ABSTRACT
AIM: To compare the impact of covered stent-graft transjugular intrahepatic portosystemic shunt (TIPS) versus serial paracentesis on survival of patients with medically refractory ascites. MATERIALS AND METHODS: In this retrospective study, cirrhotic patients who underwent covered stent-graft TIPS for refractory ascites from 2003-2013 were compared with similar patients who underwent serial paracentesis during 2009-2013. Demographic and liver disease data, Model for End-Stage Liver Disease (MELD) scores, and survival outcomes were obtained from hospital electronic medical records and the social security death index. After propensity score weighting to match study group characteristics, survival outcomes were compared using Kaplan-Meier statistics with log-rank analysis. RESULTS: Seventy TIPS (70% men, mean age 55.7 years, mean MELD 15.1) and 80 paracentesis (58% men, mean age 53.5 years, mean MELD 22.5) patients were compared. The TIPS haemodynamic success rate was 100% (mean portosystemic pressure gradient reduction 13 mmHg). Paracentesis patients underwent a mean of 7.9 procedures. After propensity score weighting to balance group features, TIPS patients showed a trend toward enhanced survival compared with paracentesis patients (median survival 1037 versus 262 days, p = 0.074). TIPS conferred a significant increase or trend toward improved survival compared with paracentesis at 1 (66% versus 44%, p = 0.018), 2 (56% versus 38%, p = 0.057), and 3 year (49% versus 32%, p = 0.077) time points. Thirty and 90 day mortality rates were not statistically increased by TIPS. CONCLUSION: Covered stent-graft TIPS improves intermediate- to long-term survival without significantly increasing short-term mortality of ascites patients, and suggests a greater potential role for TIPS in properly selected ascitic patients when medical management fails.
Subject(s)
Ascites/etiology , Ascites/surgery , Liver Cirrhosis/complications , Paracentesis/methods , Portasystemic Shunt, Transjugular Intrahepatic , Ascites/diagnostic imaging , Case-Control Studies , Female , Hemodynamics , Humans , Male , Middle Aged , Propensity Score , Retrospective Studies , Risk Factors , Severity of Illness Index , Survival Rate , Treatment Outcome , Ultrasonography, DopplerABSTRACT
PURPOSE: To assess the impact of transjugular intrahepatic portosystemic shunt (TIPS) creation on Model for End-stage Liver Disease (MELD) score temporal progression in patients with liver cirrhosis. MATERIALS AND METHODS: In this single-institution retrospective study, 256 consecutive patients who underwent TIPS creation between 1999 and 2013 were identified for potential investigation. Inclusion criteria for analysis consisted of at least 6 months of post-TIPS clinical follow-up with available lab values at 1, 3, 6, and, if available, 12 months post-TIPS for MELD score calculation. Patients who were lost to follow-up or expired within 6 months, lacked sufficient lab follow-up, or underwent liver transplantation within 6 months of TIPS were excluded from the study cohort. Within-patient variance in MELD score was assessed using repeated-measures analysis of variance. RESULTS: Sixty-six patients met criteria for study inclusion. TIPS were created for variceal hemorrhage (n = 26) or ascites, hydrothorax, or portal vein thrombosis (n = 40). Hemodynamic success rate was 97% (64/66) and median portosystemic pressure gradient reduction was 13 mm Hg. Median baseline MELD score was 14 (range 7-26). Low MELD scores (≤ 10, n = 16) increased in sequential scores over 1-year follow-up (median increase +3.5), intermediate MELD scores (11-18, n = 34) showed general stability in successive scores over 1-year follow-up (median increase +1), and high MELD scores (≥ 19, n = 16) decreased in serial scores over 1-year follow-up (median decrease -4); these trends are compatible with published MELD progression tendencies in cirrhotic patients without TIPS. However, the MELD score changes were not statistically significant (P = .172) on within-subject comparison. CONCLUSIONS: Among patients with liver cirrhosis who recover from the procedure, TIPS creation does not alter the natural MELD score evolution during intermediate term follow-up, and as such does not significantly alter liver transplant candidacy.
