Surgery versus transjugular intrahepatic portal systemic shunt in the treatment of severe variceal bleeding

Emergent Transjugular Intrahepatic Portosystemic Shunt Creation in Acute Variceal Bleeding

Emergent transjugular intrahepatic portosystemic shunt (TIPS) creation is most commonly employed in the setting of acute variceal hemorrhage. Given a propensity for decompensation, these patients often require a multidisciplinary, multimodal approach involving prompt diagnosis, pharmacologic therapy, and endoscopic intervention. While successful in the majority of cases, failure to medically control initial bleeding can prompt interventional radiology consultation for emergent portal decompression via TIPS creation. This article discusses TIPS creation in emergent, acute variceal hemorrhage, reviewing the natural history of gastroesophageal varices, presentation and diagnosis of acute variceal hemorrhage, pharmacologic therapy, endoscopic approaches, patient selection and risk stratification for TIPS, technical considerations for TIPS creation, adjunctive embolotherapy, and the role of salvage TIPS versus early TIPS in acute variceal hemorrhage.

Prosthetic H-graft portacaval shunts vs transjugular intrahepatic portasystemic stent shunts: 18-year follow-up of a randomized trial

BACKGROUND

Widespread application of transjugular intrahepatic portasystemic shunt (TIPS) continues despite the lack of trials documenting efficacy superior to surgical shunting. Here we present an 18-year follow-up of a prospective randomized trial comparing TIPS with small-diameter prosthetic H-graft portacaval shunt (HGPCS) for portal decompression.

STUDY DESIGN

Beginning in 1993, patients were prospectively randomized to undergo either TIPS or HGPCS as definitive therapy for portal hypertension due to cirrhosis. Complications of shunting and long-term outcomes were noted. Failure of shunting was prospectively defined as the inability to place shunt, irreversible shunt occlusion, major variceal rehemorrhage, unanticipated liver transplantation, or death. Survival and shunt failure were compared using Kaplan-Meier curve analysis. Median data are reported.

RESULTS

Patient presentation, circumstances of shunting, causes of cirrhosis, severity of hepatic dysfunction (eg, Child's class, Model for End-Stage Liver Disease score), and predicted survival after shunting did not differ between patients undergoing TIPS (n = 66) or HGPCS (n = 66). Survival was significantly longer after HGPCS for patients of Child's class A (91 vs 19 months; p = 0.009) or class B (63 vs 21 months; p = 0.02). Shunt failure occurred later after HGPCS than TIPS (45 vs 22 months; p = 0.04).

CONCLUSIONS

Compared with TIPS, survival after HGPCS was superior for patients with better liver function (eg, Child's class A or B). Shunt failure after HGPCS occurred later than after TIPS. Rather than TIPS, application of HGPCS is preferred for patients with complicated cirrhosis and better hepatic function.

Surgical shunt versus TIPS for treatment of variceal hemorrhage in the current era of liver and multivisceral transplantation

Over the last 3 decades, management of acute variceal bleeding and measures to prevent recurrent episodes has evolved due to the introduction of new therapeutic modalities including innovative surgical and minimally invasive shunt procedures. Such an evolution has been compounded by the parallel progress that has been achieved in organ transplantation. This article focuses primarily on the commonly used surgical and radiologic shunt procedures. Liver and multivisceral transplantation are also briefly discussed as important parts of the algorithmic management of these complex patients, particularly those with hepatic decompensation and portomesenteric venous thrombosis.

Late-onset inferior vena cava obstruction in a shunted patient--a unique cause of rebleeding in children with portal hypertension

BACKGROUND

Rebleeding in the presence of an adequate patent portosystemic shunt in a patient with portal hypertension (PHT) is uncommon. Inferior vena cava (IVC) obstruction as the cause of rebleeding in this situation has not been reported in the literature.

METHODS

Records from a pediatric tertiary care center were reviewed over a 15-year period. Portosystemic shunt procedures for bleeding esophageal varices were done in 39 children. Patients who, after a shunt surgery for PHT, developed a rebleed because of IVC obstruction in the presence of a patent shunt were identified.

RESULTS AND CONCLUSIONS

Late IVC obstruction in the presence of a patent shunt was identified in 2 patients. The etiology included adhesions, caudate lobe hypertrophy, and macronodular cirrhosis. Diagnosis was by angiography, and treatment included angioplasty and liver transplantation. Awareness of this condition helps direct treatment appropriately in the clinical scenario of a rebleed in a shunted patient with PHT.