Transjugular Intrahepatic Portosystemic Shunt Placement for Refractory Ascites: Review and Update of the Literature

Abstract

Ascites is the most common complication of cirrhosis, impairs quality of life, and carries a poor prognosis. Transjugular intrahepatic portosystemic shunt (TIPS) is a well-validated therapy for refractory ascites and is superior at reducing the accumulation of fluid compared with paracentesis. More recent evidence has shown that TIPS also provides an improved transplant-free survival compared with paracentesis. To maximize the clinical efficacy and survival advantage, proper patient selection is crucial. While current guidelines recommend that elective TIPS for ascites should be performed only in patients with MELD ≤ 18, recent literature suggests that elective TIPS safely and effectively controls ascites and potentially provides a survival advantage in patients with higher MELD scores (≤ 24). The evolution of these findings likely represents the combination of improved medical management of cirrhotic patients, improved devices, and a better knowledge of selection criteria for potential TIPS patients. This article will review the pathophysiology and management of ascites, with a focus on the evidence supporting TIPS placement for refractory ascites.

Refractory ascites—the contemporary view on pathogenesis and therapy

“…Data from the literature indicate that paracentesis with intravenous albumin infusion should be the first choice therapy in the treatment of RA, and TIPS placement may be considered a second-line treatment (Senousy & Draganov, 2009; Siqueira, Kelly & Saab, 2009; European Association for the Study of the Liver, 2010; Salerno et al, 2010; Burgos & Thornburg, 2018). Each patient diagnosed with RA should be urgently referred to a transplant center due to their poor prognosis (12-month survival is less than 50% likely) (Cardenas & Arroyo, 2005; Siqueira, Kelly & Saab, 2009).…”

Peer Review #1 of "Refractory ascites—the contemporary view on pathogenesis and therapy (v0.1)"

“…Data from the literature indicate that paracentesis with intravenous albumin infusion should be the first choice therapy in the treatment of RA, and TIPS placement should be considered a second-line treatment (Senousy & Draganov, 2009;Siqueira, Kelly & Saab, 2009; European Association for the Study of the Liver, 2010; Salerno et al 2010;Burgos & Thornburg, 2018). Each patient diagnosed with RA should be urgently referred to a transplant center due to their poor prognosis (12-month survival is less than 50% likely) (Cardenas & Arroyo, 2005;Siqueira, Kelly & Saab, 2009).…”

Retrospective Study of Transjugular Intrahepatic Portosystemic Shunt Placement for Cirrhotic Portal Hypertension

“…One of the most notable advances in this technique has been the use of expandable PTFE (polytetrafluorethylene)-covered stents, which significantly lowered occlusion rates compared to the previously used bare-metal stents, thereby improving long-term stent patency. These stents are now considered standard of care [1-4].…”

“…The model of end-stage liver disease (MELD) score was developed to predict early mortality after TIPS and is now used as a severity index of liver function. In addition, high Child-Pugh scores are regarded as a relative contraindication to TIPS placement [1, 4].…”