Gastroenterology

Gastroenterology

Volume 114, Issue 6, June 1998, Pages 1296-1303
Gastroenterology

Liver, Pancreas, and Biliary Tract
Clinical events after transjugular intrahepatic portosystemic shunt: Correlation with hemodynamic findings,☆☆

https://doi.org/10.1016/S0016-5085(98)70436-6Get rights and content

Abstract

Background & Aims: Transjugular intrahepatic portosystemic shunt (TIPS) procedures are increasingly being used, but the relationship between the hemodynamic effects of TIPS and the clinical events on follow-up remains undefined. Hence, we have investigated the hemodynamic correlations of portal hypertension–related events after a TIPS procedure. Methods: Prospective follow-up of 122 cirrhotic patients who had a TIPS procedure performed because of variceal hemorrhage was conducted. Results: The portacaval pressure gradient (PPG) significantly decreased after the TIPS procedure (from 19.7 ± 4.6 to 8.6 ± 2.7 mm Hg; P > 0.001), but increased thereafter and at rebleeding (n = 25) was >12 mm Hg in all patients (18.4 ± 4.6 mm Hg). Twenty-six patients developed ascites; the PPG (measured in 19) was always >12 mm Hg. Increasing the PPG to >12 mm Hg occurred very frequently (83% at 1 year). Within 1 year, 77% of patients underwent balloon angioplasty or restenting. However, 80% had again a PPG of >12 mm Hg 1 year after reintervention. Hepatic encephalopathy developed in 31% of patients at 1 year; 21 of 23 patients had a PPG of <12 mm Hg. Conclusions: Total protection from the risk of recurrent complications of portal hypertension after a TIPS procedure requires that the PPG be decreased and maintained <12 mm Hg. However, reintervention will be required in most patients within 1 year and again the second year. On the other hand, such portal decompression is associated with an increased risk of hepatic encephalopathy.

GASTROENTEROLOGY 1998;114:1296-1303

Section snippets

Patients and methods

This prospective study included 122 consecutive patients who were treated with a TIPS procedure between October 1992 and June 1995 at the two participating centers: Hospital Clinic i Provincial, University of Barcelona, and Hospital General Universitario Gregorio Marañón, University Complutense of Madrid. All patients treated with a TIPS procedure during that period were included in this study. The patient group included 81 men and 41 women with a mean age of 58 years (range, 27–78 years). All

Changes in portacaval pressure gradient

PPG was significantly decreased by placement of a TIPS (from 19.7 ± 4.6 to 8.6 ± 2.7 mm Hg; P < 0.0001). In 106 of 122 patients, the PPG was decreased to ≤12 mm Hg; in the remaining 16 patients, the final PPG ranged between 12.5 and 14 mm Hg. During follow-up examinations, a significant increase in PPG was observed. Mean PPG was 10.5 ± 2.5, 14.8 ± 2.4, and 16.5 ± 3.9 mm Hg at 2, 6, and 12 months, respectively, in spite of the fact that patients who were found to have a stenosed or occluded TIPS

Discussion

It is well established that a TIPS can prevent most of the complications of portal hypertension, such as variceal bleeding and ascites.2, 3, 4, 5, 6, 17, 18, 19 Other reports indicate that a TIPS may ameliorate the hepatorenal syndrome,20, 21, 22, 23 portal-hypertensive gastropathy,24 and hepatopulmonary syndrome.25 However, a major caveat of a TIPS is that its rate of occlusion is much higher than that observed after placement of surgical portosystemic shunts.2, 3, 12, 13, 26 This is caused in

Acknowledgements

The authors thank A. Baringo and L. Rocabert for their assistance in these studies and to D. Bird for secretarial support.

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    Supported by grants 94/0757, 95/1016, and 97/1309 from Fondo de Investigaciones Sanitarias and by Dirección General de Investigación Científica y Técnica grant PB95-1562.

    ☆☆

    Address requests for reprints to: Jaume Bosch, M.D., Hepatic Hemodynamic Laboratory, Liver Unit, Hospital Clinic, Villarroel 170, 08036 Barcelona, Spain. Fax: (34) 3-451-5272.

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