RPS 1909 - Portal pathways: precision interventions in hepatic vascular care

Author Block: S. Wan, J. He, X. Luo, B. Song; Chengdu/CN
Purpose: Transjugular intrahepatic portosystemic shunt (TIPS) is an essential intervention for portal hypertension but significantly risks postoperative complications such as hepatic encephalopathy (HE). This study aimed to investigate the prognostic value of portal hemodynamics assessed by four-dimensional (4D) flow MRI in predicting post-TIPS outcomes and to identify associations with procedural strategies
Methods or Background: This prospective single-center study included 20 patients who underwent TIPS between September 2023 and November 2024 and completed both pre- and post-procedural 4D flow MRI for quantitative hemodynamic assessment. Parameters measured included forward volume(FV), total volume(TV), maximum flow(MF), backward volume(BV), peak velocity(PV), pressure difference(PD), wall shear stress(WSS), and regurgitation fraction(RF) across the portal venous system and TIPS-stent. Differences by procedural strategies were evaluated, and correlations with portal pressure gradient(PPG) were analyzed. Cox regression assessed associations with postoperative outcomes.
Results or Findings: Overall, FV, TV, MF, PV, WSS, and PD increased significantly across the portal venous system after TIPS (all P<.001). Patients developing HE (n=4) showed greater FV (P=.02) and MF (P=.007) changes at the proximal main portal vein. VIATORR Controlled Expansion stents had significantly higher mid-stent PD than conventional stents(P<.05). Mid-stent BV correlated positively with post-TIPS PPG (r=0.498, P=.04), whereas higher distal-stent BV was associated with reduced risk of HE or variceal rebleeding(HR=0.48; 95% CI, 0.26-0.90; P=.02).
Conclusion: TIPS significantly improved portal hemodynamics as measured by 4D flow MRI. Backward flow volume emerged as a potential predictor of adverse outcomes, and distinct procedural strategies were associated with specific flow patterns, offering insights for surgical planning and risk stratification.
Limitations: The sample size for this exploratory study was relatively small
Funding for this study: N/A
Has your study been approved by an ethics committee? Yes
Ethics committee - additional information: West China Hospital of Sichuan University

Author Block: P. Marra, K. D. Martins De Mattos, R. Muglia, F. S. Carbone, L. Dulcetta, M. Bertuletti, M. Cheli, L. D'Antiga, S. Sironi; Bergamo/IT
Purpose: Portal vein recanalization (PVR) without TIPS is being investigated to treat non-cirrhotic portal hypertension resulting from extrahepatic portal vein obstruction (EHPVO). We describe advanced techniques and outcomes of PVR attempted in a cohort of pediatric patients and young adults.
Methods or Background: Consecutive patients suffering from non-cirrhotic portal hypertension due to perinatally-acquired EHPVO were prospectively enrolled since 2021. Wedge hepatic venography and percutaneous portal access (transhepatic and/or transplenic), were performed upon multidisciplinary discussion to attempt PVR. Clinical and procedural data, technical and clinical success, complications and follow-up data were recorded. Technical success was considered at least the partial revascularization of the native portal system.
Results or Findings: Twenty-three patients (16 males; median age 10 years) with severe portal hypertension due to EHPVO underwent 33 percutaneous transhepatic (n=2), transplenic (n=24) or simultaneous transhepatic/transplenic (n=7) for PVR. All but two were judged not eligible for Meso-Rex bypass while it failed 2 patients. Technically successful recanalization was achieved in 18/23 patients (78%), by means of advanced techniques in 4 cases, respectively 2 gun-sight sharp recanalization and 2 collateral vessel angioplasty/stenting. Severe arterial bleeding complications occurred in 2 patients, managed by transarterial embolization. After successful angioplasty, 17/18 patients required primary or secondary stenting to obtain sustained patency. Revisions due to thrombosis/stenosis were necessary in 8/18 patients. After a median follow-up of 12 months, portal vein patency was demonstrated in all but one patients who achieved successful PVR, with clinical and laboratory improvement of portal hypertension.
Conclusion: With increasing experience, more than 70% of patients with non-cirrhotic portal hypertension due to EHPVO can restore the portal flow by endovascular treatment, even when Meso-Rex is unfeasible. Technical challenges still remain but clinical outcomes seem promising.
Limitations: Retrospective cohort. Limited reproducibility due to technical challenges.
Funding for this study: None
Has your study been approved by an ethics committee? Yes
Ethics committee - additional information: Authorization code: Primo-01

Author Block: D. Santangelo, R. Vitali, A. Campisi, F. Cipriani, D. Palumbo, C. Canevari, F. Ratti, A. Chiti, F. De Cobelli; Milan/IT
Purpose: To evaluate the influence of right hepatic artery (RHA) caliber on liver regeneration in patients with primary or secondary liver malignancies undergoing liver venous deprivation (LVD), and to assess the impact of the hepatic arterial buffer response (HABR) on post-LVD regeneration.
Methods or Background: Fifty-nine patients (June 2019–September 2024) who underwent LVD were retrospectively analyzed. Right hepatic artery (RHA) caliber was measured on CT scans obtained both before LVD and within 30 days after the procedure. All patients underwent FLR volumetry on CT at three timepoints; pre-LVD (baseline), 5–15 days post-LVD (timepoint 1), and 15–30 days post-LVD (timepoint 2). FLR function was assessed with 99mTc-mebrofenin hepatobiliary scintigraphy pre-LVD and within 30 days post-LVD. Correlation analyses and linear regression were performed.
Results or Findings: A significant correlation between total liver volume and right hepatic artery caliber at baseline was found; therefore, all measured RHA caliber were standardized to the total liver volume, obtaining the new variable “s-caliber”. At baseline, RHA s-caliber showed an inverse correlation with post-procedural volumetric FLR volume (p<0.001), degree of hypertrophy (p=0.008), and kinetic growth rate (p=0.014). No significant associations were observed between s-caliber and functional hypertrophy metrics. The RHA caliber change after LVD didn’t correlate with any volumetric/functional hypertrophy parameters.
Conclusion: This is the first report demonstrating the potential impact of the RHA on volumetric FLR hypertrophy after LVD. Larger arterial calibers may attenuate hypertrophy, likely by sustaining arterial inflow to embolized segments.
Limitations: Retrospective. Small sample size.
Funding for this study: None.
Has your study been approved by an ethics committee? Yes
Ethics committee - additional information: Leatum 64/INT/2021

Author Block: R. K. Patel, T. P. Tripathy, M. Panigrahi, H. Nayak; Bhubaneswar/IN
Purpose: To compare the outcome of RTO and EUS-guided therapies in the management of fundal varices.
Methods or Background: We retrospectively analyzed the data of patients with fundal varices undergoing EUS-guided intervention or RTO, and both groups were compared after propensity matching. The study’s primary outcome was the incidence of variceal bleeding within 1 year. The secondary outcomes included procedure-related adverse events (AEs), variceal obliteration, reintervention, and mortality within 1 year.
Results or Findings: 167 patients (EUS-guided intervention: 108, RTO: 59) were included in the analysis, of which 59 patients were included in each group after propensity matching. The incidence of variceal obliteration at 4 weeks was comparable between groups (83.1% vs. 91.5%, p = 0.167). The incidence of variceal bleeding (15.3% vs. 13.6%, p = 0.793) within 1 year was also comparable between the EUS and RTO groups. Nevertheless, the need for reintervention for GVs was higher in the EUS group (28.8% vs. 5.1%, p = 0.001), and the need for reintervention for esophageal varices (EVs) was higher in the RTO group (16.9% vs. 1.7%, p = 0.008). Procedure-related adverse events (AEs), primarily new onset or worsening of ascites, were higher in the RTO group. None of the AEs were life-threatening.
Conclusion: RTO provides more complete fundal variceal obliteration, requiring a significantly lower number of reintervention than EUS-guided therapies. Thus, RTO may be considered as a more definite therapy for fundal variceal obliteration
Limitations: Retropsective analaysis
Operator bias
Funding for this study: None
Has your study been approved by an ethics committee? Yes
Ethics committee - additional information: IEC, AIIMS-Bhubaneswar
IEC number: T/IM-NF/Radiodi/25-26/48

Author Block: P. Marra, K. D. Martins De Mattos, G. De Petri, V. Casotti, R. Muglia, F. S. Carbone, M. Bertuletti, L. Dulcetta, S. Sironi; Bergamo/IT
Purpose: Congenital portosystemic shunts (CPSS) are rare vascular malformations potentially leading to liver transplantation if untreated. We evaluated whether timely, multidisciplinary use of interventional radiology (IR) for diagnostic and therapeutic management reduces complications and the need for liver transplantation in a retrospective cohort.
Methods or Background: In this single-center cohort of pediatric CPSS, all patients underwent multidisciplinary workup. Due to substantial improvement in the management protocol over time, patients were divided into two groups according to treatment period: Early (treatment before 2019) and Late (treatment in 2019 or later). In the Late cohort IR procedures included diagnostic retrograde portal venography with balloon occlusion test and endovascular shunt closure, when technically feasible; alternatively, surgical shunt closure was performed. In the Early cohort, endovascular and surgical closure were not routinely performed. We compared time from diagnosis to treatment, frequency of liver transplantation, and the number of CPSS-related complications between groups.
Results or Findings: Twenty-four patients (male n = 9) were analyzed, 11 in the Early group and 13 in the Late group. IR procedures were undertaken in 4/11 (36%) Early versus 8/13 (62%) Late patients. Liver transplantation was performed in 9/11 (82%) Early patients and in 1/13 (8%) Late patients. Surgical shunt ligation was performed in 3/24 (13%) overall. Mean age at diagnosis was similar between cohorts (~5 years). Median time from diagnosis to treatment decreased from 4 years in the Early cohort to 1 year in the Late cohort. Patients who underwent IR management had fewer documented CPSS-related complications.
Conclusion: Incorporation of IR into a multidisciplinary care pathway was associated with shorter diagnostic-to-treatment intervals, increased utilization of minimally invasive management, and a substantially lower transplant rate in children with CPSS.
Limitations: Retrospective cohort with management shift over a long time.
Funding for this study: None
Has your study been approved by an ethics committee? Yes
Ethics committee - additional information: Multicenter registry IRCPSS

Author Block: L. Dulcetta, P. Marra, R. Muglia, F. S. Carbone, M. Bertuletti, S. Sironi; Bergamo/IT
Purpose: Chronic total occlusion (CTO) of the portal vein is a major cause of portal hypertension, which may lead to life-threatening complications often managed by interventional radiology (IR). The aim of this study was to evaluate the feasibility, safety and clinical outcomes of percutaneous revascularization therapy for CTO of the portal vein in pediatric and adult patients.
Methods or Background: From January 2020 to June 2025, consecutive patients with severe portal hypertension due to portal vein CTO undergoing percutaneous recanalization were retrospectively reviewed. Technical success was defined as restoration of portal vein patency at angiography; clinical success was defined as improvement of clinical and laboratory signs of portal hypertension and control of variceal bleeding.
Results or Findings: Twenty-two patients (median age 27 years; range 6–60; 14 males; 5 children) underwent 32 procedures. Eleven (50%) were liver transplant recipients. Cavernous transformation was present in 21/22, with splenomesenteric confluence involvement in 10 patients. Technical success was achieved in 18/22 patients (82%), 11 of whom underwent portal revascularization through extrahepatic stent placement; in 6 cases, a TIPS was performed to achieve sustained portal vein patency. Embolization of varices and/or cavernoma was performed in 17 patients. Three complications (two splenic artery perforation, one hemoperitoneum) were managed conservatively. Clinical success was achieved in all 18 technically successful cases, with a median follow-up of 32 months (IQR 3–41).
Conclusion: Percutaneous revascularization is feasible and effective in managing portal vein CTO, with no significant technical contraindications to attempting the procedure. Restored portal flow physiology alone is possible in most patients; TIPS is not essential to achieve portal vein patency, but it may be useful in a few selected cases to maintain long-term patency and control portal hypertension.
Limitations: Retrospective nature and the small sample size.
Funding for this study: No funding was received for this study.
Has your study been approved by an ethics committee? Yes
Ethics committee - additional information: The Ethical Committee of Bergamo authorized this retrospective study (Portal01; N.92/21) that was conducted in respect of the ethical standards laid down in the 1964 Declaration of Helsinki.

Author Block: S. H. Lee, D. Shim, S. Baek, D. Kim, J. Yoo; Incheon/KR
Purpose: Esophageal variceal bleeding (EVB) refractory to endoscopic treatment in some patients with advanced cirrhosis, leaving few options other than transjugular intrahepatic portosystemic shunt (TIPS). However, patients with encephalopathy or heart failure are often ineligible for TIPS, alternatively opt for antegrade transvenous obliteration (ATO). This study aimed to assess the safety and efficacy of ATO compared to TIPS for refractory EVB.
Methods or Background: This study retrospectively reviewed medical records from clinical data warehouse the Catholic University of Korea which encompass eight tertiary hospitals between 2012 and 2024. Although TIPS was initially considered, ATO was indicated for patients who were ineligible for TIPS. ATO were implemented in 20 patients (age=62±10.2 years, men=13), while TIPS were created in 35 patients (age=58±12.6 years, men=26) for refractory EVB. The primary outcome was the difference in the 30-month overall survival (OS) rate between two groups, a noninferiority comparison to exclude a difference of >30 percentage point. The secondary outcomes were comparison of postprocedural adverse events and bleeding-free survival (BFS) between the ATO and TIPS groups.
Results or Findings: At a median 31-month follow-up, 30-month BFS and OS for ATO were 23.2% (95% CI, 7.8–69.7%) and 50.9% (95% CI, 32.0–81.0%); for TIPS, 63.8% (95% CI, 45.4–89.7%) and 52.2% (95% CI, 34.1–79.8%). The absolute OS difference was 1.3% (95% CI, –31.1–33.7%). One-week mortality or liver transplant occurred in 5 TIPS patients (14.3%) but none with ATO. Kaplan-Meier/log-rank analysis showed no significant differences in BFS (p=0.07) or OS (p=0.41).
Conclusion: Although the outcomes fall short for the specified noninferiority, the ATO might be an alternative for those who are ineligible for TIPS in treatment of refractory EVB.
Limitations: This study is limited by its retrospective design and sample size.
Funding for this study: No funding was received for this study.
Has your study been approved by an ethics committee? Not applicable
Ethics committee - additional information:

Author Block: F. Schön, P. Hahlbohm, T. Helmberger, S. F. U. Blum, M. Berning, S. Löck, R-T. Hoffmann, J-P. Kühn; Dresden/DE
Purpose: To develop non-invasive models for estimating the hepatic venous pressure gradient (HVPG) using computed tomography (CT) in patients receiving transjugular intrahepatic portosystemic shunt (TIPS).
Methods or Background: Patients with therapy-refractory ascites who underwent TIPS between 2017 and 2024 were retrospectively enrolled. Baseline characteristics were collected, and pre-interventional CT scans were analyzed to extract quantitative parameters (e.g., hepatic vessel diameters, sarcopenia scores). The HVPG was measured during the TIPS procedure prior to shunt placement. Univariate and multivariate linear and logistic regression analyses using backward elimination were performed to (1) predict absolute HVPG values, and (2) distinguish between patients with HVPG ≤20 mmHg and those with HVPG >20 mmHg. Model performances were assessed by area under the receiver operating characteristic curve (AUC), R², and mean absolute error (MAE).
Results or Findings: A total of 129 patients (87 men; 61.0+/-10.1 years) were enrolled with an intra-procedural HVPG value prior to shunt placement of 20.21+/-3.61 mmHg. In multivariate linear regression, the superior mesenteric vein diameter (ß = 0.431; p = 0.012) and MELD-Na Score (ß = 0.152; p = 0.031) performed best to estimate the absolute HVPG (R² = 0.134; MAE = 2.53+/-2.10 mmHg). Multivariate logistic regression identified the superior mesenteric vein diameter (OR = 1.186; 95%-CI: 1.002-1.405; p = 0.048) and ALAT (OR = 24.218; 95%-CI: 2.395-244.913; p = 0.007) as independent predictors for HVPG ≤ 20 vs. >20 mmHg (AUC = 0.729; 95%-CI: 0.638-0.820). Sarcopenia scores only revealed significant predictive value in univariate analysis.
Conclusion: Non-invasive prediction models may estimate the HVPG in patients undergoing TIPS for therapy-refractory ascites. These models could help identify patients at earlier disease stages with less severe portal hypertension, who might benefit from TIPS placement.
Limitations: Retrospective study in a single-center setting. Small sample size.
Funding for this study: None.
Has your study been approved by an ethics committee? Yes
Ethics committee - additional information: Approved by the local ethics committee of the Technical University Dresden (BO-EK-501122023_2).