European Journal of Radiology 82 (2013) 2258–2264 Contents lists available at ScienceDirect European Journal of Radiology journa l ho me p age: www.elsevier.com/locate/ejrad Portosystemic pressure reduction achieved with TIPPS and impact of portosystemic collaterals for the prediction of the portosystemic-pressure gradient in cirrhotic patients Gerd Grözinger a,∗,1 , Benjamin Wiesinger a,1 , Jörg Schmehl a , Ulrich Kramer a , Tarun Mehra b , Ulrich Grosse a , Claudius König a a Department of Diagnostic Radiology, Department of Radiology, University of Tübingen, Germany b Department of Dermatology, University of Tübingen, Germany a r t i c l e i n f o Article history: Received 14 February 2013 Received in revised form 27 July 2013 Accepted 9 August 2013 Keywords: Portosytemic pressure gradient TIPSS Collateral vessels Varices a b s t r a c t Purpose: The portosystemic pressure gradient is an important factor defining prognosis in hepatic dis- ease. However, noninvasive prediction of the gradient and the possible reduction by establishment of a TIPSS is challenging. A cohort of patients receiving TIPSS was evaluated with regard to imaging fea- tures of collaterals in cross-sectional imaging and the achievable reduction of the pressure gradient by establishment of a TIPSS. Methods: In this study 70 consecutive patients with cirrhotic liver disease were retrospectively evaluated. Patients received either CT or MR imaging before invasive pressure measurement during TIPSS procedure. Images were evaluated with regard to esophageal and fundus varices, splenorenal collaterals, short gastric vein and paraumbilical vein. Results were correlated with Child stage, portosystemic pressure gradient and post-TIPSS reduction of the pressure gradient. Results: In 55 of the 70 patients TIPSS reduced the pressure gradient to less than 12 mmHg. The pre- interventional pressure and the pressure reduction were not significantly different between Child stages. Imaging features of varices and portosystemic collaterals did not show significant differences. The only parameter with a significant predictive value for the reduction of the pressure gradient was the pre-TIPSS pressure gradient (r = 0.8, p < 0.001). Conclusions: TIPSS allows a reliable reduction of the pressure gradient even at high pre-interventional pressure levels and a high collateral presence. In patients receiving TIPSS the presence and the char- acteristics of the collateral vessels seem to be too variable to draw reliable conclusions concerning the portosystemic pressure gradient. © 2013 Elsevier Ireland Ltd. All rights reserved. 1. Introduction Patients with liver cirrhosis suffer from portal hypertension. Portal hypertension is characterized by an increased pressure gra- dient between the right atrium and the portal vein above the normal level of 1–5 mmHg [1]. A pressure gradient of more than 10–12 mmHg is called a severe portal hypertension as it marks a threshold for a number of life threatening complications and for- mation of collateral circulation [2,3]. The most threatening acute complication of portal hypertension is variceal haemorrhage which ∗ Corresponding author at: Department of Diagnostic and Interventional Radiol- ogy, University hospital Tübingen, Hoppe-Seylerstr. 3, 72076 Tübingen, Germany. Tel.: +49 7071 2987217; fax: +49 7071 295694. E-mail address: gerd.groezinger@med.uni-tuebingen.de (G. Grözinger). 1 These authors contributed equally to this project and should be considered co- first authors. is associated with a high lethality, despite treatment possibilities to reduce the pressure gradient including transjugular intrahepatic portosystemic shunt (TIPSS) [4,5]. In case of acute variceal haemorrhage patients with a portosys- temic pressure gradient of <20 mmHg have a better prognosis [6]. As a consequence, knowing the portosystemic pressure gradient is of significant importance. The gold standard for measurement of the pressure gradient is the direct intravasal pressure measurement in the portal vein and right atrium. Due to the risk of complications, direct measurement is often performed in combination with the creation of a TIPSS. Many noninvasive techniques and parameters have been pro- posed to detect portal hypertension or its consequences such as the measurement of liver stiffness via transient elastography, mea- surement of variceal pressure or biochemical essays [7]. As a more advanced method, magnetic resonance elastography of the liver and spleen has recently been proposed [8]. 0720-048X/$ – see front matter © 2013 Elsevier Ireland Ltd. All rights reserved. http://dx.doi.org/10.1016/j.ejrad.2013.08.017