SHORT-TERM AND LONG-TERM HEMODYNAMIC-EFFECTS OF TRANSJUGULAR INTRAHEPATIC PORTOSYSTEMIC SHUNTS - A DOPPLER MANOMETRIC CORRELATIVE STUDY

OBJECTIVE, The purposes of this study were to evaluate the effect of a well-functioning transjugular intrahepatic portosystemic shunt (TIPS) on the splanchnic and intrahepatic circulation, to determine if sonog raphic measurements can predict shunt dysfunction before clinical mani festations of portal hypertension occur, and to compare Doppler sonogr aphic findings with portocaval gradient measurements before and after shunt revision, SUBJECTS AND METHODS. Forty-four patients with cirrhos is (n=43) and myelofibrosis (n=1) who underwent successful TIPS insert ion were included in this prospective study, Indications for TIPS plac ement were: refractory ascites (24 patients), bleeding esophageal vari ces (17 patients), portal hypertensive gastropathy (two patients), and bleeding colonic varices (one patient), The portal vein and the infer ior vena cava were catheterized; and the portocaval gradient was recor ded before TIPS placement, at 2 and 12 months after TIPS placement, an d when clinical or Doppler findings suggested shunt dysfunction. Doppl er studies were done within 1 week before TIPS placement, within 2 day s after TIPS placement, every 2-3 months thereafter, and before and af ter a TIPS revision, The Doppler studies included flow volume measurem ents in the portal vein and in the stent, as well as determination of the direction of flow in the segmental branches of the portal vein, in the splanchnic veins, and in portosystemic collaterals. Changes in Do ppler findings and in catheter pressure measurements were compared usi ng Spearman's rank correlation test, Significance was set at the .05 l evel. RESULTS, A marked decrease (-51%) in portocaval gradient was obs erved after TIPS placement. At Doppler sonography, portal vein velocit y and diameter were both higher after TIPS placement, resulting in a m arked increase in portal venous flow (170%), Mean flow velocity in the shunt was 55.8 +/- 3.6 cm/sec, and Row volumes in the shunt and in th e main portal vein were 1596 ml/min and 1731 ml/min, respectively (p = nonsignificant), Dysfunction of the stent occurred in 27% of the pati ents. Changes in stent blood flow volume were closely related to chang es in the portocaval gradient (r=-0.67, p<.001), Reduction of blood fl ow volume in the stent or change of direction of flow in intrahepatic portal veins or in collateral veins signaled shunt dysfunction (84% se nsitivity, 89% specificity). CONCLUSION. Marked hemodynamic changes in the portal venous system occur soon after a TIPS procedure, Monitorin g of shunt function with periodic Doppler sonography, including calcul ation of shunt blood flow, is useful in detecting shunt dysfunction be fore clinical signs occur.