Consensus conference on TIPS management: Techniques, indications, contraindications

Abstract

a b s t r a c tThe trans jugular intrahepatic Porto systemic shunt (TIPS) is no longer viewed as a salvage therapy or a bridge to liver transplantation and is currently indicated for a number of conditions related to portal hypertension with positive results in survival. Moreover, the availability of self-expandable polytetrafluoroethylene (PTFE)-covered endoprostheses has dramatically improved the long-term patency of TIPS. However, since the last updated International guidelines have been published (year 2009) new evidence have come, which have open the field to new indications and solved areas of uncertainty. On this basis, the Italian Association of the Study of the Liver (AISF), the Italian College of Interventional Radiology-Italian Society of Medical Radiology (ICIR-SIRM), and the Italian Society of Anesthesia, Analgesia and Intensive Care (SIAARTI) promoted a Consensus Conference on TIPS. Under the auspices of the three scientific societies, the consensus process started with the review of the literature by a scientific board of experts and ended with a formal consensus meeting in Bergamo on June 4th and 5th, 2015. The final statements presented here were graded according to quality of evidence and strength of recommendations and were approved by an independent jury. By highlighting strengths and weaknesses of current indications to TIPS, the recommendations of AISF-ICIR-SIRM-SIAARTI may represent the starting point for further studies.

Smaller-Diameter Covered Transjugular Intrahepatic Portosystemic Shunt Stents Are Associated With Increased Survival

“…Because of its longer patency and better symptom control, these covered stents have become the standard of care. [1][2][3][4][5]17,18 With respect to optimal stent diameter, previous findings have been controversial. 6,7 The fact that 2 recently published randomized studies 19,20 in patients with variceal bleeding found HE rates of 18% and 35% with 8-and 10-mm stents, respectively, shows that smaller stents may be preferable.…”

“…7 In the clinical routine, underdilation of 10-mm stents is a frequently applied approach, and also has been recommended by a recent Italian consensus conference. 5 In case of insufficient clinical response, shunt revision with further dilation of the stent may be an option to improve its efficacy. This common practice does not take into account the physical characteristics of stents manufactured from nitinol, an alloy that always tends to reach its nominal diameter.…”

Low molecular weight heparin does not increase bleeding and mortality post‐endoscopic variceal band ligation in cirrhotic patients

“…[16][17][18][19][20] However, guidelines are scarcely evidence-based in the setting of prophylactic EVL in cirrhotic patients, being mostly based on expert opinions and small case series. 33 Indeed, timing of warfarin withdrawal and imbrication with LMWH has been extrapolated from studies on patients undergoing colonic endoscopic polypectomy. 34 This contributes to explain the lack of uniformity in the management of anticoagulation in the periendoscopic period worldwide.…”

Spleen stiffness is positively correlated with HVPG and decreases significantly after TIPS implantation

“…One of the classical complications of TIPS treatment was secondary shunt occlusion. Recently, the availability of polytetrafluoroethylene (PTFE)-covered stents was an essential step forward by markedly improving the long-term patency of TIPS [17,18]. Color Doppler sonography is widely used to survey patency by measuring flow velocity in the TIPS.…”

“…Indications for TIPS implantation were refractory ascites (n = 15; 62.5%) and refractory PH-induced upper gastrointestinal bleeding (UGIB; n = 9; 37.5%). The median Child Pugh score of the study population was 7.0 ± 1.2 [5][6][7][8][9] points, while the mean MELD score was 10.3 ± 2.8 [6][7][8][9][10][11][12][13][14][15][16][17][18] points. Majority of the study population demonstrated splenomegaly with a mean spleen size (length) of 15.0 ± 3.…”