When should I consider Transjugular Intrahepatic Portosystemic Shunt (TIPS)?

When to Consider TIPS

TIPS should be considered primarily for patients with refractory or recurrent ascites requiring repeated large-volume paracentesis, and for selected cases of acute variceal hemorrhage in high-risk patients. 1

Primary Indications for TIPS

Refractory Ascites (Strongest Indication)

In selected patients with refractory or recurrent ascites, TIPS is strongly recommended over serial large-volume paracentesis to improve both ascites control and transplant-free survival. 1

• Refractory ascites is defined as ascites that cannot be mobilized or recurs rapidly after therapeutic paracentesis despite maximal diuretic therapy (spironolactone 400 mg/day and furosemide 160 mg/day) and sodium restriction. 1

• Consider TIPS when patients require at least 3 large-volume paracenteses per year for tense ascites despite optimal medical therapy, even if they don't meet strict criteria for refractory ascites. 1

• TIPS should be discussed with the regional transplant center before proceeding if the patient is a transplant candidate. 1

Acute Variceal Hemorrhage (Specific Scenarios)

TIPS is indicated in three distinct bleeding scenarios: 1

• Pre-emptive TIPS: For Child-Pugh Class C (10-13 points) or Class B >7 points with active bleeding at endoscopy, perform within 72 hours of admission. 1

• Rescue TIPS: For patients who rebleed after initially successful endoscopic band ligation during the same admission. 1

• Salvage TIPS: Emergency placement when endoscopic band ligation cannot be performed due to profuse bleeding or bleeding persists despite endoscopic therapy (not recommended if Child-Pugh score >13). 1

Hepatic Hydrothorax

• TIPS should be considered for patients with refractory hepatic hydrothorax requiring recurrent thoracentesis after failure of medical therapy (sodium restriction and diuretics). 1

• Clinical response rates range from 42-79%, but appreciable early mortality exists, making patient selection critical. 1

Budd-Chiari Syndrome

• TIPS is recommended when patients fail to respond to medical therapy with anticoagulation or when hepatic vein interventions are not technically feasible. 1

• All patients should be managed at centers with high expertise and formal links to liver transplant centers. 1

Critical Patient Selection Criteria

High-Risk Features That Warrant Caution or Contraindication

Exercise extreme caution or avoid TIPS in patients with the following characteristics: 1, 2

• Bilirubin >50 μmol/L (approximately 3 mg/dL) 1, 2
• Platelet count <75 × 10⁹/L 1, 2
• MELD score ≥18 1, 2
• Age >70 years (significantly associated with severe hepatic encephalopathy and death) 1
• Pre-existing hepatic encephalopathy 1
• Active infection 1
• Hepatorenal syndrome 1
• Severe cardiac failure or pulmonary hypertension 1
• Progressive renal failure 1

Important Nuances on Risk Stratification

• While elevated MELD score, bilirubin, and Child-Pugh Class C are associated with increased post-TIPS complications and mortality, there is insufficient evidence to recommend absolute cutoffs that should contraindicate TIPS. 1

• Child-Pugh score has the best overall capability at predicting mortality when TIPS is used for ascites, better than MELD alone. 1

• The combination of bilirubin <50 μmol/L and platelets >75 × 10⁹/L predicts better 1-year survival following TIPS for refractory ascites. 1

Technical Approach for Ascites

For patients undergoing elective TIPS for ascites, use a covered controlled expansion stent with a staged dilation approach: 1

• Start with initial procedural stent dilation to 8 mm 1
• Perform clinical assessment at 6-week intervals 1
• Progress to 9 mm, then 10 mm dilation if needed to optimize clinical response 1
• Continue diuretics as tolerated during the staged approach 1

Timeline for Clinical Response

• Reassessment for need to further dilate the TIPS stent should be performed every 6 weeks after initial placement. 1

• The staged approach allows optimization of ascites control while minimizing risk of hepatic encephalopathy. 1

Common Pitfalls to Avoid

• Failing to screen for hepatic encephalopathy before elective TIPS using psychometric testing, Stroop testing, or Critical Flicker Frequency—covert encephalopathy is a relative contraindication. 1

• Not discussing with transplant center first when the patient is a transplant candidate—TIPS for ascites should only proceed after this discussion. 1

• Proceeding with TIPS in patients with multiple high-risk features—the presence of bilirubin >50 μmol/L, platelets <75 × 10⁹/L, and pre-existing encephalopathy together substantially increases mortality risk. 1

• Using TIPS for hepatorenal syndrome—this remains experimental with very low-quality evidence, despite some improvement in renal function observed. 1