高リスク患者に対する個別化アプローチとしての拡張型コンストレイン型経静脈肝内門脈大循環シャント術：

A transjugular intrahepatic portosystemic shunt (TIPS) can effectively overcome portal hypertension, but is prevented by contraindications in a considerable proportion of patients. In this study, we investigated the option of a constrained TIPS (cTIPS) with reduced diameter for high-risk patients.

Elective cTIPS were placed in 60 high-risk patients at Hannover Medical School (10/2020-04/2023). In the cTIPS procedure, a 6 mm stent(-graft) was inserted first into the intrahepatic tract to constrain the TIPS endoprosthesis. Procedural data, complications and 12 months follow-up were recorded. A control cohort of patients with standard TIPS (sTIPS) was generated using propensity score matching, resulting in 40 patients per group.

Indications for cTIPS were cardiac impairment, poor liver function and/or history of hepatic encephalopathy (HE) in 22, 17 and 8 patients, respectively. cTIPS was technically successful in all patients. Portosystemic gradient (PSG) was successfully lowered in both groups (sTIPS: median 60% reduction and cTIPS: median 50% reduction from an initial PSG of 15 mmHg in both groups, p = 0.006), while post-TIPS PSG remained higher in the cTIPS group compared to the sTIPS group (cTIPS: median 7 mmHg vs. sTIPS: median 6 mmHg; p = 0.042). TIPS dysfunction and revision were significantly more frequent in the cTIPS cohort than in the sTIPS cohort (sTIPS: 1 vs. cTIPS: 9; p = 0.014 and sTIPS: 7 vs. cTIPS: 13; p = 0.036). Control of portal hypertensive symptoms (no paracentesis, no bleeding) was similar in both groups (p = 0.267), but overt HE was less frequent in the cTIPS group than in the sTIPS group (sTIPS: 14 vs. cTIPS: 4; p = 0.042).

The constrained TIPS may offer a more careful step-up approach for selected high-risk TIPS patients. The technical procedure appears to be safe and feasible, however the risk for thrombosis and therefore needed revisions is increased. Larger study cohorts are needed to further explore promising results.