TRANSJUGULAR INTRAHEPATIC PORTOSYSTEMIC SHUNT IN THE MANAGEMENT OF VARICEAL BLEEDING - INDICATIONS AND CLINICAL-RESULTS

Background. Transjugular intrahepatic portosystemic shunt (TIPS) has p roved to be a successful bridge to liver transplantation in the manage ment of variceal bleeding. The safety and ease of this technique has n ow challenged standard surgical approaches to portal hypertension. To define the role of TIPS, we prospectively studied patients undergoing this procedure for variceal bleeding and/or ascites. Methods. From Sep tember 1991 to September 1992, 45 patients entered a protocol that inc luded assessment of liver chemistries, ammonia levels, coagulation pro files, liver synthetic function by caffeine-antipyrine clearance, ultr asonographic evaluation of hepatic and portal veins, portogram and dir ect measurement of portal vein pressures, upper endoscopy, computed to mography for liver volume and ascites, and formal neuropsychiatric eva luation. These studies were repealed at 3-month intervals or more freq uently if bleeding or complications occurred. Results. Technical succe ss and control of bleeding were achieved in all patients with only thr ee (7%) variceal rebleeds from recurrent portal hypertension. Complete and permanent control of clinical ascites was noted in all patients w ith this complication. Five of six deaths occurred from sepsis and mul tiorgan failure in intensive care unit-bound patients with Child class C liver disease. No serial changes were noted in liver chemistries; h owever, progressive loss of liver volume and prolongation of caffeine- antipyrine clearance was observed in most patients. In addition, hepat ic vein structure or shunt stenosis seen in nine patients (20%) requir ed TIPS revision, whereas the frequent appearance of symptomatic encep halopathy was a main indication for transplantation in 11 of 74 patien ts. Conclusions. TIPS successfully controls variceal bleeding and may serve as a novel approach to control of diuretic resistant ascites. Th e uncertain long-term patency and progressive decline in synthetic fun ction emphasize the importance of initiating proper trials comparing T IPS with other management strategies before indiscriminant use of this technique is seen.