Covered Transjugular Intrahepatic Portosystemic Shunt in the Treatment of Portal Hypertension: Looking for the Right Patient and the Right Time

Abstract

Transjugular intrahepatic portosystemic shunt (TIPS) offers an effective treatment for patients with complications of portal hypertension, specifically prevention of variceal rebleeding and recurrent or refractory ascites. TIPS reduces portal pressure and increases effective blood volume and cardiac output, but long-term adverse effects may include increased risk of liver failure, hepatic encephalopathy, and cardiac dysfunction. As such, TIPS is not indicated for primary prophylaxis of variceal bleeding. Critical to the success of TIPS is a dedicated, multidisciplinary team, along with careful patient selection and appropriate timing of the procedure; for example, in high-risk patients TIPS may offer clinical benefits when performed early in the disease course. Important patient factors to consider before performing TIPS include cardiac and renal function, severity of liver dysfunction, history of hepatic encephalopathy, and inflammatory status. Recent studies indicate that technical considerations, specifically diameter control and downsizing covered stents, may reduce adverse events and increase clinical benefits of TIPS. This review focusses on the optimisation of the use of a covered TIPS endoprosthesis in patients with portal hypertension-related complications, with consideration of evolving practices, patient selection, and multidisciplinary co-operation. Further research and patient stratification are necessary to enhance understanding of the optimal use of covered TIPS and to ensure that the right patients receive TIPS at the right time.