title: Salvage transjugular intrahepatic portosystemic shunt for uncontrolled variceal bleeding in patients with decompensated cirrhosis.
abstract: OBJECTIVE
  The place of transjugular intrahepatic porto-systemic shunt (TIPS) for variceal haemorrhage uncontrolled by sclerotherapy and medical treatment is still undefined. To investigate the outcome of early salvage TIPS for active uncontrolled variceal haemorrhage, and to identify the factors associated with mortality.
  
  
  METHODS
  Salvage TIPS was performed in 58 patients as soon as possible after the diagnosis of variceal bleeding refractory to the combination of sclerotherapy and of pharmacological therapy. Twenty-three variables were assessed prospectively to identify predictors of mortality within 60 days of the procedure.
  
  
  RESULTS
  The haemorrhage was controlled in 52 of 58 patients (90%). Bleeding persisted in six of 58 patients (10%), and recurred in four patients (7%). Overall, 17 (29%) and 20 (35%) patients died within respectively 30 days and 60 days of TIPS: five patients died of persistent bleeding, two patients died of recurrent bleeding, and 13 patients died of terminal liver failure. The actuarial survival following salvage TIPS was 51.7% at 1 year. On multivariate analysis, independent predictors of early mortality were: the presence of sepsis (P=0.001), the use of catecholamines for systemic hemodynamic impairment (P=0.009), and the use of balloon tamponade (P=0.04). Neither a single factor, nor a combination of factors before TIPS allowed to predict mortality confidently in a given patient.
  
  
  CONCLUSIONS
  Early salvage TIPS is an effective treatment to stop active variceal bleeding refractory to sclerotherapy and pharmacological treatment. Pre-treatment prognostic determinants that correlate to mortality can not be used to predict the outcome in individual cases.
authors.affiliation: Department of Liver Surgery and Liver Transplantation, Centre Hépato-Biliaire, UPRES No 1596, IFR 89.9, Hôpital Paul Brousse, Villejuif, France. daniel.azoulay@pbr.ap-hop-paris.fr
authors.forename: D
authors.initials: D
authors.lastname: Azoulay
authors.forename: D
authors.initials: D
authors.lastname: Castaing
authors.forename: P
authors.initials: P
authors.lastname: Majno
authors.forename: F
authors.initials: F
authors.lastname: Saliba
authors.forename: P
authors.initials: P
authors.lastname: Ichaï
authors.forename: A
authors.initials: A
authors.lastname: Smail
authors.forename: V
authors.initials: V
authors.lastname: Delvart
authors.forename: M
authors.initials: M
authors.lastname: Danaoui
authors.forename: D
authors.initials: D
authors.lastname: Samuel
authors.forename: H
authors.initials: H
authors.lastname: Bismuth
mesh_terms: D001663:Bilirubin / Q000097:blood; D001803:Blood Transfusion; D004932:Esophageal and Gastric Varices / Q000209:etiology / Q000401:mortality / Q000628:therapy*; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D008103:Liver Cirrhosis / Q000150:complications*; D008104:Liver Cirrhosis, Alcoholic / Q000150:complications; D008297:Male; D008875:Middle Aged; D019168:Portasystemic Shunt, Transjugular Intrahepatic; D012008:Recurrence; D015911:Sclerotherapy; D016019:Survival Analysis; D013997:Time Factors; D016896:Treatment Outcome
chemical_list: D001663:Bilirubin