Intravascular ultrasound-guided direct intrahepatic portacaval shunt: midterm follow-up.
OBJECTIVE
To describe the midterm patency and clinical results of the intravascular ultrasound (US)-guided direct intrahepatic portacaval shunt (DIPS) procedure for the treatment of intractable ascites and variceal bleeding.


METHODS
From February 23, 1999, to December 18, 2002, inferior vena cava (IVC)-to-portal vein (PV) shunts were created in 40 patients for ascites (n = 35) and bleeding (n = 5). Intravascular US was used to guide direct puncture from the IVC to the PV. The shunts were completed with the use of single (n = 15) or overlapping (n = 25) polytetrafluoroethylene (PTFE)-covered Palmaz stents. These stent-grafts were deployed primarily at diameters of 8 mm. The diameter of the shunt was increased in three cases to achieve a target portosystemic gradient (PSG) of 15 mm Hg or lower. All patients were followed clinically and with portography with manometry.


RESULTS
All DIPSs were created successfully. Mean PSGs were reduced from 23 mm Hg before DIPS creation to 9 mm afterward. During the follow-up period of a maximum of 38 months, 22 of 40 patients died or underwent liver transplantation (mean follow-up, 9 months; median, 6 months). At the time of this report, 18 of 40 patients remain living after follow-up ranging in duration from 8 to 38 months (mean, 22 months; median, 16.5 months). During the follow-up period, there was one stent-graft occlusion and three stenoses. These four patients were successfully treated by additional stent-graft placement. In addition, two patients developed IVC stenosis cephalad to the DIPS, which required IVC stent placement. The primary patency rates by Kaplan-Meier analysis were 100% at 6 months and 75% (95% CI, 53%-97%) at 12 months.


CONCLUSIONS
Intravascular US-guided direct IVC-to-PV shunts may be created successfully with minimal complications. Primary patency of the shunt is greater than that with conventional TIPS with a bare wire stent and appears equal to that with TIPS with a PTFE-covered stent-graft.
Petersen
Bryan
B
Department of Angiography, Oregon Health and Sciences University, L342, 3181 Southwest Sam Jackson Park Road, Portland, OR 97201, USA. bryan.petersen@med.va.gov
Binkert
Christoph
C
D019160:Endosonography; D004932:Esophageal and Gastric Varices / Q000601:surgery; D005500:Follow-Up Studies; D006471:Gastrointestinal Hemorrhage / Q000601:surgery; D006503:Hepatic Veins; D006801:Humans; D011138:Polytetrafluoroethylene; D011167:Portacaval Shunt, Surgical / Q000379:methods* / Q000401:mortality; D011183:Postoperative Complications; D015607:Stents; D016896:Treatment Outcome; D014654:Vascular Patency; D014682:Vena Cava, Inferior
D011138:Polytetrafluoroethylene