Small-diameter portacaval H-graft for variceal hemorrhage

This report describes the steps in the development of the concept of partial shunting from its earliest stages to the 8-mm-diameter portacaval H-graft. Sequentially decreasing the diameter of the graft from 20 mm did not seem to affect hepatic hemodynamics until the 10-mm-diameter graft was used. At this point, we began to see some patients maintain prograde portal flow. Further reduction in diameter gave a higher rate of patients with prograde flow. Postoperative flow patterns correlate with lower encephalopathy rates and better long-term survival. Important nuances of the operative technique as well as pre- and postoperative management are described.