Techniques in Vascular and Interventional Radiology最新文献

Chronic liver disease as well as various other conditions can change vascular resistance in the portal system thereby leading to portal hypertension. Acute gastroesophageal variceal bleeding is a dreaded complication of portal hypertension associated with high morbidity and mortality. Historically, endoscopy in the management of portal hypertension was limited to the prevention and treatment of esophageal varices. However, advancements in endoscopic-ultrasound techniques and availability of new devices have opened a new frontier in the management of gastric varices. Additionally, advancements in endoscopic techniques now allow for a more comprehensive diagnostic approach to portal hypertension. In this review, we summarize the role of endoscopy in the management of portal hypertension and varices.

Hepatorenal syndrome (HRS) is a severe complication of advanced liver disease, characterized by renal dysfunction in the absence of intrinsic kidney disease. It is associated with high mortality, necessitating early recognition and prompt treatment. In this review, we summarize the latest in pathophysiology, diagnosis, classification and treatment of hepatorenal syndrome relevant to a consulting interventional radiologist. The diagnosis and classification of HRS has recently been updated by the International Club of Ascites (ICA) and Kidney Disease Improving Global Outcomes (KDIGO) to include more subcategories that better reflect disease severity and prognosis. Greater insights have also been obtained into the pathophysiology of HRS, currently understood to be a complex manifestation of hemodynamic disturbances due to portal hypertension, systemic inflammation, oxidative stress, and biliary injury. We discuss the role of laboratory biomarkers in diagnosis and prognosis along with associated pitfalls. Treatment options are reviewed starting with first line medical management, adjunctive renal replacement therapy, and liver transplantation. Finally, we review the evidence to date investigating transjugular intrahepatic portosystemic shunt (TIPS) creation in this population, focusing on expected efficacy for specific subpopulations and current gaps in knowledge, all driving practical recommendations for when the procedure should be considered.

In cirrhotic patients, refractory ascites (RA) is a devastating consequence of portal hypertension and is associated with high morbidity and mortality. Over the past quarter century, transjugular intrahepatic portosystemic shunt (TIPS) placement has become a key treatment for patients with RA, but there has been an evolution of patient evaluation, stents, and procedural techniques during this time. As such, the rates of ascites control, survival, and associated hepatic encephalopathy have evolved as well. This review examines the evidence and current recommendations for TIPS in the setting of RA.

Acute portal and mesenteric vein thrombosis (PVT) can lead to fatal mesenteric ischemia, with mortality rates ranging from 37% to 76%. Early diagnosis and prompt venous revascularization are crucial in symptomatic cases. Spontaneous recanalization in portal vein thrombosis (PVT) is rare, making systemic anticoagulation the first-line treatment. However, even with early anticoagulation, recanalization occurs in only 35%-40% of cases. Involvement of the superior mesenteric vein (SMV) increases the risk of bowel ischemia, which is associated with poor outcomes. The primary goals of endovascular treatment for portomesenteric thrombectomy and lysis are to restore blood flow, prevent bowel ischemia, and reduce thrombus burden. This approach aims to alleviate symptoms, preserve liver and intestinal function, and facilitate anticoagulation while minimizing procedural risks. For patients who deteriorate despite anticoagulation, catheter-directed thrombolysis (CDT) via percutaneous transhepatic or transjugular access provides a safe and effective minimally invasive adjunctive treatment.

Transjugular intrahepatic portosystemic shunt (TIPS) is a key therapeutic intervention in the management of portal hypertension and its complications, such as variceal bleeding, hepatic hydrothorax, and refractory ascites. TIPS has historically been used as a lifesaving measure or as a bridge to liver transplantation (LT). Despite its efficacy, creation of a TIPS can be associated with significant morbidity, particularly in patients with decompensated cirrhosis. Complications include hepatic encephalopathy (HE), progressive liver dysfunction, and cardiovascular compromise. As such, accurate patient selection and risk stratification are essential to optimize clinical outcomes. This review synthesizes current evidence on predictive models for post-TIPS mortality. Traditional scoring systems such as the Child-Turcotte-Pugh (CTP) score and the Model for End-Stage Liver Disease (MELD) remain widely used, with newer iterations such as the MELD-Na and MELD 3.0 demonstrating improved prognostic accuracy. Notably, MELD 3.0 offers enhanced prediction of long-term mortality. In contrast, the Freiburg Index of Post-TIPS Survival (FIPS) has become a valuable tool for short-term mortality prediction. Additional models, including the Bilirubin-Platelet (Bili-PLT) score, offer further refinement. At the same time, the role of sarcopenia has gained attention as an independent and synergistic predictor of poor outcomes, especially when combined with MELD-based scores. Beyond mortality, this review explores the multifactorial pathophysiology of post-TIPS complications such as hepatic encephalopathy, liver failure, and right heart dysfunction that can cause significant morbidity. These outcomes are influenced by a spectrum of patient-related and procedural factors. Novel predictive approaches-encompassing clinical, radiological, and machine learning-based models-are being developed to better anticipate these risks.