The role of transjugular intrahepatic portosystemic shunt (TIPS) in the management of portal hypertension: Update 2009

Abstract

The 2009 update of the American Association for the Study of Liver Diseases (AASLD) Practice Guideline "The Role of Transjugular Intrahepatic Portosystemic Shunt (TIPS) in the Management of Portal Hypertension" is now posted online at www.aasld.org. This is the first update of the original guideline published in 2005. 1 The key changes in the 2009 guidelines are new recommendations on the use of covered versus bare stents in the creation of the TIPS. Use of expanded polytetrafluoroethylene (ePTFE)-covered stents is now preferred. The lower risk of shunt dysfunction and perhaps improved outcomes using covered as opposed to bare stents are the basis for this recommendation. 2,3 Creation of a TIPS increases the risk of hepatic encephalopathy but the prophylactic use of nonabsorbable disaccharides or antibiotics does not appear to reduce this risk and is not recommended. 4 The value of TIPS versus a surgical shunt in the prevention of variceal rebleeding in patients who have failed medical therapy has been clarified by the publication of a controlled trial comparing TIPS to distal splenorenal shunt (DSRS). 5 Both were effective in preventing rebleeding (rebleeding incidence in 5.5% of DSRS versus 10.5% of TIPS; not significant) with no difference in encephalopathy or survival. The patients in whom TIPS was performed required significantly more interventions to maintain patency because of the use of bare stents. A cost analysis showed TIPS to be slightly more cost effective than DSRS at year 5, 6 and these two approaches are now considered to be of equal efficacy in the prevention of variceal rebleeding.The other significant change to the guidelines is how TIPS should be used in the management of patients with Budd-Chiari syndrome. A large (221 patients) retrospective study was published in which patients who failed to improve with use of anticoagulation had a TIPS created (133 patients). One-year and 10-year transplant-free survival was 88% and 69%, respectively, which is better than predicted. 7 TIPS patency was best in those who received a covered stent. The recommendation now is for creation of a TIPS in those who fail to improve with anticoagulation.

Stomal varices: An unusual cause of bleeding in patients with portal hypertension

“…Among these possibilities, in several studies, TIPS proves to be effective in patients who do not respond to conservative treatment (3,8,9), as the procedure treats the underlying problem of a high portal venous pressure (8,10). However, this technique is not exempt from complications such as hepatic encephalopathy (10). In the case of our patient, a TIPS was performed as there were no contraindications for him.…”

“…Among invasive treatment options, percutaneous sclerotherapy, liver transplant, TIPS and embolization combined or not with TIPS can be performed (3,4,7,8). Among these possibilities, in several studies, TIPS proves to be effective in patients who do not respond to conservative treatment (3,8,9), as the procedure treats the underlying problem of a high portal venous pressure (8,10). However, this technique is not exempt from complications such as hepatic encephalopathy (10).…”

Ultragarsinio Tyrimo Reikšmė Vertinant Transjugulinio Intrahepatinio Portosisteminio Šunto (Tips) Procedūros Veiksmingumą Ir Komplikacijų Riziką Po Procedūros

“…Kituose tyrimuose rezultatai buvo tokie: nuo 27,67 ± 5,86 mmHg sumažėjo iki 18,00 ± 6,93 mmHg [5,8,16]. Remiantis Intervencinių radiologų sąjungos draugijos numatytais kriterijais, sėkmingos išeitys prognozuojamos, jei po TIPS sukūrimo hepatinių venų spaudimo gradientas < 12 mmHg [10].…”

Keeping high model for end‐stage liver disease score liver transplantation candidates alive

“…18 Although TIPS is often a good option in low MELD patients, it is contraindicated in high MELD patients, with the exception of when the MELD points are coming from renal dysfunction caused by HRS. 1,54 Because TIPS has been used as a treatment for HRS, when the bilirubin remains low and the ascites is causing severe malnutrition or frequent thoracentesis it can be considered. Secondary causes should always be excluded with fluid analysis of the total protein, serum albumin ascites gradient, cytology, and cell count, and, especially for inpatients, infection should be ruled out.…”