Transjugular intrahepatic portosystemic shunt for the management of acute variceal hemorrhage

Abstract

Acute variceal hemorrhage, a life-threatening condition that requires a multidisciplinary approach for effective therapy, is defined as visible bleeding from an esophageal or gastric varix at the time of endoscopy, the presence of large esophageal varices with recent stigmata of bleeding, or fresh blood visible in the stomach with no other source of bleeding identified. Transfusion of blood products, pharmacological treatments and early endoscopic therapy are often effective; however, if primary hemostasis cannot be obtained or if uncontrollable early rebleeding occurs, transjugular intrahepatic portosystemic shunt (TIPS) is recommended as rescue treatment. The TIPS represents a major advance in the treatment of complications of portal hypertension. Acute variceal hemorrhage that is poorly controlled with endoscopic therapy is generally well controlled with TIPS, which has a 90% to 100% success rate. However, TIPS is associated with a mortality of 30% to 50% in such a setting. Emergency TIPS should be considered early in patients with refractory variceal bleeding once medical treatment and endoscopic sclerotherapy failure, before the clinical condition worsens. Furthermore, admission to specialized centers is mandatory in such a setting and regional protocols are essential to be organized effectively. This review article discusses initial management and then focuses on the specific role of TIPS as a primary therapy to control acute variceal hemorrhage, particularly as a rescue therapy following failure of endoscopic approaches.

Keywords: Cirrhosis; Portal hypertension; Transjugular intrahepatic portosystemic shunt; Variceal hemorrhage.

Figure 1

Conventional transjugular intrahepatic portosystemic shunt creation technique. A: Schematic diagram shows transjugular intrahepatic portosystemic shunt (TIPS) connecting the right hepatic vein to the right portal vein. The shunt extends from main portal vein to confluence of right hepatic vein and inferior vena cava; B: Right hepatic venogram shows course of hepatic vein; C: Transhepatic portogram using iodinated contrast material shows course of portal veins; D: Injection of contrast medium through Colapinto needle confirms needle position within portal vein before passage of guidewire; E: Dilatation of a tract through the hepatic parenchyma that is interposed between the hepatic and portal veins; F: Portal venogram obtained after TIPS insertion shows flow through the FLUENCY polytetrafluoroethylene-covered stent. Peripheral portal vein branches are no longer opacified because of reversal of flow.