Predicting death or recurrence of portal hypertension symptoms after TIPS procedures.
Shawn H Sun, Thomas Eche, Chloé Dorczynski, Philippe Otal, Paul Revel-Mouroz, Charline Zadro, Ephraim Partouche, Nadim Fares, Charlotte Maulat, Christophe Bureau, Lawrence H Schwartz, Hervé Rousseau, Laurent Dercle, Fatima-Zohra Mokrane
Author Information
Shawn H Sun: Department of Radiology, Columbia University Vagellos College of Physicians and Surgeons, New York, NY, 10032, USA.
Thomas Eche: Radiology Department, Rangueil University Hospital, 1, avenue du Professeur Jean Poulhes, 31059, Toulouse, France.
Chloé Dorczynski: Radiology Department, Rangueil University Hospital, 1, avenue du Professeur Jean Poulhes, 31059, Toulouse, France.
Philippe Otal: Radiology Department, Rangueil University Hospital, 1, avenue du Professeur Jean Poulhes, 31059, Toulouse, France.
Paul Revel-Mouroz: Radiology Department, Rangueil University Hospital, 1, avenue du Professeur Jean Poulhes, 31059, Toulouse, France.
Charline Zadro: Radiology Department, Rangueil University Hospital, 1, avenue du Professeur Jean Poulhes, 31059, Toulouse, France.
Ephraim Partouche: Radiology Department, Rangueil University Hospital, 1, avenue du Professeur Jean Poulhes, 31059, Toulouse, France.
Nadim Fares: Hepato-Gastroenterology Department, Purpan University Hospital, Toulouse, France.
Charlotte Maulat: The Digestive Surgery and Liver Transplantation Department, Toulouse University Hospital, Toulouse, France.
Christophe Bureau: Hepato-Gastroenterology Department, Purpan University Hospital, Toulouse, France.
Lawrence H Schwartz: Department of Radiology, Columbia University Vagellos College of Physicians and Surgeons, New York, NY, 10032, USA.
Hervé Rousseau: Radiology Department, Rangueil University Hospital, 1, avenue du Professeur Jean Poulhes, 31059, Toulouse, France.
Laurent Dercle: Department of Radiology, Columbia University Vagellos College of Physicians and Surgeons, New York, NY, 10032, USA. laurent.dercle@gmail.com.
Fatima-Zohra Mokrane: Radiology Department, Rangueil University Hospital, 1, avenue du Professeur Jean Poulhes, 31059, Toulouse, France. mokrane_fatimazohra@yahoo.fr. ORCID
BACKGROUND: Accurate prediction of portal hypertension recurrence after transjugular intrahepatic portosystemic shunt (TIPS) placement will improve clinical decision-making. PURPOSE: To evaluate if perioperative variables could predict disease-free survival (DFS) in cirrhotic patients with portal hypertension (PHT) treated with TIPS. MATERIALS AND METHODS: We recruited 206 cirrhotic patients with PHT treated with TIPS, randomly assigned to training (n = 138) and validation (n = 68) sets. We recorded 7 epidemiological, 4 clinical, and 9 radiological variables. TIPS-distal end positioning (TIPS-DEP) measured the distance between the distal end of the stent and the hepatocaval junction on contrast-enhanced CT scans. In the training set, the signature was defined as the random forest for survival algorithm achieving the lowest error rate for the prediction of DFS which was landmarked 4 weeks after the TIPS procedure. In the training set, a simple to use scoring system was derived from variables selected by the signature. The primary endpoint was to assess if TIPS-DEP was associated with DFS. The secondary endpoint was to validate the scoring system in the validation set. RESULTS: Overall, patients with TIPS-DEP ≥ 6 mm (n = 49) had a median DFS of 24.5 months vs. 72.8 months otherwise (n = 157, p = 0.004). In the training set, the scoring system was calculated by adding age ≥ 60 years old, Child-Pugh B or C, and TIPS-DEP ≥ 6 mm (1 point each) since the signature showed high DFS probability at 6.5 months post-landmark in patients that did not meet these criteria: 86%, 80%, and 78%, respectively. The hazard ratio [95 CI] between patients determined to be low-risk (< 2 points) and high-risk (≥ 2 points) was 2.30 [1.35-3.93] (p = 0.002) in the training set and 2.01 [0.94-4.32] (p = 0.072) in the validation set. CONCLUSION: TIPS-DEP is an actionable radiological biomarker which can be combined with age and Child-Pugh score to predict death or PHT symptom recurrence after TIPS procedure. KEY POINTS: • TIPS-DEP measurement was the third most important but only actionable variable for predicting DFS. • TIPS-DEP < 6 mm was associated with a DFS probability of 78% at 6.5 months post-landmark. • A simple scoring system calculated using age, Child-Pugh score, and TIPS-DEP predicted DFS after TIPS.
Altamirano-Barrera A, Barranco-Fragoso B, Mendez-Sanchez N (2017) Management strategies for liver fibrosis. Ann Hepatol 16:48–56
[DOI: 10.5604/16652681.1226814]
Blachier M, Leleu H, Peck-Radosavljevic M, Valla DC, Roudot-Thoraval F (2013) The burden of liver disease in Europe: a review of available epidemiological data. J Hepatol 58:593–608
[DOI: 10.1016/j.jhep.2012.12.005]
Boyer TD, Haskal ZJ, American Association for the Study of Liver Diseases (2005) The role of transjugular intrahepatic portosystemic shunt in the management of portal hypertension. Hepatology 41:386–400
[DOI: 10.1002/hep.20559]
Colapinto RF, Stronell RD, Birch SJ et al (1982) Creation of an intrahepatic portosystemic shunt with a Gruntzig balloon catheter. Can Med Assoc J 126:267–268
[>PMCID: ]
de Franchis R, Baveno VIF (2015) Expanding consensus in portal hypertension: report of the Baveno VI Consensus Workshop: stratifying risk and individualizing care for portal hypertension. J Hepatol 63:743–752
[DOI: 10.1016/j.jhep.2015.05.022]
European Association for the Study of the Liver (2018) EASL Clinical Practice Guidelines for the management of patients with decompensated cirrhosis. J Hepatol 69:406–460
[DOI: 10.1016/j.jhep.2018.03.024]
European Association for the Study of the Liver (2018) Corrigendum to “EASL Clinical Practice Guidelines for the management of patients with decompensated cirrhosis” [J Hepatol 69 (2018) 406–460]. J Hepatol 69:1207
[DOI: 10.1016/j.jhep.2018.08.009]
Bureau C, Thabut D, Oberti F et al (2017) Transjugular intrahepatic portosystemic shunts with covered stents increase transplant-free survival of patients with cirrhosis and recurrent ascites. Gastroenterology 152:157–163
[DOI: 10.1053/j.gastro.2016.09.016]
Garcia-Pagan JC, Caca K, Bureau C et al (2010) Early use of TIPS in patients with cirrhosis and variceal bleeding. N Engl J Med 362:2370–2379
[DOI: 10.1056/NEJMoa0910102]
Cazzaniga M, Salerno F, Pagnozzi G et al (2007) Diastolic dysfunction is associated with poor survival in patients with cirrhosis with transjugular intrahepatic portosystemic shunt. Gut 56:869–875
[DOI: 10.1136/gut.2006.102467]
Riggio O, Angeloni S, Salvatori FM et al (2008) Incidence, natural history, and risk factors of hepatic encephalopathy after transjugular intrahepatic portosystemic shunt with polytetrafluoroethylene-covered stent grafts. Am J Gastroenterol 103:2738–2746
[DOI: 10.1111/j.1572-0241.2008.02102.x]
Allaire M, Walter A, Sutter O et al (2020) TIPS for management of portal-hypertension-related complications in patients with cirrhosis. Clin Res Hepatol Gastroenterol 44:249–263
[DOI: 10.1016/j.clinre.2019.09.003]
Gaba RC, Khiatani VL, Knuttinen MG et al (2011) Comprehensive review of TIPS technical complications and how to avoid them. AJR Am J Roentgenol 196:675–685
[DOI: 10.2214/AJR.10.4819]
Triantafyllou T, Aggarwal P, Gupta E, Svetanoff WJ, Bhirud DP, Singhal S (2018) Polytetrafluoroethylene-covered stent graft versus bare stent in transjugular intrahepatic portosystemic shunt: systematic review and meta-analysis. J Laparoendosc Adv Surg Tech A 28:867–879
[DOI: 10.1089/lap.2017.0560]
Puttemans T, Agneessens E, Mathieu J (2000) T.I.P.S.: follow-up imaging and revision procedure. Acta Gastroenterol Belg 63:174–178
[PMID: 10925455]
Feldstein VA, Patel MD, LaBerge JM (1996) Transjugular intrahepatic portosystemic shunts: accuracy of Doppler US in determination of patency and detection of stenoses. Radiology 201:141–147
[DOI: 10.1148/radiology.201.1.8816535]
Violi NV, Lewis S, Hectors S, Said D, Taouli B (2019) Radiological diagnosis and characterization of HCC. Hepatocellular Carcinoma 71–92. https://doi.org/10.1007/978-3-030-21540-8_4
Heinzow HS, Lenz P, Kohler M et al (2012) Clinical outcome and predictors of survival after TIPS insertion in patients with liver cirrhosis. World J Gastroenterol 18:5211–5218
[>PMCID: ]
Angermayr B, Cejna M, Koenig F et al (2003) Survival in patients undergoing transjugular intrahepatic portosystemic shunt: ePTFE-covered stentgrafts versus bare stents. Hepatology 38:1043–1050
[DOI: 10.1002/hep.1840380431]
Clark TW, Agarwal R, Haskal ZJ, Stavropoulos SW (2004) The effect of initial shunt outflow position on patency of transjugular intrahepatic portosystemic shunts. J Vasc Interv Radiol 15:147–152
[DOI: 10.1097/01.RVI.0000109401.52762.56]
Klasen-Sansone J, Bode J, Lanzman RS et al (2015) TIPS geometry influences patency. Z Gastroenterol 53:28–32
[DOI: 10.1055/s-0034-1385430]
Luo SH, Chu JG, Huang H, Yao KC (2017) Effect of initial stent position on patency of transjugular intrahepatic portosystemic shunt. World J Gastroenterol 23:4779–4787
[DOI: 10.3748/wjg.v23.i26.4779]
Andring B, Kalva SP, Sutphin P et al (2015) Effect of technical parameters on transjugular intrahepatic portosystemic shunts utilizing stent grafts. World J Gastroenterol 21:8110–8117
[DOI: 10.3748/wjg.v21.i26.8110]
Dercle L, Ma J, Xie C et al (2020) Using a single abdominal computed tomography image to differentiate five contrast-enhancement phases: a machine-learning algorithm for radiomics-based precision medicine. Eur J Radiol 125:108850
[DOI: 10.1016/j.ejrad.2020.108850]
Mokrane FZ, Lu L, Vavasseur A et al (2020) Radiomics machine-learning signature for diagnosis of hepatocellular carcinoma in cirrhotic patients with indeterminate liver nodules. Eur Radiol 30:558–570
[DOI: 10.1007/s00330-019-06347-w]
Geeroms B, Laleman W, Laenen A et al (2017) Expanded polytetrafluoroethylene-covered stent-grafts for transjugular intrahepatic portosystemic shunts in cirrhotic patients: Long-term patency and clinical outcome results. Eur Radiol 27:1795–1803
[DOI: 10.1007/s00330-016-4570-5]
Perello MP, Mur JP, Vives MS et al (2019) Long-term follow-up of transjugular intrahepatic portosystemic shunt (TIPS) with stent-graft. Diagn Interv Radiol 25:346–352
[DOI: 10.5152/dir.2019.18416]
Vignali C, Bargellini I, Grosso M et al (2005) TIPS with expanded polytetrafluoroethylene-covered stent: results of an Italian multicenter study. AJR Am J Roentgenol 185:472–480
[DOI: 10.2214/ajr.185.2.01850472]
Silva-Junior G, Turon F, Baiges A et al (2017) Timing affects measurement of portal pressure gradient after placement of transjugular intrahepatic portosystemic shunts in patients with portal hypertension. Gastroenterology 152:1358–1365
[DOI: 10.1053/j.gastro.2017.01.011]
Setiawan VW, Stram DO, Porcel J, Lu SC, Le Marchand L, Noureddin M (2016) Prevalence of chronic liver disease and cirrhosis by underlying cause in understudied ethnic groups: the multiethnic cohort. Hepatology 64:1969–1977
[DOI: 10.1002/hep.28677]
Cornberg M, Razavi HA, Alberti A et al (2011) A systematic review of hepatitis C virus epidemiology in Europe, Canada and Israel. Liver Int 31(Suppl 2):30–60
[DOI: 10.1111/j.1478-3231.2011.02539.x]
Scheideler JK, Klein WMP (2018) Awareness of the link between alcohol consumption and cancer across the world: a review. Cancer Epidemiol Biomarkers Prev 27:429–437
[DOI: 10.1158/1055-9965.EPI-17-0645]
John U, Hanke M (2015) Liver cirrhosis mortality, alcohol consumption and tobacco consumption over a 62 year period in a high alcohol consumption country: a trend analysis. BMC Res Notes 8:822
[DOI: 10.1186/s13104-015-1808-2]
Greenbaum LD (2013) Foreword to guidelines and good clinical practice recommendations for Contrast enhanced ultrasound (CEUS) in the liver - update 2012. Ultrasound Med Biol 39:186
[DOI: 10.1016/j.ultrasmedbio.2012.09.021]
