Correlation study between contrast-enhanced ultrasound-based stent blood flow assessment and post-TIPS complications in patients with cirrhosis

doi:10.21203/rs.3.rs-4880597/v1

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Correlation study between contrast-enhanced ultrasound-based stent blood flow assessment and post-TIPS complications in patients with cirrhosis

https://doi.org/10.21203/rs.3.rs-4880597/v1

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Objectives Transjugular intrahepatic portosystemic shunt (TIPS) is a vital procedure for alleviating portal hypertension in patients with cirrhosis, with an emphasis on preventing and minimizing complications. This study aims to explore the correlation between stent blood flow, as assessed by contrast-enhanced ultrasound (CEUS), and the occurrences of haemorrhage and hepatic encephalopathy in cirrhotic patients following TIPS. Additionally, the research seeks to develop and validate a clinical prediction model for the postoperative risks of haemorrhage and hepatic encephalopathy.

Methods A total of 102 patients with cirrhosis who received TIPS treatment at the 900th Hospital of the Joint Logistics Support Force from January 2021 to December 2022 were selected, and relevant clinical data and test results were collected. The stent average blood flow was calculated using the formula: Stent average blood flow (ml/min) =(stent length (cm)/time required for contrast agent to pass both ends of the stent (s) * stent cross-sectional area (cm²) *60. Independent predictors of postoperative haemorrhage in patients with cirrhosis were identified through univariate and multivariate Cox regression analysis. The optimal cut-off value for stent blood flow data was determined, and the predictive ability of stent average blood flow for haemorrhage after TIPS in cirrhotic patients was evaluated. Similarly, independent predictors of hepatic encephalopathy following TIPS in these patients were screened using the same approach, examining the effects of various stratified stent average blood flow values on the incidence of postoperative hepatic encephalopathy. Clinical prediction models for both haemorrhage and hepatic encephalopathy were then constructed separately.

Results 1. Among the 82 patients with liver cirrhosis who underwent TIPS and successfully completed liver CEUS, 12 patients experienced haemorrhage after the procedure. Multivariate analysis identified the average stent blood flow, postoperative portal vein pressure, and platelet count as independent predictors. When the average stent blood flow was at 31.62 ml/min, the sensitivity and specificity were 88.6% and 33.3%, respectively, with a Jorden index of 0.219. Stratified analysis of average stent blood flow indicated that the risk of postoperative haemorrhage increased when the average stent blood flow was below 31.62 ml/min, and this difference was statistically significant (P < 0.05). Twenty-six patients developed hepatic encephalopathy after TIPS. Multivariate Cox regression analysis revealed that diabetes, hypertension, and total bilirubin levels were independent predictors. When the average stent blood flow was at the optimal cut-off value of 29.93 ml/min, the corresponding sensitivity and specificity were 75.0% and 46.2%, respectively, with a Jorden index of 0.346. The risk of hepatic encephalopathy increased when the average postoperative stent blood flow exceeded 29.93 ml/min, and this difference was also statistically significant (P < 0.05).

2. The C-index for the clinical prediction models of post-TIPS haemorrhage and hepatic encephalopathy in patients with cirrhosis were 0.814 (95% CI: 0.633-0.996) and 0.712 (95% CI: 0.571-0.852), respectively. The area under the curve (AUC) of the haemorrhage prediction model at 1 year, 2 years, and 3 years were 0.881, 0.904, and 0.860, respectively. The AUC of the prediction model for hepatic encephalopathy after TIPS in cirrhotic patients was 0.786 in January, February, and March, indicating that the models demonstrated a certain degree of differentiation. The calibration curves fitted well, suggesting that they possess clinical practicality.

Conclusion 1. Stent blood flow assessment using contrast-enhanced ultrasound demonstrates predictive ability for haemorrhage after TIPS and the development of hepatic encephalopathy in patients with cirrhosis. 2. The clinical prediction models for post-TIPS haemorrhage and hepatic encephalopathy in cirrhotic patients exhibit clinical effectiveness.

cirrhotic

portal hypertension

transjugular portosystemic shunt

contrast-enhanced ultrasound

nomogram prediction model

Cirrhosis of the liver ranks as the fifth leading cause of death among adults and the eighth most economically burdensome disease. A significant consequence of cirrhosis is portal hypertension, which leads to various severe complications in affected patients. The transjugular intrahepatic portosystemic shunt (TIPS) is a crucial intervention aimed at lowering portal pressure in cirrhotic patients, yet it can lead to several postoperative complications. Studies reveal haemorrhage rates of up to 14.6% and 18.8% at one and two years, respectively, after TIPS combined with variceal embolization. Additionally, a multicenter study reported a 50% incidence of hepatic encephalopathy following TIPS in cirrhotic patients. Given the variability in hepatic portal vein pressure among individuals, the blood flow shunted by stents — even with identical inner diameters — can differ, altering the pressure dynamics between the shunted portal vein and the inferior vena cava. Consequently, stent blood flow emerges as a more intuitive measure for evaluating blood flow in the shunt than stent or balloon diameters, potentially providing predictive insights into complications. Contrast-enhanced ultrasound (CEUS) enhances the resolution, sensitivity, and specificity of ultrasound diagnoses, allowing for real-time, dynamic observation and quantitative evaluation of organ and tissue perfusion. Previous studies indicate that ultrasonography can effectively demonstrate in-stent patency, accurately assess in-stent stenosis, and improve diagnostic reliability, positioning it as a suitable tool for quantitatively assessing stent blood flow. This study aims to gather stent blood flow data through ultrasonography, comprehensively analyze its advantages and limitations compared to other predictive factors, identify risk factors for haemorrhage and hepatic encephalopathy after TIPS in cirrhotic patients, and establish a clinical prediction model for these complications. This model will take the form of a column-line diagram, enabling early identification and screening of high-risk patients and guiding clinical interventions.

Study Population This study focuses on cirrhotic patients who underwent TIPS treatment and successfully completed liver ultrasonography between January 2021 and December 2022 at the 900th Hospital of the United Logistics Force. Inclusion Criteria:1. Diagnosis of liver cirrhosis confirmed by pathology, imaging, and clinical evaluation. 2. Presence of ruptured esophagogastric fundus varices with ineffective response to standard treatments, including conservative internal measures. 3. Successful performance of the TIPS procedure. Exclusion Criteria:1. Portal vein occlusion or cavernous transformation of the portal vein. 2. Documented allergy to any component of the contrast agent used in ultrasonography or other associated medications. 3. Pregnant or lactating women. All procedures adhered to the ethical standards set forth by the institutional and/or national research committees, aligning with the 1964 Helsinki Declaration and its subsequent amendments. The study received approval from the Bioethics Committee of the 900th Hospital of the Joint Logistics Support Force.

Clinical data In this study, comprehensive data were collected to analyze the outcomes of cirrhotic patients who underwent TIPS treatment. The data categories included: General Information: Age: Patient age at the time of TIPS procedure, Gender: Male or female, Indication for TIPS: Clinical reasons for performing the TIPS procedure, such as refractory variceal bleeding,

History of Alcohol Consumption: Documentation of prior alcohol use, History of Hepatic Encephalopathy : Previous episodes of hepatic encephalopathy, Comorbid Conditions: Presence of diabetes mellitus and hypertension, CTP Score: Child-Turcotte-Pugh (CTP) score and its grading for assessing liver function, MELD Score: Model for End-Stage Liver Disease score, used for liver disease severity assessment. Laboratory Data: Hemoglobin: Levels of hemoglobin in the blood, Platelets: Platelet count, Albumin: Serum albumin levels, Liver Enzymes: Including glutamate transaminase (AST) and glutamic oxalate aminotransferase (ALT), Total Bilirubin: Measures bilirubin levels indicating liver function, Blood Ammonia: Levels relevant to hepatic encephalopathy, Blood Creatinine: Indicates kidney function, Blood Sodium: Serum sodium levels. Surgical Data: Type of Stent Used: Details of the stent types utilized during the TIPS procedure. Stent Internal Diameter: Measurement of the stent's internal diameter. Postoperative Portal Pressure: Portal vein pressure measurements following the TIPS procedure. Gradient of Portal Pressure Drop: Difference in portal pressure before and after the procedure, indicating efficacy. This extensive data collection aims to identify risk factors and develop a predictive model for postoperative complications, enhancing the management of cirrhotic patients undergoing TIPS.

Ultrasonography Procedure and Calculation Formula Ultrasonography was performed by a single, experienced ultrasonographer for all patients within one month following the TIPS procedure. The examination gathered crucial information, including: Ultrasonography Parameters: Stent Inner Diameter: The measurement of the stent's internal diameter, which can affect blood flow, Stent Length: The total length of the stent, important for assessing its fit and function, Contrast Passage Time: The time taken for the contrast agent to travel through both ends of the stent, indicating patency and flow dynamics, Stent Stenosis or Occlusion: Evaluation of the stent for any narrowing (stenosis) or blockage (occlusion), which could impact its effectiveness. This standardized approach ensures consistency in data collection and facilitates accurate assessment of stent performance post-TIPS.Calculation formula: average stent blood flow (ml/min) = (stent length (cm)/time required for contrast agent to pass through the ends of the stent (s)*stent cross-sectional area (cm2) *60.

Follow up Enrolled patients were systematically followed up through reviewing electronic medical records and conducting postoperative monthly telephone calls. The primary observational endpoints were the recurrence of gastrointestinal bleeding associated with portal hypertension and episodes of hepatic encephalopathy. The deadline for follow-up was March 2023, ensuring comprehensive data collection regarding patient outcomes after the TIPS procedure. This approach was essential for evaluating the long-term efficacy and safety of the treatment.

Statistical methods The data were analyzed using R 4.2.1, where independent predictors of haemorrhage after TIPS in cirrhotic patients were identified through unifactorial and multifactorial Cox regression analyses. The predictive ability of stent average blood flow on haemorrhage was evaluated using ROC curve analysis, while X-tile software was employed to determine the optimal cut-off value for stent blood flow. This stratification facilitated a comparison of stent average blood flow's impact on haemorrhage occurrences. A similar methodology was applied to identify independent predictors of hepatic encephalopathy following TIPS in cirrhotic patients, assessing how stent average blood flow affected postoperative hepatic encephalopathy across different strata. Utilizing the identified independent predictors for both haemorrhage and hepatic encephalopathy, clinical prediction models were constructed. These models were internally validated through the C-index and the area under the receiver operating curve (AUC) to evaluate discrimination. Calibration was assessed using calibration curve analysis (DCA), while decision curve analysis (DCA) was conducted to evaluate the clinical utility of the predictive models.

Baseline characteristics and occurrence of postoperative complications

In this study, we collected clinical and auxiliary examination data from post-TIPS cirrhosis patients who underwent ultrasonography at our hospital between January 2021 and December 2022, ultimately including 82 patients for statistical analysis. The baseline characteristics are detailed in Table 1. Among the participants, 12 patients experienced post-TIPS haemorrhage, resulting in an incidence rate of 14.63%, while 26 patients developed postoperative hepatic encephalopathy, corresponding to an incidence rate of 31.71%.

Table 1

Patient Baseline Information Sheet
clinical information	n = 82
Sex
Male	50(60.98%)
Female	22(26.83%)
Age (years)	54.02(12.67%)
Cause of disease
Hepatitis B cirrhosis	46(56.10%)
Alcoholic cirrhosis	6(7.32%)
Hepatitis B cirrhosis combined with alcoholic cirrhosis	8(9.76%)
Other causes of cirrhosis	28(26.83%)
History of alcohol consumption
No	54(65.85%)
Yes	28(34.15%)
History of hepatic encephalopathy
No	80(97.56%)
Yes	2(2.44%)
Hemoglobin (g/L)	113.40(143.76)
Platelets (*10⁹/L)	85.78(49.78)
Albumin (g/L)	33.82(5.37)
Albumin(g/L)	32.03(23.71)
Albumin(U/L)	40.21(28.04)
Total Bilirubin(umol/L)	21.41(10.08)
Creatinine(umol/L)	86.30(115.88)
Blood sodium (mmol/L)	138.56(3.97)
CTP score	6.54(1.28)
MELD score	7.18(5.54)
CTP Grading
Grade A	48(58.54%)
Grade B	32(39.02%)
Grade C	2(2.44%)
Postoperative portal vein pressure (mmHg)	23.72(10.84)
Gradient of portal vein pressure drop (mmHg)	11.03(4.82)
Stent type
Viatorr stent	26(31.71%)
Fluency stent combined with bare stent	46(56.10%)
Stent diameter
6mm	10(12.20%)
7mm	26(31.71%)
8mm	4(56.1%)
Stent average blood flow (ml/min)
≤ 31.62	28(27.45%)
>31.62	54(52.94%)

Correlation analysis of stent average blood flow and haemorrhage after TIPS in patients with cirrhosis

The results of the univariate analysis indicated that predictors associated with haemorrhage after TIPS in cirrhotic patients included stent average blood flow (P < 0.1), as shown in Table 2. Further multivariate analysis revealed that stent average blood flow was an independent predictor of haemorrhage after TIPS (P < 0.05), illustrated in Fig. 1. According to the ROC curve analysis, the optimal cut-off value for stent average blood flow had an AUC of 0.593 (95% CI: 0.435, 0.750), with sensitivity and specificity values of 88.6% and 33.3%, respectively, and a Jordon's index of 0.219, as depicted in Fig. 3. Utilizing the optimal cut-off value of 31.62, derived from X-tile software, 28 patients were categorized into the low stent average blood flow group (≤ 31.62), representing 34.15%, while 54 patients fell into the high stent average blood flow group (≥ 31.62), also accounting for 34.15%. The Kaplan-Meier curve demonstrated that the risk of TIPS haemorrhage was significantly higher in the low stent flow group compared to the high stent flow group (P < 0.05), as shown in Fig. 4.

Table 2

Univariate regression analysis of predictors of haemorrhage after TIPS in patients with liver cirrhosis
		95%CI	P- value
Sex	1.426	0.400-5.087	0.585
Age (years)	0.997	0.946–1.050	0.895
Drinking history	1.044	0.314–3.476	0.944
Hemoglobin (g/L)	0.974	0.941–1.010	0.158
Platelets (*10⁹/L)	1.018	1.007–1.029	<0.01
Albumin (g/L)	1.078	0.952–1.221	0.234
Albumin transaminase (U/L)	0.975	0.939–1.014	0.205
Glutamine aminotransferase (U/L)	0.950	0.889–1.015	0.130
Total bilirubin (umol/L)	1.034	0.961–1.13	0.369
Creatinine (umol/L)	0.996	0.984–1.009	0.531
Plasma ammonia (umol/L)	1.014	0.987–1.041	0.319
CTP score	0.4538	0.204–1.008	0.05
MELD score	0.970	0.869–1.082	0.581
Peritoneal fluid	1.604	0.469–5.482	0.451
Postoperative portal pressure (mmHg)	1.079	1.031–1.129	<0.01
Gradient of portal pressure drop (mmHg)	1.102	0.929–1.306	0.264
Stent diameter
6mm	1
7mm	0.281	0.051–1.548	0.145
8mm	0.631	0.146–2.721	0.537
Stent average blood flow (ml/min)
>31.62	1
≤ 31.62	3.255	0.990–10.700	0.052

Correlation analysis of stent average blood flow and hepatic encephalopathy after TIPS in patients with liver cirrhosis

Univariate analysis identified stent average blood flow as a significant predictor of hepatic encephalopathy in cirrhotic patients following TIPS, with a P-value less than 0.1, as shown in Table 3. Multivariate analysis further revealed independent predictors, including diabetes mellitus, hypertension, and total bilirubin, each with a P-value less than 0.05, as depicted in Fig. 5. The ROC plot analysis for stent average blood flow indicated an AUC value of 0.662 at the optimal cut-off, with a 95% confidence interval of 0.541 to 0.784, a sensitivity of 75.0%, a specificity of 46.2%, and a Yoden index of 0.346. Utilizing the X-tile software, the optimal cut-off for average blood flow was determined to be 29.93, classifying 26 patients (31.71% of the total) into the low average blood flow group and 56 patients into the high average blood flow group. Notably, 12 of the 26 patients who developed hepatic encephalopathy were in the low average stent flow group, while the remaining 14 were in the high average stent flow group. The Kaplan-Meier curve demonstrated a statistically significant higher risk of post-TIPS hepatic encephalopathy in the high average flow group compared to the low average flow group, with a P-value less than 0.05, as shown in Fig. 7.

Table 3

Univariate regression analysis of predictors of hepatic encephalopathy after TIPS in patients with cirrhosis
	HR	95%CI	P-value
Sex	0.360	0.548–1.866	0.162
Age (years)	1.055	1.019–1.092	<0.01
History of alcohol consumption	0.562	0.226–1.399	0.215
History of hepatic encephalopathy attacks	9.746	2.063–46.050	<0.01
Diabetes mellitus	4.486	1.904–10.57	<0.01
Hypertension	2.343	0.925–5.934	0.073
Portal vein thrombosis	1.892	0.739–4.843	0.184
Hemoglobin (g/L)	0.996	0.984–1.008	0.530
Platelets (*109/L)	0.999	0.992–1.006	0.842
Albumin (g/L)	0.888	0.826–0.955	<0.01
Albumin transaminase (U/L)	0.990	0.970–1.011	0.354
Glutamine transaminase (U/L)	1.010	0.999–1.020	0.058
Total bilirubin (umol/L)	1.068	1.032–1.107	<0.01
Creatinine (umol/L)	0.998	0.993–1.003	0.459
Blood sodium (mmol/L)	0.912	0.853–0.998	0.035
Plasma ammonia (umol/L)	0.987	0.837-994	0.180
CTP score	2.037	1.498–2.768	<0.01
MELD score	1.043	0.993–1.097	0.095
Peritoneal fluid	0.790	0.342–1.824	0.581
Postoperative portal pressure (mmHg)	0.981	0.930–1.035	0.476
Stent diameter
6mm	1
7mm	0.905	0.268–3.057	0.873
8mm	1.071	0.333–3.450	0.908
Stent type
Fluency Bracket	1
Viatorr Stent	0.437	0.109–1.749	0.242
Fluency stent combined with bare stent	0.972	0.324–2.910	0.959
Stent average blood flow (ml/min)
>29.93	1
≤ 29.93	0.992	1.008–0.983	0.057

Construction and Performance Evaluation of Column Line Chart Prediction Models

The independent predictors were incorporated to develop predictive models for postoperative haemorrhage and hepatic encephalopathy, as illustrated in Figs. 8 and 9, respectively. The internal validation of these models demonstrated a C-index of 0.814 (95% CI: 0.633–0.996) for the haemorrhage model and 0.712 (95% CI: 0.571–0.852) for the hepatic encephalopathy model. The haemorrhage model exhibited an AUC of 0.881, 0.904, and 0.860 at 1, 2, and 3 years postoperatively, respectively, as depicted in Fig. 8.1. The decision analysis curves indicated a favorable net clinical benefit across a range of threshold probabilities from 4.8–99.9% at 1, 2, and 3 years post-surgery, as shown in Fig. 8.3. For the hepatic encephalopathy model, the AUC at 1, 2, and 3 months postoperatively was 0.786, as indicated in Fig. 9.1. This model yielded a net clinical benefit for patients at threshold probability ranges of 5.2–59.20% and 59.20–77.0% in the first three postoperative months, as seen in Fig. 9.4. The calibration curves for both models closely aligned with the standardized line, indicating a considerable level of accuracy, as presented in Figs. 8.2 and 9.2.

In the context of cirrhosis, the normal hepatic portal venous return is impeded, while compensatory mechanisms such as intrahepatic microangiogenesis and the formation of systemic collateral branches from the portal vein substantially augment the blood flow within the portal venous system. This leads to an increase in portal venous pressure, which can precipitate the rupture of esophageal and gastric varices, a common and severe complication of cirrhosis with an annual incidence rate of 5–8% [6, 7]. These episodes are marked by abrupt onset, substantial blood loss, high mortality, and pose a significant threat to patient survival. The Transjugular Intrahepatic Portosystemic Shunt (TIPS) procedure alleviates the risk of variceal rupture and bleeding by creating a conduit between the portal and hepatic veins, thereby reducing portal pressure. TIPS has been shown to significantly enhance the 1-year survival rate among patients at high risk of cirrhosis and acute variceal hemorrhage, offering a superior outcome compared to drug-assisted endoscopic therapy [8]. However, TIPS is not without its complications. Post-TIPS, haemorrhage can occur in about 50% of patients [9], and hepatic encephalopathy, a serious neurological complication, has an incidence ranging from 5–35% following TIPS, with a median 1-year cumulative morbidity of 10–50% [10]. The early identification of risk factors for these complications is crucial for clinical decision-making and for assessing patient outcomes, guiding appropriate interventions and optimizing patient care.

In this research, ultrasonography was employed to measure shunt blood flow, identify optimal blood flow parameters, and inform corrective surgical strategies. This approach also aimed to appraise postoperative risks and minimize the occurrence of adverse events. Within the vascular pathology domain, contrast-enhanced ultrasonography (CEUS) has been recognized for its superiority over traditional ultrasound methods. Specifically, CEUS has exhibited higher sensitivity in detecting occlusive and pre-occlusive stenoses compared to color Doppler flow imaging (CDFI) [11]. Portal venography stands as the gold standard for diagnosing stent dysfunction. A clinical study by Micol et al. [12] reported a significant correlation between CEUS findings and portal venography results. Multiple studies have corroborated the high sensitivity and specificity of CEUS in identifying stent dysfunction in TIPS procedures, outperforming CDFI [13]. A case in this study exemplified the enhanced diagnostic capability of CEUS. A patient with substantial ascites was admitted, and conventional ultrasonography failed to detect stent dysfunction. However, CEUS provided a more detailed assessment, revealing in-stent thrombosis, thereby underscoring the higher diagnostic sensitivity of CEUS in comparison to standard ultrasonography.

In this study, stent average blood flow was identified as a potentially more direct and significant indicator for predicting haemorrhage and hepatic encephalopathy following TIPS in cirrhotic patients, as opposed to stent diameter. Univariate and multivariate analyses corroborated that stent average blood flow is an independent predictor of haemorrhage post-TIPS, aligning with anticipated outcomes. This metric reflects the efficacy of the shunt in diverting portal blood flow; insufficient diversion, indicated by a average blood flow below a critical threshold, can lead to increased portal pressure and a heightened risk of variceal rupture and bleeding. The study demonstrated that stent average blood flow is a robust predictor for postoperative haemorrhage. Specifically, patients with a stent average blood flow below 31.62 ml/min exhibited a higher incidence of haemorrhage compared to those above this threshold. Consequently, clinicians may consider dilating the shunt with a larger-diameter balloon when necessary, to augment shunt flow, thereby reducing portal pressure and the likelihood of haemorrhage. Special attention should be given to stent blood flow in patients with risk factors such as severe thrombocytopenia, compromised liver function, and prolonged anticoagulant use, aiming to maintain flow above the 31.62 ml/min threshold to mitigate postoperative haemorrhage risks. Additionally, the study revealed that stent average blood flow has a strong predictive capacity for postoperative hepatic encephalopathy, with a Yoden index of 0.346 at the optimal cut-off value. It was observed that cirrhotic patients with a stent average blood flow exceeding 29.93 ml/min were at a higher risk for postoperative hepatic encephalopathy. When ultrasonography indicates a average blood flow above this level, the likelihood of hepatic encephalopathy is anticipated to be higher, mandating preemptive anti-hepatic encephalopathy treatment and vigilant post-procedure monitoring. For patients with a recurrent history of hepatic encephalopathy, impacting their quality of life significantly, strategies such as shunt channel occlusion or restriction could be employed to attenuate shunt flow.

The study established predictive models for postoperative haemorrhage and hepatic encephalopathy using independent predictors, verified through univariate and multivariate analyses. These models were evaluated for discrimination, calibration, and clinical utility, yielding satisfactory results, thus offering reliable tools for post-TIPS complication prediction. This study introduces a novel application of ultrasonography for quantifying shunt blood flow post-TIPS, examining its correlation with haemorrhage and hepatic encephalopathy—outcomes more directly influenced by stent blood flow than traditional measures like stent diameter. This approach, less explored in existing literature, offers a more intuitive and clinically relevant predictor. The study's second contribution lies in pinpointing the stent blood flow ranges associated with an increased risk of postoperative complications, providing actionable insights for clinical management in high-risk patients. Identifying these critical thresholds aids in timely intervention and risk mitigation. Lastly, by extracting predictors of common post-TIPS complications in cirrhotic patients, the study conducted secondary analyses to isolate independent predictors for haemorrhage and hepatic encephalopathy. This led to the development of two clinically relevant predictive models, enhancing the ease, clarity, and applicability of predicting patient outcomes at various time points through graphical representations of clinical indicators. The study's findings thus advance the utility of ultrasonography in post-TIPS care, offering a refined method for assessing and managing patient risks, and contributing valuable predictive tools to the clinical landscape.

The study's limitations include selection bias inherent to its cohort design, patient loss to follow-up, and missing data. The need for improved follow-up methods and the influence of external factors such as surgical advancements and patient environment on data integrity are also noted. The absence of external validation and a small sample size weaken the statistical robustness of the findings. To address these issues, larger, multicenter, prospective studies are recommended for validating and strengthening the results.

Conflict of interest

No other author has pertinent conficts of interest.

Author Contribution

Concept and Design: Zhixian Wu; Analysis, Writing and Revision: Minyan Ye.

Data availability

No datasets were generated or analyzed during the current study.

Author’s contribution

Roles a.Concept and Design: Zhixian Wu; b.Analysis, Writing and Revision: Minyan Ye.

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No competing interests reported.

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Correlation study between contrast-enhanced ultrasound-based stent blood flow assessment and post-TIPS complications in patients with cirrhosis

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Abstract

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Introduction

Methods

Results

Baseline characteristics and occurrence of postoperative complications

Correlation analysis of stent average blood flow and haemorrhage after TIPS in patients with cirrhosis

Construction and Performance Evaluation of Column Line Chart Prediction Models

Discussion

Declarations

Conflict of interest

Author Contribution

Data availability

Author’s contribution

References

Additional Declarations

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