Aims:Post-transjugular intrahepatic portosystemic shunt(TIPS)hepatic encephalopathy and stent dysfunction remain the principal clinical problems restricting the procedure's application.Establishing TIPS in the lef...Aims:Post-transjugular intrahepatic portosystemic shunt(TIPS)hepatic encephalopathy and stent dysfunction remain the principal clinical problems restricting the procedure's application.Establishing TIPS in the left branch of the portal vein,as opposed to the right branch,can reduce the incidence of hepatic encephalopathy post-TIPS.This study aimed to analyze the effects of shunt position(including the puncture site of the portal vein and stent position)on the prognosis of patients undergoing TIPS for cirrhotic esophagogastric variceal bleeding(EGVB).Methods:Data from 169 patients who underwent TIPS-covered stenting between November 2015 and December 2021 for portal hypertension with EGVB at the First Affiliated Hospital of Soochow University were retrospectively analyzed.The patients were divided into three groups according to the puncture site of the portal vein,named left branch(n=92),right branch(n=27),and bifurcation(n=50)groups,respectively.The patients were also divided into the optimal stent position(O-SP)group(n=102)and the suboptimal stent position(S-O-SP)group(n=67)according to the stent position.The primary outcome was the overt hepatic encephalopathy(OHE)rate,and the secondary outcomes were the shunt dysfunction,variceal rebleeding,and liver transplant-free survival rates.Quantitative data are represented as means±standard deviations or medians(interquartile ranges),and categorical data are expressed as proportions and percentages.Categorical variables were analyzed using theχ^(2)or rank-sum test,while normally distributed continuous variables were compared using the independent samples t-test or one-way analysis of variance,and non-normally distributed continuous variables were assessed using the Mann-Whitney U test or Kruskal-Wallis test.Results:TIPS shunts were successfully created in all patients in this study,with a procedural success rate of 100%.The median follow-up time in this study was 30.5(17.6-48.6)months,and no patients lost follow-up.Based on the puncture site,the left branch group versus the right branch group(32%vs.67%,χ^(2)=14.529,p<0.001)and the bifurcation group versus the right branch group(34%vs.67%,χ^(2)=9.131,p=0.003)were significantly different in terms of OHE rate,and the right branch group was worse than the other two groups.There was no significant difference in the OHE rate between the left branch and the bifurcation groups(32%vs.34%,χ^(2)=0.165,p=0.684).The median times to OHE were 58.3(95%confidence interval[CI]:51.6-65.0)months in the O-SP group and 38.2(95%CI:29.6-46.8)months in the S-O-SP group,with significant difference between them(χ^(2)=8.890,p=0.003).The median times to shunt dysfunction were 68.4(95%CI:62.2-74.6)months for the O-SP group and 48.9(95%CI:40.8-57.0)months for the S-O-SP group,with significant difference between them(χ^(2)=12.717,p<0.001).In our study,no differences were observed in the variceal rebleeding rate,liver transplant-free survival rate,and postoperative blood ammonia level among the different puncture sites and stent positions(p>0.05).Univariate and multivariate Cox regression analyses showed that age,intraoperative puncture of the right branch of the portal vein,stent position,prothrombin time,international normalized ratio,and blood sodium were independent risk factors for the postoperative OHE rate.Conclusion:TIPS controls cirrhotic EGVB.Puncturing the right portal vein to establish a TIPS shunt may increase the risk of postoperative OHE and impairment of the liver functional reserve.A suboptimal stent position may increase the risk of OHE and shunt dysfunction after TIPS.Both ends of the stent should be optimally positioned whenever possible.展开更多
基金funded by National Natural Science Foundation of China(82472083).
文摘Aims:Post-transjugular intrahepatic portosystemic shunt(TIPS)hepatic encephalopathy and stent dysfunction remain the principal clinical problems restricting the procedure's application.Establishing TIPS in the left branch of the portal vein,as opposed to the right branch,can reduce the incidence of hepatic encephalopathy post-TIPS.This study aimed to analyze the effects of shunt position(including the puncture site of the portal vein and stent position)on the prognosis of patients undergoing TIPS for cirrhotic esophagogastric variceal bleeding(EGVB).Methods:Data from 169 patients who underwent TIPS-covered stenting between November 2015 and December 2021 for portal hypertension with EGVB at the First Affiliated Hospital of Soochow University were retrospectively analyzed.The patients were divided into three groups according to the puncture site of the portal vein,named left branch(n=92),right branch(n=27),and bifurcation(n=50)groups,respectively.The patients were also divided into the optimal stent position(O-SP)group(n=102)and the suboptimal stent position(S-O-SP)group(n=67)according to the stent position.The primary outcome was the overt hepatic encephalopathy(OHE)rate,and the secondary outcomes were the shunt dysfunction,variceal rebleeding,and liver transplant-free survival rates.Quantitative data are represented as means±standard deviations or medians(interquartile ranges),and categorical data are expressed as proportions and percentages.Categorical variables were analyzed using theχ^(2)or rank-sum test,while normally distributed continuous variables were compared using the independent samples t-test or one-way analysis of variance,and non-normally distributed continuous variables were assessed using the Mann-Whitney U test or Kruskal-Wallis test.Results:TIPS shunts were successfully created in all patients in this study,with a procedural success rate of 100%.The median follow-up time in this study was 30.5(17.6-48.6)months,and no patients lost follow-up.Based on the puncture site,the left branch group versus the right branch group(32%vs.67%,χ^(2)=14.529,p<0.001)and the bifurcation group versus the right branch group(34%vs.67%,χ^(2)=9.131,p=0.003)were significantly different in terms of OHE rate,and the right branch group was worse than the other two groups.There was no significant difference in the OHE rate between the left branch and the bifurcation groups(32%vs.34%,χ^(2)=0.165,p=0.684).The median times to OHE were 58.3(95%confidence interval[CI]:51.6-65.0)months in the O-SP group and 38.2(95%CI:29.6-46.8)months in the S-O-SP group,with significant difference between them(χ^(2)=8.890,p=0.003).The median times to shunt dysfunction were 68.4(95%CI:62.2-74.6)months for the O-SP group and 48.9(95%CI:40.8-57.0)months for the S-O-SP group,with significant difference between them(χ^(2)=12.717,p<0.001).In our study,no differences were observed in the variceal rebleeding rate,liver transplant-free survival rate,and postoperative blood ammonia level among the different puncture sites and stent positions(p>0.05).Univariate and multivariate Cox regression analyses showed that age,intraoperative puncture of the right branch of the portal vein,stent position,prothrombin time,international normalized ratio,and blood sodium were independent risk factors for the postoperative OHE rate.Conclusion:TIPS controls cirrhotic EGVB.Puncturing the right portal vein to establish a TIPS shunt may increase the risk of postoperative OHE and impairment of the liver functional reserve.A suboptimal stent position may increase the risk of OHE and shunt dysfunction after TIPS.Both ends of the stent should be optimally positioned whenever possible.
