Small-diameter TIPS combined with splenic artery embolization in the management of refractory ascites in cirrhotic patients

Özet

PURPOSEMaximally decreasing portal pressures with transjugular intrahepatic portosystemic shunt(TIPS) is associated with improved ascites control but also increased encephalopathy incidence. Since splenic venous flow contributes to portal hypertension, we assessed if combining small-diameter TIPS with splenic artery embolization could improve ascites while minimizing encephalopathy.METHODSFifty-five patients underwent TIPS creation for refractory ascites. Subjects underwent creation of 8 mm TIPS followed by proximal splenic artery embolization (group A, n=8), or of 8mm (group B, n=6) or 10 mm TIPS (group C, n=41) without splenic embolization. Data wereretrospectively reviewed.RESULTSIn group A, median portosystemic gradient decreased from 19 mmHg to 9 mmHg after TIPS,and 8 mmHg after subsequent splenic artery embolization. In groups B and C, gradient decreased from 15 mmHg to 8 mmHg and 16 mmHg to 6 mmHg. All patients except for one ingroup A and two in C had greater than 50% reduction in the number of paracenteses in 3months. Any postprocedural encephalopathy incidence was 62%, 50%, 83% in groups A, B,and C, respectively. Overall, 20% of subjects with 10 mm TIPS required TIPS reduction/closurecompared to 7% of subjects with 8 mm TIPS.CONCLUSIONWe found that 8 mm diameter TIPS provided similar ascites control compared to 10 mm TIPSregardless of splenic embolization. While more patients with 10 mm TIPS required reduction/closure for severe encephalopathy, the study was underpowered for definitive assessment.Splenic embolization might have the potential to further decrease portosystemic gradientand ascites as an alternative to dilation of TIPS to 10 mm minimizing the risk of encephalopathy, but larger studies are warranted.