Original Contribution | Published:

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

American Journal of Gastroenterology volume 96, pages 33793383 (2001) | Download Citation




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.


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.


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.


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.

Access optionsAccess options

Rent or Buy article

Get time limited or full article access on ReadCube.


All prices are NET prices.


  1. 1.

    . Variceal bleeding: Which shunt?. Gastroenterology 1986;91:1021–1023.

  2. 2.

    , . The role of TIPS for the treatment of portal hypertension: Effects and efficacy. Acta Gastroenterol Belg 1997;60:233–237.

  3. 3.

    , , , . Portacaval H-graft. Relationship of shunt diameter, portal flow patterns and hepatic encephalopathy. Ann Surg 1983;197:422–426.

  4. 4.

    , , , . Predictability and maintenance of portal flow patterns after small-diameter H-grafts in man. Ann Surg 1984;200:706–710.

  5. 5.

    , , , et al. Serial measurement of portal hemodynamics after partial portal decompression. Surgery 1986;100:52–58.

  6. 6.

    , , , et al. Hepatic encephalopathy after transjugular intrahepatic portosystemic shunts: Incidence and risk factors. Am J Gastroenterol 1995;90:549–555.

  7. 7.

    , , , et al. Hepatic encephalopathy after transjugular intrahepatic portosystemic shunt. Incidence and risk factors. Dig Dis Sci 1996;41:578–584.

  8. 8.

    , , , et al. Portal pressure, presence of gastroesophageal varices and bleeding. Hepatology 1985;5:419–424.

  9. 9.

    , , , et al. Hemodynamic events in a prospective randomized trial of propranolol versus placebo in the prevention of a first variceal hemorrhage. Gastroenterology 1990;99:1401–1407.

  10. 10.

    , , , et al. Propranolol in the prevention of the first hemorrhage from esophagogastric varices: A multicenter, randomized clinical trial. Hepatology 1991;13:902–912.

  11. 11.

    , , , et al. Clinical events after transjugular intrahepatic portosystemic shunt: Correlation with hemodynamic findings. Gastroenterology 1998;114:1296–1303.

  12. 12.

    The North Italian Endoscopic Club for the Study and Treatment of Esophageal VaricesPrediction of the first variceal hemorrhage in patients with cirrhosis of the liver and esophageal varices. N Engl J Med 1988;319:983–989.

  13. 13.

    , , De Franchis R, eds. Portal hypertension II; proceedings of the Second Baveno International Consensus Workshop 1996:1–9Blackwell Science: Oxford, UK

  14. 14.

    , , , et al. Portal hypertension and variceal bleeding: An AASLD single topic symposium. Hepatology 1998;28:868–880.

  15. 15.

    . The implantation and maintenance of TIPS: Rules of the road and tricks of the trade. In: Conn HO, Palmaz J, Rösch J, Rössle M, eds. TIPS: Transjugular intrahepatic portosystemic shunts 1996:177–196Igaku-Shoin: New York

  16. 16.

    , , , et al. The transjugular intrahepatic portosystemic stent-shunt procedure for variceal bleeding. N Engl J Med 1994;330:165–171.

  17. 17.

    , , , et al. Randomised trial of transjugular-intrahepatic-portosystemic shunt versus endoscopy plus propranolol for prevention of variceal rebleeding. Lancet 1997;349:1043–1049.

  18. 18.

    , , , et al. Transjugular intrahepatic portosystemic stent shunt versus sclerotherapy plus propranolol for variceal rebleeding. Gastroenterology 1997;113:1623–1631.

  19. 19.

    , , , et al. Transjugular intrahepatic portosystemic shunt versus sclerotherapy in the elective treatment of variceal hemorrhage. Gastroenterology 1996;110:832–839.

  20. 20.

    , , , et al. A randomized trial comparing transjugular intrahepatic portosystemic stent-shunt with variceal band ligation in the prevention of rebleeding from esophageal varices. Hepatology 1997;26:1115–1122.

  21. 21.

    , , , et al. Is the role of transjugular intrahepatic portosystemic shunts limited in the management of patients with end-stage liver disease?. Am J Surg 1996;172:536–540.

  22. 22.

    , , , et al. Relation between portal pressure response to pharmacotherapy and risk of recurrent variceal haemorrhage in patients with cirrhosis. Lancet 1995;346:1056–1059.

  23. 23.

    , , , et al. Nadolol plus isosorbide mononitrate compared with sclerotherapy for the prevention of variceal rebleeding. N Engl J Med 1996;334:1624–1629.

  24. 24.

    , , , et al. Clinical versus haemodynamic response to drugs in portal hypertension. J Hepatol 1998;28:1015–1019.

  25. 25.

    , , , et al. Failure of hemodynamic measurements to predict recurrent gastrointestinal bleeding in cirrhotic patients receiving propranolol. J Hepatol 1987;5:144–148.

  26. 26.

    , , , . Einfluβ von Alkohol auf die Hämodynamik der Pfortader bei nutritiv-toxischer Leberzirrhose. Dtsch Med Wochenschr 1993;118:89–93.

Download references

Author information


  1. Department of Gastroenterology, University Hospital, Freiburg, Germany

    • Martin Rössle
    • , Volker Siegerstetter
    • , Andreas Ochs
    • , Elisabeth Berger
    •  & Klaus Haag
  2. Institute of Biometry, Freiburg, Germany

    • Manfred Olschewski


  1. Search for Martin Rössle in:

  2. Search for Volker Siegerstetter in:

  3. Search for Manfred Olschewski in:

  4. Search for Andreas Ochs in:

  5. Search for Elisabeth Berger in:

  6. Search for Klaus Haag in:

Corresponding author

Correspondence to Martin Rössle.

About this article

Publication history






Further reading