Scientific Session 22 — Vascular InterventionsThursday, May 4, 2017
2206. TIPS Prior to Abdominal Surgery: Outcomes in Cirrhotic Patients.
Shoreibah M1*, Moawad S1, Naseemuddin M1, Hanaoka M2, Abdel Aal A1 1. University of Alabama at Birmingham, Birmingham, United States; 2. University of Sao Paulo, Sao Paulo, Brazil
Address correspondence to A. Abdel-Aal (firstname.lastname@example.org)
Objective: Abdominal surgery in patients with liver disease has been associated with an increased risk of perioperative mortality. Transjugular intrahepatic portosystemic shunt (TIPS) is typically performed to reduce portosystemic pressure gradient, often for the management of intractable ascites or variceal bleeding in patients with cirrhosis. We aimed to evaluate the utility of preoperative TIPS placement in patients with cirrhosis, especially ascites, and its effect on perioperative mortality.
Materials and Methods: This retrospective study examined 16 patients with cirrhosis who had TIPS placement before abdominal surgery between 2010 and 2015. Patients with and without hepatic decompensation were included. Hepatic decompensation was defined as the presence of one or more of the following: ascites, hepatic encephalopathy (HE), or history of variceal bleeding. We used the Mayo Clinic postoperative mortality risk calculator to determine the expected 30-day mortality and compared it with the observed mortality in our cohort.
Results: Sixteen patients with cirrhosis (12 men, four women; mean age ± SD, 50.3 ± 10 years) were included. Fifteen patients had decompensated cirrhosis (ascites [14/15, 93%], variceal bleeding [4/15, 26.7%], and HE [9/15, 60.0%]); one patient had ascites caused by allograft dysfunction after orthotopic liver transplant. The mean portosystemic pressure gradient was reduced from 14.8 ± 5.0 mm Hg before TIPS placement to 5.3 ± 2.7 mm Hg after TIPS placement. The mean Model for End-Stage Liver Disease score increased from 13.6 ± 4.4 before TIPS to 15.7 ± 4.5 after TIPS. All 16 patients underwent abdominal surgery; one was emergent and 11 were hernia repair. Median time to surgery was 39 days. Median hospital stay was 4 days. The mean expected postoperative 30-day mortality risk was 27.3% ± 21.6%. Observed 30-day postoperative mortality rate was found to be 0%. Data were available on 12/16 patients at 1 year and the observed mortality was 8%. After TIPS, HE was reported in all 16 patients and ascites in six patients, with two requiring revision of TIPS within 30 days after the surgery. One patient with a postoperative 30-day mortality risk of 43.6% died (78 days from surgery, 46 days of hospitalization), and five patients received a liver transplant.
Conclusion: Our retrospective review indicates that preoperative TIPS placement in patients with decompensated cirrhosis, especially ascites, can help reduce postoperative mortality. Further studies are needed to identify patient populations that would most benefit from such an intervention.