Systematic review and meta-analysis of trans-jugular intrahepatic portosystemic shunt for cirrhotic patients with portal vein thrombosis

Table 1 Characteristics of the included studies

Ref.	Time period	Publication year	Country	Design	Inclusion criteria	Exclusion criteria	End point
Han et al[9]	December 2001-September 2008	2011	China	Retrospective	Definite diagnosis of PVT; concomitant decompensated cirrhosis; absence of malignancy; absence of previous primary thrombosis of the hepatic vessels; absence of pancreatitis, appendicitis, and splenectomy by trauma	Patients with thrombosis, in other segments of the portal system rather than the main portal vein (MPV) or with MPV stenosis < 50% within MPV	Technical success and portal vein recanalization; procedure-related complications; shunt dysfunction and revision; hepatic encephalopathy; overall survival
Perarnau et al[10]	1990-2004	2010	France	Retrospective	Patient received TIPS with complete portal thrombosis	Lack of cirrhosis (Chiari syndrome, noncirrhotic portal hypertension, metastatic breast cancer); TIPS performed in transplanted liver; hepatocellular carcinoma; unfulfilled medical records	Technical success; early complications; long-term patency; hepatic encephalopathy; survival
Luca et al[11]	January 2003-February 2010	2011	Italy	Retrospective	Patient have associated portal vein thrombosis prior to TIPS	Non-cirrhotic patient; Thrombosis limited to right and/or left portal branch; hepatocellular carcinoma; did not undergo imaging study prior or after TIPS	Technical success; recanalization of portal vein; complications and survival
Van Ha et al[4]	December 1995-December 2003	2006	United States	Retrospective	Liver cirrhotic patient with portal vein thrombosis received TIPS	N/A	Technical success; TIPS patency; hepatic encephalopathy; survival
Luo et al[1]	January 2010-December 2012	2015	China	RCT	Patients with cirrhosis and PVT, aged 18-70 yr, previous episodes of variceal bleeding, and a Child-Pugh score of 7-13	PVT of 25% or less within the vessel lumen; limited thrombosis in the intrahepatic portal branch; portal cavernoma; gastric varices; hepatocellular carcinoma; previous endoscopic treatment of varices within 3 mo; and contradictions to TIPS, EBL, or propranolol	The primary end point was the incidence of recurrent variceal bleeding. The secondary end points were incidence of TIPS dysfunction, recanalization of the portal venous system, occurrence of hepatic encephalopathy, or death for any reason
Wang et al[2]	January 2010-September 2010	2014	China	Retrospective	Patients with cirrhosis and concomitant PVT who underwent successful TIPS creation	N/A	Rebleeding events; changes in PVT; survival
Lv et al[12]	May 2011-January 2014	2017	China	RCT	Liver cirrhosis (diagnosed by clinical presentations, laboratory tests, images or liver biopsies), age between 18 and 75 yr, PVT > 50% of the portal vein trunk and a history of endoscopy-proven variceal bleeding in the past 6 wk	Uncontrolled active variceal bleeding; technical impracticality of TIPS; previous EBL + NSBB, TIPS placement or shunt surgery; concomitant renal insufficiency; severe cardiopulmonary diseases; uncontrolled systemic infection or sepsis; hepatocellular carcinoma or other extrahepatic malignancy; and contraindications for propranolol, anticoagulation or TIPS	The primary endpoint was variceal rebleeding; The secondary endpoints included survival, overt hepatic encephalopathy, portal vein recanalization and re-thrombosis, other complications of portal hypertension and adverse effects
Wang et al[13]	October 2012-February 2014	2016	China	RCT	Patients with cirrhosis and PVT who were undergoing TIPS placement	Technical failure of TIPS; a thrombus limited to the intrahepatic portal branches; diffuse PVT involving the entire portal venous system; a contraindication to anticoagulation therapy; already undergoing anticoagulation or antiplatelet aggregation therapy; platelet count of less than 20000/mm3 or international normalized ratio greater than 2; a malignancy or myeloproliferative disorder; refusal to participate or enroll in another prospective study	The primary outcome measure was a change in portal vein patency status; secondary outcomes were gastrointestinal bleeding, shunt dysfunction, hepatic encephalopathy, and survival
Lakhoo and Gaba[14]	December 2008-March 2014	2016	United States	Retrospective	Patient underwent TIPS for PVT	Patients who lacked cross-sectional imaging follow-up after TIPS	The primary endpoint was post-TIPS spleno-mesenteric-portal venous patency; Secondary endpoint included durability of patency, patient transplant free survival, liver transplant rate, and post-TIPS variceal bleeding incidence
Modaresi Esfeh and Ansari-Gilani[15]	January 2020-December 2018	2020	United States	Retrospective	Patient with PVT before TIPS placement	N/A	Primary endpoint was recanalization of the portal vein within the first year following TIPS placement
Zhang et al[16]	March 2018-April 2019	2020	China	Retrospective	Clearly diagnosed cirrhotic patient with portal vein thrombosis (≤ 2 wk), with visceral bleeding or ascites; thrombosis involved at least 2 branches of superior mesenteric vein, splenic vein and inferior mesenteric vein; contraindication for catheter-directed thrombosis	Merely mural portal thrombosis or the thrombosis is regional; sub-acute or chronic PVT; patient without cirrhosis and portal hypertension; above Child-Pugh C category or coagulation disorders	Portal vein recanalization; TIPS patency; peri-operative complications; encephalopathy
Thornburg et al[17]	2009-2015	2017	United States	Retrospective	Medical need for transplantation and presence of chronic PVT on pre-operative imaging	The inability to be listed for transplantation for reasons other than the presence of PVT and complete, chronic portomesenteric thrombosis precluding catheterization of the portal vein or splenic vein	Portal vein and TIPS patency before and after transplantation; clinical and laboratory adverse events; survival

EBL: Endoscopic banding ligation; MPV: Main portal vein; N/A: Not applicable; NSBB: Non-selective beta-blocker; PVT: Portal vein thrombosis; RCT: Randomized controlled trial; TIPS: Trans-jugular intrahepatic portosystemic shunt.

Table 2 Demographics and results of the included studies

Ref.	No.	Male, n	Age in yr	TIPS success rate, %	Cavernoma, n	1-yr portal vein recanalization rate, %	2-yr portal vein recanalization rate, %	1-yr TIPS patency, %	Encephalopathy rate, %	Survival rate, %	Combined treatment	Follow-up time
Han et al[9]	57	20	50.9 ± 1.6	75	30	100	68.2	79.3	1-yr 25; 2-yr 27	1-yr 86.1; 5-yr 76.7	Anti-coagulation, heparin-warfarin-aspirin	5 yr
Perarnau et al[10]	34	18	58 ± 11	79	19	N/A	N/A	72	6.9	1-yr 80; 4-yr 55	Heparin for 10 d, prolong to 20 d in patients with thrombocytopenia	4 yr
Luca et al[11]	70	47	55 ± 8	100	0	51	81	64.3	1-yr 27; 2-yr 32	1-yr 89; 2-yr 81	N/A	4 yr
Van Ha et al[4]	15	13	53	86.7	4	N/A	N/A	92.3	7.7	76.9	Heparin-warfarin in 2 cases, heparin in 2 cases	Mean 17 mo
Luo et al[1]	37	19	50.78 ± 13.61	100	0	64.9	71.3	91.7	1-yr 16.2; 2-yr 38.5	1-yr 86.5; 2-yr 72.9	Low molecular weight heparin for 3 d, bridge to warfarin for at least 6 mo	2 yr
Wang et al[2]	25	14	47.28 ± 12.36	100	0		N/A	87	N/A	1-yr 96; 3-yr 39.3	Long-term warfarin	3 yr
Lv et al[12]	24	13	49 (46-62)	96	11	87	80	82.6	26.1	1-yr 83.5; 2-yr 73	Thrombolysis in 5 cases, anti-coagulation in 22 cases	2 yr
Wang et al[13]	64	38	54.76	100	4	76.6	N/A	92.2	1-yr 20.3	1-yr 98.4	Anti-coagulation in 31 cases	1 yr
Lakhoo and Gaba[14]	12	5	63	100	0	58.3	N/A	92	N/A	75%	Anti-coagulation in 3 cases	Median 109 d
Modaresi Esfeh and Ansari-Gilani[15]	50	34	55.3 ± 11	100	N/A	68	N/A	N/A	N/A	N/A	N/A	N/A
Zhang et al[16]	11	6	46 ± 9	100	0	81.8	N/A	81.8	18.2	N/A	AngioJet and anti-coagulation	1 yr
Thornburg et al[17]	61	37	58 (median)	98	29	92	N/A	92	18	5-yr 82	N/A	5 yr

N/A: Not applicable; TIPS: Trans-jugular intrahepatic portosystemic shunt.