A prospective trial of transjugular intrahepatic portasystemic stent shunts versus small-diameter prosthetic H-graft portacaval shunts in the treatment of bleeding varices

Objective The authors compare transjugular intrahepatic portasystemic stent shunts (TIPS) to small-diameter prosthetic H-graft portacaval shunts (HGPCS). Summary Background Data Transjugular intrahepatic portasystemic stent shunts have been embraced as a first-line therapy in the treatment of bleeding varices due to portal hypertension, although they have not been compared to operatively placed shunts in a prospective trial. Methods In 1993, the authors began a prospective, randomized trial to compare TIPS with HGPCSs. All patients had bleeding varices and had failed nonoperative management. Shunting was undertaken as definitive therapy in all. Failure of shunting was defined as an inability to accomplish shunting despite repeated attempts, unexpected liver failure leading to transplantation, irreversible shunt occlusion, major variceal rehemorrhage, or death. Mortality and failure rates were analyzed at 30 days (early) and after 30 days (late) using Fischer's exact test. Results There were 35 patients in each group, with no difference in age, gender, Child's class, etiology of cirrhosis, urgency of shunting, or incidence of ascites or encephalopathy between groups. In two patients, TIPS could not be placed despite repeated attempts. Transjugular intrahepatic portasystemic stent shunts reduced portal pressures from 32 +/- 7.5 mmHg (standard deviation) to 25 +/- 7.5 mmHg (p < 0.01), whereas HGPCS reduced them from 30 +/- 4.6 mmHg to 19 +/- 5.3 mmHg (p < 0.01; paired Student's t test). irreversible occlusion occurred in three patients after placement of TIPS. Total failure rate after TIPS placement was 57%; after HGPCS placement, it was 26% (p < 0.02). Conclusions Both TIPS and HGPCS reduce portal pressure. Placement of TIPS resulted in more deaths, more rebleeding, and more than twice the treatment failures. Mortality and failure rates promote the application of HGPCS over TIPS.