Background & Aims: In clinical practice, the reduction of porto-caval pressure gradient (PCPG) following trans-jugular intra-hepatic porto-systemic shunt (TIPS) does not always meet the recommendation of current guidance. We evaluated the impact of different degrees of PCPG reduction, measured at the end of an elective TIPS, on ascites control, recurrence of portal hypertension-related bleeding (PHRB) and survival. Approach and Results: Cirrhotic patients receiving TIPS for refractory ascites (RA) or for the secondary prophylaxis of PHRB were consecutively enrolled. Reduction in PCPG was defined inadequate (IHR) in patients not achieving a PCPG <12 mm Hg for both secondary prophylaxis of PHRB and RA, or a reduction of at least 50% only for PHRB. Four-hundred-fifteen patients were analyzed. An adequate hemodynamic response (AHR) was achieved in 66%. Fifty percent of patients received an under-dilated (≤7 mm) endoprosthesis. No significant differences between patients with IHR and AHR were observed in rebleeding rate and ascites control, while overt hepatic encephalopathy was higher in AHR. Regardless of TIPS indication, survival was not significantly different between IHR and AHR, while advanced age and liver function before TIPS were significantly associated with a higher cumulative incidence of liver-related death. Notably, the cumulative incidence of liver-related mortality was higher in RA patients when AHR was defined as a post-TIPS PCPG <12 mm Hg or a reduction ≥50%. Conclusions: AHR measured at the end of an elective TIPS may not be essential to define the eventual outcome, while a marked drop in PCPG could negatively affect the prognosis of patients with RA. Export

The treatment of Aortic Aneurysm disease is a growing procedure due to increase of life expectancy in Western Countries and relative incidence. In the past ten years we observed a progressive growth of endovascular over open surgery procedures with a related decline in rupture related deaths. Endo Vascular Aortic Repair [EVAR] is a well known technique of treatment of abdominal aortic aneurysms, that has changed the surgical approach to abdominal aortic aneurysms, as it is performed with low perioperative morbility and mortality rate and shorter hospital stay. However although EVAR offers immediate advantages over open surgical repair, it carries the need of close lifelong surveillance due to specific possible complications including rupture, endoleaks, graft migration and enlargement of aneurysm sac size. Contrast Enhanced Computed Tomography [CTA] is actually considered the standard reference in EVAR followup. However CTA carries high costs, radiation exposure and potential renal impairment. In the last five years several studies have been published on the role of Contrast Enhanced UltraSound [CEUS] in EVAR follow-up asserting high accuracy of this evaluation technique with absence of renal impairment, without radiation risk and at low costs. Especially since introduction of second generation Contrast Agents this evaluation technique is gaining popularity in EVAR follow-up surveillance. The diffusion of CEUS investigations by using new generation of contrast medium with appropriate software represents without any doubt an important step in the EVAR surveillance and could open up new strategies in the evaluation of endovascular aortic procedures gaining a fundamental role in EVAR follow-up.