ARRS 2022 Abstracts

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1285. Single-Center Clinical Outcomes and Risk Factor Assessment for Hepatic Infarction After TIPS Placement
Authors * Denotes Presenting Author
  1. Tisileli Tuifua *; Cleveland Clinic Imaging Institute; Cleveland Clinic Lerner College of Medicine of Case Western Reserve University
  2. Erick Remer; Cleveland Clinic Foundation; Cleveland Clinic Imaging Institute
  3. Jonathan Ragheb; Cleveland Clinic Foundation; Cleveland Clinic Imaging Institute
  4. Jennifer Bullen; Cleveland Clinic Foundation
  5. Michael Kattan; Cleveland Clinic Foundation
  6. Baljendra Kapoor; Cleveland Clinic Foundation; Cleveland Clinic Imaging Institute
Objective:
Transjugular intrahepatic portosystemic shunt (TIPS)-related hepatic infarction is rare, and outcomes are not well described. We investigated baseline risk factors, clinical course, and infarction characteristics among patients with TIPS-related hepatic infarction.

Materials and Methods:
For this IRB-approved, HIPAA compliant retrospective analysis of an institutional TIPS registry (1995–2021), patients with a CT/MRI-identified hepatic infarction were included. An asymptomatic post-TIPS control group with CT/MRI within 1 month without infarct was also identified for risk analysis and clinical comparisons. Procedural and clinical data were obtained from patient electronic medical records to assess risks and compare clinical courses. Images were reviewed to identify infarction characteristics and associated imaging findings. Comparisons were assessed using logistic and Cox proportional hazards regression, student’s t-test, Wilcoxon rank-sum, Fisher’s exact, and propensity score matching where appropriate.

Results:
33 patients with infarction and 33 controls with minimal baseline differences in age and MELD (both p>0.05) were included. Infarction involved the right posterior segment in 32/33 (97%) patients; 28/33 infarction patients had the TIPS stent placed in the right portal vein. Among the hepatic infarction cohort, hepatic arterial lesions were identified in 5, and right hepatic and right portal venous thrombi were identified in 10 and 16 patients, respectively. Higher post-operative AST (p<0.001) and ALT (p<0.001), higher INR (p=0.007), lower platelet count (p=0.042), reduction in hemoglobin (p=0.003), longer vasopressor requirement (p=0.009), and longer intensive care unit (ICU) stay (p=0.001) was observed in the infarction group. Univariate models identified lower post-TIPS portosystemic gradient (OR: 0.81, p=0.016), use of Viatorr stent (OR: 10.2, p=0.033), and higher preprocedural hemoglobin (OR: 1.29, p=0.049) as risks for infarction, however these risks were not significant in multivariable modeling. An increased hazard of death with median survival of 2.9 years was present in the infarction group, although this finding was not statistically significant (HR: 2.05, p=0.088). There was also evidence of shorter time to acute-on-chronic liver failure (ACLF) in the infarction group without reaching conventional levels of statistical significance (HR: 2.30, p=0.056).

Conclusion:
Frequent infarction of the right posterior hepatic segment in this study may aid post-procedural diagnosis. In the absence of significant pre- and intra-procedural risks, mechanisms underlying infarction may include post-operative blood loss, hemodynamic instability, or stent-related arterial or venous lesions. Closer monitoring for co-existing vascular lesions and signs of post-operative bleeding may be warranted among patients with TIPS-related infarct. Although mortality was not significantly associated with hepatic infarction in this small series, a longer ICU stay suggests poorer peri-operative course. This finding may emphasize insufficient power or safety of TIPS placement in high volume centers.