TEN-YEAR OUTCOMES OF TIPS FOR BUDD-CHIARI SYNDROME: SYSTEMATIC REVIEW AND META-ANALYSIS

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

doi:10.1590/S0004-2803.24612023-171

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Sumário

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

TEN-YEAR OUTCOMES OF TIPS FOR BUDD-CHIARI SYNDROME: SYSTEMATIC REVIEW AND META-ANALYSIS

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

Authorship SCIMAGO INSTITUTIONS RANKINGS

HIGHLIGHTS

•We performed a systematic review and meta-analysis of TIPS effectiveness in Budd-Chiari syndrome with 17 studies that comprised 618 subjects.

•The pooled results (95%CI) showed a 19% (25.9-12.5%) rate of portosystemic pressure reduction.

•We found a 92% (83-97%) prevalence of living subjects five years after TIPS placement.

•Our study showed a 77% frequency (68-83%) of patients alive ten years after TIPS placement.

ABSTRACT

Background:

Budd-Chiari syndrome (BCS) results from the obstruction of the hepatic venous flow, usually at the level of the hepatic vein or inferior vena cava. When left untreated, it can progress with several complications, including liver cirrhosis. Transjugular intrahepatic portosystemic shunt (TIPS) appears to be effective in a subgroup of BCS patients.

Objective:

To perform a systematic review and meta-analysis of TIPS effectiveness in BCS treatment, considering the survival rate, reduction in portosystemic pressure, need for liver transplantation, technical failure, and shunt dysfunction for up to 10 years of follow-up.

Methods:

We evaluated 17 studies published in PubMed, Science Direct, Web of Science, and SCOPUS databases, which used TIPS as a treatment for BCS, comprising 618 subjects between 18 and 78 years old. We assessed the bias risk by the NOS, NHI, and JBI scales for cohort studies, before-after studies, and case series, respectively. We conducted the meta-analyses by extracting the number of events and the total patients evaluated to perform the proportion meta-analyses using the R software (“meta” package - version 4.9-6).

Results:

The pooled results (95%CI) showed a 19% (25.9-12.5%) rate of portosystemic pressure reduction, 6% (1-12%) rate for the need for liver transplants despite the use of TIPS, 2% (1-6%) technical failure rate, 30% (18-46%) shunt dysfunction rate, and 88% (81-93%) for the mean frequency of patients alive between 1 and 10 years after the procedure. We stratified survival rate and found an 86% (74-93%) prevalence of living subjects during less than five years, 92% (83-97%) at five years, and a 77% frequency (68-83%) of patients alive ten years after the TIPS placement.

Conclusion:

TIPS is an effective treatment for BCS, providing a high 10-year frequency of living patients and a significant decrease in portosystemic pressure. The need for liver transplants after TIPS and the technical failure rate is low.

Keywords:
TIPS; Budd-Chiari syndrome; outcome; systematic review; meta-analysis

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