Ringed Graft Research Articles

Easy Fenestration Technique for Extracardiac Fontan Operation

During an extracardiac conduit type of Fontan operation, fenestration is not always technically easy, particularly when the right atrium is small and located posteriorly. We describe here an easy technique for performing an anastomosis of a polytetrafluoroethylene ringed graft to the atrium for fenestration in the setting of an extracardiac conduit Fontan operation. The surgical technique starts with a purse string suture that is customized to fit the atrium and utilizes a ringed graft that is inserted into the right atrium through the purse string, which is then tied.

Periscope Modification of Right Ventricle-to-Pulmonary Artery Shunt in Norwood Operation

Given the purported hemodynamic advantages of the right ventricle (RV) to pulmonary artery (PA) conduit, many surgeons have adopted it as their preferred source of pulmonary blood flow during stage I palliation for hypoplastic left heart syndrome. Potential disadvantages of the RV-PA shunt include ventricular dysfunction, pseudoaneurysm formation, arrhythmia, and conduit obstruction, which can lead to a higher rate of unplanned reinterventions. The "dunk" technique was described to reduce the RV incision and proximal conduit obstruction; however, insertion of the ringed graft from the epicardium can be cumbersome and risk RV injury. We introduce a simplified, alternative method of placing the conduit, which we call the periscope technique, whereby the graft is withdrawn from within the RV cavity.

PP-356 A Rare Cause of Pulmonary Hypertension: Distal Pulmonary Artery Stenosis Due To Takayasu Arteritis

A B S T R A C T S maximum diameter of 7.5 cm and patent lumen being 4.85 cms. Eccentric thrombus is seen in the arch. Fusiform aneurysm of infrarenal aorta and bilateral common iliac arteries (Rt > Left).In April 2011 Patient underwent subclavian carotid shunt with 8 mm ring graft under GA. Patient underwent aortic arch aneurysm repair with 24 mm Dacron graft under TCA and antegrade axillary artery perfusion after 2 days. An elephant trunk of about 5 cms was constructed at the time of surgery. MDCT Aortogram 11/12/2012 Residual aneurysm sac arising from the distal arch and proximal descending thoracic aorta has increased in diameter from 67 mm to 82 mmSI dimension of the aneurysm in 98 mm,and it projects inferiorly into the aortopulmonary window. Infra renal abdominal aorta shows fusiform dilatation to 45 mm,increased from 37 mm in previous scanImpression: Increasing size of aortic arch residual aneurysm sac.Increasing size of fusiform infrarenal abdominal aortic aneurysm. Underwent Aortic arch and proximal thoracic aneurysm stenting with a valiant thoracic stent graft 32*200 mm on 21/12/2012. Uneventful post op period. Follow up MDCT Aortogram in Dec 2012,Feb 2013,March and June showed residual aneurysm thrombus noted remains status quo.Stent graft noted in situ.No evidence or stent occlusion or thombus within the graft.

Short-term evaluation of clinical effect of bone ring grafting and immediate insertion

To observe the short-term clinical effectiveness of bone ring graft technique and to summarize the key points of related surgical operation to provide comprehensive clinical guidelines. Fifteen patients with severe alveolar bone absorption were selected to receive bone ring grafting and immediate dental implant. Final fixed prostheses were cemented five months after initial implantation. Cone beam CT scans were conducted on all subjects before the procedure, as well as four months post-operation to evaluate alveolar bone height and level of bone height and absorption around the implants. Four to six months after prosthesis installation, each implant's Jemt classification, gingiva attachment, and probing depth (PD) were analyzed. The difference of PD between implants and adjacent teeth, as well as the difference of the bone absorption between labial and lingual sides, was compared. The survival rate of the bone ring and the retention rate of implants were calculated. Complications and patient satisfaction were also investigated. Bone graft survival rate was 94.4% and dental implantation retention rate was 100% four months post-operation. Average bone level increase was (6.06 +/- 1.06) mm, average bone absorption was (1.33 +/- 0.84) mm, and average bone thickness at the neck of the dental implant body was (6.94 +/- 0.73) mm. Approximately 4 to 6 months after crown restoration, average bone level increase was (5.62 +/- 1.03) mm, average bone absorption was (1.51 +/- 1.02) mm, and average bone thickness at the neck of the dental implant body was (6.77 +/- 0.72) mm. The PD around the implant body and the adjacent teeth was statistically insignificant. No major post-operative complication was observed, restorations were successful, and patient satisfaction level was high. Bone ring graft technique and immediate dental implantation are relatively simple to perform, and these techniques facilitate reduction in required treatment time. Short-term effect is reliable and satisfactory, whereas long-term outcomes require further follow up and study.

Successful resection of malignant hemangiopericytoma originating from left neck and involving superior vena cava

Background and methods We report a case of a giant malignant hemangiopericytoma in the left neck and involving and growing in left internal jugular, left subclvian, left brachiocephalic vein, superior vena cava (SVC) and occupying part of the right atrium. Tumor was causing severe dyspnea, dysphagia and initial SVC syndrome. A 77-year-old male was admitted to our hospital due to progressive dyspnea and dysphagia. Physical examination present large tumor mass in left supraclavicular and neck region with listening a trill. CT scan explain a large tumor mass started in level of hyoid in left side neck that involve deep veins and expand vessels. Tumor have a arterial blood circulation in SVC. Transthoracic echocardiography showed a mass occupying a space of the right atrium originating from the SVC. Cervicosternotomy used for surgical access. After bluntly removed the tumor from the left neck and ligation of the jugular and subclavian vein proceed to the vascular reconstruction. SVC reconstruction was performed between the right brachiocephalic vein and the right atrial appendage with ringed pericardial graft. Atrial part of tumor was shoved into a SVC. Tumor with vena cava was removed after reconstruction.

Interrupted Inferior Vena Cava Combined with Partial Anomalous Pulmonary Venous Return Drainage to the IVC in a 67‐Year‐Old Adult

A 67-year-old woman presented with lower body edema and was found to have a suprarenal inferior vena cava (IVC) obstruction without hepatic vein obstruction and partial anomalous pulmonary venous return (PAPVR) draining the right pulmonary veins to the IVC below the obstructed IVC on CT angiography. The patient underwent retrohepatic cavoatrial bypass with a polytetrafluoroethylene (PTFE) 16-mm ringed graft via a posterolateral thoracotomy and retroperitoneal approach.

Inferior vena cava resection and reconstruction for retroperitoneal tumor excision

This study reviews the results of en bloc resection of the inferior vena cava (IVC) for malignant tumor excision and reconstruction. A prospective database was reviewed. IVC resection was categorized as suprarenal, perirenal, infrarenal, or extensive (>one segment resected). Repairs were divided into primary, patch, or circumferential. Tumor type, perioperative morbidity, mortality, and graft patency were recorded. Between 1990 and 2011, 47 patients (21 women; mean age, 56; range, 35-89 years) underwent IVC resection for en bloc tumor excision. Sarcomas were most common (36 [77%]: 30 primary IVC). Eleven patients had primary IVC repair, nine patch repair (two autogenous), and 27 had circumferential replacement with a polytetrafluoroethylene ringed graft. Extensive IVC reconstruction in 18 patients included the entire IVC, with renal (RV) and hepatic vein reimplantation in eight; suprarenal and perirenal in six (seven RVs reimplanted); and infrarenal and perirenal in four (four RVs reimplanted). Nine single-segment IVC replacements were infrarenal. Morbidity was 10.6%: one each with bowel obstruction, chyle leak, renal failure with complete recovery (left RV reimplant, right nephrectomy), reoperation for bleeding, and IVC graft thrombosis. Morbidity did not differ by type of reconstruction. There was no mortality. Follow-up ranged from 1.5 to 216 months (18 years) with a mean of 3.5 years. Computed tomography or duplex scans were available in 28 of 47 patients and in 15 of 27 patients in group 3 at a mean follow-up of 36 and 20 months, respectively. One IVC graft thrombosis was documented at 10 months after chemotherapy/sepsis. Tumor recurrence caused three graft stenoses. Cumulative 5-year patency in group 3 was 80% (imaging) and 92% (clinical). Lower extremity edema was universally avoided. Cumulative 5-year survival for the series was 45% ± 8.5%. Mean long-term survival was 5.8 ± 0.56 years (range, 4 months-17 years), with a significant difference between primary or patch (mean, 6.5 years) and circumferential or extensive repair (mean, 4.2 years; P < .005). Cumulative (47% vs 52%) and mean (3.1 vs 3.6 years; P > .12) survival was similar between patients with single-segment and extensive IVC resection and replacement. IVC resection and reconstruction for en bloc tumor excision is safe, even when extensive repairs are necessary. Replacement of the IVC with prosthetic graft avoids extremity venous complications and likely contributes to quality of survival. Survival depends on tumor behavior and degree of IVC involvement, where primary and patch repair has a better prognosis than circumferential resection.

Repair of an extensive iatrogenic tracheal rupture with a pleural patch and a vascular graft.

Here we describe a 48-year-old woman who suffered a 7-cm rupture in the lower trachea after intubation with a double-lumen tube. We repaired the rupture with a new technique using a pleural patch reinforced by a ringed vascular graft. This technique appears to be appropriate for use in patients who have large tracheal ruptures to avoid tracheal stenosis.

Ring versus ‘Mercedes-Benz’ cartilage-perichondrium graft tympanoplasty in management of pars tensa cholesteatoma

To compare anatomical and audiological outcomes of ring versus 'Mercedes-Benz' cartilage-perichondrium graft tympanoplasty in patients with pars tensa cholesteatoma. Prospective clinical study. Otolaryngology department, Tanta University Hospital, Egypt. Over three years, 60 ears in 60 patients underwent surgery for either sinus or tensa retraction cholesteatoma, reconstructed using either a ring-shaped (30 ears) or Mercedes-Benz symbol shaped (30 ears) cartilage-perichondrium graft, with at least two years' follow up. Post-operative drum perforation and retraction, cholesteatoma residue and recurrence, middle-ear effusion, and hearing acuity were monitored. Anatomical outcomes were equivalent in both groups, but slightly better in the Mercedes group. Hearing improved significantly in both groups (pre- vs post-operative results), but significantly more so in the ring group. Within-group hearing outcomes were unaffected by cholesteatoma type or tympanoplasty type. The Mercedes-Benz technique may be superior to the ring technique in preventing neodrum retraction. However, the ring graft technique had better hearing outcomes, perhaps due to its more physiological design.

Pulmonary Artery and Conduit Reintervention Rates After Norwood Using a Right Ventricle to Pulmonary Artery Conduit

There is a high incidence of cardiovascular reinterventions in patients undergoing a Norwood procedure (NP). The goal of this study was to analyze the rate of pulmonary artery (PA) and conduit stenosis using the right ventricle (RV)-to-PA modification of the NP. Patients who underwent a NP January 2005 to December 2009 were included. The procedure was performed with a ringed conduit sutured to a membrane to form a patch. The patch was sutured to the PA confluence, and the spatulated conduit was anastomosed to an appropriately sized right ventriculotomy. Rates of PA and conduit stenosis requiring reintervention were calculated based on cardiac catheterization data. Thirty-three patients with hypoplastic left heart syndrome underwent a NP. Perioperative mortality was 6% (2 of 33). Twenty-eight patients (85%) had a Glenn procedure 5 ± 1 months later, and 12 patients (36%) had a Fontan procedure 34 ± 2 months after the Glenn. Pulmonary artery stenosis occurred in 11 patients (33%), and RV-PA conduit stenosis occurred only in 2 patients (6%). One-year and 3-year actuarial survival rates were 82% and 77%, respectively. Both branch PAs showed good and symmetric growth at cardiac catheterization before Glenn. The NP with RV-PA conduit using a ringed graft and a pulmonary patch is a technique associated with a low rate of PA and conduit stenosis, and good outcomes.

Inferior Vena Cava Resection and Reconstruction for Retroperitoneal Tumor Excision

The purpose of this study was to review the results of resection and reconstruction of the inferior vena cava (IVC) for en bloc malignant tumor excision. We conducted a retrospective review of all patients having IVC resection for en bloc malignant tumor excision. IVC resection was categorized as suprarenal, perirenal, infrarenal, or extensive (>1 segment resected). Repairs were divided into primary, patch, or circumferential. Tumor type, perioperative morbidity, mortality, clinical graft patency, and survival (social security death index) were recorded. Between 1992 and 2010, 48 patients (24 female) had IVC resection for tumor en bloc excision. Sarcomas were most common (33; 69%: 5 [10%] primary IVC). Thirteen patients had primary IVC repair, nine patch repairs (one autogenous), and 26 had circumferential replacement with polytetrafluoroethylene (PTFE) ringed graft (12-16 mm). Extensive IVC reconstructions were performed in 17 cases of which seven involved the entire IVC with renal vein (RV) and hepatic vein reimplantation, six were suprarenal and perirenal (seven RV reimplanted), and four were infrarenal and perirenal (four RV reimplanted). All single segment (9) repairs were infrarenal. Overall morbidity was 6% (one bowel obstruction requiring surgery, one chyle leak resolved with medical therapy, and one renal failure with complete recovery [L RV reimplant, R nephrectomy]). There was no difference in morbidity between primary, patch, circumferential, and extensive reconstruction. There was no mortality. One IVC graft thrombosis was documented on follow-up (after chemotherapy/sepsis). There were two graft stenosis associated with tumor recurrence. Lower extremity edema was universally avoided. Mean long-term survival was 3.34 years (4 months to 11 years) with a significant difference between primary or patch (mean 66.7 months) and circumferential or extensive repair (mean 39.7 months; P < .005). There was no survival difference between single segment and extensive IVC repair (36.7 vs 42.8 months; P > .12). IVC resection and reconstruction for en bloc tumor excision is safe even when extensive repairs are necessary. Replacement of the IVC with a prosthetic graft avoids extremity venous complications and likely contributes to quality of survival. Survival is dependent on tumor behavior and degree of IVC involvement where primary and patch repair has a better prognosis than circumferential resection.

Isolated Unilateral Agenesis of the Pulmonary Artery: Surgical Repair With an Artificial Graft

This report describes a 3-month-old Japanese boy with a diagnosis of isolated unilateral agenesis of the proximal right pulmonary artery with severe pulmonary hypertension. One-stage reconstruction of the right pulmonary artery was performed without cardiopulmonary bypass. The hilar right pulmonary artery and the distal main pulmonary artery were joined by anastomosis to an artificial ring graft. The boy's postoperative course was uneventful, and the pressure in the pulmonary artery was within the normal range. Although mild right pulmonary artery stenosis remained, the authors' therapeutic strategy may provide a clinically important option for isolated unilateral agenesis of the pulmonary artery.

Dorsal Cavoatrial Bypass for Congenital Interruption of IVC

Congenital interruption of the inferior vena cava (IVC) can lead to secondary hepatic congestion, portal hypertension, and liver cirrhosis. A 49-year-old woman was admitted to the gynecology department with symptoms of menorrhalgia, known uterine myoma, and anemia. Abdominal computed tomography (CT) and venography performed at our hospital revealed congenital interruption of the IVC. The patient underwent retrohepatic cavoatrial bypass surgery with a polytetrafluoroethylene (PTFE) 16-㎜ ringed graft via posterolateral thoracotomy, and recovered without major complications. A retroperitoneal approach via posterolateral thoracotomy provides appropriate visualization during dorsal cavoatrial bypass in treating patients with congenital interruption of IVC.

Comparison between cartilage–perichondrium composite ‘ring’ graft and temporalis fascia in type one tympanoplasty in children

This study aimed to evaluate the anatomical and audiological outcomes of primary type one tympanoplasty performed with a modified cartilage-perichondrium composite 'ring' graft, and to compare them with results for primary type one tympanoplasty performed with temporalis fascia, in children. Retrospective clinical study. Otolaryngology department, Tanta University Hospital, Egypt. Records were evaluated for 82 children with dry tympanic membrane perforation (any size) and intact ossicular chain, and with no history of previous ear surgery except for tympanostomy. Patients of similar age and middle-ear pathology were selected to make the two groups as homogeneous as possible. An underlay type one tympanoplasty, using either a ring graft or temporalis fascia, was performed: 40 children were included in the ring graft group and 42 in the temporalis fascia group. All procedures were performed by the same surgeon. A successful anatomical outcome was considered to comprise full, intact healing of the graft without perforation, retraction, lateralisation or blunting, for at least one year post-operatively. Patients' post-operative pure tone average air-bone gap and speech reception threshold were compared with pre-operative levels, within and between the two groups. Type one tympanoplasty using a ring graft technique resulted in a significantly greater graft acceptance rate (95 per cent) compared with the temporalis fascia technique (76.2 per cent; p < 0.01). Pure tone average air-bone gap and speech reception threshold levels improved significantly in both the ring graft and fascia groups (p < 0.001). There was no significant difference in audiometric results between the two groups (p > 0.05), although there was a trend towards better post-operative results in the ring group. In our paediatric patients, type one tympanoplasty with a modified cartilage-perichondrium composite ring graft yielded good anatomical and functional results. The anatomical results obtained using this graft (with its unique appearance and stability during and after surgery) were superior to those for temporalis fascia. The ring graft group had equivalent, if not better, post-operative audiometric results, compared with the temporalis fascia group. Thus, the ring graft is believed to be effective in enabling both tympanic membrane closure and rapid hearing improvement, in the paediatric population.

The Longevity of Arteriovenous Graft for Hemodialysis Patients—Externally Supported or Nonsupported

Because thrombosis and stenosis are the most frequent causes of arteriovenous graft (AVG) failure, several externally supported grafts were designed to enhance incompressibility and kinking resistance to improve the patency. However, consensus on advantage of these modifications having still not been reached might relate to the previous limited patient numbers and small studies. This study analyzed the longevity of externally supported and nonsupported AVG on the basis of the nationwide database to understand whether the externally supported design could improve the duration of patency of AVG. Adult incident patients (n = 4402) were retrospectively enrolled who had began hemodialysis between January 1, 2002 and December 31, 2005. All incident patients with AVG, before or after beginning regular hemodialysis, between January 1, 2000 and December 31, 2006 were identified. The Cox proportional hazard model was used to compare the longevity of externally supported and nonsupported AVG by controlling other covariates. There were 990 patients with externally supported AVG and 3412 patients with nonsupported AVG. The patency rates of externally supported AVG were 49.4%, 31.6%, and 20.2% at 1, 2 and 3 years, respectively; those of nonsupported AVG were 31.9%, 17.4%, and 10.8%. The survival of nonsupported AVG was significantly inferior to that of externally supported AVG. Externally supported AVG are superior to nonsupported AVG for long-term patency. The incompressibility and kinking resistance of ringed grafts may shed light on a direction for the future development of dialysis graft design.

Traumatic Fracture of Polytetrafluoroethylene Axillofemoral Bypass Graft

We report traumatic disruption of a ringed polytetrafluorethylene (PTFE) axillofemoral bypass (AFB) graft due to a fall. We also review the literature of previously reported blunt traumatic PTFE graft disruptions. A 75-year-old man with previous bilateral AFB grafting presented with a painful left chest wall mass after a fall from standing height. Chest computed tomography (CT) revealed a large chest wall hematoma. The patient underwent evacuation of the hematoma, resection of the fractured graft, and placement of an interposition PTFE graft. Two prior case reports have documented the midportion PTFE graft disruption from blunt trauma. Our case report demonstrates the potential for disruption of the midportion of ringed PTFE AFB grafts with direct blunt trauma. The diagnosis was confirmed by CT scan and the graft was successfully repaired with an interposition graft.

A novel approach via combination of electrospinning and FDM for tri-leaflet heart valve scaffold fabrication

In this paper, a novel combination method of electrospinning and rapid prototyping (RP) fused deposition modeling (FDM) is proposed for the fabrication of a tissue engineering heart valve (TEHV) scaffold. The scaffold preparation consisted of two steps: tri-leaflet scaffold fabrication and heart valve ring fabrication. With the purpose of mimicking the anisotropic mechanical properties of the natural heart valve leaflet, electrospun thermoplastic polyurethane (ES-TPU) was introduced as the tri-leaflet scaffold material. ES-TPU scaffolds can be fabricated to have a well-aligned fiber network, which is important for applications involving mechanically anisotropic soft tissues. We developed ES-TPU scaffolds as heart valve leaflet materials under variable speed conditions and measured fiber alignment by fast Fourier transform (FFT). By using FFT to assign relative alignment values to an electrospun matrix, it is possible to systematically evaluate how different processing variables affect the structure and material properties of a scaffold. TPU was suspended at certain concentrations and electrospun from 1,1,1,3,3,3-hexafluoro-2-propanol onto rotating mandrels (200–3000 rpm). The scaffold morphological property and mechanical anisotropic property are discussed in the paper as a function of fiber diameter and mandrel RPM. The induction of varying degrees of anisotropy imparted distinctive material properties to the electrospun scaffolds. A dynamic optimum design of the heart valve ring graft was constructed by FDM. Fabrication of a 3D heart valve ring was constructed using pro-engineer based on optimum hemodynamic analysis and was converted to an STL file format. The model was then created from PCL which was sewed and glued with electrospun nanofibrous leaflets. This proposed method was proven as a promising fabrication process in fabricating a specially designed graft with the correct physical and mechanical properties.

Mesoatrial shunt in Budd-Chiari syndrome

Budd-Chiari syndrome (BCS) represents partial or total occlusion of the hepatic veins with or without simultaneous obstruction of vena cava inferior (VCI). The symptoms of BCS are abdominal pain, hepatomegaly, ascites, varices of the abdominal wall, sometimes bleeding from the upper part of gastointestinal tract (GIT), lower limbs swelling and jaundice. Primary BSC is a relatively rare condition occuring in one per 100,000 of the population worldwide. A male patient, 25-year-old, facing tooth postextraction complications, was presented with acute BCS. On admission, physical examination revealed pale-grayish complexion, more pronounced veins over the thorax and abdomen, ascites, enlarged liver rising 8 cm below the right costal arch and having a minor pleural effusion by the right side. The patient was submitted to Doppler sonography and computed tomography (CT) that verified the right leg deep veins thrombosis, as well as the presence of a thrombus in the intrahepatic portion of the VCI. Multislice computed tomography (MSCT) showed occlusion of hepatic veins (Budd-Chiari syndrome) and thrombosis of the VCI in the retrohepatic part 6 cm long. Also, increased values of transaminases and gamma GT and reduced values of albumines and serum ferrum were registered. Molecular examination revealed Factor V Leiden mutation--heterozygote. After preoperative preparations a mesocaval shunt was made using Gore-Tex ring graft of 12 mm. Intraoperatively, the blue enlarged liver was found with almost black zones of tense capsule. After a graft making, liver congestion decreased followed by the change of colour and volume. Within postoperative course metabolic and synthetic liver functions were obvious. In patients with BCS medicamentous treatment does not yield adequate results, but even causes worsening of general condition. Surgical therapy in the presented patient was performed timely regarding the stage of the disease due to which irreversible liver changes were prevented while decompression of the portal system provided time overbridging up to liver transplantation.

Myoclonus-Induced Bilateral Acetabular Fracture Dislocations

An uncommon case of myoclonus-induced bilateral central acetabular fracture-dislocation is presented. Although different fracture types due to forceful muscular contractions have been reported, this is an exceedingly uncommon injury pattern. Bilateral total hip arthroplasty, in combination with a reinforcement ring and autologous bone grafting, was performed after open reduction and internal fixation.

Partial portacaval shunt with H-grafts to treat portal hypertension

Partial portosystemic shunts have been popularized because of a reported low rate of mortality and morbidity (especially encephalopathy, liver failure and occlusion). The results of partial portacaval shunts [small-diameter expanded polytetrafluoroethylene (ePTFE) H-graft portacaval shunt] were retrospectively reviewed to evaluate the clinical efficacy in the treatment of portal hypertension. Forty-three patients with portal hypertension were treated by small-diameter H-graft of ePTFE portacaval shunt from May 1995 to April 2006. Thirty-three had externally ringed grafts and ten had non-ringed ones. Ten had grafts of 10 mm in diameter and 33 had grafts of 8 mm. The left gastric artery and coronary vein were ligated in all the cases. Six had pericardial devascularization and splenectomy was performed in 42. An average decrease of free portal pressure (FPP) from (33.24 ± 4.78) cmH2O before shunting and (13.65 ± 5.65) cmH2O after shunting was observed. The portal blood flow was reduced by one-third of that before shunt. Thirty-eight patients survived and no upper gastro-intestinal rebleeding occurred in the follow-up period (50.5 months in average). Two were out of contact. Color Doppler ultrasonography and/or portography revealed the shunts were patent in 38 cases and were occluded in three cases (3/41, 7.3%). Encephalopathy developed in five cases (5/41, 12.2%). Partial (small-diameter ePTFE H-graft) portacaval shunting can reduce the portal pressure effectively. Majority of the hepatic flow from the portal vein can be maintained adequately. The shunts with reinforced grafts can keep a higher rate of patency. The morbidity of encephalopathy was lower than those with total shunt. The partial portacaval shunt is effective in preventing recurrent variceal bleeding.