What are the contraindications for Transjugular Intrahepatic Portosystemic Shunt (TIPS)?

Contraindications for Transjugular Intrahepatic Portosystemic Shunt (TIPS)

TIPS is absolutely contraindicated in patients with significant pulmonary hypertension, heart failure or severe cardiac valvular insufficiency, rapidly progressive liver failure, severe or uncontrolled hepatic encephalopathy, uncontrolled systemic infection or sepsis, unrelieved biliary obstruction, and extensive primary or metastatic hepatic malignancy. 1

Absolute Contraindications

• Cardiac Conditions:

  • Severe left ventricular dysfunction
  • Severe pulmonary hypertension
  • Heart failure or severe cardiac valvular insufficiency

• Hepatic Conditions:

  • Rapidly progressive liver failure
  • Very advanced liver disease (Child-Pugh >13 points) 2
  • Severe or uncontrolled hepatic encephalopathy
  • Episodes of recurrent overt hepatic encephalopathy without identifiable precipitating factors

• Infectious Conditions:

  • Uncontrolled systemic infection or sepsis

• Biliary Conditions:

  • Unrelieved biliary obstruction

• Malignancy:

  • Extensive primary or metastatic hepatic malignancy

Relative Contraindications

• Hepatic Conditions:

  • Covert hepatic encephalopathy (requires screening with at least two tests such as PHES, Stroop testing, Critical Flicker Frequency, or EEG) 1
  • Bilirubin >50 μm/L and platelets <75×10⁹ (for TIPS in ascites) 1
  • Polycystic liver disease (though successful cases have been reported) 1

• Renal Conditions:

  • Significant intrinsic renal disease (stage 4/5) for elective TIPS 1

• Age-Related Factors:

  • Age >65 years (relative contraindication due to increased risk of encephalopathy) 1

• Anatomical Considerations:

  • Portal vein cavernoma (associated with high technical failure rate) 1

Special Considerations

Portal Vein Thrombosis

Portal vein thrombosis is not an absolute contraindication, but the presence of cavernoma significantly increases failure rates. Patients with acute PVT or cirrhotic patients with PVT and variceal bleeding should be discussed with experienced units. 1

Hepatocellular Carcinoma

While extensive hepatic malignancy is a contraindication, TIPS may be considered in selected patients with HCC to manage portal hypertension. This remains a case-by-case decision with potential risks of tumor seeding. 3

Pre-operative TIPS

For patients requiring non-hepatic surgery, TIPS may be considered in compensated cirrhotic patients undergoing curative cancer surgery, though evidence is limited. 1, 4

Pre-TIPS Evaluation Requirements

1. Cardiac Assessment:

   • Cardiac history, examination, 12-lead ECG, and NT-proBNP measurement
   • Echocardiogram and cardiology consultation if any abnormalities detected 1

2. Hepatic Encephalopathy Screening:

   • At least two of: PHES testing, Stroop testing, Critical Flicker Frequency, or quantitative EEG 1

3. Laboratory Assessment:

   • Up-to-date biochemistry (renal and liver function)
   • Hematology (full blood count and INR) 1

4. Imaging:

   • Cross-sectional imaging prior to TIPS where possible 1

5. Nutritional and Functional Assessment:

   • Detailed assessment recommended before elective TIPS 1

Common Pitfalls

1. Failure to recognize cardiac contraindications: Cardiac assessment is crucial as TIPS can worsen cardiac function by increasing preload.

2. Underestimating encephalopathy risk: Pre-existing overt or covert encephalopathy significantly increases post-TIPS encephalopathy risk.

3. Proceeding with TIPS in very advanced liver disease: Patients with Child-Pugh >13 points have poor outcomes after TIPS.

4. Inadequate pre-procedural planning: TIPS is technically challenging and requires thorough evaluation and multidisciplinary discussion.

5. Overlooking renal function: Severe intrinsic renal disease can lead to unacceptably high rates of encephalopathy after TIPS.

By carefully assessing these contraindications and following proper pre-TIPS evaluation protocols, clinicians can optimize patient selection and improve outcomes for this procedure.