Indications for Transjugular Intrahepatic Portosystemic Shunt (TIPS) in Cirrhosis
TIPS is strongly recommended for patients with cirrhosis who have refractory or recurrent ascites, uncontrolled acute variceal hemorrhage, or high-risk patients with variceal bleeding who have been successfully treated with endoscopic therapy but are at risk of rebleeding. 1
Primary Indications for TIPS
1. Variceal Bleeding
Acute Variceal Hemorrhage
- Rescue/Salvage TIPS: For uncontrolled bleeding despite pharmacological and endoscopic treatment 1
- Pre-emptive/Early TIPS (within 72 hours of admission): For high-risk patients who have been successfully treated with endoscopy but are at high risk of rebleeding 1
- Child-Pugh C (score <14) cirrhosis
- Child-Pugh B with active bleeding at endoscopy
Prevention of Variceal Rebleeding
2. Ascites and Fluid Complications
- Refractory Ascites: Ascites that cannot be managed with sodium restriction and diuretics 1
- Recurrent Ascites: Requiring at least 3 large volume paracenteses per year despite optimal medical therapy 1
- Refractory Hepatic Hydrothorax: Requiring frequent thoracentesis or with significant clinical symptoms (hypoxia, resting dyspnea) 1
Secondary Indications for TIPS
1. Portal Vein Thrombosis (PVT)
- Cirrhotic patients with PVT who:
2. Budd-Chiari Syndrome
- After failure of medical treatment with anticoagulation 1
- When hepatic vein interventions (angioplasty/stenting) are ineffective or impossible 1
- In fulminant Budd-Chiari syndrome (with concurrent liver transplant evaluation) 1
3. Other Indications
- Gastric Varices: Bleeding gastric-fundal varices when endoscopic management is not possible or has failed 1
- Portal sinusoidal vascular disease (PSVD): Same indications as cirrhotic portal hypertension 1
- Ectopic Varices: Recurrent bleeding despite standard therapy 1
Contraindications to TIPS
Absolute Contraindications
- Severe liver failure (Child-Pugh score >13 points) 1
- Congestive heart failure 1, 2
- Severe pulmonary hypertension 1
- Uncontrolled systemic infection or sepsis 1
- Unrelieved biliary obstruction 1
Relative Contraindications
- Hepatic encephalopathy (especially recurrent episodes without identifiable precipitating factors) 1, 2
- Active hepatocellular carcinoma 1
- Severe coagulopathy (INR >5) 1
- Thrombocytopenia (<20,000/mm³) 1
- Advanced age (>65 years) - increases risk of post-TIPS encephalopathy 1
- Bilirubin >50 μmol/L and platelets <75×10⁹/L (for ascites indication) 1
Post-TIPS Monitoring
- Doppler ultrasound at 3 months post-TIPS and every 6 months thereafter 1
- If TIPS stenosis/occlusion is suspected or patient rebleeds, TIPS venogram with pressure measurements is indicated 1
- For Budd-Chiari syndrome or chronic portal vein thrombosis, early Doppler ultrasound followed by surveillance every 6 months 1
Clinical Outcomes
- TIPS significantly reduces the risk of further decompensation events compared to standard of care (48% vs 63% at 2 years) 3
- TIPS improves 2-year survival compared to standard medical therapy (71% vs 63%) in selected patients 3
- For variceal bleeding prevention, small-diameter covered TIPS is more effective than medical therapy (7% vs 26% rebleeding rate) 4
Important Considerations
- TIPS should be performed by experienced operators in centers with expertise in portal hypertension management 1
- For refractory ascites, a staged approach is recommended (initial 8mm stent dilation with progressive increases to 9mm and 10mm at 6-week intervals if needed) 1
- Response to TIPS for ascites typically takes 4-6 weeks as negative sodium balance is achieved 1
- All patients receiving TIPS should be considered for liver transplant evaluation, as TIPS is not a definitive treatment for the underlying liver disease 5
TIPS represents a significant advancement in managing portal hypertension complications, but careful patient selection is critical to balance the benefits against potential complications like hepatic encephalopathy.