Recommendations are followed by quality of evidence ratings (Grades I, II-1, II-2, II-3, III) which are defined at the end of the "Major Recommendations" field.
The Procedure; Pre-TIPS Evaluation and Contraindications; Mortality
- Transjugular intrahepatic portosystemic shunt (TIPS) should only be performed by experienced interventional radiologists (or specially trained physicians). Success and complication rates should be monitored; if they fail to meet expected rates, review of the program should be considered (Grade III).
- The decision to perform a TIPS, especially in a high-risk patient, should be reached by a team consisting of a gastroenterologist/hepatologist, interventional radiologist, and, where appropriate, a transplant physician (Grade III).
- Preceding creation of a TIPS, tests of liver and kidney function should be performed in addition to cross-sectional imaging of the liver to assess portal system patency and exclude liver masses (Grade III).
- Reduction in hepatic venous pressure gradient (HVPG) to less than 12 mm Hg should be achieved when the indication is bleeding esophageal varices. Embolization of gastric varices may be required despite adequate decompression of the portal venous system (Grade II-2).
- The degree of reduction in HVPG to control ascites is unclear, but at present a gradient of 8 mm Hg or less has been suggested to be a reasonable goal (Grade II-2).
- Patients with high predicted 30-day mortalities should be informed of their prognosis, and TIPS should be performed only in the absence of other options (Grade II-2).
- In high-risk patients, the need for liver transplantation should be discussed before the performance of an elective TIPS (Grade III).
Complications; TIPS in the Transplant Candidate
- Physicians who perform TIPS need to be aware of both the procedural complications and the complications due to portal diversion and must be experienced in their management (Grade II-3).
- Each center performing TIPS should have an established program of TIPS surveillance, and although there are no established guidelines, Doppler ultrasound should be performed before the patient is discharged from the hospital and at specified intervals following the procedure and the yearly anniversary of the TIPS thereafter (Grade II-1).
- Ultrasonographic findings suggesting TIPS dysfunction or recurrence of the complication of portal hypertension that lead to the initial TIPS should lead to repeat shunt venography and intervention, as indicated. The recurrence of symptoms in the face of a "normal" ultrasound does not eliminate the need for TIPS venography (Grade II-2).
- TIPS stenosis is common, especially in the first year, and Doppler ultrasound lacks the sensitivity and specificity needed to identify many of these patients. Therefore, repeat catheterization of the TIPS or upper endoscopy should be performed at the 1-year anniversary of placement, especially in those patients who bled from varices (Grade II-3).
Indications
Primary Prevention of Variceal Bleeding; Acutely Bleeding Esophageal Varices Refractory to Medical Treatment; Esophageal Variceal Rebleeding; Bleeding from Gastric Varices; Prevention of Bleeding From Portal Hypertensive Gastropathy and Gastric Antral Vascular Ectasia
- The use of TIPS to prevent bleeding from varices that have never bled is contraindicated because of the risk of increasing morbidity and mortality (Grade III).
- TIPS is effective in controlling acute bleeding from varices that is refractory to medical therapy and is preferred to surgery in this situation (Grade II-3).
- TIPS should not be used for the prevention of rebleeding in patients who have bled only once from esophageal varices, and its use should be limited to those who fail pharmacological and endoscopic therapy (Grade I).
- TIPS is effective in the prevention of rebleeding from gastric and ectopic varices (including intestinal, stomal, and anorectal varices) and is the preferred approach for the prevention of rebleeding in this group of patients (Grade II-3).
- Pending further studies, in patients with good liver function, either a TIPS or a surgical shunt are appropriate choices for the prevention of rebleeding in patients who have failed medical therapy (Grade II-2).
- In patients with poor liver function, TIPS is preferred to surgical therapy in the prevention of rebleeding in patients who have failed medical therapy (Grade III).
- The use of TIPS in the management of portal hypertensive gastropathy (PHG) should be limited to those who have recurrent bleeding despite the use of beta-blockers (Grade II-3).
- TIPS is ineffective in controlling bleeding from gastric antral vascular ectasia (GAVE) in patients with cirrhosis and should not be used in this situation (Grade II-3).
Ascites Associated With Cirrhosis; Refractory Hepatic Hydrothorax; Hepatorenal Syndrome (HRS)
- Although TIPS will decrease the need for repeated large-volume paracentesis in patients with refractory ascites associated with cirrhosis, it should be used only in those patients who are intolerant of repeated large-volume paracentesis (Grade I).
- TIPS is effective in the control of hepatic hydrothorax, but it should be used only in patients whose effusion cannot be controlled by diuretics and sodium restriction (Grade II-3).
- TIPS is not recommended for the treatment of HRS, especially type 1 HRS, pending the publication of controlled trials (Grade II-3).
Budd-Chiari Syndrome (BCS); Veno-occlusive Disease or Sinusoidal Obstruction Syndrome; Hepatopulmonary Syndrome
- The decision to create a TIPS in a patient with BCS should be based on the severity of disease, and only patients with moderate disease appear to be reasonable candidates for a TIPS (Grade II-3).
- Patients with BCS and mild disease can be managed medically, whereas those with more severe disease or acute hepatic failure are best managed by liver transplantation. (Grade II-3).
- The use of TIPS to treat sinusoidal obstruction syndrome cannot be recommended (GradeII-3).
- The use of TIPS to treat hepatopulmonary syndrome cannot be recommended (Grade II-3).
Conclusions
TIPS is an important part of the current armamentarium used to treat the complications of portal hypertension. Most fellowship-trained interventional radiologists are capable of creating a TIPS in a patient with patent hepatic and portal veins. Creation of a TIPS ranks among the more complex procedures performed by interventional radiologists, and it is important that each physician monitor their success and complication rates. As with any complex intervention, the decision to create a TIPS should be reached by a gastroenterologist or hepatologist who is experienced in the management of these patients in concert with an interventional radiologist. Pre-TIPS evaluation includes routine tests of liver and kidney function as well as Doppler ultrasound, contrast-enhanced abdominal computed tomography, or magnetic resonance imaging of the liver. Once a TIPS is created, it cannot be forgotten--the patient requires frequent monitoring by Doppler ultrasound and clinic visits to look for the development of TIPS dysfunction. The use of polytetrafluoroethylene (PTFE)-covered stents may reduce the risk of TIPS dysfunction, but this will not eliminate the need for continued surveillance.
TIPS will effectively prevent rebleeding from varices and decrease the need for repeat thoracentesis in patients with hepatic hydrothorax or for large-volume paracentesis in patients with refractory ascites. However, TIPS will increase the incidence of hepatic encephalopathy and will not improve survival in any of these patients. Hence, TIPS should not be considered as primary therapy for any complication of portal hypertension with the exception of bleeding gastric or ectopic varices. In all other situations, TIPS should only be created when the patient has failed or is intolerant of other forms of medical therapy (i.e., pharmacological or endoscopic therapy, diuretics, or repeated large-volume paracentesis or thoracentesis). In patients with good liver function and recurrent bleeding from varices despite medical treatment, it is unclear whether a surgical shunt or TIPS is the better form of therapy pending the publication of additional controlled trials. Which patients with BCS are best managed by TIPS remains undefined, although creation of a TIPS in select patients may be of benefit. Creation of a TIPS for the treatment of HRS or hepatopulmonary syndrome is of unproven benefit and should be considered investigatory.
Definitions:
Quality of Evidence
Grade I: Randomized controlled trials
Grade II-1: Controlled trials without randomization
Grade II-2: Cohort or case-control analytic studies
Grade II-3: Multiple time series, dramatic uncontrolled experiments
Grade III: Opinions of respected authorities, descriptive epidemiology
