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Teng et al. Virology Journal (2018) 15:151Page 3 of 7and pre-TIPS PVP, complications, stents usage, modelfor end-stage liver disease (MELD) score, and ChildPugh classification. We firstly perform univariate analysis for each variable and then perform multivariateanalysis using all the variables. All tests were two-tailed,and P values of less than 0.05 were considered to indicate significant differences.ResultsBaseline characteristics of enrolled patientsThe retrospective cohort comprised 704 of liver cirrhoticpatients with TIPS insertion. Baseline characteristics ofenrolled patients were listed in Table 1. Of these patients, 581 (82.5%) showed variceal bleeding, 72 (10.2%)revealed refractory ascites, whereas 51 (7.3%) demonstrated both variceal bleeding and refractory ascites. Fivehundred and eleven (72.6%) patients were male and 193(27.4%) were female, with a mean age of 53.2 years.TIPS insertion significantly reduced PVP of patients withliver cirrhosis, but not ameliorated liver functionsIn all 704 enrolled patients with TIPS treatment, directmeasurements of portal vein pressure (PVP) were carried out in 487 cases before and after stent insertion.TIPS insertion significantly decreased PVP with 9.77cmH2O reduction (36.81 8.68 cmH2O vs. 27.04 7.79cmH2O, Wilcoxon’s matched pairs test, P 0.0001). Allpatients were also received anti-fibrosis and anti-primaryTable 1 Baseline clinical characteristics of enrolled patientsCharacteristicValuePatients enrolled (n)704Variceal bleeding581Refractory ascites72Variceal bleeding and refractory ascites51Age, years, (mean SD)53.2 13.6Gender, male/female, (n)511/193Cause of cirrhosis (n)HBV509HCV134HBV HCV52HBV HDV9Child-Pugh classification (n)A219B421C64MELD score, (mean SD)12.8 5.1Stiffness of liver, KPa, (mean SD)18.6 10.7Diameter of portal vein, cm, (mean SD)1.52 0.37Diameter of splenic vein, cm, (mean SD)0.96 0.21MELD model for end-stage liver diseasediseases therapies, and liver functions were assessed ineach visit. There were no remarkable differences in ALT,T-BIL, albumin, and stiffness of liver after TIPS insertionin comparison with baseline (Dunn’s multiple comparison test, P 0.05, Table 2). All patients were routinelytreated with anticoagulant drugs at a weight-dependentdose for 1 year after TIPS insertion, leading to the disturbance of blood coagulation which presented as the reduction in PTA and elevation in INR (Dunn’s multiplecomparison test, P 0.05 compared with baseline, Table 2).However, blood ammonia was also increased, especially inthe early stage after TIPS implantation, although ornithineaspartate were routinely used (Dunn’s multiple comparisontest, P 0.05 compared with baseline, Table 2).Complications after TIPS implantationThe major complications after TIPS therapy includedHE and re-bleeding/bleeding. The total incident rate ofHE and re-bleeding/bleeding was 37.9% and 15.5%, respectively. Patients with variceal bleeding and refractoryascites indicated higher incidences for both HE andre-bleeding/bleeding (Chi-squared test, P 0.05, Table 3).Patients with Child-Pugh C revealed a significant elevated incidence of HE than those with Child-Pugh A orB (Chi-squared test, P 0.01, Table 3). However, therewere no remarkable difference in the incidence ofre-bleeding/bleeding among Child-Pugh classification(Chi-squared test, P 0.05, Table 3). Moreover, uncovered (n 130) and covered (n 574) metal stents wereused for portosystemic shunt. No significant incidenceof HE and re-bleeding/bleeding were found between patients using uncovered and covered stents (Chi-squaredtest, P 0.05, Table 3). However, patients receiving covered, 6 mm in diameter stents indicated notably lowerincidence of HE in comparison with other groups(Chi-squared test, P 0.0001, Table 3).Patients survivalOverall median survival was 60 months with the cumulative 5-year survival of patients in 63.6% (Fig. 1a).The median survival was 60 months, 27.0 months, and11.5 months in cirrhotic patients with variceal bleeding,refractory ascites, and both complications, respectively.Moreover, the cumulative 5-year survival was significantly higher in patients with variceal bleeding (75.6%)in comparison with either that in patients with refractory ascites (12.5%, hazard ratio [HR] 69.28 [95% CI39.01–123.0], P 0.0001, Fig. 1b) or that in patients withboth complications (1.96%, HR 0.00025 [95% CI0.00011–0.00059], P 0.0001, Fig. 1b). On multivariateanalysis covered stents usage (HR 2.96 [95% CI 2.06–4.25], P 0.0001, Fig. 1c), baseline MELD score (HR 0.40 [95% CI 0.31–0.41], P 0.0001, Fig. 1d), and baseline Child-Pugh classification (Child-Pugh A versus

Teng et al. Virology Journal (2018) 15:151Page 4 of 7Table 2 Changes in liver functions of liver cirrhotic patients with TIPS treatmentBaseline1 year2 years3 years4 years(n 704)(n 638)(n 587)(n 530)(n 485)(n 445)ALT (U/L)51 2847 1955 3152 2158 2055 18T-BIL (μmol/L)29.2 19.734.8 20.132.9 21.835.9 20.834.6 19.727.6 18.0Albumin (g/L)28.9 10.229.1 11.730.0 9.828.7 8.229.7 9.2######5 years30.1 12.8#Blood ammonia (μmol/L)64.7 25.987.6 27.1PTA (%)56.8 12.537.8 9.1INR1.36 0.231.90 0.46 #1.48 0.511.50 0.491.50 0.441.47 0.38Stiffness (KPa)18.6 10.717.6 9.817.9 12.716.8 8.616.7 9.117.1 10.2P 0.05,####81.5 19.851.4 8.776.2 20.549.2 11.078.2 21.250.1 10.271.0 11.650.8 8.9P 0.01 compared with baseline, Dunn’s multiple comparison testChild-Pugh B, HR 0.73 [95% CI 0.54–0.98], P 0.038;Child-Pugh A versus Child-Pugh C, HR 0.034 [95% CI0.019–0.058], P 0.0001; Child-Pugh B versus ChildPugh C, HR 0.038 [95% CI 0.023–0.064], P 0.0001;Fig. 1e) were predictive of survival. Other variables included in the final Cox proportional hazards model wereage, male gender, and pre-TIPS PVP, but none emergedas significant predictors (P 0.05).DiscussionTo the best of our knowledge, the current study represented one of the largest cohort of patients who receivedTIPS as therapeutic method for the complications ofportal hypertension and liver cirrhosis, and followed-upfor the longest period of time, thereby allowing us tobetter understand plenty of issues related to TIPS implantation for variceal bleeding and/or refractory ascites.In this retrospective study, shunt insertion was successful in 91.3% (935/1024) of patients scheduled. Thebaseline characteristics revealed that distribution ofunderlying diseases was typical for China, with chronicviral hepatitis as the major causation for liver cirrhosis[24]. In agreement with previous findings [25–28], weconfirmed that TIPS is effective as treatment for varicealbleeding and refractory ascites in cirrhotic patients without improvement of liver function. TIPS implantationcould decrease the portal pressure gradient by 20–50%of the initial pressure, and maintained under 12 mmHg[29, 30]. This was consistent with the current results ofreduction in direct measurement of PVP. However, therewere no remarkable differences in the degree of reduction of PVP post-TIPS insertion among patients withvariceal bleeding and/or refractory ascites. Although theinitial reduction in PVP after TIPS insertion was considered to be a predictor for rebleeding risk, but not forTable 3 The incidence of major complications after TIPS treatmentTotalVariceal bleedingHERe-bleeding/Bleeding267/704 (37.9%)109/704 (15.5%)208/581 (35.8%)81/581 (13.9%)Refractory ascites31/72 (43.1%)6/72 (8.3%)Variceal bleeding and refractory ascites28/51 (54.9%) #22/51 (43.1%) ##A83/219 (37.8%)37/219 (16.9%)B142/421 (33.7%)61/421 (14.5%)C42/64 (65.6%) ##11/64 (17.2%)56/130 (43.1%)17/130 (13.1%)Diameter of stent 8 mm (n 47)17/47 (36.1%)5/47 (10.6%)Diameter of stent 10 mm (n 83)39/83 (47.0%)12/83 (14.5%)Child-Pugh classificationType of stentUncovered stent (n 130)Covered stent (n 574)211/574 (36.8%)92/574 (16.0%)Diameter of stent 6 mm (n 94)6/94 (6.4%) ###14/94 (14.9%)Diameter of stent 7 mm (n 178)67/178 (37.6%)31/178 (17.4%)Diameter of stent 8 mm (n 302)138/302 (45.7%)47/302 (15.6%)P 0.05,###P 0.01, and###P 0.01 compared with other groups, Chi-squared test

Teng et al. Virology Journal (2018) 15:151Page 5 of 7Fig. 1 Kaplan-Meier survival analysis of patients after transjugular intrahepatic portosystemic shunt (TIPS) implantation. a Overall survival. bComparison of probability of survival among patients with variceal bleeding and/or refractory ascites. c Comparison of probability of survivalbetween patients with uncovered and covered stent. d Comparison of probability of survival between patients with baseline MELD score 10and 10. e Comparison of probability of survival among patients with different Child-Pugh stagesurvival [31], we did not find notable correlation between baseline/reduction of PVP and survival, indicatingthat PVG might not be the predictor for survivalpost-TIPS treatment.In consistent with Membreno et al. [32] and Heinzowet al. [2], the current results demonstrated that overalllong-term survival was significantly better in patientswith TIPS due to variceal bleeding ( 60 months) thanthat in patients with TIPS due to refractory ascites(27.0 months), while the combination of both complications further worsened the survival (11.5 months, P 0.001) with higher rate of major complications. Theoverall occurrence of HE was nearly 40% which washigher than previous reports, although we routinely prescribed ornithine aspartate and lactulose to all patientspost-TIPS. The use of smaller diameter stents might beassociated with lower risk of HE post-TIPS, as the development of refractory HE requiring reduction in shuntdiameter in 8–10% of patients [33]. This was in accordance with our results showing the lower HE occurrencein patients with 6 mm-diameter of stent insertion,although elevated risk of treatment failure was alsoobserved among patients with smaller 8-mm stent froma randomized controlled trials [34].TIPS implantation increased the risk of acute liverand/or cardiac decompensation and failure. Thus, careful selection of patients with liver cirrhosis and portalhypertension was crucial to the successful outcomepost-TIPS [35, 36]. Previous study revealed that betterliver function might respond better to TIPS insertion[37]. The baseline age 55 years, T-BIL 35 μmol/L, andserum sodium 135 mmol/L indicated beneficial survival post-TIPS. Original Child-Pugh stage [2], modifiedChild-Na score with serum sodium incorporation [38],and MELD score [39] were independent prognostic factor of survival. We showed that patients in Child-PughC stage demonstrated higher incidence of overt HE.Moreover, in agreement with previous findings, ChildPugh stage and MELD score were significant indicatorfor survival post-TIPS, probably due to the fact that bothscoring systems were validated tools for assessing prognosis [40]. Thus, approximate 60% of overall 5-year survival was not surprising as the enrolled patients hadminimal liver dysfunction at baseline.Uncovered metal stents were one of the treatmentchoice for establishing TIPS tracts [41], with approximate 20% use of all TIPS procedures in United States[42]. The higher rate of shunt dysfunction with consecutive bleeding complications [43] has been largely overcome after the development of covered metal stents [18,19, 44]. Although Bureau and colleagues did not detectsurvival benefit of covered and bare stents [45], morerecently meta-analyses of randomized controlled trialsrevealed that covered stents for TIPS improved overallsurvival [20], especially in prevention of varicealre-bleeding [46]. In addition, it was also reported that1-year probability of remaining free of HE in patientswith post-covered TIPS was numerically lower than thatwith bare stents [35, 47]. In the present study, we foundthat there were no remarkable differences in the

Teng et al. Virology Journal (2018) 15:151occurrences of either HE or re-bleeding between coveredand uncovered stents. Furthermore, the use of coveredstents was predictive of beneficial survival, which wassimilar to the findings by Tan et al. in refractory ascites[35]. This was partly due to the better baseline liverfunction in covered stents groups, which was also foundin Tan’s study [35]. Moreover, since most covered stentswere used in recent years, the improvement in procedurerelated skills with primary patency up to 90% within firstyear application also accounted for superiority of coveredstents [19, 35]. Thus, as expected, the improved survivalwas due to era effect rather than type of stents [35], whichfurther deepened the understanding of patients selectionfor TIPS implantation.There were some limitations in this study. First, weconducted a retrospective study with limited patientsnumbers and no control group was established. Thus,large-scale, random control studies were needed toconfirm the current results. Second, we tried to identifypredictors for liver failure in patients post-TIPS. However, the definition for liver failure was hard. The classical definition for liver failure contains jaundice(T-BIL 170 μmol/L) and coagulopathy (PTA 40%).The use of anticoagulant drugs down-regulated PTAlevel, which made it hard for definition. Furthermore,only few patients suffered with high jaundice post-TIPS.Thus, we did not analyze predictors for liver failurepost-TIPS. Third, the factors regarding the cause ofcirrhosis were lacking in survival analysis after TIPS.Fourth, the cause of death of patients did not analyzedin the current study.ConclusionTIPS was an effective and safe therapeutic method fordecompression of portal hypertension and for treatmentof its complications. Child-Pugh stage and MELD scorewere independent predictors of survival in patients withTIPS implantation. Thus, careful selection of patients forTIPS was essential for better long-term outcomes.AbbreviationsALT: Alanine aminotransferase; APTT: Activated partial thromboplastin time;AST: Aspartate aminotransferas; BUN: Blood urea nitrogen; Cr: Creatinine;Fib: Fibrinogen; HE: Hepatic encephalopathy; HR: Hazard ratio;INR: International normalized ratio; MELD: Model for end-stage liver disease;PT: Prothrombin time; PTA: Prothrombin activity; PVP: Portal vein pressure; TBIL: Total bilirubin; TIPS: Transjugular intrahepatic portosystemic shunt;TT: Thrombin timeAuthors’ contributionsJD designed and supervised the study. LD, DT, and LL acquisition of data.LD, DT, HZ, LL, and JD analyzed and interpreted the data. LD, DT, HZ, and JDprepared the manuscript. All authors read and approved the finalmanuscript.Ethics approval and consent to participateThe study protocol was approved by Ethics Committees of both China-JapanUnion Hospital and 302 Military Hospital on December 2016.Page 6 of 7Consent for publicationNot applicable.Competing interestsThe authors declare that they have no competing interests.Publisher’s NoteSpringer Nature remains neutral with regard to jurisdictional claims inpublished maps and institutional affiliations.Author details1Department of Ultrasound, China-Japan Union Hospital of Jilin University,Changchun 130022, Jilin Province, China. 2Department of Pain, The SecondHospital of Jilin University, Changchun 130041, Jilin Province, China.3Department of Radiology, China-Japan Union Hospital of Jilin University, 126Xintai St, Changchun 130022, Jilin Province, China. 4Department ofRadiology, 302 Military Hospital of China, 100 West Fourth Ring Rd, Beijing100039, China.Received: 14 June 2018 Accepted: 25 September 2018References1. 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All data were analyzed using SPSS version 19.0 for Win-dows Software (SPSS Inc., Chicago, IL, USA). Wilcoxon's matched pairs test or Dunn's multiple comparison test were used for comparison of quantitative data. Chi-squared test was used for comparison of categorical data. Kaplan-Meier method was employed to calculate sur-