Introduction
Transjugular intrahepatic portosystemic shunt (TIPS) is now an effective and standard procedure to prevent variceal bleeding and recurrent ascites in decompensated cirrhosis (1). Moreover, there is increasing evidence (2, 3) showing that TIPS is feasible in patients with partial or occlusive portal vein thrombosis (PVT). However, thrombosis may develop at intrahepatic branches of the portal vein after TIPS, even in patients without PVT before the procedure. Our retrospective study showed that warfarin could prevent portal branch PVT and might improve liver function among cirrhosis patients receiving TIPS (4). Thus, to obtain clinical evidence with higher quality, a prospective study on post-TIPS de novo PVT regarding the incidence, risk factors, and impact on liver function is necessary.
Aims & Methods
Aim: We aimed to assess the incidence and risk factors for thrombosis developed at branches of the portal vein after TIPS in cirrhosis patients without preexisting PVT. In addition, we aimed to evaluate the influence of post-TIPS PVT on liver function and cirrhosis-related events.
Methods: A total of 70 decompensated cirrhosis patients who received TIPS without PVT were included. Routine laboratory and radiological examinations and assessment of cirrhosis-related complications proceed at 1, 3, 6 and 12 months after TIPS. For the primary outcome, the presence of post-TIPS PVT was assessed by doppler ultrasound showing that the blood flow signal partially or completely disappeared or by contrast-enhanced computed tomography showing filling defects or occlusion in the portal vein branches. For the liver function and complications comparison within 1 year after TIPS (secondary outcome), a 1:1 match using propensity score matching (PSM) based on age, sex and preoperative Child‒Pugh score was conducted between patients with and without post-TIPS PVT.
Results
Among 70 patients, 34 (48.6%) were Child‒Pugh class A, and the median Child‒Pugh score was 7 (5-8). The most common indication for TIPS was variceal bleeding (76.8%), followed by refractory ascites (21.4%). During the follow-up, 25 (35.7%) patients developed post-TIPS PVT, with incidences of 8.0%, 16.0% and 26.8% at 1, 2 and 3 months after TIPS, respectively. Univariate analysis showed that lower serum albumin (p = 0.023), Child‒Pugh B/C class (p = 0.029) and stenting at the left branch of the portal vein (p = 0.020) were significantly associated with post-TIPS PVT. Multivariate analysis showed that lower serum albumin (OR 0.87, p = 0.022) and stenting at the left branch of the portal vein (OR 6.56, p = 0.020) were independent risk factors. Twenty four of 25 patients with post-TIPS PVT were matched with 24 of 45 patients without post-TIPS PVT. Preoperative clinical characteristics of the matched patients were compared, and no significant differences were shown between the two groups. However, the Child‒Pugh score was significantly higher in the PVT group at 1 year after TIPS compared with non-PVT group [7 (6-8) vs 8 (7-9), p = 0.044]. In addition, the incidence of overt hepatic encephalopathy (50.0% vs 20.8%, p = 0.035) and the presence of ascites (54.2% vs 25.0%, p = 0.039) at 1 year after TIPS were significantly higher in the PVT group.
Conclusion
PVT may develop at intrahepatic branches of the portal vein early in the post-TIPS period in cirrhosis, leading to further liver damage and cirrhosis-related complications. Lower serum albumin levels and stenting at the left branch of the portal vein were independent risk factors for de novo PVT within 1 year after TIPS.
References
1.de Franchis R, Bosch J, Garcia-Tsao G, Reiberger T, Ripoll C; Baveno VII Faculty. Baveno VII - Renewing consensus in portal hypertension. J Hepatol. 2022 Apr;76(4):959-974.
2.Lv Y, Bai W, Li K, Wang Z, Guo W, Luo B, Wang J, Wang Q, Wang E, Xia D, Li X, Yuan J, Han N, Niu J, Yin Z, Fan D, Han G. Anticoagulation and Transjugular Intrahepatic Portosystemic Shunt for the Management of Portal Vein Thrombosis in Cirrhosis: A Prospective Observational Study. Am J Gastroenterol. 2021 Jul 1;116(7):1447-1464.
3.Guo DF, Fan LW, Le Q, Huang CB. Transjugular intrahepatic portosystemic shunt for the prevention of rebleeding in patients with cirrhosis and portal vein thrombosis: Systematic review and meta-analysis. Front Pharmacol. 2022 Aug 16;13:968988.
4.Zhang L, Huan H, Tong H, Wei B, Wang Z, Liu C, Wu H. Warfarin prevented de novo portal vein thrombosis after transjugular intrahepatic portosystemic shunt: A retrospective study. Medicine (Baltimore). 2020 Jan;99(2):e18737.
