Eficácia do TIPS em 10 anos na síndrome de Budd-Chiari: revisão sistemática e metanálise

MORENO, Mariana Oliveira Amarante; PAZ, Cláudio Luiz da Silva Lima; DEZAN, Maria Gabriela Fernandes; CAVALCANTE, Lourianne Nascimento; LYRA, Andre Castro

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Sumário

ORIGINAL ARTICLE/HEPATOLOGY • Arq. Gastroenterol. 61 • 2024 • https://doi.org/10.1590/S0004-2803.24612023-171 copiar

Eficácia do TIPS em 10 anos na síndrome de Budd-Chiari: revisão sistemática e metanálise

Autoria SCIMAGO INSTITUTIONS RANKINGS

RESUMO

Contexto:

A síndrome de Budd-Chiari (SBC) é resultante da obstrução do fluxo venoso hepático, usualmente no nível da veia hepática ou da veia cava inferior. Quando não tratada, pode evoluir com complicações, incluindo a cirrose hepática. O tratamento com TIPS parece ser eficaz em um subgrupo de pacientes.

Objetivo:

Realizar uma revisão sistemática e meta-análise da eficácia do TIPS no tratamento da síndrome de Budd-Chiari, considerando sobrevida, redução de pressão portossistêmica, necessidade de transplante hepático, falha técnica e disfunção no shunt em 10 anos de seguimento.

Métodos:

Foram avaliados 17 estudos publicados nas bases de dados PubMed, Science direct, Web of Science e SCOPUS, que utilizaram TIPS como tratamento da SBC, correspondendo a um total de 618 pacientes, entre 18 e 78 anos. O risco de viés foi avaliado pelas escalas de NOS, NHI e JBI, para estudos de coorte, antes e depois e séries de casos, respectivamente. As meta-análises foram conduzidas, extraindo o número de eventos e o total de pacientes avaliados para realizar as meta-análises de proporções usando o software R, com o pacote “meta” (versão 4.9-6).

Resultados:

Os resultados agrupados (IC de 95%) foram de 19% (25,9-12,5%) para a taxa de redução da pressão portossistêmica, 6% (1-12%) para a taxa de necessidade de transplantes hepáticos a despeito do uso do TIPS, 2% (1-6%) para a taxa de falha técnica, 30% (18-46%) para a taxa de disfunção do shunt e 88% (81-93%) para a sobrevida entre 1 e 10 anos depois do procedimento. Estratificando essa sobrevida, foi detectada 86% (74-93%) no período menor do que 5 anos, 92% (83-97%) com 5 anos, e 77% (68-83%) de frequência de pacientes vivos 10 anos após a realização do TIPS.

Conclusão:

O TIPS é um tratamento eficaz para a SBC, proporcionando elevada sobrevida em 10 anos e uma diminuição significativa da pressão portossistêmica. A necessidade de transplantes de fígado após TIPS e a taxa de falha técnica são baixas.

Palavras-chave:
Síndrome de Budd-Chiari; resultado; revisão sistemática; meta-análise

Author (year)	Study design	Country	Sample	Follow-up	Outcomes
			N (age)		Primary	Secondary
Blum et al. (1995)²³23. U Blum, M Rössle, K Haag, A Ochs, H E Blum, K H Hauenstein, F Astinet, M Langer. Interventional and Clinical of Treatment with Intrahepatic Portosystemic Shunt’. 1995;805-11.	Before and after	DEU	GT: 12	3 years	S1: 75%	SD: 41.7%
			GC: 0			IS: 100%
			(52 [31-71])			T: 8.3%

Perelló et al. (2002)²²22. Perelló A, García-Pagán JC, Gilabert R, Suárez Y, Moitinho E, Cervantes F, et al. TIPS is a useful long-term derivative therapy for patients with Budd-Chiari syndrome uncontrolled by medical therapy. Hepatology. 2002;35:132-9.	Cohort	ESP	GT: 13	4±3 years	S1: 92%	SD: 61.5%
			GC: 8			IS: 92.35%
			(38±13)			T: 7.7%
Mancuso et al. (2003)²⁴24. Mancuso A, Fung K, Mela M, Tibballs J, Watkinson A, Burroughs AK, et al. TIPS for acute and chronic Budd-Chiari syndrome: A single-centre experience. J Hepatol. 2003;38:751-4.	Before and after	ITA	GT: 15	3.7 years	S1: 73.3%	SD: 26.7%
			GC: 0			IS: 93.3%
			(39.5 [20-73])			T: 0%
Molmenti et al. (2005)²⁵25. Molmenti EP, Segev DL, Arepally A, Hong J, Thuluvath PJ, Rai R, et al. The utility of TIPS in the management of Budd-Chiari syndrome. Ann Surg. 2005;241:978-83.	Before and after	USA	GT: 11	10 years	S1: nr	SD: 18%
			GC: 0		S5: 91%	IS: 91%
			(53±20)			T: 9%
Eapen et al. (2006) ²⁶26. Eapen CE, Velissaris D, Heydtmann M, Gunson B, Olliff S, Elias E. Favourable medium term outcome following hepatic vein recanalisation and/or transjugular intrahepatic portosystemic shunt for Budd Chiari syndrome. Gut. [Internet]. 2006;55:878. Available from: /pmc/articles/PMC1856218/.	Cohort	GBR	GT: 26	5 years	S1: 84.6%	SD: 11.64%
			GC: 35		S5: 80.8%	IS: 100%
			(44 [21-67])			T: 3.85%
Lee et al. (2006)²⁷27. Lee BB, Villavicencio L, Kim YW, Do YS, Koh KC, Lim HK, et al. Primary Budd-Chiari syndrome: outcome of endovascular management for suprahepatic venous obstruction. J Vasc Surg. [Internet]. 2006;43:101-8. Available from: https://pubmed.ncbi.nlm.nih.gov/16414396/. https://pubmed.ncbi.nlm.nih.gov/16414396...	Case series	USA	GT: 2	4 years	S1: 100%	SD: nr
			GC: 17			IS: 100%
			(45 [28-68])			T: 0%
Murad et al. (2008)²⁸28. Murad SD, Luong TK, Pattynama PMT, Hansen BE, Van Buuren HR, Janssen HLA. Long-term outcome of a covered vs. uncovered transjugular intrahepatic portosystemic shunt in Budd-Chiari syndrome. Liver Int. [Internet]. 2008;28:249-56. Available from: https://pubmed.ncbi.nlm.nih.gov/18251982/. https://pubmed.ncbi.nlm.nih.gov/18251982...	Cohort	NLD	GT: 16	3 years	S1: 80%	SD: 62.5%
			GC: 0		S3: 72%	IS: 93.75%
			(31 [19-50])			T: 6.25%
Pagán et al. (2008)²⁹29. Garcia-Pagán JC, Heydtmann M, Raffa S, Plessier A, Murad S, Fabris F, et al. TIPS for Budd-Chiari Syndrome: Long-Term Results and Prognostics Factors in 124 Patients. Gastroenterology. 2008;135:808-15.	Case series	ESP	GT: 133	5 years	S1: 88%	SD: 41%
			GC: 29		S5: 78%	IS: 93.3%
			(38 [35-40])			T: 6.5%
Zhang et al. (2013)³⁰30. Zhang B, Jiang ZB, Huang MS, Zhu KS, Qian JS, Shan H. Effects of percutaneous transhepatic interventional treatment for symptomatic Budd-Chiari syndrome secondary to hepatic venous obstruction. J Vasc surgery Venous Lymphat Disord. [Internet]. 2013;1:392-9. Available from: https://pubmed.ncbi.nlm.nih.gov/26992761/. https://pubmed.ncbi.nlm.nih.gov/26992761...	Cohort	CHN	GT: 3	5 years	S1:nr	SD: 100%
			GC: 15			IS: 100%
			(36±9)			T: 0%
Tripathi et al. (2014)³¹31. Tripathi D, MacNicholas R, Kothari C, Sunderraj L, Al-Hilou H, Rangarajan B, et al. Good clinical outcomes following transjugular intrahepatic portosystemic stent-shunts in Budd-Chiari syndrome. Aliment Pharmacol Ther. 2014;39:864-72.	Cohort	GBR	GT: 67	10 years	S1: 92%	SD: 45%
			GC: 0		S5: 80%	IS: 98.5%
			(39.9±14.2)		S10: 72%	T: 3%
Pavri et al. (2014)³²32. Pavri TM, Herbst A, Reddy R, Forde KA. Budd-Chiari syndrome: A single-center experience. World J Gastroenterol. [Internet]. 2014;20:16236. Available from: /pmc/articles/PMC4239512/.	Cohort	USA	GT: 19	5 years	S1: 83.3%	SD: 52.6%
			GC: 21			IS: nr
			(33.3 [29.7-45.8])			T: 26.3%
He et al. (2015)³³33. He FL, Wang L, Zhao HW, Fan ZH, Zhao MF, Dai S, et al. Transjugular intrahepatic portosystemic shunt for severe jaundice in patients with acute Budd-Chiari syndrome. World J Gastroenterol. [Internet]. 2015;21:2413. Available from: /pmc/articles/PMC4342918/.	Before and after	CHN	GT: 21	1.5 years	S1: 100%	SD: 0%
			GC: 16			IS: 100%
			(39.67±2.74)			T: nr
Fan et al. (2016)³⁴34. Fan X, Liu K, Che Y, Wang S, Wu X, Cao J, et al. Good Clinical Outcomes in Budd-Chiari Syndrome with Hepatic Vein Occlusion. Dig Dis Sci. [Internet]. 2016;61:3054-60. Available from: https://pubmed.ncbi.nlm.nih.gov/27221497/. https://pubmed.ncbi.nlm.nih.gov/27221497...	Before and after	CHN	GT: 33	10 years	S1: nr	SD: nr
			GC: 27			IS: 94%
			(38.82±11.45)			T: 0%
He et al. (2016)³⁵35. He F, Zhao H, Dai S, Wu Y, Wang L, Huang H, et al. Transjugular intrahepatic portosystemic shunt for Budd-Chiari syndrome with diffuse occlusion of hepatic veins. Sci Rep. [Internet]. 2016;6:1-7. Available from: http://dx.doi.org/10.1038/srep36380. https://doi.org/10.1038/srep36380...	Cohort	CHN	GT: 91	5 years	S1: nr	SD: 10.98%
			GC: 9		S5: 93.41%	IS: 100%
			(28±10.5)			T: nr
Parekh et al. (2017)⁸8. Parekh J, Matei VM, Canas-Coto A, Friedman D, Lee WM. Budd-Chiari Syndrome Causing Acute Liver Failure: A Multicenter Case Series. Liver Transplant. 2017;23:135-42.	Case series	USA	GT: 7	2 years	S1: 42.8%	SD: nr
			GC: 12			IS: nr
			(38 [19-59])			T: 0%
Sakr et al. (2017)³⁶36. Sakr M, Abdelhakam SM, Elsayed SA, Allam EH, Farid AM, Abdelmoaty W, et al. Validation of prognostic indices in Egyptian Budd-Chiari syndrome patients: A single-center study. World J Gastroenterol. [Internet]. 2017;23:629. Available from: /pmc/articles/PMC5292336/.	Cohort	EGY	GT: 107	1 year	S1: 89.7%	SD: 19.8%
			GC: 87			IS: nr
			(28.79±8.94)			T: nr
Sonavane et al. (2018)³⁷37. Sonavane AD, Amarapurkar DN, Rathod KR, Punamiya SJ. Long Term Survival of Patients Undergoing TIPS in Budd-Chiari Syndrome. Journal of Clinical and Experimental Hepatology. 2019. Available from: https://doi.org/10.1016/j.jceh.2018.02.008. https://doi.org/10.1016/j.jceh.2018.02.0...	Before and after	SGP	GT: 42	10 years	S1: 86%	SD: 7.14%
			GC: 0		S5: 81%	IS: 100%
			(40.52±14.26)		S10:76%	T: 4.76%

Author (year)	Q1	Q2	Q3	Q4	Q5	Q6	Q7	Q8	Q9	Q10	Q11	Q12	Score
Tool:	NIH: Assessment of studies before and after inclusion
Blum et al. (1995)	Y	Y	Y	Y	Y	Y	Y	N	Y	N	N	NA	8
Mancuso et al. (2003)	Y	U	Y	Y	Y	Y	Y	N	Y	N	N	NA	7
Molmenti et al. (2005)	Y	U	Y	Y	Y	Y	Y	N	Y	N	N	NA	7
He et al. (2015)	Y	Y	Y	Y	Y	Y	Y	N	Y	Y	N	NA	9
Fan et al. (2016)	Y	U	Y	Y	Y	Y	Y	N	Y	N	N	NA	7
Sonavane et al. (2018)	Y	Y	Y	Y	Y	Y	Y	N	N	N	N	NA	7
Tool:	JBI to assess case series studies included
Lee et al. (2006)	N	Y	Y	Y	Y	Y	N	Y	Y	U	-	-	7
Pagán et al. (2008)	Y	N	Y	Y	N	Y	Y	Y	Y	Y	-	-	8
Parekh et al. (2017)	Y	Y	Y	Y	Y	Y	Y	Y	Y	Y	-	-	10
Tool:	Newcastle-Ottawa Scale (NOS)
Author (year)	Selection				Comparison				Outcome				Score
Perelló et al. (2002)	★★								★★★				5
Eapen et al. (2006)	★★								★★★				5
Murad et al. (2008)	★★★★								★★★				7
Zhang et al. (2013)	★★★								★★★				6
Tripathi et al. (2014)	★★★								★★★				6
Pavri et al. (2014)	★★★★				★				★★★				8
He et al. (2016)	★★				★				★★★				6
Sakr et al. (2017)	★★★				★★				★★★				8

Y= yes; N = no; U = unclear;
Questions (NIH/JBI):
Q1 - Was the study hypothesis or objective clearly stated? / Were there clear criteria to include studies in the case series?
Q2 - Were the eligibility/selection criteria for the study population pre-specified and clearly stated? / Was the condition measured in a standardized and reliable manner for every participant included in the case series?
Q3 - Were the study participants representative of those eligible for test/service/intervention in the general population or clinic of interest? / Were the methods used capable of identifying the condition for every participant included in the case series?
Q4 - Were all eligible participants who met the pre-specified inclusion criteria enrolled? / Did the case series have consecutive inclusion of participants?
Q5 - Was the sample size large enough to make the study findings reliable? / Did the case series have full inclusion of participants? / Did the case series have full inclusion of participants?
Q6 - Was the test/service/intervention clearly described and performed in a consistent manner for the entire study population? / Was there a clear report of demographic data of study participants?
Q7 - Were the result measurements pre-specified, clearly defined, valid, reliable and evaluated in a consistent manner for every study participant? / Was there a clear report of participants’ clinical information? / Were the results or case follow-up results clearly reported?
Q8 - Were the people responsible for result assessments blinded for exposures/interventions of participants? / Were the results or case follow-up results clearly reported?
Q9 - Was the loss to follow-up rate after baseline 20% or lower? Were losses to follow-up considered in the analysis? / Was there a clear report of demographic data of sites/clinics presented?
Q10 - Did the statistical methods evaluate changes in result measurements before and after the intervention? Were statistical tests performed to provide p values for pre- and post-changes? / Was the statistical analysis appropriate?
Q11 - Were the main result measurements performed several times before and after the intervention (that is, the studies used an interrupted time series design)?
Q12 - If the intervention was carried on at a group level (for example, an entire hospital, a community etc.), did the statistical analysis consider the use of data at an individual level in order to determine the effects at a group level?

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[1] Corresponding author: Andre Castro Lyra. E-mail: aclyra@live.com