A PROSPECTIVE TRIAL OF TRANSJUGULAR INTRAHEPATIC PORTASYSTEMIC STENT SHUNTS VERSUS SMALL-DIAMETER PROSTHETIC H-GRAFT PORTACAVAL SHUNTS IN THE TREATMENT OF BLEEDING VARICES

Objective The authors compare transjugular intrahepatic portasystemic stent shunts (TIPS) to small-diameter prosthetic H-graft portacaval sh unts (HGPCS). Summary Background Data Transjugular intrahepatic portas ystemic stent shunts have been embraced as a first-line therapy in the treatment of bleeding varices due to portal hypertension, although th ey have not been compared to operatively placed shunts in a prospectiv e trial. Methods In 1993, the authors began a prospective, randomized trial to compare TIPS with HGPCSs. All patients had bleeding varices a nd had failed nonoperative management. Shunting was undertaken as defi nitive therapy in all. Failure of shunting was defined as an inability to accomplish shunting despite repeated attempts, unexpected liver fa ilure leading to transplantation, irreversible shunt occlusion, major variceal rehemorrhage, or death. Mortality and failure rates were anal yzed at 30 days (early) and after 30 days (late) using Fischer's exact test. Results There were 35 patients in each group, with no differenc e in age, gender, Child's class, etiology of cirrhosis, urgency of shu nting, or incidence of ascites or encephalopathy between groups. In tw o patients, TIPS could not be placed despite repeated attempts. Transj ugular intrahepatic portasystemic stent shunts reduced portal pressure s from 32 +/- 7.5 mmHg (standard deviation) to 25 +/- 7.5 mmHg (p < 0. 01), whereas HGPCS reduced them from 30 +/- 4.6 mmHg to 19 +/- 5.3 mmH g (p < 0.01; paired Student's t test). irreversible occlusion occurred in three patients after placement of TIPS. Total failure rate after T IPS placement was 57%; after HGPCS placement, it was 26% (p < 0.02). C onclusions Both TIPS and HGPCS reduce portal pressure. Placement of TI PS resulted in more deaths, more rebleeding, and more than twice the t reatment failures. Mortality and failure rates promote the application of HGPCS over TIPS.