Clinical efficacy of transjugular intrahepatic portosystemic shunting for recurrent portal hypertension after liver transplantation

Abstract

Objective To investigate the clinical efficacy of transjugular intrahepatic portosystemic shunting (TIPS) for recurrent portal hypertension after liver transplantation. Methods The retrospective cross-sectional study was conducted. The clinical data of 15 patients with recurrent portal hypertension after liver transplantation who underwent TIPS in the 9th School of Clinical Medicine between January 2008 to June 2016 were collected. Course of TIPS: the portal vein pressure was measured and varicose veins were embolized after puncture, cannulation and angiography. A balloon catheter with diameter of 7 mm or 8 mm was used to dilate the preshunt channel, and a covered stent or bare stent with a diameter of 7, 8 or 10 mm was implanted to establish the shunt channel. Portal vein angiography was performed and the portal vein pressure was measured again. Observation indicators: (1) Surgical situations; (2) changes of portal vein pressure before and after TIPS; (3) follow-up and survival situations. Follow-up using outpatient examination was performed to record clinical symptoms at postoperative 1, 3, 6 and 12 months. Regular hepatic vascular ultrasonography was done at postoperative 1, 3, 6 and 12 months to detect patency of shunt. The follow-up period was up to June 2018. Measurement data with normal distribution were represented as ±s and analyzed by the paired t test. Measurement data with skewed distribution were described as M (range). Count data were represented as percentage. Results (1) Surgical situations: all the 15 patients underwent successful TIPS, without any serious complications or death. Stent implantation situation: bare stent, covered stent and bare stent + covered stent were implanted in 4, 8 and 3 patients, respectively. Among the 15 patients, 7 mm, 8 mm and 10 mm diameter shunt channel were established in 4, 8 and 3 patients respectively. (2) Changes of portal vein pressure before and after TIPS: portal vein pressure of the 15 patients decreased from (34±8)mmHg (1 mmHg=0.133 kPa) to (21±7)mmHg before and after TIPS, with a statistically significant difference (t=7.07, P<0.05). Portal vein pressure gradient decreased from (26±9)mmHg to (12±5)mmHg before and after TIPS, with a statistically significant difference (t=6.43, P<0.05). (3) Follow-up and survival situations: 15 patients were followed up for 24.0-60.0 months, with a median follow-up time of 37.8 months. Main clinical symptoms: of 12 patients with gastrointestinal hemorrhage, 3 had gastrointestinal rehemorrhage mainly due to portal vein pressure rising again caused by shunt restenosis or occlusion, 9 had no gastrointestinal rehemorrhage. Of 5 patients with portal vein thrombosis, thrombus was disappeared basically in 3 patients and decreased obviously (no effect on blood flow) in 2 patients. Three patients with refractory ascites were effectively improved after TIPS, however, 2 of them were recurred at postoperative 5 months. Postoperative restenosis or occlusion of shunt channel: among 15 patients, 7 developed restenosis or occlusion of the shunt channel (including 4 with bare stents). Five of them underwent shunt recanalization and another 2 without special clinical symptoms had no treatment. Hepatic encephalopathy: 6 of 15 patients including 1 with 7 mm shunt, 3 with 8 mm shunt and 2 with 10 mm shunt developed hepatic encephalopathy, of which grade Ⅰ, Ⅱ, Ⅲ, and Ⅳ hepatic encephalopathy were detected in 2, 3, 0 and 1 patients, respectively. Survival situations: of the 15 patients, 1 died of hepatic failure at postoperative 6 months, 3 were performed liver transplantation again at postoperative 3, 8 and 14 months, respectively, 11 survived more than 2 years with the longest survival time more than 6 years. Conclusion TIPS is safe and effective for recurrent portal hypertension after liver transplantation for patients who have not effective other treatment. Key words: Liver transplantation; Portal hypertension; Transjugular intrahepatic portosystemic shunting; Gastrointestinal hemorrhage; Ascites