Is TIPS (Transjugular Intrahepatic Portosystemic Shunt) recommended for treating gastric varices?

TIPS for Gastric Varices: Recommendations and Management

TIPS (Transjugular Intrahepatic Portosystemic Shunt) is recommended for gastric varices, particularly when they rebleed after endoscopic therapy or as first-line therapy in selected patients with large or multiple gastric varices. 1

Indications for TIPS in Gastric Variceal Bleeding

TIPS is indicated in several clinical scenarios for gastric varices:

Rescue/Salvage TIPS

• For patients with bleeding gastric-fundal varices that cannot be managed endoscopically 1
• When patients rebleed after endoscopic therapy 1
• For patients with hemodynamic instability and profuse bleeding where endoscopic therapy is not feasible 1

Pre-emptive/Early TIPS

• Should be considered within 72 hours of admission in hemodynamically stable patients with:
  • Child's C disease (C10-13) or MELD ≥19
  • Bleeding from GOV1 and GOV2 gastric varices 1
• Recent evidence suggests particular benefit in patients with Child-Pugh B or C scores bleeding from gastric fundal varices 2

Secondary Prevention

• TIPS ± embolization is recommended where patients rebleed despite endoscopic injection therapy (strong recommendation, moderate-quality evidence) 1
• Can be considered as first-line therapy in selected patients with large or multiple gastric varices (weak recommendation, moderate-quality evidence) 1

Technical Considerations

When performing TIPS for gastric varices:

• Goal portal pressure gradient (PPG) should be <12 mmHg or a 50-60% decrease from initial pressure 1
• Concurrent obliteration of varices is recommended during TIPS creation (level 1b evidence) 1
• For gastric-fundal varices, variceal obliteration with or without TIPS is recommended 1

Post-TIPS Monitoring

• Surveillance with Doppler ultrasonography three months after TIPS creation and every six months thereafter 1
• If TIPS stenosis/occlusion is suspected or if patient rebleeds, TIPS venogram with pressure measurements is indicated with consideration of TIPS revision 1

Special Considerations

Gastric Variceal Types

Different types of gastric varices may respond differently to TIPS:

• GOV1 (gastroesophageal varices extending along lesser curvature): Similar management to esophageal varices
• GOV2 (gastroesophageal varices extending toward fundus) and IGV1 (isolated gastric varices in fundus): TIPS with embolization may be particularly beneficial 1

Alternative Treatments

• Balloon-occluded retrograde transvenous obliteration (BRTO) may offer benefits for some patients with gastric varices, with potentially higher overall survival rates and lower rebleeding rates compared to TIPS in some studies 3
• For patients where TIPS is contraindicated, angiographic occlusion with sclerotherapy/embolotherapy may be considered as an alternative 4

Potential Complications and Pitfalls

• Hepatic encephalopathy is a significant risk after TIPS placement
• TIPS is not recommended where the Child-Pugh score is >13 (strong recommendation, low quality of evidence) 1
• TIPS does not have a role in the management of bleeding solely from gastric antral vascular ectasia (GAVE), although it could be considered where there is co-existing portal hypertensive gastropathy 1
• Glue migration is a potential complication of endoscopic therapy for gastric varices, which may require rescue TIPS placement 5

Algorithmic Approach to Gastric Variceal Bleeding

1. Initial management: Based on center expertise, attempt endoscopic therapy (typically cyanoacrylate glue injection)
2. If endoscopic therapy fails or is not feasible:
   • Consider immediate/salvage TIPS with concurrent variceal obliteration
3. For high-risk patients (Child's C10-13 or MELD ≥19 with GOV1/GOV2):
   • Consider pre-emptive TIPS within 72 hours if hemodynamically stable
4. After successful initial control:
   • For patients with large or multiple gastric varices: Consider TIPS ± embolization as secondary prevention
   • For patients who rebleed despite endoscopic therapy: TIPS ± embolization is recommended
5. Post-TIPS monitoring:
   • Doppler ultrasound at 3 months and every 6 months thereafter
   • TIPS venogram if rebleeding occurs or stenosis is suspected

The hemodynamic understanding of gastric varices has evolved, leading to more targeted approaches based on inflow and outflow pathways 6. This has improved management strategies beyond traditional endoscopic treatments, particularly for patients with complex gastric variceal disease.