A Systematic Appraisal of Portacaval H-Graft Diameters

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Abstract
Over a period of 10 years, the authors have systematically reduced portacaval H-graft diameters. Their objective was to achieve partial shunting of portal flow without reversal of hepatic flow. This report summarizes their clinical and hemodynamic observations in 68 surviving patients with cirrhosis (mostly alcoholic) and variceal hemorrhage who underwent portacaval H-grafts ranging from 20 to 8 mm diameters. When shunt diameters were reduced to 10 and 8 mm and combined with aggressive portal collateral ablation, portal pressures increased significantly over larger H-grafts. Only 3% of patients with 20-12 mm H-grafts had prograde portal flow after operation, compared with 46 and 82% and 10 and 8 mm H-grafts, respectively (p < 0.001). The incidence of encephalopathy diminished from 39% in the 20-12 mm H-graft group to 19 and 9% after 10 and 8 mm grafts, respectively (p < 0.04). None of the patients with 10 or 8 mm PTFE grafts rebled from varices in the follow-up period (4-61 months). It is concluded that partial shunting of portal flow is hemodynamically feasible. It can achieved in most patients using 8 mm polytetrafluoroethylene (PTFE) portacaval H-grafts combined with portal collateral ablation. Preserving prograde portal flow by partial shunting correlates with reduced encephalopathy rates after operation. Despite maintaining a relatively hypertensive portal system, partial shunts effectively prevent variceal hemorrhage.