THE TRANSJUGULAR INTRAHEPATIC PORTOSYSTEMIC STENT-SHUNT PROCEDURE FORREFRACTORY ASCITES

Background. Previous studies have suggested that the transjugular plac ement of an intrahepatic stent to establish a portosystemic shunt is a n effective treatment of uncomplicated ascites accompanying variceal b leeding. We studied the stent shunt for use in patients with liver cir rhosis and ascites refractory to medical treatment. Methods. Fifty of 62 consecutive patients with cirrhosis and refractory ascites were tre ated with the stent shunt - an expandable stent of metallic mesh place d between a major branch of the portal vein and one of the hepatic vei ns. Patients were followed for a mean (+/-SD) of 426+/-333 days. Resul ts. The stent shunt was successfully placed in all patients and reduce d the pressure gradient between the portal vein and the inferior vena cava by an average of 63 percent. Thirty-seven patients (74 percent) h ad complete responses (total remission of ascites within three months) , and nine patients (18 percent) had partial responses. Four patients did not respond, including two who died within two weeks of shunt plac ement. After the procedure, 25 patients had hepatic encephalopathy, as compared with 20 patients before the procedure; although encephalopat hy improved in 3 patients, new encephalopathy developed in 8 patients. In the 28 of the 33 patients followed for more than six months who we re evaluated, the mean serum creatinine concentration was 1.5+/-0.09 m g per deciliter (133+/-8 mu mol per liter) before placement of the ste nt shunt, 1.5+/-1.6 mg per deciliter (133+/-141 mu mol per liter) one week after the procedure, and 0.9+/-0.3 mg per deciliter (80+/-27 mu m ol per liter) after six months (P=0.008 for the comparison of concentr ations before and six months after the procedure). Renal function did not improve in the six patients with organic kidney disease. Procedure -related complications developed in 16 patients. During followup, an a dditional 29 patients died - 10 of progressive liver disease and 19 of other causes. Survival for at least one year was associated with a pa tient's being under 60 years of age, having a serum bilirubin level be fore placement of the stent shunt of less than 1.3 mg per deciliter (2 2 mu mol per liter), and having a complete response. Conclusions. Our findings in an uncontrolled prospective study suggest that the transju gular intrahepatic portosystemic stent-shunt procedure was an effectiv e treatment for many patients with liver cirrhosis and refractory asci tes, but mortality from underlying diseases was substantial.