Where does TIPS fit in the management of patients with cirrhosis?

Abstract

In this review, we summarise the current knowledge on the indications and contraindications of transjugular intrahepatic portosystemic shunt (TIPS) placement for the treatment of the complications of portal hypertension in cirrhosis, specifically variceal haemorrhage and ascites. Moreover, we discuss the role of TIPS for the treatment of portal vein thrombosis (PVT) and the prevention of complications after extrahepatic surgery ('preoperative TIPS') in patients with cirrhosis. The position of TIPS in the treatment hierarchy depends on the clinical setting and on patient characteristics. In acute variceal haemorrhage, preemptive TIPS is indicated in patients at a high risk of failing standard therapy, that is those with a Child-Pugh score of 10-13 points or Child-Pugh B with active bleeding at endoscopy, although the survival benefit in the latter group still remains to be established. Non-preemptive TIPS is a second-line therapy for the prevention of recurrent variceal haemorrhage and for the treatment of ascites. Of note, TIPS may also improve sarcopenia. Contraindications to TIPS placement, independent of clinical setting, include very advanced disease (Child-Pugh >13 points), episodes of recurrent overt hepatic encephalopathy without an identifiable precipitating factor, heart failure, and pulmonary hypertension. In patients with PVT, TIPS placement not only controls complications of portal hypertension, but also promotes portal vein recanalisation. Although the severity of portal hypertension correlates with poor outcomes after extrahepatic surgery, there is no evidence to recommend preoperative TIPS placement.

Keywords: ACLF, acute-on-chronic liver failure; AKI, acute kidney injury; ARR, absolute risk reduction; AVB, acute variceal bleeding; Ascites; BNP, brain natriuretic peptide; BRTO, balloon-occluded retrograde transvenous obliteration; Bleeding; CHF, chronic heart failure; CLD, chronic liver disease; CSPH, clinically significant portal hypertension; Cirrhosis; EVL, endoscopic variceal ligation; GOV, gastro-oesophageal varices; HCC, hepatocellular carcinoma; HE, hepatic encephalopathy; HVPG, hepatic venous pressure gradient; Haemorrhage; ICA, International Club of Ascites; IGV, isolated gastric varices; INR, international normalised ratio; ISMN, isosorbide mononitrate; LVP+A, LVP with albumin; LVP, large-volume paracenteses; MELD, model for end-stage liver disease; NNT, number needed to treat; NSBB, non-selective beta blocker; OS, overall survival; PCI, percutaneous coronary intervention; PFTE, polytetrafluoroethylene; PLT, platelet count; PSE, portosystemic encephalopathy; PV, portal vein; PVT, portal vein thrombosis; Portal hypertension; Portal vein thrombosis; RA, refractory ascites; RCTs, randomised controlled trials; SBP, spontaneous bacterial peritonitis; SEMS, self-expandable metallic stent; TFS, transplant-free survival; TIPS, transjugular intrahepatic portosystemic shunt; Transjugular intrahepatic portosystemic shunt.