Patient age predicts early mortality after transjugular intrahepatic portosystemic shunt creation in intermediate risk individuals

Purpose The Model for End Stage Liver Disease (MELD) score is the preeminent metric for stratifying patient risk prior to transjugular intrahepatic portosystemic shunt (TIPS). While low ( 25) range scores clearly portend favorable (10-15% 90-day mortality) and poor (60-80% 90-day mortality) clinical outcomes, respectively, the fate of patients with intermediate range (18-25) MELD scores, which is associated with a nearly equal probability of survival versus demise (40% 90-day mortality), is less clear-cut. Herein, we aimed to identify prognostic factors for early mortality among patients with intermediate risk MELD scores undergoing TIPS. Materials and Methods In this single institution retrospective study, 47 patients (M:F=31:16, mean age 54 years) with intermediate risk MELD scores ranging from 18-25 underwent TIPS creation between 1999-2012. Medical record review was used to identify demographic (age, gender), liver disease (Child-Pugh, MELD score), and procedure (indication, urgency, stent type, portosystemic gradient or PSG reduction, occurrence of complications) data, and the influence of these parameters on 90-day mortality was assessed using multivariate analysis of variance. Results TIPS were successfully created for variceal hemorrhage (n=24), ascites (n=17), hepatic hydrothorax (n=5), and portal vein thrombosis (n=1). Hemodynamic success was achieved in 94% (44/47), and mean PSG reduction was 13 mm Hg. Patient age was significantly associated with 90-day mortality (P=0.006). Mean ages of living (n=30) versus dead (n=17) patients at this time point were 51 and 60 years. 90-day mortality rates in patients ≤54 years versus ≥55 years were 21% (5/24) and 52% (12/23). There was no significant difference in MELD scores between these age groups (20.6 versus 21.0, P=0.600), and MELD was not a predictive factor on multivariate analysis. Conclusion Age is a significant prognostic factor for early mortality following TIPS among patients with intermediate risk MELD scores between 18-25, and mortality is considerably higher in patients older than 55 years. MELD score does not predict survival in this patient subset. Older age should be contemplated when selecting intermediate risk patients for TIPS.