What is the role of Transjugular Intrahepatic Portosystemic Shunt (TIPS) in the management of cirrhosis?

Role of Transjugular Intrahepatic Portosystemic Shunt (TIPS) in Cirrhosis Management

TIPS is strongly recommended for carefully selected patients with cirrhosis who have refractory 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, 2

Primary Indications for TIPS

Variceal Bleeding

• Acute Variceal Hemorrhage:

  • Pre-emptive TIPS: Indicated within 72 hours of admission for high-risk patients (Child-Pugh C 10-13 points or Child-Pugh B >7 points with active bleeding at endoscopy) who have been successfully treated with endoscopic therapy 1
  • Rescue TIPS: For patients who rebleed during admission after successful initial endoscopic treatment 1
  • Salvage TIPS: For patients with uncontrolled bleeding despite pharmacological and endoscopic treatment 1

• Prevention of Rebleeding:

  • Second-line therapy after failure of combined endoscopic band ligation and non-selective beta-blockers 2
  • Target portal pressure gradient should be <12 mmHg or a reduction of at least 50-60% from baseline 1

Refractory Ascites

• Strong recommendation for TIPS in patients with refractory ascites (not responding to sodium restriction and diuretics) or recurrent ascites (requiring ≥3 large volume paracenteses per year) 1
• TIPS is more effective than large volume paracentesis in controlling ascites and may improve transplant-free survival 1, 3
• A staged approach is recommended, starting with 8mm stent diameter and progressively increasing to 9mm and 10mm at 6-week intervals if needed 1, 2

Hepatic Hydrothorax

• TIPS is recommended for selected patients with refractory hepatic hydrothorax 1
• Complete response occurs in >50% of patients, with partial responses in approximately 20% 1

Contraindications to TIPS

Absolute Contraindications

• Severe liver failure (Child-Pugh score >13 points) 1, 2, 4
• Congestive heart failure 2
• Severe pulmonary hypertension 1, 2
• Uncontrolled systemic infection or sepsis 2
• Unrelieved biliary obstruction 2

Relative Contraindications

• Hepatic Encephalopathy:
  • History of recurrent overt hepatic encephalopathy 1
  • Presence of covert hepatic encephalopathy before elective TIPS 1
• Advanced Age: Age >65 years increases risk of post-TIPS encephalopathy 1
• Laboratory Parameters: Bilirubin >50 μmol/L and platelets <75×10⁹/L 1
• Poor Social Support: Especially for elective TIPS due to risk of post-TIPS encephalopathy 1

Patient Selection and Evaluation

Pre-TIPS Assessment

• Screen for covert and overt encephalopathy using at least two of: psychometric hepatic encephalopathy score (PHES), Stroop testing, Critical Flicker Frequency, or quantitative EEG 1
• Evaluate cardiac function to exclude heart failure 1, 2
• Assess liver function (MELD score, Child-Pugh score) 1
• Consider liver transplant evaluation, as TIPS is not a definitive treatment for underlying liver disease 2

Technical Considerations

• Portal vein thrombosis is not an absolute contraindication, though cavernoma is associated with high failure rates 1
• Consider embolization of spontaneous portosystemic shunts >6mm during TIPS placement to reduce risk of post-TIPS encephalopathy 1
• For variceal hemorrhage, concurrent variceal embolization decreases rebleeding risk 1

Post-TIPS Management

Monitoring

• Doppler ultrasound at 3 months post-TIPS and every 6 months thereafter 2
• If TIPS stenosis/occlusion is suspected or patient rebleeds, TIPS venogram with pressure measurements is indicated 2

Managing Complications

• Hepatic Encephalopathy: Occurs in 25-50% of patients 1
  • First-line treatment: Lactulose
  • Second-line: Add rifaximin for recurrent episodes
  • For refractory encephalopathy: Consider shunt reduction or occlusion 1

Special Situations

Budd-Chiari Syndrome

• TIPS is recommended for patients who fail to respond to medical therapy with anticoagulation or hepatic vein interventions 1
• Patients should be managed in centers with high expertise 1

Portal Vein Thrombosis

• TIPS not only controls portal hypertension complications but also promotes portal vein recanalization 4
• Cases should be discussed with experienced units 1

Recent Evidence on Outcomes

• TIPS reduces the incidence of further decompensation events compared to standard of care (48% vs 63% at 2 years) 3
• TIPS increases 2-year survival probability (71% vs 63%) in highly selected patients 3

Conclusion

TIPS is a valuable intervention for managing complications of portal hypertension in cirrhosis, particularly for refractory ascites and variceal bleeding. Patient selection is critical to optimize outcomes and minimize complications, with careful consideration of liver function, risk of encephalopathy, and cardiac status.