Prognostic and risk factors for patients undergoing recanalization due to shunt dysfunction after transjugular intrahepatic portosystemic shunt

Objective To investigate the prognostic and risk factors for cirrhotic patients undergoing recanalization due to shunt dysfunction after transjugular intrahepatic portosystemic shunt( TIPS). Methods A retrospective analysis was performed for the clinical data of 69 cirrhotic patients who were admitted to Affiliated Drum Tower Hospital of Nanjing University Medical School from January 2013 to February2019 and underwent TIPS due to esophagogastric variceal bleeding and recanalization due to shunt dysfunction after TIPS. Related clinical data included preoperative,intraoperative,and postoperative data of TIPS and recanalization,stent parameters,hepatic venous pressure gradient,site of puncture of the portal vein,and laboratory markers. The Kaplan-Meier curve was used to evaluate the cumulative rate of shunt dysfunction and cumulative survival rate after recanalization,and the log-rank test was used for comparison of cumulative patency rate between two groups. The Cox regression model was used to investigate the influencing factors for secondary shunt dysfunction and survival after recanalization. Results Of all patients undergoing recanalization,28( 40. 6%) experienced secondary shunt dysfunction and 15( 21. 7%) died. The median time to secondary shunt dysfunction was 11. 3 months. The 1-,2-,3-,and 5-year cumulative incidence rates of secondary shunt dysfunction were 29. 8%,41. 6%,48. 0%,and 52. 7%,respectively,and the 1-,2-,3-,and 5-year cumulative survival rates were 96. 9%,94. 8%,83. 0%,and 62. 6%,respectively. There was a significant difference in cumulative patency rate between the patients undergoing balloon dilatation of stent alone and those undergoing stent implantation( χ2= 9. 494,P = 0. 009).Child-Turcotte-Pugh( CTP) grade before first TIPS,stent diameter for first surgery,and international normalized ratio( INR) and prothrombin time( PT) before recanalization were associated with secondary shunt dysfunction( all P < 0. 05),and an increase in INR before recanalization was an independent risk factor for secondary shunt dysfunction( hazard ratio [HR]= 4. 398,95% confidence interval [CI]:1. 848-10. 467,P = 0. 001),while stent implantation during recanalization was an independent protective predictor against secondary shunt dysfunction( HR = 0. 370,95% CI: 0. 194-0. 704,P = 0. 002). CTP grade before first TIPS and Model for End-Stage Liver Disease( MELD) score were associated with patients' survival after recanalization( both P < 0. 05),and an increase in MELD score was the only independent risk factor for death after recanalization( HR = 1. 293,95% CI: 1. 054-1. 627,P = 0. 026). Conclusion For patients undergoing recanalization due to shunt dysfunction after TIPS,stent implantation during recanalization is a reasonable choice,while an increase in MELD score is associated with poor prognosis of patients.