Portal hypertension is a severe complication of chronic liver disease, directly associated with clinical outcomes such as ascites and variceal bleeding. Transjugular intrahepatic portosystemic shunt (TIPS) is an effective treatment that significantly reduces portal pressure. Portal pressure gradient (PPG) is commonly used to assess portal pressure in patients undergoing TIPS. Recently, a study conducted by Dr. Guohong Han's team from Xi'an International Medical Center Hospital that published in the Journal of Hepatology, explored the optimal timing of measurement and hemodynamic target of PPG in cirrhotic patients with variceal bleeding undergoing covered stent TIPS. Dr. Yong Lv from Xijing Hospital is the first author of this article, and Dr. Guohong Han is the corresponding author.

PPG levels after TIPS are important indicators of the risk of variceal rebleeding or ascites recurrence. Lower PPG values are associated with a reduced risk of these complications, but also predict higher risk of post-TIPS complications, such as hepatic encephalopathy and liver function deterioration. Therefore, it is crucial to measure PPG accurately, and the reduction target must balance the management of portal hypertension complications with the risk of hepatic encephalopathy.

Recent guidelines recommend targeting PPG below 12 mmHg or a 50% reduction from pre-TIPS baseline as the hemodynamic goal for TIPS, as these levels effectively prevent risk of variceal rebleeding and ascites recurrence. However, most studies on post-TIPS hemodynamic targets do not define the optimal timing for PPG measurement. Additionally, current hemodynamic targets were established during the era of uncovered stents, which may not fully apply to the now widely used covered stents. This study aimed to determine the ideal moment of  measuring PPG after TIPS and identify the optimal hemodynamic target for patients.

Between May 2018 and December 2021, 466 cirrhotic patients with variceal bleeding were prospectively enrolled in the study. PPG was measured immediately after TIPS (immediate PPG), 24-72 hours after (early PPG), and one month later (late PPG). Patients were followed at one, three, and six months  after TIPS, then every six months. The primary endpoint was the consistency of PPG measurements at different time points, while secondary endpoints included portal hypertension complications (PHC), overt hepatic encephalopathy (OHE), further decompensation, and mortality.

In terms of consistency, the study showed that immediate PPG values were significantly lower than early and late PPG values, with no statistical difference between early and late PPG. The agreement between immediate and early PPG was poor, while early and late PPG showed better consistency, though still not satisfactory.

Regarding the correlation between PPG and clinical outcomes, immediate PPG did not predict the risk of PHC, OHE, or mortality. Early PPG values above 12 mmHg significantly increased the risk of PHC and decreased the risk of OHE but had no independent predictive effect on mortality. Late PPG values above 12 mmHg increased the risk of PHC but had no significant impact on OHE or mortality.

When exploring the optimal hemodynamic target, a U-shaped relationship between early PPG and the 5-year risk of further decompensation was observed. The lowest risk of further decompensation was observed at an early PPG of 10.7 mmHg. For simplicity, the researchers selected 11 mmHg as the threshold. Based on the relationship between early PPG and PHC, OHE, and mortality, the researchers further identified 7 mmHg and 14 mmHg as critical values and categorized the cohort into four groups.

Results showed that subjects with an early PPG between 11 and 14 mmHg had the lowest risk of further decompensation within five years. The risk of PHC and OHE was also relatively low within this range.

Regarding relative PPG reduction, a 20%-50% decrease from pre-TIPS baseline was associated with a lower risk of OHE, but it did not compromise the clinical effectiveness of TIPS in preventing PHC.

In conclusion, the study suggests that immediate post-TIPS PPG is unstable and not suitable for clinical decision-making. PPG measured at least 24 hours post-TIPS provides a more accurate prediction of complications. Specifically, targeting an early PPG of 11-14 mmHg or achieving a 20%-50% reduction from pre-TIPS baseline can effectively balance the control of portal hypertension and the risk of hepatic encephalopathy. These findings provide valuable guidance for creating and updating TIPS guidelines, though further validation through randomized controlled trials is needed to confirm their applicability to various patient populations.

Expert Profile

Guohong Han

Executive Dean, Digestive Disease Hospital

MD, PhD Supervisor, Chief Physician, Professor

Member of the Expert Group and Scientific Committee of Baveno Ⅶ (the Most Authoritative Organization on Portal Hypertension)

Council Member of the Asian Primary and Preventable Liver Cancer Expert (APPLE) Council

President of the Interventional Medicine Branch of the Chinese Non-government Medical Institutions Association

Chairman of the Integrative Medicine Liver Cancer Professional Committee and Vice Chairman of the Oncology and Hepatology Professional Committee, China Anti-Cancer Association

Vice Chairman of the Interventional Professional Committee, Chinese Research Hospital Association

Vice Leader of the Interventional Treatment Group, Professional Committee for the Diagnosis and Treatment Guidelines of Primary Liver Cancer, National Health Commission (2011, 2017, 2019, and 2022 editions)

Standing Committee Member, Shaanxi Research-Oriented Hospital Society

Expert in digestive intervention, specializing in the interventional treatment and clinical research of hepatobiliary and pancreatic tumors, portal hypertension, and hepatic vascular diseases (including Budd-Chiari syndrome, portal vein thrombosis and cavernous transformation, idiopathic portal hypertension, and other liver diseases).