Published online Apr 28, 2017. doi: 10.4254/wjh.v9.i12.603
Peer-review started: October 27, 2016
First decision: December 29, 2016
Revised: January 26, 2017
Accepted: March 12, 2017
Article in press: March 13, 2017
Published online: April 28, 2017
To assess for passive expansion of sub-maximally dilated transjugular intrahepatic portosystemic shunts (TIPS) and compare outcomes with maximally dilated TIPS.
Polytetrafluoroethylene covered TIPS (Viatorr) from July 2002 to December 2013 were retrospectively reviewed at two hospitals in a single institution. Two hundred and thirty patients had TIPS maximally dilated to 10 mm (mTIPS), while 43 patients who were at increased risk for hepatic encephalopathy (HE), based on clinical evaluation or low pre-TIPS portosystemic gradient (PSG), had 10 mm TIPS sub-maximally dilated to 8 mm (smTIPS). Group characteristics (age, gender, Model for End-Stage Liver Disease score, post-TIPS PSG and clinical outcomes were compared between groups, including clinical success (ascites or varices), primary patency, primary assisted patency, and severe post-TIPS HE. A subset of fourteen patients with smTIPS underwent follow-up computed tomography imaging after TIPS creation, and were grouped based on time of imaging (< 6 mo and > 6 mo). Change in diameter and cross-sectional area were measured with 3D imaging software to evaluate for passive expansion.
Patient characteristics were similar between the smTIPS and mTIPS groups, except for pre-TIPS portosystemic gradient, which was lower in the smTIPS group (19.4 mmHg ± 6.8 vs 22.4 mmHg ± 7.1, P = 0.01). Primary patency and primary assisted patency between smTIPS and mTIPS was not significantly different (P = 0.64 and 0.55, respectively). Four of the 55 patients (7%) with smTIPS required TIPS reduction for severe refractory HE, while this occurred in 6 of the 218 patients (3%) with mTIPS (P = 0.12). For the 14 patients with follow-up computed tomography (CT) imaging, the median imaging follow-up was 373 d. There was an increase in median TIPS diameter, median percent diameter change, median area, and median percent area change in patients with CT follow-up greater than 6 mo after TIPS placement compared to follow-up within 6 mo (8.45 mm, 5.58%, 56.04 mm2, and 11.48%, respectively, P = 0.01).
Passive expansion of smTIPS does occur but clinical outcomes of smTIPS and mTIPS were similar. Sub-maximal dilation can prevent complications related to over-shunting in select patients.
Core tip: Sub-maximal dilation of transjugular intrahepatic portosystemic shunts (TIPS) is a method to reduce the risk of over-shunting and hepatic encephalopathy. The current study is a retrospective review to compare clinical outcomes of sub-maximally dilated TIPS (smTIPS) with maximally dilated TIPS (mTIPS) and assess for passive expansion of smTIPS. The study demonstrated that passive expansion of smTIPS does occur, however shunts may not fully expand and expansion may occur even after 6 mo. Clinical outcomes of smTIPS and mTIPS were similar, suggesting sub-maximal dilation may be an acceptable method to prevent complications related to over-shunting in select patients.