Utility of Doppler ultrasonography for predicting improvement of platelet count after transjugular intrahepatic portosystemic shunt

Abstract

ObjectivePortal pressure gradient (PPG) after transjugular intrahepatic portosystemic shunt (TIPS) <12 mmHg has been reported as the only factor predictive of increase in platelet count. As flow velocities measured on Doppler ultrasound are related to pressure gradient based on the Bernoulli equation, we used this parameter to predict increased platelet count after TIPS placement.MethodsA total of 161 consecutive patients who underwent TIPS placement entered this retrospective study. The platelet count was measured before, one week after and one month after TIPS placement. Clinically significant thrombocytopenia was defined as platelet count ≤100 000. Pre- and post-TIPS PPGs were measured. The velocity of blood flow in the proximal, mid and distal TIPS stent was measured using Doppler ultrasound, and the difference in the highest and lowest measured velocity was entitled flow velocity gradient (FVG), which was considered normal when ≤100 cm/s.ResultsIn 121 patients with pre-TIPS thrombocytopenia, the mean platelet count one week and one month after TIPS placement increased 25.7 x 103 and 35.0 x 103 in 90 patients with PPG≤12 mmHg (P=0.028 and P=0.015), while there was no significant change in platelet count in patients with a PPG >12 mmHg (P=0.098 and P=0.075). Platelets increased significantly when FVG≤ 100 cm/s (n=95) vs FVG >100 cm/s (n=26) one week (37.0x103vs 11.0x103; P = 0.005 vs 0.07) and one month after TIPS placement (17.0x103vs 5.2x103; P = 0.01 vs 0.21).ConclusionFVG >100 cm/s is not associated with increase in post-TIPS platelet count. On the other hand, findings suggestive of proper TIPS function (FVG ≤100 cm/s and PPG≤ 12 mmHg) predict a significant increase in post-TIPS platelet count.

The evolving knowledge on primary hemostasis in patients with cirrhosis: A comprehensive review

“…Indeed, if the portosystemic gradient after TIPS remains high, the platelet count does not increase. [160] Some studies found no significant increase in platelet count in patients with cirrhosis undergoing TIPS. [161][162][163] Notably, TIPS is not primarily indicated for the treatment of low platelet count but only for complications of portal hypertension.…”

“…However, the rise in platelet count is generally mild (20%–25% than baseline) 159 and occurs as early as 1 week after the TIPS, 157 which likely reflects the reduced splenic sequestration. Indeed, if the portosystemic gradient after TIPS remains high, the platelet count does not increase 160 . Some studies found no significant increase in platelet count in patients with cirrhosis undergoing TIPS 161–163 .…”

Covered Transjugular Intrahepatic Portosystemic Shunt Improves Hypersplenism-Associated Cytopenia in Cirrhosis

“…While decompression of PH by TIPS might ameliorate inflammation in some patients (by limiting bacterial translocation) and reduce splanchnic venous vascular shear stress [ 42 ], some patients do experience a further increase in splenic stiffness (which is considered a marker for portal hypertension and inflammation) after TIPS that is associated with poor post-procedural outcome and increased mortality [ 46 ]. Additionally, mechanical hemolysis of erythrocytes and platelets may impede hematologic improvement or actually worsen blood cell counts in patients undergoing TIPS, as was demonstrated by Ansari-Gilani et al [ 47 ] who reported improvement in platelet counts only in patients with G2-3 thrombocytopenia and patent TIPS according to Doppler sonography. Mechanical destruction of blood cells could be the cause for the decline in blood cell counts in our patients without apparent hematologic hypersplenism (i.e., no or G1 cytopenias).…”