Evolution of spontaneous portosystemic shunts over time and following aetiological intervention in patients with cirrhosis

Judit Vidal-González; Javier Martínez; Akhilesh Mulay; Marta López; Anna Baiges; Ahmed Elmahdy; Katharina Lampichler; Geert Maleux; Johannes Chang; Marta Poncela; Gavin Low; Gabriele Ghigliazza; Alexander Zipprich; Carmen Picón; Rushabh Shah; Elba Llop; Anna Darnell; Martin H Maurer; Lawrence Bonne; Enrique Ramón; Sergi Quiroga; Juan G Abraldes; Aleksander Krag; Jonel Trebicka; Cristina Ripoll; Vincenzo La Mura; Puneeta Tandon; Rita García-Martínez; Michael Praktiknjo; Wim Laleman; Thomas Reiberger; Annalisa Berzigotti; Virginia Hernández-Gea; José Luis Calleja; Emmanuel A Tsochatzis; Agustín Albillos; Macarena Simón-Talero; Joan Genescà; Baveno VI-SPSS group from the Baveno Cooperation

doi:10.1016/j.jhepr.2023.100977

Evolution of spontaneous portosystemic shunts over time and following aetiological intervention in patients with cirrhosis

JHEP Rep. 2023 Nov 30;6(2):100977. doi: 10.1016/j.jhepr.2023.100977. eCollection 2024 Feb.

Authors

Judit Vidal-González¹, Javier Martínez^{2

3}, Akhilesh Mulay⁴, Marta López⁵, Anna Baiges^{3

6}, Ahmed Elmahdy⁷, Katharina Lampichler⁸, Geert Maleux⁹, Johannes Chang¹⁰, Marta Poncela¹¹, Gavin Low¹², Gabriele Ghigliazza^{13

14}, Alexander Zipprich^{15

16}, Carmen Picón¹⁷, Rushabh Shah¹⁸, Elba Llop^{3

5}, Anna Darnell¹⁹, Martin H Maurer²⁰, Lawrence Bonne⁹, Enrique Ramón²¹, Sergi Quiroga²², Juan G Abraldes²³, Aleksander Krag^{24

25}, Jonel Trebicka^{10

26}, Cristina Ripoll^{15

16}, Vincenzo La Mura^{13

15}, Puneeta Tandon²³, Rita García-Martínez^{3

11}, Michael Praktiknjo^{10

26}, Wim Laleman²⁷, Thomas Reiberger²⁸, Annalisa Berzigotti⁷, Virginia Hernández-Gea^{3

6}, José Luis Calleja^{3

5}, Emmanuel A Tsochatzis⁴, Agustín Albillos^{2

3}, Macarena Simón-Talero^{1

3}, Joan Genescà^{1

3}; Baveno VI-SPSS group from the Baveno Cooperation

Affiliations

¹ Liver Unit, Digestive Diseases Department, Vall d'Hebron University Hospital, Vall d'Hebron Institute of Research (VHIR), Vall d'Hebron Barcelona Hospital Campus. Universitat Autònoma de Barcelona, Barcelona, Spain.
² Department of Gastroenterology and Hepatology, Hospital Universitario Ramón y Cajal, Instituto Ramón y Cajal de Investigación Sanitaria, Universidad de Alcalá, Madrid, Spain.
³ Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas, Instituto de Salud Carlos III, Madrid, Spain.
⁴ Sheila Sherlock Liver Unit and University College London Institute for Liver and Digestive Health, Royal Free Hospital and University College London, London, UK.
⁵ Liver Unit, Hospital U. Puerta de Hierro, Universidad Autónoma de Madrid, Madrid, Spain.
⁶ Hepatic Hemodynamic Laboratory, Liver Unit, Hospital Clínic, Institut de Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Universitat de Barcelona, Barcelona, Spain.
⁷ Department of Visceral Surgery and Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland.
⁸ Department of Biomedical Imaging and Image-Guided Therapy, Medical University of Vienna, Vienna, Austria.
⁹ Department of Radiology, University Hospitals KU Leuven, Herestraat 49, 3000 Leuven, Belgium.
¹⁰ Department of Internal Medicine I, University of Bonn, Bonn, Germany.
¹¹ Liver Unit, Hospital General Universitario Gregorio Marañón, Instituto de Investigación Sanitaria Gregorio Marañón, Universidad Complutense, Madrid, Spain.
¹² Department of Radiology, University of Alberta, Edmonton, Alberta, Canada.
¹³ Foundation I.R.C.C.S. Ca' Granda, Ospedale Maggiore Policlinico, Angelo Bianchi Bonomi and Thrombosis center, Milan, Italy.
¹⁴ Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy.
¹⁵ First Department of Internal Medicine, Martin Luther University Halle-Wittenberg, Halle (Saale), Germany.
¹⁶ Internal Medicine IV. Jena University Hospital, Jena Germany.
¹⁷ Department of Radiology, Hospital Universitario Ramón y Cajal, Instituto Ramón y Cajal de Investigación Sanitaria, Universidad de Alcalá, Spain.
¹⁸ Royal Free Hospital Radiology Department, Royal Free Hospital and University College London, London, UK.
¹⁹ Department of Radiology, Hospital Clínic, Universitat de Barcelona, Barcelona Spain.
²⁰ Department of Radiology, Inselspital, University of Bern, Bern, Switzerland.
²¹ Digestive Radiology, Hospital General Universitario Gregorio Marañón, Instituto de Investigación Sanitaria Gregorio Marañón, Universidad Complutense, Madrid, Spain.
²² Radiology Department, Hospital Universitari Vall d'Hebron, Vall d'Hebron Barcelona Hospital Campus, Barcelona, Spain.
²³ Cirrhosis Care Clinic, Division of Gastroenterology (Liver Unit), Centre of Excellence for Gastrointestinal Inflammation and Immunity Research, University of Alberta, Edmonton, Canada.
²⁴ Centre for Liver Research, Department of Gastroenterology and Hepatology, Odense University Hospital, Odense, Denmark.
²⁵ Institute of Clinical Research, University of Southern Denmark, Odense, Denmark.
²⁶ Department of Internal Medicine B, University of Münster, Münster, Germany.
²⁷ Department of Gastroenterology and Hepatology, Section of Liver and Biliopancreatic disorders, University Hospitals Leuven, KU Leuven, Leuven, Belgium.
²⁸ Division of Gastroenterology and Hepatology, Vienna Hepatic Hemodynamic Lab, Medical University of Vienna, Vienna, Austria.

Abstract

Background & aims: Spontaneous portosystemic shunts (SPSS) develop frequently in cirrhosis. Changes over time and the effect of aetiological interventions on SPSS are unknown, so we aimed to explore the effect of these variables on SPSS evolution.

Methods: Patients with cirrhosis from the Baveno VI-SPSS cohort were selected provided a follow-up abdominal CT or MRI scan was available. Clinical and laboratory data were collected at baseline and follow-up. Imaging tests were reviewed to evaluate changes in the presence and size of SPSS (large (L)-SPSS was ≥8 mm) over time. Regarding alcohol- or HCV-related cirrhosis, two populations were defined: cured patients (abstinent from alcohol or successful HCV therapy), and non-cured patients.

Results: A total of 617 patients were included. At baseline SPSS distribution was 22% L-SPSS, 30% small (S)-SPSS, and 48% without (W)-SPSS. During follow-up (median follow-up of 63 months), SPSS distribution worsened: L-SPSS 26%, S-SPSS 32%, and W-SPSS 42% (p <0.001). Patients with worse liver function during follow-up showed a simultaneous aggravation in SPSS distribution. Non-cured patients (n = 191) experienced a significant worsening in liver function, more episodes of liver decompensation and lower transplant-free survival compared to cured patients (n = 191). However, no differences were observed regarding SPSS distribution at inclusion and at follow-up, with both groups showing a trend to worsening. Total shunt diameter increased more in non-cured (52%) than in cured patients (28%). However, total shunt area (TSA) significantly increased only in non-cured patients (74 to 122 mm², p <0.001).

Conclusions: The presence of SPSS in cirrhosis increases over time and parallels liver function deterioration. Aetiological intervention in these patients reduces liver-related complications, but SPSS persist although progression is decreased.

Impact and implications: There is no information regarding the evolution of spontaneous portosystemic shunts (SPSS) during the course of cirrhosis, and especially after disease regression with aetiological interventions, such as HCV treatment with direct-acting antivirals or alcohol abstinence. These results are relevant for clinicians dealing with patients with cirrhosis and portal hypertension because they have important implications for the management of cirrhosis with SPSS after disease regression. From a practical point of view, physicians should be aware that in advanced cirrhosis with portal hypertension, after aetiological intervention, SPSS mostly persist despite liver function improvement, and complications related to SPSS may still develop.

Keywords: Advanced chronic liver disease; Alcohol; Ascites; Collateral vessels; Computed tomography; Hepatic encephalopathy; Hepatitis C virus; Magnetic resonance imaging; Portal hypertension; Sustained virological response.