Clinical Application Of Gastrorenal Shunt Occlusion In TIPS Combined With Gastric Variceal Embolization

Background and objective:Gastrorenal shunt(GRS)is a special pathological and anatomical feature of gastric varices(GV),which determines the choice of treatment for GV and allows GV connecting to the body circulation.Owing to the existence of GRS,the routine treatment for GV has risk of ectopic embolism.According to Baveno Ⅵ,transjugular intrahepatic portosystemic(TIPS)or balloon-occluded retrograde transvenous obliteration(BRTO)is preferred in the treatment of gastric fundic varices(GOV2 and IGV2).Due to the presence of GRS,portal vein pressure(PVP)in GV is lower than that in EV.So the clinical efficacy of TIPS alone for GV is limited and needs to be combined with variceal embolization to improve clinical outcomes.How to avoid ectopic embolism is still one of the keypoints of TIPS combined with variceal embolization.In our center,TIPS combined with gastric variceal embolization is one of the main treatment in the secondary prevention for GV bleeding.To prevent ectopic embolism in patients with large GRS,during TIPS procedure,GRS was occluded via the left renal vein before variceal embolization to ensure precise embolization.This study retrospectively compared the clinical efficacy and safety of patients with and without GRS occlusion during TIPS,with the aim of evaluating the clinical application of GRS occlusion in TIPS combined with gastric variceal embolization.Materials and methods:Our study retrospectively collected a total of 60 patients who were hospitalized in Shandong Provincial Hospital from January 2010 to September 2020,diagnosed with cirrhotic gastric varices with GRS and underwent TIPS combined with gastric variceal embolization,of whom 28 patients underwent GRS occlusion and 32 patients without GRS occlusion.By reviewing medical records and telephone follow-up,we collected the baseline data.Then,we summarized the technical success rate and observed the incidence of ectopic embolism,postoperative rebleeding,postoperative hepatic encephalopathy(HE),postoperative survival between two groups.SPSS 23.0 software was used for statistical analysis.P<0.05 was statistically significant.Results:1.This study finally included 60 patients with GRS treated by TIPS combined with gastric variceal embolization,of which 28 patients had combined GRS occlusion and 32 patients had no combined GRS occlusion.The technical success rate is 100%in all cases.There were no statistical differences in baseline data between two groups in terms of gender,age,etiology,Child-Pugh score,Child-Pugh classification,MELD score,MELD-Na,portal thrombus,preoperative portal venous pressure,variceal type,PLT,AST,ALT,TBIL,ALB,Cr,Na+,PT prolongation,and INR(P>0.05).However there were statistical differences in preoperative ascites,gastrorenal shunt diameter,WBC,and Hb between two enrolled groups(P=0.020、<0.001、0.047、0.040).The diameter of the gastrorenal shunt was larger in combined occlusion group.The overall ascites was heavier in non-occlusion group.2.Comparison of intraoperative ectopic embolism:There were 2 cases of intraoperative ectopic embolism both occurred in non-occlusion group,no ectopic embolism occurred in combined occlusion group.The rate of intraoperative ectopic embolism was 0%in occlusion group and 6.25%in non-occlusion group.Although there was a trend of reduction in occlusion groups there was no statistical difference in the rate of intraoperative ectopic embolism between two groups(P=0.494).Propensity score matching analysis showed that the rate of ectopic embolism was also not statistically different between two groups(0%vs.13.3%,P=0.483).3.Comparison of postoperative rebleeding:The incidence of rebleeding was 14.3%in occlusion group and 28.1%in non-occlusion group,and there was no statistical difference in postoperative rebleeding between the two groups(P=0.249).Propensity score matching analysis showed no statistical difference in postoperative rebleeding between the two groups(20%vs.33.3%,P=0.636).4.Comparison of postoperative mortality:Postoperative mortality was 10.7%in occlusion group and 18.8%in non-occlusion group,and there was no statistical difference between the two groups(P=0.444).Propensity score matching analysis showed a statistically significant difference in postoperative mortality between two groups(0%vs.33.3%,P=0.024),postoperative mortality in occlusion group is lower than non-occlusion group.5.Comparison of postoperative HE:The incidence of HE was 35.7%in occlusion group and 31.25%in non-occlusion group,and there was no statistical difference between the two groups in postoperative HE(P=0.770).Propensity score matching analysis showed no statistical difference in postoperative HE between two groups(33.3%vs.26.7%,P=0.950).6.Univariate and multifactorial analysis of postoperative rebleeding showed that stent stenosis(HR=6.77,95%CI:1.47-31.09,P=0.014)was an independent risk factor for postoperative rebleeding.7.Univariate and multifactorial analysis of postoperative death showed that intraoperative occurrence of ectopic embolism(HR=27.17,95%Cl:3.44-214.77,P=0.002)was an independent risk factor for postoperative death.8.Univariate and multifactorial analysis of postoperative HE showed that stent stenosis(HR=2.97,95%CI:1.13-7.87,P=0.028)andALT(HR=3.26,95%CI:1.19-8.89,P=0.021)were independent influencing factors for postoperative HE.Conclusion1.This study has not fully confirmed that TIPS combined with GRS occlusion significantly reduces the incidence of intraoperative ectopic embolism.However,in our study,the diameter of GRS in patients enrolled in combined occlusion group was significantly larger than that in non-occlusion group(P<0.001),and no intraoperative ectopic embolism occurred,suggesting that intraoperative combined GRS occlusion in patients with gastric varices complicated by coarse GRS would be more clinically relevant for the prevention of ectopic embolism.2.The postoperative mortality was significantly lower in combined GRS occlusion group than in non-occlusion group,and univariate and multifactorial analysis showed that ectopic embolism was an independent risk factor for postoperative death.It was confirmed that TIPS combined with GRS occlusion could avoid death due to ectopic embolism and improve the safety of operation.