predictive factor on regression analysis. CONCLUSIONS: Age is a prognostic factor for early mortality in TIPS recipients with intermediate MELD scores. Mortality rates are higher in patients at least 55 years of age, but MELD score does not predict survival in this subset. Age should be contemplated when selecting patients at intermediate risk for TIPS creation.

Prognostic capability of different liver disease scoring systems for prediction of early mortality after transjugular intrahepatic portosystemic shunt creation.

PURPOSE: To compare the performance of various liver disease scoring systems in predicting early mortality after transjugular intrahepatic portosystemic shunt (TIPS) creation. MATERIALS AND METHODS: In this single-institution retrospective study, eight scoring systems were used to grade liver disease in 211 patients (male-to-female ratio = 131:80; mean age, 54 y) before TIPS creation from 1999-2011. Scoring systems included bilirubin level, Child-Pugh (CP) score, Model for End-Stage Liver Disease (MELD) and Model for End-Stage Liver Disease sodium (MELD-Na) score, Emory score, prognostic index (PI), Acute Physiology and Chronic Health Evaluation (APACHE) 2 score, and Bonn TIPS early mortality (BOTEM) score. Medical record review was used to identify 30-day and 90-day clinical outcomes. The relationship of scoring parameters with mortality outcomes was assessed with multivariate analysis, and the relative ability of systems to predict mortality after TIPS creation was evaluated by comparing area under receiver operating characteristic (AUROC) curves. RESULTS: TIPS were successfully created for variceal hemorrhage (n = 121), ascites (n = 72), hepatic hydrothorax (n = 15), and portal vein thrombosis (n = 3). All scoring systems had a significant association with 30-day and 90-day mortality (P<.050 in each case) on multivariate analysis. Based on 30-day and 90-day AUROC, MELD (0.878, 0.816) and MELD-Na (0.863, 0.823) scores had the best capability to predict early mortality compared with bilirubin (0.786, 0.749), CP (0.822, 0.771), Emory (0.786, 0.681), PI (0.854, 0.760), APACHE 2 (0.836, 0.735), and BOTEM (0.798, 0.698), with statistical superiority over bilirubin, Emory, and BOTEM scores. CONCLUSIONS: Several liver disease scoring systems have prognostic value for early mortality after TIPS creation. MELD and MELD-Na scores most effectively predict survival after TIPS creation.