title: How much reduction in portal pressure is necessary to prevent variceal rebleeding? A longitudinal study in 225 patients with transjugular intrahepatic portosystemic shunts.
abstract: OBJECTIVE
  This longitudinal study determines the risk of rebleeding in relation to the reduction of the portosystemic pressure gradient in patients with a transjugular intrahepatic portosystemic shunt (TIPS) for variceal bleeding.
  
  
  METHODS
  The study included 225 patients in whom a TIPS revision was indicated by the endoscopic finding of varices with a high risk for rebleeding (n = 167) or a recent variceal rebleed (n = 58). The portosystemic pressure gradient was determined before and after TIPS placement and at revision performed after a mean of 10 +/- 15 months.
  
  
  RESULTS
  The portosystemic pressure gradient at revision approached the index pressure gradient before TIPS implantation (23.1 +/- 5.5 mm Hg) by 8.4 +/- 31%. Rebleeding was inversely correlated with the reduction in index pressure gradient found at revision. Thus, 80% of rebleedings occurred with pressure gradients close to the index pressure gradient (< 25% reduction) or with gradients equal to or greater than the index pressure gradient. In contrast, only one patient (0.4%) and three patients (1.3%) rebled with a pressure gradient of < 12 mm Hg or a reduction of the index pressure gradient by > 50%, respectively. Kaplan-Meier analysis of rebleeding, which included the 225 patients at risk, showed a probability of rebleeding of 18%, 7%, and 1% for a reduction of the index pressure gradient by 0%, 25-50%, and > 50%, respectively.
  
  
  CONCLUSIONS
  Most rebleedings occurred with pressure gradients similar to the index-pressure gradient measured at first bleeding. Accordingly, a graded reduction by 25-50% sufficiently prevents rebleeding. It can be assumed that, in comparison with the widely used threshold value of 12 mm Hg, a reduction by 25-50% may have a favorable benefit-to-risk ratio with respect to shunt-induced hepatic encephalopathy and liver failure. It should therefore be a goal in the decompressive treatment of portal hypertension and maintained during follow-up of patients with variceal bleeding.
authors.affiliation: Department of Gastroenterology, University Hospital, Freiburg, Germany.
authors.forename: M
authors.initials: M
authors.lastname: Rössle
authors.forename: V
authors.initials: V
authors.lastname: Siegerstetter
authors.forename: M
authors.initials: M
authors.lastname: Olschewski
authors.forename: A
authors.initials: A
authors.lastname: Ochs
authors.forename: E
authors.initials: E
authors.lastname: Berger
authors.forename: K
authors.initials: K
authors.lastname: Haag
mesh_terms: D000328:Adult; D001794:Blood Pressure; D005260:Female; D006470:Hemorrhage / Q000209:etiology / Q000517:prevention & control* / Q000601:surgery*; D006801:Humans; D008137:Longitudinal Studies; D008297:Male; D008875:Middle Aged; D011168:Portal System / Q000503:physiopathology*; D019168:Portasystemic Shunt, Transjugular Intrahepatic; D011336:Probability; D055502:Secondary Prevention; D016019:Survival Analysis; D014648:Varicose Veins / Q000150:complications* / Q000503:physiopathology*