Effects Of Stent Types And Anticoagulation Strategies On The Prognosis Of Patients With Liver Cirrhosis After TIPS

Objective Transjugular intrahepatic portosystemic shunt(transjugular intrahepatic portosystemic shunt,TIPS)is an effective method for the treatment of portal hypertension-related complications and other diseases.Through minimally invasive intervention,a stent was placed between the hepatic vein and the portal vein to relieve portal hypertension.However,postoperative stent stenosis/occlusion is the key factor affecting the long-term effect of patients.Therefore,maintaining the patency of the stent is particularly important to maintain the stent function and improve the long-term quality of life of patients.Clinically,many types of stents have been used for TIPS.Due to the differences in the incidence and mechanism of postoperative stenosis/occlusion among different types of stents,there is still no unified postoperative anticoagulation strategy.Moreover,because patients with liver cirrhosis have coagulation dysfunction on the one hand and portal vein thrombosis on the other hand,anticoagulation therapy in patients with liver cirrhosis treated by TIPS should be especially cautious.Therefore,the purpose of this study is to clarify the effects of different stent types and anticoagulation strategies on the prognosis of cirrhotic patients after TIPS,and to screen the related influencing factors,so as to provide a basis for the management of cirrhotic patients after TIPS.Method Patients with cirrhotic portal hypertension treated by TIPS in XXX Hospital from August 2014 to January 2022 were collected.The incidence of stent stenosis/occlusion,the incidence of portal vein thrombosis(PVT)new/recanalization,the incidence of liver cirrhosis complications(esophagogastric variceal bleeding,ascites,hepatic encephalopathy)and survival status after TIPS were reported after using various types of stents and different anticoagulation strategies,and the related factors were analyzed.Cases with complete important data and follow-up time greater than or equal to 1month were included.Patients complicated with malignant tumor before surgery and patients who were not reviewed after surgery and could not determine stent patency were excluded.The general data,medical history,laboratory examination,imaging examination,TIPS operation related data,anticoagulant therapy and survival data were collected.Research grouping: 1.According to the type of stent,they were divided into three groups:(1)Viatorr stent group,(2)Fluency stent combined with bare metal stent group,(3)simple Fluency stent group.2.Then each group of patients using the same type of stent was subdivided into subgroups according to anticoagulation strategy:(1)Viatorr stent group:(1)Unsustained anticoagulant/antiplatelet group,(2)Continuous anticoagulant group,(3)Continuous antiplatelet group.(2)Fluency stent combined with bare metal stent group:(1)Continuous anticoagulant group,(2)Continuous antiplatelet group.(3)simple Fluency stent group:(1)Continuous anticoagulant group,(2)Continuous antiplatelet group.Statistical analysis was performed using SPSS 24.0 and Graph Pad Prism 9.0software,and P<0.05 was recognized is statistically significant.Results1.This study included 267 patients with liver cirrhosis after TIPS,including 178males(66.7%)and 89 females(33.3%),with an average age of 53.98±10.75 years.2.Prognosis of patients with different stent types after TIPS267 patients with cirrhosis treated by TIPS,the incidence of postoperative stent strictures or occlusions(10.9% vs 38.2% vs 28.0%),the incidence of esophagogastric variceal bleeding(8.7% vs 26.5% vs 24.0%),and the incidence of hepatic encephalopathy(20.2% vs 41.2% vs 40.0%)in Viatorr stent group was lower than that in Fluency stent combined with bare stent group and simple Fluency stent group,and the difference was statistically significant(P<0.05).In addition,the postoperative PVT recanalization rate in the Viatorr stent group was higher than that in the Fluency stent group(65.1% vs 27.8%),and the incidence of moderate and massive ascites was lower(9.3% vs 22.0%),and the difference was statistically significant(P<0.05).There was no significant difference in the postoperative PVT new occurrence rate and the survival rate among Viatorr stent group,Fluency stent combined with bare stent group and simple Fluency stent group(P>0.05).3.Anticoagulant strategy and prognosis of patients using Viatorr stent Among the 183 patients who used Viatorr stent,the long-term patency rate of stent,PVT recanalization rate(66.7% vs 77.8% vs 53.8%)and postoperative incidence of hepatic encephalopathy(22.7% vs 25.0% vs 16.1%)in continuous anticoagulation group and continuous antiplatelet group were higher than those unsustained anticoagulation/antiplatelet group,but the difference was not significant(P>0.05).The incidence of moderate and massive ascites in the continuous anticoagulation group was lower than that in the unsustained anticoagulation/antiplatelet group and the continuous antiplatelet group(4.5% vs9.2% vs 13.5%),but the difference was not significant(P>0.05).There was no significant difference in the postoperative new occurrence rate of PVT,the incidence of postoperative esophagogastric variceal bleeding and the survival rate among unsustained anticoagulation/antiplatelet group,continuous anticoagulation and continuous antiplatelet group(P>0.05).4.Anticoagulant strategy and prognosis of patients using Fluency stent combined with bare stent Among the 34 patients who used Fluency stent combined with bare stent,the long-term patency rate of stent,the new occurrence rate of PVT(33.3% vs 11.1%),the recanalization rate of PVT(60.0% vs 40.0%)and the incidence of hepatic encephalopathy(55.6% vs 36.0%)were higher in the continuous anticoagulation group than in the continuous antiplatelet group.The incidence of postoperative esophagogastric variceal bleeding(11.1% vs 32.0%),the incidence of moderate and massive ascites(0.0% vs 16.0%),and the long-term survival rate were low in the continuous anticoagulation group than in the continuous antiplatelet group.But the difference was not significant(P>0.05).5.Anticoagulant strategy and prognosis of patients using Fluency stent Among the 48 patients who used Fluency stents,the new occurrence rate of PVT(0% vs 37.5%),the incidence of moderate and massive ascites(16.7% vs 25.0%)and the incidence of hepatic encephalopathy(33.3% vs 41.7%)were lower in the continuous anticoagulation group than in the continuous antiplatelet group.The recanalization rate of PVT(33.3% vs 22.2%)and the incidence of esophagogastric variceal bleeding(33.3% vs 19.4%)were high in the continuous anticoagulation group than in the continuous antiplatelet group.But the difference was not significant(P>0.05).There was no significant difference in postoperative stent patency rate and survival rate between continuous anticoagulation group and continuous antiplatelet group(P>0.05).6.Related factors affecting the prognosis of patients undergoing TIPS To explore the related factors affecting the prognosis of patients undergoing TIPS.The results showed that preoperative AST level(HR=1.011,95%CI:1.004-1.018,P=0.002<0.05)and preoperative splenic vein thrombosis(HR=6.028,95%CI:1.472-24.676,P=0.012<0.05)were the influencing factors of stent stenosis or occlusion after TIPS.The selection of Viatorr stent is the influencing factor to promote PVT recanalization after TIPS(OR=3.974,95%CI:1.071-14.754,P=0.039<0.05).Stent stenosis or occlusion was a risk factor for postoperative esophagogastric variceal bleeding(OR=13.207,95%CI:4.869-35.821,P<0.01).The risk of moderate and massive ascites after TIPS in patients with Child-pugh grade B before operation was lower than that in patients with grade C(OR=0.297,95%CI:0.117-0.751,P=0.010<0.05).The age at the time of TIPS is the influencing factor of hepatic encephalopathy after operation(OR=1.036,95%CI:1.001-1.073,P=0.043<0.05).The age at the time of TIPS(HR=1.082,95%CI:1.045-1.120,P<0.0l)and the moderate and massive ascites after operation(HR=3.730,95%CI:1.917-7.255,P< 0.0l)were the influencing factors of death risk.Conclusions1.In patients with cirrhosis treated with TIPS,the prognosis of patients with Viatorr stent was better than that of Fluency stent combined with bare stent and simple Fluency stent.2.In patients with cirrhosis treated with Viatorr stents for TIPS,continuous anticoagulant therapy had no significant effect on stent patency rate,prognosis and survival status.3.The anticoagulant strategy,which is continuous anticoagulant therapy or continuous antiplatelet therapy,has no significant effect on the stent patency,prognosis and survival status of cirrhotic patients who are treated with TIPS using the Viatorr stent,Fluency stent combined with bare stent or simple Fluency stent.4.In patients with cirrhosis treated with TIPS,preoperative elevated AST levels and preoperative splenic vein thrombosis increased the risk of postoperative stent stenosis or occlusion;stent stenosis or occlusion is the risk factor of esophagogastric variceal bleeding after operation;the older the operation age,the higher the risk of postoperative hepatic encephalopathy and death;the presence of moderate and massive ascites after operation can increase the risk of death.