Thématique :
- Foie
Originalité :
Solidité :
Très solide
Doit faire évoluer notre pratique :
Nom du veilleur :
Professeur Jean-Marie PERON
Coup de coeur :
  2017 Jan . pii: S0016-5085(17)30051-3.  
  doi: 10.1053/j.gastro.2017.01.011  
  Timing Affects Measurement of Portal Pressure Gradient After Placement of Transjugular Intrahepatic Porto-systemic Shunts in Patients With Portal Hypertension.  
  Silva-Junior G, Turon F, Baiges A, Cerda E, García-Criado Á, Blasi A, Torres F, Hernandez-Gea V, Bosch J, Garcia-Pagan JC  



A reduction in portal pressure gradient (PPG) to below 12 mmHg after placement of a transjugular intrahepatic porto-systemic shunt (TIPS) correlates with the absence of further bleeding or ascites at follow-up examinations of patients with cirrhosis. The PPG is usually measured immediately after placement of the TIPS, when different circumstances can affect PPG values - this could affect determination of risk for decompensation. We investigated variations in PPG measurements collected at different time points after TIPS, aiming to identify a time point after which PPG values were best maintained.


We performed a retrospective study of 155 consecutive patients with severe complications of portal hypertension who received placement of TIPS from January through October 2015; patients were followed until March 2016. We compared PPG values measured at different time points and under different conditions: immediate following placement of TIPS (immediate PPG); at least 24 hrs after placement to TIPS into hemodynamically stable patients, without sedation (early PPG); and again 1 month after TIPS placement (late PPG).


The immediate PPG differed significantly from the early PPG, regardless of whether the TIPS was placed using general anesthesia (8.5±3.5 mmHg vs 10±3.5 mmHg; P=.015) or deep sedation (12±4 vs 10.5±4 mmHg; P<.001). In considering the 12 mm Hg threshold, concordance between immediate PPG and early PPG values was poor. However, there was no significant difference between mean early PPG and late PPG values (8.5±2.5 vs 8±3 mmHg), or between proportions of patients with early PPG vs late PPG values below the 12 mmHg threshold. Maintenance of a PPG value below 12 mmHg during the follow-up period was associated with a lower risk of recurrent or de-novo variceal bleeding or ascites (hazard ratio, 0.11; 95% CI, 0.04 0.27; P<.001).


In a retrospective study of patients with PPG values measured at different time points after TIPS placement, we found measurements of PPG in awake, hemodynamically stable patients at least 24 hrs after TIPS, to be the best maintained values. Our findings support the concept that PPG value below 12 mmHg after TIPS placement is associated with reduced risk of bleeding and ascites.


Question posée
Quand faut-il mesurer le gradient de pression porto-sus-hépatique après la pose d’un TIPS?
Question posée
La mesure immédiate du gradient après la pose du TIPS peut donner une estimation mais il faut attendre 24 h chez un patient non endormi pour avoir une mesure fiable du gradient. Les patients avec un gradient inférieur à 12 avaient moins de risque d’hémorragie digestive ou d’ascite.

Cette étude confirme la valeur de 12 mmHg comme valeur seuil de gradient pour la prédiction des complications de l’hypertension portale.