Multivariate Analysis Of 331 Cases Of Cirrhosis And Portal Hypertension After TIPS Operation

Objectives:To evaluate the survival of patients with TIPS,changes in liver function,hepatic encephalopathy,alimentary tract rebleeding,stent patency,and its influencing factors in order to evaluate the long-term efficacy and safety of the patients,to investigate whether the liver cirrhosis patients need anti blood plate treatment after TIPS,and whether the drug is in the presence of portal vein thrombosis.Whether the long-term use of antiplatelet drugs after TIPS will affect the patency of the stent and the different regimens of antiplatelet therapy after TIPS.Methods:A total of 331 patients with cirrhosis and portal hypertension who underwent TIPS from January 2006 to the end of December 2017 in Department of Gastroenterology,Second Affiliated Hospital of Kunming Medical University were collected.The follow-up date for all patients was January,2018,with a maximum duration of 12 years.At the end of the operation,anticoagulant therapy was given during the discharge period:the patients were routinely using low molecular weight heparin calcium 4200IU,12h/times within 7 days after operation,and no low molecular weight heparin(LMWH)was used for patients with postoperative platelet counts less than 30×109/L.After 7 days of surgery,for patients with platelet counts above 100×109/L,Clopidogrel Bisulfate Tablets 75mg once daily or Aspirin Enteric-coated Tablets 75mg once a day.Postoperative platelet count in patients with 50?100×109/L,Clopidogrel Bisulfate Tablets 50mg once daily or 50mg Aspirin Enteric-coated Tablets once a day.Postoperative platelet count in patients with 30?50 x109/L,Clopidogrel Bisulfate Tablets 25mg once daily or 25mg Aspirin Enteric-coated Tablets once a day.For patients whose platelet count was less than 30×109/L or INR value was greater than 2,no antiplatelet drugs were used.After discharge,the coagulation function was monitored regularly.If there were nosebleed,oral gingival bleeding,or obvious bleeding tendency,anticoagulant drugs were stopped or the treatment was adjusted in time.Inhibition of gastric acid,antiemetic,use of gastric mucosal protective agents.The portal vein thrombosis and stent thrombosis were monitored every week after operation and during discharge.The patients were divided into cirrhosis group and PVT group and cirrhosis group without PVT group.To study the risk factors of PVT in patients with liver cirrhosis by statistical method,and to study the effect of anticoagulation on the changes of PVT in the patients with PVT after the operation of cirrhosis combined with the PVT group and the liver cirrhosis without PVT.Postoperative stent patency was followed up mainly by abdominal color Doppler ultrasound,and hepatic encephalopathy,rebleeding and patient survival were observed.Results:1.A total of 331 patients were included in our study.All 331 patients successfully completed TIPS,with a total of 387 stent implantation,315 coated stent(6 mm 4,7 mm 23,8 mm 265,10 mm 23)and 315 bare scaffolds.There were 137 cases of Child-pugh grade A,175 cases of Child-pugh B grade,and 19 cases of Child-pugh C grade.317 cases had history of hematemesis,including 153 cases of ascites,93 cases of refractory ascites,69 cases of pleural effusion,and 21 cases of severe ascites.There were 96 cases of ascites and 32 cases of postoperative pleural effusion after TIPS operation*The venous pressure gradient decreased from preoperative(31.22 ±0.3602)mm Hg to postoperative(21.47 ± 0.3414)mm Hg,and the difference was statistically significant(t=19.63,P<0.001).7%of patients had hypertension before operation and 18%suffered from diabetes.2.During the follow-up period,144 patients died.The death of the patients was mainly composed of 30%gastrointestinal bleeding,21%of hepatic encephalopathy,18%of liver failure,15%of liver cancer,6%of lung and abdominal infection.3.During the follow-up period,the total stent patency rate was 106 and the total patency rate was 68%.The main causes of obstruction were portal vein cap 40%,hepatic vein stenosis 22%and hepatic vein cap 20%.Two operations were performed in 89 patients with impermeable stents.Most of the patients underwent balloon dilatation,stent reimplantation,and varicose vein embolization for two operations.23 patients only used balloon dilatation,16 patients only used varicose vein embolization,22 patients used balloon dilatation and stent reimplantation at the same time,28 patients used the three operations simultaneously.4.During the follow-up period,there were 81 cases of hepatic encephalopathy,with a total incidence of 24.2%.84 cases of Child-Pugh A,14 cases of hepatic encephalopathy,160 cases of Child-Pugh B,28 cases of hepatic encephalopathy,87 cases of Child-Pugh C,39 cases of hepatic encephalopathy.Early(1 years)after TIPS was the peak of HE.5.During the follow-up period,66 cases of postoperative bleeding were reported.Postoperative bleeding was mainly caused by stent obstruction and bleeding of the esophagogastric base.6.Among the TIPS patients,there were 69 patients with pleural effusion and 153 patients with ascites..During the follow-up period,the total effective rate of postoperative remission was 94%,75%of them were completely effective,and 19%of them were effective.The total effective rate of postoperative remission was 86%,of which 51%were completely effective and 35%of them were effective.7.Preoperative thrombus group consisted of 92 patients,including 70 males,22 females,76%males,and 160 males,79 females and 67%male patients in the non thrombus group.The combination of thrombus composition was also different.Preoperative thrombus composition was composed mainly of portal vein and superior mesenteric vein thrombosis(28 cases),as well as the combination of left,right and portal vein thrombosis(12 cases).Preoperative PT and APTT were the independent factors of preoperative thrombosis.We found that the coagulation function of the preoperative thrombus group was worse than that of the non thrombus group.Cox test results of postoperative drug and thrombus found that thrombotic drugs were the most likely to lead to thrombosis,aspirin group and the slowest in the clopidogrel group.There were 45 cases in the drug group,which accounted for 17.3%of the total number of drugs outside the hospital,and 36 cases in the non hospital group,accounting for 50.9%.There was a significant difference between the two groups.8.In 331 patients,84 patients with grade Child-pugh a were followed up for 3 years before and after TIPS.The Child-pugh score increased 1 weeks,lmonth,3month and 6month after operation,and the difference was statistically significant.AST and ALT increased significantly in 3month and 3 years after operation.Serum albumin level increased at third months postoperatively,then decreased in third years.Of 160 patients with Child-pugh B.The Child-pugh score at each time point was significantly lower than that before operation.Both AST and ALT showed a tendency to increase first and then decrease,of which AST increased in1month,6month,2 years after operation,decreased in 3 years after operation,and ALT increased in 3month after operation,and decreased in 3 years after operation.Of 87 patients with Child-pugh C.The Child-pugh score of 2 years after operation was slightly lower than that before operation,and the difference was statistically significant.AST decreased significantly in 1 month,1 and 3 years after operation.ALT was similar to AST and decreased significantly in 1 month,1 and 3 years after operation.There was no significant difference in serum albumin,total bilirubin and PT time before and after operation.Conclusions:1.TIPS can effectively relieve the portal hypertension.2.Preoperative splenectomy history is an independent factor affecting postoperative stent penetration.The rates of postoperative patency after splenectomy and splenectomy were 52%and 80.4%respectively.3.Early postoperative period(less than 1 years)after TIPS was the peak period of HE,and the location of portal vein and Child-Pugh grading were the independent factors affecting the occurrence of HE.4.Postoperative stent patency and discharge antiplatelet therapy are independent factors affecting postoperative bleeding.5.Preoperative Child-Pugh score is an independent factor of postoperative ascites loss.6.Preoperative thrombus composition was composed mainly of portal vein and superior mesenteric vein thrombosis combination,as well as the combination of left,right and portal vein thrombosis(12 cases).Before operation,PT and APTT were independent factors of preoperative thrombus.Antiplatelet therapy is the independent factor of preoperative thrombus disappearance.Concomitant diseases and postoperative antiplatelet are independent factors that affect postoperative thrombosis7.The Child-pugh score of Child-pugh a patients was higher and then decreased following the postoperative time.The Child-pugh score in Child-pugh B and C patients showed a slow decrease with the postoperative time.