What are the indications for a Transjugular Intrahepatic Portosystemic Shunt (TIPPS) procedure in patients with advanced liver disease, specifically those with cirrhosis and complications such as refractory ascites or recurrent variceal bleeding?

Indications for TIPS Procedure

TIPS is indicated for carefully selected cirrhotic patients with refractory ascites (superior to large volume paracentesis for both ascites control and transplant-free survival), acute variceal hemorrhage in high-risk patients, and recurrent variceal bleeding despite standard therapy. 1

Primary Indications by Clinical Scenario

Refractory Ascites and Hepatic Hydrothorax

For refractory ascites, TIPS is recommended over serial large volume paracentesis to prevent recurrent ascites and improve transplant-free survival. 1

• Refractory ascites is defined as ascites unresponsive to maximum diuretic therapy (spironolactone 400 mg/day and furosemide 160 mg/day) or development of diuretic-induced complications. 1

• Recurrent ascites requiring at least 3 large volume paracenteses for tense ascites within one year despite optimal medical therapy qualifies for TIPS consideration, even if not meeting strict refractory criteria. 1

• Hepatic hydrothorax requiring recurrent thoracentesis warrants TIPS consideration, though evidence is less robust than for ascites. 1

• TIPS should be considered early in the disease course once refractory or recurrent ascites is identified to maximize transplant-free survival benefit. 1

Acute Variceal Hemorrhage

TIPS is indicated in three distinct scenarios for variceal bleeding: 1

• Pre-emptive TIPS (within 72 hours of admission): For patients successfully banded but meeting high-risk criteria—Child-Pugh Class C (10-13 points) OR Child-Pugh Class B with >7 points AND active bleeding at endoscopy. 1

• Rescue TIPS: For patients successfully banded initially but who rebleed at any time during the same admission after endoscopy. 1

• Salvage TIPS: Emergent placement when endoscopic band ligation cannot be performed due to profuse bleeding, or bleeding persists despite endoscopic therapy. 1

• A 2025 RCT demonstrated TIPS superiority over esophageal self-expandable metal stents in refractory variceal bleeding, with 6-week mortality of 10% versus 52.4% (p=0.015). 2

Secondary Prevention of Variceal Rebleeding

• TIPS serves as second-line therapy for prevention of recurrent variceal hemorrhage when combined endoscopic band ligation plus non-selective beta-blockers fail or are not tolerated. 1, 3, 4

• For bleeding gastric-fundal varices refractory to endoscopic therapy, variceal obliteration with or without TIPS should be considered. 1

Portal Vein Thrombosis in Cirrhosis

• When anticoagulation fails in cirrhotic patients with portal vein thrombosis, TIPS placement achieves portal vein recanalization in 95% of cases, with 80% portal vein patency and 85% TIPS patency at one year. 1

• In cirrhotic patients with portal vein thrombosis awaiting liver transplantation, TIPS with portal vein recanalization enables portal-to-portal anastomosis in 91% of cases. 1

• A randomized trial showed TIPS reduced 1-year rebleeding rates compared to endoscopic band ligation plus propranolol (15% vs 45%) in cirrhotic patients with portal vein thrombosis. 1

Patient Selection Criteria and Risk Stratification

Relative Contraindications Based on Liver Function

While elevated bilirubin, MELD score, and Child-Pugh Class C are associated with increased post-TIPS complications and mortality, no absolute cutoff exists that should categorically exclude TIPS. 1

• Child-Pugh >13 points represents very advanced disease where TIPS generally should not be performed. 4

• Most trials excluded patients with bilirubin >5 mg/dl, INR >2, or severe hepatic encephalopathy (>grade 2). 1

• Advanced age is significantly associated with post-TIPS complications including severe hepatic encephalopathy and death, though no specific age cutoff is recommended. 1

Absolute Contraindications

TIPS is contraindicated in the following scenarios: 3, 4

• Recurrent overt hepatic encephalopathy without identifiable precipitating factors
• Severe cardiac failure or significant valvular heart disease
• Severe pulmonary hypertension
• Active systemic infection
• Bilirubin >50 μmol/L (approximately 3 mg/dL) with platelets <75×10^9/L 3

Special Populations

• Post-liver transplant recipients: Insufficient evidence exists to support TIPS for refractory ascites in this population, and TIPS should generally be reserved for MELD ≤15 (≤12 if HCV-related). 1, 5

• Portosinusoidal vascular disorder (PSVD): TIPS demonstrates similar efficacy to cirrhotic patients for variceal bleeding with lower mortality and reduced hepatic encephalopathy risk. 1

Technical Approach and Optimization

Stent Selection and Sizing Strategy

For elective TIPS in refractory ascites, use ePTFE-covered controlled expansion stents with a staged dilation approach. 1

• Initial procedural stent dilation to 8mm, followed by clinical assessment at 6-week intervals

• Progressive dilation to 9mm, then 10mm only if needed to optimize clinical response

• Continue concomitant diuretics as tolerated throughout the staged approach 1

• This staged approach reduces hepatic encephalopathy risk while maintaining efficacy for ascites control. 1

Expected Timeline for Clinical Response

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

• For ascites and hepatic hydrothorax, start with the smallest diameter stent and progressively increase only as clinically indicated. 1

Common Pitfalls and Clinical Caveats

• Hepatic encephalopathy develops in approximately 30-50% of patients post-TIPS, with higher rates in conventional versus constrained TIPS approaches. 1, 3

• In severe refractory hepatic encephalopathy (affecting 8% of cases), shunt reduction or occlusion improves or resolves encephalopathy in 48-100% of cases, though this may cause recurrence of the original indication. 6

• TIPS in PSC patients: Enhanced risk of infection exists during passage through infected bile ducts; TIPS may be contraindicated if dilated intrahepatic ducts are present in the TIPS tract. 1

• The 30-day mortality after TIPS ranges from 10-13%, with Child-Pugh Class C and urgent TIPS placement identified as independent predictors of mortality. 7

• TIPS dysfunction from stenosis or thrombosis occurs in up to 80% with uncovered stents, necessitating regular surveillance with Doppler ultrasound at 6-12 month intervals. 1, 8, 6