Clinical Radiology (1992) 46, 166 169
Transjugular Intrahepatic Portosystemic Stent Shunt (TIPSS): Early Clinical Experience N. CHALMERS, D. N. REDHEAD, K. J. SIMPSON* and P. C. HAYES*
Departments of Radiology and *Medicine, Royal Infirmary, Edinburgh Transjugular intrahepatic portosystemic stent shunt (TIPSS) is a new percutaneous technique for reducing portal venous pressure. We attempted TIPSS in six patients with recurrent bleeding for oesophageal or gastric varices between July 1991 and January 1992 with success in five. There have been no deaths. One patient re-bled after TIPSS. His portal pressure was found to be elevated persistently indicating an inadequate shunt. Following further dilatation of the shunt, portal pressure fell to a satisfactory level and bleeding has not recurred. No bleeding episodes have occurred in the other patients following successful TIPSS. Our series contributes to the growing body of experience which suggests that TIPSS is a safe and effective treatment for recurrent variceal bleeding. Chalmers, N., Redhead, D.N., Simpson, K.J. & Hayes, P.C. (1992). Clinical Radiology 46, 166-169. Transjugular Intrahepatic Portosystemic Stent Shunt (TIPSS): Early Clinical Experience
AcceptedJor Publication 22 April 1992
Recurrent variceal bleeding cannot always be controlled by sclerotherapy especially if gastric varices or portal gastropathy are present. Surgical portosystemic shunting carries an unacceptably high mortality especially in the presence of severe liver disease ranging from 0-10% in Childs grade A disease to 14-54% in Childs grade C disease. Surgical shunting is complicated by hepatic encephalopathy, which may be disabling, in 10-50% of patients [1,2]. Portosystemic shunting is, however, highly effective in controlling variceal bleeding and therefore a safer technique, with fewer side effects would be highly desirable. A percutaneous technique for intrahepatic portosystemic shunting in man was first described in 1982 [3]. However, this technique was unsuccessful due to the failure of the shunt to remain patent. Transjugular intrahepatic portosystemic stent shunt (TIPSS) is a recent modification of this technique whereby shunt patency is maintained by the use of metallic stents [4]. We describe our experience of the technique which we attempted in six patients with success in five between July 1971 and January 1992.
and the patients are sedated with midazolam and pethidine. A 10 Fr 35 cm long sheath (William Cook Europe A/S, Bjaeverskov, Denmark) is inserted through the right internal jugular vein. The right or middle hepatic vein is catheterized and the tip of the sheath advanced into the hepatic vein. A 16 gauge 56 cm reverse-bevel curved transjugular liver biopsy needle (William Cook Europe A/S, Bjaeverskov, Denmark) is introduced via the sheath and the needle tip exposed. The needle is directed anteriorly and then advanced through the liver parenchyma until a large portal vein branch is punctured. Successful puncture of the portal vein can be confirmed by aspiration, and when blood is obtained, injection of small amounts of contrast, although care must be taken to avoid excessive parenchymal staining by contrast. Initially, a catheter placed percutaneously in the portal vein was used to guide the needle, but recently we have used the portogram and ultrasound for guidance in order to reduce complications related to the percutaneous transhepatic catheterization. After puncturing the portal vein, a stiff hydrophilic
PATIENTS AND M E T H O D S
Table 1-Clinical details
Clinical details of the six patients treated are given in Table 1. Our first attempt at TIPSS using the technique described by Richter et al. [5] was unsuccessful and we have subsequently made modifications similar to those described by Zemel et al. [6] and RSssle et al. [7]. Patient preparation involves coeliac and mesenteric angiography to confirm patency of the splenic and portal veins and to provide a 'road-map'. The angiogram also demonstrates the direction of flow in the portal vein although hepatofugal flow is not considered a contraindication to TIPSS (indeed, hepatopetal flow may be restored by TIPSS). Any clotting abnormality is corrected
Case Age Sex Diagnosis
Ascites No. ~?['Child/Pugh bleeds grade
1
54
M
Alcoholic OesophageaI varices
+
8
A5
2
51
M
Alcoholic Oesophageal varices
-
> 10
B7
3
71
M
Chronic active hepatitis Gastric varices
-
1
A6
4
' 60
M
Alcoholic Portal gastropathy Oesophageal varices
+
> 10
B8
5
71
M
Alcoholic Portal gastropathy
+
> 10
B8
6
73
F
Primary biliary cirrhosis + Oesophageal varices
4
A5
Correspondence to: Dr N. Chalmers, Department of Radiology, Royal Infirmary, Lauriston Place, Edinburgh EH3 9YW.
TRANSJUGULAR INTRAHEPATIC PO'tkTOSYSTEMIC STENT SHUNT
167
Fig. 3. The stents have been further dilated to 10 mm diameter. The left gastric vein no longer fills. The portal pressure gradient is now 10 m m H g indicating an adequate shunt.
Fig. 1 - The guide wire passes from hepatic vein to superior mesenteric vein. Prolonged balloon dilatation of the transhepatic track is required to overcome the wasting due to periportal fibrosis.
guide wire (Terumo Corp., Tokyo, Japan) is passed through the needle into the superior mesenteric vein. The needle is removed and a catheter is passed over the wire into the portal vein. Direct portal vein pressure measurement is then recorded through the catheter. The wire is replaced with an Amplatz super-stiff wire (Medi-Tech, Watertown, MA, USA) and the transhepatic parenchyreal track is then dilated using an 8 mm angioplasty balloon (Fig. 1). The periportal fibrosis produces a characteristic sharp waist which requires several minutes to dilate adequately. The sheath is then advanced across the track and one or more Palmaz stents (Johnson & Johnson Interventional Systems, Edinburgh, UK) are deployed to completely cover the length of the track. The stents are initially dilated to 8 mm diameter and repeat pressure measurements obtained (Fig. 2). The stents are progressively dilated until the portal pressure gradient (portal pressure minus free hepatic venous pressure) is 10-15 mmHg (Fig. 3). Initially, the procedure took in the region of 6 h, but with experience this has fallen to about 3 h. The most time consuming aspect is the portal vein puncture. Several passes with the needle are usually required to establish satisfactory communication with the portal vein. Following the procedure, the patients are monitored for evidence of bleeding and prophylactic antibiotics are administered for 3 days. If there are no complications they may be discharged after 72 h. Follow-up includes duplex ultrasound, which may be transabdominal or transoesophageal. The latter approach is useful in obese patients or in the presence of ascites in which case the shunt may be beyond the range of the transabdominal probe. The presence of ascites, encephalopathy or recurrent bleeding is monitored. RESULTS
Fig. 2 - After insertion of two stents dilated to 8 mm diameter, there is still filling of the dilated left gastric vein indicating an inadequate shunt.
The results are given in Table 2. Following the initial failure in case 1, a patent shunt
168
CLINICAL RADIOLOGY
TaMe 2 - Results
Case
No. of stents
Final diameter (ram)
Complications
Haem ot hora x Broken wire Neck puncture inflammation
1
3
11
2
2
8
3
3
8
4 5 6
Resolution of ascites
F/ U
Yes
3 months
8
--
6 months
13
--
5 months
15 10
No Yes
1.5 months 1 week
PPG (mmHg) Pre- 7YPSS
Post- TIPSS
29
14
Staphylococcus septicaemia Failed
3 2
8 10
24
PPG, Portal pressure gradient; F/U, duration of follow-up.
was established, using the modified technique as described above, at a subsequent attempt. The patient had a further bleed 7 days later and portal pressure measurement at this time revealed a persistently elevated pressure gradient of 29 mmHg. Portography revealed that the two stents in place did not completely cover the transhepatic track; therefore a third stent was deployed proximally. The pressure gradient remained elevated at 17 mmHg, so the stents were dilated from 8 to 11 mm diameter resulting in a pressure gradient of 14. There has been no further bleeding and the ascites has resolved. In four patients, a successful shunt was established at the first attempt. In the remaining patient, who had a shrunken liver with small intrahepatic portal vein branches, portal vein puncture proved impossible and the procedure was abandoned. There have been no deaths. L o n g term follow-up is not yet available (mean 3 months, range 0-6) but as yet no other patient has re-bled following TIPSS and none has developed encephalopathy. Ascites has persisted in one patient who is markedly hypoalbuminaemic. There have been a number of complications. In the first patient, the tip of a fine 0.018 inch guide wire was amputated in the liver parenchyma. This has produced no clinical sequelae and has not migrated. Subsequently we have not used fine guide wires. The same patient developed haemoperitoneum and right haemothorax following TIPSS. This was aspirated and no transfusion was required. Two patients developed infective complications, namely one episode of staphylococcal septicaemia which responded to antibiotics and one episode of cellulitis at the jugular vein puncture site. Following this, prophylactic antibiotics have been used with no further infective complications. A total of approximately 150 ml of non-ionic contrast medium was used in each uncomplicated case and 450 ml in case 1 over a 3 week period.
DISCUSSION We initially attempted TIPSS using the method described by Richter et al. [5]. This involved the use of an 18 gauge transjugular needle and fine guide wires. We found the fine wire did not support the passage of a stiffener through the liver track and the tip of the wire was amputated. Subsequently, in common with other authors [6,7], we have used a 16 gauge needle which permits the passage o f a 0.035 inch wire. We have found the stiff hydrophilic wire useful for gaining access to the portal
system but replace this with an Amplatz super-stiff wire for balloon dilatation and stent insertion. For the first five cases we used a catheter placed percutaneously in the right branch of the portal vein as a target to direct the liver biopsy needle. However, the percutaneous puncture is a potential source of bleeding, particularly in patients with ascites. One of our cases developed haemoperitoneum and haemothorax, and review of the literature reveals one death as a result of bleeding from the percutaneous liver puncture [5]. In the most recent case we used a combination of the portal venogram and transabdominal ultrasound for guidance, thus obviating the need for percutaneous liver puncture [7]. Ultrasound is used to assess the relationship to hepatic and portal veins in the antero-posterior plane and to position a radio-opaque marker on the anterior abdominal wall directly over the portal vein bifurcation. This marker assists the portal vein puncture under fluoroscopy. Literature review reveals two further details within 30 days [4,5,8-11] out of a total of 47 successful TIPSS (including the present series) [6,7,12,13]. All three deaths were of patients with Childs stage C disease. Thus the safety of TIPSS compares favourably with surgical shunting. Encephalopathy following TIPSS has been reported in one patient [7]. Shunt occlusion has been observed and is associated with recurrent bleeding [7] which was the cause of one late death at 18 months [10]. However, occlusion may be treated by re-dilatation of the shunt [7]. The long term effectiveness of TIPSS remains to be evaluated, but 1 and 2 year survival of approximately 80% has been reported
[10]. Surgical portosystemic shunting is undesirable prior to liver transplantation because of distortion of the portal venous anatomy but TIPSS may be used to control portal hypertension while a donor organ is awaited without compromising successful surgery t13]. The future role of TIPSS in the treatment of recurrent variceal bleeding depends on long term patency. It seems likely that TIPSS will become the standard treatment of patients who re-bleed despite sclerotherapy. It may also become the first line treatment in patients with gastric varices (which are difficult to eradicate by sclerotherapy) and in patients who bleed from portal hypertensive gastropathy. If the safety of TIPSS is confirmed, it may have a role in the treatment of intractable ascites. Followup is as yet limited, however our experience provides further evidence that TIPSS is a safe and effective method of reducing portal pressure.
TRANSJUGULAR INTRAHEPATIC PORTOSYSTEMIC STENT SHUNT
Acknowledgen/ents. Dr Chalmers' post is sponsored by E. Merck Pharmaceuticals and Du Pont (UK) Ltd. The TIPSS programme is partly funded by grants from the Urquhart Trust and the Gannochy Trust. We are grateful to Dr G. R. Sutherland for performing transoesophageal ultrasound on some of the patients. REFERENCES 1 Shearman DJC, Finlayson NDC. Diseases o f the gastrointestinal tract and liver. Edinburgh: Churchill Livingstone, 1982:596-617. 2 Drapanas T, LoCicero J, Dowling JB. Hemodynamics of the interposition mesocaval shunt. Annals of Surgery 1975; 181:523-533. 3 Colapinto RF, Stronel RD, Birch SJ, Langer B, Blendis LM, Greig PD et al. Creation of an intrahepatic portosystemic shunt with a Grfintzig balloon catheter. Canadian Medical Association Journal 1982;126:267 268. 4 Richter GM, Palmaz JC, N61dge G, R6ssle M, Siergerstetter V, Franke M et al. Der transjugul~ire intrahepatische portosystemische Stent-Shunt (TIPSS). Eine neue nichtoperative, perkutane Methode. Radiologe 1989;29:406 411. 5 Richter GM, Noeldge G, Palmaz JC, Roessle M. The transjugular intrahepatic portosystemic stent-shunt (TIPSS): results of a pilot study. Cardiovascular and Interventional Radiology 1990;13:200207. 6 Zemel G, Katzen BT, Becker G J, Benenati JF, Sallee DS. Percutaneous transjugular portosystemic shunt. Journal o.1"the American Medical Association 1991;266:390 393.
169
7 R6ssle M, Noeldge G, Pararnau JM, Haag K, Sellinger M, Wenz W et al. Transjugular intrahepatic portosystemic stent shunt (TIPSS): experience with an improved technique. AASLD Abstracts of papers. Hepatology 1991;14:96A. 8 R6ssle M, Richter GM0 Noeldge G, Siegerstetter V, Palmaz JC, Wenz W e t al. Der intrahepatische portosystemische Shunt. Erste klinische Erfahrungen bei Patienten mit Leberzirrhose. Deutsche Medizinisehe Wochenschrift 1989; 114:1511-1516. 9 Richter GM, Noeldge G, Palmaz JC, Roessle M, Siegerstetter V, Franke M e t al. Transjugular intrahepatic portacaval stent shunt: preliminary clinical results. Radiology 1990; 174:1027 1030. 10 Richter GM, Noeldge G, Roessle M, Roeren TH, Kauffmann GW, Palmaz JC. Three-year results of use of transjugular intrahepatic portosystemic stent shunt. RSNA Abstracts. Radiology 1991; 181 (P)(Suppl.):99. 11 Vinel JP, Rousseau H, Maquin P, de Haldat F, Blain F, Joffre F et al. Transjugular intra-hepatic porto-caval shunts (IPCS): experimental and clinical study. AASLD Abstracts of papers. Hepatology 1991;14:243A. 12 Zemel G, Katzen BT, Becker GJ, Benenati JF. Percutaneous transjugular portosystemic shunt. RSNA Abstracts. Radiology 1991;181(P)(Suppl.): 99 100. 13 Roberts JP, Ring E, Lake JR, Sterneck M, Ascher NL. Intrahepatic portocaval shunt for variceal hemorrhage prior to liver transplantation. Transplantation 1991;52:160 162.
Transjugular Intrahepatic Portosystemic Stent Shunt (TIPSS): Early Clinical Experience N. CHALMERS, D. N. REDHEAD, K. J. SIMPSON* and P. C. HAYES*
Departments of Radiology and *Medicine, Royal Infirmary, Edinburgh Transjugular intrahepatic portosystemic stent shunt (TIPSS) is a new percutaneous technique for reducing portal venous pressure. We attempted TIPSS in six patients with recurrent bleeding for oesophageal or gastric varices between July 1991 and January 1992 with success in five. There have been no deaths. One patient re-bled after TIPSS. His portal pressure was found to be elevated persistently indicating an inadequate shunt. Following further dilatation of the shunt, portal pressure fell to a satisfactory level and bleeding has not recurred. No bleeding episodes have occurred in the other patients following successful TIPSS. Our series contributes to the growing body of experience which suggests that TIPSS is a safe and effective treatment for recurrent variceal bleeding. Chalmers, N., Redhead, D.N., Simpson, K.J. & Hayes, P.C. (1992). Clinical Radiology 46, 166-169. Transjugular Intrahepatic Portosystemic Stent Shunt (TIPSS): Early Clinical Experience
AcceptedJor Publication 22 April 1992
Recurrent variceal bleeding cannot always be controlled by sclerotherapy especially if gastric varices or portal gastropathy are present. Surgical portosystemic shunting carries an unacceptably high mortality especially in the presence of severe liver disease ranging from 0-10% in Childs grade A disease to 14-54% in Childs grade C disease. Surgical shunting is complicated by hepatic encephalopathy, which may be disabling, in 10-50% of patients [1,2]. Portosystemic shunting is, however, highly effective in controlling variceal bleeding and therefore a safer technique, with fewer side effects would be highly desirable. A percutaneous technique for intrahepatic portosystemic shunting in man was first described in 1982 [3]. However, this technique was unsuccessful due to the failure of the shunt to remain patent. Transjugular intrahepatic portosystemic stent shunt (TIPSS) is a recent modification of this technique whereby shunt patency is maintained by the use of metallic stents [4]. We describe our experience of the technique which we attempted in six patients with success in five between July 1971 and January 1992.
and the patients are sedated with midazolam and pethidine. A 10 Fr 35 cm long sheath (William Cook Europe A/S, Bjaeverskov, Denmark) is inserted through the right internal jugular vein. The right or middle hepatic vein is catheterized and the tip of the sheath advanced into the hepatic vein. A 16 gauge 56 cm reverse-bevel curved transjugular liver biopsy needle (William Cook Europe A/S, Bjaeverskov, Denmark) is introduced via the sheath and the needle tip exposed. The needle is directed anteriorly and then advanced through the liver parenchyma until a large portal vein branch is punctured. Successful puncture of the portal vein can be confirmed by aspiration, and when blood is obtained, injection of small amounts of contrast, although care must be taken to avoid excessive parenchymal staining by contrast. Initially, a catheter placed percutaneously in the portal vein was used to guide the needle, but recently we have used the portogram and ultrasound for guidance in order to reduce complications related to the percutaneous transhepatic catheterization. After puncturing the portal vein, a stiff hydrophilic
PATIENTS AND M E T H O D S
Table 1-Clinical details
Clinical details of the six patients treated are given in Table 1. Our first attempt at TIPSS using the technique described by Richter et al. [5] was unsuccessful and we have subsequently made modifications similar to those described by Zemel et al. [6] and RSssle et al. [7]. Patient preparation involves coeliac and mesenteric angiography to confirm patency of the splenic and portal veins and to provide a 'road-map'. The angiogram also demonstrates the direction of flow in the portal vein although hepatofugal flow is not considered a contraindication to TIPSS (indeed, hepatopetal flow may be restored by TIPSS). Any clotting abnormality is corrected
Case Age Sex Diagnosis
Ascites No. ~?['Child/Pugh bleeds grade
1
54
M
Alcoholic OesophageaI varices
+
8
A5
2
51
M
Alcoholic Oesophageal varices
-
> 10
B7
3
71
M
Chronic active hepatitis Gastric varices
-
1
A6
4
' 60
M
Alcoholic Portal gastropathy Oesophageal varices
+
> 10
B8
5
71
M
Alcoholic Portal gastropathy
+
> 10
B8
6
73
F
Primary biliary cirrhosis + Oesophageal varices
4
A5
Correspondence to: Dr N. Chalmers, Department of Radiology, Royal Infirmary, Lauriston Place, Edinburgh EH3 9YW.
TRANSJUGULAR INTRAHEPATIC PO'tkTOSYSTEMIC STENT SHUNT
167
Fig. 3. The stents have been further dilated to 10 mm diameter. The left gastric vein no longer fills. The portal pressure gradient is now 10 m m H g indicating an adequate shunt.
Fig. 1 - The guide wire passes from hepatic vein to superior mesenteric vein. Prolonged balloon dilatation of the transhepatic track is required to overcome the wasting due to periportal fibrosis.
guide wire (Terumo Corp., Tokyo, Japan) is passed through the needle into the superior mesenteric vein. The needle is removed and a catheter is passed over the wire into the portal vein. Direct portal vein pressure measurement is then recorded through the catheter. The wire is replaced with an Amplatz super-stiff wire (Medi-Tech, Watertown, MA, USA) and the transhepatic parenchyreal track is then dilated using an 8 mm angioplasty balloon (Fig. 1). The periportal fibrosis produces a characteristic sharp waist which requires several minutes to dilate adequately. The sheath is then advanced across the track and one or more Palmaz stents (Johnson & Johnson Interventional Systems, Edinburgh, UK) are deployed to completely cover the length of the track. The stents are initially dilated to 8 mm diameter and repeat pressure measurements obtained (Fig. 2). The stents are progressively dilated until the portal pressure gradient (portal pressure minus free hepatic venous pressure) is 10-15 mmHg (Fig. 3). Initially, the procedure took in the region of 6 h, but with experience this has fallen to about 3 h. The most time consuming aspect is the portal vein puncture. Several passes with the needle are usually required to establish satisfactory communication with the portal vein. Following the procedure, the patients are monitored for evidence of bleeding and prophylactic antibiotics are administered for 3 days. If there are no complications they may be discharged after 72 h. Follow-up includes duplex ultrasound, which may be transabdominal or transoesophageal. The latter approach is useful in obese patients or in the presence of ascites in which case the shunt may be beyond the range of the transabdominal probe. The presence of ascites, encephalopathy or recurrent bleeding is monitored. RESULTS
Fig. 2 - After insertion of two stents dilated to 8 mm diameter, there is still filling of the dilated left gastric vein indicating an inadequate shunt.
The results are given in Table 2. Following the initial failure in case 1, a patent shunt
168
CLINICAL RADIOLOGY
TaMe 2 - Results
Case
No. of stents
Final diameter (ram)
Complications
Haem ot hora x Broken wire Neck puncture inflammation
1
3
11
2
2
8
3
3
8
4 5 6
Resolution of ascites
F/ U
Yes
3 months
8
--
6 months
13
--
5 months
15 10
No Yes
1.5 months 1 week
PPG (mmHg) Pre- 7YPSS
Post- TIPSS
29
14
Staphylococcus septicaemia Failed
3 2
8 10
24
PPG, Portal pressure gradient; F/U, duration of follow-up.
was established, using the modified technique as described above, at a subsequent attempt. The patient had a further bleed 7 days later and portal pressure measurement at this time revealed a persistently elevated pressure gradient of 29 mmHg. Portography revealed that the two stents in place did not completely cover the transhepatic track; therefore a third stent was deployed proximally. The pressure gradient remained elevated at 17 mmHg, so the stents were dilated from 8 to 11 mm diameter resulting in a pressure gradient of 14. There has been no further bleeding and the ascites has resolved. In four patients, a successful shunt was established at the first attempt. In the remaining patient, who had a shrunken liver with small intrahepatic portal vein branches, portal vein puncture proved impossible and the procedure was abandoned. There have been no deaths. L o n g term follow-up is not yet available (mean 3 months, range 0-6) but as yet no other patient has re-bled following TIPSS and none has developed encephalopathy. Ascites has persisted in one patient who is markedly hypoalbuminaemic. There have been a number of complications. In the first patient, the tip of a fine 0.018 inch guide wire was amputated in the liver parenchyma. This has produced no clinical sequelae and has not migrated. Subsequently we have not used fine guide wires. The same patient developed haemoperitoneum and right haemothorax following TIPSS. This was aspirated and no transfusion was required. Two patients developed infective complications, namely one episode of staphylococcal septicaemia which responded to antibiotics and one episode of cellulitis at the jugular vein puncture site. Following this, prophylactic antibiotics have been used with no further infective complications. A total of approximately 150 ml of non-ionic contrast medium was used in each uncomplicated case and 450 ml in case 1 over a 3 week period.
DISCUSSION We initially attempted TIPSS using the method described by Richter et al. [5]. This involved the use of an 18 gauge transjugular needle and fine guide wires. We found the fine wire did not support the passage of a stiffener through the liver track and the tip of the wire was amputated. Subsequently, in common with other authors [6,7], we have used a 16 gauge needle which permits the passage o f a 0.035 inch wire. We have found the stiff hydrophilic wire useful for gaining access to the portal
system but replace this with an Amplatz super-stiff wire for balloon dilatation and stent insertion. For the first five cases we used a catheter placed percutaneously in the right branch of the portal vein as a target to direct the liver biopsy needle. However, the percutaneous puncture is a potential source of bleeding, particularly in patients with ascites. One of our cases developed haemoperitoneum and haemothorax, and review of the literature reveals one death as a result of bleeding from the percutaneous liver puncture [5]. In the most recent case we used a combination of the portal venogram and transabdominal ultrasound for guidance, thus obviating the need for percutaneous liver puncture [7]. Ultrasound is used to assess the relationship to hepatic and portal veins in the antero-posterior plane and to position a radio-opaque marker on the anterior abdominal wall directly over the portal vein bifurcation. This marker assists the portal vein puncture under fluoroscopy. Literature review reveals two further details within 30 days [4,5,8-11] out of a total of 47 successful TIPSS (including the present series) [6,7,12,13]. All three deaths were of patients with Childs stage C disease. Thus the safety of TIPSS compares favourably with surgical shunting. Encephalopathy following TIPSS has been reported in one patient [7]. Shunt occlusion has been observed and is associated with recurrent bleeding [7] which was the cause of one late death at 18 months [10]. However, occlusion may be treated by re-dilatation of the shunt [7]. The long term effectiveness of TIPSS remains to be evaluated, but 1 and 2 year survival of approximately 80% has been reported
[10]. Surgical portosystemic shunting is undesirable prior to liver transplantation because of distortion of the portal venous anatomy but TIPSS may be used to control portal hypertension while a donor organ is awaited without compromising successful surgery t13]. The future role of TIPSS in the treatment of recurrent variceal bleeding depends on long term patency. It seems likely that TIPSS will become the standard treatment of patients who re-bleed despite sclerotherapy. It may also become the first line treatment in patients with gastric varices (which are difficult to eradicate by sclerotherapy) and in patients who bleed from portal hypertensive gastropathy. If the safety of TIPSS is confirmed, it may have a role in the treatment of intractable ascites. Followup is as yet limited, however our experience provides further evidence that TIPSS is a safe and effective method of reducing portal pressure.
TRANSJUGULAR INTRAHEPATIC PORTOSYSTEMIC STENT SHUNT
Acknowledgen/ents. Dr Chalmers' post is sponsored by E. Merck Pharmaceuticals and Du Pont (UK) Ltd. The TIPSS programme is partly funded by grants from the Urquhart Trust and the Gannochy Trust. We are grateful to Dr G. R. Sutherland for performing transoesophageal ultrasound on some of the patients. REFERENCES 1 Shearman DJC, Finlayson NDC. Diseases o f the gastrointestinal tract and liver. Edinburgh: Churchill Livingstone, 1982:596-617. 2 Drapanas T, LoCicero J, Dowling JB. Hemodynamics of the interposition mesocaval shunt. Annals of Surgery 1975; 181:523-533. 3 Colapinto RF, Stronel RD, Birch SJ, Langer B, Blendis LM, Greig PD et al. Creation of an intrahepatic portosystemic shunt with a Grfintzig balloon catheter. Canadian Medical Association Journal 1982;126:267 268. 4 Richter GM, Palmaz JC, N61dge G, R6ssle M, Siergerstetter V, Franke M et al. Der transjugul~ire intrahepatische portosystemische Stent-Shunt (TIPSS). Eine neue nichtoperative, perkutane Methode. Radiologe 1989;29:406 411. 5 Richter GM, Noeldge G, Palmaz JC, Roessle M. The transjugular intrahepatic portosystemic stent-shunt (TIPSS): results of a pilot study. Cardiovascular and Interventional Radiology 1990;13:200207. 6 Zemel G, Katzen BT, Becker G J, Benenati JF, Sallee DS. Percutaneous transjugular portosystemic shunt. Journal o.1"the American Medical Association 1991;266:390 393.
169
7 R6ssle M, Noeldge G, Pararnau JM, Haag K, Sellinger M, Wenz W et al. Transjugular intrahepatic portosystemic stent shunt (TIPSS): experience with an improved technique. AASLD Abstracts of papers. Hepatology 1991;14:96A. 8 R6ssle M, Richter GM0 Noeldge G, Siegerstetter V, Palmaz JC, Wenz W e t al. Der intrahepatische portosystemische Shunt. Erste klinische Erfahrungen bei Patienten mit Leberzirrhose. Deutsche Medizinisehe Wochenschrift 1989; 114:1511-1516. 9 Richter GM, Noeldge G, Palmaz JC, Roessle M, Siegerstetter V, Franke M e t al. Transjugular intrahepatic portacaval stent shunt: preliminary clinical results. Radiology 1990; 174:1027 1030. 10 Richter GM, Noeldge G, Roessle M, Roeren TH, Kauffmann GW, Palmaz JC. Three-year results of use of transjugular intrahepatic portosystemic stent shunt. RSNA Abstracts. Radiology 1991; 181 (P)(Suppl.):99. 11 Vinel JP, Rousseau H, Maquin P, de Haldat F, Blain F, Joffre F et al. Transjugular intra-hepatic porto-caval shunts (IPCS): experimental and clinical study. AASLD Abstracts of papers. Hepatology 1991;14:243A. 12 Zemel G, Katzen BT, Becker GJ, Benenati JF. Percutaneous transjugular portosystemic shunt. RSNA Abstracts. Radiology 1991;181(P)(Suppl.): 99 100. 13 Roberts JP, Ring E, Lake JR, Sterneck M, Ascher NL. Intrahepatic portocaval shunt for variceal hemorrhage prior to liver transplantation. Transplantation 1991;52:160 162.
