Centre for Liver Research, Institute of Biomedical Research, University of Birmingham, Birmingham, United Kingdom.
Liver Transpl. 2011 Jul;17(7):771-8. doi: 10.1002/lt.22281.
The role of transjugular intrahepatic portosystemic shunt (TIPS) insertion in managing the complications of portal hypertension is well established, but its utility in patients who have previously undergone liver transplantation is not well documented. Twenty-two orthotopic liver transplantation (OLT) patients and 44 nontransplant patients (matched controls) who underwent TIPS were analyzed. In the OLT patients, the TIPS procedure was performed at a median of 44.8 months (range = 0.3-143 months) after transplantation. Eight (36.4%) had variceal bleeding, and 14 (63.6%) had refractory ascites. The underlying liver disease was cholestatic in 10 (45.4%) and viral in 4 (18.2%). The mean pre-TIPS Model for End-Stage Liver Disease (MELD) score was 13.4 ± 5.1. There were no significant differences in age, sex, indication, etiology, or MELD score with respect to the control group. The mean initial portal pressure gradients (PPGs) were similar in the 2 groups (21.0 versus 22.4 mm Hg for the OLT patients and controls, respectively), but the final PPG was lower in the control group (9.9 versus 6.9 mm Hg, P < 0.05). The rates of both technical success and clinical success were higher in the control group versus the OLT group [95.5% versus 68.2% (P < 0.05) and 93.2% versus 77.2% (P < 0.05), respectively]. The rates of complications and post-TIPS encephalopathy were similar in the 2 groups, and there was a trend toward increased rates of shunt insufficiency in the OLT group. The mortality rate of the patients with a pre-TIPS MELD score > 15 was significantly higher in the OLT group [hazard ratio (HR) = 4.32, 95% confidence interval (CI) = 1.45-12.88, P < 0.05], but the mortality rates of the patients with a pre-TIPS MELD score < 15 were similar in the 2 groups. In the OLT group, the predictors of increased mortality were the pre-TIPS MELD score (HR = 1.161, 95% CI = 1.036-1.305, P < 0.05) and pre-TIPS MELD scores > 15 (HR = 5.846, 95% CI = 1.754-19.485, P < 0.05). In conclusion, TIPS insertion is feasible in transplant recipients, although its efficacy is lower in these patients versus control patients. Outcomes are poor for OLT recipients with a pre-TIPS MELD score > 15.
经颈静脉肝内门体分流术（TIPS）在治疗门脉高压症并发症方面的作用已得到充分证实，但在已接受肝移植的患者中，其应用效果尚未得到充分证实。对 22 例原位肝移植（OLT）患者和 44 例非移植患者（匹配对照组）进行了 TIPS 分析。在 OLT 患者中，TIPS 手术在移植后中位数为 44.8 个月（范围= 0.3-143 个月）进行。8 例（36.4%）有静脉曲张出血，14 例（63.6%）有难治性腹水。基础肝病为胆汁淤积性 10 例（45.4%）和病毒性 4 例（18.2%）。术前终末期肝病模型（MELD）评分的平均值为 13.4±5.1。与对照组相比，年龄、性别、适应证、病因或 MELD 评分在两组间无显著差异。两组初始门静脉压力梯度（PPG）相似（OLT 患者和对照组分别为 21.0 和 22.4mmHg），但对照组最终 PPG 较低（9.9 与 6.9mmHg，P<0.05）。对照组的技术成功率和临床成功率均高于 OLT 组[95.5%比 68.2%（P<0.05）和 93.2%比 77.2%（P<0.05）]。两组并发症和 TIPS 后脑病的发生率相似，OLT 组分流不足的发生率呈上升趋势。术前 MELD 评分>15 的患者的死亡率在 OLT 组明显较高[风险比（HR）=4.32，95%置信区间（CI）=1.45-12.88，P<0.05]，但术前 MELD 评分<15 的患者在两组间的死亡率相似。在 OLT 组中，增加死亡率的预测因素是术前 MELD 评分（HR=1.161，95%CI=1.036-1.305，P<0.05）和术前 MELD 评分>15（HR=5.846，95%CI=1.754-19.485，P<0.05）。总之，TIPS 植入术在移植受者中是可行的，尽管其疗效低于对照组患者。术前 MELD 评分>15 的 OLT 受者预后较差。
