Podcast Transcript: Portal Hypertension Treatment Strategies: IR & Hepatology Perspectives

[Dr. Chris Beck]
I want to talk about the future a little bit. Sometimes the questions are tricky, but I want to leave it as open as possible. As far as like the portal hypertensive practice, is there anything like any research that you feel like either as part of your group or you guys are collaborating with, is there anything that you're excited about that's on the horizon for portal hypertension and how you guys are managing it?

[Dr. Siobhan Flanagan]
Tom has mentioned this before, we're really looking forward to what the Alta TIPS data is going to show us. I think we're going to do a much better job as a field when we have that type of data. In interventional radiology we all struggle with what's the quality of our data and the completeness of our data. This is one of those things that I think would change how we manage these patients or help us just identify what are our missteps? What are our potential areas for improvement? I would say that.

Then the other thing that I really look forward to and I think our conversation honestly has touched upon it that, I think there's a role for portal hypertension management, almost service line in any hospital system. That's a catch for patients with cirrhosis, but it's actually a catch for patients who, maybe have a visceral occlusion and need that taken care of. I think there's a lot of opportunity there. Once you create a service line for these types of things, you can-- It's a big health system here, but that gives opportunity to standardize things out for the community sites. Even grazes awareness, creates understanding. I would say those are the things that really looking forward to.

[Dr. Chris Beck]
Nice. Tom, same question for you, but I'll even open it up even broader. Maybe it's not portal hypertension-related. Maybe it's just in the transplant realm. Anything that you're excited about from y'all's data or anything, maybe that, when I say y'all's data, the hepatology data or anything that maybe University of Minnesota is putting out.

[Dr. Tom Leventhal]
Siobhan and Nick, our partner has really looked at, does encephalopathy really impact your outcome in TIPS? Just publications really saying, no, probably not. I think that Alta TIPS where we are actively participating in rolling patients on a near-weekly basis, I think it's really going to give a lot of really good objective data to the hepatology and IR community to say is like, look, these are the median MELD scores of people coming in. Look at the outcomes that they're having. Maybe we can push the envelope more globally for patients with portal hypertension.

I think I get a little bit interesting perspective is that right in the GI and advanced endoscopy world, there's a lot of advancements as far as treatment of complications of portal hypertension. Not only like EUS-guided liver biopsies with portal hypertension management, but EUS-guided gluing and coiling varices. I think we're in a very different position or unique position, particularly with our relationship with interventional radiology.

I think the benefit that we have is my job as a hepatologist is to truly understand portal hypertension. Then that allows us to really say, well, where could the endoscopic approach be really valuable? Say in someone who has a really high MELD score, who's having refractory bleeding, that could be a really good indication for GI to go in and do these procedures, but also understanding that what they do isn't treating portal hypertension. It's treating a complication of it. Truly interventional radiology through TIPS and/or transplant is ultimately what's going to treat it for our patients and prevent this stuff long-term from happening again.

[Dr. Chris Beck]
Well put. Anything that I didn't bring up that I should have brought up that you thought was worth talking about? Siobhan, start with you.

[Dr. Siobhan Flanagan]
Yes. I think always an interesting conversation within interventional radiology is the question of early TIPS. How soon do we do it afterwards? I think the inpatient conundrum is what are the resources to get an inpatient TIPS done? Ideally, we would do it in 72 hours after an acute variceal bleed. Do we have the resources to get that done? Is there anesthesia availability? Is there interventional radiology availability to get that done? I think that, I'd love for us to continue to look at that. Is do we stick with that? Does that two-hour goal really ring true for us? If it does, how do we get there?

[Dr. Chris Beck]
How's the anesthesia at y'all's place? Easy to come by? Tough to come by? Depends on the day?

[Dr. Siobhan Flanagan]
Really tough to come by. It does depend on the day. Listen, they are a busy crew. What really a challenge for them I think is that everything gets the anesthesia now. I think that's just a tough thing for them. The demand has gone up exponentially and their presence hasn't. They don't grow on trees. It's hard to get them, especially for a big medical center like this, with really complex sick patients. It can be hard to build an optimum crew. They do a great job for us with what they have.

[Dr. Chris Beck]
Tom, same question. Anything that I didn't bring up that seems like a glaring hole in the outline of the show.

[Dr. Tom Leventhal]
As far as like the guise of the show, it's really interesting. You admittedly trying to figure out like what you guys are trying to do in this podcast and stuff. I started listening, and Siobhan and I were talking about it before we got on, this most recent episode and talk about moral injury. As proceduralists, I do procedures, I do paid procedures on people with active variceal hemorrhage and stuff and you understand, it's a really sick population with a very real chance of dying because of a complication of their problem.

I think it goes even beyond the trust of, can the technician, the intervention radiologist who is doing the procedure, do the procedure to the utmost of their ability with adequate restratification. It's like what Siobhan was talking about with this ideal of early TIPS. We have people come in with MELDs greater than 20 that are having active variceal hemorrhage that we can't treat because maybe they've been banded 4 times and everything's scarred down and we can't get endoscopic intervention on it. It's that real discussion and trust of, this is someone who's going to die of a complication of their portal hypertension. Let's have a discussion about risks and benefits that as a group we are willing to accept because I would never want my interventional radiologist to feel like it's in any way their fault.

It's like the idea of transplant, I don't make a decision if someone's a transplant candidate, our transplant group does. This is a, how do we have an open discussion, understanding risks on both sides are very real. What do we feel we can accept? What do we feel is safe that we don't feel that we're putting ourselves at this risk of very severe moral injury? I think that's an important thing to factor in, especially in modern medicine.

[Dr. Chris Beck]
Tom, do you feel like you have a better grip on that than, I don't know if you have any hepatology colleagues or GI, well, GSO procedure-oriented or a lot of GI docs are. Sometimes I feel like that's a little bit missed in other referring docs to interventional who don't do procedures or more clinically focused that it's almost like if you can do a procedure, you should do it. Whenever I'm talking to other proceduralists, I feel like they understand the weight of that discussion of risk versus benefits. Is it a procedure that's going to have a net positive? I just feel like you're very in tuned with that, Tom.

[Dr. Tom Leventhal]
I think as a transplant hepatologist, you have to be right on the transplant side of things. If there were an organ for everyone, it becomes less of an issue, but it's really when we go through these discussions, it's, is this, is this for all the reasons, the right thing to do, the safe thing to do that we could expect an appreciable outcome for? That translates back to the clinic work I do, the endoscopy work I do, the referrals that I'll place to other proceduralists.

I think that in transplant hepatology, we really do think about it guiding a lot of our decision-making, particularly when saying like, okay, if you've got intra-abdominal varices that, need a procedure, that's a high-risk procedure. We have to have discussions. We understand there can be really negative outcomes, but in looking at it and saying repeated admissions for encephalopathy with the opportunity to avoid that, having the discussion with our colleagues that are, that had the expertise in doing it, I think those open discussions are what ultimately push care. It will push care for everyone, not just say at our center. I think that's the important thing.

[Dr. Chris Beck]
Very nice. Well said. I have one last question and it's for Tom. Is there ever a world where there will be enough livers to go around for everybody, like in terms of work that they're doing with like stem cells and like, in like creating a liver in a laboratory, because if this is like something that I'm totally off my rocker and asking, or is this like a real possibility at some point, like do people will like talk this and in serious circles?

[Dr. Tom Leventhal]
Absolutely. It's such a great question. Full disclosure, I do research with a company that's actually working on this. It is very real, right? I think it started with, about, I couldn't even tell you, but I want to say about 20 years ago in the United States with this idea of doing living donor liver transplant. We worked didn't necessarily fully dependent on the deceased donor model that we do many of these throughout the United States a year, variability across centers as far as volumes.

Now, I just at our big transplant conference a week or so ago out in Philadelphia talking about perfusion devices, right? Taking organs from donors that have been donated and putting them on perfusion devices to sort of rehabilitate them. What we're seeing at transplant centers across the country is that our ability to use organs that before were marginal is increasing exponentially.

Then we take it a step further. There's been an incredible amount of work with like stem cells, things like that. One of our partners here at the University of Minnesota has NIH funding to look at literally growing human organs through stem cells and implanting them in sort of animal models is the first step to say, can we get to humans? Obviously, there's a lot out there right now as far as Xeno transplant, right? Transplant of organs across animal types where they have used, I want to say it was a pig heart and kidney that have been transplanted into humans that may have had reasons why they may not have been candidates for the traditional pathway of transplant.

To get to the ultimate cool stuff from my perspective is-- The Twin Cities metro area in Minnesota is a huge biomedical hub and with the undergrad university having very robust clinical sciences, there are companies that are working on growing and developing human organs then for transplant. They are already getting to the point where they are literally growing human kidneys and livers in bioreactors with the ultimate goal that they'll be able to be transplanted into humans. These aren't Xeno transplants, it's truly human cells that populate the scaffold into functioning kidneys, functioning livers that will ultimately transplant with their goal of say using cells from me, putting it into this liver, growing a liver so that they're able to transplant it into me, I would never require immunosuppression. This is very real-time. This is stuff that's really happening. It is not science fiction, and I think just we are at a time where all of these things are just skyrocketing in frequency, in studies, and in practice.

[Dr. Chris Beck]
Nothing would make me more excited to then have you on maybe in 10 years, Tom, and you can talk about how now we're doing stem cell-like transplants and patients are not requiring immunotherapy. To put this service line out of business for interventional radiology, I don't think there will be hearts breaking across the country. That's very neat stuff. That wraps things up. We'll see you next time on the Backtable podcast. Siobhan, Tom, thank you so much for coming on.

[Dr. Siobhan Flanagan]
Thank you.

[Dr. Tom Leventhal]
Thank you.