Smaller-Diameter Covered Transjugular Intrahepatic Portosystemic Shunt Stents Are Associated With Increased Survival

Abstract

BACKGROUND & AIMS: We studied the effects of diameter of covered, self-expandable, nitinol stents on survival times of patients with a transjugular intrahepatic portosystemic shunt (TIPS). METHODS: We collected data from 185 patients (median age, 55 y; 30% female) who received a covered nitinol stent, from February 2006 through September 2010, using the online multicenter German TIPS registry. TIPS were given to 107 patients for refractory ascites and to 78 patients for variceal bleeding. Patients at risk of hepatic encephalopathy (owing to advanced age, prior episodes) or liver failure (bilirubin level, >3 mg/dL), and bleeding patients receiving variceal embolization at TIPS, received 8-mm stents (n [ 53). The remaining patients received 10-mm stents (n [ 132). Eighty-one of the 10-mm stents were underdilated using 8-mm dilation balloons. Clinical and biochemical data were collected after TIPS placement at 1 month, 3 months, 6 months, 9 months, 1 year, and thereafter every 3 to 6 months. Groups were compared using propensity score analysis. RESULTS: Patients who received 8-mm stents survived significantly longer (34-26 mo) than patients who received 10-mm stents (18-19 mo), regardless of whether they were fully dilated or underdilated. When we compared 10-mm stents with or without underdilation, we found that a significantly higher proportion of patients who received underdilated stents survived for 1 month after TIPS placement (95% vs 84%; P [ .03), but not for 3 months (P [ .10). In multivariate analysis, 1-year mortality correlated with full dilation of the stent to 10 mm (hazard ratio [HR], 2.0; 95% CI, 1.1-3.5) and with serum creatinine concentration at baseline (HR, 1.5; 95% CI, 1.0-1.7). Five-year mortality was associated with use of the 10-mm stents (HR, 1.8; 95% CI, 1.4-2.7) and baseline concentration of creatinine (HR, 1.3; 95% CI, 1.1-1.6). CONCLUSIONS: A smaller stent (nominal diameter of 8 mm, but not underdilation of a 10-mm stent) is associated with a prolonged survival compared with 10-mm stents, independent of liver-specific prognostic criteria.

Total area of spontaneous portosystemic shunts independently predicts hepatic encephalopathy and mortality in liver cirrhosis

“…34,35 Growing evidence has been published that suggests less complications after TIPS by using smaller diameter stents or dilatation of stents smaller than the nominal diameter, suggesting a beneficial effect of less shunt volume. [36][37][38][39][40] Regarding other decompensating events, we were unable to find a significant difference in variceal bleeding, hepatorenal syndrome or spontaneous bacterial peritonitis between patients with L-TSA and S-TSA. Considering variceal bleeding, our data are supported by previous reports, in which only the presence of SPSS vs. no SPSS was shown to be associated with bleeding, but no differences between small and large SPSS were detected.…”

“…In non-spontaneous SPSS, such as TIPS, it has been previously shown that small diameter TIPS-shunts are associated with less hepatic encephalopathy and better survival than the commonly used 10 mm stents. 37,38,40 However, in case of TIPS, the collaterals and the A B Research Article other SPSS have been rigorously embolized in order to limit TSA to 10 mm and other persisting collaterals (in many patients present) may have contributed to non-significant results regarding survival. This study presents a large, multicentric, international, well characterized cohort of cirrhotic patients with SPSS.…”

Transjugular Intrahepatic Portosystemic Shunt Placement for Portal Hypertension: Meta-Analysis of Safety and Efficacy of 8 mm vs. 10 mm Stents

“…108 of the identified papers were abandoned with the preset inclusion and exclusion criteria. Five studies including 2 RCTs [ 13 , 16 ] and 3 retrospective cohort studies [ 15 , 20 , 21 ] from 2010 to 2019 were included into the meta-analysis. Figure 1 provides the flow diagram of publication retrieval, screening, and resulting study selection.…”

“…Figure 1 provides the flow diagram of publication retrieval, screening, and resulting study selection. Data from Trebicka et al [ 20 ] was retrieved based on a multicenter RCT and propensity score matching for known confounders, so this study was categorized as having an observational feature [ 20 ]. The total number of patients reported in the five studies was 489.…”

30 Jahre transjugulärer intrahepatischer portosystemischer Shunt (TIPS) – Rückblick und Perspektive

“…Aber welches Vorgehen ist dafür geeignet? Soll man sich auf den "optimalen" PSG von 12 mmHg verlassen [15], oder ist der Stentdurchmesser von 8 mm [23,24] das richtige Maß? Da ist es besonders wichtig, die individuellen Risiken klar abzuschätzen und danach den optimalen Stentdurchmesser (6-10 mm) einzustellen (▶ Abb.…”