Transjugular intrahepatic portosystemic stent-shunt in the management of portal hypertension

Abstract

These guidelines on transjugular intrahepatic portosystemic stent-shunt (TIPSS) in the management of portal hypertension have been commissioned by the Clinical Services and Standards Committee (CSSC) of the British Society of Gastroenterology (BSG) under the auspices of the Liver Section of the BSG. The guidelines are new and have been produced in collaboration with the British Society of Interventional Radiology (BSIR) and British Association of the Study of the Liver (BASL). The guidelines development group comprises elected members of the BSG Liver Section, representation from BASL, a nursing representative and two patient representatives. The quality of evidence and grading of recommendations was appraised using the GRADE system. These guidelines are aimed at healthcare professionals considering referring a patient for a TIPSS. They comprise the following subheadings: indications; patient selection; procedural details; complications; and research agenda. They are not designed to address: the management of the underlying liver disease; the role of TIPSS in children; or complex technical and procedural aspects of TIPSS.

Randomised clinical trial: standard of care versus early‐transjugular intrahepatic porto‐systemic shunt (TIPSS) in patients with cirrhosis and oesophageal variceal bleeding

“…This is echoed in the recent UK TIPSS guidelines for the management of portal hypertension, in addition to highlighting the uncertainties in patient selection for the procedure. 29 …”

Transjugular intrahepatic portosystemic shunt in cirrhosis: An exhaustive critical update

“…Even though the question of survival benefit in patients with Child-Pugh class B and MELD score of 12-18 remains open to debate, the reduction in rebleeding and ascites, without increasing the risk or severity of HE could also justify the use of early TIPS in this subgroup of patients. In keeping with this, the British society of interventional radiology and British association of the study of the liver recommends that "in patients who have Child’s C disease (C 10-13) or MELD ≥ 19, and bleeding from esophageal varices (EV) or GOV1 and GOV2 gastric varices (GV) and are hemodynamically stable, early or pre-emptive TIPS should be considered within 72 h of a variceal bleed where local resources allow"[ 22 ]. Despite these recom-mendations, the rate of implementation of early TIPS in a real-world situation is dismal, with only 6%-13% of eligible candidates undergoing the procedure according to two recent large multicentre observational studies[ 23 , 24 ].…”

“…The 1-year rate of recurrent VH is approximately 60% in patients without treatment, with a mortality rate approaching 30%[ 25 ]. It is recommended that endoscopic band ligation (EBL), in combination with non-selective beta-blockers (NSBB), be the first line of therapy for the prevention of recurrent VH with reservation of TIPS only for non-responders[ 15 , 22 ]. In this regard, two RCTs compared covered stents with EBL[ 26 , 27 ].…”

“…GV is frequently associated with large gastrorenal shunts (GRS) and have a “downhill” drainage as opposed to “uphill” drainage of EV via azygos-hemiazygos venous system[ 32 ]. GVs exist as “low pressure, high volume” channels, and can bleed at lower portal pressures than EVs[ 33 , 22 ]. Between 10%-16% of GV can bleed at PSPG < 12 mmHg[ 33 ].…”

Safety and feasibility of transjugular intrahepatic portosystemic shunt in elderly patients with liver cirrhosis and refractory ascites

“…Of note, the parameter age is not particularly mentioned [4]. However, TIPS insertion in elderly patients is supposed to be performed with great caution, since it might increase the risk for HE in patients of higher age [7]. In fact, higher age is even considered as a contraindication in many centers [8].…”