Transjugular Intrahepatic Portosystemic Shunt For The Prevention Of Recurrent Esophageal Variceal Bleeding In Patients With Cavernous Transformation Of Portal Vein

Background and AimCavernous transformation of portal vein refers to numerous periportal or intrahepatic venous collaterals located in the liver hilum as a result of obstruction of main trunk and/or branches of portal vein.CTPV is also referred to as portal cavernoma,due to the sponge appearance of the portal vein.The onset of collateral vessels occurs 6 to 20 days after portal vein obstruction occurs.Indeed,the formation of these numerous hepatopetal collateral vessels plays a positive role in preserving liver function.However,the collateral veins can not compensate the original portal vein because of the pathophysiological differences and tributaries of portal venous system.The sequelae of CTPV can include variceal bleeding,splenomegaly,ascites,intestinal ischaemia,obstructive jaundice,which negatively affects the prognosis of these patients or excludes patients from liver transplantation.There is no overall prevalence of CTPV.It had been considered as a rare disease in the past.In recent years,with the development of imaging technology and the improvement of understanding of CTPV,the clinical detection rate has significantly increased.Variceal bleeding is a major cause of death in patients with CTPV.Early recurrent bleeding occurs in over 70%patients because of failure to control acute variceal bleeding and marked elevations in portal pressure.Given the high recurrence rate,patients who survive acute variceal hemorrhage should receive prophylactic theraphy to prevent recurrence.However,no effective medication can attenuate portal venous hypertension of CTPV currently.Endoscopic therapy requeirs multiple sessions to achieve successful eradication of variceal veins that is associated with frequent rebleeding from variceal veins and banding ulcers.Moreover,the difficulties of bypass surgery and liver transplantation are much higher.Transjugular intrahepatic portosystemic shunt(TIPS)has been recommend in cirrhotic patients for the treatment of portal hypertension and esophageal variceal bleeding or refractory ascites.However,TIPS may be technically difficult in patients with CTPV.Until some years ago,TIPS was considered contraindicated in patients with CTPV,due to the technical difficulty and serous procedure-related complications.With the improvement of techniques and progression of imaging method,a few researchers have undertaken managing CTPV by TIPS.The reports available in literature are limited in numbers and have assorted cases with and without CTPV.It is still unknown if there are differences in post-TIPS outcomes comparing patients in TIPS success group to those in TIPS failure group.This study aimed to evaluate the feasibility,efficacy and safety of TIPS to prevent recurrent esophageal variceal bleeding in patients with CTPV.To determine whether there are differences in post-TIPS outcomes comparing patients in TIPS success group to those in TIPS failure group.To analyze the predictors associated with the TIPS success,rebleeding,shunt dysfunction,hepatic encephalopathy,and death.MethodsIn the retrospective study,67 consecutive patients receiving TIPS were recruited from January 2011 to December 2016.All patients were diagnosed with CTPV.The indication for TIPS was a previous episode of variceal bleeding.The initial part of the TIPS was performed in a standard fashion.The conventional right internal jugular approach was the first choice to recanalize the occluded portal vein.If indirect portography demonstrated poor or no visualization of the portal vein branches,TIPS was performed via a combined transjugular/transhepatic approach or a combined transjugular/transsplenic approach.Success rates,portosystemic pressure gradient,complications,recurrent variceal bleeding,TIPS patency,hepatic encephalopathy,and death were examined to compare post-TIPS outcomes between patients in TIPS success group and those in TIPS failure group.Logistic regression was used to analyze predictors associated with the TIPS success.Cox regression analysis was performed to analyze predictors associated with the rebleeding,shunt dysfunction,hepatic encephalopathy,and death.IBM SPSS Statistics for Windows,version 22.0(Armonk,New York,USA)was employed to perform all calculation.Results1.TIPS was successfully placed in 56 out of 67 patients with CTPV,with a success rate of 83.6%.No severe complications and procedure-related deaths were observed in patients.TIPS was performed via a transjugular approach alone(n=15),a combined transjugular/transhepatic approach(n=33)and a combined transjugular/transsplenic approach(n=8).The multivariate analysis demonstrated that the degree of thrombosis within left portal vein(Odds ratio[OR]= 0.047,95%confidence interval[CI]= 0.006-0.406)and right portal vein(OR = 0.090,95%CI=0.013-0.616)were the independent predictors associated with TIPS success.2.In TIPS success group,mean portosystemic pressure gradient(PPG)was significantly decreased from 28.09�7.28 mmHg to 17.53�6.12 mmHg after TIPS(P<0.001).The probability of the remaining free recurrent variceal bleeding was 87.0%.The cumulative rates free of variceal rebleeding at the 12th and 24th month were 90.4%and 86.1%,respectively.The multivariate analysis demonstrated that TIPS failure(Hazard Ratio[HR]=12.156,95%CI:2.823-52.342)was the only significant predictor associated with rebleeding.The probability of TIPS patency reached 81.5%.The cumulative rates free of shunt dysfunction at the 12th and 24th month were 83.6%and 79.0%,respectively.In the multivariate analysis,the presence of total SMV thrombosis(HR = 3.691,95%CI:1.299-10.485)and a higher plateletes count(HR = 1.005,95%CI:1.000-1.010)were independent predictors for the development of shunt dysfunction.Hepatic encephalopathy occurrence totalled 27.8%.The cumulative rates free of hepatic encephalopathy at the 12th and 24th were 67.3%and 50.5%,respectively.Hepatic encephalopathy rates have no difference between left branch shunt and right branch shunt(?2=0.807,P=0.668).Child-Pugh score was the only independent predictor(HR= 1.134,95%CI:1.079-1.593).The survival rate was 88.9%.The cumulative survival rates at the 12th and 24th month were 94.3%and 83.2%,respectively.3.In the failed transjugular intrahepatic portosystemic shunt group,4 out of 11 patients died,and 4 experienced further bleeding.The cumulative rates free of variceal rebleeding at the 12 and 24 months in TIPS failure group were 70.0%and 46.7%,respectively;and those in TIPS success group were 90.4%and 86.1%,respectively(P=0.034).The cumulative survival rates at the 12th and 24th month were 56.0%and 56.0%,respectively.The difference was statistically significant between TIPS success and failure groups(P=0.012).The multivariate Cox regression analysis demonstrated that Child-Pugh score(HR=1.856,95%CI:1.110-3.103)and TIPS failure(HR=6.558,95%CI:1.432-30.036)were the significant predictors associated with death.ConclusionTIPS should be considered a safe and feasible alternative therapy to prevent recurrent esophageal variceal bleeding in patients with CTPV,and to achieve clinical improvement.Successful TIPS insertions could effectively decrease the incidence of recurrent esophageal variceal bleeding and improve the overall survival in patients with CTPV after portal vein revascularization.Although TIPS in this patient population is technically more challenging,it is not contradicted.TIPS should be considered in patients with recurrent variceal bleeding and not responding to medical and/or endoscopic treatment due to CTPV.Combining traditional TIPS with transhepatic or transsplenic approach can facilitate technical success.The degree of thrombosis within left portal vein and right portal vein were associated with TIPS success.Child-Pugh score and a TIPS failure were significant predictors associated with death.