The Impact Of TIPS Combined With Large Spontaneous Portosystemic Shunt Embolization On Hepatic Encephalopathy, Variceal Bleeding And Survival

?Background?Cirrhosis is a chronic, progressive and diffuse injury resulted from different mechanisms. It is the 14 th most common cause of death in adults worldwide and it results in 1.03 million deaths per year worldwide. Infection with hepatitis B virus is the most common cause in most parts of Asia. In recent years, the prevalence of chronic alcoholic liver disease and non-alcoholic fatty liver disease increased greatly owing to the changes in diet and habits. Portal hypertension induced gastrointestinal bleeding and refractory ascites are direct causes of death for patients with cirrhosis. Transjugular intrahepatic portosystemic shunt(TIPS) has been recommended as the mainstay treatment option for the complications of portal hypertension in liver cirrhosis by the the European Association for the Study of the Liver(EASL) and American Association for the Study of Liver Diseases(AASLD). Shunt dysfunction and hepatic encephalopathy(HE) are two complications after TIPS. Notably, the rate of shunt dysfunction has reduced from 44% to 13% after the use of covered stents. But the rate of HE is still as high as 36.6% after TIPS, especially for those with large spontaneous portosystemic shunt(SPSS). Several studies has demonstrated that embolization of SPSS can reduce the rate of HE effectively. Furthermore, there is rare data about whether or not TIPS combined with SPSS embolization can reduce the rate of HE without increasing the rate of variceal bleeding. ?Aims?To explore the safety and feasibility of TIPS combined with large SPSS embolization for variceal bleeding in liver cirrhosis. ?Methods?This study retrospectively included consecutive cirrhotic patients who received TIPS implantation from January 2010 to June 2014 who had large SPSS(the diameter of SPSS > 1/2 the diameter of portal vein trunk) confirmed by image study or portography. The patients were divided into embolization group and non-embolization group according whether or not received embolization of large SPSS. Comparisons between both groups were made by the Kaplan�Meier method for incidence of recurrent encephalopathy, rebleeding and survival. Cox's proportional hazards regression model was used for analyzing the independent risk factors. ?Results?74 cirrhotic patients with large SPSS(the diameter of SPSS > 1/2 the diameter of portal vein trunk) were included finally. The success rate of TIPS was 100%?There are 45 patients in the embolization group and 29 patients in the non-embolization group. There is no significant difference for the baseline characteristics between two groups. The mean follow-up period was 44.5 months and 41.1 months. Total of 33 patients had hepatic encephalopathy during follow-up. The 6 months, 1 year, 3 years cumulative incidence of patients without HE were 77.3%, 72.7%, 70.5%, respectively in embolization group. The 6 months, 1 year, 3 years cumulative incidence of patients without HE were 55.2%,51.7%,37.9%,respectively in the non-embolization group. There were significant difference between this two groups(P = 0.011). Total of 17 patients had variceal rebleeding during follow-up with 10 in the embolization group and 7 in the non-embolization group. The 6 months, 1 year and 3 years cumulative incidence of patients without HE were 93.3%,91.1% and 84.4%, respectively in embolization group. The 6 months, 1 year and 3 years cumulative incidence of patients without HE were 93.1%,82.8% and 79.3%, respectively in the non-embolization group. There were no significant difference between this two groups(P = 0.609). Albumin, INR and Child-Pugh score were significantly associated with the incidence of rebleeding. Total of 21 patients died during follow-up. The 6 months, 1 year and 3 years cumulative incidence of patients without HE were 95.6%,88.9% and 82.2%, respectively in embolization group. The 6 months, 1 year and 3 years cumulative incidence of patients without HE were 85.7%,78.6% and 75%, respectively in the non-embolization group. There were no significant difference between this two groups(P = 0.777). Only Child-Pugh score were significantly associated with survival(P=0.014,HR: 1.348, 95%CI: 1.062-1.711).?Conclusions? TIPS combined with large SPSS embolization should be considered a safe and effective method for cirrhotic patients with large SPSS. Large SPSS embolization can significantly reduce the risk of post-TIPS HE without significant increase the risk of variceal bleeding. However, survival was not significant influenced. Liver function was independent risk factors for variceal bleeding and the survival. So we should try our best to embolize large SPSS during TIPS according to the results which needs further studies to confirm.