Outcomes of transjugular intrahepatic portosystemic shunt creation for flow-enabled dissolution of spleno-mesenterico-portal venous thrombosis.

PURPOSE: To evaluate the outcomes of transjugular intrahepatic portosystemic shunt (TIPS) for flow-enabled clearance of portal (PVT), splenic (SVT) and/or superior mesenteric (MVT) vein thrombosis. PATIENTS AND METHODS: In this single-center study, 12 patients underwent TIPS using Viatorr covered stent-grafts (W.L. Gore & Associates, Flagstaff, AZ, USA) from 2008-2014 for PVT as a primary (n=8) or secondary (n=4) indication. TIPS were not accompanied by pharmacomechanical clot disruption; rather, shunts served to increase portal blood flow to allow flow-mediated physiologic clot dissolution. Pre- and post-TIPS cross-sectional imaging were used to assess clot location, size, and clearance, defined by resolution (vessel patency with no clot), reduction (decrease in clot size), stability (no change in clot size), or extension (increase in clot size). RESULTS: The cohort included 5 men and 7 women (median age 63 years, range 45-73 years, median MELD score 15) with 30 non-occlusive and asymptomatic thrombi spanning main or intrahepatic PVT (n=15/30, 50%), SVT (n=6/30, 20%), and MVT (n=9/30, 30%). TIPS were generally created with 10mm covered stent-grafts; mean final portosystemic pressure gradient was 8mmHg. At mean 190 days post-TIPS, 58% (n=7/12) had clot resolution, 33% (n=4/12) had clot reduction, and 8% (n=1/12) had stable clot; there were no cases of clot extension. Resolution rate was 67% for PVT (10/15), SVT (4/6), and MVT (6/9). Two of 12 (17%) patients underwent successful liver transplant post-TIPS. CONCLUSION: TIPS prompts dissolution of or decrease in PVT, SVT, and MVT in cirrhotic patients. This may be a useful approach notwithstanding omission of pharmacomechanical methods.

Survival benefit of TIPS versus serial paracentesis in patients with refractory ascites: a single institution case-control propensity score analysis.

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.