Emergency transjugular intrahepatic portasystemic stent shunts to control acute variceal hemorrhage resistant to sclerotherapy

Objective: To prospectively assess the efficacy and outcome of emergency transjugular intrahepatic portasystemic stent shunts (TIPSS) in patients with acute variceal haemorrhage resistant to sclerotherapy. Design: Patients in whom active variceal haemorrhage was observed at endoscopy were treated initially with sclerotherapy. If this failed to control bleeding, emergency TIPSS were undertaken. Patients: Thirteen patients underwent emergency TIPSS during an 18-month period. Main outcome measures: Survival, re-bleeding, disturbance of liver function and the occurrence of post-TIPSS encephalopathy. Results: TIPSS were successfully performed in 11 out of 13 patients. The two patients in whom TIPSS were unsuccessful died, one patient died from a procedure-related complication and three patients with functioning shunts died within 1 week from severe liver failure. The eight surviving patients are alive and well between 2 and 1 7 months post-TIPSS; one has had a successful liver transplant. Only two episodes of re-bleeding occurred, both during the first week post-TIPSS, due to an inadequate shunt in one patient and from sclerotherapy ulcers in the other. One patient developed clinically apparent encephalopathy following TIPSS. Conclusions: TIPSS are a valid therapeutic option in patients with acute variceal haemorrhage in whom variceal sclerotherapy has failed. Prevention of re-bleeding is noted in the long-term survivors. However, severe liver failure with a fatal outcome following successful TIPSS occurred in 27% of these severely ill patients.