From the Guidelines
The target for hepatic venous pressure gradient (HVPG) post transjugular intrahepatic portosystemic shunt (TIPS) should be reduced to <12 mmHg or by >=20% of baseline. This recommendation is based on the strongest and most recent evidence available, as outlined in the study published in Gut in 2020 1. The goal of TIPS is to reduce portal pressure enough to alleviate complications like variceal bleeding or refractory ascites while avoiding excessive reduction that could lead to hepatic encephalopathy.
Key Considerations
- The portal pressure gradient should be measured as that between the portal pressure and IVC, and measured pre- and post-stent deployment 1.
- For other indications beyond variceal bleeding, further reductions in the portal pressure gradient need to balance efficacy with risk of hepatic encephalopathy, and should be individualized 1.
- The role of embolisation with TIPSS is not clear and decisions should be individualised and based on cross-sectional imaging and portography showing large varices when portal pressure reduction alone may not be sufficient 1.
Monitoring and Follow-up
- A Doppler ultrasound is recommended a week after TIPSS implantation in patients with prothrombotic conditions, and in other patients where TIPSS dysfunction is suspected 1.
- Doppler ultrasound is recommended at 6–12 monthly intervals or 6-monthly in patients undergoing HCC surveillance 1.
- Patients with prothrombotic conditions such as BCS require follow-up with Doppler ultrasound with careful consideration for TIPSS venography as determined by the interventional radiologist 1.
From the Research
Target for HVPG post TIPS
- The target for hepatic venous pressure gradient (HVPG) post transjugular intrahepatic portosystemic shunt (TIPS) is not explicitly stated in the provided studies, but it can be inferred that the goal is to reduce HVPG to a level that prevents variceal rebleeding.
- A study published in the European journal of gastroenterology & hepatology 2 found that covered TIPS was more effective than endoscopic therapy + β-blocker in preventing rebleeding in patients with HVPG ≥16 mmHg.
- Another study published in the Journal of clinical gastroenterology 3 stated that TIPS is more effective than standard therapy for patients with HVPG >20 mmHg.
- A study published in the International journal of clinical and experimental medicine 4 found that HVPG-guided treatment is feasible and effective in preventing esophageal varices rebleeding, and that TIPS is recommended for patients with HVPG >20 mmHg.
HVPG Measurement and TIPS
- HVPG measurement is an important tool in guiding treatment for variceal rebleeding in cirrhosis, and can be used to select patients for TIPS 4, 5.
- A study published in the World journal of gastroenterology 5 found that HVPG measurement can be used to identify candidates for early insertion of TIPS or maintenance of traditional pharmacological and/or endoscopic therapy.
- Another study published in the Journal of vascular and interventional radiology 6 emphasized the importance of accurate HVPG measurement in clinical practice, including in the management of patients undergoing TIPS.