Fifty of 62 consecutive patients with
cirrhosis and refractory
ascites (18 with Child-Pugh class B
liver disease and 32 with class C) were treated with the
stent shunt--an expandable
stent of metallic mesh placed between a major branch of the portal vein and one of the hepatic veins. Patients were followed for a mean (+/- SD) of 426 +/- 333 days. Those with advanced
cancer, severe
heart failure, or severe
liver failure were excluded.
RESULTS: The
stent shunt was successfully placed in all patients and reduced the pressure gradient between the portal vein and the inferior vena cava by an average of 63 percent. Thirty-seven patients (74 percent) had complete responses (total remission of
ascites within three months), and nine patients (18 percent) had partial responses (
ascites detected by ultrasound but with no need for paracentesis). Four patients did not respond, including two who died within two weeks of shunt placement. After the procedure, 25 patients had
hepatic encephalopathy, as compared with 20 patients before the procedure; although
encephalopathy improved in 3 patients, new
encephalopathy developed in 8 patients. In the 28 of the 33 patients followed for more than six months who were evaluated, the mean serum
creatinine concentration was 1.5 +/- 0.09 mg per deciliter (133 +/- 8 mumol per liter) before placement of the
stent shunt, 1.5 +/- 1.6 mg per deciliter (133 +/- 141 mumol per liter) one week after the procedure, and 0.9 +/- 0.3 mg per deciliter (80 +/- 27 mumol per liter) after six months (P = 0.008 for the comparison of concentrations before and six months after the procedure). Renal function did not improve in the six patients with organic
kidney disease. Procedure-related complications developed in 16 patients, including intraabdominal
bleeding requiring
blood transfusions in 2 patients. Thrombotic occlusion of the
stent shunt occurred within two weeks in 5 patients, and later insufficiency of the shunt occurred in 16 patients, including 12 with recurrence of
ascites after complete remission. During followup, an additional 29 patients died--10 of progressive
liver disease and 19 of other causes. Survival for at least one year was associated with a patient's being under 60 years of age, having a serum
bilirubin level before placement of the
stent shunt of less than 1.3 mg per deciliter (22 mumol per liter), and having a complete response.
CONCLUSIONS: Our findings in an uncontrolled prospective study suggest that the transjugular intrahepatic porto-systemic
stent-shunt procedure was an effective treatment for many patients with
liver cirrhosis and refractory
ascites, but mortality from underlying diseases was substantial.