确定小直径经颈静脉肝内门体分流术治疗腹水后的最佳门静脉压力梯度：一项回顾性研究。
Determining the optimal portal pressure gradient after small-diameter TIPS for ascites: a retrospective study.
作者信息
Liu Guofeng, Xiao Songchi, Wang Xiaoze, Shen Yi, He Yuping, Yang Li, Luo Xuefeng
机构信息
Department of Gastroenterology and Hepatology, Sichuan University-University of Oxford Huaxi Joint Centre for Gastrointestinal Cancer, West China Hospital, Sichuan University, Chengdu, Sichuan, People's Republic of China.
Department of Gastroenterology and Hepatology, Sichuan University-University of Oxford Huaxi Joint Centre for Gastrointestinal Cancer, West ChinaHospital, Sichuan University, 37 Guoxue Lane, Chengdu, Sichuan 610041, People's Republic of China.
出版信息
Therap Adv Gastroenterol. 2025 Sep 10;18:17562848251372265. doi: 10.1177/17562848251372265. eCollection 2025.
BACKGROUND
The optimal hemodynamic threshold for portal pressure gradient (PPG) following transjugular intrahepatic portosystemic shunt (TIPS) for ascites remains uncertain.
OBJECTIVE
This study aimed to elucidate the relationship between post-TIPS PPG and clinical outcomes in patients undergoing small-diameter (8-mm) TIPS for ascites.
DESIGN
Single-center retrospective study.
METHODS
From June 2015 to June 2023, consecutive patients receiving small-diameter (8-mm) TIPS for refractory or recurrent ascites were considered for inclusion retrospectively. The impact of PPG on clinical outcomes-including ascites response, overt hepatic encephalopathy (OHE), further decompensation, and mortality-was evaluated using Fine and Gray competing risk regression models, both unadjusted and adjusted for potential confounders.
RESULTS
A total of 143 patients were included in the analysis, of whom 65.7% had refractory ascites, with a median Child-Pugh score of 9. Receiver operating characteristic (ROC) curve analysis identified post-TIPS PPG as a reliable predictor of ascites response (cutoff: 10.5 mmHg, area under curves (AUC): 0.733, < 0.001) and OHE (cutoff: 7.5 mmHg, AUC: 0.716, < 0.001). Univariate and multivariate Fine and Gray competing risk regression analyses further revealed that patients with PPG between 8 and 10 mmHg had favorable outcomes, including a lower incidence of ascites (>10 vs 8-10 mmHg: hazard ratio (HR) = 5.74, 95% confidence interval (CI) 2.11-15.58, < 0.001), a reduced risk of OHE (<8 vs 8-10 mmHg: HR = 2.87, 95% CI 1.29-6.35, = 0.010), and a decreased risk of further decompensation (>10 vs 8-10 mmHg: HR = 2.78, 95% CI 1.43-5.41, = 0.003; <8 vs 8-10 mmHg: HR = 2.42, 95% CI 1.20-4.90, = 0.014) after TIPS placement.
CONCLUSION
This study revealed that post-TIPS PPG was associated with clinical outcomes in patients with refractory or recurrent ascites undergoing small-diameter TIPS. A post-TIPS PPG of 8-10 mmHg seems to be the optimal range, effectively controlling ascites without significantly increasing the risk of shunt-related hepatic encephalopathy, while also reducing the risk of further decompensation.
背景
经颈静脉肝内门体分流术（TIPS）治疗腹水后门静脉压力梯度（PPG）的最佳血流动力学阈值仍不确定。
目的
本研究旨在阐明接受小直径（8毫米）TIPS治疗腹水患者的TIPS术后PPG与临床结局之间的关系。
设计
单中心回顾性研究。
方法
回顾性纳入2015年6月至2023年6月连续接受小直径（8毫米）TIPS治疗难治性或复发性腹水的患者。使用Fine和Gray竞争风险回归模型评估PPG对临床结局的影响，包括腹水反应、显性肝性脑病（OHE）、进一步失代偿和死亡率，未调整和调整潜在混杂因素。
结果
共143例患者纳入分析，其中65.7%为难治性腹水，Child-Pugh评分中位数为9。受试者工作特征（ROC）曲线分析确定TIPS术后PPG是腹水反应（临界值：10.5 mmHg，曲线下面积（AUC）：0.733，P<0.001）和OHE（临界值：7.5 mmHg，AUC：0.716，P<0.001）的可靠预测指标。单因素和多因素Fine和Gray竞争风险回归分析进一步显示，PPG在8至10 mmHg之间的患者预后良好，包括腹水发生率较低（>10 vs 8-10 mmHg：风险比（HR）=5.74，95%置信区间（CI）2.11-15.58，P<0.001），OHE风险降低（<8 vs 8-10 mmHg：HR=2.87，95%CI 1.29-6.35，P=0.010），TIPS置入后进一步失代偿风险降低（>10 vs 8-10 mmHg：HR=2.78，95%CI 1.43-5.41，P=0.003；<8 vs 8-10 mmHg：HR=2.42，95%CI 1.20-4.90，P=0.014）。
结论
本研究表明，TIPS术后PPG与接受小直径TIPS治疗难治性或复发性腹水患者的临床结局相关。TIPS术后PPG为8-10 mmHg似乎是最佳范围，可有效控制腹水，而不会显著增加分流相关肝性脑病的风险，同时也降低了进一步失代偿的风险。
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