Prosthetic H-graft Portacaval Shunt Research Articles

Prosthetic H-Graft Portacaval Shunts vs Transjugular Intrahepatic Portasystemic Stent Shunts: 18-Year Follow-Up of a Randomized Trial

Widespread application of transjugular intrahepatic portasystemic shunt (TIPS) continues despite the lack of trials documenting efficacy superior to surgical shunting. Here we present an 18-year follow-up of a prospective randomized trial comparing TIPS with small-diameter prosthetic H-graft portacaval shunt (HGPCS) for portal decompression. Beginning in 1993, patients were prospectively randomized to undergo either TIPS or HGPCS as definitive therapy for portal hypertension due to cirrhosis. Complications of shunting and long-term outcomes were noted. Failure of shunting was prospectively defined as the inability to place shunt, irreversible shunt occlusion, major variceal rehemorrhage, unanticipated liver transplantation, or death. Survival and shunt failure were compared using Kaplan-Meier curve analysis. Median data are reported. Patient presentation, circumstances of shunting, causes of cirrhosis, severity of hepatic dysfunction (eg, Child's class, Model for End-Stage Liver Disease score), and predicted survival after shunting did not differ between patients undergoing TIPS (n = 66) or HGPCS (n = 66). Survival was significantly longer after HGPCS for patients of Child's class A (91 vs 19 months; p = 0.009) or class B (63 vs 21 months; p = 0.02). Shunt failure occurred later after HGPCS than TIPS (45 vs 22 months; p = 0.04). Compared with TIPS, survival after HGPCS was superior for patients with better liver function (eg, Child's class A or B). Shunt failure after HGPCS occurred later than after TIPS. Rather than TIPS, application of HGPCS is preferred for patients with complicated cirrhosis and better hepatic function.

Survival and Variceal Rehemorrhage After Shunting Support Small-Diameter Prosthetic H-graft Portacaval Shunt

This study was undertaken to report variceal rebleeding and survival after small-diameter prosthetic H-graft portacaval shunts (HGPCS) and to compare actual to predicted survival after shunting. Since 1987 we have prospectively followed patients after undergoing HGPCS to treat bleeding varices failing/not amenable to sclerotherapy/banding. One hundred and seventy patients underwent shunting. Cirrhosis was because of alcohol in 56%, hepatitis in 12%, both in 11%, and other causes in 21%. Child class was A for 10%, B for 28%, and C for 62%. Thirty-three patients died by 6 months, 54 by 24 months, 87 by 60 months, and 112 by 10 years, generally because of liver failure. Fifty-one patients are alive at a median of 48.3 months, 76 months ± 57.8 (mean ± SD). Variceal rehemorrhage was documented in 3 (2%) patients. By child class, 5-year/10-year survival rates were as follows: A 66.7/33.3%, B 48.6/15.6%, and C 29.2/7.0%. Actual survival was superior to predicted survival (Model for End-Stage Liver Disease [MELD]), (p < 0.001).Variceal rehemorrhage in patients undergoing small-diameter prosthetic H-graft portacaval shunting was very uncommon. Actual survival was superior to predicted survival (MELD). Long-term survival paralleled degree of hepatic function, although long-term survival was possible even with very advanced cirrhosis. Application of HGPCS is encouraged.

Conventional Predictors of Survival Poorly Predict and Significantly Underpredict Survival after H-graft Portacaval Shunts

ObjectiveThis study was undertaken to evaluate the ability to predict survival after 8 mm prosthetic H-graft portacaval shunts (HGPCS). MethodsSince 1988, 170 patients have been prospectively followed after HGPCS. Using preshunt data, predictors of survival after shunting [MELD Score, Emory Score, Child Pugh Score, Discriminant Function (DF), and Child Class] were determined and related to actual survival. ResultsChild Class was: (a) 10%, (b) 28%, and (c) 62%. Actual 5- and 10-year survival by Child Class was: (a) 67% and 33%, (b) 49% and 16%, (c) 29% and 7%. Survival correlated with all predictors of survival (p < 0.01 for each). Actual survival was better than predicted by MELD (p < 0.001). By Multiple Variable Regression Analysis—Computed Model, explained variation in survival was greatest for Child Class (18%), followed by MELD (14%), with DF, Emory Score, and Child Pugh Score not significantly contributing. ConclusionsAfter HGPCS, actual survival is better than predicted by MELD. Child Class explains only a minor variation in survival, although it better explains survival than MELD, Emory Score, Child Pugh Score, or DF. Conventional predictors of survival poorly and underpredict survival after HGPCS and should be used with caution.

Intraoperative color flow doppler ultrasound measurements of portal blood flow predicts outcome following small diameter prosthetic H-graft portacaval shunt

Intraoperative color flow doppler ultrasound measurements of portal blood flow predicts outcome following small diameter prosthetic H-graft portacaval shunt

Preshunt and Postshunt Portal Vein Pressures and Portal Vein-to-inferior Vena Cava Pressure Gradients Do Not Predict Outcome following Partial Portal Decompression

This study was undertaken to determine whether preshunt, postshunt, or changes in portal vein (PV) pressures or portal vein-to-inferior vena cava (PV-IVC) pressure gradients determine outcome following partial portal decompression attained through small-diameter prosthetic H-graft portacaval shunt (HGPCS). Seventy-seven adults underwent HGPCS (Child's class A 10%, B 56%, and C 34%) and were prospectively evaluated per protocol. PV pressures and PV-IVC pressure gradients decreased significantly in all patients with shunting (P < 0.001). Eight (10%) patients died within 30 days of shunting (Child's class B 50% and C 50%); seven of these deaths were due to liver failure. Preshunt, postshunt, and changes in PV pressures or PV-IVC pressure gradients with shunting were not different among eight perioperative deaths and survivors. At a mean follow-up of 3 years 24 (35%) additional patients died. Of late deaths 62 per cent were due to liver failure (Child's class B 40% and C 60%). Again preshunt, postshunt, or changes in PV pressures and PV-IVC pressure gradients with shunting did not predict who would die of late liver failure. We conclude that the small-diameter HGPCS effectively provides partial portal decompression. Preshunt or postshunt PV pressures or PV-IVC pressure gradients or changes in pressures with shunting do not determine outcome following HGPCS. Long-tern outcome is influenced by the severity of cirrhosis before shunting and by the self-destructive behaviors typical of patients with alcoholic cirrhosis.

Transjugular intrahepatic portosystemic shunt vs. small-diameter prosthetic H-graft portacaval shunt: extended follow-up of an expanded randomized prospective trial

We report herein the results of extended follow-up of an expanded randomized clinical trial comparing transjugular intrahepatic portosystemic shunt (TIPS) to 8 mm prosthetic H-graft portacaval shunt as definitive treatment for variceal bleeding due to portal hypertension. Beginning in 1993, through this trial, both shunts were undertaken as definitive therapy, never as a “bridge to transplantation.” All patients had bleeding esophageal/gastric varices and failed or could not undergo sclerotherapy/banding. Patients were excluded from randomization if the portal vein was occluded or if survival was hopeless. Failure of shunting was defined as inability to shunt, irreversible shunt occlusion, major variceal rehemorrhage, hepatic transplantation, or death. Median follow-up after each shunt was 4 years; minimum follow-up was 1 year. Patients undergoing placement of either shunt were very similar in terms of age, sex, cause of cirrhosis, Child's class, and circumstances of shunting. Both shunts provided partial portal decompression, although the portal vein-inferior vena cava pressure gradient was lower after H-graft portacaval shunt ( P <0.01). TIPS could not be placed in two patients. Shunt stenosis/occlusion was more frequent after TIPS. After TIPS, 42 patients failed (64%), whereas after H-graft portacaval shunt 23 failed (35%) ( P <0.01). Major variceal rehemorrhage, hepatic transplantation, and late death were significantly more frequent after TIPS ( P <0.01). Both TIPS and H-graft portacaval shunt achieve partial portal decompression. TIPS requires more interventions and leads to more major rehemorrhage, irreversible occlusion, transplantation, and death. Despite vigilance in monitoring shunt patency, TIPS provides less optimal outcomes than H-graft portacaval shunt for patients with portal hypertension and variceal bleeding.

A prospective randomized trial of TIPS vs small diameter prosthetic H-graft portacaval shunt in the treatment of bleeding varices

A prospective randomized trial of TIPS vs small diameter prosthetic H-graft portacaval shunt in the treatment of bleeding varices

Role of transjugular intrahepatic portosystemic shunt in the treatment of portal hypertension in pediatric patients.

Role of transjugular intrahepatic portosystemic shunt in the treatment of portal hypertension in pediatric patients.

Small-diameter prosthetic H-graft portacaval shunt: definitive therapy for variceal bleeding

Partial portal decompression has become a popular option in the treatment of complicated portal hypertension. This study was undertaken to report long-term follow-up after partial portal decompression obtained utilizing 8 mm prosthetic H-graft portacaval shunts. A total of 110 consecutive patients underwent H-graft portacaval shunting through a protocol that detailed care and studies from 1988 to 1996. Prospective follow-up recorded efficacy of partial portal decompression, shunt patency, morbidity of shunting, and survival. Seventy males and 40 females, whose average age was 54 ± 12.7 years (standard deviation), underwent shunting. Cirrhosis was due to alcohol abuse in 64%. Fourteen percent were in Child's class A, 55% in Child's class B, and 31% in Child's class C. Shunts were undertaken as emergencies in 20%, urgently in 13%, and electively in 67%. Shunting decreased portal pressure in all patients (30 ± 5.3 mm Hg to 19.9 ± 5.5 mm Hg; P <0.001). Early and late thrombosis was 6.4% and 3.6%, respectively. Late rebleeding occurred in 5.4%. Perioperative (30-day) mortality was 11.8%, and was highest for patients in Child's class C. Three-year survival was 53%. Five-year survival was 41%. Partial portal decompression is achieved with H-graft portacaval shunting. Rebleeding, shunt occlusion, and encephalopathy are uncommon. In this series of unselected older patients with alcoholic cirrhosis, 5-year survival after H-graft portacaval shunting was greater than 40% with minimal intervention.

Immediate and Long-Term Portal Hemodynamic Consequences of Small-Diameter H-Graft Portacaval Shunt

Background.Effective hepatic blood flow is thought to play a critical role in outcome following portal decompressive procedures. We have shown previously that hepatic arterialization occurs soon after shunting, preserving nutrient flow, but the remote effects of shunting are unknown. The purpose of this study was to determine the effect of small-diameter prosthetic H-graft portacaval shunt (HGPCS) on effective hepatic blood flow (EHF) and portal pressures 1 year from shunt placement.Methods.Patients undergoing 8-mm HGPCS had effective hepatic blood flow determined using low-dose galactose clearance preoperatively, postoperatively, and at 1 year postshunt. Portal blood flow, pressures, and portal vein/inferior vena cava pressure gradients were determined intraoperatively before and after shunt placement and at 1 year.Results.Twenty patients undergoing shunting had flows measured. All patients had significant reductions in portal vein/inferior vena cava pressure gradients while effective hepatic flow was maintained immediately postoperatively. At 1 year following shunting, effective hepatic blood flow was significantly lower than both pre- and postoperative rates of flow while portal pressures and gradients were significantly increased. Albumin, cholesterol, and PT were improved at 1 year while total bilirubin was slightly worse. Nineteen of 20 patients are still alive with average follow-up of 26 ± 10.3 months. Four patients were encephalopathic preop, 5 postop, and none chronicly.Conclusions.Recollateralization of varices and progression of cirrhosis may account for the observed reductions in EHF at 1 year. Regardless of the cause, diminution of EHF at 1 year is well compensated as demonstrated by minimal encephalopathy and ascites, improved hepatic function reflected in blood chemistry profiles, and good survival.

Transjugular intrahepatic portosystemic shunt versus H-graft portacaval shunt in the management of bleeding varices: A cost-benefit analysis

Background . Transjugular intrahepatic portosystemic shunt (TIPS) is popular in treating portal hypertension because of its perceived efficacy and cost benefits, although it has never been compared with surgical shunting in a cost-benefit analysis. This study was undertaken to determine the cost benefit of TIPS versus small-diameter prosthetic H-graft portacaval shunt (HGPCS). Methods . Cost of care was determined in 80 patients prospectively randomized to receive TIPS or HGPCS as definitive treatment for bleeding varices, beginning with shunt placement and including subsequent admissions for complications or follow-up related to shunting. Results . Patients were similar in age, gender, severity of illness/liver dysfunction, and urgency of shunting. After TIPS or HGPCS, variceal rehemorrhage (8 versus 0, respectively; p = 0.03), shunt occlusion (13 versus 4; p = 0.03), shunt revision (16 versus 4; p < 0.005), and shunt failure (18 versus 10; p = 0.10) were compared; all were more common after TIPS. Through the index admission, TIPS cost $48,188 ± $43,355 whereas HGPCS cost $61,522 ± $47,615. With follow-up, TIPS cost $69,276 ± $52,712 and HGPCS cost $66,034 ± $49,118. Conclusions . Early cost of TIPS was less than, though not different from, cost of HGPCS. With followup, costs after TIPS mounted. The initially lower cost of TIPS is offset by higher rates of subsequent occlusion and rehemorrhage.

Does the direction of portal blood flow determine outcome with small-diameter prosthetic H-graft portacaval shunt?

Background. Partial portal decompression, as attained by small-diameter prosthetic H-graft portacaval shunting, continues to gain popularity because of favorable outcomes. This study was undertaken to determine whether the direction of preshunt or postshunt portal blood flow or reversal in the direction of portal flow occurred with shunting effect outcome after small-diameter prosthetic H-graft portacaval shunt. Methods. In 56 consecutive patients the direction of portal flow was determined before and after shunting. The direction of portal blood flow before and after shunting and changes in the direction of portal flow that occur with shunting were correlated with 30-day and 1-year survival, as well as with the rate of postshunt encephalopathy. Results. Portal pressures significantly decreased in all with shunting. Whether or not stratified by Child's classification, neither the preshunt nor postshunt direction of portal flow affected 30-day or 1-year survival or incidence of encephalopathy. Eleven patients (significant at p < 0.001, Fisher's exact test) had reversal of portal blood flow with shunting without an increase in 30-day or 1-year survival or incidence of encephalopathy. Conclusions. Small-diameter prosthetic H-graft portacaval shunts significantly reduce portal pressure and lead to reversal of portal flow in significant numbers. Significant hepatic dysfunction is uncommon after shunting. Neither the direction of preshunt or postshunt portal blood flow nor the reversal of portal blood flow with shunting has an effect on clinical outcome after small-diameter prosthetic H-graft portacaval shunt.

The effect of small-diameter H-graft portacaval shunts on portal blood flow

Small-diameter prosthetic H-graft portacaval shunts have been shown to promote preservation of total hepatic blood flow relative to large-diameter H-graft shunts. Nonetheless, specific changes in portal hemodynamics occurring with small-diameter H-graft shunting are unknown. This study was undertaken to evaluate changes in portal flow that occur with these shunts. Portal vein and inferior vena cava (IVC) blood flow were determined intraoperatively in 36 consecutive adults before and after prosthetic H-graft portacaval shunting using color-flow Doppler ultrasound. Postshunt measurements were made immediately cephalad and caudad to the shunt. Comparisons were undertaken using a paired Student's t-test with 95% confidence. Portal pressures decreased in all (P < 0.001), but never to normal. Postshunt portal flow cephalad and caudad to the shunt were not different from preshunt flow (P = 0.09, P = 0.28, respectively), although they were different from each other (P = 0.004). Postshunt IVC flow cephalad to the shunt was greater than caudad IVC flow (P = 0.004) and greater than preshunt IVC flow (P < 0.001), reflecting high flow through the shunt into the IVC. Small-diameter prosthetic H-graft portacaval shunts divert a significant amount of blood from the portal vein and significantly decrease portal pressures. The decreases in portal pressures with shunting are significant whereas changes in portal blood flow into the liver are not. These findings help explain the low incidence of variceal rebleeding and hepatic dysfunction after these shunts.

The Effect of Partial Portal Decompression on Portal Blood Flow and Effective Hepatic Blood Flow in Man: A Prospective Study

With the advent of transjugular intrahepatic portasystemic stent shunt and the wider application of the surgically placed small diameter prosthetic H-graft portacaval shunt (HGPCS), partial portal decompression in the treatment of portal hypertension has received increased attention. The clinical results supporting the use of partial portal decompression are its low incidence of variceal rehemorrhage due to decreased portal pressures and its low rate of hepatic failure, possibly due to maintenance of blood flow to the liver. Surprisingly, nothing is known about changes in portal hemodynamics and effective hepatic blood flow following partial portal decompression. To prospectively evaluate changes in portal hemodynamics and effective hepatic blood flow brought about by partial portal decompression, the following were determined in seven patients undergoing HGPCS: intraoperative pre- and postshunt portal vein pressures and portal vein-inferior vena cava pressure gradients, intraoperative pre- and postshunt portal vein flow, and pre- and postoperative effective hepatic blood flow. With HGPCS, portal vein pressures and portal vein-inferior vena cava pressure gradients decreased significantly, although portal pressures remained above normal. In contrast to the significant decreases in portal pressures, portal vein blood flow and effective hepatic blood flow do not decrease significantly. Changes in portal vein pressures and portal vein-inferior vena cava pressure gradients are great when compared to changes in portal vein flow and effective hepatic blood flow. Reduction of portal hypertension with concomitant maintenance of hepatic blood flow may explain why hepatic dysfunction is avoided following partial portal decompression.

Direction or Reversal of Preshunt Portal Blood Flow as Determinants of Outcome up to 1 Year after Small-Diameter Prosthetic H-Graft Portacaval Shunt

Partial portal decompression (PPD) is gaining popularity in the treatment of portal hypertension. We have achieved PPD in over 80 patients by utilizing an 8-mm prosthetic H-graft portacaval shunt (HGPCS). We have been pleased with the infrequency of encephalopathy and liver failure after shunting. While maintenance of portal blood flow would presumably play a role in outcome after shunting, changes in portal hemodynamic occurring within the first year after shunting are generally unknown. In 31 patients (Child's class 6% A, 61% B, 32% C) of an average age of 55 ± 13.3 (SD) years undergoing HGPCS, clinical outcome was prospectively evaluated relative to the direction of portal blood flow determined before and after shunting and at 1 year after shunting using color-flow Doppler ultrasound. Preshunt hepatopetal flow reversed in 2/29 (7%) patients with shunting and in an additional 5/27 (18%) patients by 1 year after shunting. Death (due to alcoholism in 1, old age in 1) and encephalopathy (Child's class A = 1, B = 2, C = 1) were uncommon by 1 year after shunting. Eighty-one percent had excellent outcome (alive without encephalopathy or rebleeding) at 1 year. Though preshunt hepatopetal flow is generally maintained postshunt and after one year, maintenance of hepatopetal flow does not ensure an excellent outcome and reversal of hepatopetal flow does not predispose to a suboptimal outcome. Outcome up to 1 year after HGPCS is not determined by direction or reversal of portal blood flow.

Postprandial augmentation of portal hepatic inflow after prosthetic h-graft portacaval shunt

Encephalopathy after portasystemic shunting generally occurs after eating. After partial portal decompression, encephalopathy is uncommon, presumably because of associated portal hemodynamics. However, after partial shunting, the changes in portal venous hemodynamics that occur with eating are unknown. With this in mind, 11 nonencephalopathic adults were studied more than 1 year after 8-mm H-graft portacaval shunt (PCS). The studies utilized color flow duplex ultrasound to determine the changes in portal vein (PV) and inferior vena cava blood flow that occur with eating a standardized meal. Following H-graft PCS, there is increased blood flow in the inferior vena cava after eating, particularly cephalad to the H-graft PCS, implying increased flow through the prosthetic shunt. Eating also increases hepatopedal blood flow in the PV distal to the H-graft PCS. Postprandial increases in hepatopedal portal blood flow may play an important role in avoiding encephalopathy after H-graft PCS.

Prospective study of a prosthetic H-graft portacaval shunt

This study was undertaken to prospectively evaluate the 8-mm Gore-Tex interposition H-graft portacaval shunt. Thirty-six high-risk patients at the University of South Florida-affiliated hospitals received small-diameter shunts because of bleeding esophagogastric varices over a recent 2-year period. Portal vein and portal vein-inferior vena cava gradients were significantly reduced after shunting. These pressure changes were manifested clinically by the absence of variceal rebleeding and improvement of ascites; in addition, the incidence of encephalopathy was low. The 8-mm graft maintained hepatopedal flow in 67% of the patients, but reversal of flow did not result in complications commonly associated with poor portal perfusion. Graft thrombosis occurred in four (11%) patients. All grafts were successfully revised, three by operative revision and one by an interventional radiologist. Operative mortality was low (11%), and morbidity was unusual. The small-diameter H-graft portacaval shunt is a safe and effective method of treatment for bleeding esophagogastric varices.