Transjugular Intrahepatic Portosystemic Shunt: Devices Evolution, Technical Tips and Future Perspectives

Abstract

Portal hypertension (PH) constitutes a pivotal factor in the progression of cirrhosis, giving rise to severe complications and a diminished survival rate. The transjugular intrahepatic portosystemic shunt (TIPS) procedure has undergone significant evolution, with advancements in stent technology assuming a central role in managing PH-related complications. This review aims to outline the progression of TIPS and emphasizes the significant influence of stent advancement on its effectiveness. Initially, the use of bare metal stents (BMSs) was limited due to frequent dysfunction. However, the advent of expanding polytetrafluoroethylene-covered stent grafts (ePTFE-SGs) heralded a transformative era, greatly enhancing patency rates. Further innovation culminated in the creation of ePTFE-SGs with controlled expansion, enabling precise adjustment of TIPS diameters. Comparative analyses demonstrated the superiority of ePTFE-SGs over BMSs, resulting in improved patency, fewer complications, and higher survival rates. Additional technical findings highlight the importance of central stent placement and adequate stent length, as well as the use of smaller calibers to reduce the risk of shunt-related complications. However, improving TIPS through technical means alone is inadequate for optimizing patient outcomes. An extensive understanding of hemodynamic, cardiac, and systemic factors is required to predict outcomes and tailor a personalized approach. Looking forward, the ongoing progress in SG technology, paired with the control of clinical factors that can impact outcomes, holds the promise of reshaping the management of PH-related complications in cirrhosis.

Keywords: complications; patency; personalized medicine; portal hypertension; stent technology; transjugular intrahepatic portosystemic shunt (TIPS).

Figure 1

Milestones in TIPS development [10,13,14,17,18,19,20,21,22,23,24,25,26]. (°) = International Ascites Club definition of recurrent and refractory ascites; (*) = recurrent ascites defined by the performance of at least two large-volume paracenteses within a minimum interval of 3 weeks. Abbreviations: AASLD, American Association for the Study of Liver Diseases; AVB, acute variceal bleeding; BMSs, bare metal stents; CX, controlled expansion; ePTFE-SGs, expanded polytetrafluoroethylene-stent grafts; GL, guidelines; PH, portal hypertension; PV, portal vein; TFS, transplant-free survival; TIPS, transjugular intrahepatic portosystemic shunt. (Created with BioRender.com).

Figure 2

Schematic illustration of the evolution of TIPS devices from the BMSs era to the ePTFE-SGs with controlled expansion technology. (a) Palmaz^® (Cordis, Miami, FL, USA), a balloon-expandable stainless steel stent; (b) Wallstent^® (Boston Scientific, Marlborough, MA, USA), a self-expandable BMS made of nickel–cobalt–titanium–steel alloy, with a braided closed-cell design; (c) Fluency^® (Angiomed GmbH, a subsidiary of C.R. Bard, Inc., Karlsruhe, Germany), a fully covered grid-like stent composed of a biocompatible nickel–titanium alloy, wrapped internally and externally in ePTFE, with 2 mm of bare regions and two radiopaque titanium markers for imaging purposes at both extremities; (d) VIATORR^® (W.L. Gore & Associates in Phoenix, AZ, USA), a self-expandable dedicated nitinol stent made of a 4 to 8 cm portion covered with ePTFE on the inside and a bare 2 cm long PV portion. A circumferential radiopaque gold band (arrowhead) marks the transition between the covered and uncovered portions and an additional radiopaque gold marker (*) is embedded at the trailing edge of the device; (e) VIATORR^® Endoprosthesis with Controlled Expansion (W.L. Gore & Associates, Phoenix, AZ, USA), analogous to the VTS with an additional outer constraining balloon-expandable sleeve on the lined region of the stent. Abbreviations: BMSs, bare metal stents; ePTFE, expanded polytetrafluoroethylene; PV, portal vein; TIPS, transjugular intrahepatic portosystemic shunt.

Figure 3

Example of mispositioned TIPS. (a) C-shaped TIPS (white arrow), results of coaxial positioning of a second stent graft in order to adequately cover the intraparenchymal and hepatic vein tracts (white dot and arrowhead). (b) Placement of a new straight TIPS covering the junction of the HV with the IVC (white dot); the previous short and curved TIPS (white arrow) developed a complete thrombosis despite the deployment of a coaxial longer stent graft (white arrowhead). (c) To cover the entire length of the HV beyond the junction with the IVC, a new coaxial stent graft was deployed inside the original TIPS. The white bracket indicates the distance between the original and the coaxial stent graft distal markers (white arrowheads). HV, hepatic vein; IVC, inferior vena cava, TIPS, transjugular intrahepatic portosystemic shunt.

Figure 4

Determinants of TIPS outcomes. Closed circle = intrinsic factors; dashed circle = unknown factors; red squared = extrinsic factors. Abbreviations: HE, hepatic encephalopathy; OLT, orthotopic liver transplantation; PV, portal vein; TIPS, transjugular intrahepatic portosystemic shunt; US, ultrasound. (Created with BioRender.com).