Shunting branch of portal vein and stent position predict survival after transjugular intrahepatic portosystemic shunt

Abstract

Aim: To evaluate the effect of the shunting branch of the portal vein (PV) (left or right) and the initial stent position (optimal or suboptimal) of a transjugular intrahepatic portosystemic shunt (TIPS).

Methods: We retrospectively reviewed 307 consecutive cirrhotic patients who underwent TIPS placement for variceal bleeding from March 2001 to July 2010 at our center. The left PV was used in 221 patients and the right PV in the remaining 86 patients. And, 224 and 83 patients have optimal stent position and sub-optimal stent positions, respectively. The patients were followed until October 2011 or their death. Hepatic encephalopathy, shunt dysfunction, and survival were evaluated as outcomes. The difference between the groups was compared by Kaplan-Meier analysis. A Cox regression model was employed to evaluate the predictors.

Results: Among the patients who underwent TIPS to the left PV, the risk of hepatic encephalopathy (P = 0.002) and mortality were lower (P < 0.001) compared to those to the right PV. Patients who underwent TIPS with optimal initial stent position had a higher primary patency (P < 0.001) and better survival (P = 0.006) than those with suboptimal initial stent position. The shunting branch of the portal vein and the initial stent position were independent predictors of hepatic encephalopathy and shunt dysfunction after TIPS, respectively. And, both were independent predictors of survival.

Conclusion: TIPS placed to the left portal vein with optimal stent position may reduce the risk of hepatic encephalopathy and improve the primary patency rates, thereby prolonging survival.

Keywords: Cirrhosis; Portal vein; Stent position; Transjugular intrahepatic portosystemic shunt; Variceal bleeding.

Figure 1

Stent position classifications. The initial stent position was classified according to the angiography imaging as follows: A: Suboptimal in the hepatic vein (HV) (arrow) and optimal in the portal vein (PV) (arrow head); B: Optimal in the HV (arrow) and suboptimal in the PV (arrow head); C: Optimal in the HV (arrow) and optimal in the PV (arrow head).

Figure 2

Selection flowchart for the consecutive patients who underwent transjugular intrahepatic portosystemic shunt between March 2001 and July 2010. TIPS: Transjugular intrahepatic portosystemic shunt.

Figure 3

Hepatic encephalopathy results from the Kaplan-Meier analyses. Comparison of hepatic encephalopathy between the patients with a transjugular intrahepatic portosystemic shunt (TIPS) to the left portal vein (PV) and those with a TIPS to the right PV in all patients (A), an 8-mm stent subgroup (C) and a 10-mm stent subgroup (E). Comparisons of survival between the patients with a TIPS to the left PV and those with a TIPS to the right PV in all patients (B), an 8-mm stent subgroup (D) and a 10-mm stent subgroup (F).

Figure 4

Patency results from the Kaplan-Meier analyses. Comparison of primary patency between patients with optimal initial stent position (O-SP) and those with sub-O-SP in all patients (A), an 8-mm stent subgroup (C) and a 10-mm stent subgroup (E). Comparisons of survival between the patients with O-SP and those with sub-O-SP in all patients (B), an 8-mm stent subgroup (D) and a 10-mm stent subgroup (F).

Figure 5

Patency results in patients with different stent positions. Comparison of primary patency between patients with optimal initial stent position (O-SP) and those with sub-O-SP in the hepatic vein (HV) only, sub-O-SP in the portal vein (PV) only and sub-O-SP in both the HV and PV.

Figure 6

Relationship between stent positions and stenosis/occlusion sites. The stenosis/occlusion sites of the first shunt dysfunction among patients with optimal initial stent position (O-SP) in the hepatic vein(HV) and portal vein (PV), patients with sub-O-SP in the HV and patients with sub-O-SP in the PV are significantly different.