Experience with transjugular intrahepatic portosystemic shunts for gastroesophageal variceal bleeding.

BACKGROUND

Variceal bleeding is a major life-threatening complication of cirrhosis of the liver. Transjugular intrahepatic portosystemic shunts (TIPS) have been accepted as an effective method for portal decompression. Experiences here with the use of TIPS for control of gastroesophageal variceal bleeding is presented.

METHODS

Sixteen TIPS procedures were performed for 15 patients who suffered from intractable gastroesophageal variceal bleeding. Nine cases (60%) were hepatitis-related cirrhosis of liver, four (27%) were alcoholic liver cirrhosis and two were cryptogenic in origin. Liver function tests revealed four patients were Child-Pugh's classification A, five were B and six, C. Twelve cases had received failed endoscopic management of varices; and one patient had recurrent variceal bleeding after devascularization. TIPS procedure was performed electively in nine cases and, as an emergency in six cases.

RESULTS

Fifteen of the 16 TIPS procedures attempted were successfully performed. The technically successful rate was 94% (15/16), but two cases with successful TIPS procedure expired at the end of the procedure from hypovolemic shock and acute respiratory distress, respectively; thus the completely successful rate was 81% (13/16), The initial bleeding control rate was 83% (5/6) for the six patients with active bleeding. Portal venous pressure was significantly decreased from 30.8 +/- 5.8 mmHg before TIPS to 21.7 +/- 6.0 mmHg after the procedure (P < 0.01) and the porto-systemic pressure gradient also significantly decreased from 23.0 +/- 3.6 mmHg to 11.9 +/- 2.7 mmHg after TIPS (P < 0.01). Recurrent variceal bleeding was noted in four patients (33%) and that was managed by percutaneous transluminal angioplasty (PTA) of shunt, placement of additional stent, second TIPS procedure and a devascularization operation. Hepatic encephalopathy was noted in three patients (25%) after TIPS.

CONCLUSIONS

TIPS is an effective method to control variceal bleeding caused by portal hypertension, especially when endoscopic or surgical management has failed or is contraindicated.