End-procedural adherence to hemodynamic targets does not improve the outcome of elective transjugular intrahepatic portosystemic shunt (TIPS) in patients with cirrhosis

Background & aims: Transjugular intrahepatic portosystemic shunt (TIPS) has progressively become the treatment of choice for the complications of portal hypertension (PH) in patients with cirrhosis. Currently adopted hemodynamic targets aim to balance clinical efficacy and the risk of shunt-related complications. Nevertheless, clear hemodynamic targets for covered TIPS are still not defined. We aimed to compare mortality rate and control/recurrence of portal hypertensive complications according to different end-procedural hemodynamic targets. Methods: We performed a multicenter, retrospective study including 415 consecutive patients with cirrhosis, of whom 212 patients received TIPS for refractory ascites (RA) and 203 patients for secondary prophylaxis of PH-related bleeding (PHRB). All patients underwent TIPS using old or new generation VIATORR endoprosthesis. Reduction in porto-caval pressure gradient (PCPG) was defined inadequate (IHR) in patients not achieving a PCPG <12 mm Hg for both secondary prophylaxis of PHRB and RA, or a reduction of at least 50% only for PHRB. Results: An adequate hemodynamic response (AHR) was achieved in 66%. In the PHRB group, the number of patients who had recurrence of variceal bleeding did not significantly differ between AHR and IHR (5% vs 4%, p value = 0.731). In the RA group, the 12-month overall cumulative incidence of LVP was significantly higher in IHR compared to AHR (67% vs 43%, p = 0.005); however, after the first month, the cumulative incidence of LVP between the two groups became not statistically different (p value = 0.2). The 60-month cumulative incidence of death was significantly higher in RA group, but did not significantly differ between AHR and IHR. Regardless of TIPS indication, survival was not significantly different between IHR and AHR (p value = 0.14), while advanced age and liver function before TIPS were significantly associated with a higher cumulative incidence of liver-related death. Interestingly, liver-related mortality in RA group was significantly higher for AHR patients when the combined hemodynamic response was applied (p value = 0.037). Conclusions: The study showed that achieving currently adopted hemodynamic targets, measured at the end of an elective TIPS for PHRB and RA, is not associated with a better PH-related complications control. Furthermore, the adherence to these hemodynamic targets does not improve survival and their combined use in patients with RA could negatively affect the prognosis.