Clinical outcome and predictors of survival after TIPS insertion in patients with liver cirrhosis

Abstract

Aim: To determine the clinical outcome and predictors of survival after transjugular intrahepatic portosystemic stent shunt (TIPS) implantation in cirrhotic patients.

Methods: Eighty-one patients with liver cirrhosis and consequential portal hypertension had TIPS implantation (bare metal) for either refractory ascites (RA) (n = 27) or variceal bleeding (VB) (n = 54). Endpoints for the study were: technical success, stent occlusion and stent stenosis, rebleeding, RA and mortality. Clinical records of patients were collected and analysed. Baseline characteristics [e.g., age, sex, CHILD score and the model for end-stage liver disease score (MELD score), underlying disease] were retrieved. The Kaplan-Meier method was employed to calculate survival from the time of TIPS implantation and comparisons were made by log rank test. A multivariate analysis of factors influencing survival was carried out using the Cox proportional hazards regression model. Results were expressed as medians and ranges. Comparisons between groups were performed by using the Mann-Whitney U-test and the χ2 test as appropriate.

Results: No difference could be seen in terms of age, sex, underlying disease or degree of portal pressure gradient (PPG) reduction between the ascites and the bleeding group. The PPG significantly decreased from 23.4 ± 5.3 mmHg (VB) vs. 22.1 ± 5.5 mmHg (RA) before TIPS to 11.8 ± 4.0 vs. 11.7 ± 4.2 after TIPS implantation (P = 0.001 within each group). There was a tendency towards more patients with stage CHILD A in the bleeding group compared to the ascites group (24 vs 6, P = 0.052). The median survival for the ascites group was 29 mo compared to > 60 mo for the bleeding group (P = 0.009). The number of radiological controls for stent patency was 6.3 for bleeders and 3.8 for ascites patients (P = 0.029). Kaplan-Meier calculation indicated that stent occlusion at first control (P = 0.027), ascites prior to TIPS implantation (P = 0.009), CHILD stage (P = 0.013), MELD score (P = 0.001) and those patients not having undergone liver transplantation (P = 0.024) were significant predictors of survival. In the Cox regression model, stent occlusion (P = 0.022), RA (P = 0.043), CHILD stage (P = 0.015) and MELD score (P = 0.004) turned out to be independent prognostic factors of survival. The anticoagulation management (P = 0.097), the porto-systemic pressure gradient (P = 0.460) and rebleeding episodes (P = 0.765) had no significant effect on the overall survival.

Conclusion: RA, stent occlusion, initial CHILD stage and MELD score are independent predictors of survival in patients with TIPS, speaking for a close follow-up in these circumstances.

Keywords: Ascites; Gastrointestinal hemorrhage; Liver cirrhosis; Transjugular intrahepatic portosystemic stent shunt; Treatment outcome.

Figure 1

Fluoroscopic images showing transjugular intrahepatic portosystemic shunt placement procedure. A: Portogram after catheterisation of the portal vein, showing perfusion of the portal vein system (1) and oesophageal varices (2); B: Portogram after transjugular intrahepatic portosystemic stent placement. Contrast can be seen in the portal vein (1), through the shunt (2) flowing into the hepatic vein and inferior vena cava (3). Decompression of the portosystemic pressure can be seen in reduced contrast in the portal branch (4). The varices can no longer be identified in the fluoroscopic image.

Figure 2

Kaplan-Meier survival analysis of patients after transjugular intrahepatic portosystemic shunt placement. A: In patients with initial ascites as indication for transjugular intrahepatic portosystemic stent (TIPS), survival is significantly shorter than that in patients with variceal bleeding [refractory ascites (RA) vs variceal bleeding (VB), log rank test P = 0.009]; B: In patients with occluded stent at first fluorographic control, survival is significantly shorter than that in patients with open stent (occluded vs open, log rank test P = 0.027).

Figure 3

Kaplan-Meier survival analysis of patients after transjugular intrahepatic portosystemic shunt placement. A: Subgroup analysis with patients having a model for end-stage liver disease score (MELD) < 10: Significant difference in overall survival relating to indication [refractory ascites (RA) vs variceal bleeding (VB) group, log rank test P = 0.031]; B: Subgroup analysis with patients having a MELD score > 10: No significant difference in overall survival relating to indication (RA vs VB group, log rank test P = 0.274); C: Subgroup analysis with patients with CHILD B or C cirrhosis: Significant difference in overall survival relating to indication (RA vs VB group, log rank test P = 0.021); D: Subgroup analysis with patients age > 65 years: Significant difference in overall survival relating to indication (RA vs VB group, log rank test P = 0.021); E: Subgroup analysis with stent occlusion at first control: No significant difference in overall survival relating to indication (RA vs VB group, log rank test P = 0.289).