CRITICAL-APPRAISAL OF THE ANGIOGRAPHIC PORTACAVAL-SHUNT (TIPS)

The transjugular intrahepatic portacaval shunt (TIPS) is a novel angio graphic method for achieving portal decompression without operation. F ifty-nine consecutive patients underwent a total of 80 consecutive TIP S procedures. The procedure was unsuccessful in 4 patients (7%) and in itially succeeded in 55 (93%). Eighteen patients (30%) underwent 2 or more TIPS procedures during the same hospitalization due to technical difficulties, early rebleeding, shunt stenosis, or thrombosis. Early T IPS occlusion occurred in seven patients (12%) and led to recurrent va riceal hemorrhage in five. Forty-two percent of the cases of persistin g or recurrent bleeding were nonvariceal. Procedure-related complicati ons occurred in 10% of TIPS procedures or 14% of patients. Twenty-thre e patients (39%) were actively bleeding at the time of the procedure, and, in 6 of these (26%), bleeding was never controlled. In-hospital m ortality (25%) was related only to the presence of bleeding at the tim e of TIPS (56% for emergent versus 5.5% for nonemergent, p < 0.0001). Mortality was not related to the Child-Pugh classification. Hemodynami c stabilization, vasoconstrictor therapy, balloon tamponade, and scler otherapy were underutilized in 30% to 40% of patients, prior to TIPS. Aggressive medical management should be used to stop variceal hemorrha ge prior to TIPS in all patients, regardless of the Child-Pugh classif ication. Prospective trials comparing TIPS with sclerotherapy and surg ical shunt are required to demonstrate the proper role of this procedu re in the management of portal hypertension and variceal hemorrhage.