Increased cerebral and peripheral vasodilation, and whole body nitric oxide production after insertion of a transjugular intrahepatic portal-system stent in patients with cirrhosis

Although increased intracranial pressure is classically associated with acute liver failure, some patients with cirrhosis, who undergo insertion of a transjugular intrahepatic portosystemic stent (TIPSS), develop this complication. The aims of this study were to investigate whether TIPSS insertion results in an increase in cerebral blood flow (CBF) and to study nitric oxide (NO) metabolism, prior to and following insertion of TIPSS.We studied twelve patients with cirrhosis, who were undergoing TIPSS insertion for variceal bleeding. Cardiovascular hemodynamics were monitored continuously, cardiac output was measured using a Swan-Ganz catheter, cerebral blood flow was measured using the Kety-Schmidt technique, and whole body NO production was measured using a stable isotope technique, which involved a primed, continuous infusion of L[guanidine-N-15(2)] arginine (1 mg/kg/hr) and L-[ureido-C-13;5,5-H-2(2)] citrulline (0.1 mg/kg/min).TIPSS insertion was followed by a significant reduction in mean arterial pressure and an increase in cardiac output and CBF. There was also a significant increase in whole body NO production. The change in NO production correlated with the changes in mean arterial pressure, cardiac output and CBF.The results suggest an important role for NO as a mediator of systemic and cerebrovascular disturbances after TIPSS.