Smaller Diameter Covered Transjugular Intrahepatic Portosystemic Shunt Stents are Associated With Increased Survival

Abstract Background & Aims We studied effects of diameter of covered, self-expandable nitinol stents on survival times of patients with a transjugular intrahepatic portosystemic shunt (TIPS). Methods We collected data from 185 patients (median age, 55 years; 30% female) who received a covered nitinol stent, from February 2006 through September 2010, using the online, multicenter, German TIPS registry. TIPS were given to 107 patients for refractory ascites and to 78 patients for variceal bleeding. Patients at risk of hepatic encephalopathy (due to advanced age, prior episodes) or liver failure (bilirubin >3 mg/dl), and bleeding patients receiving variceal embolization at TIPS, received 8 mm stents (n=53). The remaining patients received 10 mm stents (n=132). 81 of the 10 mm stents were underdilated using 8 mm dilation balloons. Clinical and biochemical data were collected after TIPS placement at 1 month, 3 months, 6 months, 9 months, 1 year, and thereafter every 3–6 months. Groups were compared using propensity score analysis. Results Patients who received 8 mm stents survived significantly longer (34+/-26 months) than patients who received 10 mm stents (18+/-19 months), regardless whether they were fully dilated or underdilated. When we compared 10 mm stents with or without underdilation, we found that a significantly higher proportion of patients who received underdilated stents survived for 1 month after TIPS placement (95% vs. 84%, P =.03) but not for 3 months ( P =.10). In multi-variate analysis, 1-year mortality correlated with full dilation of the stent to 10 mm (hazard ratio [HR], 2.0; 95% CI, 1.1–3.5) and with serum concentration of creatinine at baseline (HR, 1.5; 95% CI, 1.0–1.7). Five-year mortality was associated with use of the 8 mm stents (HR, 1.8; 95% CI, 1.4–2.7) and baseline concentration of creatinine (HR, 1.3; 95% CI, 1.1–1.6). Conclusion A smaller stent (nominal diameter 8 mm, but not underdilation of a 10 mm stent) is associated with a prolonged suvival compared to 10 mm stents, indpendent of liver specific prognostic criteria.