When is a referral for a Transjugular Intrahepatic Portosystemic Shunt (TIPS) procedure recommended?

Indications for Transjugular Intrahepatic Portosystemic Shunt (TIPS) Procedure

TIPS referral is strongly recommended for patients with variceal bleeding refractory to endoscopic and drug therapy, refractory or recurrent ascites, refractory hepatic hydrothorax, and Budd-Chiari syndrome unresponsive to medical therapy, provided there are no contraindications to the procedure. 1

Variceal Bleeding Indications

• Rescue/Salvage TIPS: Strongly recommended for patients with gastroesophageal variceal bleeding refractory to endoscopic and drug therapy (as defined by Baveno 6 criteria), though not recommended when Child-Pugh score is >13 1

• Early/Pre-emptive TIPS: Should be considered within 72 hours of variceal bleeding in hemodynamically stable patients with Child's C disease (C10-13) or MELD ≥19 who have bled from esophageal varices or GOV1/GOV2 gastric varices 1

• Gastric Varices: For IGV1 and GOV2 varices, TIPS is indicated after failure of endoscopic therapy with cyanoacrylate glue injection 2

• Inaccessible Varices: TIPS is particularly useful for bleeding from varices that cannot be accessed endoscopically 3

Ascites and Fluid-Related Indications

• Refractory/Recurrent Ascites: TIPS insertion is recommended for selected patients with refractory or recurrent ascites who have failed standard medical therapy 1

• Refractory Hepatic Hydrothorax: Selected patients with hepatic hydrothorax not responding to conventional therapy may be considered for TIPS 1

• Hepatorenal Syndrome: While renal function may improve following TIPS, its use for HRS (types 1 and 2) remains experimental 1

Vascular Indications

• Budd-Chiari Syndrome: TIPS is recommended for patients who:

  • Fail to respond to medical therapy with anticoagulation
  • Fail to respond to hepatic vein interventions
  • Have technically unfeasible hepatic vein interventions 1

• Portal Vein Thrombosis:

  • In cirrhotic patients with chronic, complete portal vein thrombosis being considered for liver transplantation, portal vein recanalization and TIPS creation could facilitate transplant eligibility 1
  • For non-cirrhotic portal hypertension with acute portal vein thrombosis unresponsive to anticoagulation, portal vein thrombectomy/thrombolysis with or without small caliber TIPS should be considered 1

• Non-Cirrhotic Portal Hypertension: TIPS may be considered for the same indications as in cirrhotic portal hypertension 1

Pre-Surgical Considerations

• There is insufficient evidence to recommend preoperative TIPS to prevent bleeding complications or need for blood transfusion during non-transplant surgical procedures 1

• In patients with clinically significant ascites requiring abdominal surgery, a multidisciplinary approach is recommended to individualize management 1

Contraindications and Patient Selection

• Absolute Contraindications:

  • Child-Pugh score >13 for variceal bleeding 1
  • Severe right heart failure or severe pulmonary hypertension 1
  • Active uncontrolled infection 1

• Relative Contraindications for Ascites:

  • Bilirubin >50 μmol/L 1
  • Platelets <75×10^9/L 1
  • Pre-existing hepatic encephalopathy 1

Special Considerations

• Patients eligible for liver transplantation should have TIPS for ascites only after discussion with the regional transplant center 1

• Patients with Budd-Chiari syndrome should be managed at centers with expertise in hematological evaluation, clinical management, and percutaneous intervention 1

• Pre-TIPS cardiac evaluation is essential, including comprehensive echocardiographic assessment of left and right ventricular function 1, 4

• Post-TIPS monitoring is critical, with Doppler ultrasound recommended at regular intervals to assess shunt patency 4, 5

Common Pitfalls to Avoid

• Failing to screen for hepatic encephalopathy risk before TIPS placement 4

• Not considering TIPS early enough in high-risk variceal bleeding patients (Child's C or MELD ≥19) 1

• Inadequate post-TIPS surveillance leading to undetected shunt dysfunction 4, 5

• Referring patients with portal vein thrombosis or cavernoma without consulting experienced centers 1

• Performing TIPS in centers with low procedure volumes (<10 cases annually) 4