The role of transjugular intrahepatic portosystemic shunt in patients with portal hypertension: Advantages and pitfalls

Abstract

Transjugular intrahepatic portosystemic shunt (TIPS) is an effective interventional procedure to relieve portal hypertension, which is a main mechanism for the development of complications of liver cirrhosis (LC), such as variceal hemorrhage, ascites, and hepatorenal syndrome. However, the high incidence of adverse events after TIPS implementation limits its application in clinical practice. Esophageal variceal hemorrhage is one of the major indications for TIPS. Recently, preemptively performed TIPS has been recommended, as several studies have shown that TIPS significantly reduced mortality as well as rebleeding or failure to control bleeding in patients who are at high risk of treatment failure for bleeding control with endoscopic variceal ligation and vasoactive drugs. Meanwhile, recurrent ascites is another indication for TIPS with a proven survival benefit. TIPS may also be considered as an effective treatment for other LC complications, usually as an alternative therapy. Although there are concerns about the development of hepatic encephalopathy and hepatic dysfunction after TIPS implementation, careful patient selection using prognostic scores can lead to excellent outcomes. Assessments of cardiac and renal function prior to TIPS may also be considered to improve patient prognosis.

Keywords: Hypertension, Portal; Liver cirrhosis; Portal pressure; Transjugular intrahepatic portosystemic shunt.

Figure 1.

Overview of TIPS. The main complications of TIPS and their countermeasures are presented. TIPS, transjugular intrahepatic portosystemic shunt; PPG, porto-systemic pressure gradient.

Figure 2.

The main indications for TIPS are presented. CTP, Child-Turcotte-Pugh; EBL, endoscopic band ligation; NSBB, nonselective beta-blockers; GOV, gastroesophageal varices; IGV, isolated gastric varices; EVO, endoscopic variceal obliteration; BRTO, balloon occluded retrograde transvenous obliteration; PARTO, plug-assisted retrograde transvenous obliteration; TIPS, transjugular intrahepatic portosystemic shunt. ^*The survival benefit of TIPS was demonstrated in randomized controlled trials.