URGENT TRANSJUGULAR INTRAHEPATIC PORTOSYSTEMIC SHUNT FOR CONTROL OF ACUTE VARICEAL BLEEDING

Objective: Endoscopic sclerotherapy and pharmacological therapy are wi dely used in the treatment of acute variceal hemorrhage. However, they fail at arresting acute bleeding in 20-30% of bleeding episodes. The efficacy of transjugular intrahepatic portosystemic shunt (TIPS) in th e prevention of recurrent variceal bleeding has been proved recently, but the effectiveness and safety of urgent TIPS in the treatment of ac ute variceal bleeding refractory to conventional therapy are still und er evaluation. Methods: Over 4.5 yr, 358 variceal hemorrhage episodes were treated in our hospital. Pharmacological and endoscopic therapy f ailed to control hemorrhage in 93 episodes. Thirty-two patients died b ecause of uncontrolled massive bleeding. In 56 patients, TIPS (Strecke r stent) was performed after temporary control of the episode with bal loon tamponade. Results: Eleven of 56 patients with urgent TIPS belong ed to Child-Pugh class A, 22 to class B, and 23 to class C. The mean t ime between indication and insertion was 17 +/- 10 h (range 4-24 h). C ontrol of bleeding was achieved in 53 patients (95%). Eight patients h ad recurrent bleeding at 1 month after TIPS, seven of them during the first week after the procedure. The 1-month actuarial probability of r ebleeding was 22%. The main complications of the procedure were massiv e hemoperitoneum (n = 1), cardiorespiratory arrest (n = 2), cardiac fa ilure (n = 1), acute renal failure (n = 2), and bacteremia (n = 7). Op erative mortality (30 days) was 28%. The actuarial probability of surv ival at 30 days was significantly lower in Child-Pugh class C than in class A or B (48% vs 90%; p < 0.001). The presence of ascites, hepatic encephalopathy, and serum albumin level before TIPS were independent prognostic factors associated with the risk of operative mortality. Co nclusions: Urgent TIPS is an effective alternative for the treatment o f acute variceal bleeding refractory to endoscopic and pharmacological therapy, but sometimes is associated with major complications. Becaus e of the high operative mortality rate in patients with severe liver f ailure, careful selection of patients is required before TIPS. (C) 199 8 by Am. Coll. of Gastroenterology.