IMPACT OF STENT TYPE ON OUTCOME OF CIRRHOTIC PATIENTS TREATED WITH TRANSJUGULAR INTROHEPATIC PORTOSYSTEMIC SHUNT

Abstract

Paper-1: Introduction: Hepatic encephalopathy (HE) following transjugular intrahepatic portosystemic shunt (TIPS) placement remains a leading adverse event. Controversy remains regarding optimal stent diameter given that smaller stents may decrease the amount of shunted blood and decrease the risk of HE, but stent patency and/or clinical adequacy of portal decompression may also be affected. We aim to provide meta-analysis-based evidence regarding the safety and efficacy of 8-mm vs. 10-mm stents during TIPS placement. Methods: PubMed, EMBASE, Cochrane Library and Web of Science were searched for studies comparing 8-mm and 10-mm stents during TIPS placement for portal hypertension decompression in cirrhotic patients. Randomized controlled trials and cohort studies were prioritized for inclusion. Overall evaluation of quality and bias for each study was performed. The outcomes assessed were prevalence of HE, rebleeding or failure to control refractory ascites, and overall survival. Subgroup analysis based on TIPS indication was conducted. Results: Five studies with a total number of 489 cirrhotic patients were identified. The pooled hazard ratio (HR) of post-TIPS HE was significantly lower in patients in the 8-mm stent group than in the 10-mm stent group (HR:0.68, 95% CI:0.51~0.92, p value.0001). The combined HR of post-TIPS rebleeding/need for paracentesis was significantly higher in patients in the 8-mm stent group than in the 10-mm stent group (HR:1.76, 95% CI:1.22~2.55, p value.0001). There was no statistically significant difference in the overall survival between the 8-mm and 10-mm stent groups. The combined risk of HE in the variceal bleeding subgroup was statistically lower (HR:0.52, CI: 0.34-0.80) with an 8-mm stent compared with a 10-mm stent. The combined risk of both rebleeding/paracentesis and survival was not statistically significant between 8-mm and 10-mm stent use in subgroup analysis. Conclusion: 8-mm stents during TIPS placement are associated with a significant lower risk of HE compared to 10-mm stents (32% decreased risk), but also a 76% increased risk of rebleeding/paracentesis. Meta-analysis results suggest that there is not one superior stent choice for all clinical scenarios, and that the TIPS indication of variceal bleeding or refractory ascites might have different appropriate selection of shunt diameter.

Paper-2: Background and Aims: The survival benefit of covered stents in transjugular intrahepatic portosystemic shunt (TIPS) placement has not been clearly demonstrated. The aim of this study was to investigate whether covered stents offer a survival benefit relative to bare-metal stents (BMS) in general cirrhotic population as well as in subgroup patients stratified with TIPS indication. Methods: We performed a retrospective cohort study of all patients who had a first-time TIPS between 1995 and 2018. A multivariate logistic model including the type of stent, age, portosystemic gradient (PSG) pre-and post-TIPS creation, indication for TIPS (variceal bleeding /refractory ascites), TIPS urgency (selective/emergency), any degree of hepatic encephalopathy (HE), etiology of cirrhosis, model for end-stage liver disease (MELD) score and year of TIPS were used to identify relationship between covered stent and 1-year mortality in general cirrhotic population as well as sub-group of variceal bleeding and refractory ascites. Results: A total of 427 patients were eligible for the study with 312 in covered-stent group and 115 in BMS group. Covered stent placement was associated with significantly reduced odds of mortality by 58% at 1-year post TIPS in multivariate regression model (OR=0.42; p=0.001). The use of a covered stent was associated with decreased odds of mortality by 88% in patients with refractory ascites (OR=0.12; p.001). Conclusions: PTFE-covered stent placement was associated with reduced 1-year mortality compared to BMS in general cirrhotic population. The benefit effect was more remarkable in the subgroups of patients with refractory ascites. Further large-scale hypothesis-driven studies with comparative effectiveness analysis are needed to confirm the present conclusion.