Transjugular Intrahepatic Portosystemic Shunt Creation in 151 Patients with MELD Scores ≥ 20 with shunt sizes of 6-, 8-, 10- and 12-mm.

Tuesday, March 7, 2023

4:03 PM – 4:12 PM

Location: Phoenix Convention Center, 226ABC

Presenting Author(s)

Howard H. Dabbous, MD

Research Fellow
Emory University

Disclosure(s): No financial relationships to disclose

Author/Co-author(s)

Mohammed Loya, M.D

Assistant Professor
Kaiser Permanente
MC

Mircea Cristescu, MD, MBA

Assistant Professor
Medical College of Wisconsin
Nima Kokabi, MD

Assistant Professor of Radiology
Emory School of Medicine
RS

Ram Subramanian, MD

Professor of Medicine and Surgery
Emory
RF

Ryan Ford, MD

Associate Professor
Emory
GR

Giorgio Roccaro, MD, MSCE

Assistant Professor
Emory Universtiy
JM

Joseph Magliocca, MD

Associate Professor of Surgery
Emory University
WS

Wael E. A Saad, MD, FSIR

Senior Vascular and Interventional Radiologist
National Institute of Health (NIH)
Bill Majdalany, MD FSIR (he/him/his)

Associate Professor of Radiology
University of Vermont Medical Center

Disclosure(s):

Howard H. Dabbous, MD: No financial relationships to disclose

Mohammed Loya, M.D: No financial relationships to disclose

Nima Kokabi, MD: No financial relationships to disclose

Wael E. A Saad, MD, FSIR: No financial relationships to disclose

Bill Majdalany, MD FSIR: Balt USA: Advisory Committee or Review Panel Member (Ongoing)

Purpose:

A Model for End-Stage Liver Disease (MELD) score of greater than 19 is a relative contraindication for transjugular intrahepatic portosystemic shunt (TIPS) creation. Standard TIPS sizes have ranged from 6 mm to 12 mm. Outcomes following TIPS creation of varying sizes in patients with MELD ≥ 20 in the setting of variceal hemorrhage or ascites/hydrothorax were analyzed.

Materials and Methods:

A single-center retrospective review of patients with end-stage liver disease (ESLD), portal hypertensive complications, and MELD ≥ 20 who received TIPS of any size between January 2003 and March 2022 was conducted. Procedure indication, ESLD etiology, and baseline MELD were documented. 8-,10- and 12-mm sizes were created in standard fashion from a right hepatic to portal vein. 6 mm TIPS was created by constraining a Viatorr stent with a previously deployed 6-mm balloon-expandable stent in the parenchymal tract. Outcomes included technical success of TIPS creation, clinical resolution of variceal hemorrhage or decreased ascites/hydrothorax, 90- and 540-day mortality, and 90- and 540 -day liver transplant (LT) rates.

Results:

151 patients with mean age of 53.1 years had ESLD from alcoholic cirrhosis in 60 (40%), viral hepatitis in 34 (23%), NASH in 25 (17%), and a variety in the remainder. TIPS indication was variceal hemorrhage in 69 (46%), ascites/hydrothorax in 67 (44%), and other in 10 (7%). Baseline MELD ranged from 20 to 50 (mean 26.2; median 23). TIPS creation was technically successful in all cases 151 (100%). Clinical success was observed in 51/69 (77%) with variceal hemorrhage and 28/67 (42%) with ascites/hydrothorax. 90-day mortality was 14/34 (41%), 20/73 (27%), 10/21 (48%), and 4/18 (22%) and 540-day mortality was 17/34 (50%), 32/71 (45%), 13/21 (62%), and 10/18 (56%) for TIPS sizes 12-, 10-, 8- and 6-mm respectively. 90-day transplant rate was 8/34 (24%), 13/73 (18%), 5/21 (24%), and 6/18 (33%) and 540-day transplant rate was 12/34 (35%), 17/71 (24%), 5/21 (24%), and 7/18 (39%) for TIPS sizes 12-, 10-, 8- and 6-mm respectively. The mean transplant-free survival for the previous TIPS sizes was 1049-, 735-, 437-, and 224-days, respectively, with a p-value < .0001.

Conclusion: TIPS creation in patients with a MELD score greater than 20 was more successful in resolving variceal hemorrhage than ascites and hydrothorax, across all size TIPS. It is a viable bridge to transplant, with mortality being the lowest in the 6-mm and 8-mm TIPS groups.