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The 2009 update of the American Association for the Study of Liver Diseases (AASLD) Practice Guideline “The Role of Transjugular Intrahepatic Portosystemic Shunt (TIPS) in the Management of Portal Hypertension” is now posted online at www.aasld.org. This is the first update of the original guideline published in 2005.1

The key changes in the 2009 guidelines are new recommendations on the use of covered versus bare stents in the creation of the TIPS. Use of expanded polytetrafluoroethylene (ePTFE)-covered stents is now preferred. The lower risk of shunt dysfunction and perhaps improved outcomes using covered as opposed to bare stents are the basis for this recommendation.2, 3 Creation of a TIPS increases the risk of hepatic encephalopathy but the prophylactic use of nonabsorbable disaccharides or antibiotics does not appear to reduce this risk and is not recommended.4

The value of TIPS versus a surgical shunt in the prevention of variceal rebleeding in patients who have failed medical therapy has been clarified by the publication of a controlled trial comparing TIPS to distal splenorenal shunt (DSRS).5 Both were effective in preventing rebleeding (rebleeding incidence in 5.5% of DSRS versus 10.5% of TIPS; not significant) with no difference in encephalopathy or survival. The patients in whom TIPS was performed required significantly more interventions to maintain patency because of the use of bare stents. A cost analysis showed TIPS to be slightly more cost effective than DSRS at year 5,6 and these two approaches are now considered to be of equal efficacy in the prevention of variceal rebleeding.

The other significant change to the guidelines is how TIPS should be used in the management of patients with Budd-Chiari syndrome. A large (221 patients) retrospective study was published in which patients who failed to improve with use of anticoagulation had a TIPS created (133 patients). One-year and 10-year transplant-free survival was 88% and 69%, respectively, which is better than predicted.7 TIPS patency was best in those who received a covered stent. The recommendation now is for creation of a TIPS in those who fail to improve with anticoagulation.

References

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  2. References
  • 1
    Boyer TD, Haskal Z. AASLD Practice Guidelines: The role of transjugular intrahepatic portosystemic shunt in the management of portal hypertension. HEPATOLOGY 2005; 41: 386400.
  • 2
    Bureau C, Garcia Pagan JC, Layrargues GP, Metivier S, Bellot P, Perreault P, et al. Patency of stents covered with polytetrafluoroethylene in patients treated by transjugular portosystemic shunts: long-term results of a randomized multicentre study. Liver Int 2007; 27: 742747.
  • 3
    Angermayr B, Cejna M, Koenig F, Karnel F, Hackl F, Gangl A, et al.; for Vienna TIPS study group. Survival in patients undergoing transjugular intrahepatic portosystemic shunt: ePTFE-covered stentgrafts versus bare stents. HEPATOLOGY 2003; 38: 10431050.
  • 4
    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.
  • 5
    Henderson JM, Boyer TD, Kutner M, Galloway JR, Rikkers LF, Jeffers LJ, et al. Distal splenorenal shunt versus transjugular intrahepatic portal systemic shunt for variceal bleeding: A randomized trial. Gastroenterology 2006; 130: 16431651.
  • 6
    Boyer TD, Henderson JM, Heerey AM, Arrigain S, Konig V, Connor J, et al. Cost of preventing variceal rebleeding with transjugular intrahepatic portal systemic shunt and distal splenorenal shunt. J Hepatol 2008; 48: 407414.
  • 7
    Garcia-Pagan JC, Heydtmann M, Raffa S, Plessier A, Murad S, Fabris F, et al. TIPS for Budd-Chiari syndrome: Long-term results and prognostics factors in 124 patients. Gastroenterology 2008; 135: 808815.