Efficacy and safety of transjugular intrahepatic portosystemic shunt in patients with hepatocellular carcinoma: a single center experience

Background and aims: Portal hypertension and hepatocellular carcinoma (HCC) are major complications of advanced liver cirrhosis. As HCC typically represents a late-stage complication of liver cirrhosis, most of these patients are also affected by symptomatic portal hypertension. Transjugular intrahepatic portosystemic shunt (TIPS) is an effective treatment for portal hypertension and its complications. However, no established guidelines for the treatment of portal hypertension in HCC patients are currently available and only limited information exists about the consequence of TIPS implantation in patients with HCC. Therefore, we evaluated the efficacy, safety and overall survival (OS) in HCC patients who underwent TIPS implantation.

Methods: 40 HCC patients with symptomatic portal hypertension who were treated with TIPS between January 1995 and June 2013 were included in the analysis. Medical records, laboratory results and imaging studies were analyzed. The indication for TIPS implantation, procedure-related complications, treatment success and overall survival (OS) were assessed.

Results: TIPS implantation was performed in 27 patients (67.5%) due to refractory ascites and in 13 patients (32.5%) due to recurrent variceal bleeding. 14 of 40 patients (35.0%) had portal vein thrombosis (PVT). 22 patients (55.0%) had solitary HCC nodules (one or two intrahepatic HCC nodules) while 18/40 patients (45.0%) presented with multifocal HCC. The shunt was successfully placed in all 40 patients. After TIPS implantation, no variceal bleeding reoccurred and ascites was controlled in 74.1%. No severe procedure-related complications and no deterioration of liver function were observed. Post-TIPS hepatic encephalopathy (HE) occurred in 40.0% of all patients. Multivariate logistic regression analysis showed that high aspartate aminotransferase (AST) levels (OR: 15.18, p = 0.005) and low sodium (OR: 0.13, p = 0.047) were independent predictors of post-TIPS HE. 30-day, 90-day-, 1-year- and 5-year survival rates were 97.5%, 75.0%, 42.5% and 7.5%, respectively. Median OS after TIPS implantation was 180 days. During follow-up only one patient developed lung metastasis seven years after diagnosis of HCC and six years after TIPS implantation.

Conclusions: TIPS implantation is an effective and safe treatment for portal hypertension in patients with HCC.