Department of Radiology, Division of Vascular and Interventional Radiology, Beth Israel Deaconess Medical Center, Harvard Medical School, WCC 308-B, 1 Deaconess Rd, Boston, MA 02215.
Department of Radiology, Division of Vascular and Interventional Radiology, Massachusetts General Hospital, Harvard Medical School, Boston, MA.
AJR Am J Roentgenol. 2021 May;216(5):1267-1272. doi: 10.2214/AJR.19.22497. Epub 2021 Mar 11.
The purpose of this study was to determine clinical outcomes of patients undergoing TIPS reduction. In this institutional review board-approved, HIPAA-compliant study, all TIPS reductions performed at two institutions from January 1, 2008 to January 31, 2016, were retrospectively identified. Patients were divided into two groups according to pre-TIPS symptoms: volume overload due to ascites or hydrothorax (VO; = 14) or variceal bleeding (VB; = 12). Patient demographics, pre-TIPS model for end-stage liver disease score, pre- and post-TIPS portosystemic gradients, and clinical parameters were recorded. The primary endpoint was change in symptoms of hepatic encephalopathy (HE; West Haven criteria), right heart failure, or liver dysfunction. Secondary endpoints included paracentesis rate for the VO group and rebleeding for the VB group. The degree of HE increased in 24 of 26 patients (92%) after TIPS placement and decreased in 24 of 26 patients (92%) after TIPS reduction. Mean West Haven scores for the VO group decreased after TIPS reduction (from 2.57 ± 0.97 [SD] to 1.07 ± 0.70; < .001). Mean West Haven scores for the VB group also decreased after TIPS reduction (from 2.45 ± 0.89 to 1.27 ± 0.86; = .007). Right heart failure improved in two of three patients (67%), and total bilirubin improved in one of three patients (33%). Follow-up data were available up to median of 134 days (interquartile range, 44-286). TIPS reduction led to an increased paracentesis rate compared with before TIPS placement in four of 14 patients with VO (29%). One patient had a stable paracentesis rate after TIPS reduction compared with before TIPS placement. Variceal rebleeding did not occur in any patients with VB after TIPS reduction. At 54 days after TIPS reduction, one of the 12 patients with VB (9%) experienced hematemesis due to an endoscopically proven band-related ulcer. TIPS reduction successfully resolved HE and refractory right heart failure in most patients. In patients with VB, TIPS reduction with variceal embolization results in a low risk of short-term recurrent VB. However, in patients with VO, ascites may return or worsen after TIPS reduction despite improvement in HE.
本研究旨在确定行经颈静脉肝内门体分流术（TIPS）减压治疗患者的临床转归。本研究经机构审查委员会批准，符合 HIPAA 规定，回顾性分析了 2008 年 1 月 1 日至 2016 年 1 月 31 日在两个机构进行的所有 TIPS 减压治疗。根据 TIPS 治疗前的症状将患者分为两组：腹水或胸腔积液所致容量超负荷（VO；=14 例）或静脉曲张出血（VB；=12 例）。记录患者的人口统计学资料、TIPS 治疗前终末期肝病模型评分、TIPS 治疗前后门体系统梯度以及临床参数。主要终点为肝性脑病（HE；West Haven 标准）、右心衰竭或肝功能障碍症状的变化。次要终点包括 VO 组的腹腔穿刺率和 VB 组的再出血率。26 例患者中有 24 例（92%）在 TIPS 放置后 HE 程度加重，26 例患者中有 24 例（92%）在 TIPS 减压后 HE 程度减轻。VO 组 TIPS 减压后 West Haven 评分中位数降低（从 2.57 ± 0.97[SD]降至 1.07 ± 0.70；<.001）。VB 组 TIPS 减压后 West Haven 评分中位数也降低（从 2.45 ± 0.89降至 1.27 ± 0.86；=0.007）。3 例患者中有 2 例（67%）右心衰竭改善，3 例患者中有 1 例（33%）总胆红素改善。中位随访时间为 134 天（四分位距，44-286）。与 TIPS 治疗前相比，14 例 VO 患者中有 4 例（29%）在 TIPS 减压后行腹腔穿刺术的比例增加。1 例患者 TIPS 减压后与 TIPS 治疗前相比，腹腔穿刺术的比例保持稳定。VB 组患者在 TIPS 减压后均未发生静脉曲张再出血。TIPS 减压后 54 天，12 例 VB 患者中的 1 例（9%）因内镜证实的与 band 相关的溃疡而呕血。TIPS 减压术可成功缓解 HE 和难治性右心衰竭。在 VB 患者中，TIPS 减压联合曲张静脉栓塞术可降低短期复发 VB 的风险。然而，在 VO 患者中，尽管 HE 改善，但 TIPS 减压后腹水可能会再次出现或加重。
