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Transjugular intrahepatic portosystemic shunt (TIPS), a new technique for the treatment of portal hypertension, has been successful in preliminary studies to treat acute variceal hemorrhage and to prevent variceal rebleeding. The purpose of this multicenter, randomized controlled trial is to compare the efficacy of TIPS with that of endoscopic sclerotherapy in the prevention of variceal rebleeding in cirrhosis. Eighty-one cirrhotic patients, with endoscopically proven variceal bleeding, were randomized to either TIPS (38 patients) or endoscopic sclerotherapy (43 patients). Randomization was stratified according to the following: if bleeding occurred F 1 week (stratum I); if bleeding occurred 1 to 6 weeks (stratum II); and if bleeding occurred 6 weeks to 6 months (stratum III) before enrollment. Follow-up included clinical, biochemical, Doppler Ultrasound, and endoscopic examinations every 6 months. During a mean follow-up of 17.7 months, 51% of the patients treated with sclerotherapy and 24% of those treated with TIPS rebled (P ‫؍‬ .011). Mortality was 19% in sclerotherapy patients and 24% in TIPS patients (P ‫؍‬ .50). Hepatic encephalopathy (HE) developed in 26% and 55%, respectively (P ‫؍‬ .006). A separate analysis of the three strata showed that TIPS was significantly more effective than sclerotherapy (P ‫؍‬ .026) in preventing rebleeding only in stratum I patients. TIPS is significantly better than sclerotherapy in preventing rebleeding only when it is performed shortly after a variceal bleed; however, TIPS does not improve survival and is associated with a significantly higher incidence of HE. The overall performance of TIPS does not seem to justify the adoption of this technique as a first-choice treatment to prevent rebleeding from esophageal varices in cirrhotic patients. (HEPATOLOGY 1998; 27:40-45.)Cirrhotic patients who survive an episode of bleeding from esophageal varices have an extremely high risk of rebleeding. 1 For this reason, several treatment modalities aimed at preventing variceal rebleeding have been tested by means of randomized controlled trials. 2 So far, pharmacological therapy with betablockers and endoscopic injection sclerotherapy are the most widely used treatments. 3 Nevertheless, both treatments are not fully satisfactory, as the average rebleeding rate with each therapy is about 48%. 2 Recently, a new angiographic technique, i.e., the transjugular intrahepatic portosystemic shunt (TIPS) has been proposed to treat portal hypertension. 4 This procedure creates a communication between the hepatic and the portal vein within the liver, thus decompressing portal hypertension. 5 Patency of the shunt is maintained by an expandable metal stent. Currently, TIPS has been successfully used in the following: in acute variceal hemorrhage uncontrolled by medical and endoscopic treatment 6,7 ; in preventing rebleeding in patients in whom sclerotherapy failed 5 ; in refractory ascites 8 ; in the Budd-Chiari Syndrome 9 ; and in patients who bleed while awaiting liver transplantation. 10 However, ...

The usefulness in cirrhotic patients of hemodynamic measurements by Doppler ultrasonography (US) is still not defined. We investigated the relationships between Doppler measurements and the severity of ascites. Portal blood flow velocity and volume, and hepatic and renal arterial resistance indexes (RI) were measured in 57 cirrhotic patients (19 without ascites, 28 with responsive ascites, and 10 with refractory ascites) and 15 healthy controls. The renal arterial RI were obtained for the main renal artery, interlobar vessels, and cortical vessels. Cirrhotic patients had decreased portal blood flow and an increased congestion index (CI). Only the CI was correlated to the severity of ascites, showing that it is also a reliable measure of the severity of portal hypertension in patients with ascites. The hepatic and renal artery RI were increased in cirrhotic patients, and the two values were correlated (r ‫؍‬ .68; P ‫؍‬ .00001). The RI of renal interlobar and cortical vessels were higher in patients with refractory ascites than in patients without ascites (P F .02 and P F .009), and correlated with sodium excretion rate (r ‫؍‬ Ϫ.45; P F .003), the reninaldosterone system, and creatinine clearance (r ‫؍‬ Ϫ.62; P F .0002). The RI decreased from the hilum of the kidney to the outer parenchyma in healthy subjects and patients with responsive ascites, but this difference disappeared in patients with refractory ascites. This indicates that the degree of renal vasoconstriction varies in different areas according to the severity of the ascites. Cortical vessels are involved mainly in patients with refractory ascites, suggesting that the intrarenal blood flow distribution in cirrhosis tends to preserve the cortical area and that severe cortical ischemia is a feature of refractory ascites. (HEPATOLOGY 1998; 28:1235-1240.) Doppler ultrasonography (US) is a noninvasive tool for the assessment of vascular patency. It has been used to measure the hepatic arterial and venous flows of patients with portal hypertension [1][2][3][4] and to document the increases in renal resistances that occur in some cirrhotic patients. [5][6][7][8] That some of these measures have prognostic value has been demonstrated. 4,7-9 Although a diagnostic gray-scale US is widely employed in the evaluation of cirrhotic patients, Doppler is rarely used. One pending problem is to establish which Doppler measurements correlate best with the different complications of portal hypertension. This could also help to determine whether or not the Doppler is useful in monitoring the effects of pharmacological therapies.The aim of the present study was to correlate the Doppler measurements of portal blood flow and of hepatic and renal arterial resistances with the presence and severity of ascites and renal failure in cirrhotic patients. PATIENTS AND METHODSFifty-seven cirrhotic patients, 35 men and 22 women, admitted consecutively to our hospital were enrolled in the present study. Their mean age was 57 Ϯ 9 years (range, 37-73 years), and their mean body weight was 6...

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