Long-term Outcome And Predictors After Transjugular Intrahepatic Portosystemic Shunt With Fluency Stent-grafts

Background:Transjugular intrahepatic portosystemic shunts (TIPS) have been effectively used for the treatment of complications of portal hypertension in patients with cirrhosis,such as esophageal varices bleeding(EVB) and refractory ascites(RA) TIPS not only rapidly reduce portal pressure in the short term, but also effectively to relieve ascites or stop bleeding. With the development of expanded polytetrafluoroethylene (ePTFE)-covered stent grafts, short-term TIPS patency has improved.At present, the domestic and foreign research on postoperative TIPS are mainly concentrated in the former midium-term, but few studies on the long-term effects and changes of liver function. This study evaluate long-term outcome and predictors after transjugular intrahepatic portosystemic shunt with covered stent by a group of 10 years of TIPS postoperative follow-up data.Purpose:To evaluate the changes of liver function,survival rate, patency, hepatic encephalopathy, symptomatic recurrence rates and predictors following transjugular intrahepatic portosystemic shunt (TIPS) creation with expanded polytetrafluoroethylene (ePTFE)-covered stent grafts (Fluency covered stent. Bard Corp).Materials and Methods:A retrospective review including 369 patients who underwent TIPS created with covered stent grafts between October 2005 to December 2015 was performed. According to the inclusion and exclusion criteria, a total of 252patients (176men and 76 women; mean age:51+12)were subordinated to our study.102 patients had Child-Pugh class A cirrhosis,97 Child-Pugh Class B and 53Child-Pugh class C. All patients were diagnosed esophageal varices by endoscopy.29 patients had surgical splenectomy or splenectomy with devascularization history.214 patients had a history of repeated melena or haematemesis, including 86 cases with different degree of ascites.38 patients had refractory ascites. To observe the changes of liver function..survival rate, stent patency, hepatic encephalopathy, symptomatic recurrence rates after the 1-120 months follow-up. The survival rate, incidence of HE, the shunt patency rate, rebleeding rate was drawn by the life table at 1 years,2 years,3 years,4 years,5 years. T test、Kaplan-meier and Cox multivariate regression analysis are performed.Results:Immediate technical success of the TIPS procedure was 100%.252 stents were implanted 252 covered stents (6mm=41,8mm=189,10mm=22). The mean portosystemic pressure of portal vein decreased from (28.2+5.8)mmHg to(16.7+4.9) mmHg (t=12.7、p<0.05)There were 56 patients in whom TIPS dysfunction developed during the follow-up period. The overall primary patency rates was77.6%. Cumulative primary patency rate were 97%、88%、80%、78%、78% at 1、2、3、4 and 5 years,respectively.53 patients underwent revision of their TIPS, and 3 of these patients ultimately required multiple revisions to keep the shunts patent. The secondary patency rates were 98.7%. Previous splenectomy is the independent fator of patency.There were 69 patients in whom hepatic encephalopathy developed during the follow-up period. Overall rate was 27.4%. Cumulative hepatic encephalopathy rate were 14%、17%、20%、24%、27% at 1、2、3、4 and 5 years,respectively..The affect fator of HE rates included Child-pugh class before TIPS by Pearson chi square test (x2=6.843,p=0.033). And with the Child-pugh class increasing, the incidence of hepatic encephalopathy has an increasing trend. Stent diameter has nothing to do with the incidence of hepatic encephalopathy (x2=2.894, p=0.235). In 252 patients(LP=34,RP=47),the portal vein location of stent was independent affect fator of hepatic encephalopathy.There were 49 patients in whom haematemesis or (and) melena occurred during the follow-up period.Overall rate was 19.74%. Cumulative haematemesis or (and) melena were 7%、15%、19%、19%、19%。 at 1、2、3、4 and 5 years,respectively. TIPS dysfunction (HR:2.01,95%CI:1.02-1.93,P<0.01),Esophageal gastric vein embolization (HR:0.89,95%CI:1.81-3.08,P=0.019) were independent affect fators of haematemesis or (and) melena.There were 38 patients (complete remission 15 cases, partial 12 cases, inaction 8 cases, died 3 cases)with refractory ascites treated with TIPS during the follow-up period. The effective rate of ascites was 71.1%. During the follow-up period, a total of 17 people died. survival rate of RA was significantly lower than the EVB (84.1% VS54.3%).During the follow-up period, a total of 64 people died. Overall survival rate was 78.6%.. Cumulative survival rate were 87%、73%、73%、69%、69% at 1、2、3、 4 and 5 years,respectively. Child-pugh score(HR:0.46,95%CI:1.11-2.01, p<0.01) and ascites (HR:1.74,95%CI:1.023-3.21,P=0.022) were independent affect fators of survival.For patients with Child-pugh A,the Chil-pugh score increased at 1、6、12、 24months after treatment and the difference was statistically significant (p<0.05). For patients with Child-pugh B,the score increased at 1、6、12months after treatment and the difference was statistically significant (p<0.05). For patients with Child-pugh C,the score increased at1、6 months after treatment and the difference was statistically significant (p<0.05).The Child-pugh scores of the diameter (<8cm) was lower than the diameter (≥8cm) at 1、6months (p<0.05). The Child-pugh scores of patients who underwent TIPS to the left PV was lower compared to those to the right PV at 1、6、12、24month(p<0.05).Conclusion:1、Atransjugular intrahepatic portosystemic shunt(TIPS) is a frequently used and effective treatment of refractory ascites and refractory variceal bleeding. but the survival rate of ascites patients was significantly lower than the patients with esophageal gastric varices bleeding after TIPS. Child-pugh score (HR:1.46,95%CI:1.11-2.01,p<0.01)and ascites (HR: 1.74,95%CI:1.023-3.21,P=0.022) were independent affect fators of survival.2、The overall primary patency rates was77.6%. Previous splenectomy is the independent fator of patency. It is necessary to take an active treatment to TIPS dysfunction, for it can get a better secondary patency rate. TIPS dysfunction is the main cause of rebleeding after TIPS. TIPS combined with embolization of varices reduce the incidence rate of rebleeding3、The hepatic encephalopathy rate was 27.4%. With the Child-pugh class increasing, the incidence of hepatic encephalopathy has an increasing trend. TIPS placed to the left portal vein has lower risk of hepatic encephalopathy.4、The long-term liver function has not been significantly damaged after TIPS. Nevertheless,it is not beneficial to patients in former midium-term.Diameter and the location in portal vein of shent are the important factors influencing the postoperative early liver function.5、During the follow-up period, patency rates gradually decrease, mortality rates continue to increase, and the chance of bleeding remains present. Together, these findings suggest that continued clinical follow-up beyond 2 years is necessary in patients with a TIPS created with an covered stent graft.