Lv Yong, Wang Qiuhe, Luo Bohan, Bai Wei, Li Menghao, Li Kai, Wang Zhengyu, Xia Dongdong, Guo Wengang, Li Xiaomei, Yuan Jie, Zhang Na, Wang Xing, Xie Huahong, Pan Yanglin, Nie Yongzhan, Yin Zhanxin, Fan Daiming, Han Guohong
National Clinical Research Center for Digestive Diseases and State Key Laboratory of Holistic Integrative Management of Gastrointestinal Cancers, Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an 710032, China; Department of Liver Diseases and Digestive Interventional Radiology, National Clinical Research Centre for Digestive Diseases, Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an 710032, China.
Department of Liver Diseases and Digestive Interventional Radiology, National Clinical Research Centre for Digestive Diseases, Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an 710032, China.
J Hepatol. 2025 Feb;82(2):245-257. doi: 10.1016/j.jhep.2024.08.007. Epub 2024 Aug 22.
BACKGROUND & AIMS: The optimal timing of measurement and hemodynamic targets of portacaval pressure gradient (PPG) after transjugular intrahepatic portosystemic shunt (TIPS) placement remain unclear. This study aimed to identify the ideal moment for hemodynamic measurements and the optimal target of PPG in patients undergoing covered TIPS for variceal bleeding.
Between May 2018 and December 2021, 466 consecutive patients with recurrent variceal bleeding treated with covered TIPS were prospectively included. Post-TIPS PPG was measured immediately (immediate PPG), 24-72 hours (early PPG), and again 1 month (late PPG) after TIPS placement. The agreement among PPGs measured at different time points was assessed by intra-class correlation coefficient (ICC) and Bland-Altman method. The unadjusted and confounder-adjusted effects of PPGs on clinical outcomes (portal hypertensive complications [PHCs], overt hepatic encephalopathy [OHE], further decompensation, and death) were assessed using Fine and Gray competing risk regression models.
The agreement between early PPG and late PPG (ICC: 0.34) was better than that between immediate PPG and late PPG (ICC: 0.23, p <0.001). Early PPG revealed an excellent predictive value for PHCs (early PPG≥ vs. <12 mmHg: adjusted hazard ratio 2.17, 95% CI 1.33-3.55, p = 0.002) and OHE (0.40, 95% CI 0.17-0.91, p = 0.030), while immediate PPG did not. Late PPG showed a predictive value for PHC risk but not OHE. By targeting the lowest risk of further decompensation, we identified an optimal hemodynamic target with early PPG ranging from 11 to 14 mmHg that was associated with a decreased risk of OHE and effective prevention of PHCs.
PPG measured 24 to 72 hours after TIPS correlates with long-term PPG and clinical outcomes, and a hemodynamic target PPG of 11-14 mmHg is associated with reduced encephalopathy but not compromised clinical efficacy.
The optimal timing of measurement and hemodynamic targets of portacaval pressure gradient (PPG) after transjugular intrahepatic portosystemic shunt (TIPS) remain unclear. Here we show that post-TIPS PPG measured at least 24 hours but not immediately after the procedure correlated with long-term PPG and clinical events. Thus, PPG measurements taken at least 24 hours after TIPS should be used to guide decision making in order to improve clinical outcomes. Targeting a post-TIPS PPG of 11-14 mmHg or a 20%-50% relative reduction from pre-TIPS baseline measured 24-72 hours after the procedure was associated with reduced encephalopathy but not compromised clinical efficacy. Thus, these criteria could be used to guide TIPS creation and revision in patients with cirrhosis and variceal bleeding undergoing covered TIPS.
ClinicalTrials.gov, ID: NCT03590288.
经颈静脉肝内门体分流术（TIPS）置入术后门腔静脉压力梯度（PPG）的最佳测量时机及血流动力学目标仍不明确。本研究旨在确定接受覆膜TIPS治疗静脉曲张出血患者进行血流动力学测量的理想时机以及PPG的最佳目标值。
2018年5月至2021年12月，前瞻性纳入466例连续接受覆膜TIPS治疗复发性静脉曲张出血的患者。TIPS术后立即测量（即时PPG）、术后24 - 72小时（早期PPG）以及术后1个月再次测量（晚期PPG）PPG。采用组内相关系数（ICC）和Bland - Altman方法评估不同时间点测量的PPG之间的一致性。使用Fine和Gray竞争风险回归模型评估PPG对临床结局（门静脉高压并发症[PHC]、显性肝性脑病[OHE]、进一步失代偿和死亡）的未调整和混杂因素调整后的影响。
早期PPG与晚期PPG之间的一致性（ICC：0.34）优于即时PPG与晚期PPG之间的一致性（ICC：0.23，p <0.001）。早期PPG对PHC（早期PPG≥ vs. <12 mmHg：调整后风险比2.17，95% CI 1.33 - 3.55，p = 0.002）和OHE（0.40，95% CI 0.17 - 0.91, p = 0.030）具有良好的预测价值，而即时PPG则无。晚期PPG对PHC风险有预测价值，但对OHE无预测价值。通过针对进一步失代偿的最低风险，我们确定了早期PPG在11至14 mmHg范围内的最佳血流动力学目标，该目标与OHE风险降低以及有效预防PHC相关。
TIPS术后24至72小时测量的PPG与长期PPG及临床结局相关，血流动力学目标PPG为11 - 14 mmHg与脑病减少相关，但不影响临床疗效。
经颈静脉肝内门体分流术（TIPS）后门腔静脉压力梯度（PPG）的最佳测量时机及血流动力学目标仍不明确。在此我们表明，TIPS术后至少24小时而非术后立即测量的PPG与长期PPG及临床事件相关。因此，TIPS术后至少24小时进行的PPG测量应用于指导决策以改善临床结局。将TIPS术后PPG目标设定为11 - 14 mmHg或术后24 - 72小时相对于TIPS术前基线降低20% - 50%与脑病减少相关，但不影响临床疗效。因此，这些标准可用于指导接受覆膜TIPS治疗的肝硬化和静脉曲张出血患者的TIPS创建和修订。
ClinicalTrials.gov，ID：NCT03590288
