TRANSJUGULAR INTRAHEPATIC PORTOSYSTEMIC SHUNTS FOR PATIENTS WITH ACTIVE VARICEAL HEMORRHAGE UNRESPONSIVE TO SCLEROTHERAPY

Background & Aims: Despite urgent sclerotherapy, active variceal hemor rhage has a 70%-90% mortality rate in patients with advanced age, seps is, renal or pulmonary compromise, tense ascites, or deep coma. The ai m of this study was to test the safety and efficacy of transjugular in trahepatic portosystemic shunt (TIPS) performed semiemergently and pre ceded by stabilization by balloon tamponade in such patients. Methods: Patients with actively bleeding esophageal or contiguous gastric vari ces despite sclerotherapy were assessed for risk of dying after emerge nt portacaval shunt. Those considered to be at high risk were stabiliz ed by balloon tamponade and vasopressin/nitroglycerin and TIPS placed semiurgently within 12 hours. Balloon tamponade and pharmacological th erapy were discontinued within 24 hours after TIPS in all cases. Resul ts: Thirty-two patients met entry criteria, and 2 were excluded due to portal vein thrombosis. TIPS was successfully placed in 29 of 30 pati ents acid achieved hemostasis in all. Thirty-day and 6-week survival r ates were 63% and 60%, respectively; in those without aspiration, the 6-week survival rate was 90%. After a median follow-up period of 920 d ays, 46% of the original cohort was alive. Only 2 episodes of early re bleeding and 4 late rebleeds occurred. Eight patients developed enceph alopathy. Stent stenosis requiring dilation occurred in 6 of 11 patien ts within 6 months. Conclusions: TIPS is highly effective as salvage t herapy in high-risk patients with active variceal hemorrhage despite e ndoscopic sclerotherapy.