Transjugular intrahepatic portosystemic shunts and portal hypertension-related complications

Abstract

Portal hypertension (PH) plays an important role in the natural history of cirrhosis, and is associated with several clinical consequences. The introduction of transjugular intrahepatic portosystemic shunts (TIPS) in the 1980s has been regarded as a major technical advance in the management of the PH-related complications. At present, polytetrafluoroethylene-covered stents are the preferred option over traditional bare metal stents. TIPS is currently indicated as a salvage therapy in patients with bleeding esophageal varices who fail standard treatment. Recently, applying TIPS early (within 72 h after admission) has been shown to be an effective and life-saving treatment in those with high-risk variceal bleeding. In addition, TIPS is recommended as the second-line treatment for secondary prophylaxis. For bleeding gastric varices, applying TIPS was able to achieve hemostasis in more than 90% of patients. More trials are needed to clarify the efficacy of TIPS compared with other treatment modalities, including cyanoacrylate injection and balloon retrograde transvenous obliteration of gastric varices. TIPS should also be considered in bleeding ectopic varices and refractory portal hypertensive gastropathy. In patients with refractory ascites, there is growing evidence that TIPS not only results in better control of ascites, but also improves long-term survival in appropriately selected candidates. In addition, TIPS is a promising treatment for refractory hepatic hydrothorax. However, the role of TIPS in the treatment of hepatorenal and hepatopulmonary syndrome is not well defined. The advantage of TIPS is offset by a risk of developing hepatic encephalopathy, the most relevant post-procedural complication. Emerging data are addressing the determination the optimal time and patient selection for TIPS placement aiming at improving long-term treatment outcome. This review is aimed at summarizing the published data regarding the application of TIPS in the management of complications related to PH.

Keywords: Ascites; Cirrhosis; Portal hypertension; Transjugular intrahepatic portosystemic shunts; Varices.

Figure 1

Conventional transjugular intrahepatic portosystemic shunt insertion technique. A: From a transjugular approach, the right hepatic vein is catheterized; B: A needle inserted through the catheter is used to puncture the liver parenchyma and enters a portal vein branch; C: Transhepatic portogram with the tip of a calibrated catheter at the portosplenic confluence. This catheter is used to measure the length of the parenchymal tract for endograft placement; D: The parenchymal tract is then dilated with an angioplasty balloon to allow passage of the transjugular intrahepatic portosystemic shunt (TIPS) sheath into the portal vein; E: Once stent is fully deployed, an angioplasty balloon is used again to dilate the created tract to obtain the desirable portosystemic gradient (PSG); F: Trans-TIPS portal venography shows flow through the deployed stent. Peripheral portal vein branches are no longer opacified because of reversal of flow.