Shawn H Sun1,2, Thomas Eche3, Chloé Dorczynski3, Philippe Otal3, Paul Revel-Mouroz3, Charline Zadro3, Ephraim Partouche3, Nadim Fares4, Charlotte Maulat5, Christophe Bureau4, Lawrence H Schwartz1,2, Hervé Rousseau3, Laurent Dercle6,7, Fatima-Zohra Mokrane8. 1. Department of Radiology, Columbia University Vagellos College of Physicians and Surgeons, New York, NY, 10032, USA. 2. Department of Radiology, New York Presbyterian Hospital, New York, NY, USA. 3. Radiology Department, Rangueil University Hospital, 1, avenue du Professeur Jean Poulhes, 31059, Toulouse, France. 4. Hepato-Gastroenterology Department, Purpan University Hospital, Toulouse, France. 5. The Digestive Surgery and Liver Transplantation Department, Toulouse University Hospital, Toulouse, France. 6. Department of Radiology, Columbia University Vagellos College of Physicians and Surgeons, New York, NY, 10032, USA. laurent.dercle@gmail.com. 7. Department of Radiology, New York Presbyterian Hospital, New York, NY, USA. laurent.dercle@gmail.com. 8. Radiology Department, Rangueil University Hospital, 1, avenue du Professeur Jean Poulhes, 31059, Toulouse, France. mokrane_fatimazohra@yahoo.fr.
Abstract
BACKGROUND: Accurate prediction of portal hypertension recurrence after transjugular intrahepatic portosystemic shunt (TIPS) placement will improve clinical decision-making. PURPOSE: To evaluate if perioperative variables could predict disease-free survival (DFS) in cirrhotic patients with portal hypertension (PHT) treated with TIPS. MATERIALS AND METHODS: We recruited 206 cirrhotic patients with PHT treated with TIPS, randomly assigned to training (n = 138) and validation (n = 68) sets. We recorded 7 epidemiological, 4 clinical, and 9 radiological variables. TIPS-distal end positioning (TIPS-DEP) measured the distance between the distal end of the stent and the hepatocaval junction on contrast-enhanced CT scans. In the training set, the signature was defined as the random forest for survival algorithm achieving the lowest error rate for the prediction of DFS which was landmarked 4 weeks after the TIPS procedure. In the training set, a simple to use scoring system was derived from variables selected by the signature. The primary endpoint was to assess if TIPS-DEP was associated with DFS. The secondary endpoint was to validate the scoring system in the validation set. RESULTS: Overall, patients with TIPS-DEP ≥ 6 mm (n = 49) had a median DFS of 24.5 months vs. 72.8 months otherwise (n = 157, p = 0.004). In the training set, the scoring system was calculated by adding age ≥ 60 years old, Child-Pugh B or C, and TIPS-DEP ≥ 6 mm (1 point each) since the signature showed high DFS probability at 6.5 months post-landmark in patients that did not meet these criteria: 86%, 80%, and 78%, respectively. The hazard ratio [95 CI] between patients determined to be low-risk (< 2 points) and high-risk (≥ 2 points) was 2.30 [1.35-3.93] (p = 0.002) in the training set and 2.01 [0.94-4.32] (p = 0.072) in the validation set. CONCLUSION: TIPS-DEP is an actionable radiological biomarker which can be combined with age and Child-Pugh score to predict death or PHT symptom recurrence after TIPS procedure. KEY POINTS: • TIPS-DEP measurement was the third most important but only actionable variable for predicting DFS. • TIPS-DEP < 6 mm was associated with a DFS probability of 78% at 6.5 months post-landmark. • A simple scoring system calculated using age, Child-Pugh score, and TIPS-DEP predicted DFS after TIPS.
BACKGROUND: Accurate prediction of portal hypertension recurrence after transjugular intrahepatic portosystemic shunt (TIPS) placement will improve clinical decision-making. PURPOSE: To evaluate if perioperative variables could predict disease-free survival (DFS) in cirrhotic patients with portal hypertension (PHT) treated with TIPS. MATERIALS AND METHODS: We recruited 206 cirrhotic patients with PHT treated with TIPS, randomly assigned to training (n = 138) and validation (n = 68) sets. We recorded 7 epidemiological, 4 clinical, and 9 radiological variables. TIPS-distal end positioning (TIPS-DEP) measured the distance between the distal end of the stent and the hepatocaval junction on contrast-enhanced CT scans. In the training set, the signature was defined as the random forest for survival algorithm achieving the lowest error rate for the prediction of DFS which was landmarked 4 weeks after the TIPS procedure. In the training set, a simple to use scoring system was derived from variables selected by the signature. The primary endpoint was to assess if TIPS-DEP was associated with DFS. The secondary endpoint was to validate the scoring system in the validation set. RESULTS: Overall, patients with TIPS-DEP ≥ 6 mm (n = 49) had a median DFS of 24.5 months vs. 72.8 months otherwise (n = 157, p = 0.004). In the training set, the scoring system was calculated by adding age ≥ 60 years old, Child-Pugh B or C, and TIPS-DEP ≥ 6 mm (1 point each) since the signature showed high DFS probability at 6.5 months post-landmark in patients that did not meet these criteria: 86%, 80%, and 78%, respectively. The hazard ratio [95 CI] between patients determined to be low-risk (< 2 points) and high-risk (≥ 2 points) was 2.30 [1.35-3.93] (p = 0.002) in the training set and 2.01 [0.94-4.32] (p = 0.072) in the validation set. CONCLUSION: TIPS-DEP is an actionable radiological biomarker which can be combined with age and Child-Pugh score to predict death or PHT symptom recurrence after TIPS procedure. KEY POINTS: • TIPS-DEP measurement was the third most important but only actionable variable for predicting DFS. • TIPS-DEP < 6 mm was associated with a DFS probability of 78% at 6.5 months post-landmark. • A simple scoring system calculated using age, Child-Pugh score, and TIPS-DEP predicted DFS after TIPS.
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