Transjugular intrahepatic portosystemic shunt in the management of variceal bleeding: indications and clinical results.
BACKGROUND
Transjugular intrahepatic portosystemic shunt (TIPS) has proved to be a successful bridge to liver transplantation in the management of variceal bleeding. The safety and ease of this technique has now challenged standard surgical approaches to portal hypertension. To define the role of TIPS, we prospectively studied patients undergoing this procedure for variceal bleeding and/or ascites.


METHODS
From September 1991 to September 1992, 45 patients entered a protocol that included assessment of liver chemistries, ammonia levels, coagulation profiles, liver synthetic function by caffeine-antipyrine clearance, ultrasonographic evaluation of hepatic and portal veins, portogram and direct measurement of portal vein pressures, upper endoscopy, computed tomography for liver volume and ascites, and formal neuropsychiatric evaluation. These studies were repeated at 3-month intervals or more frequently if bleeding or complications occurred.


RESULTS
Technical success and control of bleeding were achieved in all patients with only three (7%) variceal rebleeds from recurrent portal hypertension. Complete and permanent control of clinical ascites was noted in all patients with this complication. Five of six deaths occurred from sepsis and multiorgan failure in intensive care unit-bound patients with Child class C liver disease. No serial changes were noted in liver chemistries; however, progressive loss of liver volume and prolongation of caffeine-antipyrine clearance was observed in most patients. In addition, hepatic vein stricture or shunt stenosis seen in nine patients (20%) required TIPS revision, whereas the frequent appearance of symptomatic encephalopathy was a main indication for transplantation in 11 of 14 patients.


CONCLUSIONS
TIPS successfully controls variceal bleeding and may serve as a novel approach to control of diuretic resistant ascites. The uncertain long-term patency and progressive decline in synthetic function emphasize the importance of initiating proper trials comparing TIPS with other management strategies before indiscriminant use of this technique is seen.
Martin
M
M
Department of Surgery, University of Pittsburgh Medical Center, Pa.
Zajko
A B
AB
Orons
P D
PD
Dodd
G
G
Wright
H
H
Colangelo
J
J
Tartar
R
R
D001201:Ascites / Q000150:complications / Q000601:surgery; D005260:Female; D006439:Hemodynamics; D006470:Hemorrhage / Q000209:etiology* / Q000601:surgery*; D006501:Hepatic Encephalopathy / Q000209:etiology; D006801:Humans; D008099:Liver / Q000378:metabolism / Q000503:physiopathology; D008102:Liver Circulation; D016031:Liver Transplantation; D008297:Male; D008875:Middle Aged; D009017:Morbidity; D011168:Portal System; D011170:Portasystemic Shunt, Surgical / Q000379:methods; D011183:Postoperative Complications / Q000401:mortality; D011446:Prospective Studies; D014648:Varicose Veins / Q000150:complications*; D014654:Vascular Patency