Transjugular intrahepatic portosystemic shunts: An update

Abstract

T ransjugular intrahepatic portosystemic shunts (TIPS), which function in effect, like a side to side portocaval shunt, have become a valuable tool in the management of patients with cirrhosis. TIPS has been used in the treatment of complications of portal hypertension such as variceal bleeding, refractory ascites, Budd-Chiari syndrome, hepatic hydrothorax, and hepatorenal syndrome. TIPS enables the reduction of elevated portal pressure by creating a communication between the hepatic vein and an intrahepatic branch of the portal vein via a percutaneous approach. These shunts can be easily placed by a skilled interventional radiologist with a mortality rate less than 1-2%. However, the major drawbacks of TIPS are stent dysfunction and hepatic encephalopathy. This review focuses on TIPS as it relates to liver transplantation.

Mortality and complications in patients with portal hypertension who underwent transjugular intrahepatic portosystemic shunt (TIPS) - 12 years experience

“…In a review, Rosado and Kamath (23) report that the worsening and new cases of encephalopathy occur from 13% to 44%, need of intervention to keep stent patency was reported from 18% to 78% of patients treated with TIPS. Stent dysfunction is the most common cause of rebleeding which is reported in 26% within 1 year after procedure and in 32% in 2 years.…”

“…Pressure of ascites, serous albumin < 3.3 g/dL and portal pressure gradient > 18 mm Hg are important risk factors associated with rebleeding (18) . There are many therapeutic options for the treatment of acute and recurrent varices bleeding, which include pharmacological, endoscopic treatment and the surgical portosystemic shunts (9,11,12,23) . The transjugular intrahepatic portosystemic shunt (TIPS) appeared as a non-surgical option as treatment for portal hypertension complications due to the low level of morbimortality, possibility of performance in patients with severe hepatic dysfunction, and for being a minimally invasive procedure that can be carried out without the need of general anesthetics.…”

“…Recent studies show that factors associated with bad prognosis in patients who underwent TIPS include previous encephalopathy, Chil dPugh class C, emergency TIPS and MELD > 18, being these mortality predictors (5,10,20,24,28) . TIPS complications divide in those concerning its installation and immediate and late hemodynamic consequences which occur in about 10% of patients being mostly mild (6,23) . More severe complications occur from 1% to 2% and include hemoperitoneum, sepsis, hemobilia, worsening of hepatic and cardiopulmonary insufficiency (23) .…”

“…TIPS complications divide in those concerning its installation and immediate and late hemodynamic consequences which occur in about 10% of patients being mostly mild (6,23) . More severe complications occur from 1% to 2% and include hemoperitoneum, sepsis, hemobilia, worsening of hepatic and cardiopulmonary insufficiency (23) . After the procedure, there may occur complications as lung acute edema, pneumonias, adult respiratory distress syndrome and kidney acute insufficiency (4) .…”

Challenges of Designing Hepatic Encephalopathy Treatment Trials

“…These types of patients were relatively common in the era of widespread use of surgically created portosystemic shunts to prevent recurrent variceal bleeding. 7 Importantly, because variceal bleeding occurred relatively early in the progression of liver failure, patients fit enough to undergo these surgeries were relatively stable. Thus, studies on the treatment of HE could be performed without development of other complications of advanced liver disease such as spontaneous bacterial peritonitis, renal failure, or other forms of sepsis.…”