Full text of DOI:10.1016/S0016-5085(00)70422-7

GASTROENTEROLOGY 2000;118:138–144
LIVER, PANCREAS, AND BILIARY TRACT
Determinants of Mortality in Patients With Advanced Cirrhosis
After Transjugular Intrahepatic Portosystemic Shunting
࿣
NAGA CHALASANI,* W. SCOTT CLARK,‡ L. G. MARTIN,§ JEFFRIE KAMEAN, M. ABDUL KHAN,*
࿣
NILESH H. PATEL,¶ and THOMAS D. BOYER
Departments of *Medicine and ¶Radiology, Indiana University School of Medicine, Indianapolis, Indiana; and ‡Department of Biostatistics,
Rollins School of Public Health, and Departments of §Radiology and Medicine; School of Medicine, Emory University, Atlanta, Georgia
࿣
Background & Aims: Transjugular intrahepatic portosys-
temic shunt (TIPS) placement is effective in the treat-
ment of complications of portal hypertension. This
study evaluated the predictors of mortality in a group of
cirrhotic patients with advanced liver disease after
placement of TIPS. Methods: A retrospective analysis
of all patients undergoing TIPS placement over a
21⁄2-year period was undertaken. Results: Fifty-six pa-
tients had TIPS placement for variceal hemorrhage, 49
for refractory ascites, and 24 for hepatic hydrothorax
(total, 129). Of 21 variables available before TIPS
placement, variceal hemorrhage requiring emergent
TIPS placement (relative risk [RR], 37.5; 95% confi-
dence interval [CI], 5.4–259) and bilirubin concentra-
tion G 3.0 mg/dL (RR, 5.4; 95% CI, 1.4–10.2) were
independent predictors of 30-day mortality. Variceal
hemorrhage requiring emergent TIPS placement (haz-
ard ratio [HR], 5.1, 95% CI, 2.2–9.1), alanine amino-
transferase level G 100 IU/L (HR, 2.5; 95% CI, 1.2–
5.5), bilirubin level G 3.0 mg/dL (HR, 2.6; 95% CI,
1.1–4.6), and pre-TIPS encephalopathy unrelated to
bleeding (HR, 2.2; 95% CI, 1.2–4.8) independently
predicted death during the follow-up period. A model
was developed that separated the patients into 3
groups with significantly different survival rates.
Conclusions: A clinical index consisting of 4 pre-TIPS
variables can reliably predict outcome after TIPS.
placement for the treatment of variceal hemorrhage in
humans by Colapinto et al.,3 more than 15,000 TIPS
placements have been performed worldwide. The proce-
dure has gained popularity because of its relative noninva-
siveness and effectiveness in relieving portal hyperten-
sion. Although TIPS was initially used in the treatment
of variceal hemorrhage,4–19 it was later reported to be
effective in the management of refractory ascites20–23 and
hepatic hydrothorax.24–26
Although TIPS effectively relieves portal hyperten-
sion, the patient’s condition may deteriorate after shunt
placement. Thirty-day mortality rates after TIPS place-
ment range from 3% to 44%, and 1-year mortality rates
range from 10% to 58%.6–10,13–16 Ideally, if patients
whose condition is likely to deteriorate after TIPS
placement could be identified before the procedure, then
evaluation for liver transplantation could be initiated in
those patients. Factors associated with a poor prognosis
after TIPS placement for variceal bleeding include hypo-
natremia, encephalopathy, Child’s class C cirrhosis, and
urgent TIPS placement.6,8,10,13,16 Factors associated with
a poor prognosis after TIPS placement for refractory
ascites include jaundice and renal insufficiency.20,23 Al-
though the above studies suggest that certain clinical
factors can be used to predict outcome after TIPS
placement, uncertainty about the relative importance of
each variable remains. The aim of this study was to
examine the determinants of 30-day as well as the overall
survival in a large cohort of consecutive patients with
advanced cirrhosis who underwent TIPS placement for
complications of portal hypertension.
he transjugular intrahepatic portosystemic shunt
T(TIPS) is a side-to-side, nonselective portosystemic
shunt that effectively lowers portal pressure.1 The first
TIPS placement in dogs was reported in 1969 by Rosch
et al.2 using nonexpandable coil stents; however, patency
of the shunts was short-lived. The introduction of
expandable metallic endoprostheses to buttress the trans-
hepatic tract prolonged the patency of TIPS and led to its
widespread use in the treatment of complications of
portal hypertension. Since the first report of TIPS
Abbreviations used in this paper: CI, confidence interval; CT,
computerized tomography; GEC, galactose elimination capacity; HR,
hazard ratio; RR, relative risk; TIPS, transjugular intrahepatic porto-
systemic shunt.
2000 by the American Gastroenterological Association
௠
0016-5085/00/$10.00

January 2000
MORTALITY AFTER TIPS PLACEMENT 139
Short-term mortality. Death occurring within 30 days
after TIPS placement.
Mate rials and Me thods
The study was a retrospective analysis of all patients
with cirrhosis who underwent TIPS placement from July 1,
1994, through December 31, 1996, at Emory University
Hospital. Emory University Hospital is a tertiary care facility
located in Atlanta, Georgia, and serves as a referral center for
the southeastern United States. The TIPS procedures were
performed using techniques previously described in detail.3,5
Informed consent was obtained for every TIPS procedure. In
general, the patency of TIPS was monitored using Doppler
ultrasonography on day 1 and then every 4–6 months. In those
with suspected shunt dysfunction, assessed either by ultrasonog-
raphy and/or clinical symptoms, TIPS patency was assessed
using TIPS angiography.
This study included all patients who had undergone TIPS
placement for the following indications: control of acute or
recurrent bleeding from esophageal or gastric varices, bleeding
from severe portal hypertensive gastropathy, refractory ascites,
and refractory hepatic hydrothorax. At this center, patients
with Child–Pugh class A cirrhosis with variceal bleeding are
treated in most cases with distal splenorenal shunts, and TIPS
is usually reserved for those with Child–Pugh class B and C
cirrhosis. Therefore, this report contains no Child–Pugh class A
patients. Patients who underwent TIPS for other reasons (such
as bone marrow transplant recipients with veno-occlusive
disease), received distal splenorenal shunts soon after TIPS
placement, had hepatocellular carcinoma at the time of TIPS,
or were lost to follow-up were excluded from the analysis.
Overall mortality. Death of the patients after TIPS
during the entire follow-up period.
Data Collection
The list of patients who underwent TIPS during the
study period was retrieved from the database maintained by 1
of the authors (L.G.M.). The medical records of eligible
patients were reviewed to obtain demographic, clinical, labora-
tory, and follow-up data. When necessary, additional informa-
tion was obtained from the referring physicians, from medical
records of other hospitals, and from patients or their families
through telephone interviews. Twenty-one clinical variables
were collected. Continuous variables included age (years),
prothrombin time (seconds), bilirubin level (mg/dL), albumin
level (g/dL), blood urea nitrogen level (mg/dL), creatinine level
(mg/dL), alanine aminotransferase (ALT) level (IU/L), aspartate
aminotransferase (AST) level (IU/L), galactose elimination
capacity (GEC [mg/min]), serum sodium level (mmol/L), liver
volume (cm3), spleen volume (cm3), pre- and post-TIPS
portosystemic gradient (mm Hg), and Child–Pugh score.
Categorical variables included sex, indication for TIPS, emer-
gent TIPS, cause of liver disease, and history of hepatic
encephalopathy. All data were collected from the time of
admission for TIPS except GEC, liver volume, and spleen
volume. For these 3 variables, data available either from
admission or within a prior 4-month period were considered
acceptable. The liver and spleen volumes were measured using
the techniques described previously.27 In brief, an electronic
cursor is manually traced around the margins of hepatic or
splenic parenchyma on each computerized tomography (CT)
scan. The cross-sectional area (cm2) within the region of
interest is determined. The individual areas are then added,
yielding the total liver or splenic volume (cm3). Patients were
followed up until death, liver transplantation, or June 15,
1997.
Definitions
Refractory ascites. Ascites that could not be con-
trolled with salt restriction and diuretic therapy and required
frequent (approximately monthly) large-volume paracenteses
for control of ascites.
Refractory hepatic hydrothorax. Recurrent pleural ef-
fusion that, despite salt restriction and diuretic therapy,
required repeated therapeutic thoracenteses to control symp-
toms.
Data Analysis
Recurrent variceal hemorrhage. Two or more epi-
sodes of bleeding (each requiring at least 2 units of packed cell
transfusion) from esophageal or gastric varices during or after
endoscopic therapy (sclerotherapy or band ligation) with or
without ␤-blockers.
Emergent TIPS. Placement of TIPS on an emergent
basis to control hemorrhage from esophageal or gastric varices
not controlled by medical (vasopressin or octreotide) or endo-
scopic (either sclerotherapy or band ligation) therapy. The time
interval between medical treatment failure or transfer to Emory
Hospital and emergent TIPS was less than 48 hours.
Pre-TIPS encephalopathy. Presence of hepatic encepha-
lopathy before TIPS placement. The diagnosis of encephalopa-
thy was based on the history as detailed in the medical record.
Encephalopathy precipitated by the variceal hemorrhage was
not considered pre-TIPS encephalopathy.
Quality control procedures, database management, and
statistical analyses were performed using SAS software. Basic
descriptive statistics, including means, SDs, ranges, and percent-
ages, were used to characterize the study patients. For univari-
ate survival comparisons, several continuous measures were
dichotomized. The distributions of bilirubin and creatinine
were dichotomized based on the existing literature,8,20,23 and
other continuous variables were divided based on a median
split of the sample distribution.
Predictors of mortality after TIPS placement were evaluated
in terms of both 30-day and overall mortality. Because
follow-up information was complete at 30 days, 30-day
mortality could be evaluated with contingency tables, includ-
2
ing ␹ statistics, for univariate analysis and with logistic
regression for multivariate analysis. Thus, relative risks (RRs)
and corresponding 95% confidence intervals (CIs) are used to

140 CHALASANI ET AL.
GASTROENTEROLOGY Vol. 118, No. 1
assess the relationship between clinical variables and 30-day
mortality. Overall survival was univariately assessed with
Kaplan–Meier survival estimates, and log-rank statistics were
used for comparison of univariate survival curves. Overall
survival was estimated as the interval from the time of TIPS
placement to death or to the end of the observation ( June 15,
1997). Patients were censored at the time of transplantation.
Evaluation of independent predictors of survival was carried
out using the Cox proportional hazards model; hazard ratios
(HRs) and corresponding CIs are reported. Aptness of the
proportional hazards assumption was assessed. A P value of
Ͻ0.05 is considered statistically significant. All reported P
values are unadjusted for the number of comparisons, but
conclusions regarding associations were adjusted for this
multiplicity.
Figure 1. Kaplan–Meier survival analysis of patients after TIPS
placement based on indication. *, Hydrothorax; ᭿, variceal bleeding;
᭜, ascites. The curves do not differ significantly (P ϭ 0.5). The mean
follow-ups of hydrothorax, variceal bleeding, and ascites groups were
363 Ϯ 229 days, 330 Ϯ 255 days, and 340 Ϯ 229 days, respectively.
Re s ults
During the study period, 147 patients underwent
TIPS placement. Eighteen patients were excluded from
this analysis (veno-occlusive disease, 6; splenorenal shunt
soon after TIPS placement, 4; preoperative correction of
portal hypertension for cardiac surgery, 2; hepatoma at
the time of TIPS, 1; no follow-up, 5). The remaining 129
patients are the subjects of this report. Selected character-
istics of the study group are shown in Table 1. Of the 129
patients, 56 had TIPS placement performed for the
treatment of variceal hemorrhage, 49 for refractory
ascites, and 24 for refractory hepatic hydrothorax. Of the
56 patients who had TIPS placed for variceal hemorrhage,
43 had esophageal variceal bleeding, 10 had gastric
variceal bleeding, and 3 had portal hypertensive gastrop-
athy. Twenty-one patients had acute variceal bleeding
requiring emergent TIPS (15 with esophageal and 6 with
gastric varices). The 49 patients who had TIPS placement
for control of refractory ascites had an average (ϮSD) of
6.1 Ϯ 2.2 large-volume paracenteses before TIPS. Their
mean daily furosemide and spironolactone doses were
91 Ϯ 40 and 150 Ϯ 61 mg, respectively. The 24 patients
who received TIPS for refractory hepatic hydrothorax had
an average of 3.6 Ϯ 2.2 therapeutic thoracenteses and
2.0 Ϯ 1.4 large-volume paracenteses before TIPS place-
ment, and their mean daily furosemide and spironolac-
tone dosages were 89 Ϯ 55 and 157 Ϯ 70 mg,
respectively. During follow-up, the incidence of shunt
dysfunction and the number of angiographic interven-
tions were 26% and 2.0 Ϯ 1.1, respectively.
The short- and long-term survival for each indication
are shown in Figure 1. Univariate analysis showed 4
factors associated with 30-day mortality after TIPS
placement: variceal bleeding, need for emergent TIPS,
prothrombin time Ͼ 17 seconds, and bilirubin level Ͼ
3.0 mg/dL (Table 2). Need for emergent TIPS, presence
of encephalopathy preceding TIPS, ALT Ͼ 100 IU/L,
prothrombin time Ͼ 17 seconds, and bilirubin level Ͼ
3.0 mg/dL were associated with overall mortality by
univariate analysis (Table 2). Age (P ϭ 0.18), gender
(P ϭ 0.76), cause of liver disease, AST level (P ϭ 0.7),
blood urea nitrogen level (P ϭ 0.12), creatinine level
(P ϭ 0.12), creatinine clearance (P ϭ 0.5), GEC (P ϭ
Table 1. Selected Characteristics of the Study Group
Age (yr)
Sex (male/ female [%])
Cause
54.8 Ϯ 10.7
70/ 30
Alcohol
Cryptogenic
34%
19%
Hepatitis B or C
Alcohol ϩ hepatitis C
Other
25%
10%
12%
Sodium (mEq/ L) (n ϭ 128)a
Prothrombin time (s) (n ϭ 127)a
Bilirubin (mg/ dL)
Albumin (g/ dL)
AST (IU/ L) (n ϭ 128)a
ALT (IU/ L) (n ϭ 127)a
Blood urea nitrogen (mg/ dL)
Creatinine (mg/ dL)
Child–Pugh class
B
136 Ϯ 6.4 (118–155)b
17.6 Ϯ 3.5 (12–32.8)b
3.5 Ϯ 4.5 (0.3–35)b
2.3 Ϯ 0.6 (0.6–4.8)b
75 Ϯ 95.1 (14–943)b
59 Ϯ 48 (11–406)b
29.9 Ϯ 20.2 (2–113)b
1.5 Ϯ 1.3 (0.4–12.3)b
30%
C
70%
Child–Pugh score
Liver volume (cm3 ) (n ϭ 69)a
Spleen volume (cm3 ) (n ϭ 67)a
GEC (mg/ min) (n ϭ 85)a
PSG (mm Hg)
10.4 Ϯ 1.8 (7–15)b
1335 Ϯ 528 (586–3242)b
832 Ϯ 483 (128–2020)b
244 Ϯ 74.5 (87–420)b
Pre-TIPS
Post-TIPS
18.3 Ϯ 5.17 (9–34)b
6.2 Ϯ 2.6 (0–13)b
NOTE. Other characteristics include autoimmune hepatitis (6); nonal-
coholic steatohepatitis (1); sclerosing cholangitis (5); primary biliary
cirrhosis (3); and Wilson’s disease (1).
PSG, portosystemic gradient.
aNumber of patients undergoing test if Ͻ129.
bNumbers in parentheses represent ranges of values.

January 2000
MORTALITY AFTER TIPS PLACEMENT 141
Table 2. Predictors of Survival After TIPS Placement
30-Day survival
Univariate P Multivariate P
Long-term survival
Variable
Cutoffa
Univariate P
0.5
Multivariate P
Indication
A (56) vs. B (49) vs. C (24)b
0.01
0.9
Active bleeding requiring emergent
TIPS placement
Yes (21) vs. no (108)
Yes (26) vs. no (101)
Ͻ100 (110) vs. Ͼ100 (17)
Ͻ17 (67) vs. Ͼ17 (60)
Ͻ3 (88) vs. Ͼ3 (41)
0.0001
0.31
0.14
0.008
0.0006
0.0001
0.0001
0.02
0.04
0.008
0.0001
0.0001
0.02
0.009
Encephalopathyc
ALT (IU/ L)
Prothrombin time (s)
Bilirubin (mg/ dL)
0.61
0.013
0.001
aValues in parentheses represent numbers of patients.
bA, variceal hemorrhage; B, refractory ascites; C, refractory hepatic hydrothorax.
cData on encephalopathy for 2 patients could not be obtained.
0.07), Child–Pugh score (P ϭ 0.18), pre-TIPS portosys-
temic gradient (P ϭ 0.9), liver volume (P ϭ 0.3), spleen
volume (P ϭ 0.5), albumin level (P ϭ 0.08), and serum
sodium level (P ϭ 0.3) were not associated with survival
after TIPS placement on univariate analysis. A logistic
regression model showed that refractory variceal hemor-
rhage requiring emergent TIPS (RR, 37.5; 95% CI,
5.4–259) and bilirubin level Ͼ 3.0 mg/dL (RR, 5.4; 95%
CI, 1.4–10.2) were independent predictors of 30-day
mortality. From the Cox proportional hazards model,
variceal hemorrhage requiring emergent TIPS (HR, 5.1;
95% CI, 2.2–9.1), ALT level Ͼ 100 IU/L (HR, 2.5; 95%
CI, 1.2–5.5), bilirubin level Ͼ 3.0 mg/dL (HR, 2.6; 95%
CI, 1.1–4.6), and pre-TIPS encephalopathy (HR, 2.2;
95% CI, 1.2–4.8) were independent predictors of overall
mortality (Table 2).
Each of the 4 variables that independently predicted
overall mortality on the Cox proportional hazards model
analysis was given a weighted value based on HR:
emergent TIPS, 2; ALT level Ͼ 100 IU/L, 1; bilirubin
level Ͼ 3.0 mg/dL, 1; pre-TIPS encephalopathy, 1. After
summation of these weights, the cohort was separated
into 3 groups based on individual scores: high risk, 4–5
points; medium risk, 1–3 points; low risk, 0 points.
There were 13 patients in the high-risk group, 61 in the
medium-risk group, and 53 in the low-risk group (2
patients with missing laboratory data could not be
included for this risk stratification). The survival curves
for each of these groups are shown in Figure 2. Survival in
each group was significantly different from those for the
other 2 groups (P Ͻ 0.0001).
patients died during the follow-up period; 30 of them
died within the first 30 days after TIPS placement. The
causes of death are shown in Table 3. Sepsis with shock
and multiorgan failure were the 2 most common causes of
death among patients who died within the first 30 days.
The most common cause of death beyond 30 days was
progressive liver failure (defined as worsening jaundice,
coagulopathy, and encephalopathy). Of 14 patients whose
death was secondary to progressive liver failure, 6 had
TIPS placed for variceal hemorrhage, 5 for refractory
ascites, and 3 for refractory hepatic hydrothorax.
The prediction model developed on the data collected
from Emory University was tested on an independent
cohort.28 This cohort consisted of 57 consecutive patients
with cirrhosis who underwent TIPS from January 1,
1994, to March 31, 1997, at Indiana University Medical
Center. Their mean age and Child–Pugh score were
51.7 Ϯ 12.6 years and 8.6 Ϯ 1.9, respectively. Forty-six
percent of patients had Child–Pugh class B and 42% had
Child–Pugh class C cirrhosis. The indications for TIPS
were variceal hemorrhage in 66%, ascites in 26%, and
hydrothorax in 7%. Using the prediction model, the
Twenty-five patients underwent liver transplantation
during the follow-up period at a mean of 5.2 Ϯ 3.4
months after TIPS placement (range, 10 days to 12
months). The indications for TIPS in these 25 were
hydrothorax, 3; refractory ascites, 13; and bleeding, 9.
The incidences of shunt dysfunction and new encephalopa-
thy were 26% and 20%. The frequency of rebleeding
after TIPS was 8% (bleeding group, 15%). Fifty-four
Figure 2. Kaplan–Meier survival analysis of patients after TIPS
placement based on risk stratification. High risk (᭜), 4–5 points;
moderate risk (᭡), 1–3 points; low risk (᭿), 0 points. Each survival
curve is significantly different from the others (P Ͻ 0.001).

142 CHALASANI ET AL.
GASTROENTEROLOGY Vol. 118, No. 1
Table 3. Causes of Death After TIPS
TIPS was the strongest predictor of mortality (HR, 5.1;
95% CI, 2.2–9.1). Emergent TIPS as a significant
predictor of poor outcome was first reported by Helton et
al.,6 who found a 56% hospital mortality in patients
undergoing emergent TIPS placement for variceal bleed-
ing. In a series of semiemergent TIPS placements for
patients with active variceal hemorrhage unresponsive to
sclerotherapy, the 30-day mortality was 37%.11 Similarly,
emergent portosystemic surgical shunt is also associated
with a poor prognosis.30
We found that an elevated ALT level independently
predicted a poor outcome after TIPS placement. This
finding is consistent with an earlier report showing that
increased ALT, on univariate analysis, had a significant
association with 30-day and 1-year mortality in patients
undergoing TIPS placement for variceal hemorrhage.8
The reasons for such an association are unclear, but it may
be related to active liver disease, liver ischemia after
variceal bleeding, or both.
In a previous study of patients undergoing emergent
TIPS placement for uncontrolled variceal hemorrhage,
aspiration pneumonia before TIPS placement was a very
strong determinant of mortality after TIPS placement.11
In our study, only 16% of patients had uncontrolled
variceal hemorrhage requiring emergent TIPS placement,
and only 5 of them had documented aspiration pneumo-
nia. Because of such a low frequency, aspiration pneumo-
nia could not be tested as a prognostic variable in our
analysis.
In other studies, 1-year survival appears to be worse in
patients undergoing TIPS placement to control refractory
ascites compared with those undergoing TIPS placement
for control of variceal bleeding.6–10,20–23 However, the
number of patients with Child–Pugh class A cirrhosis is
much greater in the patients who received TIPS for
bleeding varices than in those who underwent TIPS
placement for refractory ascites. In the current study,
1-year survival was not influenced by the indication for
TIPS (variceal bleeding, 49%; ascites, 51%; hydrothorax,
56%; Figure 1). The lack of difference reflects the fact
that the severity of liver disease was the same in all 3
groups. For example, the Child–Pugh scores for patients
with variceal hemorrhage, refractory ascites, and hepatic
hydrothorax were similar (10.5 Ϯ 1.8, 10.6 Ϯ 1.8, and
10.9 Ϯ 1.8, respectively). Thus, if hepatic function is
poor, 1-year survival is expected to be approximately
50%, irrespective of the reason for TIPS placement.
In summary, 30-day and 1-year survival rates in a large
cohort of consecutive patients with advanced cirrhosis
who underwent TIPS placement to control complications
of portal hypertension were 81% and 52%, respectively.
A model was developed that separates patients into 3 risk
Survival
Cause of death
Sepsis
30-Day
Long-term
11
2
5
3
0
3
12
0
0
2
Worsening liver function
Multiorgan failure
Renal failure
Recurrent variceal bleeding
Unknown
Othersa
0
9
5
2
aIncluding myocardial infarction (2), hepatocellular carcinoma (1),
pulmonary edema (1), adult respiratory distress syndrome (2), portal
vein thrombosis/ mesenteric ischemia (1), anoxic encephalopathy (1),
esophageal perforation (1), disseminated intravascular coagulation
(1), and candida meningitis (1).
group was separated into high (n ϭ 10), medium (n ϭ
19), and low (n ϭ 27) risk. The survival rates of these 3
groups were significantly different one from another (P ϭ
0.037). The 1-year survival rates of high-, medium-, and
low-risk patients were 30%, 49%, and 67%, respectively.
These survival rates were similar to those of high-,
medium-, and low-risk groups from Emory data (10%,
43%, and 70%; P ϭ 1.0, P ϭ 0.7, and P ϭ 0.8,
respectively).
Dis cus s ion
In a monograph on TIPS by Conn et al.,29 the
authors note that TIPS is a technology whose time has
come; however, they also caution that its place in
medicine is yet to be determined. Although evidence
increasingly demonstrates the effectiveness of TIPS in the
management of complications of portal hypertension,
there is also evidence that TIPS has little effect on
prognosis compared with other forms of therapy.12,14,17–19
If clinical factors that accurately predict outcome after
TIPS placement were known, it is possible that certain
groups of patients would show a clear survival benefit
from TIPS compared with other forms of therapy. The
goal of our study was to determine if pre-TIPS clinical
variables could be used to predict short-term as well as
overall mortality after placement of TIPS in a cohort of
consecutive cirrhotic patients with advanced liver disease.
Four independent variables were identified, including
need for emergent TIPS, ALT level Ͼ 100 IU/L, bilirubin
level Ͼ 3.0 mg/dL, and pre-TIPS encephalopathy, which
predicted overall mortality after TIPS. The sum of the
above weighted factors stratified patients into 3 groups
with significantly different survival rates after TIPS
placement. We believe this model may allow for better
stratification of patients when TIPS is compared with
other forms of therapy.
In our study, variceal hemorrhage requiring emergent

January 2000
MORTALITY AFTER TIPS PLACEMENT 143
term follow-up of transjugular intrahepatic portasystemic stent
shunt (TIPS) for the treatment of portal hypertension: results in
130 patients. Gut 1996;39:470–485.
groups based on easily obtained clinical data. Use of this
model should facilitate treatment of patients after TIPS
placement because their prognoses can be predicted more
accurately. The present study identified a subgroup of
high-risk cirrhotic patients with ϳ90% mortality within
a few weeks after TIPS placement. Accordingly, the
appropriateness of TIPS placement in such high-risk
patients should be questioned (especially if they cannot
receive liver transplants). In addition, stratification of
patients in controlled trials before they are randomized
may help better define which patients are most likely to
benefit from TIPS compared with other forms of therapy.
14. Rossle M, Delbert P, Haag K, Ochs A, Olschewski M, Siegertetter
V, Hauenstein KH, Gieger R, Stiepak C, Keller W, Blum HE.
Randomized trial of transjugular intrahepatic portasystemic shunt
versus endoscopy plus propranolol for prevention of variceal
rebleeding. Lancet 1997;349:1043–1049.
15. Sanyal AJ, Freedman AM, Luketic VA, Purdum PP III, Shiffman ML,
DeMeo J, Cole PE. The natural history of portal hypertension after
transjugular intrahepatic portosystemic shunts. Gastroenterol-
ogy 1997;112:889–898.
16. Sahagun G, Benner KG, Saxon R, Barton RE, Rabkin J, Keller FS,
Rosch J. Outcome of 100 patients after transjugular intrahepatic
portasystemic shunt for variceal hemorrhage. Am J Gastroenterol
1997;92:1444–1452.
17. Sauer P, Theilman L, Stremmel W, Benz C, Richter GM, Stiehl A.
Transjugular intrahepatic portasystemic stent shunt versus sclero-
therapy plus propranolol for variceal rebleeding. Gastroenterology
1997;113:1623–1631.
18. Sanyal AJ, Freedman AM, Luketic VA, Purdum PP, Shifffman ML,
Cole PE, Tisnado J, Simmon S. Transjugular intrahepatic portosys-
temic shunts compared with endoscopic sclerotherapy for the
prevention of recurrent variceal hemorrhage. A randomized con-
trolled trial. Ann Intern Med 1997;126:849–857.
19. Cello JP, Ring EJ, Olcott EW, Koch J, Gordon J, Gordon R, Sandhu
J, Morgan DR, Ostroff JW, Rockey DC, Bacheti P, LaBerge J, Lake
JR, Somberg K, Doherty C, Davila M, McQuaid K, Wall SD.
Endoscopic sclerotherapy compared with percutaneous transjugu-
lar intrahepatic portasystemic shunt after initial sclerotherapy in
patients with acute variceal hemorrhage: a randomized, con-
trolled trial. Ann Intern Med 1997;126:858–865.
20. Ochs A, Rossle M, Haag K, Hauenstein KH, Deibert P, Siegerstet-
ter V, Huonker M, Langer M, Blum HE. The transjugular intrahe-
patic portasystemic stent-shunt procedure for refractory ascites.
N Engl J Med 1995;332:1192–1197.
21. Quiroga J, Sangro B, Nunez M, Bilbao I, Longo J, Garcia-Villarreal
L, Zozaya JM, Betes M, Herrero JI, Prieto J. Transjugular intrahe-
patic portasystemic shunt in the treatment of refractory ascites:
effect of clinical, renal, humoral, and hemodynamic parameters.
Hepatology 1995;21:986–994.
22. Martinet JP, Fenyves D, Legault L, Roy L, Dufresne MP, Spahr L,
Lafortune M, Pomier-Layrargues G. Treatment of refractory asci-
tes using transjugular intrahepatic portasystemic shunt (TIPS): a
caution. Dig Dis Sci 1997;42:161–166.
23. Najarian GK, Bjarnason H, Dietz CA Jr, Bernadas CA, Foshager
MC, Ferral H, Hunter DW. Refractory ascites: midterm results of
treatment with a transjugular intrahepatic portosystemic shunt.
Radiology 1997;205:173–180.
24. Strauss RM, Martin LG, Kaufman SL, Boyer TD. Transjugular
portal systemic shunt for the management of symptomatic
cirrhotic hydrothorax. Am J Gastroenterol 1994;89:1520–1522.
25. Gordon FD, Anastopoulos HT, Crenshaw W, Gilchrost B, McEniff
N, Falchuk KR, LoCicero J 3rd, Lewis WD, Jenkins RL, Trey C. The
successful treatment of symptomatic, refractory hydrothorax with
transjugular intrahepatic portosystemic shunt. Hepatology 1997;
25:1366–1369.
Re fe re nce s
1. Conn HO. Transjugular intrahepatic portal-systemic shunts: the
state of the art. Hepatology 1993;17:148–158.
2. Rosch J, Hanafee WN, Snow H. Transjugular portal venography
and radiological portacaval shunt: an experimental study. Radiol-
ogy 1969;92:1112–1114.
3. Colapinto RF, Stronell RD, Birch SJ, Langer B, Blendis LM, Grieg
PD, Gilas T. Creation of an intrahepatic portosystemic shunt with
a Gruntzig balloon catheter. Can Med Assoc J 1982;126:267–
268.
4. Gordon JD, Colapinto RF, Abecassis M, Makowka L, Langer B,
Blendis LM, Taylor B, Stronell RD. Transjugular intrahepatic
portosystemic shunt: a nonoperative approach to life threatening
variceal bleeding. Can J Surg 1987;30:45–49.
5. LaBerge JM, Ring EJ, Gordon RL, Lake JR, Doherty MM, Somberg
KA, Roberts JP, Ascher NL. Creation of intrahepatic portosystemic
shunts with the wallstent prosthesis: results in 100 patients.
Radiology 1993;187:413–420.
6. Helton WS, Belshaw A, Althaus S, Park S, Coldwell D, Johansen K.
Critical appraisal of the angiographic portacaval shunt (TIPS). Am
J Surg 1993;165:566–571.
7. Rossle M, Haag K, Ochs A, Sellinger M, Noldge G, Perarnau JM,
Berger E, Blum E, Gabelmann A, Hauenstein K. The transjugular
portosystemic stent-shunt procedure for variceal bleeding. N Engl
J Med 1994;330:165–171.
8. Jalan R, Elton R, Redhead DN, Finlayson NDC, Hayes PC. Analysis
of prognostic variables in the prediction of mortality, shunt failure,
variceal rebleeding and encephalopathy following the transjugular
intrahepatic portasystemic stent-shunt for variceal haemorrhage.
J Hepatol 1995;23:123–128.
9. Coldwell DM, Ring EJ, Rees CR, Zemel G, Darcy MD, Haskal ZJ,
McKusick MA, Greenfield AJ. Multicenter investigation of the role
of transjugular intrahepatic portosystemic shunt in the manage-
ment of portal hypertension. Radiology 1995;196:335–340.
10. LaBerge JM, Somberg KA, Lake JR, Gordon RL, Kerlan RK Jr,
Ascher NL, Roberts JP, Simon MM, Doherty CA, Hahn J. Two-year
outcome following transjugular intrahepatic portosystemic shunt
for variceal bleeding: results in 90 patients. Gastroenterology
1995;108:1143–1151.
11. Sanyal AJ, Freedman AM, Luketic VA, Purdum PP, Shiffman ML,
Tisnado J, Cole PE. Transjugular intrahepatic portasystemic
shunts for the patients with active variceal hemorrhage unrespon-
sive to sclerotherapy. Gastroenterology 1996;111:138–146.
12. Cabrera J, Mynar M, Grnados R, Gorriz E, Reyes R, Puliodo-Duque
JM, Rodriquez-SanRoman JL, Guerra C, Kravetz D. Transjugular
intrahepatic portasystemic shunt versus sclerotherapy in the
elective treatment of variceal hemorrhage. Gastroenterology
1996;110:832–839.
26. Chalasani N, Martin LG, Strauss RM, Boyer TD. Transjugular
intrahepatic portasystemic shunt (TIPS) for refractory hepatic
hydrothorax—good for the lungs, not so good for the liver (abstr).
Hepatology 1997;26:A630.
27. Henderson JM, Heymsfield SB, Horowitz J, Kutner MH. Measure-
ment of liver and spleen volume by computed tomography.
Radiology 1981;141:525–527.
13. Stanley AJ, Jalan R, Forrest EH, Redhead DN, Hayes PC. Long-
28. Khan A, Imperiale T, Kwo P, Born L, Chalasani N, Patel N, Lumeng

144 CHALASANI ET AL.
GASTROENTEROLOGY Vol. 118, No. 1
L. What predicts survival in cirrhotics undergoing transjugular
intrahepatic portasystemic shunt (TIPS)? (abstr). Gastroenterol-
ogy 1998:114:A1271.
text book of liver diseases. 3rd ed. Philadelphia: Saunders,
1996:720–763.
29. Conn HO, Palmaz JC, Rosch J, Rossle M. Preface. In: Conn HO,
Palmaz JC, Rosch J, Rossle M, eds. TIPS: transjugular intra-
hepatic portosystemic shunts. New York: Igaku-Shoin, 1996:
V11–1X.
30. Boyer TD, Henderson JM. Portal hypertension and bleeding
esophageal varices. In: Zakim D, Boyer TD, eds. Hepatology: a
Received March 26, 1999. Accepted September 7, 1999.
Address requests for reprints to: Thomas D. Boyer, M.D., Depart-
ment of Medicine, Emory University School of Medicine, 1639 Pierce
Drive, Room 2101 WMB, Atlanta, Georgia 30322. e-mail:
tboyer@emory.edu; fax: (404) 727-5767.
Supported in part by National Institutes of Health grant DK50680.