Transjugular intrahepatic portosystemic shunt: Is it the ultimate solution for refractory ascites?

Abstract

Background. Previous studies have suggested that the transjugular placement of an intrahepatic stent to establish a portosystemic shunt is an effective treatment of uncomplicated ascites accompanying variceal bleeding. We studied the stent shunt for use in patients with liver cirrhosis and ascites refractory to medical treatment. Methods. Fifty of 62 consecutive patients with cirrhosis and refractory ascites were treated with the stent shunt–an expandable stent of metallic mesh placed between a major branch of the portal vein and one of the hepatic veins. Patients were followed for a mean (±SD) of 426 ± 333 days. Results. The stent shunt was successfully placed in all patients and reduced the pressure gradient between the portal vein and the inferior vena cava by an average of 63 percent. Thirty-seven patients (74 percent) had complete responses (total remission of ascites within three months), and nine patients (18 percent) had partial responses. Four patients did not respond, including two who died within two weeks of shunt placement. After the procedure, 25 patients had hepatic encephalopathy, as compared with 20 patients before the procedure; although encephalopathy improved in 3 patients, new encephalopathy developed in 8 patients. In the 28 of the 33 patients followed for more than six months who were evaluated, the mean serum creatinine concentration was 1.5 ± 0.09 mg per deciliter (133 ± 8 μmol per liter) before placement of the stent shunt, 1.5 ± 1.6 mg per deciliter (133 ± 141 μmol per liter) one week after the procedure, and 0.9 ± 0.3 mg per deciliter (80 ± 27 μmol per liter) after six months (P = 0.008 for the comparison of concentrations before and six months after the procedure). Renal function did not improve in the six patients with organic kidney disease. Procedure-related complications developed in 16 patients. During follow-up, an additional 29 patients died–10 of progressive liver disease and 19 of other causes. Survival for at least one year was associated with a patient's being under 60 years of age, having a serum bilirubin level before placement of the stent shunt of less than 1.3 mg per deciliter (22 μmol per liter), and having a complete response. Conclusions. Our findings in an uncontrolled prospective study suggest that the transjugular intrahepatic porto-systemic stent-shunt procedure was an effective treatment for many patients with liver cirrhosis and refractory ascites, but mortality from underlying diseases was substantial. (N Engl J Med 1995; 332:1192-7. Copyright 1995. Massachusetts Medical Society. All rights reserved).