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Abbreviations
HE

hepatic encephalopathy

MELD

Model for End-Stage Liver Disease

TIPS

transjugular intrahepatic portosystemic shunt

Cirrhosis leads to complications related to portal hypertension, including hepatic encephalopathy (HE), varices, and ascites. In the past, surgical decompression was used when portal decompression was warranted; however, this approach is associated with significant risks. Transhepatic intrahepatic portosystemic shunt (TIPS) stent placement is a minimally invasive procedure that is preferred for the management of portal decompression.

TIPS Procedure

  1. Top of page
  2. Abstract
  3. TIPS Procedure
  4. Patient Selection
  5. Indications for TIPS
  6. Other Uses of TIPS in the Management of Portal Hypertension
  7. Complications
  8. Follow-Up
  9. Summary
  10. References

A TIPS stent is placed via interventional radiology using an aseptic technique with conscious sedation. A needle catheter is passed via the right internal jugular vein to the hepatic vein, and then a tract is made to the intrahepatic portion of the portal vein. The hepatic tract is then dilated and kept patent through deployment of a metal stent. The TIPS placement is illustrated in Fig. 1.[1] The technical goal of TIPS placement is to decrease the hepatic venous pressure gradient to <12 mm Hg unless there is clinically significant encephalopathy, in which case clinical judgment must be used.[2]

image

Figure 1. TIPS stent placement. (A) Portal hypertension. (B) Portal decompression. Reprinted with permission from Clinical Gastroenterology and Hepatology.[1] Copyright 2011, Elsevier, Inc.

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Patient Selection

  1. Top of page
  2. Abstract
  3. TIPS Procedure
  4. Patient Selection
  5. Indications for TIPS
  6. Other Uses of TIPS in the Management of Portal Hypertension
  7. Complications
  8. Follow-Up
  9. Summary
  10. References

The individual patient factors and clinical scenario should be evaluated when considering TIPS placement. Table 1 outlines the absolute and relative contraindications for a TIPS shunt.[2] Patients should have baseline blood work to assess their liver and kidney function.[2] A high bilirubin level can lead to poor outcomes post-TIPS.[3] The Model for End-Stage Liver Disease (MELD) score was created to identify 3-month mortality post-TIPS. There is no absolute MELD score above which TIPS is not possible; however, as the MELD score increases, so does mortality.[4] Patients with a clinical history suggestive of cardiac disease should undergo a cardiac evaluation, as TIPS increases the cardiac filling volume.[2] The TIPS stent shunts blood directly from the portal circulation to the hepatic vein, raising the concern for HE. In general, if a patient has a history of HE, one should cautiously evaluate whether TIPS is appropriate in this setting.

Table 1. Absolute and Relative Contraindications for TIPS
Absolute ContraindicationsRelative Contraindications
Congestive heart failureInternational normalized ratio > 5
Severe pulmonary hypertensionPlatelet count < 20,000/cm3
Multiple hepatic cystsModerate pulmonary hypertension
Uncontrolled systemic infection; sepsisPortal vein thrombosis
Unrelieved biliary obstruction 

Indications for TIPS

  1. Top of page
  2. Abstract
  3. TIPS Procedure
  4. Patient Selection
  5. Indications for TIPS
  6. Other Uses of TIPS in the Management of Portal Hypertension
  7. Complications
  8. Follow-Up
  9. Summary
  10. References

The current accepted indications for TIPS placement are seen in patients who fail medical therapy for prevention of variceal rebleeding or in acute variceal bleeding that is refractory to medical management, and for management of refractory ascites.

Varices

There are two settings in which TIPS is considered in subjects with variceal hemorrhage. First, in patients who present with severe active hemorrhage and continue to bleed or have early rebleeding despite initial control with pharmacological and endoscopic treatment, TIPS has been shown to induce hemostasis in over 90% of subjects and substantially improve survival.[5] TIPS is also effective in establishing hemostasis in subjects with isolated gastric varices, which are not amenable to endoscopic treatment. The first-line treatment for secondary prophylaxis of variceal hemorrhage is a combination of endoscopic band ligation and nonselective beta blockade. Subjects who experience recurrent bleeding despite an adequate attempt to provide secondary prophylaxis should also be considered for TIPS.[6] Two studies have demonstrated that the timing of TIPS may be an important determinant of outcomes. In subjects with variceal hemorrhage, early institution of TIPS (within 72 hours) is associated with superior outcomes compared with medical therapy.[7] The results of this study are outlined in Fig. 2.[7] This may be particularly true for patients who have a hepatic venous pressure gradient >20 mm Hg, a critical threshold that is associated with a greater risk of failure of medical management of active bleeding.[8, 9]

image

Figure 2. Early TIPS compared with endoscopic band ligation. (A) The probability of remaining free from rebleeding or uncontrolled bleeding. (B) Survival. Reprinted with permission from New England Journal of Medicine.[7] Copyright 2010, Massachusetts Medical Society.

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Refractory Ascites

Refractory ascites is defined as ascites that is unresponsive to diuretics or ascites that prevents patients from tolerating diuretics due to side effects.[10] Studies that have evaluated TIPS compared with repeated paracentesis have demonstrated that TIPS is superior in managing ascites. The impact of TIPS on survival in randomized controlled trials has varied, with two studies demonstrating a survival advantage[11, 12] and three demonstrating no such advantage.[12-15] However, of the two studies that demonstrated a survival advantage, one included patients with both refractory ascites and recivident ascites (defined as at the occurrence of tense ascites at least three times in 12 months despite a low sodium diet and diuretics), and the other included only patients with relatively preserved liver and renal function.[11, 12] Although conventional meta-analyses have failed to show a survival benefit with TIPS, as illustrated in Fig. 3, a single meta-analysis that stratified subjects by the MELD score found that those undergoing TIPS had a survival advantage.[16-18]

image

Figure 3. Relative risks and 95% confidence intervals for recurrence of ascites, encephalopathy, and mortality for TIPS compared with repeated paracentesis for management of refractory ascites in a meta-analysis. Reprinted with permission from Journal of Hepatology.[18] Copyright 2005, Elsevier, Inc.

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Other Uses of TIPS in the Management of Portal Hypertension

  1. Top of page
  2. Abstract
  3. TIPS Procedure
  4. Patient Selection
  5. Indications for TIPS
  6. Other Uses of TIPS in the Management of Portal Hypertension
  7. Complications
  8. Follow-Up
  9. Summary
  10. References

TIPS has been used in the management of other complications of portal hypertension, including hepatic hydrothorax,[19] hepatorenal syndrome,[20] and portal vein thrombosis[21]; however, these are not widely accepted indications, and they have not been studied in rigorous randomized controlled trials.

Complications

  1. Top of page
  2. Abstract
  3. TIPS Procedure
  4. Patient Selection
  5. Indications for TIPS
  6. Other Uses of TIPS in the Management of Portal Hypertension
  7. Complications
  8. Follow-Up
  9. Summary
  10. References

The complications of TIPS placement can be related to the technique or to portosystemic shunting or can be unique complications.

Complications Related to the Technique or Stent

Complications that may occur during stent placement include inadvertent puncture of the carotid artery, cardiac arrhythmia, hepatobiliary fistula, capsule puncture, or stent migration.[22] Periprocedural infection can take the form of bacteremia or stent infection, known as endotipsitis.[23] It is recommended to administer prophylactic antibiotics prior to the procedure.[24] TIPS-induced hemolysis is another recognized complication.[22] An important complication of TIPS stent is stent occlusion, and although the advent of covered stents has resulted in lower occlusion rates compared with uncovered stents, it remains a complication.

Complications Related to Portosystemic Shunting

HE is an important complication of TIPS.[25] Risk factors include pre-TIPS recurrent HE, age, and liver dysfunction.[25, 26] Prophylactic lactitol or rifaximin has not been shown to decrease the incidence of post-TIPS HE.[27] Post-TIPS HE can be treated with standard of care treatment for HE. Recurrent HE that does not respond to standard treatment may require shunt revision to decrease the diameter or shunt occlusion.[25]

Follow-Up

  1. Top of page
  2. Abstract
  3. TIPS Procedure
  4. Patient Selection
  5. Indications for TIPS
  6. Other Uses of TIPS in the Management of Portal Hypertension
  7. Complications
  8. Follow-Up
  9. Summary
  10. References

There are no guidelines of frequency of follow-up imaging to ensure the TIPS stent is patent. However, it is generally accepted that Doppler ultrasound imaging should be performed initially at 3 months and then every 6 months to assess patency of the shunt. Shunt revision may be required if the complications for which the TIPS was inserted return, such as varices or ascites. Shunt thrombosis may be required in patients with post-TIPS HE refractory to medical therapy.

Summary

  1. Top of page
  2. Abstract
  3. TIPS Procedure
  4. Patient Selection
  5. Indications for TIPS
  6. Other Uses of TIPS in the Management of Portal Hypertension
  7. Complications
  8. Follow-Up
  9. Summary
  10. References

TIPS has been used to manage the complications of portal hypertension that are refractory to medical management, including varices and refractory ascites. With the introduction of covered stents, shunt patency is improved compared with the previously used uncovered stents.[28] Evaluations should be made prior to consideration of TIPS to assess individual patient suitability. Providers should be aware of the periprocedural and stent-related complications of TIPS. Once the stent is placed, regular follow-up of shunt patency is recommended.

References

  1. Top of page
  2. Abstract
  3. TIPS Procedure
  4. Patient Selection
  5. Indications for TIPS
  6. Other Uses of TIPS in the Management of Portal Hypertension
  7. Complications
  8. Follow-Up
  9. Summary
  10. References
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  • 2
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  • 3
    Rajan DK, Haskal ZJ, Clark TW. Serum bilirubin and early mortality after transjugular intrahepatic portosystemic shunts: results of a multivariate analysis. J Vasc Interv Radiol 2002;13:155161.
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    Kamath PS, Wiesner RH, Malinchoc M, Kremers W, Therneau TM, Kosberg CL, et al. A model to predict survival in patients with end-stage liver disease. Hepatology 2001;33:464470.
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    Moitinho E, Escorsell A, Bandi JC, Salmeron JM, Garcia-Pagan JC, Rodes J, et al. Prognostic value of early measurements of portal pressure in acute variceal bleeding. Gastroenterology 1999;117:626631.
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    Monescillo A, Martinez-Lagares F, Ruiz-del-Arbol L, Sierra A, Guevara C, Jimenez E, et al. Influence of portal hypertension and its early decompression by TIPS placement on the outcome of variceal bleeding. Hepatology 2004;40:793801.
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    Arroyo V, Ginès P, Gerbes AL, Dudley FJ, Gentilini P, Laffi G, et al. Definition and diagnostic criteria of refractory ascites and hepatorenal syndrome in cirrhosis. Hepatology 1996;23:164176.
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    Narahara Y, Kanazawa H, Fukuda T, Matsushita Y, Harimoto H, Kidokoro H, et al. Transjugular intrahepatic portosystemic shunt versus paracentesis plus albumin in patients with refractory ascites who have good hepatic and renal function: a prospective randomized trial. J Gastroenterol 2011;46:7885.
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    Salerno F, Merli M, Riggio O, Cazzaniga M, Valeriano V, Pozzi M, et al. Randomized controlled study of TIPS versus paracentesis plus albumin in cirrhosis with severe ascites. Hepatology 2004;40:629635.
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    Rössle M, Ochs A, Gulberg V, Siegerstetter V, Holl J, Deibert P, et al. A comparison of paracentesis and transjugular intrahepatic portosystemic shunting in patients with ascites. N Engl J Med 2000;342:17011707.
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    Ginès P, Uriz J, Calahorra B, Garcia-Tsao G, Kamath PS, Del Arbol LR, et al. Transjugular intrahepatic portosystemic shunting versus paracentesis plus albumin for refractory ascites in cirrhosis. Gastroenterology 2002;123:18391847.
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    Sanyal AJ, Genning C, Reddy KR, Wong F, Kowdley KV, Benner K, et al. The North American Study for the Treatment of Refractory Ascites. Gastroenterology 2003;124:634641.
  • 16
    Saab S, Nieto JM, Ly D, Runyon BA. TIPS versus paracentesis for cirrhotic patients with refractory ascites. Cochrane Database Syst Rev 2004;3:CD004889.
  • 17
    Salerno F, Camma C, Enea M, Rossle M, Wong F. Transjugular intrahepatic portosystemic shunt for refractory ascites: a meta-analysis of individual patient data. Gastroenterology 2007;133:825834.
  • 18
    Albillos A, Banares R, Gonzalez M, Catalina MV, Molinero LM. A meta-analysis of transjugular intrahepatic portosystemic shunt versus paracentesis for refractory ascites. J Hepatol 2005;43:990996.
  • 19
    Dhanasekaran R, West JK, Gonzales PC, Subramanian R, Parekh S, Spivey JR, et al. Transjugular intrahepatic portosystemic shunt for symptomatic refractory hepatic hydrothorax in patients with cirrhosis. Am J Gastroenterol 2010;105:635641.
  • 20
    Wong F, Pantea L, Sniderman K. Midodrine, octreotide, albumin, and TIPS in selected patients with cirrhosis and type 1 hepatorenal syndrome. Hepatology 2004;40:5564.
  • 21
    Luca A, Miraglia R, Caruso S, Milazzo M, Sapere C, Maruzzelli L, et al. Short- and long-term effects of the transjugular intrahepatic portosystemic shunt on portal vein thrombosis in patients with cirrhosis. Gut 2011;60:846852.
  • 22
    Freedman AM, Sanyal AJ, Tisnado J, Cole PE, Shiffman ML, Luketic VA, et al. Complications of transjugular intrahepatic portosystemic shunt: a comprehensive review. Radiographics 1993;13:11851210.
  • 23
    Sanyal AJ, Reddy KR. Vegetative infection of transjugular intrahepatic portosystemic shunts. Gastroenterology 1998;115:110115.
  • 24
    Venkatesan AM, Kundu S, Sacks D, Wallace MJ, Wojak JC, Rose SC, et al. Practice guideline for adult antibiotic prophylaxis during vascular and interventional radiology procedures. J Vasc Interv Radiol 2010;21:16111630.
  • 25
    Riggio O, Angeloni S, Salvatori FM, De Santis A, Cerini F, Farcomeni A, et al. Incidence, natural history, and risk factors of hepatic encephalopathy after transjugular intrahepatic portosystemic shunt with polytetrafluoroethylene-covered stent grafts. Am J Gastroenterol 2008;103:27382746.
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  • 26
    Riggio O, Nardelli S, Moscucci F, Pasquale C, Ridola L, Merli M. Hepatic encephalopathy after transjugular intrahepatic portosystemic shunt. Clin Liver Dis 2012;16:133146.
  • 27
    Riggio O, Masini A, Efrati C, Nicolao F, Angeloni S, Salvatori FM, et al. Pharmacological prophylaxis of hepatic encephalopathy after transjugular intrahepatic portosystemic shunt: a randomized controlled study. J Hepatol 2005;42:674679.
  • 28
    Bureau C, Pagan JC, Layrargues GP, Metivier S, Bellot P, Perreault P, et al. Patency of stents covered with polytetrafluoroehtylene in patients treated by transjugular intrahepatic portosystemic shunts: long-term results of a randomized multicentre study. Liver Int 2007;27:742747.