Salvage Transjugular Intrahepatic Portosystemic Shunt: Survival and Predictive Factors

To investigate the short and intermediate term survival after salvage TIPS and to identify predictive variables for survival.

Transjugular intrahepatic portosystemic shunt (TIPS) is an effective treatment of portal hypertension-related complications in selected patients. However, survival following salvage TIPS for profuse and persistent bleeding despite endoscopic ligation and maximal medical treatment is not well defined.

Materials and Methods:

This is an IRB-approved retrospective study of 121 patients who underwent salvage TIPS during a 10 year period at an academic tertiary medical center. Clinical, laboratory, and procedural data were collected.  Kaplan-Meier method was used for survival analysis. Multivariate logistical regression by Cox proportional hazards was used for multivariate analysis. Receiver operator curve was used to calculate threshold value.  Binary logistic regression analysis was used to assess odd ratio.

Results:

One hundred twenty one patients, mean age 54 years ± 11, 77% male, underwent salvage TIPS. Mean MELD was 18 ± 7, mean MELD-Na was 19 ± 7, mean MELD3.0 was 20 ± 7. The pre and post TIPS portosystemic gradients were 21 ±7 mmHg and 10 ±4 mmHg respectively. Concurrent variceal embolization in addition to TIPS was performed in 59 patients (49%). Hemorrhage was controlled in 116 patients (96%). Rebleeding rate during hospitalization was 17%. Eleven patients were transplanted within 90days post TIPS. Transplant free survival rates at 30 days and 90 days were 67% and 63% respectively. Overall survival rates at 30 days and 90 days were 67% and 59% respectively. Multivariate analysis showed that the MELD 3.0 score was significantly and independently associated with 90 day transplant free survival (OR 0.76 (95% CI 0.59- 0.99), p-value = 0.05). MELD, MELD-Na, and MOTS did not demonstrate statistical significance as predictors of 90 day transplant free survival, (OR 1.09 (95% CI 0.83- 1.43), p-value = 0.51), (OR 0.75 (95% CI 0.49- 1.1), p-value = 0.17) ,(OR 0.68 (95% CI 0.27- 1.66), p-value = 0.4) respectively. Binary logistical regression analysis found that for every 1-point rise in MELD 3.0 above the threshold (18), the odds of 90-day transplant-free survival decreases by approximately 20% (OR 0.8 (95% CI 0.74- 0.88), p < 0.001).

Conclusion:

Transplant free survival for salvage TIPS at 30 days and 90 days is 67% and 63% respectively. MELD 3.0 score is a statistically significant predictor of 90day transplant free survival and transplant free survival significantly decreases over a MELD3.0 above 18.