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BackTable / VI / Article
Under Pressure: IR Management of Portal Hypertension in The Outpatient Setting
Thomas "T.J." Turner • Updated Mar 11, 2025 • 33 hits
Portal hypertension, a condition characterized by elevated pressure in the portal venous system, can lead to severe complications, including ruptured esophageal varices and refractory ascites, if left untreated. Traditionally, management has focused on hospitalized patients with advanced liver disease—often among the sickest of the sick. These cases typically require a multidisciplinary approach, with hepatologists, surgical and medical oncologists, and interventional radiologists collaborating to provide comprehensive care.
In this article, hepatologist Dr. Tom Leventhal and interventional radiologist Dr. Siobhan Flanagan explore how a clinical interventional radiology (IR) model can be adapted to the outpatient setting. By working closely with hepatology teams, the outpatient management of portal hypertension has the potential to improve patient outcomes and reduce lengthy and costly hospitalizations.
The content featured here includes key excerpts from the BackTable Podcast. We've compiled a highlight reel for quick insights, and the full podcast is available below for deeper exploration.
The BackTable Brief
• Effective management of portal hypertension relies on multidisciplinary collaboration, with hepatologists guiding patient care trajectory and interventional radiologists providing expertise in procedures and their pre- and post-operative care.
• Portal pressure measurements and liver biopsy may further clarify the etiology and severity of the disease when needed, but do not replace a thorough history and basic workup.
• Decisions on TIPS placement should consider a number of factors including the patient’s MELD score (with favorable outcomes reported for scores up to 20 as reported by Dr. Leventhal) and involve shared decision-making among the healthcare team and the patient.
• The clinical IR's role post-procedure includes monitoring recovery, screening for complications, initiating preliminary workups for any issues, and ensuring seamless communication with the primary hepatologist.
• Under Dr. Flanagan’s model, patients are observed for 4 to 6 hours in the PACU after TIPS placement and discharged the same day. This outpatient model has proven successful with a low rate of reported complications and overall good patient outcomes.
Table of Contents
(1) Patient Referrals from Hepatology
(2) Working Up Portal Hypertension
(3) The Role of Interventional Radiology Procedures in Diagnosis & Treatment
(4) Pearls of Post-Procedure Management in The Outpatient Setting
Patient Referrals from Hepatology
Hepatologists often serve as the primary ‘gatekeepers’ for patients entering the portal hypertension treatment pathway. Their primary objective is to optimize medical management before considering procedural interventions. If a patient’s condition fails to improve with medical therapy, the hepatologist may then refer the patient to an interventional radiologist for minimally invasive treatment options, most notably transjugular intrahepatic portosystemic shunt (TIPS) placement.
By the time patients reach the IR clinic, they have typically been prepped by the hepatology team regarding the potential need for TIPS or related interventions. Much of the diagnostic work-up is usually completed by this stage. However, pre-procedural visits in the IR clinic remain essential for assessing the patient’s understanding of the risks and expected outcomes of the procedure, as well as their capacity and willingness to engage in the necessary post-procedural care.
[Dr. Chris Beck]
You guys mentioned maybe potentially like a shared clinic space, everyone's got each other's cell phone numbers, no formal like dedicated portal hypertension discussion or anything. The patients that come through transplant, is the inbound always from hepatology and then from hepatology, it gets sent to the other stakeholders in the system like IR, surgery, or like how does that process work for maybe like a new referral to you guys, Tom?
[Dr. Tom Leventhal]
I think probably about 90% to 95% of it is that we're sort of the gatekeepers as far as patients with portal hypertension, but what we see now is, as a quaternary referral center, whether it's coming through surgical oncology or our transplant surgeons for like non-transplant related surgery, interventional radiology for hepatocellular carcinoma management, they're seeing these patients in initial consultation and recognizing, oh, okay, this is someone with portal hypertension, cirrhosis, liver disease, they obviously need some expertise on the medical side, then they get referred over to us.
[Dr. Chris Beck]
You guys as the gatekeepers make sure that they get plugged in to see interventional radiology whenever is appropriate. Let me ask you this. Without going through the perfect patient or the worst patient, when do you think, so if it's a cirrhotic patient, non-HCC related, when is the right time to refer to interventional radiology, sooner the better, or as soon as they, you think maybe they need a procedure?
[Dr. Tom Leventhal]
I think a little bit more on the latter. I think that the data in liver disease has advanced so much over the last 10 years as far as medical management and some options. Very aggressively working with people with the underlying causes of their liver disease, getting rid of hepatitis C, that can help portal hypertension. Getting people to stop drinking and getting resources for that can decrease portal hypertension.
I think we've gotten better at those things and so that helps. I think medical management, diuretics, beta-blockers, things of that nature, staying on top of screening endoscopies for esophageal and gastric varices, I think we have a pretty robust and aggressive practice about those things. Then recognizing that patients progress and get sicker and or they'll have a complication of those medications like progressive kidney dysfunction in the setting of diuretics.
I think that using that through work and publications that Siobhan and her partners have done independently and with our group, as she mentioned, Nick Lim, one of our partners, we've actually published data on how can we sort of push the limit on who's safe to do TIPS on, who's going to benefit from ascites that's refractory or hepatic hydrothorax, early TIPS for variceal hemorrhage. These are all things that are really guiding us towards getting interventional radiology involved.
[Dr. Chris Beck]
From your perspective, Siobhan, are you guys, whenever you're getting referrals, how do the patients look as far as like when they're coming through your clinic? Are they all teed up and there's been some discussion about a potential procedure and then you're cleaning it up or do you treat everyone like [you’re] starting from square one?
[Dr. Siobhan Flanagan]
From a conversational standpoint, everybody starts from square one. I would say that I can't recall when I've had a liver patient come into clinic who hasn't been at least given some information from our hepatology clinics. What does the TIPS look like? What are the potential problems after you have this placed? They're prepped with most of that information that they really care about. How likely am I to be encephalopathic afterwards and how is that managed, et cetera.
When they come to clinic, most of the workup is done on a rare occasionally still need to complete it and echo cardiac echo for these patients. Most of the conversation with me is what are the technical nuts and bolts of the procedure risks, et cetera. Most of our patients are going home same day after TIPS is placed, which I think has been a good change for practice in general and for patients. Just walking them through what your follow-up is going to look like with me. When are we doing our imaging and laboratory data, how long after placement.
I think a really useful thing about seeing these patients in person, we're now we have this video capability and we don't have to see patients in person, but we've been really strict about seeing these patients in person just so we can understand what their functional status is going into the procedure. Then we get to understand what their investment is for their aftercare. If you're willing to come to the clinic visit to meet me, I feel more comfortable that you're going to follow up with what's necessary afterwards, whereas the patient who really doesn't want to come be seen in person, it's an inconvenience, et cetera. That always gives me a little pause and a little concern. In general, that's how things go with the clinic visit process.
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Working Up Portal Hypertension
Understanding the diagnostic workup for portal hypertension enables interventional radiologists to better anticipate a patient’s level of understanding about their condition and facilitates their own involvement in the workup process when applicable. A detailed patient history is critical in identifying the etiology of liver disease, which may include hepatitis C, alcoholic cirrhosis, or a combination of factors. Additional diagnostic clues can be obtained from imaging studies (CT, MRI, ultrasound), laboratory evaluations of liver function and enzymes, and, in uncertain cases, liver biopsy with portal pressure measurements.
The Model for End-Stage Liver Disease (MELD) score, a dynamic tool for risk stratification, incorporates variables such as INR and serum sodium to assess liver function and disease progression. In the context of TIPS placement, Drs. Leventhal and Flanagan’s team reports favorable outcomes with MELD scores as high as 20, comparable to those with scores closer to 15. However, determining an appropriate MELD threshold for TIPS placement is a nuanced decision that requires input from multiple specialties and active discussions with the patient, emphasizing the value of shared decision-making.
[Dr. Chris Beck]
What I want to know, that I think a lot of interventional radiologists don't know, or it may be a black box or somebody is what is the initial workup for a portal hypertensive patient look like? I know that can be like super super broad. If you can give us like the focused H&P segment, what labs you like to look at, why? Then like some basic imaging, like high-level stuff.
[Dr. Tom Leventhal]
We'll get referrals from throughout the we have a pretty large catchment area here in the Twin Cities and we'll get referrals for concerns of cirrhosis. So many of these people have already had cross-sectional imaging, CT, MRI, or ultrasound demonstrating splenomegaly, things like that. That's really what's prompting them to come over to our clinic, given that it is a subspecialty.
We take that, we sort of parse out the history of what may have led to it, as we alluded to earlier. Are there potential interventions that we can provide treating hepatitis C, treating an alcohol use disorder that can reduce overall portal hypertension. Working with them on lifestyle modifications of things like weight loss, restricting sodium intake, avoiding alcohol, things again that we know they can do to reduce portal hypertension.
As I tell people that if there is a diagnosis of cirrhosis that's made, it's a scarring condition of the liver that affects the whole liver, that's such a common question. How much my liver is affected? It's 100%. We really need an objective way of risk stratifying them and that's where the MELD score comes in. From a transplant perspective, the MELD score has been very dynamic. By that, new labs have been added, new variables have been added because of disparities that are resulted that we see in transplant.
Right, the reason that the MELD score was invented was looking at risk of 90-day mortality in patients with alcohol-related liver disease who got a TIPS. In the Mayo Clinic, in the University of Minnesota, Hennepin County here in Minneapolis, were all participating centers in the initial MELD study. We have a lot of pride and belief in this as a marker of risk. Looking at things like the serum bilirubin right delivers sort of overall functional status. Now we look at things like albumin and INR as a marker of impaired synthetic function of the liver, not bleeding risk.
We look at serum sodium concentration as a marker of, has the hormonal milieu changed so much in the setting of portal hypertension that they're holding on to excess free water. There is from the purposes of transplant, we look at male versus female because we know that there was a discrepancy. Then we also look at kidney function because the liver and the kidneys are so intimately connected from a hormonal perspective. Putting those things together, we get our MELD score and data for decades has really looked at it.
I think I'm fortunate to practice in a place where this data came from, that Siobhan and Nick Lim have published data even more recently this year looking at outcomes in hepatic encephalopathy going into TIPS. We did a study that looked at is there a difference if you've got a MELD score of 15, which it sounds like is sort of the national landscape for consideration for TIPS, but we felt very comfortable in pushing that score up to 20 with comparable if not the same outcomes.
It's like knowing that data and looking at that, we're like, okay, this is important stuff. I think the outlying thing is knowing and understanding potential complications of TIPS, the potential for worsening encephalopathy, having those discussions with patients, making sure they're aware of the signs and symptoms and have medications, but also it's the increased right-sided preload. We need to do our due diligence to make sure we've got an up-to-date echocardiogram that's not demonstrating right heart dysfunction so that we're not setting up our patients for failure.
The Role of Interventional Radiology Procedures in Diagnosis & Treatment
Interventional radiologists have a variety of tools to diagnose and manage portal hypertension and its complications. Transjugular liver biopsy (TJLB) is frequently performed when the etiology of a patient’s portal hypertension symptoms remains unclear. However, biopsy results are not always definitive and must be interpreted within the context of the patient’s overall clinical picture. Portal pressure measurements, often performed concurrently with TJLB, assess pressures in the hepatic venous system, inferior vena cava (IVC), and right atrium. These measurements are crucial for evaluating the severity of portal hypertension and determining the patient’s candidacy for TIPS placement.
Other commonly performed procedures in this patient population include paracentesis and thoracentesis for fluid management, TIPS for decompression of the portal system, and Coil-Assisted Retrograde Transvenous Obliteration (CARTO) for managing gastric varices. For patients with peristomal varices who are not candidates for standard interventions, localized therapies can provide additional treatment options.
[Dr. Chris Beck]
Where does a biopsy play a role in as far as the patients that come through and there's imaging and lab criteria that's meeting the diagnosis of cirrhosis? How does that fit in into the overall like picture of where patients stay either on the transplant line or in how they get moved on to other services?
[Dr. Tom Leventhal]
Awesome question. We know globally that by the time that someone develops cirrhosis with significant portal hypertension, if we get a biopsy, the likelihood that we actually see the cause or etiology of the liver disease is very low. We're going to see a lot of fibrosis and that's about it. Even this past week when I was on service, someone was having peristomal variceal bleeding and didn't have a great history for any particular reason for why they would have developed cirrhosis. That was going into the interventional radiology workroom, sitting down with a couple of the staff, reviewing the imaging, and me saying to them, I don't feel that I feel comfortable with the diagnosis of cirrhosis yet.
I want to move forward with a transjugular liver biopsy with portal pressure measurements to say, hey, we get the objective information of the biopsy, potential etiology, but we also get an objective measurement of portal hypertension to help us say, okay, we believe then that this is the because of the bleed.
[Dr. Chris Beck]
Siobhan, real quick, I'm just curious of whatever you're doing, your trans jugs, how do you take your portal pressures?
[Dr. Siobhan Flanagan]
This is a hot topic of conversation, it has been for a few years now.
[Dr. Chris Beck]
This is not the trans jug podcast, but we could go back to it. It's hard to talk about trans jug without asking another IR doc how they do it.
[Dr. Siobhan Flanagan]
Yes, absolutely. We've found with our hepatology colleagues that old method of taking that wedge hepatic vein pressure and just moving your catheter back to the right atrium is actually not reflective on the actual what's the degree of portal hypertension. When we're seeing our patients for the first time, we know that really the most accurate way to determine the gradient is getting that good wedge pressure and you want an IVC pressure. We take it one step further, we're actually looking at hepatic venous outflow obstruction as well.
We're measuring the wedge, the free, a few other points along that hepatic vein, including the central hepatic vein, IVC, and who doesn't always get a right atrial pressure. That IVC pressure is important in the calculation.
[Dr. Chris Beck]
Okay. Good. All right. Before we dive into the TIPS part of it, though, what are some of the things or some of the procedures that you consider the offering from interventional radiology, like the full gamut of procedures, from, all the way from paras to TIPS that you see in your portal hypertension practice?
[Dr. Siobhan Flanagan]
Just from diagnosis. There's the liver biopsy, transjugular liver biopsy with portal pressures. It runs the gamut from fluid drainages, paracentesis, thoracentesis, I'm really interested in the whole physiology behind ascites. If fluid's looking suspicious, you have to have it on your radar to check for chylous ascites potentially in patients. From other diagnostic workup, we're offering the transjugular liver biopsy with those pressures to estimate the portal hypertension.
Then from pure management of the portal hypertension itself and appropriate candidates, we're of course offering TIPS for those patients with isolated gastric variceal bleeding who are encephalopathic or their liver function can't tolerate TIPS who are offering, we primarily do CARTO here. Then, Tom brought up this interesting case of, every once in a while we're dealing with a patient with peristomal varices and if those ideally, if they truly have portal hypertension TIPS is what they need. On occasion that's not possible and you're just looking at doing localized therapy for those peristomal varices, whether it be, sclero, coiling.
[Dr. Chris Beck]
Pretty much the full gamut. What about the, is there a role for Denver shunts ever in this patient population or is it something?
[Dr. Siobhan Flanagan]
That exited our practice pretty quickly. Just from an outcome standpoint, patients didn't do well with it. I think for us, we're a big transplant center. We see far more patients that may be destined for transplantation than are palliative.
Pearls of Post-Procedure Management in The Outpatient Setting
In Dr. Flanagan’s treatment model, patients who undergo TIPS are observed in the post-anesthesia care unit (PACU) for 4 to 6 hours to ensure stability before being discharged the same day. Post-procedure management by IR focuses on monitoring the patient’s recovery, screening for potential complications, initiating a preliminary workup if complications arise, and communicating the patient’s status and disposition to the primary hepatologist. In most cases, medications required post-TIPS are prescribed by the managing hepatologist prior to the procedure. This collaborative approach, characterized by consistent communication between healthcare teams and a strong clinical presence of IR, not only enhances patient outcomes but also fosters increased referrals from other providers, as observed by Drs. Flanagan and Leventhal.
[Dr. Chris Beck]
Got you. As far as what happens at the patient's post, you said a lot of your patients now are going home same day?
[Dr. Siobhan Flanagan]
They're going home same day.
[Dr. Chris Beck]
Is that relatively new for you guys?
[Dr. Siobhan Flanagan]
We've been doing this for about 18 months now. Our protocol for this is the patient will stay up in the PACU recovery room for about four hours. Some patients who are maybe a little borderline, you're a little more concerned about them, you'll watch them for six. As long as they're doing well after the procedure, they're going home after that observation time.
[Dr. Chris Beck]
They go home same day and then-- so one, I want to, Siobhan, I want to know when they follow up with IR. Then also Tom, I would like to know like what they look like as you guys are starting to pick them up post-TIPS. Siobhan, we'll start with you.
[Dr. Siobhan Flanagan]
Yes, and IR, I see them at one-month post-procedure, but we've got a great nurse clinician support team and IR and they're calling the patient, day after, we have a day one and a day three call just to make sure that it doesn't sound like they're having issues with encephalopathy early on that maybe they aren't even recognizing. Part of our, setup for our patients when we're meeting them in clinic is to understand what's your social and in-house support at home. Knowing that they've got someone else in the household with them is a more comforting thing than thinking about them being on their own so there's someone to really watch out for any development of encephalopathy as well.
[Dr. Chris Beck]
Cool. Do you send them home with any meds for potential encephalopathy treatment? Do they have that going home or, so I've heard some IR docs will get them these prescriptions even before the TIPS goes in or I didn't know if you guys had anything like that in place.
[Dr. Siobhan Flanagan]
Yes. I know Tom can talk to the hepatology side of that that's a desirable thing on our end to have the patient ready with those medications.
[Dr. Chris Beck]
Tom, what does it look like from your end?
[Dr. Tom Leventhal]
We made the assessment, they go in for it. I have to say, it's not that you're selling it, right? It's that you're doing the right thing medically, but when you have these discussions with patients in hepatology clinic, how long am I in the hospital after the surgery? To be able to say, no, it's a procedure, it's a day procedure, you'll probably go home the same day, it takes away a lot of reticence that they may have to go through with it, which is huge.
My guess is that the majority of patients that we're referring for TIPS are already on treatment medications for hepatic encephalopathy with either lactulose or rifaximin. Many of them already are. I certainly have had colleagues reach out afterwards, at that one-month follow-up visit where they're starting to hear through their nurse coordinators and stuff, oh, maybe there are some changes that may signify it. Not uncommon, right? That they're practicing the medicine and getting those medicines on board or else our team will take over and manage it. I feel like it's very rare that we're actually seeing a clinically significant worsening of encephalopathy after the procedure.
[Dr. Chris Beck]
Cool. Very nice. As far as after they have their TIPS, when do they get plugged back in to your clinic? Does necessarily having a TIPS mean that, oh, you need to go back and see transplant clinic, two weeks after, one month after, or do they still just stay on their regular schedule of what they normally go?
[Dr. Tom Leventhal]
They actually, they'll stay on their regular schedule and I think a lot of that has to do with the trust and I think the aggressive medical management on the IR side, seeing these patients in follow-up, I don't think happens everywhere. It might, but like in my experience, it hasn't. We feel that they are getting comprehensive care and that we know if issues come up, especially in the setting of the pandemic, virtual visits, access to the EMR, you're much more likely to get alerts from your patients, things are a little bit off. Because they had this interventional procedure, even with the known risks, it doesn't escalate our need to get them back in.
[Dr. Chris Beck]
That's great. What has the IR team done right as far as their clinic presence to make you guys feel more comfortable with, once you send them for the procedure that you understand that all that will be taken care of? I just imagine, Siobhan, maybe you guys have been very sophisticated for a long time, but I was just curious as maybe as if they've been more sophisticated in their clinic presence that's endeared them or made them more or instilled more confidence on the other side of things.
[Dr. Tom Leventhal]
Sure. I started back, I came back to the University of Minnesota in 2019 and very early on after ordering one of these, I was getting inbox alerts and messages from interventional radiology of, oh, hey, they had their TIPS. I got their ultrasound one month post, saw them in clinic, seems like they're having lower extremity edema, are you okay with higher ordering diuretics? It completely caught me off guard that this was even a practice that was in place, that other people were managing this stuff. I just always assumed that I'd be getting the call.
Very quickly in coming back that this was, it was, it was beyond procedural from my perspective. It was true medical management and recognition of this stuff. Then, hey, would you mind ordering the diuretics? Absolutely, that's my job. you guys don't have to worry about that, but having someone lay eyes on someone and know that and passing it along just made it so much easier and I think led to way better outcomes.
[Dr. Chris Beck]
That's great. Siobhan, from your perspective, so I also want to know like what you think is, as you've seen the practice progress and evolve, what you guys have done right? I also want to put you on the hot seat. Can you think of anything that, any missteps that y'all have had along the way that y'all have used for improvement? You know what I mean? Lessons learned.
[Dr. Siobhan Flanagan]
I'm going to have to think about that for a minute. We make plenty of mistakes in IR.
[Dr. Chris Beck]
Zero mistakes, zero mistakes.
[Dr. Siobhan Flanagan]
No, not zero mistakes. I've got to think about that for a minute.
[Dr. Chris Beck]
What are the things that you think of as you've seen like the clinic progress or those clinical presence progress, like that y'all have done right to, I guess, have a more, I'm always trying to like push the idea that like having a procedural presence is a better thing for intervention radiology. You get better outcomes. You get better referrals. You have better relationship with your colleagues. I was just curious if y'all's practice, like if you've seen that evolve and see that relationship build because of how clinical y'all's practice has become.
[Dr. Siobhan Flanagan]
Yes, I've seen a distinct change in our service and our relationships with more than just hepatology. Our relationship with hepatology has been the model to do this with other procedures, partner with other clinicians. I would say predating, 2015, there was a tumor conference, but outside of tumor conference, not nearly as much conversation and collaboration as there is today.
I know that, overall patient outcomes, they've always been good, but they've improved from regards to how quickly patients are managed with, maybe like Thomas was mentioning, or you were mentioning, peripheral edema after their TIPS is placed. Maybe in the past, it was something that patients struggled with for, two or three months, but, we're talking to them early, seeing them upfront, recognizing that this is happening, and getting them the medical management they need sooner. From that standpoint, we're leaps and bounds beyond where we were before. Our whole field is wanting to progress to this more clinical practice. This has just been a good example of how that's successful and improves patient outcomes just from, the ultimate outcome of success. You've managed their portal hypertension, but just those intricacies afterwards from a symptom management standpoint.
[Dr. Tom Leventhal]
To go to the other end of the spectrum, and I think how important the relationship is, I've gotten a call from one of our IR partners to come to the IR suite, and something that was scheduled for TIPS that day is an elective outpatient procedure. They'd gotten labs that morning, they had done their assessment and they had significant concerns about, was this someone where this procedure was going to be safe on this day.
In going there, taking a look at the labs, taking a look at the patient, and having had that longitudinal relationship saying, hey, there has been a significant clinical decline. This would not be safe right now. I don't know. I don't know. Again, don't know if that happens everywhere, but it made a big difference and probably prevented a really bad outcome.
[Dr. Siobhan Flanagan]
I would say, missteps on our end probably is in line with the previous conversation, the times when before the close follow-up and collaboration, patients just not doing well with post-procedure symptoms. I would say that in the past was our biggest misstep, really the clinical management side, not the procedural management side. Even that close collaboration has resulted in us not placing TIPS in patients who may be on the day of, like Tom mentioned, aren't appropriate to have it done.
I think in the past we had one case where, the updating or echo we're pretty stringent about it'd be great to have it in the last six months because things change over time. One misstep I recall on our part was not having an updated echo. This was probably maybe seven years ago and not having an updated echo on a patient who went into a right heart failure after their TIPS.
[Dr. Chris Beck]
How many days a week do or days a month do you spend in clinic?
[Dr. Siobhan Flanagan]
I have four clinic days per month.
[Dr. Chris Beck]
Okay. You do one a week basically. Then procedural the rest of the time.
[Dr. Siobhan Flanagan]
Correct.
Podcast Contributors
Dr. Thomas Leventhal
Dr. Thomas Leventhal is an associate professor of medicine at the University of Minnesota Medical School and a transplant hepatologist, gastroenterologist and critical care physician with M Health Fairview.
Dr. Siobhan Flanagan
Dr. Siobhan Flanagan is an interventional radiologist and associate professor in the Department of Radiology at the University of Minnesotat Medical Center/
Dr. Christopher Beck
Dr. Chris Beck is a practicing interventional radiologist with Regional Radiology Group in New Orleans.
Cite This Podcast
BackTable, LLC (Producer). (2024, August 13). Ep. 473 – Portal Hypertension Treatment Strategies: IR & Hepatology Perspectives [Audio podcast]. Retrieved from https://www.backtable.com
Disclaimer: The Materials available on BackTable.com are for informational and educational purposes only and are not a substitute for the professional judgment of a healthcare professional in diagnosing and treating patients. The opinions expressed by participants of the BackTable Podcast belong solely to the participants, and do not necessarily reflect the views of BackTable.
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