Abstract No. 588 A Tale of Two Veins: Does the Right versus Middle Hepatic Vein Access Impact One-Year TIPS Patency?

Transjugular intrahepatic portosystemic shunt (TIPS) remains pivotal in managing portal hypertension complications but the preferred shunt configuration remains unclear. The aim of our study was to compare one-year clinical outcomes between the right (RHV) and middle hepatic vein (MHV) access. 295 patients who underwent single Viatorr (Gore, Flagstaff, AR, USA) TIPS placement between 2014-2022 were retrospectively reviewed. 247 were accessed from the RHV (83.7%) and 48 from the MHV (16.3%). Primary clinical endpoints for our one-year analysis were revision free-survival (RFS) and primary patency rates. Secondary endpoints included clinical efficacy and hepatic encephalopathy (HE). The significance threshold was set at p<.05. Demographics and baseline clinical characteristics were similar. One-year RFS showed a trend toward improvement in the MHV group (70% vs 58% RHV, p=.13). One year TIPS patency was similar (95% MHV vs 88% RHV, p=.5), as well as overall rate of TIPS revision (16% MHV vs 17% RHV, p=.8). MHV TIPS more frequently had a smaller diameter (8 mm in 77% of MHV vs 8 mm in 47% of RHV, p< .001) and a trend toward a shorter TIPS length (8.7 cm MHV vs 9.0 cm RHV, p=.07). However, TIPS dimensions did not influence RFS. One-year clinical efficacy rates for hydrothorax, bleeding, and ascites were similar in the 2 groups (p-values of .5, .2, and .2 respectively). HE was analyzed in the subgroup of 23 MHV and 135 RHV patients with no pre-procedural HE. HE incidence was significantly lower in MHV (50% vs 91% for RHV, p=.01), and with a trend toward less severe HE (37% for MHV vs 72% for RHV, p=.07) Our initial hypothesis posited that MHV TIPS would demonstrate superior patency rates compared to RHV TIPS from a more linear flow and stent configuration. Our analysis revealed a trend toward improved one-year RFS in the MHV group. Primary patency rates were similar despite frequently smaller diameters with MHV access. In a subgroup without pre-procedural HE, the MHV group was associated with a significantly lower incidence of HE. Our data suggests that prospective randomized controlled trials are now needed to determine potential advantages of a MHV vs RHV approach for future patients to maximize clinical efficacy and minimize patient morbidity.