The results from the present study showed that GRS embolization in addition to TIPS was associated with the higher 1-year incidences of HE but had no difference in clinical relapse, mortality or shunt dysfunction. Furthermore, the distribution of initially performed HE was characterized by obvious stages, which performed significant difference between the two groups (p < 0.001). However, there was no significant difference in the 1-year cumulative risk of HE (p = 0.287). In addition, during up to two years follow-up, there was no longer increased incidence of HE after the 250th post-TIPS, and all the cases of performing HE can be controlled medically with cellulose, protein-restricted diet or branched-chain amino acids. And during the whole 2 years follow-up, the GRS group performed lower incidence of ascites after GRS embolization with TIPS (p < 0.002). An important showing of a relatively precise presence of HE after TIPS was recorded through the long-term follow-up. The precious article showed the incidence of new onset or worsening HE was up to be 50% [15, 16]. In our study, the overall post-procedural HE rate is 35.7% (25/70), but the HE rate in patients with GRS is 56%, compared to 44% in patients without a shunt. The results of this study clearly showed that the patients with GRS undergoing TIPS significantly perform the higher incidence of HE in the statistical. The reasons for the result may be as follows. TIPS with embolotherapy may increase the incidence of shunt dysfunction and liver dysfunction, for a relative growth of portal venous flow in patients with GRS, contrasting with whom has not formed a spontaneous shunt. The extrapolation can be testified by the poor liver function and improved renal function. In addition, the existence of shunts induces excessive portosystemic shunts, thereby increasing the incidence of HE episodes. Moreover, in our study, the distribution of initially performed HE was characterized by obvious stages. Specifically, HE is mostly found within 50 days or as late as the 250th after TIPS, in which only 5 patients over half years, similar to the previous report . And also, the stages have significant difference between the two groups (p < 0.001). The patients with GRS embolization after TIPS more tend to be HE in the earlier stage, while the patients with no GRS undergoing TIPS also performance HE obviously in the late period. We speculated that the early or the late occurrences of HE may respectively relate to the insufficient liver function and the development of novel or cannibalization of occluded GRS, which was consistent with the previous viewpoint . However, there was no significant difference in the 1-year cumulative risk of HE between the two groups (p = 0.287). Our finding might be explained by the previous study  that a significantly increased risk of HE was only found in patients with a large SPSS. Then, in the later research, we need to pay attention to the diameter of GRS. During the second year of follow-up, 49 followed patients (48/49, 97.96%) present HE-free. Fortunately, all patients respond well to standard treatment for HE and no death is associated with HE. Because of the long-term follow-up, we could mainly understand the dynamic change of HE, then draw the conclusion pertinently that GRS embolization during TIPS procedure have no influence on the presence of HE after 1 year of post-TIPS, although the earlier performance of HE was significance.
The rates of rebleeding and ascites recurrence post-TIPS in our study had the similar and difference with those present articles [18, 19]. Dissegna reported that only 3% patient experienced two episodes of rebleeding within 1 year, while in our study, the rate of rebleeding was 14.3% (10/70). However, our results showed that the rates of clinical relapse did not differ significantly between the patents with GRS embolization and without GRS, indicating that the procedure had no deterioration on clinical outcomes. Furthermore, GRS embolization with TIPS decreased the recurrences of ascites for the long-term of 2-year follow-up. This finding of our study has not been proposed in other reports [9, 20] that may be due to the long-term follow-up. Thus, in evaluating the outcome of GRS embolization with TIPS, the long-term follow-up should be put forward. The study of He et al. provided the similar results and strongly explained the factor by the shunt patency. As well, no significant differences in mortality were observed, which is consistent with the previous report . Overall shunt dysfunction was observed in 11.43% of our study, which was similar to most other studies on TIPS stent [10, 19], and there was no difference in shunt dysfunction between our research groups. And reasonably, the higher incidence of shunt dysfunction was found in the second year than in the first year.
Our report has several uniqueness. Firstly, the long-term follow-up, more convincing to reveal the truth of GRS embolization with TIPS. Secondly, clearly describe the stages of HE performance. Finally, the present study only for GRS, not SPSS that including all kinds, was limitless. However, the inherent limitations of this study included the retrospective analysis, missing data, the diameter of GRS and the inarticulate TIPS stent.
In conclusion, our study showed that GRS embolization in addition to TIPS was more likely to perform HE, which showed difference on the stages but no difference on the cumulative risk. And with the long-term follow-up, GRS embolization with TIPS reduced the recurrences of ascites and had no impact on rebleeding, mortality and shunt dysfunction. Thus, we suggest the profit of GRS embolization during TIPS placement on the cirrhosis with GRS. A lot of large, prospective studies are warranted to confirm our findings.