Does Transjugular Intrahepatic Portosystemic Shunt Stent Differentially Improve Survival in a Subset of Cirrhotic Patients?

Abstract

Does transjugular intrahepatic portosystemic shunt stent (TIPS) improve survival in a subgroup of patients? Yes. TIPS nearly halves portal pressure and increases the effective blood volume. In cases of acute variceal hemorrhage and with a high risk of treatment failure, defined as either hepatic venous pressure gradient higher than 20 mm Hg, Child B with active bleeding at the endoscopy, or Child C with less than 14 points, early or preemptive placement of TIPS (within 72 hours) improves survival. Also, in suitable patients with intractable or refractory ascites, TIPS improves survival if placed early in the course of treatment. While TIPS does not improve survival in other situations, it improves disease management, especially in patients without TIPS contraindications but with refractory bleeding, early rebleeding, portal vein thrombosis, and hepatorenal syndrome. Experience gained at the centers and follow-up of TIPS patients are key features that improve outcome. Important factors for selection and follow-up include cardiac function, inflammation, sarcopenia, age, and early evaluation for liver transplantation.

Left Ventricular Longitudinal Contractility Predicts Acute‐on‐Chronic Liver Failure Development and Mortality After Transjugular Intrahepatic Portosystemic Shunt

“…However, there are no good parameters for early identification of patients at risk to develop circulatory failure. Moreover, the reduced effective arterial volume, which occurs particularly in patients who are acutely decompensated, possibly predisposes or even induces organ failure, especially renal failure, which is highly dependent on organ perfusion . STE parameters of the LV function have been shown in other large studies to be clearly related to the development of renal dysfunction .…”

“…Portal hypertension in liver cirrhosis is frequent, causes serious complications, and predisposes for the development of acute‐on‐chronic liver failure (ACLF) . Insertion of a transjugular intrahepatic portosystemic shunt (TIPS) induces a prompt decompression of the portal venous system and effectively treats complications of portal hypertension; however, careful selection of patients is required . TIPS insertion increases central blood volume despite a severe aggravation of preload .…”

Gut-Liver Axis Links Portal Hypertension to Acute-on-Chronic Liver Failure

“…Especially, when PHT is present (increased pressure in the portal vein and the mesenteric veins collecting blood from the splanchnic organs to the liver), complications arise [42]. A TIPS is the most effective treatment of PHT and yet, even after this procedure, many patients develop complications of liver disease [43,44], especially due to the spillover of inflammation with resulting development of ACLF as shown by recent data [5,45,46]. Additionally, it was found that the presence of ascites, as a sign of decompensation, determines the composition of the circulating microbiome in the portal vein compared to the hepatic vein, right atrium, and peripheral venous blood, and that specific circulating microbiome members correlate with inflammatory markers [47].…”

Editorial: diastolic dysfunction seems not to be decisive for survival after transjugular intrahepatic portosystemic stent‐shunt

“…Although highly selected in their patients, presence of diastolic dysfunction was not associated with survival, but Model for End‐Stage Liver Disease (MELD) score remained the best predictor of survival. The clinical “gut‐feeling” and pathophysiological understanding suggest that the cardiac function should play a role and should be investigated prior to TIPSS insertion in these patients . Therefore, the question arises, is echocardiography relevant for selection of patients to TIPSS and if yes what parameters are the relevant ones?…”