What are the indications and management strategies for the Transjugular Intrahepatic Portosystemic Shunt (TIPS) procedure?

Indications and Management Strategies for Transjugular Intrahepatic Portosystemic Shunt (TIPS)

TIPS is strongly recommended for variceal bleeding refractory to endoscopic and drug therapy, prevention of rebleeding in patients who have bled despite standard therapies, refractory ascites, and selected cases of Budd-Chiari syndrome and portal vein thrombosis. 1, 2

Primary Indications

Variceal Bleeding

• Rescue/Salvage TIPS: Strongly recommended for patients with acute variceal bleeding unresponsive to standard treatments (endoscopic banding and drug therapy) 2, 3
• Early/Pre-emptive TIPS: Should be considered within 72 hours of variceal bleeding in high-risk patients (Child's C <14 points or MELD ≥19) who are hemodynamically stable, though evidence remains conflicting 1, 4
• Secondary Prevention: Recommended for non-emergency situations where patients have experienced rebleeding despite standard endoscopic and medical therapies 1, 3

Ascites and Fluid Accumulation

• Recommended for refractory or recurrent ascites that persists despite standard treatments including paracentesis and diuretics 1, 2
• May be used for hepatic hydrothorax when fluid accumulation persists despite other treatments, though evidence for survival benefit is limited 1, 3

Vascular Disorders

• Recommended for selected patients with Budd-Chiari syndrome who fail medical therapy with anticoagulation or hepatic vein interventions 1, 2
• Can be considered for portal vein thrombosis in selected patients at specialized centers, particularly when thrombosis extends or does not regress under anticoagulant therapy 1, 3

Contraindications

Absolute Contraindications

• Significant pulmonary hypertension 2
• Heart failure or severe cardiac valvular insufficiency 2
• Rapidly progressive liver failure 2

Relative Contraindications

• Hepatic encephalopathy 4
• Active infection 4
• Severe thrombocytopenia (platelet count <50×10^5/L) 1
• Bilirubin >50 μmol/L 4

Pre-TIPS Evaluation

• All patients should be discussed in a multidisciplinary team and reviewed by both hepatology and interventional radiology 1
• Cross-sectional imaging is recommended prior to TIPS where possible 1
• Evaluation should include:
  • Cardiac function assessment 3
  • Liver and kidney function tests 3
  • Coagulation studies (thromboelastography preferred over INR) 1, 3
  • Nutritional and functional assessment 2
  • Screening for covert and overt encephalopathy 2

Procedural Considerations

• General anesthesia or deep sedation using propofol is recommended 1, 3
• PTFE-covered stents should be used as they provide better patency rates than bare stents 1
• Portal pressure gradient should be measured pre- and post-stent deployment 1
• Target reduction of portal pressure gradient to <12 mmHg or by ≥20% of baseline for variceal bleeding 1, 5
• Prophylactic antibiotics are recommended for TIPS procedures for variceal bleeding, complex procedures, or where there is previous biliary instrumentation 1

Post-TIPS Monitoring

• Doppler ultrasound is recommended one week after TIPS implantation in patients with prothrombotic conditions 1
• Regular Doppler ultrasound surveillance at 6-12 month intervals is recommended 1
• More frequent monitoring is needed for patients with prothrombotic conditions such as Budd-Chiari syndrome 1

Complications and Management

Hepatic Encephalopathy

• Affects approximately one-third of patients after TIPS 2, 3
• Management includes:
  • Lactulose and rifaximin as first-line treatments 4
  • Protein restriction and branched-chain amino acids 4
  • In severe cases, consider shunt reduction, embolization, or occlusion 2

Other Complications

• Short-term complications (<5% of patients) include bleeding, infection, heart failure, liver failure, kidney failure, and damage to blood vessels 3
• Long-term complications include TIPS stenosis or occlusion requiring revision 1

Uncertain Indications

• The role of early/pre-emptive TIPS within 72 hours of stabilized acute variceal bleeding remains controversial with conflicting evidence 1, 3
• TIPS in patients with chronic kidney disease has limited evidence 3
• Prophylactic TIPS before non-hepatic surgery lacks good-quality data 3
• TIPS for idiopathic non-cirrhotic portal hypertension has limited evidence 1, 3

Service Delivery Considerations

• TIPS procedures should be performed at centers handling a minimum of 10 cases annually 3
• Complex cases (thrombosed vessels or transplant recipients) should be reserved for centers doing at least 20 cases per year 3
• All patients who require TIPS for treatment of complications of cirrhosis should be considered for liver transplantation evaluation 5