Transjugular intrahepatic portosystemic shunts (TIPSs) are used to treat variceal hemorrhage and refractory ascites. We sought to determine factors associated with stenosis and mortality after TIPS placement in patients with end-stage liver disease. This is a retrospective review of 90 TIPSs placed over a 3-year period. Demographic, clinical, and biochemical parameters were analyzed in univariate analyses to determine their association with stenosis and death. Multivariate analyses were conducted using logistic regression and Cox proportional hazard modeling. Thirty-five TIPSs were placed for recurrent variceal bleeding; 14 TIPSs, for uncontrolled variceal bleeding; 34 TIPSs, for refractory ascites; and 7 TIPSs, for other causes. The overall mortality rate was 33%, and 18 patients died within 30 days of TIPS placement. The 1-year stenosis rate was 49%. Fourteen patients underwent liver transplantation a mean of 116 ؎ 143 days after TIPS placement. Prothrombin time greater than 17 seconds, serum creatinine level greater than 1.7 mg/dL, total bilirubin level greater than 3 mg/dL, and uncontrolled variceal bleeding as an indication for TIPS placement were significant predictors of 30-day mortality. Serum creatinine level was a predictor of 30-day mortality in individuals with recurrent variceal hemorrhage or ascites. Multivariate analyses showed that creatinine level greater than 1.7 mg/dL and uncontrolled variceal bleeding as an indication for TIPS placement were independently associated with 30-day mortality. Individuals with both coagulopathy and renal insufficiency had a 30-day mortality rate of 78%. Urgent placement of TIPS was associated with an increased risk for stenosis (hazard ratio ؍ 4.5; 95% confidence interval, 1.9 to 10.1; P < .001), but no other clinical variables were associated with stenosis. Uncontrolled variceal bleeding as an indication for TIPS placement, coagulopathy, hyperbilirubinemia, and renal insufficiency were associated with increased mortality in patients with TIPSs. Individuals with both coagulopathy and renal insufficiency had high mortality. Urgent TIPS placement for uncontrolled variceal bleeding was associated with stenosis. (Liver Transpl 2002;8:271-277.) T ransjugular intrahepatic portosystemic shunts (TIPSs) are used to treat sequelae of portal hypertension that are not responsive to medical and endoscopic therapy. A TIPS is effective in stopping acute variceal bleeding and preventing rebleeding from varices refractory to endoscopic and medical therapy. [1][2][3][4][5] Ascites refractory to diuretic therapy is effectively treated with TIPS placement. 6,7 TIPS placement is effective in reducing variceal rebleeding rates to 10% over 1 year and may be effective in treating ascites in 60% of patients. 6 Although TIPS placement is effective in reducing portal hypertension, it is associated with a high stenosis rate. Stenosis occurs in 50% of TIPSs at 1 year. 8 Stenosis is a result of several factors, one of which is neointimal hyperplasia within the stent. 9 Surveillance for steno...
For the prevention of recurrent esophageal variceal bleeding, studies show that patients treated with transjugular intrahepatic portosystemic shunt (TIPS) have lower rebleeding rates compared with endoscopic therapy. However, TIPS is associated with higher rates of portosystemic encephalopathy and possibly higher costs. The aim of this study was to conduct a cost-effectiveness analysis comparing TIPS with endoscopic sclerotherapy and endoscopic ligation for the prevention of recurrent esophageal variceal bleeding. Data for rates of rebleeding, death, complications, and crossover from endoscopy to TIPS were obtained from the literature. Variceal bleeding is a major cause of morbidity and mortality in patients with cirrhosis. Variceal bleeding occurs in 33% of patients with cirrhosis and carries a mortality of 30% to 50%. [1][2][3] Up to 70% of patients have recurrent bleeding within the first year of the first bleeding episode. 1,3 Strategies have been developed for the prevention of recurrent esophageal bleeding in the high-risk group of patients who have had a first bleed.Treatment for acute variceal bleeding includes endoscopic therapy and the transjugular intrahepatic portosystemic shunt (TIPS). Endoscopic sclerotherapy can stop bleeding in 75% to 85% of cases, but recurrent bleeding occurs in 30% to 50% of patients within the first year. 4-9 Studies comparing endoscopic sclerotherapy to endoscopic ligation (banding) show higher rates for controlling bleeding with ligation and lower, but still substantial, recurrent bleeding rates of 26% to 36%. 5,8,9 Twelve percent to 28% of patients undergoing follow-up endoscopy have recurrent variceal bleeding and receive TIPS. [10][11][12][13][14][15][16] TIPS reduces the portosystemic gradient by placing a stent joining the hepatic and portal veins. By reducing portal hypertension, TIPS decompresses varices and prevents recurrent bleeding. Randomized controlled trials comparing TIPS with endoscopic sclerotherapy for recurrent variceal bleeding show that recurrent bleeding rates are 15% to 20% at 1 year, which is 28% to 38% lower than sclerotherapy. 11,13-16 Although TIPS leads to lower recurrent bleeding rates, it may lead to hepatic encephalopathy. [10][11][12][13][14][15]
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