Clinical Study Of Early Transjugular Intrahepatic Portosystemic Shunt(TIPS) In The Treatment Of Esophageal Variceal Bleeding In Senile Cirrhosis

Objectives:To investigate the safety and clinical efficacy of early transjugular intrahepatic portosystemic shunt in the treatment of esophageal variceal bleeding in senile cirrhosis.Methods:A retrospective analysis was performed on the clinical data of 282 senile cirrhosis who are acute esophageal variceal bleeding in our hospital from March 2016 to July 2019.Usingl:1 propensity score matching(PSM)to divide the Patients into early TIPS group and endoscopic ligation group.Patients in both groups were followed up at 1,3,6,12 and 24 months after operation.the follow-up indexes including rebleeding and grading of hepatic encephalopathy,survival status,degree of esophageal varices,stent function,etc.The primary end point was esophageal variceal rupture and rebleeding,and the secondary end points were death from any cause,obvious hepatic encephalopathy and stent stenosis.all subjects were followed up for 2 years or until the cut-off date(2020-07-30).Chi-square test and independent sample T test were used to compare the baseline.Kaplan-Meier analysis was used to calculate the cumulative incidence of various indicators in the two groups,and Log-Rank test was used to compare the cumulative incidence between groups.Univariate COX regression was used to analyze the factors affecting survival,and the variables with P<0.1 in univariate regression analysis were included in multivariate COX regression analysis.Result:According to the propensity score matching,60 patients in early-TIPS group and 60 patients in EVL group were enrolled in this study.There were no serious complications during the operation in both groups.During the follow-up of 12 and 24 months,the cumulative rebleeding rate in early-TIPS and EVL group was 3.7%vs 28.8%and 10.4%vs 45.2%,respectively.The cumulative rate of rebleeding in early-TIPS group was significantly lower than that in EVL group(P<0.05).The cumulative incidence of hepatic encephalopathy in early-TIPS and EVL groups was 11.7%vs 5.0%,16.8%vs 12.0%,26.7%vs 18.0%and 33.7%vs 20.5%after 3,6,12 and 24 months follow-up,respectively.There was no significant difference between the two groups(P>0.05).The cumulative survival rates of early-TIPS and EVL groups were 84.7%vs 76.7%and 72.8%vs 55.8%respectively after 12-and 24-month follow-up.The cumulative survival rates of early-TIPS group were higher than those of EVL group(P<0.05).During the 12-month follow-up,the effective rate of esophageal varices in early-TIPS and EVL groups was 85.0%VS 68.3%.The effective rate of esophageal varices in the EVL group was higher than that in the EVL group(P<0.05).During the 12-month and 24-month follow-up,the cumulative stent patency rate of early-TIPS group was 90.7%and 80.6%,respectively.COX univariate regression analysis of 2-year cumulative survival rate showed that EVL treatment,preoperative underlying diseases(COPD,diabetes,hypertension,etc.),MELD score,Child score and PT value were predictors of 24-month postoperative mortality.The results of COX multivariate regression showed that EVL treatment(HR=2.117,95%CI=1.100-4.076,P=0.025)and preoperative MELD score(HR=1.417,95%CI=1.121-1.791,P=0.004)were independent risk factors for 24-month postoperative mortality.Conclusion:1.Early-TIPS is a safe and effective method for the treatment of acute esophageal variceal bleeding in elderly patients with liver cirrhosis.Clinicians can make a reasonable choice according to hospital conditions and patients’ conditions.2.Compared with EVL,early TIPS has lower incidence of rebleeding,higher survival rate,and effective rate of esophageal varices.The incidence of hepatic encephalopathy was similar between the two groups.3.Preoperative MELD score and Treatment by EVL is an independent risk factor for death 24 months after EVB in elderly patients with acute liver cirrhosis.