North American Practice-Based Recommendations for Transjugular Intrahepatic Portosystemic Shunts in Portal Hypertension

Abstract

Complications of portal hypertension, including ascites, gastrointestinal bleeding, hepatic hydrothorax, and hepatic encephalopathy, are associated with significant morbidity and mortality. Despite few high-quality randomized controlled trials to guide therapeutic decisions, transjugular intrahepatic portosystemic shunt (TIPS) creation has emerged as a crucial therapeutic option to treat complications of portal hypertension. In North America, the decision to perform TIPS involves gastroenterologists, hepatologists, and interventional radiologists, but TIPS creation is performed by interventional radiologists. This is in contrast to other parts of the world where TIPS creation is performed primarily by hepatologists. Thus, the successful use of TIPS in North America is dependent on a multidisciplinary approach and technical expertise, so as to optimize outcomes. Recently, new procedural techniques, TIPS stent technology, and indications for TIPS have emerged. As a result, practices and outcomes vary greatly across institutions and significant knowledge gaps exist. In this consensus statement, the Advancing Liver Therapeutic Approaches group critically reviews the application of TIPS in the management of portal hypertension. Advancing Liver Therapeutic Approaches convened a multidisciplinary group of North American experts from hepatology, interventional radiology, transplant surgery, nephrology, cardiology, pulmonology, and hematology to critically review existing literature and develop practice-based recommendations for the use of TIPS in patients with any cause of portal hypertension in terms of candidate selection, procedural best practices and, post-TIPS management; and to develop areas of consensus for TIPS indications and the prevention of complications. Finally, future research directions are identified related to TIPS for the management of portal hypertension.

Keywords: Ascites; Cirrhosis; Complications; Consensus Statement; End-Stage Liver Disease; Guidance Document; TIPS Procedure; Variceal Bleeding.

Figure 1.. Team-Based Approach to TIPS Care.

A team-based approach to TIPS is of critical importance in all stages of TIPS planning and management. Initial consideration for decision on TIPS candidacy should involve the patient and corresponding caregiver as well as a gastroenterologist or hepatologist and a proceduralist with competency in TIPS. Complex cases should include consultation with additional specialties (e.g., cardiology, pulmonology, transplant surgery, hematology, nephrology) as appropriate. Once a patient is determined to meet criteria for TIPS creation, longitudinal care includes a spectrum of multi-specialty (e.g., anesthesia, critical care, IR, GI/hepatology, primary care provider), multi-practitioner (e.g., nursing, physician, pharmacy, mid-level providers) providers. Abbreviations: GI, gastroenterologist; IR, interventional radiologist; PCP, primary care provider; TIPS, transjugular intrahepatic portosystemic shunt.

Figure 2.. Proposed Approach to Gastric Fundal Variceal Bleeding in Cirrhosis

Management of gastric fundal variceal bleeding depends on the admitting center’s expertise as well as the patient’s portal vascular anatomy and severity of their liver disease. Initial management is similar to the approach for all patients presenting with acute gastrointestinal bleeding, particularly in the setting of known portal hypertension. Once gastric varices (GV) are confirmed as the bleeding source, use of endoscopic therapy with “glue” injection can be considered depending on proceduralist’s expertise. If hemostasis is not achieved, TIPS evaluation +/− variceal obliteration should then be considered. In addition, TIPS +/− variceal obliteration should be considered for secondary prophylaxis or if there is GV rebleeding. Abbreviations: BRTO, balloon-occluded retrograde transvenous obliteration; GOV, gastroesophageal varices; IGV, isolated gastric varices; NSBB, nonselective beta-blocker; TIPS, transjugular intrahepatic portosystemic shunt. *Sarin SK, Lahoti D, Saxena SP, Murthy NS, Makwana UK. Prevalence, classification and natural history of gastric varices: a long-term follow-up study in 568 portal hypertension patients. Hepatology 1992 Dec;16(6):1343–9. doi: 10.1002/hep.1840160607.