From the Guidelines
Patients with refractory ascites should be considered for Transjugular Intrahepatic Portosystemic Shunt (TIPS) placement, as it is a recommended treatment option with high-quality evidence. When evaluating candidacy for TIPS, several factors should be taken into account, including the patient's liver function, age, and presence of comorbidities. According to the guidelines on the management of ascites in cirrhosis 1, TIPS should be considered in patients with refractory ascites, with a strong recommendation based on high-quality evidence.
Key Considerations for TIPS Candidacy
- Patients with age >70 years, serum bilirubin >50 μmol/L, platelet count <75×10^9/L, model for end-stage liver disease (MELD) score ≥18, current hepatic encephalopathy, active infection, or hepatorenal syndrome require caution when considering TIPS placement, as these factors may increase the risk of complications 1.
- The decision to perform TIPS in patients with severe liver disease or multiple organ failure should be made on a case-by-case basis, taking into account the patient's potential for liver transplantation and overall prognosis 1.
- Salvage TIPS may be futile in patients with multiple organ failure, Child-Pugh score ≥14, or MELD score ≥30 and/or lactatemia ≥12 mmol/L after initial resuscitation, and should be considered carefully in these cases 1.
Evaluation and Follow-up
Before TIPS placement, patients should undergo comprehensive evaluation, including liver function tests, coagulation studies, renal function assessment, cardiac evaluation, and cross-sectional imaging to assess portal vein patency and hepatic anatomy. Following TIPS placement, patients require regular follow-up with Doppler ultrasound to assess shunt patency and monitor for potential complications, such as hepatic encephalopathy and TIPS dysfunction. Prophylactic measures for hepatic encephalopathy, such as lactulose or rifaximin, may be considered in high-risk patients.
From the Research
Candidacy for TIPS
Candidacy for Transjugular Intrahepatic Portosystemic Shunt (TIPS) is determined by several factors, including the presence of complications of portal hypertension, such as variceal hemorrhage and ascites. The following are some of the key indications for TIPS:
- Persistent bleeding despite combined pharmacological and endoscopic therapy 2
- Rebleeding during the first five days 2
- Early TIPS placement within 72 hours, ideally within 24 hours, in patients bleeding from esophageal or gastroesophageal varices at high risk for treatment failure 2
- Prevention of recurrent variceal hemorrhage in patients who have failed first-line therapy 2, 3
- Secondary prophylaxis in patients with refractory ascites who are intolerant to non-selective beta blockers (NSBBs) 2, 3
Contraindications for TIPS
Contraindications for TIPS placement include:
- Very advanced disease (Child-Pugh score >13 points) 3
- Episodes of recurrent overt hepatic encephalopathy without an identifiable precipitating factor 3
- Heart failure 3
- Pulmonary hypertension 3
Predictive Factors for Mortality
The Model for End-Stage Liver Disease (MELD) score has been shown to be a better predictor of early mortality in patients with refractory ascites treated by TIPS compared to the Child-Pugh score 4. A higher MELD score is associated with an increased risk of early mortality.
TIPS vs. Endoscopic Treatment
TIPS has been shown to be more effective in preventing recurrent variceal bleeding and reducing mortality compared to endoscopic treatment (ET) 5. However, TIPS is typically reserved for patients who have failed first-line therapy or are at high risk for treatment failure.