经颈静脉肝内门体分流术后分流道失功再通肝硬化患者预后影响因素分析

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

目的 探讨影响经颈静脉肝内门体分流术(TIPS)后分流道失功行再通的肝硬化患者的预后及危险因素分析。方法 回顾性分析2013年1月-2019年2月南京大学医学院附属鼓楼医院收治的因肝硬化食管胃底静脉曲张破裂出血行TIPS术,且术后因分流道失功行再通的69例患者的临床资料,包括患者初次TIPS和再通术中、术前及术后资料;支架参数、门静脉压力梯度、门静脉穿刺部位、实验室指标等。Kaplan-Meier曲线评估再通后患者的累积分流道失功率和生存率,2组间累积通畅率比较采用log-rank检验。Cox回归模型分析影响再通患者术后发生分流道再失功和生存的影响因素。结果 69例患者再通术后28例(40.6%)发生再失功,15例(21.7%)死亡。再失功中位时间11.3个月。患者1、2、3、5年再失功的累积发生率分别为29.8%、41.6%、48.0%、52.7%,累积生存率分别为96.9%、94.8%、83.0%和62.6%。单纯行支架内球囊扩张术患者与行支架置入术患者累积通畅率比较差异有统计学意义(χ^2=9.494,P=0.009)。初次TIPS前肝功能CTP分级、初次手术支架直径、再通前INR和PT水平与再失功相关(P值均<0.05),再通前INR升高是分流道再失功的独立危险因素[风险比(HR)=4.398, 95%可信区间(95%CI):1.848~10.467, P=0.001];再通术中置入支架是分流道再失功的独立保护性因素 (HR=0.370, 95%CI: 0.194~0.704, P=0.002)。初次TIPS术前CTP分级和MELD评分与再通后患者生存相关(P值均<0.05),MELD评分升高是再通后患者死亡唯一的独立危险因素 (HR=1.293, 95%CI: 1.054~1.627, P=0.026)。结论 对于TIPS术后分流道失功行再通术的患者,再通术中置入支架是更合理的选择,而MELD评分升高提示着患者预后较差。

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 February 2019 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 (χ^2=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.