Which study recommends Transjugular Intrahepatic Portosystemic Shunt (TIPS) in variceal bleeding?

TIPS in Variceal Bleeding: Key Studies and Recommendations

The García-Pagán study (2010) is the landmark study that established pre-emptive TIPS within 72 hours for high-risk patients with variceal bleeding, demonstrating significant improvement in survival and reduced rebleeding rates compared to standard therapy. 1

Indications for TIPS in Acute Variceal Hemorrhage

Pre-emptive TIPS

• Pre-emptive TIPS is recommended in high-risk patients who have been successfully banded but meet criteria for high risk of rebleeding: Child-Pugh Class C (10-13 points) or Child-Pugh Class B >7 points with active bleeding at endoscopy 1
• TIPS should be performed within 72 hours of admission in these patients without contraindications to TIPS 1
• This approach is supported by evidence showing improved control of bleeding and survival in high-risk patients 1

Rescue TIPS

• Recommended for patients who have been successfully banded but rebleed at any time during admission (after endoscopy) 1
• Covered TIPS is recommended for patients with gastro-esophageal variceal bleeding refractory to endoscopic and drug therapy as defined by Baveno 6 criteria 1
• Salvage TIPS is not recommended where the Child-Pugh score is >13 due to poor outcomes 1

Salvage TIPS

• Should be performed emergently for patients in whom endoscopic band ligation cannot be performed because of profuse bleeding or when bleeding persists at endoscopy despite endoscopic band ligation 1
• For persistent esophageal variceal bleeding despite vasoactive pharmacological and endoscopic hemostasis therapy, urgent rescue TIPS should be considered 2

TIPS for Specific Types of Variceal Bleeding

Gastric Varices

• For bleeding gastric-fundal varices, variceal obliteration/embolization with or without TIPS should be considered if unable to be managed endoscopically 1
• For rebleeding gastric-fundal varices after endoscopic therapy, variceal obliteration with or without TIPS creation is recommended 1
• Recent evidence from the GAVAPROSEC trial (2025) showed pre-emptive TIPS significantly reduced the risk of rebleeding or death at 1 year in patients with acute bleeding from fundal varices 3

Ectopic Varices

• In patients with bleeding from ectopic varices refractory to local and pharmacological therapies, TIPS usually with embolization is suggested 1
• TIPS provides long-term control of bleeding in most cirrhotic patients with ectopic variceal bleeding, particularly effective for stomal varices but may be less effective for duodenal varices 4

Procedural Considerations

• When placing TIPS for variceal hemorrhage, the goal PSG should be <12 mmHg or 50-60% decrease from initial pressure 1
• Concurrent obliteration of varices during TIPS creation is recommended 1
• Post-TIPS surveillance with Doppler ultrasonography is recommended at three months after TIPS creation and every six months thereafter 1

Cautions and Contraindications

• TIPS is associated with higher rates of hepatic encephalopathy (55% vs 26% with endoscopic therapy in some studies) 5
• Salvage TIPS is not recommended where the Child-Pugh score is >13 due to poor outcomes 1
• In patients with Fontan-type circulation, TIPS is generally not indicated but may be considered in highly selected cases of severe uncontrolled variceal bleeding 1

Ongoing Research Needs

• Multi-center RCTs are necessary to determine whether patients with Child's B disease and active bleeding or with MELD 12-18 benefit from early pre-emptive TIPS 1
• Further large controlled trials are required to investigate the role of TIPS as first-line therapy in secondary prevention of variceal bleeding 1

The evidence clearly demonstrates that TIPS is an effective intervention for variceal bleeding in specific clinical scenarios, with the strongest evidence supporting pre-emptive TIPS in high-risk patients and rescue TIPS for refractory bleeding.