Transjugular intrahepatic portosystemic shunts and liver transplantation in patients with refractory hepatic hydrothorax

Hepatic hydrothorax is a relatively infrequent but potentially serious comp lication of cirrhosis resulting from the accumulation of ascitic fluid in t he chest cavity. Medical management is initially directed at controlling as cites formation, but invasive therapeutic procedures may be required if sym ptoms persist. The aim of this study was to report on the long-term efficac y and safety of transjugular intrahepatic portosystemic shunt (TIPS) placem ent to reduce portal hypertension in 12 consecutive subjects with refractor y hepatic hydrothorax. Most subjects had evidence of advanced cirrhosis of varying causes (Child-Pugh class A, 1; B, 5; C, 6). Mean subject age was 54 years, and subjects were followed up for a mean of 173 days (range, 7-926 days). The portosystemic pressure gradient after TIPS was reduced to <12 mm Hg in all cases. Periprocedural morbidity was noted in 2 subjects, and 30-d ay survival after TIPS placement was 75%. Overall, 58% of subjects experien ced either a complete or partial response following TIPS placement. Subject response did not correlate with age, baseline creatinine clearance, or Chi ld-Pugh score. Cumulative subject survival was 42%, and 4 of the 5 long-ter m survivors required eventual liver transplantation. Subject age >65 years was associated with early mortality after TIPS placement, but this trend wa s not statistically significant. All 4 subjects undergoing liver transplant ation required perioperative pleural fluid drainage, but only 1 subject has experienced recurrent effusion. We conclude that TIPS may be a safe and ef fective temporizing treatment for carefully selected patients with refracto ry hepatic hydrothorax. However, patient survival is limited after TIPS and is primarily determined by availability of liver transplantation. Copyrigh t (C) 1998 by the American Association for the Study of Liver Diseases.