Prognostic factors with the use of the transjugular intrahepatic portosystemic shunt for bleeding varices.

Abstract

To evaluate the outcome of patients undergoing the transjugular intrahepatic portosystemic shunt (TIPS) procedure for bleeding esophageal varices and to outline the factors affecting outcome. Uncontrolled, nonrandomized, retrospective study. A 320-bed university-associated urban emergency adult hospital. Thirty-three patients undergoing TIPS procedures for bleeding esophageal varices with at least 18 months of follow-up. Five patients (15%) had Child class B disease and 28 (85%) had Child class C disease. The mean transfusion requirements were 12.6 U of red blood cells, 18 U of fresh-frozen plasma, and 7 U of platelets. The mean portosystemic gradients before and after the initial TIPS procedure were 18 and 7 mm Hg, respectively. The incidence, time and causes of death, and recurrent variceal hemorrhage were correlated with various clinical and laboratory factors. By 18 months after the TIPS procedure, 16 patients (48%) died of rebleeding or hepatic failure. Subsequent upper gastrointestinal tract bleeding occurred in 14 patients (42%). Of 8 in whom occlusion or stenosis of the TIPS was promptly corrected, all 8 survived. Of 6 in whom occlusion or stenosis of the TIPS was not corrected, 5 (83%) died. Laboratory values (mean +/- SD) predictive of death before 18 months (compared with those of patients alive at 18 months) included a low initial serum albumin level (22 +/- 4 vs 29 +/- 5 g/L; P < .001); an increased initial total bilirubin level (68 +/- 75 vs 34 +/- 20 mumol/L [4.0 +/- 4.4 vs 2.0 +/- 1.2 mg/dL]; P = .001), and an elevated prothrombin time after attempts at correction (18.0 +/- 3.4 vs 14.6 +/- 1.2 seconds; P < .001). The TIPS procedure in patients with Child class C alcoholic cirrhosis was associated with a high incidence of death or rebleeding within 18 months. Prompt correction of TIPS abnormalities in patients with rebleeding increased survival. The albumin, bilirubin, and prothrombin time values obtained before performance of the TIPS procedure were predictive of outcome.