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Objectives: Salvage transjugular intrahepatic portosystemic shunt (TIPS) is indicated in patients with active endoscopically uncontrollable variceal bleeding. TIPS alone is not effective in the management of gastric varices, and balloon occluded transvenous obliteration (BRTO) requires favourable variceal anatomy. Concomitant placement of a TIPS stent with antegrade variceal embolization leads to control of gastric variceal bleeding with no significant increase in portal pressure. Methods: A single-centre retrospective observational study in which patients with active uncontrollable gastric variceal bleeding were included. Technical success of the procedure, 5-day rebleeding, 6-week, and 6-month survival, as well as other additional outcomes, were evaluated. Results: A total of 18 patients were included in the study. Technical success was 100% and significant non-target embolization was seen in 0% of patients. The 6-week and 6-month survival rates were 66.67%, with an overall survival of 108.786 days (censored at 180 days). The 5-day rebleed rate was 11.1%. A significant difference in Child-Turcotte-Pugh score (P = .03), model for end-stage liver disease-sodium (MELD–Na) score (P = .022), requirement of intubation (P = .038), haemoglobin (Hb) levels (P = .042), haematocrit value (P = .018), packed red blood cell infusion required prior to and after the procedure (P = .045,.044), and presence of refractory shock (P = .013) was observed between the survival and the mortality groups. Post-variceal bleeding Hb levels, mean arterial pressure, and MELD-Na scores were significant predictors of mortality. Conclusion: TIPS in adjunct to antegrade transvenous embolization is a safe and effective modality for the management of active uncontrolled gastric variceal bleeding in patients with variceal anatomy unfavourable for performing retrograde obliteration. Advances in knowledge: (1) TIPS alone may not be effective in the management of gastric varices. BRTO requires favourable variceal anatomy and may lead to catastrophic oesophageal variceal haemorrhage. Concomitant placement of a TIPS stent with antegrade variceal embolization leads to control of gastric variceal bleeding with no significant increase in portal pressure. (2) TIPS, in conjunction with antegrade transvenous embolization, requires proper knowledge of variceal anatomy and the embolizing agent. Post-variceal bleeding Hb levels, mean arterial pressure, and MELD-Na scores were significant predictors of mortality. [ABSTRACT FROM AUTHOR]

Ascites remains a significant challenge in patients with cirrhosis, posing difficulties in management and affecting prognosis. This review examines the current understanding of ascites, including its underlying mechanisms, symptoms, and treatment options, with a specific focus on the innovative Alfa Pump device. The review begins by discussing traditional approaches to managing ascites while also addressing their limitations and potential complications. It then explores the emergence of the Alfa Pump system, a novel implantable device designed to tackle refractory ascites by continuously draining fluid from the abdomen while minimizing circulatory issues. Through a synthesis of current literature and clinical evidence, this narrative review underscores the importance of a multidisciplinary approach in the management of ascites, with a particular emphasis on the evolving role of the Alfa Pump in improving outcomes and quality of life for patients with refractory ascites. [ABSTRACT FROM AUTHOR]

Objectives Methods Results Conclusion Although the incidence of isolated gastric varices type 1 (IGV1) bleeding is low, the condition is highly dangerous and associated with high mortality, making its treatment challenging. We aimed to compare the safety and efficacy of endoscopic clipping combined with cyanoacrylate injection (EC‐CYA) vs. transjugular intrahepatic portosystemic shunt (TIPS) in treating IGV1.In a single‐center, randomized controlled trial, patients with IGV1 bleeding were randomly assigned to the EC‐CYA group or TIPS group. The primary end‐points were gastric variceal rebleeding rates and technical success. Secondary end‐points included cumulative nonbleeding rates, mortality, and complications.A total of 156 patients between January 2019 and April 2023 were selected and randomly assigned to the EC‐CYA group (n = 76) and TIPS group (n = 80). The technical success rate was 100% for both groups. The rebleeding rates were 14.5% in the EC‐CYA group and 8.8% in the TIPS group, showing no significant difference (P = 0.263). Kaplan–Meier analysis revealed that the cumulative nonbleeding rates at 6, 12, 24, and 36 months for the two groups lacked statistical significance (P = 0.344). Similarly, cumulative survival rates at 12, 24, and 36 months for the two groups were not statistically significant (P = 0.916). The bleeding rates from other causes were 13.2% and 6.3% for the respective groups, showing no significant difference (P = 0.144). No instances of ectopic embolism were observed in either group. The incidence of hepatic encephalopathy (HE) in the TIPS group was statistically higher than that in the EC‐CYA group (P = 0.001).Both groups are effective in controlling IGV1 bleeding. Notably, EC‐CYA did not result in ectopic embolism, and the incidence of HE was lower than that observed with TIPS. [ABSTRACT FROM AUTHOR]

Purpose: To report antegrade transvenous obliteration, with or without concurrent portosystemic shunt creation, for the treatment of hemorrhagic rectal varices. Materials and methods: Eight patients, including five (62.5%) females and three (37.5%) males, with mean age of 55.8 ± 13.8 years (range: 30–70 years), underwent transjugular-approach antegrade transvenous obliteration of rectal varices, with or without portosystemic shunt creation. Demographic data, procedural details, technical success of variceal obliteration, clinical success, adverse events, and follow-up outcomes were retrospectively recorded. Clinical success was defined as resolution of rectal hemorrhage. Results: Portal venous access was achieved via a transjugular intrahepatic approach in all patients. The inferior mesenteric vein was selected, and foamy sclerosant (1:2:3 mixture by volume of ethiodized oil: sodium tetradecyl sulfate: air) was injected into the rectal varices with antegrade balloon occlusion in seven (87.5%) and without balloon occlusion in one (12.5%). Five of eight (62.5%) patients underwent concomitant transjugular intrahepatic portosystemic shunt (TIPS) creation (mean diameter 8.4 ± 0.9-mm) immediately following transvenous obliteration. Technical success of variceal obliteration was achieved in all patients. There were no immediate post-procedural adverse events. There were no reported occurrences of rectal ischemia, perforation, or stricture following obliteration. Two (40%) of the patients who underwent concomitant TIPS creation developed hepatic encephalopathy within 30 days of the procedure, which was medically managed. Clinical resolution of hemorrhage was achieved in all patients with no recurrent rectal variceal hemorrhage during mean follow-up of 666 ± 396 days (range: 14 − 1,224 days). Conclusion: Transvenous obliteration, with or without concurrent TIPS creation, is feasible with promising results for the management of rectal variceal hemorrhage. [ABSTRACT FROM AUTHOR]

Transjugular intrahepatic portosystemic shunt (TIPS) has become essential in the treatment or prevention of portal hypertension‐related complications. In the early 1990s, the primary indication was refractory bleeding. It is now proposed for the treatment of ascites for the prevention of bleeding and in patients with vascular diseases of the liver. Thus, there are a growing number of patients being treated with TIPS all over the world. The broadening of indications, the involvement of multiple stakeholders, the need for an accurate selection, the positioning in relation to transplantation and the lack of standardization in pre‐therapeutic assessment, in the procedure itself and in the follow‐up have led the board of the French Association for the Study of the Liver to establish recommendations. [ABSTRACT FROM AUTHOR]

In Europe, transjugular intrahepatic portosystemic shunt (TIPS) is considered the primary treatment for gastric varix (GV) bleeding to reduce portal hypertension. However, in Asian countries, balloon-occluded retrograde transvenous obliteration (BRTO) and its variants plug/coil assisted transvenous retrograde obliteration (PARTO/CARTO) are the preferred approaches. The purpose of this study is to report a European single-center experience in the use of PARTO/CARTO techniques for the treatment of GVs in patients with portal hypertension, focusing on the effectiveness and safety of the procedure. All the procedures involving the PARTO/CARTO techniques performed from 2019 to 2023 were retrospectively evaluated. Technical success was defined as the complete obliteration of both the GVs and the gastro-renal (GR) shunt on review of the Computed Tomography (CT) scan performed 3 days after the procedure. The obliteration rate was also evaluated through performing CT scans 1 and 12 months after the procedure, and through endoscopic follow-up at 3 and 6 months. Additionally, major and minor complications were reported. The study involved seven patients, with a technical success of 100%. During follow-up, there were no episodes of variceal rebleeding or upper gastrointestinal bleeding. Two patients developed ascites, which resolved with medical therapy. One patient exhibited focal portal thrombosis, which was successfully treated with heparin. PARTO/CARTO techniques demonstrated high technical and clinical success rates, offering advantages over traditional BRTO. The use of coils and plugs simplifies the procedure, eliminates sclerosing agents, and prevents complications associated with balloon guiding catheters. [ABSTRACT FROM AUTHOR]

Abstract Ascites remains a significant challenge in patients with cirrhosis, posing difficulties in management and affecting prognosis. This review examines the current understanding of ascites, including its underlying mechanisms, symptoms, and treatment options, with a specific focus on the innovative Alfa Pump device. The review begins by discussing traditional approaches to managing ascites while also addressing their limitations and potential complications. It then explores the emergence of the Alfa Pump system, a novel implantable device designed to tackle refractory ascites by continuously draining fluid from the abdomen while minimizing circulatory issues. Through a synthesis of current literature and clinical evidence, this narrative review underscores the importance of a multidisciplinary approach in the management of ascites, with a particular emphasis on the evolving role of the Alfa Pump in improving outcomes and quality of life for patients with refractory ascites.

Ascites is a frequent complication in patients with cirrhosis, associated with a bad prognosis. Ascites is associated with severe complications, such as spontaneous bacterial peritonitis and kidney dysfunction, which must be diagnosed and managed rapidly. First-line management is based on diuretics use. Beta-blockers role remains debated but an early administration could probably decrease complications associated with portal hypertension. Albumin infusion is validated in large volume paracenteses, spontaneous bacterial peritonitis, or kidney dysfunction, but is debated in other situations. Technical progresses allow the worldwide use of TIPS (transjugular intrahepatic portosystemic shunt), but patient selection must be rigorous because of potential severe complications. An alternative treatment, automated low-flow ascites pump, can be offered in patients without TIPS possibility: It is a recent technique, whose patients’ selection and installation conditions were improved, with interesting results. Liver transplantation remains the gold standard, but the lack of grafts, and specific side effects, lead to prefer other methods. In case of acute kidney injury due to hepatorenal syndrome, terlipressin remains the standard of care; continuous infusion is associated with fewer side effects.

Purpose The aim of this study was to evaluate the safety and efficacy of using a trans-splenic approach for transjugular intrahepatic portosystemic shunt (TIPS) creation in patients with portal vein thrombosis. (PVT).

Objective: to improve the results of treatment of patients with complicated intrahepatic portal hypertension by developing optimal surgical treatment tactics and choosing drug correction aimed at preventing thrombotic venous complications.Materials and methods: 82 patients with clinically significant portal hypertension of cirrhotic origin were examined and treated. The I group consisted of 24 patients who underwent transjugular intrahepatic portosystemic stent bypass surgery, the II group included 58 patients for whom the operation was supplemented with selective embolization of the gastric veins. Methods: clinical and laboratory examination, “Thrombodynamics” test using a “prognostic calculator” (RF patent), surgical, statistical.Results: it was established that 26,8% of patients had a risk of developing venous thrombotic complications: in group I 4/24 (16,6%), in group II — 18/58 (31,0%). Personalized drug correction carried out in the postoperative period led to the absence of risk in 2/22 (9,1%) patients in group I and in 8/53 (15,1%) in group II. The number of deaths in group I was 2/24 (8,33%) and in group II 5/58 (8,62%). Shunt thrombosis was detected in 3/22 (13,63%) patients of group I and in 1/53 (1,88%) patients of group II in the period from 24 to 32 months after surgery. Varicose esophageal-gastric bleeding occurred in 2/22 (9,00%) patients with shunt thrombosis of group I and in 1/53 (1,88%) of group II patients who underwent endoscopic ligation of esophageal varices.Conclusion: a method for predicting the risk of developing thrombotic complications in patients with liver cirrhosis is a convenient tool for risk stratification of patients. An individual approach ensures monitoring of the patient not only before, but also after the operation. Drug correction regimens for identifying high, moderate and low risks of complications made it possible to prevent them. TIPS surgery alone and in combination with selective embolization of gastric veins allows achieving comparable results in observation groups against the background of corrective therapy.

Background: During pseudoglandular stage of the human lung development the primitive bronchial buds are initially conformed by simple tubules lined by endoderm-derived epithelium surrounded by mesenchyme, which will progressively branch into airways and start to form distal epithelial saculles. For first time alveolar type II (AT2) pneumocytes appears. This study aims to characterize the genes and microRNAs involved in this differentiation process and decipher its role in the starting alveolar differentiation. Methods: Gene and microRNA profiling was performed in human embryonic lungs from 7 to 12 post conception weeks (pcw). Protein expression location of candidate genes were analyzed by immunofluorescense in embryonic lung tissue sections. mRNA/miRNA target pairs were identified using computational approaches and their expression was studied in purified epithelial/mesenchymal cell populations and in isolated tips and stalks from the bronchial tree. Additionally, silencing experiments in human embryonic lung mesenchymal cells and in human embryonic tip-derived lung organoids were performed, as well as organoid differentiation studies. AT2 cell markers were studied by qRT-PCR and by immunofluorescence. The TGFB-β phosphorylated pathways was analyzed with membrane protein arrays. Lung explants were cultured in air/liquid interface with/without peptides. Results: We identified 88 differentially expressed genes, including IGFBP3. Although IGFBP3 mRNA was detected in both epithelial and mesenchymal populations, the protein was restricted to the epithelium, indicating post-transcriptional regulation preventing IGFBP3 protein expression in the mesenchyme. MicroRNA profiling identified miR-34a as an IGFBP3 regulator. miR-34a was up-regulated in mesenchymal cells, and its silencing in human embryonic lung mesenchymal cells increased IGFBP3 levels. Additionally, IGFBP3 expression showed a marked downregulation from 7 to 12 pcw, suggesting its involvement in the differentiation process. The differentiation of human tip-derived lung embryonic organoids showed a drastic reduction in IGFBP3, supported by the scRNAseq data. IGFBP3 silencing in organoids activated an alveolar-like differentiation process characterized by stem cell markers downregulation and upregulation of AT2 markers. This process was mediated by TGFβ signalling inhibition and BMP pathway activation. Conclusions: The IGFBP3/miR-34a axis restricts IGFBP3 expression in the embryonic undifferentiated lung epithelium, and the progressive downregulation of IGFBP3 during the pseudoglandular stage is required for alveolar differentiation. [ABSTRACT FROM AUTHOR]

Purpose: To assess the safety and effectiveness of percutaneous transsplenic access (PTSA) for portal vein (PV) interventions among patients with PV disease. Materials and methods: Adult patients with PV disease were enrolled if they required percutaneous catheterization for PV angioplasty, embolization, thrombectomy, variceal embolization, or transjugular intrahepatic portosystemic shunt (TIPS) placement for a difficult TIPS or recanalization of a chronically occluded PV. The procedures were performed between January 2018 and January 2023. Patients were excluded if they had an active infection, had a chronically occluded splenic vein malignant infiltration of the needle tract, had undergone splenectomy, or were under age 18 years. Results: Thirty patients (15 women, 15 men) were enrolled. Catheterization of the PV through PTSA succeeded for 29 of 30 patients (96.7%). The main adverse effect recorded was flank pain in 5 of 30 cases (16.7%). No bleeding events from the spleen, splenic vein, or percutaneous access point were recorded. Two cases (6.7%) each of hepatic bleeding and rethrombosis of the PV were reported, and a change in hemoglobin levels (mean [SD], − 0.5 [1.4] g/dL) was documented in 14 cases (46.7%). Conclusion: PTSA as an approach to accessing the PV is secure and achievable, with minimal risk of complications. Minimal to no bleeding is possible by using tract closure methods. [ABSTRACT FROM AUTHOR]

Background/Aims: Transjugular intrahepatic portosystemic shunt (TIPS) is a commonly performed procedure in patients with liver cirrhosis to treat portal hypertension-related conditions, including variceal bleeding and refractory ascites. However, while the increased risk of hepatic encephalopathy (HE) after TIPS is important to consider when determining whether a patient is a good candidate for TIPS, currently there is no widely used method to predict the development of post-TIPS HE, although the model for end-stage liver disease (MELD) score is used to predict post-TIPS mortality. We conducted a systematic review and meta-analysis to evaluate sarcopenia as a risk factor for HE and mortality in patients undergoing TIPS. Methods: A comprehensive search strategy was used to identify reports of post-TIPS HE and mortality in sarcopenia vs. non-sarcopenia patients with liver cirrhosis who received TIPS in March 2023. Open Meta Analyst was used to compute the results. Results: Twelve studies with 2056 patients met inclusion criteria and were included in the final meta-analysis. Sarcopenia was associated with a significantly higher post-TIPS HE rate than non-sarcopenia (risk ratio [RR]: 1.68, 95% CI: 1.48–1.92, p < 0.00001, I2 = 65%), as well as a significantly higher post-TIPS mortality rate (RR: 1.73, 95% CI: 1.14–2.64, p < 0.00001, I2 = 87%). Conclusion: Patients with sarcopenia have a significantly increased risk of post-TIPS HE and mortality. Presence of sarcopenia should be considered when weighing the risks and benefits of performing TIPS in patients with cirrhosis. Further studies are needed to determine the clinical utility of important risk factors such as sarcopenia on post-TIPS outcomes. [ABSTRACT FROM AUTHOR]

Purpose The aim of this study was to evaluate the safety and efficacy of using a trans-splenic approach for transjugular intrahepatic portosystemic shunt (TIPS) creation in patients with portal vein thrombosis. (PVT). Material and Methods A retrospective review was performed on 36 consecutive patients with PVT who underwent TIPS using a trans-splenic approach from February 2018 to June 2021. Preprocedural data including demographic information and Model for End-Stage Liver Disease (MELD) scores were obtained. Outcomes measured included technical success, clinical success, complications, and survival. Results Technical success was achieved in 32 of 36 patients (89%). During the follow-up period, 16 of 32 (50%) required secondary TIPS interventions, most of which were planned as part of a staged procedure. 30/32 (94%) had stent patency on their most recent follow-up, with a median follow-up of 164 days. No patients had variceal bleeding following TIPS. 12 of 32 (38%) patients underwent successful transplant after TIPS. Anatomical portal vein end-to-end anastomosis was achieved in 11/12 (92%) patients. Conclusion The trans-splenic approach to TIPS is a reliable alternative to traditional TIPS in patients with PVT and provides high technical and clinical success rates. This technique can also be utilized to improve future liver transplant outcomes by facilitating anatomic portal vein end-to-end anastomoses. [ABSTRACT FROM AUTHOR]

Introduction: Inflammatory and thrombotic biomarkers are simple prognostic indicators of adverse clinical outcomes in patients with ischemic stroke (IS). However, isolated assessment of inflammatory or thrombus biomarkers in patients with IS is limited in clinical practice. Methods: This study aimed to evaluate the predictive value of a novel, simplified thrombo-inflammatory prognostic score (TIPS) that combines both inflammatory and thrombus biomarkers in the early phase of IS and to identify high-risk patients at the time of admission. The study population comprised 915 patients with a primary diagnosis of IS in the emergency departments of five grade A tertiary hospitals in China. Results: Patients were divided into two groups based on the modified Rankin Scale (mRS): <3 and ≥3. TIPS with a value of "2" indicates biomarkers for high inflammation and thrombosis, "1" represents a biomarker, and "0" signals the absence of a biomarker. Multivariate logistic regression analysis was employed to identify the association between TIPS and clinical outcomes. TIPS was an independent predictor of unfavorable functional outcomes and mortality. It had a superior predictive value for clinical outcomes compared to the National Institutes of Health Stroke Scale (NIHSS) (effect ratio, 37.5%), D-dimer (effect ratio, 12.5%), and neutrophil-to-lymphocyte ratio (effect ratio, 25%). Conclusion: The survival probability of TIPS with a score of 0 is twice as high as that of TIPS with a score of 2. The survival rate for TIPS with a score of 1 is one time higher than that for TIPS with a score of 2. The predictive value of TIPS for unfavorable functional outcomes is represented by an AUC of 0.653. TIPS is associated with an increased risk of death and unfavorable functional outcomes in patients with IS and may be a useful tool for identifying high-risk patients at the time of admission. [ABSTRACT FROM AUTHOR]

Institutional ethnography (IE), a term coined by sociologist Dorothy Smith, explores the nuances of institutions and their complex relationships in sociology. IE is an approach to studying and analysing social organization, and it provides a more holistic understanding of 'invisible' relationships that govern institutions and how those relationships interact with each other. Health sciences researchers in patient care, patient experience, and allied health professionals have recently become more interested in the use of this methodology and how to incorporate it into their research. However, in health professions education (HPE) there is little use of IE. We hypothesize this may be because of limited practical knowledge of this methodology. This paper serves as an introduction to the use of IE in HPE, describing the differences between IE and traditional ethnographies, recognizing the common pitfalls when utilising IE, and incorporating texts into IE. While ethnographies may be daunting to researchers less familiar with these approaches, the tips in this paper will provide an introduction and help educators and researchers successfully navigate the use of IE in health profession scholarship and education. [ABSTRACT FROM AUTHOR]

BACKGROUND: The impact of renal function on hepatic encephalopathy (HE) following transjugular intrahepatic portosystemic shunt (TIPS) placement for refractory ascites is poorly understood. We investigated the role of renal function on HE following TIPS placement. METHODS: A retrospective study was performed for patients undergoing TIPS for refractory ascites from 2007-2019. Patients were stratified by GFR at time of TIPS placement and by whether they were on hemodialysis (HD). Chronic kidney disease (CKD) stage 3 or higher was defined as pre-TIPS GFR < 60 for at least 3 months. Logistic regression analyses were used to identify the role of GFR and CKD at time of TIPS placement on HE within 60 days post TIPS placement. RESULTS: Among 201 TIPS patients for refractory ascites (61% male; mean age 59.1), 78 (39%) patients were in CKD, and 16 (21%) were on HD. Mean GFR at time of TIPS placement was 62.7 ± 28.2 for all non-HD patients (n = 185). Compared with the GFR ≥ 90 group, GFR < 30 or HD (OR, 3.56; 95%CI, 1.19-10.7; p = 0.023) and CKD (OR, 2.52; 95%CI, 1.40-4.53; p = 0.002) at time of TIPS placement were significant predictors of post-TIPS placement HE within 60 days. GFRs between 30-60 and 60-90 were not significant predictors. CONCLUSIONS: In TIPS patients for recurrent ascites, patients with acutely impaired renal function or chronic renal dysfunction were at an increased risk for HE after TIPS.

ObjectivesThe concept of frailty has gained importance, especially in patients with liver disease. Our study systematically investigated the effect of frailty on post-procedural outcomes in patients undergoing transjugular intrahepatic portosystemic shunt (TIPS).MethodsWe used National Inpatient Sample(NIS) 2016-2019 data to identify patients who underwent TIPS. Hospital frailty risk score (HFRS) was used to classify patients as frail (HFRS>=5) and non-frail (HFRS

The development of a chylothorax after robot-assisted laparoscopic splenectomy combined with pericardial devascularization (LSPD) is rare. The robot-assisted procedure is similar to the standard LSPD, but surgeons must remain vigilant about potential chylothorax caused by recurrence of portal hypertension in patients with cirrhosis, an event that leads to variceal bleeding in the gastric fundus or a massive chylothorax caused by a thoracic duct fistula. We report a rare case of massive chylothorax after robot-assisted LSPD and review the literature to help elucidate the mechanisms of portal hypertension after LSPD, reduce surgical complications, and improve long-term patient outcomes. After LSPD, portal pressure monitoring, coagulation function testing, and portal vein CT imaging help in excluding portal vein thromboses and ensuring appropriate anticoagulation to reduce the development of thoracic duct fistulas. If portal hypertension recurs after surgery and a high-output chylothorax develops, conservative treatment becomes ineffective. Treatment with an active trans-jugular intrahepatic portosystemic shunt (TIPS) is recommended to lower the portal pressure.

Relevance. Liver transplantation involves reconstruction of several vascular structures. Portal reconstruction presents many difficulties due to the frequent intraoperative detection of thrombosis. Portal vein thrombosis is a condition caused by stagnation of blood flow, vascular injury, or hypercoagulability, leading to partial or complete occlusion of the portal vein. The prevalence of thrombosis ranges from 2.1 to 23.3% among liver transplant candidates without hepatocellular cancer. According to autopsy data, the incidence of thrombosis in liver cirrhosis is 6– 64%.Purpose: to analyze a case of portal vein thrombosis in a patient with two preliminary attempts to install transjugular intrahepatic portosystemic stents and their thrombosis.Materials and methods: a clinical case of thrombosis of the stent and portal vein in a 53-year-old patient with decompensated liver cirrhosis as a result of viral hepatitis C with portal hypertension. The peculiarity of this case is that after double transjugular intrahepatic portosystemic stenting, thrombosis of the venous vein was detected only intraoperatively. A liver transplant was performed; the functionality of the graft was not impaired.Conclusion. This case illustrates the need for future research on the topic of portal vein thrombosis and techniques for identifying it preoperatively.

Background & Aims: Long-term albumin (LTA) is currently standard of care for patients with decompensated cirrhosis in many Italian hepatology centres. In this real-life study, we aimed to describe patient, logistical and treatment-related characteristics in daily clinical practice and to identify predictors of response. Methods: We performed a multicentre, retrospective, observational study in patients with cirrhosis and ascites receiving LTA between 01/2016 and 02/2022 and followed until death, TIPS (transjugular intrahepatic portosystemic shunt) placement, transplantation or 02/2023. Results: A total of 312 patients, the majority with alcohol-related cirrhosis, were included. At baseline, median Child-Pugh, MELD, and MELD-Na were 8, 15, and 18, respectively. Ascites was grade 2 in 55% of patients, grade 3 in 35% and refractory in 27%, while 47% had received large volume paracentesis in the previous 6 months. Median LTA was 10 months with a median dose of 40 g/week. Ascites resolved to grade 0-1 in 34% of patients within the first 3 months and 56% by the end of treatment. Predictors of ascites resolution were age (p = 0.007), baseline grade of ascites (p = 0.007), no paracentesis in the previous 6 months (p = 0.001), aetiological treatment in the past 12 months or during LTA (p = 0.005), weekly albumin dose (p = 0.014) and serum albumin concentration of 40 g/L after 1 month of treatment (p = 0.017). Of the 83 patients with refractory ascites at inclusion, 26% had grade 0/1 ascites at the last observation. No severe albumin-related side-effects were reported and only 1% discontinued for logistical reasons. Conclusions: LTA is feasible as an outpatient treatment for the management of ascites. In the current study, ascites resolved in more than half of patients receiving LTA on top of diuretics, including in some with refractory ascites. Predictors of response to LTA provide useful information for tailoring treatment. Impact and implications:: The ANSWER randomised-controlled trial has shown that long-term albumin treatment (LTA) is an effective approach for the management of patients with cirrhosis and ascites. This observational study provides novel information on target patients, modalities and length of treatment, predictors of ascites resolution, stopping criteria, and clinical trajectories of patients on treatment. LTA is a feasible option in the daily clinical practice for the management of ascites when given on top of diuretics. Rather than an alternative therapy, LTA should be integrated with the other treatment options already available for patients with difficult-to-treat ascites. The predictive factors of response identified in the present study can help physicians to individualise LTA and optimise the decision-making process.

BackgroundAneurysms are rare anomalies of the portomesenteric venous system. Thrombotic complications of these lesions can lead to mesenteric venous ischemia and bowel infarction, potentially requiring surgical intervention. Herein we describe a case of mesenteric ischemia due to a large thrombosed portomesenteric aneurysm treated with endovascular techniques.Case presentationA 37-year-old previously healthy male who presented with abdominal pain to his local emergency department was found to have a thrombosed 12.0 × 5.1 cm portomesenteric venous aneurysm with evidence of mesenteric ischemia on CT. When conservative management with anticoagulation failed, transhepatic pharmacomechanical thrombolysis was initially performed. This was followed by TIPS placement with additional trans-TIPS thrombectomy to improve sluggish portal outflow and prevent re-thrombosis. The patient's symptoms and imaging findings of ischemia resolved after endovascular therapy. No surgical intervention was required, and the patient was discharged on enoxaparin before being transitioned to apixaban. The TIPS remained patent at 2-year follow-up, with no change in the size of the aneurysm or re-thrombosis noted. The patient's synthetic liver function was preserved with no evidence of hepatic encephalopathy during the follow-up period.ConclusionsEndovascular therapies may be used to manage thrombotic complications of portomesenteric venous aneurysms, obviating the need for surgical intervention in selected patients.

Writing a research grant proposal is a challenge. The biggest challenge relates to writing a grant without understanding the audience. There are two audiences one needs to have in mind when planning to write a grant. The first audience is the agency to which you plan to submit the grant application and the second audience is your own institution. You need to ensure that whatever research idea you plan to put forward not only fits the funding agency's research priorities but also that it aligns with your organisation's research priorities. If you fail to articulate your grant application within these two parameters, then you know that it may not necessarily be competitive. Hence, you need to look back and try to understand whether you are aware of the funding agency's mission, research agenda, and guidelines, especially grant submission rules and inclusion and exclusion criteria. You do not want to waste your time putting a grant proposal and then realise at the last minute that you are not going to be eligible. In this paper I outline some of the tips to help you make your grant writing journey a rewarding exercise. [ABSTRACT FROM AUTHOR]

Overt hepatic encephalopathy (OHE) is a major complication of transjugular intrahepatic portosystemic shunt (TIPS) placement, given its high incidence and possibility of refractoriness to medical treatment. Nevertheless, the impact of post-TIPS OHE on mortality has not been investigated in a large population. We designed a multicenter, non-inferiority, observational study to evaluate the mortality rate at 30 months in patients with and without OHE after TIPS. We analyzed a database of 614 patients who underwent TIPS in three Italian centers and estimated the cumulative incidence of OHE and mortality with competitive risk analyses, setting the non-inferiority limit at 0.12. During a median follow-up of 30 months (IQR 12-30), 293 patients developed at least one episode of OHE. Twenty-seven (9.2%) of them experienced recurrent/persistent OHE. Patients with OHE were older (64 [57-71] vs. 59 [50-67] years, p < 0.001), had lower albumin (3.1 [2.8-3.5] vs. 3.25 [2.9-3.6] g/dl, p = 0.023), and had a higher prevalence of pre-TIPS OHE (15.4% vs. 9.0%, p = 0.023). Child-Pugh and MELD scores were similar. The 30-month difference in mortality between patients with and without post-TIPS OHE was 0.03 (95% CI -0.042 to 0.102). Multivariable analysis showed that age (subdistribution hazard ratio 1.04, 95% CI 1.02–1.05, p < 0.001) and MELD score (subdistribution hazard ratio 1.09, 95% CI 1.05–1.13, p < 0.001), but not post-TIPS OHE, were associated with a higher mortality rate. Similar results were obtained when patients undergoing TIPS for variceal re-bleeding prophylaxis (n = 356) or refractory ascites (n = 258) were analyzed separately. The proportion of patients with persistent OHE after TIPS was significantly higher in the group of patients who died. The robustness of these results was increased following propensity score matching. Episodic OHE after TIPS is not associated with mortality in patients undergoing TIPS, regardless of the indication. Overt hepatic encephalopathy (OHE) is a common complication in patients with advanced liver disease and it is particularly frequent following transjugular intrahepatic portosystemic shunt (TIPS) placement. In patients with cirrhosis outside the setting of TIPS, the development of OHE negatively impacts survival, regardless of the severity of cirrhosis or the presence of acute-on-chronic liver failure. In this multicenter, non-inferiority, observational study we demonstrated that post-TIPS OHE does not increase the risk of mortality in patients undergoing TIPS, irrespective of the indication. This finding alleviates concerns regarding the weight of this complication after TIPS. Intensive research to improve patient selection and risk stratification remains crucial to enhance the quality of life of patients and caregivers and to avoid undermining the positive effects of TIPS on survival. [Display omitted] • In patients with cirrhosis outside the setting of TIPS, the development of OHE negatively impacts survival. • OHE is considered a major complication in patients treated with TIPS. • We show that post-TIPS episodic OHE does not increase the risk of death in patients undergoing TIPS, irrespective of the indication. • This finding alleviates concerns regarding the impact of this complication on survival after TIPS. [ABSTRACT FROM AUTHOR]

The barbed repositioning pharyngoplasty surgical technique is becoming more widely used for patients with obstructive sleep apnea due to its safety, effectiveness, and rapidity, as evidenced by multicenter studies and Meta‐analyses. In order to achieve uniform surgical outcomes, avoid errors that could worsen outcomes, and enable adequate data comparison, a standardized procedure is required to overcome surgeon‐related variability. The aim of this paper is to provide practical tips and tricks based on our surgical practice that can make the surgeon's work easier and aid in achieving desired outcomes. [ABSTRACT FROM AUTHOR]

Objectives The objective of our study was to develop a nomogram to predict post-transjugular intrahepatic portosystemic shunt (TIPS) survival in patients with cirrhosis based on CT images. Methods This retrospective cohort study included patients who had received TIPS operation at the Wenzhou Medical University First Affiliated Hospital between November 2013 and April 2017. To predict prognosis, a nomogram and Web-based probability were developed to assess the overall survival (OS) rates at 1, 3, and 5 years based on multivariate analyses. With deep learning algorithm, the automated measurement of liver and spleen volumes can be realized. We assessed the predictive accuracy and discriminative ability of the nomogram using the concordance index (C-index), receiver operating characteristic (ROC) curve, calibration curve, and decision curve analysis (DCA). Results Age, total bilirubin, and spleen volume-to-platelet ratio (SVPR) were identified as the independent risk factors for OS. The nomogram was constructed based on the above risk factors. The C-index (0.80, 0.74, 0.70), ROC curve (area under curve: 0.828, 0.761, 0.729), calibration curve, and DCA showed that nomogram good at predictive value, stability, and clinical benefit in the prediction of 1-, 3-, 5-year OS in patients with TIPS creation. Conclusions We constructed a nomogram for predicting prognosis in patients with TIPS creation based on risk factors. The nomogram can help clinicians in identifying patients with poor prognosis, eventually facilitating earlier treatment and selecting suitable patients before TIPS. Advances in knowledge This study developed the first nomogram based on SVPR to predict the prognosis of patients treated with TIPS. The nomogram could help clinician in non-invasive decision-making. [ABSTRACT FROM AUTHOR]

The development and progression of ascites represent a crucial event in the natural history of patients with cirrhosis, predisposing them to other complications and carrying a heavy impact on prognosis. The current standard of care for the management of ascites relies on various combinations of diuretics and large-volume paracenteses. Periodic long-term albumin infusions on top of diuretics have been recently shown to greatly facilitate the management of ascites. The insertion of a transjugular intrahepatic portosystemic shunt (TIPS), an artificial connection between the portal and caval systems, is indicated to treat patients with refractory ascites. TIPS acts to decrease portal hypertension, thus targeting an upstream event in the pathophysiological cascade of cirrhosis decompensation. Available evidence shows a significant benefit on ascites control/resolution, with less clear results on patient survival. Patient selection plays a crucial role in obtaining better clinical responses and avoiding TIPS-related adverse events, the most important of which are hepatic encephalopathy, cardiac overload and failure, and liver failure. At the same time, some recent technical evolutions of available stents appear promising but deserve further investigations. Future challenges and perspectives include (i) identifying the features for selecting the ideal candidate to TIPS; (ii) recognizing the better timing for TIPS placement; and (iii) understanding the most appropriate role of TIPS within the framework of all other available treatments for the management of patients with decompensated cirrhosis. [ABSTRACT FROM AUTHOR]

Background: Post-transjugular intrahepatic portosystemic shunt (TIPS) liver failure (PTLF) is a serious complication of TIPS procedure with poor patient prognosis. This study tried to investigate the incidence of PTLF following elective TIPS procedure and evaluated possible predictive factors for the same. Methods: A retrospective analysis of patients who underwent elective TIPS placement between 2012 and 2022 and was conducted to determine development of PTLF (≥ 3-fold bilirubin and/or ≥ 2-fold INR elevation from the baseline) within 30 days following TIPS procedure. Medical record review was done and factors predicting development of PTLF and the 90-day transplant-free survival was determined. Results: Thirty of 352 (8.5%) patients developed PTLF within 30 days of TIPS (mean age 54.2 ± 9.8 years, 83% male). The etiology of cirrhosis was related to non-alcoholic steatohepatitis (NASH) in 50%, alcohol in 33.3%, and hepatitis B/C virus infection in 16.7% of the patients. The mean Child–Turcotte–Pugh (CTP) score was 9.5 ± 1.2 and mean model for end stage liver disease (MELD) score was 14.6 ± 4.5 at the time of admission in patients who developed PTLF. The indication for TIPS was recurrent variceal bleed in 50% (15 of 30) and refractory ascites in 46.7% (14 of 30) patients with PTLF. Multivariate analysis identified prior HE (OR 6.1; CI 2.57–14.5, p < 0.0001) and higher baseline CTP score (OR 1.47; CI 1.07–2.04; p = 0.018) as predictors of PTLF. PTLF was associated with significantly lower 90-day transplant-free survival, as compared to patients without PTLF (40% versus 96%, p < 0.001). Conclusion: Almost 10% of patients with cirrhosis develop post-TIPS liver failure and is associated with significant early mortality and morbidity. Higher baseline CTP score and prior HE were identified as predictors for PTLF. [ABSTRACT FROM AUTHOR]

Purpose of Review: This review summarizes the pathophysiology of portal hypertension, outcome data through the years supporting the use of TIPS in refractory ascites (RA) and hepatic hydrothorax (HH), and considerations for ideal TIPS candidates. Recent Findings: Advances in stent technology over the last three decades have dramatically improved both quality of life and survival for patients with RA and HH. Importantly, the advent of controlled-expansion, covered stents has reduced the incidence of post-TIPS hepatic encephalopathy (HE) and mortality rates. Summary: Controlled-expansion covered stents are now the guideline-recommended device for patients undergoing TIPS. Prospective trials including these newer TIPS recipients are still needed to determine ideal stent diameter, effective intra-operative portosystemic gradient cutoffs, and utility of pharmacologic HE prophylaxis for the indications of RA and/or HH. [ABSTRACT FROM AUTHOR]

To avoid recurrent variceal bleeding, transjugular intrahepatic portosystemic shunt (TIPS) in conjunction with variceal embolization is considered to be an effective strategy. However, due to changes in conditions and variations in the patient's state, individuals undergoing TIPS may face challenges and limitations during procedures. The transjugular technique and combined transsplenic portal venous recanalization (PVR) with TIPS were not effective in this case due to a blocked portal vein and a previous splenectomy. With an abdominal incision, we successfully punctured the mesenteric venous system and navigated the occluded segment of the portal vein through the mesenteric approach. TIPS was then performed under balloon guidance. This study aims to explore the management of risks and complications during surgical operations and propose multiple preoperative surgical techniques to improve the success rate of the procedure.

ABSTRACT Background: Budd-Chiari syndrome (BCS) results from the obstruction of the hepatic venous flow, usually at the level of the hepatic vein or inferior vena cava. When left untreated, it can progress with several complications, including liver cirrhosis. Transjugular intrahepatic portosystemic shunt (TIPS) appears to be effective in a subgroup of BCS patients. Objective: To perform a systematic review and meta-analysis of TIPS effectiveness in BCS treatment, considering the survival rate, reduction in portosystemic pressure, need for liver transplantation, technical failure, and shunt dysfunction for up to 10 years of follow-up. Methods: We evaluated 17 studies published in PubMed, Science Direct, Web of Science, and SCOPUS databases, which used TIPS as a treatment for BCS, comprising 618 subjects between 18 and 78 years old. We assessed the bias risk by the NOS, NHI, and JBI scales for cohort studies, before-after studies, and case series, respectively. We conducted the meta-analyses by extracting the number of events and the total patients evaluated to perform the proportion meta-analyses using the R software (“meta” package - version 4.9-6). Results: The pooled results (95%CI) showed a 19% (25.9-12.5%) rate of portosystemic pressure reduction, 6% (1-12%) rate for the need for liver transplants despite the use of TIPS, 2% (1-6%) technical failure rate, 30% (18-46%) shunt dysfunction rate, and 88% (81-93%) for the mean frequency of patients alive between 1 and 10 years after the procedure. We stratified survival rate and found an 86% (74-93%) prevalence of living subjects during less than five years, 92% (83-97%) at five years, and a 77% frequency (68-83%) of patients alive ten years after the TIPS placement. Conclusion: TIPS is an effective treatment for BCS, providing a high 10-year frequency of living patients and a significant decrease in portosystemic pressure. The need for liver transplants after TIPS and the technical failure rate is low.

A parallel shunt (PS) is often necessary to regain portal decompression in a dysfunctional transjugular intrahepatic portosystemic shunt (TIPS). Here, we successfully utilized the gun-sight technique to create a PS. An 81-year-old male with decompensated NASH cirrhosis and recent TIPS placement presents with recurrent ascites and pleural effusions in the setting of a persistent portosystemic gradient. Due to a lack of access to endovascular ultrasound and complex patient anatomy, a gun-site technique was approached to create a PS (left portal vein [PV] to left hepatic vein [HV]). After the right HV and existing TIPS were accessed via the right internal jugular vein access, the left HV was accessed. Following a left portal venogram, 10 mm snares were placed into the left HV and the left PV. An 18-gauge needle was then fluoroscopically placed through and through both snares. A 0.035 Glidewire was snared with the help of both snares, establishing access from the left HV via the left PV to the right PV. After serial dilation, a roadrunner wire and catheter were placed into the main PV and superior mesenteric vein, followed by stent dilation. Post-TIPS portal venogram showed prompt flow of contrast from the main PV to the right atrium without any stenosis through both TIPS stents in the left and right PVs. Initial and postprocedural TIPS gradients were 24 mm Hg and 6 mm Hg, respectively. Gun-site technique is a valuable technique in creating a parallel TIPS shunt.

A transjugular intrahepatic portosystemic shunt (TIPS) is one of the most challenging procedures in interventional radiology. Hepatic and portal venous anatomy can be highly variable, and access to the portal vein, which can be quite difficult even for experienced surgeons, is the most critical step in a TIPS. Although there are multiple techniques to achieve a portal venous puncture, each access technique carries a unique set of risks and benefits. Thus, knowledge of these assistive techniques will add to the resources available to the surgeon when planning and subsequently performing a TIPS and, ultimately, increase the likelihood of a safe and successful procedure.

Background: In patients affected by chronic slipped capital femoral epiphysis (C-SCFE), the performance of a subcapital osteotomy is an effective procedure to correct the deformity at the proximal femur. However, the rate of postoperative complications is very high, with iatrogenic avascular necrosis of the femoral head (AVN) being the most bothersome. To overcome the risk of AVN, the modified Dunn procedure according to Ganz and, more recently, the Vascular Sparing Subcapital Osteotomy (VASSCO) technique have been proposed; however, only short-term follow-up studies are available on the latter technique being used. The aim of this study is therefore to show our mid-term clinical and radiological results with the VASSCO technique. Materials and Methods: A total of 26 patients underwent VASSCO for moderate or severe stable C-SCFE between 2012 and April 2016 with an average 10-year follow-up (range 8–12 years). The outcomes was evaluated using the HHS and pre- and postoperative ROM. The radiological outcomes and complications were collected. Results: No major intraoperative complications occurred; three patients reported postoperative transient apraxia of the lateral femoral cutaneous nerve, which completely recovered in six months. All the radiological outcomes showed substantial improvement postoperatively. One case patient developed AVN of the femoral head and required a total hip arthroplasty after 12 years. Conclusions: The current data suggest that VASSCO osteotomy is a reliable technique with very good clinical results at mid-term follow-up; it could be considered a valuable alternative to using more complex techniques to restore the proximal femoral anatomy in moderate to severe C-SCFE. [ABSTRACT FROM AUTHOR]

Hepatic vein outflow obstruction causes congestion of the liver, leading to necrosis, fibrosis, and portal hypertension (PH). A transjugular intrahepatic portosystemic shunt (TIPS) reduces congestion and PH by providing artificial outflow. The aim of the study was to investigate fibrosis progression in patients with Budd–Chiari syndrome (BCS) and TIPS using transient elastography (TE). From 2010 to 2022, 25 patients received 80 TEs using FibroScan®, Echosens, Paris, France (3.2 ± 2.1 per patient). TIPS function was assessed via Doppler ultrasound or radiological intervention. At the time of TE examination, 21 patients had patent shunts. Four patients had occluded shunts but normal pressure gradients during the intervention. The first TE measurement performed 9.8 ± 6.8 years after the BCS diagnosis showed stiffness values of 24.6 ± 11.5 kPa. A second or last measurement performed 7.0 ± 2.9 years after the first measurement showed similar stiffness values of 24.1 ± 15.7 kPa (p = 0.943). Except for three patients, the liver stiffness was always >12 kPa, indicating advanced fibrosis. Stiffness values obtained <5 years (n = 8, 23.8 ± 9.2 kPa) or >5 years after the BCS diagnosis (24.9 ± 12.7 kPa) did not differ (p = 0.907). In addition, stiffness was not related to the interval between BCS and TIPS implantation (p = 0.999). One patient received liver transplantation, and two patients died from non-hepatic causes. Most patients developed mild to moderate cirrhosis, possibly during the early phase of the disease. Timing of TIPS did not influence fibrosis progression. This and the release of portal hypertension may argue in favor of a generous TIPS implantation practice in patients with BCS. [ABSTRACT FROM AUTHOR]

Rectal varices are the result of cirrhotic or non-cirrhotic portal hypertension, due to a network of collaterals between the portal circulation (superior rectal vein from the inferior mesenteric vein) and the systemic circulation (middle and inferior rectal veins from the iliac vein). Although their prevalence is high, the occurrence of life-threatening bleeding is rare. Rectoscopy is the easiest diagnostic method, although echo-endoscopy with Doppler is more sensitive. Management of active bleeding is not strictly codified. The literature is long-standing, essentially composed of clinical cases or small retrospective series. Endoscopic treatment (band ligation or sclerotherapy) and radiological treatments (TIPS) must be discussed on a case-by-case strategy. [ABSTRACT FROM AUTHOR]

Lateral lumbar interbody fusion (LLIF) is a popular technique as it allows for the placement of a large interbody implant through a retroperitoneal, transpsoas working corridor. Historically, the interbody is placed with the patient in lateral decubitus and then repositioned to prone for the posterior instrumentation. While this has been an effective and successful technique, removing the interoperative flip would improve the efficiency of these cases. This has led to modified LLIF approaches including single-position prone LLIF (pLLIF). This modification has shown to be an efficient and powerful technique; however, learning to navigate the LLIF approach in the prone position has its own challenges. The purpose of this article is to provide a detailed description of our pLLIF technique while simultaneously introducing surgical tips to overcome the challenges of the approach and optimize the implantation of the interbody device. Novel Techniques & Technology. [ABSTRACT FROM AUTHOR]

Liver transplantation is currently the only curative therapy for patients with liver cirrhosis. Not all patients in the natural course of the disease will undergo transplantation, but the majority of them will experience portal hypertension and its complications. In addition to medical and endoscopic therapy, a key role in managing these complications is played by the placement of a transjugular intrahepatic portosystemic shunt (TIPS). Some indications for TIPS placement are well-established, and they are expanding and broadening over time. This review aims to describe the role of TIPS in managing patients with liver cirrhosis, in light of liver transplantation. As far as it is known, TIPS placement seems not to affect the surgical aspects of liver transplantation, in terms of intraoperative bleeding rates, postoperative complications, or length of stay in the Intensive Care Unit. However, the placement of a TIPS "towards transplant" can offer advantages in terms of ameliorating a patient's clinical condition at the time of transplantation and improving patient survival. Additionally, the TIPS procedure can help preserve the technical feasibility of the transplant itself. In this context, indications for TIPS placement at an earlier stage are drawing particular attention. However, TIPS insertion in decompensated patients can also lead to serious adverse events. For these reasons, further studies are needed to make reliable recommendations for TIPS in the pre-transplant setting. [ABSTRACT FROM AUTHOR]

In this study, we introduce novel microporous poly(D,L-lactide) acid–carbon nanodot (PLA-CD) nanocomposite scaffolds tailored for potential applications in image-guided bone regeneration. Our primary objective was to investigate concentration-dependent structural variations and their relevance to cell growth, crucial aspects in bone regeneration. The methods employed included comprehensive characterization techniques such as DSC/TGA, FTIR, rheological, and degradation assessments, providing insights into the scaffolds' thermoplastic behavior, microstructure, and stability over time. Notably, the PLA-CD scaffolds exhibited distinct self-fluorescence, which persisted after 21 days of incubation, allowing detailed visualization in various multicolor modalities. Biocompatibility assessments were conducted by analyzing human adipose-derived stem cell (hADSC) growth on PLA-CD scaffolds, with results substantiated through cell viability and morphological analyses. hADSCs reached a cell viability of 125% and penetrated throughout the scaffold after 21 days of incubation. These findings underscore the scaffolds' potential in bone regeneration and fluorescence imaging. The multifunctional nature of the PLA-CD nanocomposite, integrating diagnostic capabilities with tunable properties, positions it as a promising candidate for advancing bone tissue engineering. Our study not only highlights key aspects of the investigation but also underscores the scaffolds' specific application in bone regeneration, providing a foundation for further research and optimization in this critical biomedical field. [ABSTRACT FROM AUTHOR]

Pre-emptive transjugular intrahepatic portosystemic shunt (TIPS) is the treatment of choice for high-risk acute variceal bleeding (AVB; i.e. , Child-Turcotte-Pugh [CTP] B8-9+active bleeding/C10-13). Nevertheless, some 'non-high-risk' patients have poor outcomes despite the combination of non-selective beta-blockers and endoscopic variceal ligation for secondary prophylaxis. We investigated prognostic factors for re-bleeding and mortality in 'non-high-risk' AVB to identify subgroups who may benefit from more potent treatments (i.e. , TIPS) to prevent further decompensation and mortality. A total of 2,225 adults with cirrhosis and variceal bleeding were prospectively recruited at 34 centres between 2011-2015; for the purpose of this study, case definitions and information on prognostic indicators at index AVB and on day 5 were further refined in low-risk patients, of whom 581 (without failure to control bleeding or contraindications to TIPS) who were managed by non-selective beta-blockers/endoscopic variceal ligation, were finally included. Patients were followed for 1 year. Overall, 90 patients (15%) re-bled and 70 (12%) patients died during follow-up. Using clinical routine data, no meaningful predictors of re-bleeding were identified. However, re-bleeding (included as a time-dependent co-variable) increased mortality, even after accounting for differences in patient characteristics (adjusted cause-specific hazard ratio: 2.57; 95% CI 1.43-4.62; p = 0.002). A nomogram including CTP, creatinine, and sodium measured at baseline accurately (concordance: 0.752) stratified the risk of death. The majority of 'non-high-risk' patients with AVB have an excellent prognosis, if treated according to current recommendations. However, about one-fifth of patients, i.e. those with CTP ≥8 and/or high creatinine levels or hyponatremia, have a considerable risk of death within 1 year of the index bleed. Future clinical trials should investigate whether elective TIPS placement reduces mortality in these patients. Pre-emptive transjugular intrahepatic portosystemic shunt placement improves outcomes in high-risk acute variceal bleeding; nevertheless, some 'non-high-risk' patients have poor outcomes despite the combination of non-selective beta-blockers and endoscopic variceal ligation. This is the first large-scale study investigating prognostic factors for re-bleeding and mortality in 'non-high-risk' acute variceal bleeding. While no clinically meaningful predictors were identified for re-bleeding, we developed a nomogram integrating baseline Child-Turcotte-Pugh score, creatinine, and sodium to stratify mortality risk. Our study paves the way for future clinical trials evaluating whether elective transjugular intrahepatic portosystemic shunt placement improves outcomes in presumably 'non-high-risk' patients who are identified as being at increased risk of death. [Display omitted] • International study to determine prognostic factors in patients with 'non-high-risk' acute variceal bleeding. • No clinically meaningful predictors of re-bleeding were observed. • Child-Turcotte-Pugh score, creatinine, and sodium stratified mortality risk. • Future clinical trials should investigate whether elective TIPS placement reduces mortality in a subset of patients. [ABSTRACT FROM AUTHOR]

This conceptual paper presents a framework that integrates 11 forms of voluntary payments as seemingly disparate as bribes and bequests, and gifts and gratuities to show that "voluntary" payments vary in the shades of gray not only in terms of how much like bribes they are but also in terms of how voluntary they actually are. We provocatively suggest that these payment types might be susceptible to becoming entrenched through self‐reinforcing norms because the voluntary payments are not necessarily voluntary and to an extent akin to bribes. Specifically, it provides an overarching framework to showcase the similarities and differences between bribes, lobbying efforts, suggested fees, pay what you want, tips, bequests, legacies, charity, crowdsourcing, dowry, and gifts, identifying gaps in domains that are under‐researched. Starting with the question as to whether a service has been, is being, or will be performed for the voluntary payment, and whether payments are made to an individual or a cause, the framework highlights the following: (1) the differences in the purpose underlying these payments, (2) the different modes of payment used; (3) the economic and social norms governing the payments; and (4) external and internal emotions associated with these payment types. The integrative framework allows for an amalgam of disparate literatures ranging from morality and behavioral pricing to charity and gift giving. The process model suggests a multitude of areas for future research in the domain of consumers' voluntary payment decisions. [ABSTRACT FROM AUTHOR]

A transjugular intrahepatic portosystemic shunt (TIPS) is one of the most challenging procedures in interventional radiology. Hepatic and portal venous anatomy can be highly variable, and access to the portal vein, which can be quite difficult even for experienced surgeons, is the most critical step in a TIPS. Although there are multiple techniques to achieve a portal venous puncture, each access technique carries a unique set of risks and benefits. Thus, knowledge of these assistive techniques will add to the resources available to the surgeon when planning and subsequently performing a TIPS and, ultimately, increase the likelihood of a safe and successful procedure. [ABSTRACT FROM AUTHOR]

Background: The management of complex, intra‐ and extrahepatic portal vein thrombosis (PVT) after liver transplantation (LT) is challenging. Although most of the patients remain asymptomatic or oligosymptomatic in the chronic setting, some of them may develop severe portal hypertension and related complications, notably gastrointestinal (GI) bleeding. In the emergency scenario, clinical and endoscopic treatments as well as intensive support constitute the bases of conservative management, while more definitive treatment options such as surgical shunting and retransplantation are related to high morbidity rates. Transjugular intrahepatic portosystemic shunt (TIPS) was largely considered of limited role due to technical difficulties arising from extensive PVT. Recently, however, new minimally invasive image‐guided techniques emerged, allowing portal vein recanalization and TIPS creation simultaneously (TIPS‐PVR), even in complex PVT pretransplant patients. Methods: Herein, we describe a novel indication for TIPS‐PVR in a post‐LT adolescent presenting with life‐threatening, refractory GI bleeding. Results: The patient presented with complete resolution of the hemorrhagic condition after the procedure, with no deterioration of hepatic function or hepatic encephalopathy. Follow‐up Doppler ultrasound after TIPS‐PVR showed normal hepatopetal venous flow within the stents, and no evidence of complications, including intraperitoneal or peri splenic bleeding. Conclusions: This report describes the feasibility of TIPS‐PVR in the post‐LT scenario complicated by extensive PVT. In this case, a complete resolution of the life‐threatening GI bleeding was achieved, with no major complications. Other patients with complex chronic PVT might benefit from the use of the described technique, but further studies are required to determine the correct timing and indications of the procedure, eventually before the occurrence of life‐threatening complications. [ABSTRACT FROM AUTHOR]

Background & Aims: Transjugular intrahepatic portosystemic shunt (TIPS) is the most effective therapy for complications of portal hypertension. However, clinical outcomes following TIPS placement vary widely between patients and identifying ideal candidates remains a challenge. Soluble urokinase plasminogen activator receptor (suPAR) is a circulating marker of immune activation that has previously been associated with liver inflammation, but its prognostic value in patients receiving TIPS is unknown. In the present study, we evaluated the potential clinical relevance of suPAR levels in patients undergoing TIPS insertion. Methods: suPAR concentrations were measured by ELISA in hepatic vein (HV) and portal vein (PV) blood samples from 99 patients (training cohort) as well as peripheral venous blood samples from an additional 150 patients (validation cohort) undergoing TIPS placement. The association between suPAR levels and patient outcomes was assessed using Kaplan-Meier methods and Cox-regression analyses. Results: suPAR concentrations were significantly higher in HV samples compared to PV samples and correlated with PV concentration, the presence of ascites, renal injury, and consequently with the Child-Pugh and MELD scores. Patients with lower suPAR levels had significantly better short- and long-term survival after TIPS insertion, which remained robust after adjustment for confounders in multivariate Cox-regression analyses. Sensitivity analysis showed an improvement in risk prediction in patients stratified by Child-Pugh or MELD scores. In an independent validation cohort, higher levels of suPAR predicted poor transplant-free survival after TIPS, particularly in patients with Child-Pugh A/B cirrhosis. Conclusion: suPAR is largely derived from the injured liver and its levels are predictive of outcome in patients undergoing TIPS. suPAR, as a surrogate of hepatic inflammation, may be used to stratify care in patients following TIPS insertion. Impact and implications: Transjugular intrahepatic portosystemic shunt (TIPS) is the most effective therapy for complications of portal hypertension. However, clinical outcomes following TIPS placement vary widely between patients and identification of the ideal candidates remains challenging. We show that soluble urokinase plasminogen activator receptor (suPAR), a circulating marker of immune activation that can easily be measured in routine clinical practice, is a novel marker to identify patients who will benefit from TIPS and those who will not.

Since its advent, the transjugular intrahepatic portosystemic shunt (TIPS) procedure has been accepted as an effective option to treat patients with complications of portal hypertension. While generally considered a safe procedure, TIPs can be associated with certain complications, including inadvertent puncture of the liver capsule with the needle/catheter combination during needle passes. In addition, the accompanying post-TIPS intraperitoneal hemorrhage has not been well reported and guidelines behind its management are not well described. We present a case of a 33-year-old male with refractory ascites who underwent TIPS, during which the hepatic capsule was inadvertently punctured, leading to the development of hemoperitoneum in the patient due to a bleeding diathesis.