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. 2023 Aug;17(4):979-988.
doi: 10.1007/s12072-023-10522-z. Epub 2023 Apr 25.

Transjugular intrahepatic collateral-systemic shunt is effective for cavernous transformation of the portal vein with variceal bleeding

Jun Tie  1 , Xiaoyuan Gou  2 , Chuangye He  2 , Kai Li  2 , Xulong Yuan  2 , Wenyuan Jia  2 , Jing Niu  2 , Na Han  2 , Jiao Xu  2 , Ying Zhu  2 , Wenlan Wang  3
Affiliations

Transjugular intrahepatic collateral-systemic shunt is effective for cavernous transformation of the portal vein with variceal bleeding

Jun Tie et al. Hepatol Int. 2023 Aug.

Abstract

Background: The transjugular intrahepatic portal collateral-systemic shunt (transcollateral TIPS) is used to treat portal hypertension-related complications in patients with cavernous transformation of the portal vein (CTPV) and whose main portal vein cannot be recanalized. It is still not clear whether transcollateral TIPS can be as effective as portal vein recanalization-transjugular intrahepatic portosystemic shunt (PVR-TIPS). This study aimed to evaluate the efficacy and safety of transcollateral TIPS in the treatment of refractory variceal bleeding with CTPV.

Methods: Patients with refractory variceal bleeding caused by CTPV were selected from the database of consecutive patients treated with TIPS in Xijing Hospital from January 2015 to March 2022. They were divided into the transcollateral TIPS group and the PVR-TIPS group. The rebleeding rate, overall survival, shunt dysfunction, overt hepatic encephalopathy (OHE) and operation-related complications were analyzed.

Results: A total of 192 patients were enrolled, including 21 patients with transcollateral TIPS and 171 patients with PVR-TIPS. Compared with the patients with PVR-TIPS, the patients with transcollateral TIPS had more noncirrhosis (52.4 vs. 19.9%, p = 0.002), underwent fewer splenectomies (14.3 vs. 40.9%, p = 0.018), and had more extensive thromboses (38.1 vs. 15.2%, p = 0.026). There were no differences in rebleeding, survival, shunt dysfunction, or operation-related complication rates between the transcollateral TIPS and PVR-TIPS groups. However, the OHE rate was significantly lower in the transcollateral TIPS group (9.5 vs. 35.1%, p = 0.018).

Conclusion: Transcollateral TIPS is an effective treatment for CTPV with refractory variceal bleeding.

Keywords: Cavernous transformation; Occlusive portal vein thrombosis; Refractory variceal bleeding; Transjugular intrahepatic portosystemic shunt.

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Conflict of interest statement

Jun Tie has no conflict of interest. Xiaoyuan Gou has no conflict of interest. Chuangye He has no conflict of interest. Kai Li has no conflict of interest. Xulong Yuan has no conflict of interest. Wenyuan Jia has no conflict of interest. Jing Niu has no conflict of interest. Na Han has no conflict of interest. Jiao Xu has no conflict of interest. Ying Zhu has no conflict of interest. Wenlan Wang has no conflict of interest.

Figures

Fig. 1
Fig. 1
Flowchart of patient selection
Fig. 2
Fig. 2
Using a collateral vessel that communicated with the variceal veins to establish a portosystemic shunt in a 50-year-old man with cirrhosis and cavernous transformation. a Spiral enhanced CT with multiplanar reconstruction showed cavernous transformation of the portal vein. The collateral vessels directly communicated with the variceal veins. b Direct portography confirmed that the targeted collateral vessels communicated with the variceal veins. c A stent was successfully placed between a large collateral vein and the right hepatic vein. Direct portography showed that the variceal veins had disappeared. LCV large collateral vessels, EGV esophageal and gastric varices
Fig. 3
Fig. 3
Using a collateral vessel that did not communicate with the variceal veins to establish a portosystemic shunt in a 57-year-old woman with cirrhosis and cavernous transformation. a Direct portography via a percutaneous transsplenic approach clearly showed that a large, cavernous collateral vessel could be used to establish a portosystemic shunt. b Direct splenoportography showed that the severe varicose veins did not communicate with the collateral vessel due to splenic vein thrombosis. c The collateral vessel was used to establish the portosystemic shunt. At the same time, the splenic vein was opened with a bare stent to make the varicose veins communicate with the collateral vessels, and the varicose veins were embolized. Direct splenoportography showed that the shunt was patent and that the varicose veins had disappeared. d The stents are shown on spiral enhanced CT with multiplanar reconstruction at 1 month after TIPS. LCV large collateral vessels, EGV esophageal and gastric varices, SV spleen vein
Fig. 4
Fig. 4
Outcome measurements were compared between the transcollateral TIPS group and the PVR–TIPS group. a Competing risk CIF analysis showed that b Kaplan‒Meier curves showed that the overall survival between the transcollateral TIPS group and the PVR–TIPS group was not different. c Competing risk CIF analysis showed that there was no significant difference in the competitive risk events between the transcollateral TIPS group and the PVR–TIPS group (p = 0.619). However, the incidence of encephalopathy in the transcollateral TIPS group was lower than that in the PVR–TIPS group after controlling for competitive risk events (p = 0.033). PVR–TIPS portal vein recanalization–transjugular intrahepatic portosystemic shunt, HE hepatic encephalopathy
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