| Objective:Chronic portal vein thrombosis usually results in Cavernous Transformation of the Portal Vein(CTPV).Complete occlusion of the main portal vein or a dominant segment results in serious complications related to portal hypertension including bleeding due to ruptured gastroesophageal varices,making it difficult to treat.A preferred therapeutic option is non-selective β-blocker,and endoscopic variceal ligation(EVL)is applied for a secondary prevention of variceal bleeding,whereas anticoagulation treatment is prescribed after the eradication of varices.transjugular intrahepatic portosystemic shunt(TIPS)conducted in patients with CTPV,can be technically difficult,which limits abroad application.TIPS techniques have been significantly matured and TIPS application has been expanded in the past decades.TIPS delivers both recanalization of the thrombosed portal vein and alleviation of the symptoms of portal hypertension.TIPS combined with gastric coronary vein embolization is a interventional therapy for the treatment of esophageal variceal rebleeding in patients with CTPV,it can contral the bleeding of esophageal variceal quickly and effectively,TIPS combined with gastric coronary vein embolization is a modified TIPS,it can decrease portal hypertension as well as contral the bleeding of esophageal variceal.we conducted this retrospective study aiming to compare the results of TIPS combined with gastric coronary vein embolization and EVL plus propranolol for the prevention of esophageal variceal rebleeding in patients with CTPV.Methods:Medical records of the cirrhotic patients with CTPV who were admitted to the Department of Gastroenterology and Hepatology,Shandong Provincial Hospital affiliated to Shandong University(Jinan,Shandong Province,China)between June 2010 and July 2016 were retrospectively reviewed,Altogether 102 cirrhotic patients with CTPV who had recurrent variceal bleeding were recruited in the study.After excluded those with variceal bleeding for the first time,with serious cardiopulmonary diseases,those having malignancies including hepatocellular carcinoma,and one with sudden cardiac death,as well as those who were lost to the follow-up,51 patients were finally enrolled and divided into the TIPS group(n = 25)(all the TIPS group combined with gastric coronary vein embolization)and the EVL plus propranolol(n =26).Patients’ demographics and clinical data were recorded.Data of the patients such as their age,gender,etiologies of liver cirrhosis,Child-Pugh classification,the grading of ascites,with or without hepatic encephalopathy before the treatment and the grading of the hepatic encephalopathy,previous history of variceal bleeding,and laboratory test results(alanine aminotransferase,aspartate aminotransferase,glutamyl transpeptidase,alkaline Phosphatase,total Bilirubin,albumin,serum creatinine,prothrombin time,international normalized ratio,white blood cell,haemoglobin,platelet,follow-up time)were recorded.Low-molecular-weight heparin was prescribed twice daily for 1 week,and then switched to warfarin at an initial dose of 2.5 mg daily to reach a target international normalized ratio(INR)of 2-3.Warfarin was prescribed for an additional 6 months to those who had a successful TIPSinsertion.In the EVL group neither anticoagulation nor sclerotherapy was used.Propranolol was initially administered at a dose of 20 mg/d in the EVL group and generally,the dose rose if patient could tolerate it and systolic blood pressure was at 90 mm/Hg or higher,and a static heart rate of at least 55 beats/min was reached.In our study,in the TIPS group,the handling of patients with variceal bleeding in our hospital followed a standardized protocol,which includes regular visits to physicians at week 1,and month 1,3 and 6 and then every 6 months after procedure,laboratory test results,color Doppler ultrasound and CT were necessary.If the ultrasound shows the shunt dysfunction,portography was necessary to make sure if we should dilate the obstructed stent using a balloon or place an additional stent insertion.In the EVL plus propranolol group,Outpatient visits and endoscopic follow-up was performed every 3-6 months.If there were recurrent varices,we must carry out EVL again until all the varices were eliminated.They were followed up until either death or August 2016.The follow-up contents included blood routine,PT,liver function,blood biochemistry,color Doppler ultrasound and CT to see if the stent is patency,the death and the complication(fever,hepatic encephalopathy,recurrent bleeding,ascite),If there is doubt about the shunt dysfunction,portography was necessary.If the portography shows the shunt dysfunction,we should dilate the obstructed stent using a balloon or place an additional stent insertion.And if the patient has recurrent bleeding,inform them to be hospitalized as so as possible,emergency endoscopy was necessary to find the cause of bleeding,and if necessary make the hemostatic treatment.Statistical analyses were performed by using the GraphPad Prism 5.0(GraphPad Software,San Diego,CA,USA).Mean ± standard deviation was used to compare continuous variables,and for the univariate analysis,t test was used to compare the qualitative variables.The Fisher’s exact test and the χ2 test were used to compare the differences between the two groups.The Kaplan-Meier estimates and the logrank test were applied to analyze the survival data.A P value of<0.05 was regarded as statistically significant.Results:There was no significant differences in baseline characteristics and clinical findings between the TIPS and EVL+ propranolol groups.The mean duration of follow-up was 21 months for patients in the TIPS group(range,1-47 month)and 27 months for patients in the EVL group(range,6-73 month).Technical success was achieved in 21of 25 patients(84%)in the TIPS group and in all 26 patients(100%)in the EVL group(P=0.051).In TIPS group,a transjugular approach was successfully performed in 4 patients,14 patients underwent a combined transjugular/percutanous transhepatic approach(with 2 technical failures),and 7 patients received a combined transjugular/percutanous transsplenic approach(with 2 technical failures).The 4 patients with the unsuccessful TIPS underwent EVL.The recurrent variceal bleeding rate was 4.8%(1/21)in the TIPS group,and 26.9%(7/26)in the EVL+ propranolol group,The recurrent variceal bleeding free probability was increased remarkable in the TIPS group compared with the EVL + propranolol group(P =0.047).Three patients 14.3%(3/21)died in the TIPS group,and one 3.8%(1/26)in the EVL+propranolol group,The causes of death included upper gastrointestinal bleeding,hepatic encephalopathy,and progressive liver failure,there were no significant differences in the survival rate(P = 0.305).Hepatic encephalopathy(HE)occurred in 14.3%(3 of 21)of patients in the TIPS group,and 3.8%(1 of 26)in the EVL +propranolol group(p =0.202).Two patients in the TIPS group were Grade 1 and Grade 2 according to West-Haven classification,and after the drug treatment(Lactulose,branched chain amino acid,ornithine aspartate),they were all cured.One patient in the TIPS group was Grade 4 according to West-Haven classification,and after the drug treatment,he was dead,One patient in the EVL +propranolol group was Grade 2 according to West-Haven classification,and after the drug treatment(Lactulose,branched chain amino acid,ornithine aspartate),he was cured.Two patients with initial TIPS success suffered from shunt dysfunction and received an additional stent insertion.Conclusion:In our study,Technical success was reached 84%in the TIPS group,this proved TIPS can not be considered to be contraindication,In conclusion,TIPS was significantly more effective than EVL plus propranolol in preventing rebleeding in cirrhotic patients with CTPV in our study.However,the reduced recurrent variceal bleeding after TIPS did not lead to better survival rates.Enlarging sample is necessary to the further study.It is challenging for gaining access to the portal system in patients with cavernous transformation of the portal vein,selecting a combined transjugular/percutanous transhepatic approach or a combined transjugular/percutanous transsplenic approach according to portography. |
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