Where does TIPS fit in the management of patients with cirrhosis?

García‐Pagán, Juan Carlos; Saffo, Saad; Mandorfer, Mattias; García–Tsao, Guadalupe

doi:10.1016/j.jhepr.2020.100122

Cited by 83 publications

(87 citation statements)

References 133 publications

(259 reference statements)

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“…Age, degree of liver and kidney failure, chronic inflammation, ureaseproducing intestinal bacteria, bacterial translocation and malnutrition/sarcopenia, are other very important factors that can modulate the therapeutic effort. 3 Several of them are associated not only with post-TIPS encephalopathy, but also with post-TIPS survival. 3 Administration of rifaximin, started before TIPS, was shown to be effective in a recent randomised controlled trial, 28 leading to a 40% reduction in cases of hepatic encephalopathy.…”

Section: Complementing a Small Diameter Tips With Drugsmentioning

confidence: 99%

“…3 Several of them are associated not only with post-TIPS encephalopathy, but also with post-TIPS survival. 3 Administration of rifaximin, started before TIPS, was shown to be effective in a recent randomised controlled trial, 28 leading to a 40% reduction in cases of hepatic encephalopathy. Pre-habilitation (e.g.…”

Section: Complementing a Small Diameter Tips With Drugsmentioning

confidence: 99%

“…dehydration, constipation, hypoglycaemia in diabetics, early identification of bacterial infection, including periodontitis) to patients and their relatives is mandatory before discharge. 3 A combination of all these strategies should be attempted to further improve outcomes in this particular population.…”

Section: Complementing a Small Diameter Tips With Drugsmentioning

confidence: 99%

“…1,2 The most frequent indications for TIPS are currently recurrent variceal bleeding, treatment of acute variceal bleeding in high-risk patients, difficult to treat and refractory ascites, severe portal hypertensive gastropathy, hepatic hydrothorax, portal vein thrombosis and Budd-Chiari syndrome. 3 From a functional perspective, TIPS is a "calibrated" side-to-side portacaval shunt (like the "H-graft" surgical shunt). 4,5 One potential advantage of TIPS is that it may have less of an effect on liver perfusion because it is constructed in a portal vein branch rather than in the mesenteric vein (as it is in H-graft shunts).…”

Section: Introductionmentioning

confidence: 99%

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

Bosch

2021

Journal of Hepatology

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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.

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Section: Complementing a Small Diameter Tips With Drugsmentioning

confidence: 99%

Section: Complementing a Small Diameter Tips With Drugsmentioning

confidence: 99%

Section: Complementing a Small Diameter Tips With Drugsmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

See 2 more Smart Citations

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

Bosch

2021

Journal of Hepatology

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“…It remained largely unknown why adherence to the guidelines was so low. In addition, recent data indicates underutilization of early transjugular intrahepatic portosystemic shunt (TIPS) in clinical routine, although its benefits are well established [16,17]. Importantly, there is an ongoing controversy regarding the use of NSBB in patients with refractory ascites with or without spontaneous bacterial peritonitis (SBP) [18][19][20][21], which likely impacts on the use of NSBB for bleeding prophylaxis by treating physicians, especially in patients with a history of ascites.…”

Section: Introductionmentioning

confidence: 99%

Perceptions on the management of varices and on the use of albumin in patients with cirrhosis among GI specialists in Austria

Pfisterer

Schmidbauer

Riedl

et al. 2020

Wien Klin Wochenschr

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Summary Background Portal hypertension (PH) causes severe complications in patients with liver cirrhosis, such as variceal bleeding and ascites; however, data on the knowledge and perceptions on guideline recommendations for the management of varices and the use of albumin is scarce. Methods We designed two structured surveys on (i) the management of varices and (ii) the use of albumin for Austrian physicians of specialized Gastro-Intestinal (GI) centers. The interviewed physicians were confronted spontaneously and provided ad hoc responses to the questionnaire. Results In total, 158 surveys were completed. Interestingly, many specialists (30%) would recommend a follow-up gastroscopy after 1 year in patients with compensated cirrhosis without varices (i.e., overtreatment). For small varices, 81.5% would use non-selective beta blockers (NSBB) for primary prophylaxis (PP). For PP in patients with large varices, endoscopic band ligation (EBL) plus NSBB was preferred by 51.4% (i.e., overtreatment). Knowledge on the indication criteria for early TIPS (transjugular intrahepatic portosystemic shunt) was reported by 54.3%, but only 20% could report these criteria correctly. The majority (87.1%) correctly indicated a preference to use NSBB and EBL for secondary prophylaxis (SP). The majority of participating gastroenterologists reported no restrictions on the use of albumin (89.8%) in their hospitals. Of the interviewed specialists, 63.6% would use albumin in patients with SBP; however, only 11.4% would use the doses recommended by guidelines. The majority of specialists indicated using albumin at the recommended doses for hepatorenal syndrome (HRS-AKI, 86.4%) and for large volume paracentesis (LVP, 73.3%). The individual responses regarding albumin use for infections/sepsis, hyponatremia, renal impairment, and encephalopathy were heterogeneous. Conclusion The reported management of PH and varices is mostly adherent to guidelines, but endoscopic surveillance in patients without varices is too intense and EBL is overused in the setting of PP. Knowledge on the correct use of early TIPS must be improved among Austrian specialists. Albumin use is widely unrestricted in Austria; however, albumin is often underdosed in established indications.

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Elective Surgery but not Transjugular Intrahepatic Portosystemic Shunt Precipitates Acute‐On‐Chronic Liver Failure

et al. 2021

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Acute-on-chronic liver failure (ACLF) is a syndrome associated with organ failure and high short-term mortality. Presence of ACLF at interventions, such as surgery or transjugular intrahepatic portosystemic shunt (TIPS), has been shown to determine outcome, but those interventions have also been attributed to precipitate ACLF in different studies. However, dedicated investigation for the risk of ACLF development in these interventions, especially in elective settings, has not been conducted. Patients with cirrhosis undergoing elective surgery were propensity score matched and compared to patients receiving TIPS. The primary endpoint was ACLF development within 28 days after the respective procedure. The secondary endpoint was 3-month and 1-year mortality. In total, 190 patients were included. Within 28 days, ACLF developed in 24% of the surgery and 3% of the TIPS cohorts, with the highest ACLF incidence between 3 and 8 days. By day 28 after the procedure, ACLF improved in the TIPS cohort. In both cohorts, patients developing ACLF within 28 days after surgery or TIPS placement showed significantly worse survival than patients without ACLF development at follow-up. After 12 months, mortality was significantly higher in the surgery cohort compared to the TIPS cohort (40% vs. 23%, respectively; P = 0.031). Regression analysis showed a European Foundation Chronic Liver Failure Consortium acute decompensation (CLIF-C AD) score ≥50 and surgical procedure as independent predictors of ACLF development. CLIF-C AD score ≥50, C-reactive protein, and ACLF development within 28 days independently predicted 1-year mortality. Conclusion: Elective surgical interventions in patients with cirrhosis precipitate ACLF development and ultimately death, but TIPS plays a negligible role in the development of ACLF. Elective surgery in patients with CLIF-C AD ≥50 should be avoided, while the window of opportunity would be CLIF-C AD <50. (Hepatology Communications 2021;0:1-13).C irrhosis is the common end stage of chronic liver disease. Unstable clinical courses of disease may occur after the development of acute decompensation (AD). However, AD can progress to acute-on-chronic liver failure (ACLF), a specific syndrome characterized by the development of organ

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Where does TIPS fit in the management of patients with cirrhosis?

Cited by 83 publications

References 133 publications

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

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

Perceptions on the management of varices and on the use of albumin in patients with cirrhosis among GI specialists in Austria

Elective Surgery but not Transjugular Intrahepatic Portosystemic Shunt Precipitates Acute‐On‐Chronic Liver Failure

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