Transjugular intrahepatic portosystemic shunt in cirrhosis: An exhaustive critical update

Abstract

More than five decades after it was originally conceptualized as rescue therapy for patients with intractable variceal bleeding, the transjugular intrahepatic portosystemic shunt (TIPS) procedure continues to remain a focus of intense clinical and biomedical research. By the impressive reduction in portal pressure achieved by this intervention, coupled with its minimally invasive nature, TIPS has gained increasing acceptance in the treatment of complications of portal hypertension. The early years of TIPS were plagued by poor long-term patency of the stents and increased incidence of hepatic encephalopathy. Moreover, the diversion of portal flow after placement of TIPS often resulted in derangement of hepatic functions, which was occasionally severe. While the incidence of shunt dysfunction has markedly reduced with the advent of covered stents, hepatic encephalopathy and instances of early liver failure continue to remain a significant issue after TIPS. It has emerged over the years that careful selection of patients and diligent post-procedural care is of paramount importance to optimize the outcome after TIPS. The past twenty years have seen multiple studies redefining the role of TIPS in the management of variceal bleeding and refractory ascites while exploring its application in other complications of cirrhosis like hepatic hydrothorax, portal hypertensive gastropathy, ectopic varices, hepatorenal and hepatopulmonary syndromes, non-tumoral portal vein thrombosis and chylous ascites. It has also been utilized to good effect before extrahepatic abdominal surgery to reduce perioperative morbidity and mortality. The current article aims to review the updated literature on the status of TIPS in the management of patients with liver cirrhosis.

Friend or Foe? Spontaneous Portosystemic Shunts in Cirrhosis—Current Understanding and Future Prospects

“…Transjugular intrahepatic portosystemic shunting (TIPS) has become an established treatment option for complications of portal hypertension such as acute or recurrent variceal bleeding and difficult-to-treat ascites [ 85 ]. TIPS is minimally invasive and achieves impressive reduction in portal pressure.…”

Unpacking the challenge of gastric varices: A review on indication, timing and modality of therapy

“…Although haemostasis rates exceed 90%, re-bleeding is reported to occur in 15%-30%[ 18 - 20 ] and concerns remain over post-TIPS encephalopathy, which can be recalcitrant to standard medical therapy and necessitate revision of the TIPS. Several hypotheses have been proposed to explain the risk of re-bleeding[ 21 , 22 ]; ‘Proximity’ theory – feeding vessels to GV lie further away from a TIPS shunt than feeding vessels to oesophageal varices, hence the shunt is less effective in decompressing GV; ‘Throughput’ theory – gastro-renal shunts that occur in high frequency in association with bleeding GV compete with the TIPS for portal flow and can continue to feed the gastric variceal bed; ‘Recruitment’ theory – development of new feeder vessels after proximal embolization of a GV.…”

Early Hepatic Encephalopathy after a Transjugular Intrahepatic Portosystemic Shunt Procedure: Case Report

“…The EV resulting from portal hypertension can be corrected with the procedure of transjugular intrahepatic portosystemic shunt (TIPS) [6]. This procedure creates an artificial passage, allowing the blood to pass directly from the portal system to the systemic circulation, decreasing the pressure in the portal system which is elevated due to liver cirrhosis [7]. However, this procedure can cause ammonia to pass into the system, being able to reach the brain, and developing Post-TIPS HE [7], which is a complication that occurs in 25% -33% of patients undergoing TIPS and is usually resolved with protein restriction and the use of lactulose or neomycin sulfate.…”

“…This procedure creates an artificial passage, allowing the blood to pass directly from the portal system to the systemic circulation, decreasing the pressure in the portal system which is elevated due to liver cirrhosis [7]. However, this procedure can cause ammonia to pass into the system, being able to reach the brain, and developing Post-TIPS HE [7], which is a complication that occurs in 25% -33% of patients undergoing TIPS and is usually resolved with protein restriction and the use of lactulose or neomycin sulfate. However, in about 5% -10% of patients, HE needs to be solved with a new intervention to occlude the TIPS or reduce its diameter [8].…”