U cause of death in patients with end-stage liver

Transcription

1 Transjugular Intrahepatic Portosystemic Shunt in Patients With End-Stage liver Disease: Results in 85 Patients- Nicolas Jabbour, * Albert?. Zajko, # Philip D. Orons, # William Irish, * Fabio Bartoli, * Wallis J. Marsh, * Gerald D. Dodd 111, # Luca Aldreghitti, * Joan n Colangelo, * Jorge Rakela, 'f' and John J. Fun@ Transjugular intrahepatic portosystemic shunt (TIPS) is becoming an accepted procedure as a bridge to orthotopic liver transplantation (OLT) in patients with end-stage liver disease (ESLD) and bleeding from portal hypertension. It allows the immediate control of acute bleeding and decreases the risk of recurrent acute bleeding while the patient is awaiting OLT. We review in this report, our experience with 85 patients who underwent a TIPS procedure for gastrointestinal variceal bleeding from September 1991 until April All patients had liver cirrhosis and all had previous sclerotherapy before TIPS. Child-Pugh score was calculated at enrollment, and all patients were evaluated for possible OLT. Thirteen patients were Child A, 49 were Child B, and 23 were Child C. Fifty-three patients were candidates for OLT, and 32 were not. TIPS was performed urgently in 25 patients. At a median follow-up of 582 days (range, 1 to 1,095), 35 patients underwent transplantation, 21 patients died, and 29 patients are still alive and did not undergo transplantation. Technical complications were observed in 7% of patients and new onset of clinical encephalopathy in 37%. The 30-day mortality rate after TIPS was 13%. Actuarial survival was 60% at 1 and 3 years. Child class C and urgent TIPS were shown to be two independent predictor factors for mortality. TIPS was shown to be a valuable procedure, not only as a bridge to OLT but also as palliation for bleeding from portal hypertension in patients who were not candidates for either surgical shunt or OLT. However, its role in bleeding patients with acceptable liver function needs further investigation. Copyright by the American Association for the Study of Liver Diseases pper gastrointestinal tract bleeding is a major U cause of death in patients with end-stage liver disease (ESLD) second only to progressive liver failure. 1,2 Surgical shunts and/or sclerotherapy are able to control the bleeding but have no effect on the underlying liver di~ease.~.~ With improved management of patients undergoing orthotopic liver transplantation (OLT), this form of treatment has clearly become the most effective therapy for patients with ESLD.5,h However, this form of treatment is limited to patients who are able to withstand such major surgery. The waiting time for OLT candidate patients has been increasing because of the limited donor pool and the continuous expansion of indications for OLT. Recently, transjugular intrahepatic portosystemic shunt (TIPS) has been considered in patients with ESLD mainly for acute variceal bleeding that cannot be successfully controlled with medical treatment and recurrent variceal bleeding in patients who are refractory or intolerant to conventional medical management.'-i4 TIPS may serve as a bridge to OLT without the negative technical effect observed with central surgical shunts during the transplantation procedure and the possible morbidity and mortality associated with shunt procedure itself. We report our experience in patients who underwent TIPS regardless of their eligibility for OLT with an emphasis on the incidence of technical complications associated with this procedure, assessment of clinical course, and long-term survival. Patients and Methods From September 1991 through April 1994, TIPS was attempted in 88 patients and was successfully completed in 85 under a protocol approved by our Institutional Review Board for Biomedical Research. All patients involved were 18 years of age or older and From the *Pittsburgh Transplantation Inztitute, tdepartment 01 Radiology, #Transplantation Medicine, University of Pittsburgh Medical Center, Pittsburgh, PA Address repnnt requestc to NicolasJahbour, MD, L'SC Center for Liver Disease, 1510 San Pablo St, Suite 430 Lo\ Angeles, CA CoDnght hy the Amencan Ammation for the Studj of Liver Diseases /96/ $ liver Transplantation and Surpy, Vol2, No 2 (March), 1996: pp

2 140 Jabbour et al had cirrhosis and portal hypertension documented by clinical assessment, endoscopic, angiographic, and/or computed tomography findings with or without liver biopsy confirmation. All patients underwent an esophagogastroduodenoscopy to rule out other sources of gastrointestinal tract bleeding as well as Doppler ultrasonography to confirm patency of the extrahepatic portal vein and hepatic veins. Inclusion criteria included life-threatening bleeding from esophageal varices, continuous bleeding despite optimum medical management, bleeding from gastric varices, or recurrent mild variceal bleeding (less than 3 U of blood transfusion) despite repeated sclerotherapy. Exclusion criteria included uncontrollable coagulopathy, uncontrollable acute bleeding, hemodynamic instability, multiple organ system failure (MOSF), and sepsis in any patient whose life expectancy was less than 24 hours and any patient with stage 3 or 4 encephalopathy or portal vein thrombosis. The three patients who had failure of TIPS placement were excluded from data analysis. Clinical status was assessed at enrollment using the Child- Pugh modified sconng system. Laboratory work performed pre- TIPS included serum albumin and total bilimbin levels, prothrombin time, cell blood count, platelet count, and serum creatinine, serum electrolyte, and aminotransferase levels. Abdominal computed tomography was performed and liver volume was measured if the patient was not actively bleeding at the time of enrollment. Patients were followed after discharge from the hospital at our outpatient clinic with complete physical examination and repeat laboratory data at regular intervals. All patients were discussed at the liver transplantation selection meeting before or after TIPS procedure and were evaluated for possible OLT. Candidate patients were listed according to their clinical status. TIPS was performed in the interventional radiology suite according to previously described techniq~e.~ Prophylactic broad spectrum intravenous antibiotics were administered immediately before the procedure and for 24 hours thereafter. A baseline sonogram was obtained within 24 hours after TLPS in all patients. The first 45 patients were routinely studied with both Doppler sonography and angiography at 3, 6, and 12 months, whereas in the remaining 40, we only performed Doppler studies at 3-month intervals, and direct portography was obtained only if stenosis or thrombosis was suspected based on the result of sonography. Shunts were evaluated for the site and the severity of stenosis or the presence of complete thrombosis. The occurrence of shunt stenosis and a hemodynamic measurement of a portosystemic gradient greater than 15 mm Hg was considered significant and followed using either balloon dilatation of the site of the stenosis or insertion of a new stent. Hepatic encephalopathy was evaluated based on direct clinical observation or clinical history of memory loss, confusion, speech or personality changes. TIPS was considered urgent if the patient required Sengstaken- Blakemoore tube insertion and endotracheal intubation to control an acute episode of upper gastrointestinal tract bleeding, and sclerotherapy would not be performed or was unsuccessful, within 48 hours of TIPS insertion. In all other cases, the TIPS was considered nonurgent or elective. Twenty-five patients had TIPS inserted urgently and 60 electively. Follow-up time was calculated from the time of TIPS until the patient either died, underwent OLT, or the latest point of follow-up (August 31, 1994). Statistical Analyses Differences in means between groups were tested using the one-way analysis of variance (ANOVA), whereas differences in proportions by Pearson s x2 test. Multiple pair-wise comparisons were made using Tukey s Honestly Significant Difference test. The Kruskal-Wallis test, a nonparametric equivalent to the one-way ANOVA was used for highly skewed data. Patient survival was calculated from the date of TIPS until death. Survival curves were generated using the Kaplan-Meier (Product-Limit) method and were compared by the log-rank test. Cox s Proportional hazard model was used to identify risk factors for mortality after TIPS procedure. Relative risk and 95% confidence intervals (Ci) were computed using Cox s model. Patients alive as of August 31, 1994 were right censored, and patients undergoing OLT were censored at the time of transplantation. Multiple logistic regression was used to analyze factors for post-tips encephalopathy. Results TIPS was performed in 85 of 88 patients yielding a success rate of 96.6%. All patients had three or more sclerotherapy sessions before TIPS, and failure to control gastrointestinal tract bleeding from portal hypertension was the main indication for TIPS in these patients. The study population consisted of 85 patients, 29 female and 56 male, with a mean age of 54.1 years (range, 19 to 79 years). Thirteen patients were Child A, 49 Child B, and 23 Child C. The primary diagnosis in these patients is presented in Table 1. Fifty-three patients were considered for OLT and were listed, and 32 patients were not considered candidates for OLT for various reasons (Table 2). The overall outcome of patients included in the study is presented in Fig 1. Demographic and clinical data of the study group is presented in Table 3. Technical Complications Complications directly related to the procedure were observed in 6 patients (7%) and consisted of misplacement, migration, or extrahepatic needle punctures during attempted portal vein catheterization. Misplacement of the stent was observed at the time of OLT in 3 patients: 2 patients had the stent inserted above the hepatic vein and inferior vena cava junction, and in 1 patient, the stent extended into the

3 TIPS: Ekperience in 85 Patients 141 Table 1. Pretransplantation Diagnosis in Patients Undergoing TIPS Diagnosis Alcoholic cirrhosis Cryptogenic cirrhosis Hepatitis C infection with cirrhosis Hepatitis 6 infection with cirrhosis Autoimmune hepatitis with cirrhosis Primary biliary cirrhosis Primary sclerosing cholangitis Alcohol cirrhosis and hepatitis 6 Alcohol cirrhosis and hepatitis C Liver tumor and cirrhosis Total Number of Patients No. of Patients n=35 candidate Noncandidate n=32 Figure 1. Overall patient outcome. extrahepatic portal vein at the hilum. All 3 patients had the sent removed completely at the time of OLT without operative complications. Stent migration into the extrahepatic portal vein led to partial portal vein thrombosis in 1 patient, which resulted in rapid ascites accumulation and encephalopathy requiring OLT within 6 days of the TIPS. The stent was completely removed, and portal vein thrombectomy was performed successfully at the time of OLT. Inadvertent extrahepatic needle puncture during the TIPS procedure occurred in 2 patients: 1 patient had liver capsule perforation that resulted in self-limited intraabdominal bleeding of 4 U of blood and a hematoma at the hilum of the liver, and in the other patient, perforation of the gallbladder resulted in bile peritonitis that required abdominal exploration and cholecystectomy. Both patients underwent OLT within 2 weeks of TIPS without an added operative morbidity. Table 2. Diagnosis in 32 Noncandidates for OLT Undergoing TIPS Diagnosis Number Metastatic tumor 1 Hepatitis 6 infection* 4 Active alcohol abuse 9 Patients refusal 6 Other medical factors (age, heart disease, chronic health problems) 12 Total number of patients 32 *Serum HBV-DNA positive. 1 Patient Survival Twenty-one patients died after TIPS for an overall mortality rate of 24.7% (median, 29 days; range, 1 to 734 days). The cause of death in these patients was analyzed in relation to the time of its occurrence after TIPS and is shown in Table 4. Thirteen of 25 patients who underwent an urgent TIPS died (52%) a median of 13 days (range, 1 to 147 days), 11 of them died within 1 month of the procedure in the intensive care unit with MOSF and sepsis. Liver failure was the main cause of death in 8 of 10 patients who died later than 1 month after TIPS. Cox s Proportional Hazard model was used to determine the risk of mortality after TIPS. Only two risk factors were found to be independently associated with mortality; the urgency of TIPS (PR, 6.01; 95% Ci, 2.33 to 15.52) and Child class C at enrollment (PR, 4.98; 95% Ci, 1.09 to 22.76). In the remaining 60 patients with elective TIPS, there were 8 deaths (13.3%) at a median time of 185 days (range, 51 to 734 days). The causes of death in these two groups of patients were different; MOSF and sepsis were the main causes of death in the urgent group, and progressive liver failure in the elective TIPS patients. Actuarial survival by Child-Pugh class at enrollment is presented in Fig 2 (note the difference in survival in patients with Child-Pugh C as compared with those with Child-Pugh A and B). Actuarial 1-year survival for Child-Pugh A and B was 85% and 89%, respectively, compared with 27% for Child- Pugh C. Actuarial survival was also calculated for patients who did not undergo transplantation (n = 50) and was found to be 62%, 59%, and 56% at 1, 2 and 3 years, respectively. The survival rates were

4 142 Jabbour et al Table 3. Demographic and Clinical Data Total No. of Patients Child A Child B Child C P No. of patients Mean age Age 260 Liver volume (ml) Pre-TIPS ascites Pre-TIPS encephalopathy Urgent TIPS ( 7) Platelet count (103imm3) Total bilirubin (mg/dl) Prothombin time (sec) Albumin (gr/dl) Creatinine (mg/dl) Pre-TIPS portosystemic gradient (mm Hg) Post-TIPS portosystemic gradient 54.1 f (37.6%) 1,707 t % 20% 25 (29%) 104 t t t t O t t t 10 9 (69.2%) 1,601 t % 0% 3 (23%) f f ? f t (34.7%) 1,675 f % 16% 10 (20%) t ? ? O t t t (26.1%) 1,963 f % 39% 12 (52%) f t t 6.6 (mm Hg) 10 f t % f 3.5 *Child C versus Child A. tchild C versus Child A and Child B. *Child C versus Child A, and Child B versus Child A..047*,030,588, ,019,178 <.ooott.0009t.009*,127,011 t.025* similar in both candidate and noncandidate patients for OLT (Fig 3). Encephalopathy Encephalopathy was present in 17 patients (20%) before TIPS and was well controlled medically using Lactulose. Onset of clinically significant encephalopathy was analyzed in 74 patients who survived without OLT for more than 1 month after TIPS. Thirty-five of 74 patients (47.3%) developed encephalopathy after TIPS placement, 12 of 35 (16.2%) had encephalopathy before TIPS, and 23 of 35 (37%) had new onset encephalopathy after TIPS. Patients with post-tips Table 4. Causes of Mortality After TIPS Time of Death No. of From TIPS Patients Cause of Death < 1 month 11 MOSF, sepsis in 9. Esophageal perforation in months 3 Pharyngeal laceration in 1. Liver failure in 2. Sepsis and gastric bleeding in 1. > 3 months 7 Liver failure in 6. Endocarditis in 1. I encephalopathy were compared with patients without encephalopathy to determine any predicting risk factors. Only the presence of pre-tips encephalopathy was an independent risk factor for post-tips encephalopathy, whereas age, Child class at enrollment, diameter of TIPS, portosystemic gradient reduction, the absolute portosystemic gradient after TIPS, and liver volume were not significant. Post-TIPS encephalopathy was well controlled medically; however, it became the main indication for OLT in 7 patients at a median time of 4 months (range, 0.5 to 100 &:.....! : a. 5 g Overall (n=85) ChildA(n=13) <..... Child B (n=49) - Child C (n=23) 0 I Months After TIPS Figure 2. Overall actuarial patient survival after TIPS.

5 TIPS: Experience in 85 Patients 143 f 401 z- i pvalu (Log-nnk h.1) Noncandidates (n=32) - Candidates waling 0 n a months) after TIPS; 2 of these patients were Child A, 4 Child B and 1 Child C. Variceal Bleeding When TIPS was performed as an emergency procedure (25 patients), the control of the acute gastrointestinal tract bleeding from portal hypertension was achieved immediately in all patients with the exception of 1 patient who continued to bleed. Repeat esophagogastroduodunoscopy in this patient revealed the bleeding site to be an upper pharyngeal laceration caused by an emergent endotracheal intubation. Subsequently, the patient died as a result of this laceration. Long-term follow-up of all patients showed recurrent gastrointestinal tract bleeding in 17 patients (20%). The source of bleeding was due to recurrent variceal bleeding in 7 patients, esophageal ulcers in 3 (most likely as a result of previous sclerotherapy), and duodenal ulcer in 1. In the remaining 6 patients, no obvious source of bleeding was found. When recurrent gastrointestinal tract bleeding was the result of portal hypertension, complete TIPS evaluation with ultrasound and angiography showed significant stenosis of the stent and/or hepatic vein at the outflow site in 6 patients (the shunt gradient was greater than 15 mm Hg in all 6 patients) and thrombosis of the shunt in 1 patient. All 7 patients had shunt revision consisting of balloon angioplasty and/or new stent insertion. In all 7 patients the bleeding responded to shunt revision. TIPS and Transplantation After TIPS, patients were followed for a median time of 582. days (range, 120 to 1,095 days). Thirty-five patients underwent transplantation with a median time of 79 days (range, 1 to 748 days) after TIPS. Of 35 patients who underwent transplantation, 4 patients died after OLT (l-year actuarial survival of 88%). One patient died in the operating room from graft failure and bleeding, another died 10 days after OLT from an unrelated cardiac temponade, and the remaining 2 patients died at 11 and 257 days, from graft failure and sepsis, respectively. TIPS did not result in any significant intraoperative complications. Twenty-nine patients remain alive and did not undergo transplantation after TIPS. Thirteen of them are currently listed for OLT with a median waiting time of 778 days (range, 139 to 1,095 days). Eighteen patients were not candidates for OLT at the time of the TIPS and are still alive at a median time of 811 days (range, 398 to 1,044 days) after TIPS (6 patients were denied OLT because of medical reasons, 4 patients refused OLT, and the remaining 8 patients were actively drinking at the time of the TIPS). Shunt Patency In the first 44 patients, for whom complete radiological evaluation was obtained, shunt stenosis was observed in 50% of patients and complete thrombosis in 1 patient at a median follow-up of 6 months (range, 2 to 12 months). The site of the stenosis was at the hepatic veins in 90% of patients and limited to the stent in the remaining. All patients were treated successfully with either angioplasty balloon dilatation and/or shunt revision by placing a new stent through the stenosed shunt. Discussion Portal hypertension with gastrointestinal tract bleeding is the natural course of disease in cirrhotic patients. 1.2 Surgical shunts and sclerotherapy have been very valuable in controlling the bleeding in cirrhotic patient^;^,^ however, OLT is the only available treatment that directly affects the underlying liver During the past 4 years, TIPS has been used as a nonsurgical treatment for portal As with any new procedure, the enthusiasm shown in the early reports is balanced by the occurrence of late complications and the better understanding of the exact indications. Because hemodynamically TIPS is a side-to-side portocaval shunt, it is not surprising to see many similarities in the clinical course of patients after this procedure as compared with those with a central surgical shunt, especially in regards to encephalopathy, progressive

6 144 Jabbaur et al liver failure, and long-term survival The technique of TIPS has been well described in other review~.~j~%'~j~ In the present study, we intend to describe TIPS complications, patient survival, and the short- and long-term advantages of TIPS in patients with portal hypertension, regardless of their candidacy for OLT. Technical success was achieved in 96.5% of patients, which is similar to that shown in most large series. Doppler ultrasound was performed in all patients to document vessel patency, and all patients underwent an upper endoscopy before TIPS. Although some have suggested TIPS as a treatment option for intractable ascites,19,20 refractory gastrointestinal tract bleeding from portal hypertension was the principal indication in our patients. Immediate control of bleeding was achieved in all patients, including those in whom TIPS was placed urgently (25 patients). During the follow-up period, recurrent gastointestional tract bleeding was observed in 17 of 85 patients; however, only 7 patients appear to have bled from portal hypertension. This incidence of 8.2% compares favorably with the rate of rebleeding after surgical shunts and is lower than that observed in patients treated with sclerotherapy alone. 14,20-25 These results are encouraging considering the highrisk population who underwent TIPS: 27% were Child class C, and TIPS was performed urgently in 29% of the patients. However, like any new procedure these early encouraging results should be weighed against late morbidity and mortality rates. Most TIPS complications are predictable and can be related to one of three mechanisms: (1) procedural, (2) caused by shunting of portal blood flow from the liver, and (3) caused by the insertion of prosthetic material in cirrhotic patients. Technical complications were observed in 6 patients (7%) and were mainly caused by either extrahepatic needle puncture during the procedure or stent misplacement, neither one however had any added morbidity during OLT. More serious complications have been reported by others, including stent migration into the right atrium, perforation of the posterior wall of the vena cava just above the hepatic vein junction with resultant intraoperative death,18 injury to the right hepatic artery leading to liver failure,29 and delayed fatal cardiac perforation from the introducer sheath.30 The use of ultrasound guidance during TIPS insertion may prevent complications such as liver capsule or gallbladder perforation. The precise placement of the TIPS, especially in cirrhotic patients with a small liver, is crucial and prevents any added operative complication. These complications are observed less frequently as operator experience is gained.27 The second type of complication is directly related to the shunting of portal blood flow away from the liver. This includes hepatic encephalopathy and progressive deterioration of liver function. New onset hepatic encephalopathy was observed in 37% of our patients. Patients who had encephalopathy before TIPS continue to manifest occasional episodes after the procedure, leading to a total incidence of 47%. This rate is higher than that observed in other TIPS series that range around 20%,14.31,32 or with surgical sh~nts.~~j~.~~ The high incidence of encephalopathy observed in our patients may be caused by the exclusion from the analysis of patients who died within 1 month of TIPS and to the greater number of Child class C patients. No predictable factor was observed in our series including age, Child class at enrollment, and the shunt diameter, unlike other studies in which age and stent diameter were shown to be significant factor^.'^,^^ This type of complication is of clinical concern because it is unpredictable and could develop in patients with well-preserved hepatic function at the time of the TIPS insertion and has led to early OLT in some patients. This becomes an issue in patients who might otherwise be considered candidates for selective surgical shunt where encephalopathy is reported to occur less frequently,22, In addition to encephalopathy, the shunting of the blood from the liver may lead to progressive liver failure. This decline in liver synthetic function has been observed in patients undergoing surgical shunts but has not been well-documented in patients after TIPS. Some reports did show minor changes or even mild improvement in the overall Child-Pugh score after T1PS.13%14 Most of these data however reflect the early benefit from medical attention paid especially in alcoholics whose liver function may improve after alcohol discontinuation. Also, because TIPS is considered by most as a bridge to OLT, long-term follow-up data are not readily available. The third aspect of complications after TIPS is related to the insertion of prosthetic material in cirrhotic patients whose immune system is already abn~rmai.~~-~~ This may lead to infection and sepsis. Although it is hard to prove scientifically that bacterial translocation and shunting through the TIPS may lead to localized or generalized sepsis, this possibility should be considered in these patients. Bacterial

7 TIPS: Eiperience in 85 Patients I45 endocarditis was the cause of death in 1 of our patients 6 months after the TIPS procedure. No sourcis of infection or underlying heart disease was observed in this patient at autopsy; the TIPS was patent and without e\.idence of infection. Another 2 patients died at 2 and 4 months after TIPS; sepsis contributed to their death and liver failure. Bacterial translocation and shunting may have contributed to the death of these 3 patients. Sepsis and MOSF found in patients who died within the first month after m s is mainly related to their acute bleeding and liver failure and is not directly related to the pro~edure.~~~~~ Another potential side effect from TIPS is worsening of the hyperdynamic state of cirrhosis.42 However, none of our patients manifested any clinical cardiovascular abnormalities after TIPS, and even when this procedure was performed on 7 patients with abnormal cardiac function (these patients were denied OLT because of their underlying severe cardiac function), none of them suffered cardiovascular dysfunction after TIPS. However, the rapid absorption of ascites after TIPS may lead to congestive heart failure and invasive hemodynamic monitoring in the intensive care unit may be necessary in critically ill patients in the early period after TIPS insertion. The incidence of shunt stenosis is high in this series but similar to that observed in other studies.42 Recurrent gastrointestinal tract bleeding may be the only clinical manifestation. However, many were detected during routine ultrasound follow-up. A recent report from our institution has shown that under optimal conditions ultrasound is a sensitive and specific test to detect either stenosis or complete occlusion of TIPS43 and should be performed at regular intervals after the procedure. Angiographic balloon dilatation or new stent placement have been successful in most patients. Pseudointimal hyperpla- sia at the stent/hepatic vein junction is the most likely underlying and was found at pathological examination of the specimen of several of our patients after OLT. Future investigations using different sent material or the use of agent to prevent pseudointimal hyperplasia may lead to better longterm results. The high incidence of shunt stenosis is of concern in patients with preserved liver function in whom gastrointestinal variceal bleeding was the only indication for TIPS. The early mortality rate observed in our patients (13%) is higher than that shown in other series of TIPS4 but is comparable to mortality rates in urgent shunt s~rgery~o.~' and may reflect patient selection. All 11 patients who died within 1 month had TIPS performed on an emergency basis. All of them were intubated and had their bleeding controlled with balloon tamponade and maximal medical treatment, and 8 of them were Child class C. However, it is important to point out that before undergoing TIPS all patients received maximal medical management with sclerotherapy, balloon tamponade, pitressin, or octreotide acetate infusion, were hemodynamically stable before the procedure, and uncontrolled bleeding was the cause of death in only 1 patient who had an iatrogenic pharyngeal laceration. As pointed out by others,45 TIPS should not be performed urgently in hemodynamically unstable patients, because an aggressive medical management (including balloon temponade) will effectively control variceal bleeding in more than 90% of patients,40 and because intensive monitoring and resuscitation are better accomplished in an intensive care unit. In our series, both Child class C and the urgency of TIPS were shown to be independent predictors for mortality. The actuarial survival in all patients was similar in both Child A and B patients and significantly higher than Child C patients. When we excluded patients who had undergone transplantation, the actuarial survival of 60% at 1 and 3 years was similar in patients awaiting OLT and in noncandidate patients. This finding may suggest TIPS as a procedure not only as a bridge to OLT but also for palliation in patients with refractory upper gastointestinal tract bleeding from portal hypertension who are not candidates for OLT. TIPS is less invasive and can be better tolerated in older patients or in those with other underlying diseases. In patients who are actively drinking and who present with acute gastrointestinal tract bleeding and severe liver dysfunction, TIPS may allow relative improvement in the liver function and offer these patients the chance for rehabilitation. In conclusion, TIPS is an effective procedure for variceal bleeding, obviating the need for a major surgical procedure. This will control bleeding and allow a safer waiting period for an available organ in the face of organ shortage. TIPS is also acceptable for patients who are not candidates for either surgical shunt or OLT. Its main disadvantages are encephalopathy, progressive liver failure, and potential sepsis. Also, because of a high incidence of shunt stenosis, it requires routine follow-up with ultrasound to detect asymptomatic outflow obstruction thus permitting angioplasty or shunt revision if necessary. The use of TIPS in patients with preserved

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