critically reducing liver perfusion, which may cause hepatic dysfunction and may accelerate the

progression of cirrhosis. It is possible to readily measure the portal pressure during TIPS, and many

authors have proposed these measurements as a guide to optimal management of the TIPS to balance

control of bleeding with hepatic perfusion. To control bleeding, the therapeutic goal is to reduce the

hepatic–portal venous pressure gradient to below 12 mm Hg. TIPS reduces the portosystemic pressure

gradient to a mean of approximately 9 to 15 mm Hg (average, 10 mm Hg) or to 40% to 62% below

baseline.239–241 A residual portal gradient less than 5 mm Hg has been associated with a deleterious

impact on hepatic flow.242 Earlier studies documented high mortality (40% to 60% at 6 to 7 weeks)

despite the relative noninvasiveness of the procedure, reflecting the gravity of the clinical condition of

most patients requiring this intervention. One potential cause of the high mortality is a delay in

instituting TIPS until multiple unsuccessful attempts at sclerotherapy or banding have been made. Since

well-validated instruments predict the survival of patients after TIPS, the procedure should be used with

caution in patients with high MELD scores, though TIPS has been used successfully to bridge patients to

transplantation.243,244 The use of TIPS in massive variceal bleeding in a patient with a high MELD score

who has contraindications to liver transplant should be regarded as a palliative intervention.

Algorithm 59-1. Suggested treatment options, in order of preference, for patients who fail medical management for variceal

bleeding.

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Figure 59-8. Schematic representation of the steps used to create a transjugular intrahepatic portosystemic shunt. A: A needle is

directed from the IVC or hepatic veins into an intrahepatic portal venous branch. B: A guidewire is advanced into the portal

venous system. C: The resulting tract is then balloon dilated. D: A stent is then placed into the dilated tract. E: Completed TIPS

shunt. Arrows indicate direction of blood flow.

As with all portosystemic shunts, a significant complication of TIPS is the development of hepatic

encephalopathy. The rate of hepatic encephalopathy following TIPS is 34%, compared to 19% following

EVL for acute variceal bleeding, although the use of covered stents has reduced the rate of post-TIPS

encephalopathy from when bare metal stents were used primarily.245,246 Although in early series

stenosis or occlusion of the stent developed in up to 50% to 60% of patients in the first year, long-term

patency can be maintained by ongoing surveillance of the shunt with redilatation, as needed. Shunt

stenosis is managed angiographically with thrombolytic therapy, dilation, or replacement of the stent.

The newest shunts are lined with polytetrafluoroethylene (PTFE) and have a much higher patency than

the original permeable wallstents. Primary patency rates are 76% to 89% with shunt dysfunction

occurring in only 15% of patients at 1 year.236 Patients are usually followed at 3-month intervals by

ultrasonography to assess the patency of the shunt. At 6 months of follow-up, 92% of patients had had

no episodes of rebleeding, and 82% were free of hemorrhage at 1 year. It is safe to assert that the TIPS

is now the standard procedure used to halt bleeding in patients who fail medical therapy. The ability to

effectively decompress the portal circulation without open surgery in these critically ill patients has

transformed clinical hepatology. Patients become medically stable and can be evaluated for

transplantation electively. Patients with reversible liver disease (e.g., abstinent alcoholics) may recover

fully without further intervention because the TIPS will slowly close as the liver heals.

Surgical Decompression

Background. Surgeons have been performing shunt procedures since the 1800s. The first was an end-to1521

side portacaval shunt with ligation of the distal portal vein, performed by Nicolai Eck (Eck fistula) in

dogs. In 1945, Whipple247 at the Columbia-Presbyterian Medical Center in New York performed this

shunt for the first time for the indication of variceal bleeding. This group was also responsible for the

development of the tube for the tamponade of bleeding esophageal varices, which adopted the name of

Blakemore, as discussed previously.

11 Surgical interventions for the treatment of bleeding varices are divided into three main types: (a)

liver transplantation, (b) shunt procedures, and (c) devascularization procedures. The only definitive

procedure for the treatment of portal hypertension caused by cirrhosis is orthotopic liver

transplantation, and the success of this option during the past two decades has revolutionized the

treatment of portal hypertension and its complications in patients with end-stage liver disease.

However, for the treatment of portal hypertension in patients without cirrhosis or in those whose liver

function does not warrant a transplant (e.g., patients with portal vein thrombosis), decompressive

surgically created shunts or devascularization procedures may be performed.

Shunts. Portosystemic shunts created operatively can be divided into three categories: (a) totally

diverting (nonselective) shunts, (b) partially diverting shunts, and (c) selective shunts. Total shunts are

created by completely bypassing the flow of blood away from the liver by joining the portal vein to the

vena cava. Examples include the end-to-side portacaval shunt (Eck fistula) (Fig. 59-9) and the largediameter (>10-mm) side-to-side portacaval (Fig. 59-10), mesocaval, and central splenorenal shunts.

Because the pressure in the portal vein is much higher than that in the vena cava (or the renal vein),

large side-to-side shunts divert all blood flow through the path of least resistance, so that flow in the

portal vein is reversed, creating “hepatofugal” flow, out of the liver and decreasing total hepatic

perfusion. One of the causes of ascites in patients with portal hypertension is high pressure at the level

of the hepatic sinusoids with protein-rich fluid leaking directly out of the swollen liver. The main

difference between end-to-side and side-to-side shunts is that maintenance of high pressure with end-toside shunts may worsen ascites, whereas side-to-side procedures effectively relieve this problem by

reducing sinusoidal pressure. Complete portal blood flow diversion lowers portal pressure and is highly

effective in the treatment of bleeding esophageal varices but, as noted earlier, may accelerate hepatic

decompensation.

Figure 59-9. End-to-side portacaval shunt, also referred to as an Eck fistula. The portal vein is divided, the hepatic limb of the

portal vein is ligated, and the splanchnic end of the portal vein is anastomosed end to side to the vena cava. All portal blood is

necessarily diverted into the vena cava, and the hepatic limb of the portal vein cannot serve as an outflow tract.

The main complications of totally diverting shunts are a worsening of liver function and hepatic

encephalopathy as a result of decreased flow through the liver and loss of hepatotropic factors from the

mesenteric venous system. Another disadvantage of portacaval shunts is that the porta hepatis must be

dissected, so that future surgical procedures in the area (e.g., liver transplantation) are more difficult.

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Partially diverting shunts allow for the maintenance of hepatopetal flow while decompressing the

high pressures in the portal system. The original shunts were larger than 10 mm in diameter and were

able to create a gradient between the portal vein and vena cava that maintained some prograde hepatic

flow. All these shunts, however, dilated over time and became complete shunts in that the portal vein to

inferior vena cava pressure gradient disappeared. The small-diameter (8-mm) side-to-side mesocaval

(Fig. 59-11) and portacaval (Sarfeh) (Fig. 59-12) shunts are performed with an interposition graft made

of either expanded PTFE or dacron. A significant component of the Sarfeh procedure is ligation of the

coronary (left gastric), gastroepiploic, and other collateral veins. Bleeding from varices resolves in more

than 90% of patients.248,249 This smaller-diameter shunt has a higher resistance than the larger shunt, is

synthetic and therefore does not dilate, can maintain hepatic perfusion, and is associated with a lower

incidence of hepatic encephalopathy. With these shunts, portal pressure gradients can be reduced to the

critical 12 mm Hg while hepatopetal flow is maintained in up to 80% to 90% of patients. In addition,

the maintenance of mesenteric pressure at or relatively close to normal levels may prevent the

hyperammonemia associated with total shunts. One relatively common complication is graft thrombosis,

which occurs in up to 16% of patients.249 Shunt thrombosis can usually be treated angiographically.

Dissection at the porta hepatis leads to the formation of adhesions, which may compromise later liver

transplantation.

Figure 59-10. Side-to-side portacaval shunt. An anastomosis is made between the side of the portal vein and the side of the

inferior vena cava. With a shunt of standard diameter, almost all splanchnic blood is diverted around the liver into the lowpressure vena cava. The hepatic limb of the portal vein serves as an outflow tract from the liver toward the low-pressure vena

cava.

Selective shunts are designed to create two separate drainage systems within the portal venous

network. A high pressure is maintained within the mesenteric system and a low pressure is created in

the esophagogastric system by shunting blood from the latter into the systemic circulation without

decompressing the mesenteric network. The most traditional and most favored selective shunt is the

distal splenorenal shunt (Fig. 59-13).250 The distal splenorenal shunt selectively decompresses the

gastroesophageal venous system through an anastomosis between the distal end of the splenic vein and

the side of the renal vein. Decompression occurs through the short gastric veins, which are in continuity

with the splenic vein. In addition, as in the small side-to-side shunts described earlier, collateral veins

must be ligated.

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