Indications and outcomes of transjugular intrahepatic portosystemic shunt insertion in a regional hepatology center

Abstract

Background and Aim: Transjugular intrahepatic portosystemic shunt (TIPS) is an established therapeutic option for treating complications of portal hypertension, including refractory ascites and variceal bleeding. Despite its proven efficacy, TIPS is underused in the majority of hospitals that provide care to patients with chronic liver disease and, in Australia, is largely limited to metropolitan liver units, often liver transplant centers. Patients in regional centers are potentially disadvantaged by limited access to this procedure, particularly as the burden of cirrhosis continues to grow. We evaluated the experience of a single regional Australian institute with regard to TIPS, exploring the indications and clinical outcomes, and comparing our data with those reported by larger Australian institutions. Methods: A retrospective analysis was conducted of patients treated with TIPS at a single regional hepatology unit in Queensland between January 2017 and December 2018. Comparison of pre- and post-TIPS data were conducted using the Wilcoxon signed rank test. Results: Ten patients underwent TIPS during this period (Table 1). There was a significant reduction in median portosystemic gradient after TIPS from 14 mmHg (IQR, 11.5–18) to 6 mmHg (IQR, 2–9.2) (P = 0.004). In patients who underwent TIPS for refractory ascites (n = 4), the median number of paracenteses undertaken per patient reduced from 14 (4–16) in the year before TIPS to 1.5 (0–3.75) after TIPS (P = 0.125). At the time of the last follow up, no patient had an ongoing requirement for paracentesis, and 75% of patients achieved freedom from diuretics. In patients who received TIPS for treatment or secondary prevention of variceal bleeding (n = 5), 100% of patients achieved freedom from variceal rebleeding, and no further endoscopic procedures were required for this indication (Fig. 1). Twenty percent of patients developed medically managed hepatic encephalopathy. There were no deaths or hepatic decompensation. There was a dramatic reduction in hospital admission days for complications of cirrhosis, from a total of 154 days before TIPS to 17 days after TIPS (P = 0.02). This was associated with significant cost savings for our unit. Clinical outcomes from our unit were comparable to those in published data from larger Australian centers, with no increase in adverse events. Conclusion: TIPS can be performed successfully and safely in regional centers, with outcomes comparable to those in large metropolitan liver units.