The Efficacy of Transjugular Intrahepatic Portosystemic Shunt (TIPS) for Complications of Portal Hypertension in a Non-liver Transplant Teaching Medical Center

Abstract

Introduction: Transjugular Intrahepatic Portosystemic Shunt (TIPS) has been used in the management of patients with complications of portal hypertension such as uncontrolled variceal bleeding, refractory ascites and hepatic hydrothorax. The relative efficacy of TIPS in controlling these complications is not clearly documented. Methods: We conducted a chart review including demographics, etiology of liver disease, pre-procedure MELD score and indication of all patients who underwent TIPS at Northshore University and Long Island Jewish hospitals from January 1st 2010 to April 30th 2017. The duration of follow up was 12 months. Outcomes were assessed for recurrence of symptoms (bleeding, ascites, and hydrothorax) and time to onset of these symptoms. Results: A total of 50 patients had a TIPS performed. Patient demographics are listed in table 1. The immediate mean post-TIPS hepatic venous portal gradient was 8.6 mm Hg (range 5 to 16) for uncontrolled variceal bleeding and 8.1 mm Hg (range 7 to 12) for refractory ascites. Indications for TIPS included refractory ascites (50%, n=25), uncontrolled variceal bleeding (46%, n=23), hepatic hydrothorax (2%, n=1) and portal vein thrombosis (2%, n=1). There were no peri-procedural complications, and MELD scores remained unchanged within a week. Twenty two out of 25 patients (88%) with refractory ascites had follow up evaluation. Symptoms of ascites recurred in 18 out of 22 patients (82%) at a mean of 16 days (range 7 - 45 days) following TIPS. Only one patient was able to completely discontinue diuretics. Twenty two out of 23 (96%) cases of uncontrolled variceal bleeding did not require further blood transfusion or have recurrent variceal bleeding. The 2 patients who underwent TIPS for hepatic hydrothorax and portal vein thrombosis were lost to followup. Conclusion: TIPS is rather safe for patients with complications from portal hypertension. TIPS is highly effective as a salvage therapy for uncontrolled variceal bleeding. In contrast, it is not as effective for management of refractory ascites. It is possible that ascites formation is not a direct consequence of portal hypertension. Other factors such as renovascular and neurohormonal systems may be involved. Further investigation is warranted to better assess the efficacy of TIPS for various indications.Table: Table. Patient Demographics