How much reduction in portal pressure is necessary to prevent variceal rebleeding? A longitudinal study in 225 patients with transjugular intrahepatic portosystemic shunts

Am J Gastroenterol. 2001 Dec;96(12):3379-83. doi: 10.1111/j.1572-0241.2001.05340.x.


Objectives: This longitudinal study determines the risk of rebleeding in relation to the reduction of the portosystemic pressure gradient in patients with a transjugular intrahepatic portosystemic shunt (TIPS) for variceal bleeding.

Methods: The study included 225 patients in whom a TIPS revision was indicated by the endoscopic finding of varices with a high risk for rebleeding (n = 167) or a recent variceal rebleed (n = 58). The portosystemic pressure gradient was determined before and after TIPS placement and at revision performed after a mean of 10 +/- 15 months.

Results: The portosystemic pressure gradient at revision approached the index pressure gradient before TIPS implantation (23.1 +/- 5.5 mm Hg) by 8.4 +/- 31%. Rebleeding was inversely correlated with the reduction in index pressure gradient found at revision. Thus, 80% of rebleedings occurred with pressure gradients close to the index pressure gradient (< 25% reduction) or with gradients equal to or greater than the index pressure gradient. In contrast, only one patient (0.4%) and three patients (1.3%) rebled with a pressure gradient of < 12 mm Hg or a reduction of the index pressure gradient by > 50%, respectively. Kaplan-Meier analysis of rebleeding, which included the 225 patients at risk, showed a probability of rebleeding of 18%, 7%, and 1% for a reduction of the index pressure gradient by 0%, 25-50%, and > 50%, respectively.

Conclusions: Most rebleedings occurred with pressure gradients similar to the index-pressure gradient measured at first bleeding. Accordingly, a graded reduction by 25-50% sufficiently prevents rebleeding. It can be assumed that, in comparison with the widely used threshold value of 12 mm Hg, a reduction by 25-50% may have a favorable benefit-to-risk ratio with respect to shunt-induced hepatic encephalopathy and liver failure. It should therefore be a goal in the decompressive treatment of portal hypertension and maintained during follow-up of patients with variceal bleeding.

MeSH terms

  • Adult
  • Blood Pressure*
  • Female
  • Hemorrhage / etiology
  • Hemorrhage / prevention & control*
  • Hemorrhage / surgery*
  • Humans
  • Longitudinal Studies
  • Male
  • Middle Aged
  • Portal System / physiopathology*
  • Portasystemic Shunt, Transjugular Intrahepatic*
  • Probability
  • Secondary Prevention
  • Survival Analysis
  • Varicose Veins / complications*
  • Varicose Veins / physiopathology*