A Systematic Appraisal of Portacaval H-Graft Diameters

Abstract

Over a period of 10 years, the authors have systematically reduced portacaval H-graft diameters. Their objective was to achieve partial shunting of portal flow without reversal of hepatic flow. This report summarizes their clinical and hemodynamic observations in 68 surviving patients with cirrhosis (mostly alcoholic) and variceal hemorrhage who underwent portacaval H-grafts ranging from 20 to 8 mm diameters. When shunt diameters were reduced to 10 and 8 mm and combined with aggressive portal collateral ablation, portal pressures increased significantly over larger H-grafts. Only 3% of patients with 20-12 mm H-grafts had prograde portal flow after operation, compared with 46 and 82% after 10 and 8 mm H-grafts, respectively (p less than 0.001). The incidence of encephalopathy diminished from 39% in the 20-12 mm H-graft group to 19 and 9% after 10 and 8 mm grafts, respectively (p less than 0.04). None of the patients with 10 or 8 mm PTFE grafts rebled from varices in the follow-up period (4-61 months). It is concluded that partial shunting of portal flow is hemodynamically feasible. It can be achieved in most patients using 8 mm polytetrafluoroethylene (PTFE) portacaval H-grafts combined with portal collateral ablation. Preserving prograde portal flow by partial shunting correlates with reduced encephalopathy rates after operation. Despite maintaining a relatively hypertensive portal system, partial shunts effectively prevent variceal hemorrhage.

A model to predict poor survival in patients undergoing transjugular intrahepatic portosystemic shunts

“…4 The hypothesis that patients in whom partial blood flow is maintained after portosystemic shunts have a better outcome has intuitive appeal. 27 However, we found determinants of portal hypertension; namely, direction of blood flow (hepatopetal vs. hepatofugal), initial portocaval pressure gradient, post-TIPS portacaval pressure gradient, and decrease in the portacaval pressure gradient postshunt had no effect on survival. Although surprising, these data are consistent with findings from other studies.…”

Small-Diameter Portacaval H-Graft Shunt: A Paradigm Shift Back to Surgical Shunting in the Management of Variceal Bleeding in Patients With Preserved Liver Function

“…This is consistent with other reports of SDPHG shunts. 5,[8][9][10][11]19 The second requirement of therapies for variceal bleeding is to preserve hepatic function. Our series suggests that SDPHG shunts accomplish this goal; nearly three fourths of the patients had no change or an improvement from their preoperative Child-Pugh classification during long-term follow-up.…”

“…Sarfeh et al 11 have described the surgical technique in detail. We did not perform collateral ligation.…”

“…Gore & Associates, Inc, Flagstaff, AZ) graft between the portal vein (PV) and inferior vena cava. [4][5][6][7][8][9][10][11] The goal of the SDPHG shunt is to definitively decompress the PV while preserving prograde nutrient portal flow to the liver to diminish postoperative encephalopathy. The role of surgical portal decompression has been redefined in the era of transjugular intrahepatic portosystemic shunt (TIPS) stenting.…”

Effect of coronary-caval shunt combined with partial pericardial devascularisation on oesophageal and gastric variceal bleeding caused by portal hypertension

“…Currently, the surgical strategy for oesophageal and gastric variceal bleeding includes devascularisation and shunt operations (15). Devascularisation is an effective way to control bleeding and assure blood supply to the liver; however, this surgery may lead to increased postoperative portal pressure and induce portal hypertensive gastropathy and rebleeding (16). Therefore, it has been almost abandoned in all countries except for China.…”