Covered stents are better than uncovered stents for transjugular intrahepatic portosystemic shunts in cirrhotic patients with refractory ascites: a retrospective cohort study

Background and study aims: Transjugular intrahepatic portosystemic shunt (TIPS) is an accepted interventional technique to treat refractory ascites in cirrhotic patients with severe portal hypertension. The expanded-polytetrafluoroethylene (e-PTFE) covered stent-graft (cs-TIPS) gives a better shunt patency rate than uncovered stents (ncs-TIPS). Our aim was to retrospectively evaluate whether cs-TIPS indeed improves refractory ascites and overall survival in a more effective way than ncs-TIPS in patients with cirrhosis. Patients and methods: From 1992 to 2006, 222 cirrhotic patients with refractory ascites underwent a TIPS-procedure. In 126 patients a ncs-TIPS was inserted, in the remaining 96 patients a csTIPS was inserted. Liver transplantation and/or death were the end points of the follow-up. Results: The baseline characteristics of both groups were similar: age (55 ± 11 years, ncs-TIPS/56 ± 10 years, cs-TIPS), alcoholic cirrhosis (73% ncs-TIPS/80% cs-TIPS), Child-Pugh (9 ± 2.0 ncs-TIPS/9.2 ± 1.3 cs-TIPS) and MELD (15 ± 6 ncs-TIPS/15 ± 4.9 cs-TIPS), except that the bilirubin level was higher in the cs-TIPS group (2.5 ± 2.7 mg/dL in cs-TIPS vs. 1.5 ± 3.6 mg/dL in ncs-TIPS). One year shunt dysfunction occurred in 49% (n=63) of the ncs-TIPS vs. 19% (n = 18) of the cs-TIPS (P < 0.0001) and post TIPS encephalopathy in 56% (n = 70) of the ncs-TIPS vs. 22% (n = 22) in the cs-TIPS group. Ascites control and overall survival were better in the cs-TIPS (P = 0.0071). The gain in survival in the cs-TIPS patients occurred especially in patients with a baseline MELD score <16 (P < 0.0001). Post TIPS encephalopathy and ncs-TIPS were independently related with poor survival (P < 0.0001, P = 0.0150 ; respectively). Conclusions: In cirrhotic patients with refractory ascites cs-TIPS offers better symptomatic control of the ascites at one year follow-up and a better overall survival, especially in patients with a MELD score of <16 at baseline.