To TIPS or Not to TIPS in High Risk of Variceal Rebleeding and Acute-on-Chronic Liver Failure

Abstract

Variceal bleeding is a consequence of severe portal hypertension in patients with liver cirrhosis. Although the rate of bleeding has decreased over time, variceal bleeding in the presence of acute-on-chronic liver failure (ACLF) carries a high-risk of treatment failure and short-term mortality. Treatment and/or removal of precipitating events (mainly bacterial infection and alcoholic hepatitis) and decrease of portal pressure may improve outcome of patients with acute decompensation or ACLF. Transjugular intrahepatic systemic shunts (TIPS), especially in the pre-emptive situation, have been found to efficiently control bleeding, prevent rebleeding and reduce short-term mortality. Therefore, TIPS placement should be considered as an option in the management of ACLF patients with variceal bleeding.

Role of Transjugular Intrahepatic Portosystemic Shunt in the Liver Transplant Setting

“…Numerous studies have explored both preemptive and salvage TIPS placements. Gu et al recently published a comprehensive narrative review, highlighting that preemptive TIPS benefits ACLF patients when compared with non-ACLF patients and that salvage TIPS improves one-year mortality rates in patients with ACLF grade 1, albeit not in grades 2 or 3 [88]. Based on this emerging evidence, preemptive TIPS may be taken into consideration as a bridge-to-transplant option in cirrhotic patients with ACLF and variceal bleeding.…”