Underdilated neoadjuvant-TIPS in patients with cirrhosis and portal hypertension candidates to operative interventions

Introduction Clinically significant portal hypertension (CSPH) often excluded patients with cirrhosis from operative procedures due to high complications rates. Neoadjuvant-transjugular intrahepatic-portosystemic shunt (Neo-TIPS) can enable surgery and improve post-operative outcomes, but concerns about shunt-related complications limit its use. The underdilation-TIPS strategy, using a stent-graft dilated to diameters <8mm, has been shown to reduce complications while maintaining effectiveness. Aims The objective of this study was to assess the safety and effectiveness of the underdilation strategy in patients with cirrhosis candidates to Neo-TIPS for CSPH or its complications. Materials and Methods A retrospective study on a prospective database encompassing 315 patients who underwent TIPS was conducted at two Italian referral centers. The rate of surgery access following underdilated Neo-TIPS, the incidence of intra-operative and peri-operative complications, the risk of shunt-related complications, and the 6-month and 1-year survival rates were analyzed. Results Thirty-six consecutive patients were included in the study, with a mean age of 63±10 years and a mean MELD-score of 12±3 at the time of TIPS placement. Twelve patients (33%) had refractory ascites, while 9 patients (25%) had a history of variceal bleeding. Abdominal surgery was the main indication (78%) and in 28 patients the intervention was prompted by a diagnosis of resectable cancer. The average TIPS dilation diameter was 6±1mm. After Neo-TIPS, 92% of patients successfully underwent scheduled interventions, within a median time of 43 days. No major intra-operative complications were recorded. Twelve patients (36%) experienced peri-operative complications, two of which resulted in death. The 6-month and 1-year survival rates were 83% and 70%, respectively. Over a median follow-up of 18-months, episodic overt hepatic encephalopathy and heart failure were evident in 22% and 8% of patients, respectively. Conclusion Underdilation Neo-TIPS strategy exhibited a safe profile and a high success rate in patients with cirrhosis associated to CSPH or its complications.