Tripathi et al. report their experience with transjugular intrahepatic portosystemic stent-shunts (TIPSS) in Budd-Chiari syndrome (BCS). In this single-centre retrospective study of 67 BCS patients who underwent TIPSS, Tripathi et al. show encouraging long-term outcomes, particularly with the use of covered stents. Long-term survival was excellent (80% at 5 years and 72% at 10 years). While procedure-related complications were common, they were not life threatening. The authors also validated the BCS-TIPS prognostic score in their entire cohort over the other scores.
This excellent outcome, however, may be contingent on local expertise and patient characteristics. It is to be noted that all the procedures were performed single-handedly by two experienced physicians, cases had been carefully selected (only 68 of the 104 patients actually underwent TIPSS) and all patients were maintained on full anticoagulation throughout. It would have been helpful to know what criteria were used for patient selection to generalise these findings, and whether the improved survival was a function of effective anticoagulation.
Owing to the lack of randomised controlled evidence and the relative rarity of BCS, the management of BCS will likely continue to be based on expert opinions and local expertise. In general, recanalisation attempts are advocated as the first line, and TIPSS as the rescue step when the former is unsuitable or ineffective. While angioplasty is common in Asia and surgical shunts are favoured in certain US centres,[5, 6] TIPSS has become increasingly popular in Europe.[3, 7] Given the feasibility, safety, efficacy profile and excellent long-term survival, the authors add to the growing body of evidence regarding the importance of TIPSS as a viable option for Budd-Chiari syndrome.