Hepatic Perfusion before and after the Transjugular Intrahepatic Portosystemic Shunt Procedure: Impact on Survival

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PURPOSE

This study correlates transjugular intrahepatic portosystemic shunt (TIPS) mortality with flow patterns in the cirrhotic liver.

MATERIALS AND METHODS

Twenty-seven TIPS patients and 10 control subjects were used for this study. The authors evaluated hepatic perfusion with venous injections of Tc-99m pertechnetate before and after TIPS. Hepatic time-activity curves were analyzed for type and amount of liver perfusion. These parameters were correlated with survival for a mean follow-up of 18 months.

RESULTS

The mean arterial contribution to liver blood flow was 25.4% in the normal control patients, 39.9% in patients prior to TIPS, and increased to 48.3% after TIPS. Although the proportion of arterial supply to the cirrhotic liver varied widely, TIPS mortality did not correlate with the preprocedure hepatic artery/portal venous perfusion ratio. However, patients with both an “arterialized” flow pattern and low total hepatic perfusion had higher mortality, with a mean survival of 2 months compared to patients with a more favorable perfusion profile (mean survival, 28.4 months).

CONCLUSION

The proportion of arterial perfusion to the liver before TIPS did not affect survival. However, patients with a combination of reduced total hepatic perfusion and an arterial flow pattern had poorer survival, suggesting that both the quantity and quality of hepatic perfusion predicts TIPS outcome.

Section snippets

MATERIALS AND METHODS

From 1995 to 1997, we evaluated 34 potential TIPS patients with nuclear medicine flow studies. Fortythree patients underwent a TIPS procedure during this interval but we excluded nine patients who had TIPS performed emergently or during the evening hours or weekends. Seven additional patients were excluded from the study population for other reasons. Four had unsuccessful TIPS procedures (all with chronic portal vein thrombosis) and one patient was excluded because of Budd-Chiari syndrome.

RESULTS

Seventeen patients died of progressive liver failure (63% of patients), occurring between 4 days and 22 months after the procedure (mean, 6.2 months). The remaining 10 patients were followed clinically and by means of ultrasound shunt surveillance for 27–45 months (mean, 37 months). The breakdown of arterial versus portal flow revealed significant differences between patients with cirrhosis, patients with cirrhosis after TIPS, and normal control subjects. The mean hepatic arterial contribution

DISCUSSION

Currently, TIPS is accepted treatment for variceal hemorrhage that has failed to respond to endoscopic therapy. A more recent indication is medically refractory ascites, and active research is hinting that TIPS may be a viable option in hepatorenal syndrome (16) and as primary therapy in portal hypertension complicated by bleeding (17). As indications broaden, increasing numbers of cirrhotic patients will be subjected to TIPS. Accordingly, methods to identify high-risk patients become quite

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