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

Indications for Transjugular Intrahepatic Portosystemic Shunt (TIPS)

Transjugular Intrahepatic Portosystemic Shunt (TIPS) is strongly recommended for variceal bleeding refractory to endoscopic and drug therapy, selected patients with refractory or recurrent ascites, and in Budd-Chiari syndrome patients who fail medical therapy with anticoagulation or hepatic vein interventions. 1

Primary Indications

Variceal Bleeding

• Rescue/Salvage TIPS: Strongly recommended for patients with gastro-esophageal variceal bleeding refractory to endoscopic and drug therapy (as defined by Baveno 6 criteria) 1
• Early/Pre-emptive TIPS: Should be considered within 72 hours of variceal bleeding in high-risk patients with Child's C disease (C10-13) or MELD ≥19 who are hemodynamically stable 1
• Salvage TIPS: Should be performed emergently when endoscopic band ligation cannot be performed due to profuse bleeding or when bleeding persists despite endoscopic intervention 1
• Not recommended when Child-Pugh score is >13 due to high mortality risk 1

Refractory Ascites

• Strongly recommended for selected patients with refractory or recurrent ascites who have failed standard therapy 1
• Patients should be carefully selected, excluding those with:
  • Bilirubin >50 μmol/L
  • Platelets <75×10⁹
  • Pre-existing encephalopathy
  • Active infection
  • Severe cardiac failure
  • Severe pulmonary hypertension 1

Hepatic Hydrothorax

• Recommended for selected patients with refractory hepatic hydrothorax 1
• Further studies comparing TIPS with standard of care for this indication are needed 1

Secondary Indications

Budd-Chiari Syndrome

• Recommended for patients who fail to respond to medical therapy with anticoagulation or hepatic vein interventions 1
• Can be considered when hepatic vein interventions are not technically feasible 1
• All patients should be managed in centers of high expertise with formal links to liver transplant centers 1

Portal Vein Thrombosis

• Portal vein thrombosis is not an absolute contraindication to TIPS placement 1
• Patients with acute portal vein thrombosis should be discussed with experienced units 1
• In cirrhotic patients with chronic, complete portal vein thrombosis, portal vein recanalization and TIPS creation could facilitate transplant eligibility 1
• The presence of cavernoma is associated with a significantly high failure rate 1

Gastric Varices

• For bleeding gastric-fundal varices, management should be based on center expertise 1
• Variceal obliteration/embolization with or without TIPS should be considered if endoscopic management is not feasible 1
• For rebleeding gastric-fundal varices after endoscopic therapy, variceal obliteration with or without TIPS creation is recommended 1

Experimental/Limited Evidence Indications

• Hepatorenal Syndrome: Although renal function may improve following TIPS, its use for hepatorenal syndrome (types 1 and 2) remains experimental 1
• Prophylactic TIPS before non-hepatic surgery: Insufficient evidence to recommend routinely, although there may be a role in compensated cirrhotic patients undergoing curative cancer surgery 1
• Idiopathic Non-Cirrhotic Portal Hypertension: Indications should be similar to cirrhosis, with particular attention to risk factors for hepatic encephalopathy 1

Contraindications to TIPS

Absolute Contraindications

• 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
• Extensive primary or metastatic hepatic malignancy 1

Relative Contraindications

• Child-Pugh score >13 1
• Presence of covert hepatic encephalopathy 1
• Age >65 (increases risk of encephalopathy) 1
• Significant intrinsic renal disease (stage 4/5) 1

Pre-TIPS Evaluation

• Patients should be referred to a TIPS expert center to assess eligibility 1
• Pre-TIPS assessment should include:
  • Cardiac evaluation (history, examination, 12-lead ECG, NT-proBNP) 1
  • Detailed nutritional and functional assessment 1
  • Screening for covert and overt encephalopathy using at least two methods (PHES testing, Stroop testing, Critical Flicker Frequency, or quantitative EEG) 1
  • Liver and kidney function tests 1
  • Tests of blood coagulation 1
  • Specialized scans of liver and surrounding vessels 1

Post-TIPS Monitoring

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

Complications and Management

• Hepatic encephalopathy affects approximately one-third of patients 1, 2
• If encephalopathy persists despite standard management, consider shunt reduction, embolization, or occlusion 1
• Other potential complications include bleeding, infection, heart failure, liver failure, kidney failure, fever, and damage to blood vessels and bile ducts (occur in <5% of patients) 1

TIPS has been shown to reduce the incidence of further decompensation events and increase survival in selected patients with portal hypertension-related complications 3, making appropriate patient selection and timing crucial for optimal outcomes.