Small diameter shunts should lead to safe expansion of the use of TIPS

Abstract

Transjugular intrahepatic portosystemic shunt (TIPS) is increasingly used worldwide to treat the complications of portal hypertension in patients with advanced cirrhosis. However, its use is hampered by the risk of causing hepatic encephalopathy and of worsening liver function. The reported haemodynamic targets used to guide TIPS are too narrow to be achieved in most cases and are perhaps not entirely adequate nowadays as they were obtained in the pre-covered stent era. We propose that small diameter TIPSalone or combined to pharmacological therapy or ancillary interventional radiology proceduresmay overcome these limitations while maintaining the beneficial effects of the procedure.

Reply to: “Achieving an effective pressure reduction after TIPS: The need for a new target”

“…On the other hand, it is likely that what could appear an insufficient reduction in PPG (to 14.5 mmHg, for instance) could be more than enough in a patient with a baseline PPG of 30 mmHg, or even if initial PPG was 21 mmHg, provided that the TIPS was complemented with a small dose of propranolol or with embolization of the collaterals (if TIPS was done to prevent rebleeding). 2 The experience of Wang et al 1 is in agreement with the above reasoning. They show equal results in terms of efficacy, adverse effects and survival between patients treated with covered 8 mm stents and collateral occlusion irrespective of achieving or not a final PPG below 12 mmHg (83% of the cohort) or not.…”

“…As I emphasized, hemodynamic targets for TIPS are largely based on studies from the pre-covered stent era, when TIPS dysfunction was extremely common. 2 At that time, we showed that reducing the portal pressure gradient (PPG, the difference between portal vein and hepatic vein pressure) to values below 12 mmHg was necessary to prevent rebleeding or ascites, but that reductions below 10 mmHg were associated with an increased risk of encephalopathy. 3 Thus, it was difficult to achieve the correct balance between protecting against portal hypertension and not causing excessing shunting of portal blood away from the liver.…”

Diagnosis, Evaluation, and Management of Ascites, Spontaneous Bacterial Peritonitis and Hepatorenal Syndrome: 2021 Practice Guidance by the American Association for the Study of Liver Diseases

“…Certain risk factors (e.g., advanced age, cardiopulmonary insufficiency, and sarcopenia) predispose patients to more complications post-TIPS and hepatic encephalopathy (86)(87)(88), although sarcopenia per se may not affect survival after TIPS insertion for RA (89). TIPS stents with a smaller (8-10 mm) diameter than conventional ones have been associated with lower incidence of post-TIPS hepatic encephalopathy without compromising the efficacy on ascites control (90)(91)(92). A recent study suggests that TIPS inserted at an earlier stage of ascites' natural history (such as those with recurrent ascites) could result in fewer side effects and improved survival when compared to LVP (93).…”

Management of the major complications of cirrhosis: Beyond guidelines

“…86 Therefore, it could well be that using smaller stents may expand the indication of TIPS in patients with refractory ascites and compromised liver function. 94 This should obviously be evaluated in adequate clinical studies.…”