| The management
of acute variceal hemorrhage from portal hypertension has
traditionally included pharmacologic agents, mechanical compression
with tamponading balloons, and endoscopic techniques including
sclerotherapy and variceal banding. The role of operative
portosystemic shunting has diminished in the past several
years because of unpredictable postoperative morbidity from
hepatic failure or encephalopathy [1-8]. Although orthotopic
liver transplantation provides a unique and effective solution
to these problems, it is often impractical in the emergent
setting and may not be necessary if the hemorrhage can be
reliably controiled by other means.
The transjugular intrahepatic
portosystemic shurit (TIPS) was developed to relieve portal
hypertension without the mor-tality and morbidity of an open
surgical procedure. This review summarizes the salient history,
technique, and results of this procedure. The evolving role
of TIPS in the management of portal hypertension, including
indications, contraindications, and the durability of the
procedure, is assessed.
History
In 1969, Rosch et al. [9] first reported a new method
of decompressing the portal venous system through a perçutane-ousiy
created shunt between the portal and hepatic veins. In a series of experiments
on dogs, they showed the feasibility of passing a needle from the jugular
vein into a hepatic vein and then advancing the needle through the hepatic
parenchyma into a portal vein branch: Coaxial dilators were then used
to enlarge the track in hopes of creating a functional shunt. In a follow-up
study published in 1971 [10], they expanded on this initial work using
Silastic tubing (Dow Corning, Midiand, Ml) and silicone-coated coil spring
stents to bridge the hepatic parenchyma; the longest duration of shunt
patency was 12 days. |
In 1977, Reich et al.
[11] used a 9-mm cryoprobe to create a larger track through the hepatic
parenchyma. Six of the 11 swine that underwent the procedure had patent
portal venous to hepatic venous intraparenchymal tracks for 9-42 days.
The development of modern angioplasty balloons in the late 1970s allowed
Gutierrez and Burgener [12] to create 12-to 15-mm intrahepatic parenchymal
shunts in dogs with experimentally created portal hypertension. Normalization
of portal pressure was achieved in ali animais, and although short-term
patency was a significant problem and necessi-tated repeat dilatations
at weekly intervals (up to five times), some shunts remained patent for
a full year.
In 1982, Colapinto et al. [13] reported the first clinical use of TIPS
to treat a cirrhotic patient bleeding from varices. A 12-mm-diameter angioplasty
balloon was left inflated for 12 hr between the hepatic and portal veins;
when the balloon was deflated, a track persisted and portal pressure dropped
by 20%.
In 1983, Colapinto et al. [14], in a follow-up study, reported
five additional patients on whom they performed TIPS by inflating
a 9-mm balloon in the track for 10-15 min. Each of these shunts
was shown to be patent by angiography 12 hr after the procedure.
Although all patients died within 6 months, three of four
autopsies showed the shunt was patent.
In 1985, Palmaz and coileagues [15, 16] began investigating
balloon-expandable metallic stents for TIPS and found that, in dogs with
experimentally created portal hypertension, stented shunts remained patent
through 48 weeks.
|
Received September 21,1994;
accepted after revision December 19, 1994.
1 Department of Radiology,
University of Califrrnia, San Francisco, 505 Parnassus Ave.,
Box 0628, San Francisco, CA 94143.
2 Department of Radiology,
C-250, University of California, San Francisco, Mount Zion
medical Center, 1600 Divisadero, San Francisco, CA 94115.
Address correspondence to R. K. Kerlan, Jr.
A/ff1995;164:1059-1066 0361-803X/95/1645-1059 ©American Roentgen
Ray Society |
