Cardiovasc Intervent Radiol (2022) 45:102–111
https://doi.org/10.1007/s00270-021-03003-z
SCIENTIFIC PAPER (OTHER) TIPS
Transjugular Portosystemic Stent Shunt: Impact of Right Atrial
Pressure on Portal Venous Hemodynamics Within the First Week
Michael Bernhard Pitton1 • Arndt Weinmann2 • Roman Kloeckner1 •
Jens Mittler3 • Christian Ruckes4 Christoph Düber1• • Gerd Otto5
Received: 9 June 2021 / Accepted: 30 October 2021 / Published online: 1 December 2021
 The Author(s) 2021
Abstract 8.5 ± 3.5 mmHg and only 66 patients (53%) met that tar-
Purpose Porto-systemic pressure gradient is used to get. In patients exceeding the target PSG at follow-up, PVP
prognosticate rebleeding and resolution of ascites after was significantly higher and RAP was lower resulting in the
TIPS. This study investigates the reliability of portal increased PSG. The highly variable changes of RAP were
pressure characteristics as quantified immediately after the main contributor to different pressure gradients. In the
TIPS placement and at short-term control. multivariate regression analysis, PVP and RAP immediately
Patients and Methods Portal venous pressure (PVP) and after TIPS were predictors for PSG at short-term control
right atrial pressure (RAP) were prospectively obtained with moderately predictive capacity (AUC = 0.75).
before and after TIPS as well as C 48 h after TIPS pro- Conclusion Besides the reduction of portal vein pressure,
cedure. Porto-systemic pressure gradients (PSG) and the highly variable right atrial pressure was the main
pressure changes were calculated. A multivariate regres- contributor to different pressure gradients. Thus, immedi-
sion analysis was performed to predict portal hemody- ate post-TIPS measurements do not reliably predict portal
namics at short-term control. hemodynamics during follow-up. These findings need to be
Results The study included 124 consecutive patients. Indi- further investigated with respect to the corresponding
cations for TIPS were refractory ascites, variceal bleeding or clinical course of the patients.
combinations of both. Pre- and post-interventional PSG
yielded 16.4 ± 5.3 mmHg and 5.9 ± 2.7 mmHg, respec- Keywords Liver cirrhosis  Portal hypertension 
tively. At that time, 105/124 patients (84.7%) met the target Transjugular portosystemic stent shunt (TIPS) 
(PSG B 8 mmHg). After 4 days (median), PSG was Portosystemic pressure gradient (PSG)
& Michael Bernhard Pitton
michael.pitton@unimedizin-mainz.de
1 Department of Diagnostic and Interventional Radiology,
University Medical Center, Johannes Gutenberg University Introduction
Mainz, Langenbeckstr.1, 55131 Mainz, Germany
2 Department of Internal Medicine, University Medical Center, Portal hypertension is the crucial pathophysiological finding
Langenbeckstr.1, 55131 Mainz, Germany in end-stage liver cirrhosis and is responsible for clinical
3 Department of General and Visceral Surgery and complications such as refractory ascites and variceal
Transplantation Surgery, University Medical Center, bleeding [1, 2]. Portal pressure gradients exceeding
Langenbeckstr.1, 55131 Mainz, Germany 10 mmHg are defined as clinically significant portal hyper-
4 Present Address: Interdisciplinary Center for Clinical Trials tension [3]. Transjugular Portosystemic Stent Shunt (TIPS)
(IZKS), University Medical Center, 55131 Mainz, Germany has shown to reduce portal venous pressure (PVP) and
5 Emeritus of the Division of Transplantation Surgery, porto-systemic pressure gradients (PSG) [4–8] and has been
University Medical Center, Langenbeckstr.1, 55131 Mainz, used for risk stratification regarding variceal bleeding and
Germany
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M.B. Pitton et al: Transjugular portosystemic stent shunt: impact of right atrial pressure… 103
refractory ascites [3, 9, 10]. The diameter of the stent shunts
is adjusted to pre-defined pressure levels [11, 12] which 165 TIPS 
have to be balanced against hepatic encephalopathy [13]. From Dec 2016 to Jul 2020 
In clinical practice, we noticed considerable deviations
from portal pressure gradients taken immediately after
 18 porto-mesenterial 
TIPS compared to control measurements after a few days. thrombolysis 
Patients undergoing TIPS procedures obviously feature
varying hemodynamic conditions depending not only on
the degree of cirrhosis but also on factors such as pre- 3 portal stenng  
existing spontaneous porto-venous collaterals, extent of
fluid overload, use of diuretics, cardiac pre-conditions and
others. The immediate pressure relief after TIPS creation
144 TIPS  
therefore only reflects the instantaneous hemodynamic
changes after opening the shunt but does not reflect portal
pressure load after equilibration during further follow-up
[14]. This study was performed to quantify those time- 20 incomplete pressure protocol 
dependent effects on portal hemodynamics and to predict or paents refused follow-up 
future deviations from the intended PSG at follow-up.
124 TIPS                       
Methods 88 ascites, 36 bleeding  
Study Population
Fig. 1 Flowchart of patient selection
Between November 2017 and July 2020, a total of 165 the tip of the 10F-sheath remained in the right atrium.
patients were treated with TIPS at our tertiary referral center. Mean portal vein pressure (PVP) and mean right atrial
Patients with TIPS for porto-mesenterial thrombosis were pressure (RAP) were registered, and the porto-systemic
excluded due to a lack of reliable initial pressure values. pressure gradient (PSG) was calculated by the difference of
Patients who refused short-term follow-up and patients with both. Measurements were obtained before (PVPpre,
incomplete pressure protocol were also excluded. Finally, a RAPpre) and immediately after TIPS (PVPpost, RAPpost),
total of 124 patients with complete pressure measurement, as well as at short-term follow-up (PVPcontrol, PARcon-
including pre-TIPS and immediate post-TIPS data, and trol). At these points of time, pressure changes were cal-
short-term follow-up entered this study (Fig. 1). The study culated by subtraction of the respective values,
was approved by the local ethics committee (Rhineland immediately after TIPS (D post–pre) and at follow-up (D
Palatinate Ethics Committee, Germany, 15582). control-post). All registrations were performed in expira-
tory arrest, both during general anesthesia pre- and
TIPS Technique immediately post-TIPS. Measurements at follow-up were
obtained without any sedation under controlled expiratory
The basic technique for TIPS has been introduced in the arrest avoiding any Valsalva effects. Measurements were
1990s [10] and has been adapted during the years. All TIPS simultaneously obtained with continuous double line reg-
procedures were performed under general anesthesia by istration of PVP and RAP pressure curves using two par-
two experienced interventional radiologists (MBP, RK). allel electromechanical transducers (LogiCal, Smiths
After transjugular approach, the 10F sheath was advanced Medical) and a dedicated workstation (Axiom Sensis XP,
into the inferior vena cava. The right hepatic vein was Siemens). The system was calibrated at the level of the
catheterized and the sheath was advanced into the right right atrium against the surrounding atmosphere and set to
hepatic vein. A flexible trocar stylet was advanced until the 0 mmHg. Pressure registrations were obtained for at least
tip entered the right portal vein (RUPS-100, Cook). TIPS 10 s to allow for equilibration of the pressure curves of
was created via standard access (n = 119), left hepatic vein PVP and RAP and to avoid any Valsalva effects.
to left portal vein (n = 2), middle hepatic vein to right PTFE-covered stentgrafts were used (Viatorr and
(n = 1) and left portal vein (n = 1), and direct transcaval to ViatorrCx, Gore) for TIPS. In variceal bleeding, the
right hepatic vein (n = 1). respective varices and large volume porto-systemic shunts
Pressure measurements were performed using a 5F- were embolized. The target for post-TIPS PSG was defined
pigtail catheter positioned in the main portal vein, whereas
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104 M.B. Pitton et al: Transjugular portosystemic stent shunt: impact of right atrial pressure…
as PSG B 8 mmHg. In patients with a PSG[ 8 mmHg cut-off (group I), whereas 58 patients (46.8%) did not
after TIPS, the stentgrafts were adapted by further balloon (group II, Table 4). The post hoc analysis of pressure data
dilation. In cases in whom this cut-off could not be a- showed that compared to group I, group II presented with
chieved, no further action was taken at that point. Patients significantly higher PVP before and after TIPS, as well as
were supervised on the intermediate or intensive care unit at TIPS control (Table 2). A separate subgroup analysis of
and set on heparin according to the underlying co-mor- those 105 patients who primarily met the cut-off is pro-
bidities and previous coagulation status. Short-term follow- vided as supplement data. However, there were no dis-
up was scheduled not before 48 h after TIPS creation. cernible relevant differences between the baseline criteria
Patients who fulfilled the cut-off of B 8 mmHg at short- of those patients who subsequently met or did not meet the
term follow-up (PSGcontrol) were allocated to group I, and cut-off PSG at short-term follow-up (Suppl.Tab.3).
patients who failed this cut-off were allocated to group II. Pressure changes during follow-up were significantly
different between group I and II. In particular, group II
Statistical Methods presented with reduced DPVPcontrol-post and a greater
DRAPcontrol-post, resulting in a significantly greater
Statistical calculations were performed using SPSS, ver- DPSGcontrol-post at follow-up (Table 3, Fig. 2a). The
sion 26 and SAS, Version 9.4. Analysis included descrip- volatility and the greater amounts of changes of the right
tive demographic patient data and hemodynamic data atrial pressure was the main contributor to the different
before and immediately after TIPS as well as respective PSG levels in patients who failed the cut-off at follow-up.
hemodynamic data at follow-up. Multivariate regression At follow-up, PSGcontrol increased in100 patients com-
analysis was performed in order to identify predictors for pared to after TIPS. In 67 of these patients, the increase in
PSG at short-term follow-up. P values B 0.05 were con- PSG was associated with an absolute decrease in PVP and
sidered significant. Based on significant predictors, the sum was thus caused by an even greater drop in RAP (Fig. 2b).
of the products of the regression coefficients multiplied by If using a different cut-off for PSGcontrol of B 10
the respective individual values was calculated. Receiver mmHg or even B 12 mmHg, the respective post-TIPS cut-
operating characteristics (ROC) and areas under the ROC offs were met in 118 and 122 cases, respectively. However,
curves (AUROC) were calculated to evaluate the accuracy at short-term TIPS control, even these cut-offs were ful-
of risk prediction. Optimal cut-off values for predictors filled in only 94 and 104 cases, respectively (Table 4).
were determined by maximizing the score test statistic. In order to test whether unexpected pressure levels at
short-term follow-up would be predictable, all pre- and
post-operative pressures (PVP, RAP, PSG) and respective
Results pressure changes were entered into a binary multiple
regression analysis. PVPpost and RAPpost after TIPS
A total of 124 patients were included in this prospective placement proved to be the best predictors for meeting the
register study, 81 male, 43 female, age 58.2 ± 13.1 years targeted PSG at follow-up (PSGcontrol). The ROC analysis
(Table1). Patients were treated because of refractory ascites yielded only a moderate predictive capacity (AUC =
(n = 78), variceal bleeding (n = 34) or a combination of 0.748) and sensitivity and specificity of 69.7% and 75.8%,
both (n = 12). Before TIPS creation, PVP and RAP were respectively. Likewise, the AUC values for the follow-up
24.7 ± 5.2 and 8.3 ± 4.6 mmHg, respectively, resulting in PSG cut-off B 10 mmHg or B 12 mmHg were again only
a PSG of 16.4 ± 5.3 mmHg. After TIPS creation, PVP moderately predictive (Table 5, Fig. 3).
dropped to 17.6 ± 4.6 mmHg, RAP rose to
11.7 ± 4.4 mmHg yielding a PSG of 5.9 ± 2.7 mmHg. At
short-term follow-up, PVP was further reduced to Discussion
15.0 ± 5.1 mmHg and RAP equilibrated to
6.4 ± 4.6 mmHg resulting in a respective increase of PSG This study investigates the changes of portal hemody-
of 8.5 ± 3.5 mmHg (Table 2). At this point, patients were namics during short-term follow-up after TIPS creation.
allocated in two groups, those who met the target criterion Our data show that the PSG obtained immediately after
of PSGcontrol B 8 mmHg (group I) and those who did not shunt creation does not represent the hemodynamics during
(group II). The median interval for short-term follow-up further follow-up. Instead, a dynamic equilibration of the
was 4 days (detailed data of follow-up intervals are avail- pressure values is to be expected resulting in considerable
able in Suppl.Tab.1 and 2). proportion of patients out of the desired pressure range. In
Considering all 124 patients, 105 of 124 patients particular, the pressure changes of the right atrium were
(84.7%) primarily fulfilled the cut-off immediately after significantly different after TIPS and give an insight into
TIPS. At follow-up, only 66 patients (53%) still met that the pathophysiology of different PGS resultants during
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M.B. Pitton et al: Transjugular portosystemic stent shunt: impact of right atrial pressure… 105
Table 1 Demographics Demographics n %
Patients (n) 124
Age (years; mean ± SD) 58.3 ± 13.4
Male / Female (n) 81/43 65.3/34.7
Clinical stage
Child–Pugh (A/B/C) 12/78/43 9.7/62.9/27.4
Child–Pugh points Median (Q1/Q3) 9 (8/10)
MELD Median(Q1/Q3) 13 (10/15)
NaMELD Median(Q1/Q3) 16 (12/20)
Etiology of underlying liver disease
Alcohol 75 60.5
Viral hepatitis 7 5.6
Budd-Chiari syndrome 7 5.6
PBC/PSC 2 1.6
NASH 7 5.6
Cryptogenic/others 26 21.0
Clinical indication for TIPS
Refractory ascites / hydrothorax 78 62.9
Refractory ascites ? history of bleeding 10 8.1
Variceal bleeding 34 27.4
Variceal bleeding ? ascites 2 1.6
Concomitant findings of cirrhosis
Esophageal varices (grade I/II/III/IV) 94 (34/38/18/4) 75.1 (27.4/30.6/14.5/3.2)
Previous treatment of varices 67 54.0
Rectal hemorrhoidal varices 4 4.8
HE total (grade I-II/grade III-IV) 24 (15/9) 19.4 (12.1/7.3)
Hepatorenal syndrome 38 60.6
Spontaneous bacterial peritonitis 22 17.7
Hypersplenic syndrome 11 8.9
Hepatic hydrothorax 13 10.5
Hypertensive gastropathy 49 39.5
Additional co-morbidities
Cardiac diseases 26 21.0
Coronary heart disease 12 9.7
Valvular heart disease 1 0.8
Myocardial insufficiency 9 7.3
Combination of these / others 4 3.2
Arterial Hypertension 42 33.9
Chronic pancreatitis 3 2.4
Polyneuropathy 3 2.4
Diabetes mellitus 33 26.6
Pumonary diseases 15 12.1
Congenital coagulopathy 5 4.0
Hypo-/Hyperthyroidism 15 12.1
Other diseases 24 19.4
Laboratory test Median (Q1/Q3) Range
INR 1.3 (1.2/1.4) 1.0–2.2
Creatinine (mg/dl) 1.03 (0.77/1.36) 0.45–4.92
Bilirubin (mg/dl) 1.30 (0.80/2.24) 0.30–12.80
Albumin (g/l) 27.0 (23.0/31.0) 1.0–40.0
Thrombocytes (n/ll) 118 (73/201) 25–679
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106 M.B. Pitton et al: Transjugular portosystemic stent shunt: impact of right atrial pressure…
Table 2 Portal hemodynamics before and after TIPS creation. Total: all 124 patients. Group I and II: post hoc allocation of patients to both
groups depending on whether patients fulfilled or failed the PSG target at follow-up (PSGcontrol)
Portal PVPpre RAPpre PSGpre PVPpost RAPpost PSGpost PVPcontrol RAPcontrol PSGcontrol
Hemodynamics
Total 24.7 ± 5.2 8.3 ± 4.6 16.4 ± 5.3 17.6 ± 4.6 11.7 ± 4.4 5.9 ± 2.7 15.0 ± 5.1 6.4 ± 4.6 8.5 ± 3.5
(13 to 48) (- 3 to 27) (3 to 38) (6 to 31) (2 to 26) (0 to 14) (3 to 29) (- 2 to 18) (1 to 20)
Group I 23.3 ± 4.3 7.7 ± 3.9 15.6 ± 4.8 16.4 ± 4.6 11.5 ± 4.4 4.9 ± 2.4 13.2 ± 5.0 7.2 ± 5.0 6.0 ± 1.8
(13 to 33) (- 3 to 20) (3 to 31) (6 to 29) (2 to 26) (1 to 14) (3 to 26) (0 to 19) (1 to 8)
Group II 26.3 ± 5.7 9.1 ± 5.2 17.2 ± 5.7 18.9 ± 4.2 12.0 ± 4.4 6.9 ± 2.5 17,0 ± 4.3 5.6 ± 3.8 11.5 ± 2.5
(16 to 48) (0 to 27) (6 to 38) (12 to 31) (4 to 24) (0 to 13) (10 to 29) (- 2 to 16) (9 to 20)
p \ 0.01 0.092 0.096 0.02 0.507 \ 0.001 \ 0.001 0.051 \ 0.001
Group I, cut-off PSG\ 8 mmHg at short-term TIPS control fulfilled; Group II, cut-off PSG failed at short-term TIPS control; P, significance
level comparing group I and II, T-Test; PVP, Portal vein pressure; RAP, Right atrial pressure; PSG, Porto-systemic pressure gradient; PVP/RAP/
PSG pre, pressure levels before TIPS; PVP/RAP/PSGpost, pressure levels immediately after TIPS; PVP/RAP/PSGcontrol, pressure levels at
short-term follow-up
Table 3 Individual changes of portal hemodynamics (DPVP, DRAP, DPSG). Dpost-pre, pressure difference between the post-TIPS and pre-
TIPS values. Dcontrol-post, pressure difference between TIPS control and immediate post-TIPS values
DPVPpost-pre DRAPpost-pre DPSGpost-pre DPVPcontrol-post DRAPcontrol-post DPSGcontrol-post
Group I - 6.9 ± 3.9 3.8 ± 3.5 - 10.7 ± 4.7 - 3.2 ± 4.7 - 4.3 ± 4.7 1.1 ± 2.6
(- 18 to 2) (- 3 to 21) (- 28 to 0) (- 14 to 5) (- 17 to 6) (- 8 to 5)
Group II - 7.4 ± 5.1 2.9 ± 3.8 - 10.3 ± 5.1 - 1.9 ± 4.2 - 6.4 ± 5.0 4.5 ± 3.2
(- 34 to 2) (- 8 to 11) (- 28 to 1) (- 12 to 9) (- 21 to 3) (- 3 to 12)
p 0.583 0.198 0.643 0.1 0.017 0.001
Group I, cut-off PSG\ 8 mmHg at short-term TIPS control fulfilled; Group II, cut-off PSG failed at short-term TIPS control, P, significance
level comparing group I and II, T-Test
follow-up. This is of particular interest because the right RAP, and PSG as well as individual pressure changes over
atrium, the zero point of cardiopulmonary circulation, acts time. Thereby, the specific cut-off level for the target PSG
retrograde on portal pressure after TIPS creation. This itself is of minor impact on our general statement that the
includes that different portal pressures might result in the immediate PSG should not be used for risk prediction or
same pressure gradient. Vice versa, a particular portal further decision-making regardless of the targeted PSG (8,
pressure might result in diverse portal pressure gradients. 10, or 12 mmHg). Clinical guidelines with respective rec-
Silva-Junior et al. have already reported on timing effects ommendations based on a certain PSG immediately mea-
of portal pressure gradients after TIPS placement [14]. The sured after TIPS should be questioned.
authors reported either reduced or even increased immediate The pathophysiology of venous return is very complex,
pressure gradients depending on whether TIPS was per- particularly in cirrhotic patients. As defined by Guyton,
formed under general anesthesia or in deep sedation. Their venous return (VR) is the result of the pressure gradient
data were retrospectively collected over 8 years at seven between the mean systemic filling pressure (MSFP) and the
institutions and covered different conditions concerning right atrial pressure (RAP) divided by the resistance to
emergencies versus elective procedures. The major draw- venous return (RVR) (VR = MSFP-RAP/RVR). According
back of that publication is, however, the lack of precise data to this equation, venous return increases with high MSFP
explaining those PSG changes over time. It is of crucial and low right atrial pressure [15–17]. In a clinical setting,
interest to show if changes in PSG are caused by altering only RAP and not factors such as volume load, elastic
PVP or by RAP. In contrast, our data were prospectively distension of the veins, sympathetic tone, cardiac function,
collected and are based on simultaneous registration of PVP, drugs etc. can reliably be obtained during a TIPS
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M.B. Pitton et al: Transjugular portosystemic stent shunt: impact of right atrial pressure… 107
a Δ PVPGroup I  Group II  Δ RAP
PSG cut-off 8mmHg fulfilled PSG cut-off 8mmHg failed Δ PSG
Δ RAP p=0.017
Δ PSG p=0.001
Δ post-pre Δ control-post Δ post-pre Δ control-post
ΔRAP control-post
b
9
7
5 1 
3
1
-15 -13 -11 -9 -7 -5 -3 --11 1 3 5 7 9
-3 ΔPVP control-post
-5
-7
-9
-11
-13
-15
-17
2 -19
-21
-23
-25
Fig. 2 Pressure changes following TIPS. a DPVPpost-pre (blue), follow-up measurements. Cases localized above the oblique red line
DRAPpost-pre (red), DPSGpost-pre (green): Mean pressure changes had a further decrease in PSG at follow-up compared to immediate
immediately after TIPS compared to pre-interventional measurement. post-TIPS measurement with diverse DPVP and DRAP. Cases on the
DPVPcontrol-post, DRAPcontrol-post, DPSGcontrol-post: Mean pres- red line had identical PSG after TIPS and at follow-up but different
sure changes at short-term follow-up compared to immediate post- DPVP and DRAP. Cases below the red line had a further increase of
TIPS measurement. Group I: Cut-off PSG B 8 mmHg at short-term PSG at follow-up compared to immediate post-TIPS. Two examples
follow-up fulfilled. Group II: Cut-off PSG failed at short-term follow- (green dotted line): Example 1: DPVP ?7 mmHg, DRAP ?1
up. b Dotplot of the distribution of individual pressure changes at mmHg = DPSG ?6 mmHg compared to PSG after TIPS. Example
short-term follow-up (DPVPcontrol-post and DRAPcontrol-post); 4 2: DPVP -10 mmHg, DRAP -16 mmHg = DPSG ?6 mmHg com-
dots lacking because of identical characteristics at post-TIPS and pared to PSG after TIPS despite an absolute reduction of PVP
procedure. The venous return and the potential backpres- characterized by the reduced porto-venous pressure gradi-
sure from the right atrium into the liver veins cover a ent entailing increased thoracic blood volume and reduced
variety of pathophysiological effects that need for equili- splanchnic blood volume, increasing right atrial and pul-
bration during follow-up and potentially impact the further monary artery pressure, as well as respective changes of
clinical course. After TIPS placement, the situation is pulmonary vascular resistance. Systemic vascular
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108 M.B. Pitton et al: Transjugular portosystemic stent shunt: impact of right atrial pressure…
Table 4 a Number of patients who met the cut-off of PSG B 8 mmHg (Group I) or failed the cut-off (Group II) at short-term follow-up
(PSGcontrol). b Number of patients who met or failed the cut-off of PSG B 10 mmHg c Number of patients who met or failed the cut-off of
PSG B 12 mmHg
PSGcontrol B 8 mmHg PSGcontrol[ 8 mmHg
Group I Group II
(a)
PSGpost B 8 mmHg 60 45 105
(84.7%)
PSGpost[ 8 mmHg 6 13 19
(15.3%)
66 (53%) 58 (46.8%) 124
(100%)
PSGcontrol B 10 mmHg PSGcontrol[ 10 mmHg
(b)
PSGpost B 10 mmHg 91 27 118 (95.2%)
PSGpost[ 10 mmHg 3 3 6 (4.8%)
94 (75.8%) 30 (24.2%) 124 (10%)
PSGcontrol B 12 mmHg PSGcontrol[ 12 mmHg
(c)
PSGpost B 12 mmHg 102 20 122 (98.4%)
PSGpost[ 12 mmHg 2 0 2 (1.6%)
104 (83.9%) 20 (16.1%) 124 (100%)
PSGpost, PSG immediately after TIPS; PSGcontrol, PSG at short-term follow-up
Table 5 ROC analysis of the risk factors and calculation of AUC for the target PSG at short-term follow-up (PSGcontrol)
AUC Intercept PVPpost RAPpost Optimal Sensitivity Specificity
coefficient coefficient cut-off
PSGcontrol B 8 mmHg 0.748 3.3947 - 0.3769 0.2879 - 3.1511 69.7% 75.8%
PSGcontrol B 10 mmHg 0.766 4.8949 - 0.3549 0.2297 - 3.9240 76.6% 70.0%
PSGcontrol B 12 mmHg 0.757 4.9863 - 0.3044 0.1907 - 3.1135 59.6% 90.0%
PVPpost, portal venous pressure, immediately after TIPS; RAPpost, right atrial pressure, immediately after TIPS
resistance decreases and renal function improves by discussed in clinical studies in order to find adequate cut-
increased central blood volume, decreased renal vasocon- off levels (B 10, B 12, or B 20 mmHg) with respect to
striction, decreased activation of the sympathetic nervous clinical outcome [20, 22–26]. However, these indirect
system and renin-angiotensin–aldosterone system [18, 19]. pressure levels might not be compared with directly reg-
In this study, a reliable prediction which patients will istered PSG values because of the different technical
experience an increase in PSG was not possible. We methods. This is particularly true for a TIPS cohort in
therefore suggest short-term follow-up within the first week whom vascular anatomy has been changed by creation of
after TIPS after equilibration of portal hemodynamics. shunt flow. Furthermore, there have been concerns on
The hepatic venous pressure gradient (HVPG) as used whether to obtain the reference measurement from the right
by the American Association for the Study of the Liver atrium, the hepatic veins, from a certain positions within an
[20] is defined as difference between the pressure of the particular hepatic vein, or, alternatively, from the inferior
wedged hepatic vein and the free hepatic vein and is an vena cava as results may be different [27, 28]. In order to
indirect calculation of pressure gradients rather than a cover all these individual confounders, mean right atrial
direct measurement [21]. Those HVPG levels have been pressure was used as reference pressure in this study.
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M.B. Pitton et al: Transjugular portosystemic stent shunt: impact of right atrial pressure… 109
bFig. 3 ROC analysis of the risk factors and calculation of AUC for
the target PSG at short-term follow-up. Results for PSGcon-
trol B 8 mmHg (Fig. 3a), PSGcontrol B 10 mmHg (Fig. 3b), and
PSGcontrol B 12 mmHg (Fig. 3c)
Positioning the tip of the sheath in the right atrium and the
catheter within the main portal vein is easy to perform and
allows for standardized simultaneous pressure measure-
ments before and after TIPS. In addition, factors like deep
sedation, patient movement, and coughing or breathing
during measurement may impact pressure levels [29–31].
These factors were overcome by standardized conditions as
described above.
PSG, as defined here, is impacted by the whole vascular
resistance between the portal vein and the right atrium and
includes potential factors such as pre-sinusoidal patholo-
gies, intrahepatic veno-venous shunts, or stenoses of the
hepatic and caval vein [21, 23]. Finally, the PSG is affected
by the compliance of the right atrium, increased atrial
pressures, particularly in heart and pulmonary diseases
which cause backpressure for venous return [15–17]. In
this study, our suggested PSG cut-off of B 8 mmHg at
follow-up is challenging; therefore, the data had also been
analyzed for a PSG cut-off of B 10 and B 12 mmHg.
However, looking at reports on TIPS using PTFE stent-
grafts, the immediate post-TIPS pressure gradients are
often between PSG 7 and 9 mmHg, independent of the
formally defined cut-off level of\ 12 mmHg in the
respective methods Sects. [32–34]. Insofar, the cut-off
defined in our study (PSG B 8 mmHg) is more an adaption
to clinical practice.
Our study may be criticized as pathophysiological
pressure data follow-up was not correlated with clinical
data. Since clinical complications such as rebleeding and
alleviation of ascites have been reported to correlate with
PSG, we herein focused on this issue to point out the
changes of porto-venous features and not the clinical
sequelae. Another point of criticism may be that secondary
alterations of the TIPS tract impacting shunt flow or
remodeling of the TIPS tract by curving, kinking, and
radial forces of the stent which may take longer than 4 days
[35, 36]. Finally and most important, clinical outcome is
influenced by the entity and progression of the underlying
diseases, which was also beyond the scope of this study.
Further studies should therefore investigate the portal
hemodynamics and correlate with clinical outcome and re-
intervention rates during mid-term and long-term follow-
up.
In conclusion, pressure characteristics significantly
changes within a few days after TIPS placement. Data
obtained immediately after the TIPS procedure have only
moderate predictive power for the future portal
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110 M.B. Pitton et al: Transjugular portosystemic stent shunt: impact of right atrial pressure…
hemodynamics. Besides the absolute pressure reduction in transjugular intrahepatic portosystemic shunt. World J Gas-
the portal vein, the highly variable right atrial pressure troenterol. 2016;22(25):5780–9.
5. Bercu ZL, Fischman AM. Outcomes of transjugular intrahepatic
changes were the main contributor to different pressure portosystemic shunts for ascites. Semin Interv Radiol.
gradients. This includes the possibility that different portal 2014;31(3):248–51.
vein pressures may result in the same pressure gradients 6. Garcia-Pagan JC, Caca K, Bureau C, Laleman W, Appenrodt B,
and vice versa. Since pressure gradients have been reported Luca A, et al. Early use of TIPS in patients with cirrhosis and
variceal bleeding. N Engl J Med. 2010;362(25):2370–9.
to impact further clinical proceeding, studies are required 7. Li GQ, Yang B, Liu J, Wang GC, Yuan HP, Zhao JR, et al.
to correlate detailed hemodynamic changes with clinical Hepatic venous pressure gradient is a useful predictor in guiding
outcome. treatment on prevention of variceal rebleeding in cirrhosis. Int J
Clin Exp Med. 2015;8(10):19709–16.
8. Qi XS, Fan DM. Hepatic venous pressure gradient measurement
before TIPS for acute variceal bleeding. World J Gastroenterol.
Funding Open Access funding enabled and organized by Projekt
2014;20(23):7523–4.
DEAL. This study was not supported by any funding.
9. Garcia-Tsao G. Current Management of the Complications of
Cirrhosis and Portal Hypertension: Variceal Hemorrhage,
Declarations Ascites, and Spontaneous Bacterial Peritonitis. Dig Dis.
2016;34(4):382–6.
Conflict of interest The authors declare that they have no conflict of 10. Rossle M, Haag K, Ochs A, Sellinger M, Noldge G, Perarnau JM,
interest. et al. The transjugular intrahepatic portosystemic stent-shunt
procedure for variceal bleeding. N Engl J Med.
Ethical Approval For this type of study, formal consent is not 1994;330(3):165–71.
required, approved by the local ethic committee (Rhineland Palatinate 11. Geeroms B, Laleman W, Laenen A, Heye S, Verslype C, van der
Ethics Committee, Germany). Merwe S, et al. Expanded polytetrafluoroethylene-covered stent-
grafts for transjugular intrahepatic portosystemic shunts in cir-
Informed Consent For this type of study, informed consent is not rhotic patients: Long-term patency and clinical outcome results.
required. Eur Radiol. 2017;27(5):1795–803.
12. Miraglia R, Maruzzelli L, Di Piazza A, Mamone G, Caruso S,
Consent for Publication For this type of study, consent for publi- Gentile G, et al. Transjugular Intrahepatic Portosystemic Shunt
cation is not required. Using the New Gore Viatorr Controlled Expansion Endopros-
thesis: Prospective, Single-Center. Preliminary Experience Car-
Supplementary Information The online version contains diovasc Intervent Radiol. 2019;42(1):78–86.
supplementary material available at https://doi.org/10.1007/s00270- 13. Rowley MW, Choi M, Chen S, Hirsch K, Seetharam AB.
021-03003-z. Refractory Hepatic Encephalopathy After Elective Transjugular
Intrahepatic Portosystemic Shunt: Risk Factors and Outcomes
Open Access This article is licensed under a Creative Commons with Revision. Cardiovasc Intervent Radiol.
Attribution 4.0 International License, which permits use, sharing, 2018;41(110):1765–72.
adaptation, distribution and reproduction in any medium or format, as 14. Silva-Junior G, Turon F, Baiges A, Cerda E, Garcia-Criado A,
long as you give appropriate credit to the original author(s) and the Blasi A, et al. Timing Affects Measurement of Portal Pressure
source, provide a link to the Creative Commons licence, and indicate Gradient After Placement of Transjugular Intrahepatic Portosys-
if changes were made. The images or other third party material in this temic Shunts in Patients With Portal Hypertension. Gastroen-
article are included in the article’s Creative Commons licence, unless terology. 2017;152(6):1358–65.
indicated otherwise in a credit line to the material. If material is not 15. Guyton AC, Lindsey AW, Abernathy B, Richardson T. Venous
included in the article’s Creative Commons licence and your intended return at various right atrial pressures and the normal venous
use is not permitted by statutory regulation or exceeds the permitted return curve. Am J Physiol. 1957;189(3):609–15.
use, you will need to obtain permission directly from the copyright 16. Guyton AC. Physiology of heart failure. Trans Am Coll Cardiol.
holder. To view a copy of this licence, visit http://creativecommons. 1957;7:214–24.
org/licenses/by/4.0/. 17. Moller PW, Winkler B, Hurni S, Heinisch PP, Bloch A, Son-
dergaard S, et al. Right atrial pressure and venous return during
cardiopulmonary bypass. Am J Physiol Heart Circ Physiol.
References 2017;313(2):H408–20.
18. Busk TM, Bendtsen F, Henriksen JH, Fuglsang S, Clemmesen
JO, Larsen FS, et al. Effects of transjugular intrahepatic por-
1. Tsochatzis EA, Bosch J, Burroughs AK. Liver cirrhosis. Lancet.
tosystemic shunt (TIPS) on blood volume distribution in patients
2014;383(9930):1749–61.
with cirrhosis. Digestive Liver Dis. 2017;49(12):1353–9.
2. EASL. EASL clinical parctice guidelines on the management of
19. Busk TM, Bendtsen F, Poulsen JH, Clemmesen JO, Larsen FS,
ascites, spontaneous bacterial peritonitis, and hepatorenals syn-
Goetze JP, et al. Transjugular intrahepatic portosystemic shunt:
drome in cirrhosis. Journal of hepatology. 2010;53(53):397–417.
impact on systemic hemodynamics and renal and cardiac function
3. de Franchis R, Baveno VIF. Expanding consensus in portal
in patients with cirrhosis. Am J Physiol Gastrointest Liver
hypertension: Report of the Baveno VI Consensus Workshop:
Physiol. 2018;314(2):G275–86.
Stratifying risk and individualizing care for portal hypertension.
20. Garcia-Tsao G, Abraldes JG, Berzigotti A, Bosch J. Portal
J Hepatol. 2015;63(3):743–52.
hypertensive bleeding in cirrhosis: Risk stratification, diagnosis,
4. Lee EW, Kuei A, Saab S, Busuttil RW, Durazo F, Han SH, et al.
and management: 2016 practice guidance by the American
Nationwide trends and predictors of inpatient mortality in 83884
123
M.B. Pitton et al: Transjugular portosystemic stent shunt: impact of right atrial pressure… 111
Association for the study of liver diseases. Hepatology. 30. Reverter E, Blasi A, Abraldes JG, Martinez-Palli G, Seijo S,
2017;65(1):310–35. Turon F, et al. Impact of deep sedation on the accuracy of hepatic
21. Kibrit J, Khan R, Jung BH, Koppe S. Clinical Assessment and and portal venous pressure measurements in patients with cir-
Management of Portal Hypertension. Semin Interv Radiol. rhosis. Liver Int. 2014;34(1):16–25.
2018;35(3):153–9. 31. Tandon P, Ripoll C, Assis D, Wongcharatrawee S, Groszmann
22. Kim TY, Lee JG, Sohn JH, Kim JY, Kim SM, Kim J, et al. RJ, Garcia-Tsao G. The interpretation of hepatic venous pressure
Hepatic Venous Pressure Gradient Predicts Long-Term Mortality gradient tracings - excellent interobserver agreement unrelated to
in Patients with Decompensated Cirrhosis. Yonsei Med J. experience. Liver Int. 2016;36(8):1160–6.
2016;57(1):138–45. 32. Miraglia R, Maruzzelli L, Tuzzolino F, Petridis I, D’Amico M,
23. Tey TT, Gogna A, Irani FG, Too CW, Lo HG, Tan BS, et al. Luca A. Transjugular Intrahepatic Portosystemic Shunts in
Application of a standardised protocol for hepatic venous pres- Patients with Cirrhosis with Refractory Ascites: Comparison of
sure gradient measurement improves quality of readings and Clinical Outcomes by Using 8- and 10-mm PTFE-covered Stents.
facilitates reduction of variceal bleeding in cirrhotics. Singapore Radiology. 2017;284(1):281–8.
Med J. 2016;57(3):132–7. 33. Masson S, Mardini HA, Rose JD, Record CO. Hepatic
24. Lee JG, Sohn JH, Jeong JY, Kim TY, Kim SM, Cho YS, et al. encephalopathy after transjugular intrahepatic portosystemic
Combined effect of hepatic venous pressure gradient and liver shunt insertion: a decade of experience. QJM.
stiffness on long-term mortality in patients with cirrhosis. Korean 2008;101(6):493–501.
J Intern Med. 2020;35(1):88–98. 34. Lv Y, Qi X, He C, Wang Z, Yin Z, Niu J, et al. Covered TIPS
25. Liu C, Liu Y, Shao R, Wang S, Wang G, Wang L, et al. The versus endoscopic band ligation plus propranolol for the pre-
predictive value of baseline hepatic venous pressure gradient for vention of variceal rebleeding in cirrhotic patients with portal
variceal rebleeding in cirrhotic patients receiving secondary vein thrombosis: a randomised controlled trial. Gut.
prevention. Ann Transl Med. 2020;8(4):91. 2018;67(12):2156–68.
26. Maruyama H, Kobayashi K, Kiyono S, Ogasawara S, Ooka Y, 35. Sauerbruch T, Mengel M, Dollinger M, Zipprich A, Rossle M,
Suzuki E, et al. Incidence and hemodynamic feature of risky Panther E, et al. Prevention of Rebleeding From Esophageal
esophageal varices with lower hepatic venous pressure gradient. Varices in Patients With Cirrhosis Receiving Small-Diameter
Int J Med Sci. 2019;16(12):1614–20. Stents Versus Hemodynamically Controlled Medical Therapy.
27. La Mura V, Abraldes JG, Berzigotti A, Erice E, Flores-Arroyo A, Gastroenterology. 2015;149(3):660–8.
Garcia-Pagan JC, et al. Right atrial pressure is not adequate to 36. Pieper CC, Sprinkart AM, Nadal J, Hippe V, Meyer C, Schild
calculate portal pressure gradient in cirrhosis: a clinical-hemo- HH, et al. Postinterventional passive expansion of partially
dynamic correlation study. Hepatology. 2010;51(6):2108–16. dilated transjugular intrahepatic portosystemic shunt stents.
28. Rossle M, Blanke P, Fritz B, Schultheiss M, Bettinger D. Free J Vasc Interventional Radiol. 2015;26(3):388–94.
Hepatic Vein Pressure Is Not Useful to Calculate the Portal
Pressure Gradient in Cirrhosis: A Morphologic and Hemody- Publisher’s Note Springer Nature remains neutral with regard to
namic Study. J Vasc Interventional Radiol. 2016;27(8):1130–7.
jurisdictional claims in published maps and institutional affiliations.
29. Steinlauf AF, Garcia-Tsao G, Zakko MF, Dickey K, Gupta T,
Groszmann RJ. Low-dose midazolam sedation: an option for
patients undergoing serial hepatic venous pressure measurements.
Hepatology. 1999;29(4):1070–3.
123