Portosystemic shunt creation in hepatic malignancies: Evaluation of risk for pulmonary metastasis development and...

Portal hypertension is a prognostically unfavorable complication in settings of hepatic malignancy. A transjugular intrahepatic portosystemic shunt (TIPS), or a direct intrahepatic portocaval shunt (DIPS), may be considered if a patient develops refractory or life-threatening symptoms. Given blood vessel disruption and new portal outflow directly to the heart after TIPS/DIPS, the risk of post-procedure pulmonary metastasis should be considered. This study evaluates the safety and efficacy of portosystemic shunt creation in patients with hepatic malignancy and the incidence of pulmonary metastases.

In this retrospective study, data were collected on patients with hepatic malignancy who underwent TIPS/DIPS at a large tertiary care center between 2010 and 2024. The primary outcome was the development or progression (growth of >20% of the longest diameter) of pulmonary metastases within one year of shunt creation, with patients censored at death if it occurred earlier. Technical success was assessed at the time of the procedure. Adverse events and clinical success were evaluated within 1 month, laboratory values were compared between baseline and 3 months, and reintervention rates were recorded during follow-up for up to 1 year.

Thirty-nine patients (n = 39) were included, 32 (32/39, 82.1%) with hepatocellular carcinoma (HCC) and 7 (7/39, 17.9%) with hepatic metastases. Portosystemic shunt creation (TIPS/DIPS) was technically successful in all (39/39, 100%) patients. Clinical success was achieved in 36 patients (36/39, 92.3%). Adverse events included recurrent variceal bleeding in 2 patients (2/39, 5.1%). Reintervention was required in 12 patients (12/39, 30.8%) during the 1-year follow-up period. Five patients (5/39, 12.8%) developed new or progressive pulmonary metastases: two (2/5, 40%) developed new pulmonary metastases (both with colorectal cancer), and three (3/5, 60%) (HCC = 1, pancreatic cancer = 1, and colorectal cancer = 1) exhibited progression of pre-existing pulmonary metastases.

Portosystemic shunt creation was safe and effective in managing portal hypertension in patients with hepatic malignancy in this study. Pulmonary metastatic disease progression was observed in a minority of patients, and while a potential association with TIPS/DIPS cannot be entirely excluded, this finding may reflect the natural progression of advanced malignancy.