Evaluation of a model to predict poor survival in patients undergoing elective TIPS procedures

Updates on the Model for End-Stage Liver Disease Score and Impact on the Liver Transplant Waiting List: A Narrative Review

The model for end-stage liver disease (MELD) score is an established indicator of cirrhosis severity and a predictor of morbidity and mortality in patients undergoing transjugular intrahepatic portosystemic shunt (TIPS) creation and for allocation in liver transplantation. Since the adoption of the score, its use has been expanded to multiple new indications requiring model modifications, including relevant clinical and demographic variables, to increase predictive accuracy. The purpose of this report is to provide an update on the modifications made to the MELD score, comparing their performance with C statistics, advantages and disadvantages, and impact on mortality at 3 months after placing a TIPS or awaiting liver transplantation.

MELD or MELD-Na as a Predictive Model for Mortality Following Transjugular Intrahepatic Portosystemic Shunt Placement

BACKGROUND AND AIM

The model for end-stage liver disease (MELD) was originally developed to predict survival after transjugular intrahepatic portosystemic shunt (TIPS). The MELD-sodium (MELD-Na) score has replaced MELD for organ allocation for liver transplantation. However, there are limited studies to compare the MELD with MELD-Na to predict mortality after TIPS.

METHODS

We performed a retrospective chart review of patients who underwent TIPS placement between 2006 and 2016 at our institution. The primary outcome was mortality, and the secondary outcomes sought to assess which variables could provide prognostic information for mortality after TIPS placement. We performed receiver operating characteristic (ROC) curve analysis to assess the performance of MELD and MELD-Na.

RESULTS

There were 186 eligible patients in the analysis. The mean pre-TIPS MELD and MELD-Na were 13 and 15, respectively. Overall, mortality after TIPS was 15% at 30 days and 16.7% at 90 days. In a comparison of the areas under the ROCs for MELD and MELD-Na, MELD was superior to MELD-Na for 30-day (0.762 vs. 0.709) and 90-day (0.780 vs. 0.730) mortality after TIPS. The optimal cutoff score for 30-day mortality was 15 (0.676-0.848) for MELD and 17 (0.610-0.808) for MELD-Na, whereas the optimal cutoff score for 90-day mortality was 16 (95% CI: 0.705-0.855) for MELD and 17 (95% CI: 0.643-0.817) for MELD-Na. There were 24 patients with high MELD-Na ≥17, but with low MELD <15, and 90-day mortality in this group was 8.3%.

CONCLUSIONS

Although MELD-Na is a superior prognostic tool to MELD for predicting overall mortality in cirrhotic patients, MELD tended to outperform MELD-Na to predict mortality after TIPS.

A comprehensive review of prognostic scoring systems to predict survival after transjugular intrahepatic portosystemic shunt placement

Patient prognosis after transjugular intrahepatic portosystemic shunt (TIPS) placement is relatively poor and highly heterogeneous; therefore, a prognostic scoring system is essential for survival prediction and risk stratification. Conventional scores include the Child–Turcotte–Pugh (CTP) and model for end‐stage liver disease (MELD) scores. The CTP score was created empirically and displayed a high correlation with post‐TIPS survival. However, the inclusion of subjective parameters and the use of discrete cut‐offs limit its utility. The advantages of the MELD score include its statistical validation and objective and readily available predictors that contribute to its broad application in clinical practice to predict post‐TIPS outcomes. In addition, multiple modifications of the MELD score, by incorporating additional predictors (e.g., MELD‐Sodium and MELD‐Sarcopenia scores), adjusting coefficients (recalibrated MELD score), or combined (MELD 3.0), have been proposed to improve the prognostic ability of the standard MELD score. Despite several updates to conventional scores, a prognostic score has been proposed (based on contemporary data) specifically for outcome prediction after TIPS placement. However, this novel score (the Freiburg index of post‐TIPS survival, FIPS) exhibited inconsistent discrimination in external validation studies, and its superiority over conventional scores remains undetermined. Additionally, several tools display potential for application in specific TIPS indications (e.g., bilirubin‐platelet grade for refractory ascites), and biomarkers of systemic inflammation, nutritional status, liver disease progression, and cardiac decompensation may provide additional value, but require further validation. Future studies should consider the effect of TIPS placement when exploring predictors, as TIPS is a pathophysiological approach that substantially alters systemic hemodynamics and ameliorates bacterial translocation and malnutrition.

30 Jahre transjugulärer intrahepatischer portosystemischer Shunt (TIPS) – Rückblick und Perspektive

Der transjuguläre intrahepatische portosystemische Shunt (TIPS) wird seit 30 Jahren in der Therapie der portalen Hypertonie erfolgreich eingesetzt. In nationalen und internationalen Leitlinien ist die Indikation zur TIPS-Anlage bei Varizenblutung und refraktärem Aszites wissenschaftlich gut belegt und klar definiert. Bei seltenen Indikationen wie dem hepatorenalen Syndrom, der Pfortaderthrombose oder dem neoadjuvanten Einsatz fehlt derzeit noch eine eindeutige Studienlage. Eine wichtige Kontraindikation und klinisch bedeutendste Komplikation nach TIPS ist die hepatische Enzephalopathie (HE). Es wird versucht, die Post-TIPS HE mit technischen Weiterentwicklungen der Stents zu reduzieren.

TIPS for management of portal-hypertension-related complications in patients with cirrhosis

Portal hypertension is primarily due to liver cirrhosis, and is responsible for complications that include variceal bleeding, ascites and hepatorenal syndrome. The transjugular intrahepatic portosystemic shunt (TIPS) is a low-resistance channel between the portal vein and the hepatic vein, created by interventional radiology, that aims to reduce portal pressure. TIPS is a potential treatment for severe portal-hypertension-related complications, including esophageal and gastric variceal bleeding. TIPS is currently indicated as salvage therapy in this setting when patients fail to respond to standard endoscopic and medical treatment. More recently, early TIPS has been shown to be effective in decreasing risk of rebleeding after variceal hemorrhage and mortality in Child-Pugh B patients with active hemorrhage at endoscopy, and in Child-Pugh C patients. TIPS is also an efficient treatment for refractory ascites and hepatic hydrothorax. In contrast, the role of TIPS in the hepatorenal syndrome has not been precisely defined. The aim of this review was to specifically describe the current role of TIPS in management of portal hypertension in patients with cirrhosis.

A Standardized Assessment of Functional Disability Predicts 1-year Mortality in Patients Undergoing Transjugular Intrahepatic Portosystemic Shunt for Refractory Ascites

GOALS

To determine the association between functional disability and mortality after transjugular intrahepatic portosystemic shunt (TIPS).

BACKGROUND

TIPS is a common therapeutic procedure for cirrhotic patients with refractory ascites. The conventional metric for periprocedure risk stratification is the model for end-stage liver disease (MELD), which uses biochemical parameters to predict post-TIPS mortality. It does not account for functional disability.

STUDY

This is a retrospective cohort study of 83 patients admitted at an academic liver transplant center with cirrhosis and refractory ascites for the purpose of TIPS placement. We assessed the association of patients' reported activities of daily living (ADL) on a scale of 1 to 21 before TIPS with a primary outcome of 1-year mortality. Multivariable regression to adjust for MELD and Child class was performed.

RESULTS

A higher ADL score or functional independence, was associated with decreased 1-year mortality when modeled as both a continuous variable [odds ratio (OR), 0.80; 95% confidence interval (CI), 0.66-0.97; P=0.02) and a dichotomous variable (ADL 21 vs. <21; OR, 0.21; 95% CI, 0.05-0.70; P=0.01). After adjusting for MELD and Child class, functional independence was associated with decreased 1-year transplant-free mortality (OR, 0.22; 95% CI, 0.05-0.77; P=0.02). An ADL score consistent with dependence (<21) was significantly associated with a 3.40-day (95% CI, 1.76-5.04) longer hospital stay, adjusting for MELD and Child class (P<0.0001).

CONCLUSIONS

Functional disability is a predictor of post-TIPS mortality and length of stay after controlling for MELD.

Transjugular intrahepatic portosystemic shunt

Transjugular intrahepatic portosystemic shunt (TIPS) is an established procedure for the complications of portal hypertension. The largest body of evidence for its use has been supported for recurrent or refractory variceal bleeding and refractory ascites. Its use has also been advocated for acute variceal bleed, hepatic hydrothorax, and hepatorenal syndrome. With the replacement of bare metal stents with polytetrafluoroethylene-covered stents, shunt patency has improved dramatically, thus, improving outcomes. Therefore, reassessment of its utility, management of its complications, and understanding of various TIPS techniques is important.

The history and future of transjugular intrahepatic portosystemic shunt: food for thought

The origins of transjugular intrahepatic portosystemic shunt (TIPS) date back to the 1960s with inadvertent portal access during the early years of transjugular cholangiography. TIPS is now the most frequently performed portal hypertension decompressive procedure performed by interventional radiologists, and has become the primary portosystemic shunt (surgical or percutaneous) performed in the United States. One of the least discussed major advantages of TIPS in the transplant era is that it is intrahepatic and thus is removed in situ during a liver transplant, while extrahepatic shunts (surgical or percutaneous) have to be ligated or revised during the liver transplantation. However, since the widespread clinical utilization of TIPS in the 1990s, it has been plagued with two major problems, namely, patency and hepatic encephalopathy. With the advent of commercially available expanded polytetraflouroethylenne (e-PTFE) covered stents a decade ago, 12- to 24-month TIPS patency has improved significantly (by ∼20-30%). However, hepatic encephalopathy (although not proven to have increased due to e-PTFE covered stents grafts) remains a significant morbidity problem. The article discusses the history of TIPS, critiques the retrospective encephalopathy data in the literature, and discusses futuristic TIPS-design ideas about the management of post-TIPS hepatic encephalopathy.

TIPS: 25 years later

In the 25 years since the first TIPS intervention has been performed, technical standards, indications, and contraindications have been set up. The previous considerable problem of shunt failure by thrombosis or intimal proliferation in the stent or in the draining hepatic vein has been reduced considerably by the availability of polytetrafluoroethylene (PTFE)-covered stents resulting in reduced rebleeding and improved survival. Unfortunately, most clinical studies have been performed prior to the release of the covered stent and, therefore, do not represent the present state of the art. In spite of this, TIPS has gained increasing acceptance in the treatment of the various complications of portal hypertension and vascular diseases of the liver.

The Effect of Balloon-Occluded Transvenous Obliteration of Gastric Varices and Gastrorenal Shunts on the Hepatic Synthetic Function

Purpose:

To evaluate the effect of balloon-occluded transvenous obliteration (BRTO) on the model for end-stage liver disease (MELD) and the Child-Pugh (C-P) score and their individual components.

Methods:

A retrospective review of patients undergoing only BRTO without transjugular intrahepatic portosystemic shunt was performed (08, 2007 to 06, 2010). Pre- and post-BRTO MELD and C-P scores were calculated. The post-BRTO MELD and C-P score samplings were categorized as (1) immediate (within 14 days), (2) early (14-90 days), and (3) delayed (90-180 days) post-BRTO. The C-P and MELD scores and their individual components before and after (various sample intervals) were compared.

Results:

A total of 29 consecutive successful BRTO procedures were found and assessed. In all, 26 had immediate post-BRTO sampling (average 1.8 days after BRTO), 13 (57%) had an early post-BRTO sampling (average 47 days from BRTO), and 10 (38%) had a delayed post-BRTO sampling (average 121 days from BRTO). The bilirubin rises significantly ( P = .007) within days after BRTO, but synthetic function improves significantly between 1.5 and 4.0 months post-BRTO (international normalized ration: P = .02, bilirubin: P = .027, and albumin: P = .012). However, 31% (N = 8/ 26) of the patients had worsening ascites with or without hydrothorax. The MELD score significantly improved circa 4 months post-BRTO (from 14.1 to 10.7, P = .0008). However, the C-P score did not change significantly (from 7.6 to 6.7, P = .063).

Conclusion:

The BRTO has a positive effect on the hepatic synthetic function. However, there is a high incidence of post-BRTO ascites (31% of the patients). As a result, the MELD score appears to be a more sensitive gauge for hepatic synthetic function compared to the C-P score for patients undergoing BRTO.

Transjugular intrahepatic portosystemic shunt placement for refractory ascites: a single-centre experience

BACKGROUND

The presence of refractory ascites is a common indication for transjugular intrahepatic portosystemic shunt (TIPS). Different models have been proposed for the prediction of survival after TIPS. The aim of this study was to evaluate the predictive factors associated with patients' survival after TIPS placement for refractory ascites.

METHODS

Data from all consecutive patients undergoing TIPS placement in our center for refractory ascites between February 2003 and January 2008 were prospectively recorded.

RESULTS

Seventy-three patients (52M/21F; 57 ± 10 years) met the inclusion criteria; mean follow-up was 17 ± 2 months. Mean MELD value, before TIPS placement, was 15.7 ± 5.3. TIPS placement led to an effective resolution of refractory ascites in 54% of patients (n = 40) with no significant increase in severe portosystemic encephalopathy. The 1-year survival rate observed was 65.7%, while the overall mortality was 23.3% (n = 17) with a mean survival of 17 ± 14 months. MELD score (B = 0.161, p = 0.042), basal AST (B = 0.020, p = 0.090), and pre-TIPS HVPG (B = 0.016, p = 0.093) were independent predictors of overall mortality, while MELD (B = 0.419, p = 0.018) and HVPG (B = 0.223, p = 0.060) independently predicted 1-year survival. ROC curves identified MELD ≥ 19 and HVPG ≥ 25 mmHg as the best cut-off points for the prediction of 1-year mortality.

CONCLUSIONS

TIPS is an effective treatment for refractory ascites in cirrhotic patients, leading to an effective ascites control in more than half patients. Improvement in patients' selection criteria could lead to better outcome and survival after this procedure. Liver function (MELD), presence of active necroinflammation (AST), and portal hypertension (HVPG) are independent predictors of patients' outcome after TIPS.

The transjugular intrahepatic portosystemic shunt: an update

OBJECTIVE

The purpose of this article is to review the indications, outcomes, complications, patient selection, and technical aspects of creating a transjugular intrahepatic portosystemic shunt (TIPS).

CONCLUSION

The best available evidence supports the use of TIPS in secondary prevention of variceal bleeding and in refractory ascites, although TIPS is also commonly used for other indications such as Budd-Chiari syndrome, hepatic hydrothorax, and acute variceal hemorrhage. The TIPS procedure was revolutionized by the introduction of covered stents, which dramatically improved long-term shunt patency.

Transjugular intrahepatic portosystemic shunts in patients with hepatic malignancy

Since its first clinical application in 1988, the transjugular intrahepatic portosystemic shunt (TIPS) has emerged as a safe and effective means of managing patients with morbid portal hypertension. Despite the considerable body of literature on TIPS, portal decompression in patients with malignancy has not been sufficiently examined. These patients typically experience sequelae of portal hypertension that requires palliation. The purpose of this article is to review the reported experience with TIPS in patients with malignancy.

The evaluation of the patient undergoing an elective transjugular intrahepatic portosystemic shunt procedure

In its early stages, the transjugular intrahepatic portosystemic shunt (TIPS) was utilized as a lifesaving procedure to treat uncontrollable esophageal variceal bleeding. Most of the initial cases were performed in an emergency situation in the worst possible conditions. The experience gained over the past 15 years has established TIPS as an important therapeutic option in the management of patients with complications of portal hypertension such as variceal bleeding or refractory ascites who do not respond to medical therapy. In current medical practice, 80 to 90% of TIPS procedures are performed in an elective or semielective fashion and only a small percentage of cases are now performed on an emergency basis. The experience gained has demonstrated that certain patients do not benefit from a TIPS procedure and furthermore, their baseline condition may even worsen after a TIPS. This article reviews the most important aspects of the clinical evaluation of patients undergoing an elective TIPS procedure.

The transjugular intrahepatic portosystemic shunt (TIPS)

The creation of an intrahepatic portosystemic shunt via a transjugular approach (TIPS) is an interventional radiological procedure used to treat the complications of portal hypertension. TIPS insertion is principally indicated to prevent or arrest variceal bleeding when medical or endoscopic treatments fail, and in the management refractory ascites. This review discusses the development and execution of the technique, with focus on its clinical efficacy. Patient selection, imaging surveillance, revision techniques, and complications are also discussed.

Transjugular intrahepatic portosystemic shunts in liver transplant recipients

BACKGROUND

The aim of this study was to determine the efficacy and safety of transjugular intrahepatic portosystemic shunts (TIPS) in liver transplant (LT) recipients with refractory ascites/variceal bleeding and to compare the observed outcomes with those obtained in cirrhotic controls.

METHODS

Clinical features of 14 LT recipients referred for TIPS placement between August 1985 and September 2006 were reviewed and compared with published series and 28 cirrhotic control patients undergoing TIPS.

RESULTS

The median age of the 14 LT recipients was 52 years, 57% had chronic hepatitis C virus and the median time from LT to TIPS placement was 46 months. Portal vein thromboses in two patients and a procedural complication in another patient precluded TIPS deployment. Among the 11 patients who completed TIPS, the mean hepatic venous pressure gradient was significantly reduced post-TIPS (18.3 +/- 6.1 to 9.0 +/- 3.5 mmHg, P<0.01). However, only 50% of the patients with varices had no further bleeding and 57% of the refractory ascites patients required no further paracentesis. In addition to a single peri-procedural death and renal failure in three others, four patients (29%) developed infection and nine (82%) developed new onset or worsening encephalopathy at a median of 11 days post-TIPS. The 1-year patient survival of 14% was substantially lower than that observed in other series of LT recipients (57-67%) as well as the matched cirrhotic control group undergoing TIPS (58%).

CONCLUSION

The frequent morbidity noted in LT recipients undergoing TIPS, coupled with the low 1-year patient survival, demonstrates that portal decompression provides only marginal short-term benefit in the absence of retransplantation.

The model for end-stage liver disease (MELD)

The Model for End-stage Liver Disease (MELD) was initially created to predict survival in patients with complications of portal hypertension undergoing elective placement of transjugular intrahepatic portosystemic shunts. The MELD which uses only objective variables was validated subsequently as an accurate predictor of survival among different populations of patients with advanced liver disease. The major use of the MELD score has been in allocation of organs for liver transplantation. However, the MELD score has also been shown to predict survival in patients with cirrhosis who have infections, variceal bleeding, as well as in patients with fulminant hepatic failure and alcoholic hepatitis. MELD may be used in selection of patients for surgery other than liver transplantation and in determining optimal treatment for patients with hepatocellular carcinoma who are not candidates for liver transplantation. Despite the many advantages of the MELD score, there are approximately 15%-20% of patients whose survival cannot be accurately predicted by the MELD score. It is possible that the addition of variables that are better determinants of liver and renal function may improve the predictive accuracy of the model. Efforts at further refinement and validation of the MELD score will continue.

Transjugular intrahepatic portosystemic shunt for acute variceal bleeding in patients with viral liver cirrhosis: predictors of early mortality

OBJECTIVE

The purpose of our study was to assess the predictors of early mortality after the creation of transjugular intrahepatic portosystemic shunts (TIPS) for acute variceal bleeding in patients with viral liver cirrhosis.

MATERIALS AND METHODS

Seventy-three patients (56 men and 17 women; mean age, 51.3 years) with viral liver cirrhosis who underwent TIPS placement for acute variceal bleeding were studied. Multiple covariates, including demographic, clinical, and biochemical parameters, were included in univariate and multivariate analyses to determine their association with early (30-day) mortality.

RESULTS

During the follow-up period (mean, 35 months 3 days), shunt dysfunction occurred in 33 patients (45.2%). Forty-three patients (58.9%) died, and 23 patients (31.5%) died within 30 days of TIPS. Early death was predicted independently by hyperbilirubinemia (> 3 mg/dL; p = 0.004; odds ratio, 10.6) and elevated serum creatinine level (> 1.7 mg/dL; p =0.018; odds ratio, 12.0).

CONCLUSION

Hyperbilirubinemia and elevated serum creatinine level are predictive of early mortality after TIPS creation for acute variceal bleeding in patients with viral liver cirrhosis.

Selection Criteria for Patients Undergoing Transjugular Intrahepatic Portosystemic Shunt Procedures: Current Status

The transjugular intrahepatic portosystemic shunt (TIPS) procedure has a well-established role in the management of patients with complications of portal hypertension such as variceal bleeding or refractory ascites. Several clinical variables have been described to be associated with a poor prognosis after a TIPS procedure, including the presence of uncontrollable ascites, the number of sclerotherapy sessions to control a bleeding episode, the use of drugs for hemodynamic support, the use of balloon tamponade to control bleeding, the need for an emergency TIPS procedure, the need for mechanical ventilation, prothrombin time, increased serum creatinine, increased serum bilirubin, encephalopathy, and sepsis. In addition, several scoring systems have been developed and applied to patients undergoing TIPS procedures in an attempt to improve patient selection criteria for this invasive procedure. This article reviews the most important scoring systems that have been developed and applied to patients undergoing emergency or elective TIPS procedures, with particular emphasis on the prognostic index designed for patients undergoing emergency TIPS procedures and the Model for End-stage Liver Disease score designed for patients undergoing elective TIPS procedures. The most practical application of these scoring systems is probably that, with the information provided, the operator is able to discuss with referring physicians, patients, and family members the expected outcomes of this challenging procedure.

Comparison of MELD and Child-Pugh scores to predict survival after chemoembolization for hepatocellular carcinoma

PURPOSE

To compare the value of the Child-Pugh and Model for End-stage Liver Disease (MELD) scores to predict patient survival rates after transarterial chemoembolization (TACE) for hepatocellular carcinoma (HCC).

MATERIALS AND METHODS

Eighty-seven patients underwent 169 TACE sessions. Child-Pugh and MELD values were calculated before initial treatment. Survival length was tracked from the date of the first TACE procedure. Transplant recipients were censored from the study at the time of surgery. Child-Pugh and MELD scores as well as bilirubin and albumin levels and International Normalized Ratio were placed in high and low categories defined by their respective medians. Patient survival was compared at 3 months, 6 months, 12 months, and 24 months, and patterns were tested with chi2 or Fisher exact tests. Survival over the entire period was examined with Kaplan-Meier analysis and differences were tested with log-rank tests.

RESULTS

Mean and median survival times for all patients were 24 and 17 months, respectively. Sixteen patients were censored for transplantation at a mean of 12.9 months. MELD and Child-Pugh scores correlated well with each other (r = 0.68). Child-Pugh score (r = -0.35, P = .04) correlated more strongly with 12-month survival than did MELD score (r = -0.26, P = .12). After high/low score category division, a significantly greater survival difference was predicted by Child-Pugh score (27.2 months vs 10.3 months; P = .03) versus MELD score (27.5 months vs 15.8 months; P = .19). An albumin level greater than 3.4 g/dL was also associated with significantly improved survival (29.3 months vs 10.1 months; P = .0032). Survival differences between high-risk and low-risk groups at the 3-, 6-, 12-, and 24-month intervals were significant for low Child-Pugh scores and for albumin levels greater than 3.4 g/dL. Statistical significance was not approached at any of the time lengths with MELD scores.

CONCLUSIONS

Child-Pugh score correlates better than MELD score to overall patient survival and is a better predictor than MELD score of survival at specific time points. Of the components of the Child-Pugh and MELD systems, albumin level is the most useful predictor of survival.

Transjugular intrahepatic portosystemic shunts: experience in the oncology setting

BACKGROUND

Transjugular intrahepatic portosystemic shunt (TIPS) placement has emerged as an effective and minimally invasive method of treating portal hypertension and its associated complications. To the authors' knowledge there is limited documentation of its use for percutaneous shunting in patients with hepatic and extrahepatic malignancies. The current study reports the authors' experience with TIPS in the oncology setting.

METHODS

Thirty-eight patients with cancer underwent TIPS procedures. Nineteen patients had a history of hepatic malignancy. All medical records and imaging studies were reviewed retrospectively. The indication for TIPS, the presence of malignancy, procedural details, complications, survival, and treatment success were assessed.

RESULTS

Primary technical success was accomplished in 37 of 38 patients (97%) without technical procedure-related complications. Hepatic encephalopathy occurred in 15 of 34 patients (44%), with 3 patients requiring shunt reduction. Premature shunt occlusion (< 30 days) occurred in 3 patients (8%). Recurrent hemorrhage occurred in 1 of 19 patients (5%), and ascites and hepatic hydrothorax resolved or improved subjectively in 9 of 12 patients (75%). Shunts traversed malignancy in 9 patients, and varying degrees of portal compromise were encountered in 12 patients (32%). The overall 30-day and 90-day survival rates were 84% and 60%, respectively. There was a statistically significant difference in 90-day survival rates for patients who had ascites and hepatic hydrothorax indications (27%) compared with patients who had variceal and portal gastropathy indications (84%; P = 0.0075). In addition, the 90-day survival rate was significantly lower in patients who had primary hepatic malignancies (36%) compared with the remainder of the study population (74%; P = 0.0077), and it was significantly lower in patients who had model for end-stage liver disease (MELD) scores > or = 12 (P = 0.0020).

CONCLUSIONS

TIPS was performed safely for patients with cancer without increasing rates of procedure-related complications. However, some patients subgroups, such at those with malignancy and ascites, primary hepatic malignancy, or MELD scores > or = 12, had the lowest 90-day survival rates.

Survival after elective transjugular intrahepatic portosystemic shunt creation: prediction with model for end-stage liver disease score

PURPOSE

To evaluate the ability of a model of end-stage liver disease (MELD) score to predict survival in a diverse group of patients who underwent elective transjugular intrahepatic portosystemic shunt (TIPS) creation in two tertiary care institutions.

MATERIALS AND METHODS

Patients who underwent elective TIPS creation in two institutions between May 1, 1999, and June 1, 2002, were selected. Patients who underwent emergency TIPS creation were excluded. One hundred sixty-six patients met the inclusion criteria. The MELD score was computed and compared with the survival rate. Survival curves were estimated with Kaplan-Meier product limit estimates and were compared with the log-rank test. Accuracy of the model was evaluated with the c statistic.

RESULTS

The survival rate for all patients was 88.4% at 30 days, 78.1% at 3 months, and 71.8% at 6 months. Significantly lower survival rates were found in patients with MELD scores of 18 or more in comparison to those with MELD scores of 17 or less (P =.001). The c statistic for prediction of 3-month survival on the basis of the MELD score was 0.76. The early (30-day) death rate for this series was 11.4%. There was a significant difference in the 30-day mortality rate between patients with MELD scores of 17 or less and those with scores of 18 or more (P =.001). Patients who underwent TIPS creation for the management of refractory ascites had a significantly lower survival rate in comparison to that for the management of variceal bleeding (P =.001).

CONCLUSION

Results confirm that after elective TIPS creation, patients with a MELD score of 18 or more have a significantly lower 3-month survival rate than do those with a MELD score of 17 or less.

Hepatic Perfusion as a Predictor of Mortality after Transjugular Intrahepatic Portosystemic Shunt Creation in Patients with Refractory Ascites

PURPOSE

To determine whether hepatic perfusion patterns predict mortality after transjugular intrahepatic portosystemic shunt (TIPS) creation in patients with severe ascites.

MATERIALS AND METHODS

This retrospective study included 22 patients who had enhanced cine magnetic resonance (MR) imaging performed immediately before TIPS creation in the angled coronal plane including the left kidney, liver, and main portal vein. Regions of interest were centered over the liver and kidney, and perfusion curves were generated and reviewed before the standard TIPS procedure was performed. Four patients did not undergo TIPS creation as a result of very poor hepatic perfusion by MR. All patients were followed clinically and by ultrasound surveillance of their shunt.

RESULTS

Eleven patients died within 6 months, including all four patients who did not have a TIPS because of MR evidence of poor hepatic perfusion. Of these 11 patients, eight (73%) had unfavorable liver flow consisting of diminished enhancement compared to the kidney and early peak enhancement of less than 50 seconds. The surviving patients all showed a delayed peak enhancement of greater than 50 seconds.

CONCLUSIONS

In patients undergoing TIPS creation for refractory ascites, blunted arterial-type hepatic enhancement is a poor prognostic sign. Cine MR imaging with evaluation of hepatic perfusion can be performed and reviewed before the TIPS procedure. Alternative techniques for ascites reduction may be preferred for patients with unfavorable hepatic perfusion.