Abstract: Objective
To investigate the risk factors of shunt dysfunction and hepatic encephalopathy after transjugular intrahepatic portosystemic shunt (TIPS), and explore the preventive strategies.
Methods
The clinical data of 116 patients with esophagus and gastric varices bleeding (EGVB) who were admitted to the Affiliated Drum Tower Hospital of Nanjing University Medical School from August 2008 to January 2013 were retrospectively analyzed. All patients received TIPS, including 39 patients treated with bare stents, 32 with coated stents 〖HJ*5〗and  45 with combined stents. Gender, age, causes of hepatic cirrhosis, Child Turcotte Pugh (CTP) classification and scores, history of EGVB treatment, timing of operation, types of stents, location of puncture in the portal vein were recorded. Follow up began from the day of TIPS. Patients received color Doppler ultrasonography examination of the shunt at post TIPS day 5, month 1, 3, 6, and every 6 months thereafter. All the patients were followed up till March 2013. Risk factors influencing the incidence of shunt dysfunction and hepatic encephalopathy were screened out using the COX regression model, and then related factors were processed with multivariate analysis.
Results
Shunt dysfunction was detected in 18 patients at post TIPS day 5 to month 36. Of the 18 patients with shunt dysfunction, 10 patients were treated with bare stents, 4 with coated stents and 4 with combined stents. Sixty five patients were followed up more than 1 year, the shunt remained patency within the 1 year in 59 patients, and the postoperative 1 year stent patency rate was 90.8%(59/65). The shunt of 12 patients restored patency after interventional therapy, and interventional therapy was failed in 5 patients, 1 patient gave up treatment due to economical reasons. The patency rate after interventional therapy was 95.65%(110/115). Twenty nine patients were complicated with hepatic encephalopathy at post TIPS month 1 -18 in 8 patients. The hepatic encephalopathy ranked West Haven Ⅰ Ⅱ in 26 patients and Ⅲ in 3 patients. The results of univariate analysis showed that CTP classification and score and levels of TBil were risk factors of shunt dysfunction after TIPS ( RR=0.314, 0.600, 0.940, P <0.05). Age, CTP classification and score were risk factors of hepatic encephalopathy after TIPS ( RR= 2.798, 2.683, 1.328, P <0.05). The results of multivariate analysis showed that CTP classification and score and level of TBil were not the independent risk factors of shunt dysfunction after TIPS ( RR=0.762, 0.650, 0.952, P >0.05). Age and CTP classification were independent risk factors of hepatic encephalopathy after TIPS ( RR=2.641, 2.510, P <0.05). History of splenectomy was the risk factor of shunt dysfunction in a short term after TIPS ( RR=0.168, P <0.05).
Conclusions
CTP classification and score, and level of TIPS are risk factors of shunt dysfunction after TIPS. Age and CTP classification are independent risk factors of hepatic encephalopathy after TIPS. Post TIPS anticoagulant therapy for patients with splenectomy should be reappraised. Ameliorating the liver function before TIPS, strengthening the modalities to prevent hepatic encephalopathy in the first 3 months after TIPS and sufficient anticoagulating for patients with splenectomy after TIPS are important for improving the therapeutic efficacy and quality of life.