Transarterial Chemoembolization in Hepatocellular Carcinoma Patients with and without Transjugular Intrahepatic Portosystemic Shunt: a Systematic Review and Meta-Analysis

Hepatocellular carcinoma (HCC) is a prevalent and deadly form of liver cancer, often requiring transarterial chemoembolization (TACE) for disease management. For patients with advanced portal hypertension, the use of a transjugular intrahepatic portosystemic shunt (TIPS) can help manage complications, but its impact on tumor treatment with TACE is not fully understood. Methods A comprehensive search was conducted across four major databases — PubMed, Embase, Cochrane Library, and Web of Science — using specific search terms related to HCC, TIPS, and TACE. The inclusion criteria required studies with at least 10 patients and an evaluation of tumor response or refractory complications. Tumor control was measured by mRECIST criteria, categorizing responses as complete response (CR), partial response (PR), stable disease (SD), and progressive disease (PD). Tumor control was defined as the sum of the first three categories, while tumor worsening was immediately given by the PD incidence. Safety outcomes were also assessed, this review evaluated the effect of these procedures on variceal rebleeding (VRB), refractory ascites (RA), and hepatic encephalopathy (HE). Risk ratios (RRs) shown in results were calculated under the random effects model. Results Out of an initial pool of 230 studies, 104 unique records were identified. After screening by title and abstract, 6 studies were retained for full-text analysis, with 5 ultimately meeting the inclusion criteria, amounting to 315 and 424 patients in the TACE+TIPS and TACE alone groups, respectively. Even though there was a slight tendency towards favoring the TACE+TIPS group when analyzing for tumor control, the achieved result was not statistically significant (RR = 1.11; 95% CI: 0.87-1.41; I² = 75%). Tumor worsening followed the same tendency, subtly favoring TACE+TIPS without a statistically significant result (RR = 0.75; 95% CI: 0.43-1.31; I² = 67%). Nevertheless, TACE+TIPS proved to be effective in avoiding VRB (RR = 0.37; 95% CI: 0.26-0.52; I² = 0%) and RA (RR = 0.36; 95% CI: 0.23-0.55; I² = 0%). This was not true for HE, as TACE alone has shown better results (RR = 2.23; 95% CI: 1.41-3.53; I = 0%). Fig. 1: Tumor control Fig. 2: Tumor worsening Fig. 3: Variceal rebleeding Fig. 4: Refractory ascites Fig. 5: Hepatic encephalopathy Conclusion TACE and TIPS combined in HCC patients reduces VRB and RA, but it does not significantly improve tumor control. Moreover, TACE+TIPS increases the risk of HE. While it offers benefits in managing some complications, its impact on tumor treatment remains unclear.