title: Emergent salvage direct intrahepatic portocaval shunt procedure for acute variceal hemorrhage.
abstract: OBJECTIVE
  To review the safety and effectiveness of direct intrahepatic portocaval shunt (DIPS) creation with variceal embolization for acute variceal hemorrhage after a failed transjugular intrahepatic portosystemic shunt (TIPS) creation attempt or in patients with prohibitive anatomy.
  
  
  METHODS
  Transjugular intrahepatic portosystemic shunt and DIPS procedures performed for variceal hemorrhage between January 2008 and July 2014 were reviewed. The default procedure was TIPS creation, with DIPS creation reserved for patients with unfavorable anatomy or who had technically unsuccessful TIPS creation. Thirteen patients underwent DIPS creation (mean age, 60 y ± 12; Child-Pugh class A/B/C, 8%/62%/30%; Model for End-stage Liver Disease score, 15 ± 5; range, 8-26) and 117 underwent TIPS creation. Four patients underwent a TIPS attempt and were converted to DIPS creation upon technical failure; 9 were treated primarily with DIPS creation because of preprocedural imaging revealing unfavorable anatomy (intrahepatic portal thrombosis, n = 2; venous distortion from prior hepatic resections, n = 2; severely angulated hepatic veins, n = 5).
  
  
  RESULTS
  Direct intrahepatic portocaval shunt creation with variceal embolization (six gastric or esophageal; seven stomal, duodenal, or rectal) was successful in all patients; 11 also had concomitant variceal sclerotherapy. Mean DIPS procedure time was less than 2 hours. There was 1 major procedural complication. During a mean follow-up of 13.0 months ± 15.5, 1 patient developed DIPS thrombosis and recurrent hemorrhage; 1 patient underwent successful transplantation. Two deaths were observed within 30 days, neither associated with recurrent hemorrhage.
  
  
  CONCLUSIONS
  Direct intrahepatic portocaval shunt creation appears to be a safe, expedient, and effective treatment for patients with acute variceal hemorrhage who are poor anatomic candidates for TIPS creation or who have undergone unsuccessful TIPS creation attempts.
authors.affiliation: Division of Interventional Radiology, Stanford University Medical Center, 300 Pasteur Dr., Stanford, CA 95305.. Electronic address: thomas.ward@mountsinai.org.
authors.forename: Thomas J
authors.initials: TJ
authors.lastname: Ward
authors.affiliation: Division of Interventional Radiology, Stanford University Medical Center, 300 Pasteur Dr., Stanford, CA 95305.
authors.forename: Tust
authors.initials: T
authors.lastname: Techasith
authors.affiliation: Division of Interventional Radiology, Stanford University Medical Center, 300 Pasteur Dr., Stanford, CA 95305.
authors.forename: John D
authors.initials: JD
authors.lastname: Louie
authors.affiliation: Division of Interventional Radiology, Stanford University Medical Center, 300 Pasteur Dr., Stanford, CA 95305.
authors.forename: Gloria L
authors.initials: GL
authors.lastname: Hwang
authors.affiliation: Division of Interventional Radiology, Stanford University Medical Center, 300 Pasteur Dr., Stanford, CA 95305.
authors.forename: Lawrence V
authors.initials: LV
authors.lastname: Hofmann
authors.affiliation: Division of Interventional Radiology, Stanford University Medical Center, 300 Pasteur Dr., Stanford, CA 95305.
authors.forename: Daniel Y
authors.initials: DY
authors.lastname: Sze
mesh_terms: D000208:Acute Disease; D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D002140:California; D004621:Embolization, Therapeutic; D004630:Emergencies; D004932:Esophageal and Gastric Varices / Q000175:diagnosis / Q000401:mortality / Q000503:physiopathology / Q000601:surgery*; D005260:Female; D006471:Gastrointestinal Hemorrhage / Q000175:diagnosis / Q000401:mortality / Q000503:physiopathology / Q000601:surgery*; D006801:Humans; D008297:Male; D008875:Middle Aged; D061646:Operative Time; D011167:Portacaval Shunt, Surgical / Q000009:adverse effects / Q000401:mortality; D019168:Portasystemic Shunt, Transjugular Intrahepatic / Q000009:adverse effects / Q000401:mortality; D011183:Postoperative Complications / Q000209:etiology; D015641:Radiography, Interventional; D012008:Recurrence; D012189:Retrospective Studies; D012307:Risk Factors; D016879:Salvage Therapy / Q000009:adverse effects / Q000401:mortality; D015911:Sclerotherapy; D013997:Time Factors; D014057:Tomography, X-Ray Computed; D017211:Treatment Failure