Abstract
Background
Measuring the portal pressure gradient from the portal vein (PV) to the inferior vena cava (IVC) or to the right atrium (RA) remains controversial. The aim of our study was to compare the predictive ability of portoatrial gradient (PAG) and portocaval gradient (PCG) for variceal rebleeding.
Methods
The data of 285 cirrhotic patients with variceal bleeding undergoing elective transjugular intrahepatic portosystemic shunt (TIPS) in our hospital were analyzed retrospectively. The variceal rebleeding rates were compared between groups categorized by established or modified thresholds. The median follow-up time was 30.0 months.
Results
After TIPS, PAG was equal to (n = 115) or more than (n = 170) PCG. The pressure of IVC was defined as an independent predictor for a PAG-PCG difference of ≥ 2 mmHg (p < 0.001, OR 1.23, 95% CI 1.10–1.37). Using a threshold of 12 mmHg, PAG (p = 0.081, HR 0.63, 95% CI 0.37–1.06) could not predict variceal rebleeding but PCG could (p = 0.003, HR 0.45, 95% CI 0.26–0.77). This pattern was unchanged when a ≥ 50% reduction from baseline was also considered as a threshold (PAG/PCG: p = 0.114 and 0.001). Subgroup analyses showed that only in patients with post-TIPS IVC pressure < 9 mmHg (p = 0.018), PAG could predict variceal rebleeding. Because PAG was on average 1.4 mmHg higher than PCG, patients were classified by a PAG of 14 mmHg, and there was no difference in rebleeding rates between these two groups (p = 0.574).
Conclusions
For patients with variceal bleeding, the predictive ability of PAG is limited. The portal pressure gradient should be measured between the PV and IVC.
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Abbreviations
- CI:
-
Confidence interval
- GOV2:
-
Gastroesophageal varices type 2
- HR:
-
Hazard ratio
- IVC:
-
Inferior vena cava
- IVCP:
-
Inferior vena cava pressure
- MELD:
-
Model of end-stage liver disease
- NSBBs:
-
Non-selective beta-blocks
- OLT:
-
Orthotopic liver transplantation
- PPG:
-
Portal pressure gradient
- PAG:
-
Portoatrial gradient
- PCG:
-
Portocaval gradient
- PV:
-
Portal vein
- PVP:
-
Portal vein pressure
- RA:
-
Right atrium
- RAP:
-
Right atrium pressure
- sHR:
-
Subdistribution hazard ratio
- SPSS:
-
Spontaneous portosystemic shunts
- TIPS:
-
Transjugular intrahepatic portosystemic shunt
- VRB:
-
Variceal rebleeding
References
Garcia-Tsao G, Bosch J. Management of varices and variceal hemorrhage in cirrhosis. N Engl J Med. 2010;362:823–32.
de Franchis R, Bosch J, Garcia-Tsao G, et al. Baveno VII - renewing consensus in portal hypertension. J Hepatol. 2022;76:959–74.
Angeli P, Bernardi M, Villanueva C, Francoz C, Mookerjee RP, Trebicka J, Krag A, Laleman W, Gines P. Gines P (2018) EASL clinical practice guidelines for the management of patients with decompensated cirrhosis. J Hepatol. 2018;69:406–60.
Garcia-Tsao G, Abraldes JG, Berzigotti A, et al. Portal hypertensive bleeding in cirrhosis: risk stratification, diagnosis, and management: 2016 practice guidance by the American association for the study of liver diseases. Hepatology. 2017;65:310–35.
Boyer TD, Haskal ZJ. The role of transjugular intrahepatic portosystemic shunt in the management of portal hypertension. Hepatology. 2005;41:386–400.
Tripathi D, Stanley AJ, Hayes PC, et al. Transjugular intrahepatic portosystemic stent-shunt in the management of portal hypertension. Gut. 2020;69:1173–92.
La Mura V, Abraldes JG, Berzigotti A, et al. Right atrial pressure is not adequate to calculate portal pressure gradient in cirrhosis: a clinical-hemodynamic correlation study. Hepatology. 2010;51:2108–16.
Bosch J, Mastai R, Kravetz D, et al. Measurement of azygos venous blood flow in the evaluation of portal hypertension in patients with cirrhosis. Clinical and haemodynamic correlations in 100 patients. J Hepatol. 1985;1:125–39.
Gouya H, Grabar S, Vignaux O, et al. Portal hypertension in patients with cirrhosis: indirect assessment of hepatic venous pressure gradient by measuring azygos flow with 2D-cine phase-contrast magnetic resonance imaging. Eur Radiol. 2016;26:1981–90.
Dariushnia SR, Haskal ZJ, Midia M, et al. Quality improvement guidelines for transjugular intrahepatic portosystemic shunts. J Vasc Interv Radiol. 2016;27:1–7.
Boike JR, Thornburg BG, Asrani SK, et al. North american practice-based recommendations for transjugular intrahepatic portosystemic shunts in portal hypertension. Clin Gastroenterol Hepatol. 2021;20:1636–62.
Lv Y, Chen H, Luo B, et al. Transjugular intrahepatic portosystemic shunt with or without gastro-oesophageal variceal embolisation for the prevention of variceal rebleeding: a randomised controlled trial. Lancet Gastroenterol Hepatol. 2022;7:736–46.
Pitton MB, Weinmann A, Kloeckner R, et al. Transjugular portosystemic stent shunt: impact of right atrial pressure on portal venous hemodynamics within the first week. Cardiovasc Intervent Radiol. 2022;45:102–11.
Zhuang Z, Ma J, Ju S, et al. A new alternative technique for the guidance of transjugular intrahepatic portosystemic shunt creation using DSA overlay reference. Acta Radiol. 2022;64:868–73.
Markou N, Grigorakos L, Myrianthefs P, et al. Venous pressure measurements in the superior and inferior vena cava: the influence of intra-abdominal pressure. Hepatogastroenterology. 2004;51:51–5.
Gaba RC. Transjugular intrahepatic portosystemic shunt creation with embolization or obliteration for variceal bleeding. Tech Vasc Interv Radiol. 2016;19:21–35.
Chikamori F, Kuniyoshi N, Shibuya S, et al. Correlation between endoscopic and angiographic findings in patients with esophageal and isolated gastric varices. Dig Surg. 2001;18:176–81.
Tripathi D, Bureau C. Prophylactic embolization of large spontaneous portosystemic shunts with transjugular intrahepatic portosystemic shunt (TIPS): a panacea for post-TIPS hepatic encephalopathy? Hepatology. 2022;76:551–3.
Steinlauf AF, Garcia-Tsao G, Zakko MF, et al. Low-dose midazolam sedation: an option for patients undergoing serial hepatic venous pressure measurements. Hepatology. 1999;29:1070–3.
Reverter E, Blasi A, Abraldes JG, et al. Impact of deep sedation on the accuracy of hepatic and portal venous pressure measurements in patients with cirrhosis. Liver Int. 2014;34:16–25.
Silva-Junior G, Turon F, Baiges A, et al. Timing affects measurement of portal pressure gradient after placement of transjugular intrahepatic portosystemic shunts in patients with portal hypertension. Gastroenterology. 2017;152:1358–65.
Mollaiyan A, Bettinger D, Rossle M. The underdilation of nitinol stents at TIPS implantation: solution or illusion? Eur J Radiol. 2017;89:123–8.
Zheng M, Chen Y, Bai J, et al. Transjugular intrahepatic portosystemic shunt versus endoscopic therapy in the secondary prophylaxis of variceal rebleeding in cirrhotic patients: meta-analysis update. J Clin Gastroenterol. 2008;42:507–16.
Chen S, Li X, Wei B, et al. Recurrent variceal bleeding and shunt patency: prospective randomized controlled trial of transjugular intrahepatic portosystemic shunt alone or combined with coronary vein embolization. Radiology. 2013;268:900–6.
Acknowledgements
The authors thank for Danqing Zhao’s valuable statistical assistance.
Funding
This study was supported by grants from Device development exploration project from National Clinical Research Center for Interventional Medicine (2021–001), Shanghai key clinical specialty construction program (W2019028), Excellent youth program from Zhongshan Hospital, Fudan University (2019ZSYXQN38) and Clinical research special fund from Zhongshan Hospital, Fudan University (2018ZSLC23).
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Conceptualization: JL and JM; Methodology: ZY and JL; Formal analysis and investigation: YL, WZ, ZZ, MY, JY, XZ, SC and JW; Writing—original draft preparation: LM; Writing—review and editing: JL and JM. Funding acquisition: ZY, JL and JM; All authors read and approved the final manuscript.
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The protocol of this study was approved by the ethics committee of Zhongshan hospital, Fudan university (No. B2022-017R). This study was conducted in accordance with the Helsinki Declaration.
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Ma, L., Liu, Y., Yan, Z. et al. Comparing the predictive ability of portoatrial and portocaval gradient after transjugular intrahepatic portosystemic shunt creation for variceal rebleeding. J Gastroenterol 58, 494–502 (2023). https://doi.org/10.1007/s00535-023-01977-w
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DOI: https://doi.org/10.1007/s00535-023-01977-w