Clinical Study Of TIPS In The Treatment Of Portal Vein Thrombosis With Gastrointestinal Bleeding In Patients With Cirrhosis

Objective: To analyze the clinical and therapeutic characteristics of transjugular intrahepatic portosystemic shunt(TIPS)in the treatment of patients with portal vein thrombosis(PVT)associated with gastrointestinal bleeding in cirrhosis.At the same time,to evaluate the effect of TIPS in preventing rebleeding in patients with different types of PVT and the occurrence and survival of postoperative complications in order to provide guidance for clinical practice.Methods:The clinical data of patients with decompensated liver cirrhosis treated by TIPS in the First Affiliated Hospital of Kunming Medical University from October2018 to October 2022 were collected retrospectively.Finally,193 patients were included.According to the presence or absence of PVT,118 patients were divided into non-PVT group and 75 patients in PVT group.Preoperative baseline data,blood routine,blood biochemistry,liver function score,imaging data and intraoperative and postoperative data were collected.Follow-up was conducted at 1,3,and 6 months after operation,and then every 6 months to observe the effect of PVT on patients with cirrhosis and the effect of TIPS.At the same time,PVT patients were divided into 34 patients with type I thrombosis,25 patients with type II thrombosis,and 16 patients with type III thrombosis according to Yerdel classification.The clinical characteristics and postoperative effects of the three groups of patients were analyzed and compared,and the factors affecting the prognosis of the patients were analyzed.Results: 1.Clinical and therapeutic characteristics of patients with cirrhosis with or without PVTThe proportion of patients with cirrhosis and PVT undergoing splenectomy or partial splenic artery embolization was higher(P=0.023).There was a difference in the constituent ratio of Child-Pugh rating between the two groups(P<0.001).In terms of liver function reserve,the Child-Pugh score,model for end-stage liver disease(MELD)score and MELD-Na+ score of patients with cirrhosis and PVT were higher than those of patients without PVT(P<0.05).In terms of coagulation indexes,prothrombin time(PT),international normalized ratio(INR)and D dimer in patients with cirrhosis and PVT were higher than those in patients without PVT(P<0.05).In addition,in terms of inflammatory index,interleukin-6(IL-6)in PVT group was higher than that in non-PVT group(P=0.031).In other indicators,there was no significant difference between the two groups(P>0.05).The portal vein pressure of patients in both groups decreased after TIPS(P<0.001).For intraoperative embolization of gastric coronary vein,the proportion of embolization in liver cirrhosis with PVT group was lower than that in non-PVT group(P=0.047).In terms of postoperative efficacy,the incidence of overt hepatic encephalopathy in cirrhosis with PVT group(33.3%)was higher than that in non-PVT group(19.5%),and the difference was statistically significant(P=0.030).However,there was no significant difference in survival rate,rebleeding rate,stent failure rate,and rethrombosis rate after operation(P>0.05).2.Clinical and therapeutic characteristics of PVT patients with different typesThere were differences in PLR value and Child-Pugh rating constituent ratio among the three types of patients(P<0.05).In terms of other indicators,there was no significant difference among the three types of patients(P>0.05).After TIPS,the portal vein pressure ofthe three types of patients decreased(P<0.001).However,there was no significant difference in survival rate,rebleeding rate,incidence of overt hepatic encephalopathy,stent failure rate,thrombus recanalization rate and rethrombosis rate among the three types of patients(P>0.05).3.Analysis of univariate and multivariate factors affecting the efficacy of liver cirrhosis patients with PVTThe results showed that the absolute value of portal vein pressure drop(P=0.045)was an independent predictor of death after TIPS.The rebleeding after TIPS was independently associated with high preoperative white blood cell count(P=0.041).Multivariate analysis of the occurrence of overt hepatic encephalopathy after TIPS showed that the elderly(P=0.019)and the preoperative high white blood cell count(P=0.004)were closely related to the occurrence of overt hepatic encephalopathy after TIPS.This study also found that low preoperative hemoglobin(Hb)count(P=0.019)was associated with an increased risk of stent failure after TIPS.The results of multivariate analysis of complete recanalization of thrombus after TIPS showed that patients with faster flow velocity of the anterior portal vein were more likely to achieve complete recanalization(P=0.014).However,the multivariate analysis of rethrombosis showed that the history of splenectomy or partial splenic embolization(PSE)before operation(P=0.044)were closely related to thrombosis.Conclusions: 1.The incidence of overt hepatic encephalopathy after TIPS in cirrhosis with PVT group was higher than that in non-PVT group.However,there was no significant difference in postoperative survival rate,rebleeding rate,stent failure rate and rethrombus formation rate between the two groups.Patients with PVT can achieve a significant decrease in portal vein pressure after operation.And it has been preliminarily confirmed that TIPS is feasible and effective in the treatment of liver cirrhosis PVT with gastrointestinal bleeding;2.Patients with cirrhosis combined with PVT are classified into three types based on Yerdel classification.There was no significant difference in the efficacy characteristics of TIPS among the three types of patients.But the portal vein pressure of the three types of patients decreased significantly after operation;3.Compared with the non PVT group,patients in the PVT group with cirrhosis have poorer liver function reserve.Patients who have previously undergone splenectomy or PSE are more likely to develop PVT;4.The absolute decrease in preoperative high portal vein pressure in patients in the PVT group is an independent predictor of postoperative mortality in TIPS.High preoperative white blood cell count levels are independently associated with postoperative rebleeding;5.The older the patients in PVT group,the higher the level of white blood cell count before operation,and the more likely to develop OHE after TIPS.Low preoperative Hb count is an independent predictor of postoperative stent dysfunction.In addition,patients with faster preoperative portal vein flow were more likely to achieve complete recanalization,while patients with a history of splenectomy or PSE were more likely to develop rethrombosis.