MORTALITY AND REBLEEDING FOLLOWING TRANSJUGULAR INTRAHEPATIC PORTOSYSTEMIC STENT-SHUNT FOR VARICEAL HEMORRHAGE

The present study investigates clinical factors associated with decrea sed survival following Transjugular Intrahepatic Portosystemic Stent S hunt (TIPSS). Sixty-seven patients underwent TIPSS for bleeding relate d to portal hypertension, 42 (63%) on an urgent basis. TIPSS was succe ssfully placed in 65 (97%) patients with no fatal procedural complicat ions. Thirty day mortality was 21%, there being several predictive fac tors: transfer from another institution, urgency of procedure, sepsis, encephalopathy, higher mean serum bilirubin and low serum albumin. Ho wever, using regression analysis, 30 day mortality was predicted indep endently only by severe liver disease (Child-Pugh C, P = 0.003) and ol der age (P = 0.003). When stratified by Child-Pugh class, cumulative s urvival rates at 1 year for class A, B and C were 100, 90 and 34%, res pectively. Only three of 25 patient deaths were due to variceal reblee ding. Thirty (46%) patients had a total of 41 rebleeding episodes, wit h mean time to first rebleed of 4.8 months (range, 3 days-38 months). Cumulative rebleeding rate at 1 year was 25%. Log-rank analysis did no t reveal a significant difference in overall survival between rebleede rs and non-rebleeders (P = 0.125). When investigated, shunt abnormalit ies (stenosis, occlusion) were identified in all cases of rebleeding. Our findings confirm TIPSS can be safe and effective in the control of refractory variceal haemorrhage. However, prognosis remains poor for patients with advanced liver disease, particularly if older and in the emergency setting. Vigilant surveillance and high rate of interventio n is necessary to maintain shunt patency. Consideration could be given to elective shunt surgery instead of TIPSS for patients with recurren t bleeding and good prognosis liver disease.