Outcome and Predictors of Survival after Transjugular Intrahepatic Portosystemic Shunt (TIPS) in Patients with Cirrhosis of Liver and Portal Hypertension

Abstract

Purpose: Cirrhosis of liver is the 10th leading cause of death in United States. Major complications of cirrhosis and portal hypertension include variceal bleeding (VB) and refractory ascites (RA). VB is the most dreaded complication, with 30-day mortality of 20%. Standard therapies include endoscopic variceal sclerotherapy/ligation/banding and pharmacological management. RA is another major complication of cirrhosis. Medical treatments include sodium restriction, diuretics, and/or paracentesis. Definitive long-term treatment of VB and RA involves liver transplantation (LT) or transjugular intrahepatic portosystemic shunt (TIPS) in patients who are waiting or not candidates for LT. Aim: To determine the clinical outcome and predictors of survival after TIPS insertion in patients with cirrhosis of liver and portal hypertension. Methods: This retrospective single-center study was conducted at a tertiary referral center after IRB approval. Data was collected on all consecutive patients with cirrhosis of liver who underwent TIPS for VB and RA between January, 2004 and March, 2012. The Kaplan-Meier method was employed to calculate survival from the time of TIPS insertion to the last encounter (alive or dead), and comparisons were made by log rank test. Results: Two hundred forty-nine patients met the inclusion criteria. Mean age was 55 years (21-85). Baseline characteristics of the patients, etiology of cirrhosis, Child-Turcotte-Pugh (CTP) score, model for end-stage liver disease (MELD) score, indication for TIPS, and hepatic venous pressure gradient (HVPG) difference post-TIPS were tabulated (Table 1). HVPG difference was calculated by subtracting the post-TIPS pressure gradient to pre-TIPS pressure gradient. MELD score (p=0.017), CTP score (p=0.042), and TIPS indication (EV vs. RA) (p=0.004) (Figure 1) were the significant predictors of survival. No significant difference in survival was noted in terms of age, gender, ethnicity, etiology of cirrhosis, and HVPG reduction.Table 1: Baseline characteristics of patients with mean survival times based on various parametersFigure 1: Kaplan-Meier overall survival for EV and RA (survival is calculated in days).Conclusion: TIPS is a safe and effective way to manage the complication of portal hypertension, including EV and RA. Mean survival was significantly lower in patients with VB and those with higher MELD and CTP scores.