From the Guidelines
Signs of Transjugular Intrahepatic Portosystemic Shunt (TIPS) failure include recurrence of the original symptoms that prompted the TIPS procedure, such as variceal bleeding, ascites, or hepatic hydrothorax, with the most common indicator being the reappearance of ascites, which manifests as abdominal distension and increased abdominal girth. The failure of TIPS for bleeding is defined by recurrence of PHT-related rebleeding, while the failure of TIPS for ascites is defined by the absence of response after 4 weeks or a new episode later, as stated in the french guidelines on TIPS 1. Other signs of TIPS failure include new episodes of variceal bleeding, worsening encephalopathy, and elevated portal pressure gradients on measurement. TIPS failure can occur due to stenosis or occlusion of the stent, which happens when the shunt narrows or becomes blocked by thrombus or tissue overgrowth. Some key points to consider when monitoring for TIPS failure include:
- Clinical efficacy should be assessed based on the capacity to manage and prevent the PHT-related complications, as recommended in the french guidelines on TIPS 1
- A clinical examination should be conducted before discharge at 1 month and every 3 months during the initial year with a focus on identifying signs of liver and heart decompensation, such as jaundice, hepatic encephalopathy, lower limb oedema, and dyspnoea 1
- Liver function tests should be conducted before discharge, at 1 month and every 3 months during the first year to monitor for signs of liver decompensation 1
- Hepatic encephalopathy should be systematically assessed at each clinical visit, using the West Haven classification, and the animal naming test could be used for the screening of minimal HE 1 Regular surveillance with Doppler ultrasound is recommended to detect TIPS dysfunction before clinical symptoms appear, as early intervention with revision procedures can restore shunt function and prevent complications, as discussed in the acr appropriateness criteria for radiologic management of portal hypertension 1. Patients should be monitored for these signs and promptly evaluated if they develop, as timely intervention is crucial for maintaining the effectiveness of the TIPS.
From the Research
Signs of TIPS Failure
- Rebleeding or recurrent ascites after TIPS creation are often associated with shunt stenosis or occlusion 2
- Technical complications related to TIPS placement, such as venous access and imaging, transhepatic needle puncture, shunt insertion, and variceal embolization, can also lead to TIPS failure 3
- TIPS dysfunction can be caused by biologic and technical factors, including the use of bare stents, which have limited and unpredictable patency 2
- The incidence of recurrent variceal bleeding is higher in patients treated with endoscopic treatment (ET) compared to those treated with TIPS, indicating a potential sign of TIPS failure if bleeding recurs 4
Factors Predisposing to TIPS Failure
- Advanced liver disease, with a Child-Pugh score >13 points, is a contraindication to TIPS placement and may predispose to TIPS failure 5
- Episodes of recurrent overt hepatic encephalopathy without an identifiable precipitating factor, heart failure, and pulmonary hypertension are also contraindications to TIPS placement and may contribute to TIPS failure 5
- The use of bare stents, rather than expandable polytetrafluoroethylene (PTFE)-covered stents, may increase the risk of TIPS failure due to limited patency 2