Transjugular Intrahepatic Portosystemic Shunts With Covered Stents Increase Transplant-Free Survival of Patients With Cirrhosis and Recurrent Ascites
Transjugular Intrahepatic Portosystemic Shunts With Covered Stents Increase Transplant-Free Survival of Patients With Cirrhosis and Recurrent Ascites
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DOI：
10.1053/j.gastro.2016.09.016
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发表时间：
2017-01-01
期刊：
影响因子：
29.4
通讯作者：
Vinel, Jean Pierre
中科院分区：
文献类型：
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作者：
Bureau, Christophe;Thabut, Dominique;Vinel, Jean Pierre
背景与目的：经颈静脉肝内门体分流术（TIPS）是否能延长肝硬化难治性腹水患者的生存期存在争议。使用裸支架时分流功能障碍的高发生率抵消了TIPS的益处。我们进行了一项随机对照试验，以确定使用聚四氟乙烯覆膜支架的TIPS对这些患者的影响。
方法：我们对62例肝硬化患者进行了一项前瞻性研究，这些患者在至少3周内至少进行了2次大容量腹腔穿刺；该研究于2005年8月至2012年12月在法国的4个三级医疗中心进行。患者被随机分配到接受覆膜TIPS组（n = 29）或根据需要进行大容量腹腔穿刺及补充白蛋白组（LVP + A，n = 33）。所有患者均保持低盐饮食，并在术后1个月接受检查，之后每3个月检查一次，直至1年。每次就诊时，记录肝病相关并发症、治疗调整以及计算Child - Pugh和终末期肝病模型评分所需的临床和生化变量。在研究开始时以及术后6个月和12个月进行多普勒超声检查。主要研究终点是术后1年无肝移植生存情况。
结果：TIPS组达到主要终点的患者比例（93%）高于LVP + A组（52%）（P = 0.003）。TIPS组腹腔穿刺总次数为32次，而LVP + A组为320次。与TIPS组相比，LVP + A组有更高比例的患者出现门静脉高压相关出血（18%对0%；P = 0.01）或疝气相关并发症（18%对0%；P = 0.01）。LVP + A组患者的住院天数（35天）是TIPS组（17天）的两倍（P = 0.04）。每组1年无脑病发生的概率均为65%。
结论：在一项随机试验中，我们发现与反复进行LVP + A的患者相比，用于TIPS的覆膜支架可提高肝硬化复发性腹水患者术后1年无移植生存的比例。这些发现支持将TIPS作为此类患者的一线干预措施。
BACKGROUND & AIMS: There is controversy over the ability of transjugular intrahepatic portosystemic shunts (TIPS) to increase survival times of patients with cirrhosis and refractory ascites. The high rate of shunt dysfunction with the use of uncovered stents counteracts the benefits of TIPS. We performed a randomized controlled trial to determine the effects of TIPS with stents covered with polytetrafluoroethylene in these patients. METHODS: We performed a prospective study of 62 patients with cirrhosis and at least 2 large-volume paracenteses within a period of at least 3 weeks; the study was performed at 4 tertiary care centers in France from August 2005 through December 2012. Patients were randomly assigned to groups that received covered TIPS (n = 29) or large-volume paracenteses and albumin as necessary (LVP+A, n = 33). All patients maintained a low-salt diet and were examined at 1 month after the procedure then every 3 months until 1 year. At each visit, liver disease-related complications, treatment modifications, and clinical and biochemical variables needed to calculate Child-Pugh and Model for End-Stage Liver Disease scores were recorded. Doppler ultrasonography was performed at the start of the study and then at 6 and 12 months after the procedure. The primary study end point was survival without a liver transplant for 1 year after the procedure. RESULTS: A higher proportion of patients in the TIPS group (93%) met the primary end point than in the LVP+A group (52%) (P = .003). The total number of paracenteses was 32 in the TIPS group vs 320 in the LVP+A group. Higher proportions of patients in the LVP+A group had portal hypertension-related bleeding (18% vs 0%; P = .01) or hernia-related complications (18% vs 0%; P = .01) than in the TIPS group. Patients in LVP+A group had twice as many days of hospitalization (35 days) as the TIPS group (17 days) (P = .04). The 1-year probability of remaining free of encephalopathy was 65% for each group. CONCLUSIONS: In a randomized trial, we found covered stents for TIPS to increase the proportion of patients with cirrhosis and recurrent ascites who survive transplantation-free for 1 year, compared with patients given repeated LVP+A. These findings support TIPS as the first-line intervention in such patients.