title: Two-stage transjugular intrahepatic porta-systemic shunt for patients with cirrhosis and a high risk of portal-systemic encephalopathy patients as a bridge to orthotopic liver transplantation: a preliminary report.
abstract: OBJECTIVE
  Placement of a transjugular intrahepatic porta-systemic shunt (TIPS) is a therapeutic option for the management of bleeding esophageal varices. However, the procedure is associated with an increased risk of portal-systemic encephalopathy (PSE). In this study, a two-stage modification of the standard TIPS technique was introduced for the management of variceal bleeding in cirrhotic patients with a high risk of PSE before liver transplantation.
  
  
  METHODS
  The modified procedure was applied to four patients with cirrhosis, portal hypertension, and ascites. Two had a history of encephalopathy after variceal bleeding; the other two were encephalopathic at the time of the first stage of the modified procedure. In the first stage, a 6-mm diameter intrahepatic shunt was created using a Palmaz-Schatz stent. One month later, in the second stage, the lumen of the shunt was expanded to a diameter of 10 mm.
  
  
  RESULTS
  Both stages of this TIPS procedure were undertaken without any associated adverse events. In particular, neither stage was followed by a deterioration of neurologic status. From completion of the second stage to undertaking orthotopic liver transplantation (a period of 2 to 6 months), no rebleeding from esophageal varices occurred.
  
  
  CONCLUSIONS
  A two-stage TIPS procedure to reduce portal hypertension enables a more gradual adaptation to post-TIPS hemodynamic and metabolic changes than occurs after creation of a conventional TIPS. A two-stage TIPS procedure may be the method of choice for treating bleeding from esophageal varices in patients who have a high risk of developing PSE and give them a chance for liver transplantation.
authors.affiliation: Department of General, Transplant and Liver Surgery, the Warsaw Medical University, ul. Banacha 1a, 02-097 Warsaw, Poland. wroblewskitad@o2.pl
authors.forename: T
authors.initials: T
authors.lastname: Wróblewski
authors.forename: O
authors.initials: O
authors.lastname: Rowiński
authors.forename: B
authors.initials: B
authors.lastname: Ziarkiewicz-Wróblewska
authors.forename: B
authors.initials: B
authors.lastname: Górnicka
authors.forename: J
authors.initials: J
authors.lastname: Albrecht
authors.forename: E A
authors.initials: EA
authors.lastname: Jones
authors.forename: M
authors.initials: M
authors.lastname: Krawczyk
mesh_terms: D000328:Adult; D004932:Esophageal and Gastric Varices / Q000601:surgery; D005260:Female; D006501:Hepatic Encephalopathy / Q000453:epidemiology / Q000517:prevention & control*; D006801:Humans; D008103:Liver Cirrhosis / Q000601:surgery*; D016031:Liver Transplantation; D008297:Male; D008875:Middle Aged; D019168:Portasystemic Shunt, Transjugular Intrahepatic / Q000379:methods*