Critical appraisal of the angiographic portacaval shunt (TIPS).
The transjugular intrahepatic portacaval shunt (TIPS) is a novel angiographic method for achieving portal decompression without operation. Fifty-nine consecutive patients underwent a total of 80 consecutive TIPS procedures. The procedure was unsuccessful in 4 patients (7%) and initially succeeded in 55 (93%). Eighteen patients (30%) underwent 2 or more TIPS procedures during the same hospitalization due to technical difficulties, early rebleeding, shunt stenosis, or thrombosis. Early TIPS occlusion occurred in seven patients (12%) and led to recurrent variceal hemorrhage in five. Forty-two percent of the cases of persisting or recurrent bleeding were nonvariceal. Procedure-related complications occurred in 10% of TIPS procedures or 14% of patients. Twenty-three patients (39%) were actively bleeding at the time of the procedure, and, in 6 of these (26%), bleeding was never controlled. In-hospital mortality (25%) was related only to the presence of bleeding at the time of TIPS (56% for emergent versus 5.5% for non-emergent, p < 0.0001). Mortality was not related to the Child-Pugh classification. Hemodynamic stabilization, vasoconstrictor therapy, balloon tamponade, and sclerotherapy were underutilized in 30% to 40% of patients prior to TIPS. Aggressive medical management should be used to stop variceal hemorrhage prior to TIPS in all patients, regardless of the Child-Pugh classification. Prospective trials comparing TIPS with sclerotherapy and surgical shunt are required to demonstrate the proper role of this procedure in the management of portal hypertension and variceal hemorrhage.
Helton
W S
WS
Department of Surgery, University of Washington School of Medicine, Seattle.
Belshaw
A
A
Althaus
S
S
Park
S
S
Coldwell
D
D
Johansen
K
K
D000328:Adult; D000368:Aged; D000792:Angiography / Q000379:methods; D004932:Esophageal and Gastric Varices / Q000150:complications / Q000000981:diagnostic imaging / Q000601:surgery*; D005260:Female; D006471:Gastrointestinal Hemorrhage / Q000000981:diagnostic imaging / Q000209:etiology / Q000401:mortality / Q000601:surgery; D006501:Hepatic Encephalopathy / Q000209:etiology; D006801:Humans; D007902:Length of Stay; D008107:Liver Diseases / Q000150:complications; D008297:Male; D008875:Middle Aged; D011167:Portacaval Shunt, Surgical / Q000009:adverse effects / Q000401:mortality; D012008:Recurrence; D012189:Retrospective Studies; D015996:Survival Rate