Predictors of mortality after transjugular portosystemic shunt

Abstract

AIM:To investigate if echocardiographic and hemodynamic determinations obtained at the time of transjugular intrahepatic portosystemic shunt (TIPS) can provide prognostic information that will enhance risk Predictors of mortality after transjugular portosystemic shunt Retrospective Study ORIGINAL ARTICLEstratification of patients. METHODS:We reviewed medical records of 467 patients who underwent TIPS between July 2003 and December 2011 at our institution. We recorded information regarding patient demographics, underlying liver disease, indication for TIPS, baseline laboratory values, hemodynamic determinations at the time of TIPS, and echocardiographic measurements both before and after TIPS. We recorded patient comorbidities that may affect hemodynamic and echocardiographic determinations. We also calculated Model for Endstage Liver Disease (MELD) score and Child Turcotte Pugh (CTP) class. The following pre-and post-TIPS echocardiographic determinations were recorded: Left ventricular ejection fraction, right ventricular (RV) systolic pressure, subjective RV dilation, and subjective RV function. We recorded the following hemodynamic measurements: Right atrial (RA) pressure before and after TIPS, inferior vena cava pressure before and after TIPS, free hepatic vein pressure, portal vein pressure before and after TIPS, and hepatic venous pressure gradient (HVPG). RESULTS:We reviewed 418 patients with portal hypertension undergoing TIPS. RA pressure increased by a mean ± SD of 4.8 ± 3.9 mmHg (P < 0.001), HVPG decreased by 6.8 ± 3.5 mmHg (P < 0.001). In multivariate linear regression analysis, a higher MELD score, lower platelet count, splenectomy and a higher portal vein pressure were independent predictors of higher RA pressure (R = 0.55). Three variables predicted 3-mo mortality after TIPS in a multivariate analysis: Age, MELD score, and CTP grade C. Change in the RA pressure after TIPS predicted long-term mortality (per 1 mmHg change, HR = 1.03, 95%CI: 1.01-1.06, P < 0.012). CONCLUSION:RA pressure increased immediately after TIPS particularly in patients with worse liver function, portal hypertension, emergent TIPS placement and history of splenectomy. The increase in RA pressure after TIPS was associated with increased mortality. Age, splenectomy, MELD score and CTP grade were independent predictors of long-term mortality after TIPS. Core tip: Transjugular intrahepatic portosystemic shunt (TIPS) is a procedure accompanied by morbidity and mortality. We hypothesize that echocardiographic and hemodynamic determinations obtained at the time of TIPS can provide prognostic information that will enhance risk stratification of patients. We measured echocardiographic and hemodynamic variables before and immediately after the TIPS procedure in a large cohort of patients at our institution. Our findings corroborate previous literature stating that right atrial pressure increased after TIPS. Our study demonstrates several predictors of long-term mortality after TIPS, such as age, splenectomy, and Model for End-s...

Safety and efficacy of transjugular intrahepatic portosystemic shunt combined with palliative treatment in patients with hepatocellular carcinoma

“…The transjugular intrahepatic portosystemic shunt (TIPS) reduces portal pressure and relieves the clinical symptoms associated with various medical conditions[3]. TIPS has found a wide range of applications, including treatment of portal hypertension due to cirrhosis, variceal bleeding (VB), refractory ascites (RA), hepatic hydrothorax, hepatorenal syndrome, Budd–Chiari syndrome, hepatopulmonary syndrome, and portal thrombosis and as a bridge to liver transplantation[4].…”

Targeted puncture of left branch of intrahepatic portal vein in transjugular intrahepatic portosystemic shunt to reduce hepatic encephalopathy

“…Transjugular intrahepatic portosystemic shunt (TIPS) is currently used for the treatment of complications of portal hypertension[1]. The establishment of TIPS is widely accepted as an alternative to surgery in the management of complications from portal hypertension such as variceal bleeding, refractory ascites, Budd-Chiari syndrome, hepatorenal syndrome, hepatic hydrothorax, and even hepatopulmonary syndrome[2]. After TIPS was introduced as an alternative treatment for complications related to portal hypertension, it was progressively recognized as an effective therapeutic option in a growing number of clinical situations[3,4].…”

Transjugular Intrahepatic Portosystemic Shunts in High-Risk Patients

“…The authors concluded that the absence of diastolic dysfunction on echocardiogram essentially ruled out post-TIPS cardiac decompensation. Similarly, Ascha et al 36 assessed pre-and post-TIPS right atrial pressures and found pre-TIPS right atrial pressure of > 9 mm Hg to be a predictor of 3-month survival after TIPS. However, patients with higher right atrial pressures also had worse liver disease, and when adjusted for age, MELD score, and Child-Pugh class, the effects of right atrial pressure on survival became nonsignificant.…”