Abstract No. 284 Multicenter Prospective Registry Analysis of Current Practice Patterns in Transjugular Portosystemic Shunt (TIPS) Creation in North America

To describe current practice patterns for creation of transjugular portosystemic shunts (TIPS) in North America. A multi-center prospective registry study (Advancing Liver Therapeutic Approaches; ALTA) included 587 patients who had TIPS placement at 14 US centers between 2019-2023. Age, pre-TIPS MELD, indication, etiology of liver disease, portal vein thrombosis (PVT) presence, performing center, use of intracardiac echocardiography (ICE), location of pressure measurements, and final TIPS diameter were studied. 587 patients underwent TIPS placement at 14 centers, with success in 561 cases (95.6%). Indications included ascites/hydrothorax (HH) in 292 (50.6%), variceal bleeding in 117 (20.3%), and PVT management in 59 (10.2%). Most common liver disease etiologies were alcohol in 42.6% and NAFLD/NASH in 31.9%. 507 (86.4%) patients were cirrhotic and 80 (13.6%) were non-cirrhotic. PVT was present in 122/587 (22.8%) of cases (acute 6.6%, chronic 14.2%; 14.5% (42/290) of ascites/HH and 23% (27/116) of variceal patients had PVT). Performing center was correlated with presence of PVT (p=0.0132). ICE was used in 384 (65.4%) cases. The ICE group had higher pre-TIPS MELD (12.0) than the non-ICE group (10.9) (p=0.0126) and performing center (p< 0.001) was associated with ICE use. Post-TIPS systemic pressures were measured at: right atrium (RA) only 62.5% of cases (n = 367), inferior vena cava only 2.4% (n = 14), both RA and IVC 23.7% (n = 139), or neither in 11.4% (n = 67), with association with performing center (p < 0.0001). In patients with both IVC and RA pressures, median difference was 0 mm Hg (p=0.22). Final TIPS diameter was 8 mm in 55.9% of cases (n = 328), 9 mm in 1.5% (n = 9), 10 mm in 30.8% (n = 181), or other/not reported in 11.7% of cases (n = 69). TIPS diameter was associated with performing center (p< 0.001) and TIPS indication (p=0.0075) but neither TIPS indication (p=0.5079) nor TIPS diameter (p=0.3038) was associated with final portosystemic gradient (PSG). ALTA TIPS registry analysis shows that ascites/HH is the most common TIPS indication across 14 US centers. ICE guidance was used in most cases, but this is center dependent. Previously a contraindication, PVT was present in nearly a quarter of cases and was the indication for TIPS in 10%. Despite guidelines that suggest using IVC as systemic pressure, most operators continue to use RA only. However, there was no difference between IVC and RA pressures. TIPS indication had an effect on the decision of final TIPS diameter, but neither indication nor TIPS diameter effected final PSG.