To the Editor:--We are interested to note Yonker-Sell et al.'s comments on the role of the anesthesiologist during transjugular intrahepatic portosystemic shunt procedures, in their report of mortality during such a procedure under monitored anesthesia care. [1]They suggest that anesthesiologists should “… provide the necessary support should inadvertent complications occur.” In contrast, 30 of the last 38 transjugular intrahepatic portosystemic shunt procedures that we performed through December 1995 were performed under general anesthesia, and we advocate increased anesthesiologist participation for this procedure.

Patients with hepatic failure and portal hypertension already have risk factors for aspiration of gastric contents, including ascites and esophageal varices (often with recent or active bleeding). In addition, airway access may be impeded after cannulation of the internal jugular vein and catheter and shunt placement is underway.

Securing of the airway electively with an endotracheal tube would also seem prudent, because emergency airway manipulation is more likely to cause hemorrhage in these patients with preexisting coagulopathies. Our current policy of general anesthesia was initiated after a patient, who required airway manipulation bled profusely from an atraumatic insertion of a nasopharyngeal airway. The trachea was intubated, with difficulty, over a radio-opaque guidewire (one of the advantages of being in the angiography suite!).

For these reasons, we believe that the anesthesiologist is better prepared to manage inadvertent complications with the airway already secured in an elective, atraumatic fashion, and with an anesthetized patient as opposed to techniques that involve conscious sedation.

Evan G. Pivalizza, M.B.Ch.B., F.F.A., Lewis I. Gottschalk, M.B.Ch.B., F.F.A., L.M.C.C., Department of Anesthesiology.

Alan Cohen, M.D., Michael Middelbrook, M.D., George Soltes, M.D., Department of Interventional Radiology, University of Texas Medical School at Houston, MSMB 5.020, 6431 Fannin, Houston, Texas 77030.

(Accepted for publication July 18, 1996.)

Yonker-Sell AE, Connolly LA: Mortality during transjugular intrahepatic portosystemic shunt placement. ANESTHESIOLOGY 1996; 84:231-3.