Outcomes and survival after TIPS positioning: a single center experience

Background and aim: Refractory ascites is an accepted indication for transjugular intrahepatic porto-systemic shunt. However, the factors associated with mortality after TIPS positioning for this specific indication are not well established yet. This retrospective analysis was conducted to investigate this issue. Material and methods: Patients who underwent TIPS for refractory ascites in the period 02/2003-01/2008 at our tertiary care Center were identified and were the subjects of our study. Kaplan-Meier curves were used to analyse long term survival. Cox proportional-hazards regression model was performed to assess risk factors for mortality, and factors significant at univariate analysis were entered in a multivariate model to identify independent predictors of mortality. ROC curves were used to define the best cut-off of continuous variables for mortality prediction. Patients who underwent orthotopic liver transplantation were censored at the moment of OLT. P values < 0.05 were considered statistically significant. Results: The study included 73 patients (67% males). Mean age at the time of TIPS creation was 57.4 years (range, 34-76 y). MELD score at the moment of TIPS positioning was 15.7±5.3. Mean survival after TIPS was 17±14 months. 12 patients (16.4%) underwent OLT, and 17 (23.3%) died during follow-up. At univariate analysis, increasing values of MELD score, TIPS Risk Score, AST, bilirubin, INR and HVPG at the time of TIPS placement significantly increased the risk of death on follow-up. In our population age, gender, creatinine and sodium were not associated to mortality. Multivariate analysis showed that MELD score, AST and HVPG were independent predictors of mortality overall. As expected, patients with MELD score <10 (n=6, 16% mortality) had a low probability of death after TIPS; patients with HVPG <16 mmHg (n=6) had no mortality in this study. Maximum risk of death was found in patients with MELD score ≥ 19 (n=16, 31% mortality) and in those with HVPG ≥ 25 mmHg (n=27, 26% mortality). Conclusions: In our experience TIPS allows long survival of the majority of patients treated for refractory ascites. Liver function (assessed by MELD score), necroinflammation (assessed by AST) and portal hypertension (assessed by HVPG) are independent predictors of mortality after TIPS.