Three-Dimensional Transjugular Intrahepatic Portosystemic Shunt Geometry Predicts Shunt Dysfunction

Abstract

Background: Patients with decompensated cirrhosis are at risk of portal hypertension-related complications, such as refractory ascites or variceal bleeding. Transjugular intrahepatic portosystemic shunt (TIPS) insertion is the most effective treatment to reduce portal hypertension. However, patients are at risk for TIPS dysfunction.

Aims: We aimed to investigate the prognostic value of three-dimensional (3D) TIPS geometry in predicting TIPS dysfunction.

Methods: A total of 107 patients who underwent TIPS insertion between 2014 and 2019 and received a computed tomography (CT) scan after TIPS insertion during routine clinical practice were included. We used a semiautomated algorithm and multiplanar reconstructions of these CT scans to calculate parameters of 3D TIPS geometry. The primary outcome of this study was the development of TIPS dysfunction (defined as need for invasive TIPS revision). To identify predictors for the development of TIPS dysfunction, Cox regression analyses were performed with TIPS dysfunction as the endpoint.

Results: Thirty-two patients developed TIPS dysfunction and were compared to the dysfunction-free 75 patients. A larger distance from the cranial TIPS stent end to the vena cava inferior (p < 0.001, HR 1.061, 95% CI 1.030-1.093) and the maximum stent curvature (p = 0.003, HR 1.020, 95% CI 1.007-1.034) were significantly associated with TIPS dysfunction in a multivariate Cox regression analysis.

Conclusion: A more pronounced stent curvature and a longer cranial stent distance from the inferior vena cava were identified as independent predictors of TIPS dysfunction. Interventionalists should choose a more central and less curved TIPS tract during the TIPS procedure to reduce the risk of development of TIPS dysfunction.

Trial registration: This retrospective monocentric study includes patients from the NEPTUN cohort (registered at ClinicalTrials.gov; Identifier: NCT03628807).

Keywords: cirrhosis; portal hypertension; transjugular intrahepatic portosystemic shunt.

FIGURE 1

Flow chart of study population.

FIGURE 2

Schematic illustration of the 3D TIPS geometry parameters. 3D cranial TIPS stent end (mm): Length from the cranial TIPS stent end in the liver vein to the IVC; 3D minimal stent diameter (mm): Smallest diameter in the entire TIPS stent; 3D length of covered stent portion (mm): Length from the beginning of the distal covered stent end to the end of the cranial covered stent end; 3D stent curvature (degrees/cm): Result of segmentation of the path within the TIPS stent into straight lines with gaps of 5 mm and angle measurements over 1 cm. The parameter describes the maximum change in direction between these sections within the entire stent; 3D angle between the covered stent ends (degrees): Angle between two straight lines orthogonal to the covered stent ends; 3D α angle (degrees): Angle formed between the beginning of the covered stent in the PV to the course of the PV; 3D confluence to TIPS stent (mm): Length from the beginning of the path to the beginning of the uncovered distal stent end.