Successful Percutaneous Ultrasonic Lithotripsy of Gallstones

Background: Acute calculous cholecystitis is the obstruction of the cystic duct by a gallstone that leads to inflammation of the gallbladder necessitating cholecystectomy. Case Series: We present the cases of 2 patients with acute calculous cholecystitis who were deemed ineligible candidates for cholecystectomy because of their complicating medical histories. Both patients initially underwent cholecystostomy and drain placement with interventional radiology for management of acute calculous cholecystitis. Their large gallstones remained refractory to attempts at removal by electrohydraulic lithotripsy via the cholecystostomy access. The patients' gallstones were successfully removed via percutaneous ultrasonic lithotripsy during a collaborative procedure with interventional radiology and urology. Conclusion: An interdisciplinary approach using percutaneous cholecystolithotomy with rigid ultrasonic lithotripsy is an effective method for removing challenging gallstones in patients for whom traditional approaches fail.

Impact of General Anesthesia on the Right Atrial Pressure During Transjugular Intrahepatic Portosystemic Shunt Creation: A Propensity Score Match Analysis

PURPOSE

To evaluate the effect of general anesthesia on right atrial (RA) pressure measurements during transjugular intrahepatic portosystemic shunt (TIPS) placement using propensity score match analysis.

MATERIALS

A single-institution database was used to identify 664 patients who underwent TIPS creation under either conscious sedation (CS) or general anesthesia (GA) between 2009 and 2018. A propensity-matched cohort was created using logistic regression of sedation method on demographics, liver disease status, and indications. Paired analyses were performed using mixed models for RA pressure and Cox proportional hazards model with robust standard errors for mortality.

RESULTS

Of the 664 patients, 270 patients were matched based on similar characteristics (135 for GA and 135 for CS). Indications for TIPS creation included intractable ascites (n = 170, 63%), hepatic hydrothorax (n = 30, 11%), variceal bleeding (n = 43, 16%), and other (n = 27, 10%). Pre-TIPS RA pressure was greater in the matched GA group as compared to CS group by a mean of 4.2 mmHg (p < 0.0001). Similarly, post-TIPS RA pressure was greater in the matched GA group as compared to CS group by a mean of 3.3 mmHg (p < 0.0001). Pre- and post-procedure RA pressure was found to have no association with post-procedure mortality (0.8891, HR 1.077; p 0.917, HR 0.997; respectively).

CONCLUSIONS

Utilization of GA during TIPS creation raises the intra-procedural RA pressure compared to CS. However, this elevated intra-procedural RA pressure does not appear to be predictive of mortality post-TIPS creation.

High-Force Application by a Nanoscale DNA Force Spectrometer

The ability to apply and measure high forces (>10 pN) on the nanometer scale is critical to the development of nanomedicine, molecular robotics, and the understanding of biological processes such as chromatin condensation, membrane deformation, and viral packaging. Established force spectroscopy techniques including optical traps, magnetic tweezers, and atomic force microscopy rely on micron-sized or larger handles to apply forces, limiting their applications within constrained geometries including cellular environments and nanofluidic devices. A promising alternative to these approaches is DNA-based molecular calipers. However, this approach is currently limited to forces on the scale of a few piconewtons. To study the force application capabilities of DNA devices, we implemented DNA origami nanocalipers with tunable mechanical properties in a geometry that allows application of force to rupture a DNA duplex. We integrated static and dynamic single-molecule characterization methods and statistical mechanical modeling to quantify the device properties including force output and dynamic range. We found that the thermally driven dynamics of the device are capable of applying forces of at least 20 piconewtons with a nanometer-scale dynamic range. These characteristics could eventually be used to study other biomolecular processes such as protein unfolding or to control high-affinity interactions in nanomechanical devices or molecular robots.

Propensity-matched comparison of transjugular intrahepatic portosystemic shunt placement techniques: Intracardiac echocardiography (ICE) versus fluoroscopic guidance

PURPOSE

To compare procedure characteristics and outcomes when TIPS is performed under intracardiac echocardiography guidance (iTIPS) compared to conventional fluoroscopic guidance (cTIPS).

MATERIALS AND METHODS

A retrospective propensity-matched study of 30 iTIPS and 30 cTIPS procedures from January 2014 to March 2017 at a single US high volume academic medical center was performed. iTIPS and cTIPS cases were propensity score matched using predictive variables: age, race, gender, etiology of liver disease, indication for TIPS, MELD score, and portal vein patency. Procedure characteristics and post- procedure outcomes were compared between propensity-matched groups including: total procedure time, technical success, radiation dose, contrast volume, complication rate, 30- day mortality, and revision rate within 3 months.

RESULTS

Radiation dose (875.3 vs 457.4 mGY, p = 0.039) and contrast volume (141 vs 103 mL, p = 0.005) were significantly decreased in the iTIPS versus the cTIPS group. There was no significant difference in procedure time (81.5 cTIPS vs 84 min iTIPS) or rate of TIPS revisions within 3 months. Average operator experience in the iTIPs group was 4.2 years and cTIPS group 11.0 years (p = 0.0004). All procedures were technically successful with no mortalities within 30 days.

CONCLUSION

iTIPS resulted in significantly reduced radiation dose and contrast volume. However, there was no difference in total procedure time or overall outcomes despite greater operator experience in the cTIPS group.

Liver-dominant Breast Cancer Metastasis: A Comparative Outcomes Study of Chemoembolization Versus Radioembolization

AIM

To compare toxicity, response, and survival outcomes of patients with hepatic metastases from breast cancer who underwent transarterial chemoembolization (TACE) or radioembolization (TARE).

MATERIALS AND METHODS

A retrospective review was carried out of all patients who underwent TACE or TARE for liver-dominant breast cancer metastases between January 2006 and March 2016 at an academic medical center in the United States.

RESULTS

Seventeen patients in the TACE group and 30 patients in the TARE group received 32 TACE and 49 TARE treatments, respectively. Median follow-up was 9 months. Both groups had similar background variables. More all-grade adverse events were seen in the TACE group (71% vs. 44%; p=0.02). Median overall survival in the TACE group was 4.6 months compared to 12.9 months in the TARE group (p=0.2349). Treatment type was not an independent prognostic factor.

CONCLUSION

TARE is better tolerated than TACE for the treatment of liver-dominant breast cancer metastasis. There was a trend towards improved survival with TARE; however, it did not approach statistical significance. Larger studies are needed to validate these findings.

A comparison between endoscopic ultrasound-guided rendezvous and percutaneous biliary drainage after failed ERCP for malignant distal biliary obstruction

BACKGROUND AND STUDY AIMS

Selective biliary cannulation is unsuccessful in 5 % to 10 % of patients undergoing endoscopic retrograde cholangiopancreatography (ERCP) for malignant distal biliary obstruction (MDBO). Percutaneous biliary drainage (PBD) has been the gold standard, but endoscopic ultrasound guided rendezvous (EUSr) have been increasingly used for biliary decompression in this patient population. Our aim was to compare the initial success rate, long-term efficacy, and safety of PBD and EUSr in relieving MDBO after failed ERC Patients and methods: A retrospective study involving 50 consecutive patients who had an initial failed ERCP for MDBO. Twenty-five patients undergoing EUSr between 2008 - 2014 were compared to 25 patients who underwent PBD immediately prior to the introduction of EUSr at our center (2002 - 2008). Comparisons were made between the two groups with regard to technical success, duration of hospital stay and adverse event rates after biliary decompression.

RESULTS

The mean age at presentation was 66.5 (± 12.6 years), 28 patients (54.9 %) were female. The etiology of MDBO was pancreaticobiliary malignancy in 44 (88 %) and metastatic disease in 6 (12 %) cases. Biliary drainage was technically successful by EUSr in 19 (76 %) cases and by PBD in 25 (100 %) (P = 0.002). Median length of hospital stay after initial drainage was 1 day in the EUSr group vs 5 days in PBD group (P = 0.02). Repeat biliary intervention was required for 4 patients in the EUSr group and 15 in the PBD group (P = 0.001).

CONCLUSIONS

Initial technical success with EUSr was significantly lower than with PBD, however when EUSr was successful, patients had a significantly shorter post-procedure hospital stay and required fewer follow-up biliary interventions. Meeting presentations: Annual Digestive Diseases Week 2015.

Older age is associated with increased early mortality after transjugular intrahepatic portosystemic shunt

INTRODUCTION & AIM

The role of age as a predictor of mortality after transjugular intra hepatic portosystemic shunt (TIPS) is controversial. Age has been found to be an important predictor of post-TIPS mortality in some, but not all, studies and is not a component of the MELD score. The purpose of this study was to compare the 90-day survival of subjects with cirrhosis age ≥ 70 years with younger subjects undergoing TIPS.

MATERIAL AND METHODS

A database of adult with cirrhosis undergoing TIPS from 2003-2011 was analyzed. The primary endpoint was survival 90-days post-TIPS. Survival was analyzed by the Kaplan-Meier method and proportional hazard modeling.

RESULTS

539 subjects met study criteria. 474 (88%) were between the ages of 24-69 and 65 (12%) were age 70-89 years. The groups were similar with respect to the indication for TIPS, mean MELD score and distribution of MELD score. Survival 90-days post-TIPS was 60% in the older cohort compared with 85% in the younger cohort (p < 0.001). Proportional hazards modeling controlled for comorbidities identified age ≥ 70 and MELD score as predictors of early post-TIPS survival. The hazard ratio associated with age increased monotonically, became significant at age ≥ 70 years (HR 3.22; 95% CI 1.81-5.74; p < 0.001) and exceeded the effect of MELD on survival.

CONCLUSIONS

Age ≥ 70 was associated with reduced survival within 90 days following TIPS. The findings from this study indicate that age is a relevant consideration in assessing the early mortality risk of TIPS.

Made to Measure: Taming Practices with Results-based Accountability

This paper focuses on what happens when accountability regimes, represented in calculative planning processes, migrate onto situated, sociomaterial practices. Specifically, the article investigates what happens when the practices of results-based accountability (RBA) are translated into the social justice practices of locally-based community organizations. Based on the tenets of contemporary practice theory and a three-year participatory action research project with community organizations in Australia, the study illustrates that performance measurement and accountability frameworks such as RBA are not technologies that peer and measure innocently and disinterestedly from a distance. Rather, RBA, as a bundle of material-discursive practices, is part of the performance measuring apparatus creating differences that include some things and exclude others. We articulate some of the organizing practices of social justice in a locally-based community organization, follow their translation into RBA planning practices and then return to analyse the introduction of RBA practices into the daily work of an organization. In this way, we demonstrate how situated and ongoing practices begin to unravel through intra-action with RBA boundary-making practices and its redrawn relations of accountability.

Management of excluded bile ducts in paediatric orthotopic liver transplant recipients of technical variant allografts

BACKGROUND

A strategy to increase the number of size- and weight-appropriate organs and decrease the paediatric waiting list mortality is wider application of sectional orthotopic liver transplantation (OLT). These technical variants consist of living donor, deceased donor reduced and split allografts. However, these grafts have an increased risk of biliary complications. An unusual and complex biliary complication which can lead to graft loss is inadvertent exclusion of a major segmental bile duct. We present four cases and describe an algorithm to correct these complications.

METHODS

A retrospective review of the paediatric orthotopic liver transplantation database (2000-2010) at Washington University in St. Louis/St. Louis Children's Hospital was conducted.

RESULTS

Sixty-eight patients (55%) received technical variant allografts. Four complications of excluded segmental bile ducts were identified. Percutaneous cholangiography provided diagnostic confirmation and stabilization with external biliary drainage. All patients required interval surgical revision of their hepaticojejunostomy for definitive drainage. Indwelling biliary stents aided intra-operative localization of the excluded ducts. All allografts were salvaged.

DISCUSSION

Aggressive diagnosis, percutaneous decompression and interval revision hepaticojejunostomy are the main tenets of management of an excluded bile duct. Careful revision hepaticojejunostomy over a percutaneous biliary stent can result in restoration of biliary continuity and allograft survival.

Renal cysts and urinomas

Renal cysts are a common imaging finding. Although most cysts never have symptoms, some cause pain, collecting system compression, hematuria, hypertension, and secondary infection. The mere presence of a cyst is not an indication for intervention, but treatment may be indicated in symptomatic patients or those with secondary obstruction. Urinomas generally are a contained collection of urine outside of the normal pathways where urine travels. As such, urinomas can arise anywhere from the upper abdomen down into the low pelvis and have a variety of etiologies. Ureteral obstruction with forniceal rupture and trauma (blunt, penetrating, or iatrogenic) are the most common causes of urinomas. When urinomas arise spontaneously, the likely cause varies with the patient's age. Blunt or penetrating trauma can cause perinephric urinomas by two mechanisms-direct disruption of the pelvis or collecting system or by degeneration of nonviable tissue. These urinomas are often perinephric, but can also occur in a subcapsular location. This review will discuss diagnosis, classification, and treatment of renal cysts and urinomas.

Longitudinal stent fracture and migration of a stent fragment complicating treatment of hepatic vein stenosis after orthotopic liver transplantation

We report a case of inferior vena cava (IVC) stent placement complicated by longitudinal stent fracture and migration of a stent fragment to the right pulmonary artery 2 years after initial placement. During attempted stenting of a hepatic venous anastomotic stenosis following orthotopic liver transplantation, a Palmaz P308 stent (Cordis International, Miami, FL) migrated and was redeployed into the IVC. Two years later, the patient had recurrent ascites and liver failure. Chest radiograph showed the Palmaz P308 stent had fractured longitudinally with a fragment in the right interlobular pulmonary artery. Half of the stent remained in the IVC. Mild stenosis was noted in the IVC where the stent was deployed. Overdilation of stents may be associated with stent fracture and should be performed with caution.

Single-session treatment of portal vein thrombosis using combined pharmacomechanical thrombolysis

A patient with portal hypertension developed thrombosis of her transjugular intrahepatic portosystemic shunt (TIPS) and the portal vein. The Trellis device (Bacchus Vascular, Santa Clara, CA) was used to achieve rapid lysis of the portal vein thrombus and help restore portal and TIPS patency in a single session.

Biliary strictures in pediatric liver transplant recipients - early diagnosis and treatment results in excellent graft outcomes

Biliary complications in pediatric LT are important causes of morbidity and graft loss. We examined our recent pediatric LT experience to determine the outcome of post-LT biliary complications and their relationship to graft type. All initially isolated LTs performed at our institution between January 1, 2000 and August 20, 2007 were reviewed. Recipient data, donor type, graft survival, and biliary complications data were examined. Of 66 LTs, 32 patients received whole organ grafts, and 34 received partial grafts; 11 split, seven reduced size, and 16 live donors. Seventy-seven percent of patients had biliary reconstruction using a RYH. Overall, 17 (26%) developed biliary complications, and 15 were diagnosed within six months post-LT. Live donor and split allografts had more biliary complications than reduced size or whole allografts (50% and 36% vs. 0% and 16%, respectively). Seventy-one percent responded to percutaneous or endoscopic treatment. Five failed initial non-operative management and required reoperation (one retransplantation). These data suggest that biliary strictures occur most frequently in live donor and split allografts and that non-operative therapy is highly successful. Partial grafts are essential in pediatric LT, and a high clinical suspicion for biliary complications combined with aggressive and early diagnosis and therapy rarely results in graft loss.

Uretro-arterial fistulas

Ureteral arterial fistula (UAF) is an uncommon condition but one that has been increasing with over 100 cases reported. The presentation is gross hematuria in a patient with predisposing factors, such as prior pelvic surgery, past radiation therapy, and chronic ureteral stenting. When not correctly diagnosed, the associated mortality is significant. Diagnosis is best accomplished by careful angiography with frequent use of provocative maneuvers. The current best therapeutic option is sealing off the UAF by deploying a stent graft in the artery.

‘Working Together?’: The Salvation Army and the Job Network

This article explores the changing relationship between government and The Salvation Army, as manifested in the development and implementation of employment policy in Australia between 1998 and 2007. This exploration focuses on the introduction of market discourse throughout the contracting process, in particular how this discourse seeks to reconstruct service users as ‘consumers’, and the Salvation Army’s response to this. By studying the ways in which this religiously and socially motivated non-profit organization sought to mediate neo-liberal discourses of competition and consumerism, we seek to shed light on the processes and pressures affecting faith-based and other non-profit organizations that increasingly find themselves acting as agents of government policy under the principles of New Public Management (NPM).

Portal anatomic variants relevant to transjugular intrahepatic portosystemic shunt

Transjugular intrahepatic portosystemic shunt (TIPS) creation is an accepted treatment for portal hypertension. TIPS creation remains a challenging procedure because it involves the successful passage of a needle from a point of origin (hepatic vein) to a target point (portal vein) through the liver substance. An understanding of the anatomy of these two vascular beds facilitates overcoming the challenge of the spatial relationship between these two points. In this article the authors review the vascular and parenchymal anatomic variations, both congenital and acquired that impact the success of TIPS creation.

Iatrogenic bile duct injury during laparoscopic cholecystectomy

Laparoscopic cholecystectomy has largely replaced open cholecystectomy as the standard of care for gallbladder excision. A major disadvantage of this trend has been the increased incidence of bile duct injuries, which, while uncommon, are significantly higher with laparoscopic cholecystectomy. Most injuries are not recognized at the time of surgery and present in a delayed fashion, leading to significant patient morbidity and a negative impact on the quality of life of patients. Treatment is governed by the time of presentation and the nature of the bile duct injury incurred and requires a multidisciplinary approach. Radiologists play a key role in management, with diagnosis of complications, accurate depiction of the biliary injury, and facilitating or providing definitive therapy depending on the type of injury.

Prospective evaluation of the PleurX catheter when used to treat recurrent ascites associated with malignancy

PURPOSE

To prospectively assess the safety of the PleurX catheter in the management of recurrent ascites in patients with advanced abdominal malignancy and the consequent quality of life among these patients.

MATERIALS AND METHODS

This was a multicenter, prospective study of PleurX catheters implanted between March 2004 and April 2005 for control of nonhepatic abdominal ascites associated with malignancy. A total of 34 subjects were included (age range, 40-81 years; mean age, 64.3 y) who underwent 440 drainage sessions. Subjects kept records of volume and frequency of ascites drainage and recorded any difficulties encountered with use of the device. Subjects assessed symptoms before device insertion and weekly for as long as 12 weeks. Serum laboratory values reflecting overall volume status were tracked.

RESULTS

All catheter insertions were successful without major procedural complications. Twenty-nine (85%) required no catheter intervention or separate therapeutic paracentesis during 12 weeks observation or until the patient's death. Three needed a total of 13 interventions to restore catheter function. Before 12 weeks, 26 subjects died. Five discontinued catheter use as a result of catheter function despite the presence of ascites. Ascites resolved in five patients. Bloating and abdominal discomfort were significantly reduced at 2 and 8 weeks (P < .05). At weekly follow-up, 83%-100% of subjects reported their ascites to be well controlled. There were no significant changes in blood chemistry results between baseline and 12 weeks. One case of peritonitis at 10 weeks resolved with antibiotic treatment.

CONCLUSIONS

In terminally ill patients, PleurX catheter use resulted in improvement of ascites-related discomfort and was associated with low rates of serious adverse clinical events and catheter failure.

Treatment of lower gastrointestinal bleeding: vasopressin infusion versus embolization

Traditionally, embolization has been reserved for treatment of upper gastrointestinal bleeding whereas lower gastrointestinal (LGI) bleeding has been controlled with vasopressin infusion. This is based on findings in older literature in which infarction frequently complicated LGI embolization. With modern embolization techniques, clinically significant bowel ischemia has become an uncommon complication. Although the efficacies of vasopressin and embolization are fairly comparable, embolotherapy has advantages in terms of quicker completion of therapy and decreased likelihood of systemic complications. Although vasopressin is still probably preferable for diffuse lesions and cases in which superselective catheterization is not technically possible, embolization should be considered a primary option for treating LGI bleeding.

Combined percutaneous and retrograde approach to staghorn calculi with application of the ureteral access sheath to facilitate percutaneous nephrolithotomy

PURPOSE

We describe our technique and clinical experience with application of the ureteral access sheath for single access ablation of staghorn and partial staghorn calculi.

MATERIALS AND METHODS

We retrospectively reviewed our experience with 9 patients who underwent percutaneous nephrolithotomy for staghorn (6) or partial staghorn (3) renal calculi using a combined antegrade and retrograde approach. Patient data, operative parameters, efficacy of stone ablation and convalescence parameters were reviewed.

RESULTS

Mean operative time for the primary procedure was 3.1 hours with a mean estimated blood loss of 290 ml. Postoperatively, the mean analgesic requirement was 33.2 mg. MSO(4) equivalents. Hospital stay was 3.2 days. There were no major and 4 minor (44%) complications. No patient required transfusion. Complete stone clearance was achieved in 7 of the 9 cases (78%) using a single percutaneous nephrostomy tract.

CONCLUSIONS

Our preliminary clinical experience using the ureteral access sheath during percutaneous nephrolithotomy for simultaneous antegrade and retrograde stone treatment has been favorable. A large renal stone burden can be successfully managed with a single percutaneous access and limited blood loss.

Identification and biological characterization of heterocyclic inhibitors of the hepatitis C virus RNA-dependent RNA polymerase

The hepatitis C virus (HCV) NS5B protein encodes an RNA-dependent RNA polymerase (RdRp), the primary catalytic enzyme of the HCV replicase complex. We established a biochemical RNA synthesis assay, using purified recombinant NS5B lacking the C-terminal 21 amino acid residues, to identify potential polymerase inhibitors from a high throughput screen of the GlaxoSmithKline proprietary compound collection. The benzo-1,2,4-thiadiazine compound 1 was found to be a potent, highly specific inhibitor of NS5B. This agent interacts directly with the viral polymerase and inhibits RNA synthesis in a manner noncompetitive with respect to GTP. Furthermore, in the absence of an in vitro-reconstituted HCV replicase assay employing viral and host proteins, the ability of compound 1 to inhibit NS5B-directed viral RNA replication was determined using the Huh7 cell-based HCV replicon system. Compound 1 reduced viral RNA in replicon cells with an IC(50) of approximately 0.5 microm, suggesting that the inhibitor was able to access the perinuclear membrane and inhibit the polymerase activity in the context of a replicase complex. Preliminary structure-activity studies on compound 1 led to the identification of a modified inhibitor, compound 4, showing an improvement in both biochemical and cell-based potency. Lastly, data are presented suggesting that these compounds interfere with the formation of negative and positive strand progeny RNA by a similar mode of action. Investigations are ongoing to assess the potential utility of such agents in the treatment of chronic HCV disease.

Lower extremity venous thrombolysis with adjunctive mechanical thrombectomy

PURPOSE

To evaluate the use of adjunctive mechanical thrombectomy (MT) with pharmacologic catheter-directed lower extremity venous thrombolysis.

MATERIALS AND METHODS

Catheter-directed thrombolysis with adjunctive MT was used to treat 28 symptomatic limbs in 20 patients (22 procedures) with lower extremity deep vein thrombosis (DVT) between August 1997 and July 2001. Procedural success, major bleeding, thrombolytic infusion time, and total thrombolytic agent dose were recorded.

RESULTS

Procedural success was achieved in 23 of 28 limbs (82%). Fifteen patients (18 limbs) received iliac vein stents. Major bleeding was observed after three of 22 procedures (14%) and resulted in transfusion in two patients and endometrial ablation in the third patient. Mean per-limb infusion time was 16.8 hours +/- 12.8. Mean per-limb total doses were lower than those reported in published studies of DVT thrombolysis: 2.67 million U +/- 1.60 urokinase, 18.4 mg +/- 10.7 tissue plasminogen activator, and 13.8 U +/- 6.9 reteplase. Venographic analysis demonstrated minimal thrombus removal (26.0% +/- 24.1) when using MT alone, compared with substantial thrombus removal (62.0% +/- 24.9) when using MT after pharmacologic thrombolytic agents had been administered (P =.006).

CONCLUSION

The use of adjunctive MT to augment pharmacologic catheter-directed DVT thrombolysis provides comparable procedural success and may reduce the required thrombolytic dose and infusion duration.

Intraoperative localization of small intestinal bleeding in an infant by methylene blue injection: a case report

During the evaluation of patients with profuse gastrointestinal bleeding, it is often difficult to accurately localize bleeding sites in the small intestine. Moreover, during laparotomy, there may be no intraoperative findings to allow identification and resection of the bleeding lesion. Here the authors report a case of severe intestinal bleeding in an infant in whom the intraoperative injection of methylene blue dye into a terminal branch of the superior mesenteric artery was critical in determining the exact location of bleeding. After accurate localization of the bleeding source and segmental intestinal resection, the child recovered uneventfully with no recurrence of gastrointestinal bleeding. To the authors' knowledge, this is the first reported use of this technique in infancy.

Intrahepatic portosystemic vascular stents: a bridge to hepatic transplantation

Refractory esophageal variceal hemorrhage (EVH) remains a formidable problem in patients awaiting liver transplantations. Transjugular intrahepatic portosystemic shunts (TIPS) have provided an alternative approach for managing EVH that may obviate the need for portosystemic shunt surgery. Experience with TIPS placement and subsequent successful hepatic transplantation in patients without previous portosystemic shunt surgery has not been previously reported. Two patients are reported who underwent TIPS placement and subsequent successful hepatic transplantation without previous portosystemic shunt surgery. This experience indicates that (1) TIPS can provide effective control of EVH for at least several weeks, (2) TIPS placement decreases portal hypertension, thus facilitating technical performance of the transplant procedure and minimizing blood loss, (3) TIPS may undergo vascular incorporation, thus requiring that they be accurately positioned so that the lengths of suprahepatic inferior vena cava and portal vein are not compromised at the time of transplantation, (4) TIPS thrombosis can be effectively treated and prolonged patency may be observed, and (5) deterioration in hepatic function and exacerbation of hepatic encephalopathy were not observed after TIPS placement. In summary, TIPS provide an attractive, effective means for managing refractory EVH in patients awaiting liver transplantation.