Patients
A retrospective analysis of 9 consecutive patients (6 males and 3 females was conducted; age range 49-78 years; median age, 59 years) who were diagnosed with GS-related HSOS and received TIPS at Union Hospital, Tongji Medical College, Huazhong University of Science and Technology from January 2014 to July 2019. Based on the diagnostic criteria for GS-related HSOS in China [7], the patients were diagnosed as GS-related HSOS when they had 1) a history of recent GS intake, 2) clinical manifestation of hepatomegaly, jaundice and ascites, 3) laboratory values showing liver function abnormalities, especially an increase in total bilirubin, and 4) characteristic findings of HSOS on CT images, including hepatomegaly, hepatic parenchyma with heterogeneous hypoattenuation, patchy heterogeneous enhancement with or without thin or non-visualized hepatic veins. Patients were excluded from this study if they had any other potential risk factors associated with the development of HSOS, such as pre-existing liver disease and bone marrow transplantation [3]. They were also unsuitable for or unwilling to liver transplantation.
This study was approved by the Ethics Committee of Tongji Medical College, Huazhong University of Science and Technology (IORG No: IORG0003571) and performed in accordance with local and national laws and the principles of the declaration of Helsinki. Written informed consent was obtained for all patients.
Pre-TIPS workup and medication
Prior to TIPS, all patients underwent complete history and physical examination with particular attention to liver disease and patients’ performance status. A contrast-enhanced CT scan was performed on all patients to assess the hepatic and vascular anatomy and to select the most proper portosystemic shunting tract. Baseline laboratory values, including liver function tests, complete blood count, creatinine, and coagulation profile were also obtained. Hepatic encephalopathy (HE) was graded based on the West Haven Grading System [12].
Of the 9 patients, 7 received at least 2 weeks of supportive measures including fluid and sodium restriction, diuretics and therapeutic paracenteses, combined with anticoagulation with low molecular weight heparin. The remaining two subjects received supportive measures alone as obvious gastroesophageal varices were noted on pre-procedure CT scan, but the symptoms did not improve or became worse. After TIPS, all patients received extended anticoagulation with oral warfarin until complete remission.
TIPS procedure
The TIPS procedure was performed under the guidance of ultrasound and digital subtraction angiography (Artis Zee Celling, Siemens Medical Solutions, Muenchen, Germany). In summary, venous access was attained through the right internal jugular vein, then afterwards the right or middle hepatic vein was catheterized. A standard Rösch-Uchida TIPS set (Cook Medical, Bloomington, IN, US) was used to create a parenchymal tract between the hepatic vein and the intrahepatic portion of the portal vein. In some patients in whom access to the portal vein by transhepatic puncture proved difficult, percutaneous insertion of a 0.014-in wire into the portal system would be used to provide access. After measurement of pressures in the portal vein and the right atrium, the tract was dilated with balloon catheters, and then a bare stent (Bard E-Luminexx® Vascular Stent, C. R. Bard, Inc, Karlsruhe, Germany) followed by a stent-graft (Viabahn, W. L. Gore & Associates, Inc, Flagstaff, Arizona, US) were deployed in series to line the tract and dilated to achieve an internal diameter. All stents were 8 mm in size. The length of bare stent was selected according to the general rule of thumb, measuring the length from the entry site in the portal vein to the inferior vena cava and then adding 1-2 cm to the length. The added length of bare metal was meant to be in the portal vein. The covered stents were 5 or 10 cm in length, with its distal portion extending slightly into the portal vein. No further embolization of gastroesophageal varices was required in all patients. The portosystemic pressure gradient (PPG) was measured after the creation of portosystemic shunts (Figure 1a-f). Technical success of the TIPS was defined as the successful creation of a shunt between the hepatic vein and intrahepatic branch of the portal vein.
Complications and efficacy evaluation
The complications related to the TIPS procedure, including hepatic venography, nontarget needle puncture and stent malposition, were assessed during periprocedural period. The incidence of post-TIPS complications, such as shunt failure, development of HE, liver failure and other severe adverse events, were also assessed during the periprocedural and follow-up periods.
All patients underwent repeat clinical and laboratory assessment 5–7 days after TIPS, and then were followed up at 1 month and every 3–6 months thereafter. The follow-up CT scan was performed for assessment of stent patency as well as hepatic and vascular changes. The maximal liver height was measured on coronal CT image and the diameter of the portal vein trunk was measured on axial CT images by two experienced radiologists in consensus. Patients were followed up until death, loss to follow-up or the end of the study (October, 2019).
Statistical analysis
Statistical analysis was performed by using SPSS 17.0 software (SPSS, Chicago, Ill). Data was presented as mean ± standard deviation and as range and median unless otherwise stated. Difference in PPG, bilirubin, ascites and CT findings before and after TIPS were compared with Mann-Whitney U-test. A P value of less than 0.05 was considered statistically significant.