Early Transjugular Intrahepatic Portosystemic Shunt Research Articles

Early transjugular intrahepatic portosystemic shunt for acute variceal bleeding: a systematic review and meta-analysis.

The alleged benefit of early placement of transjugular intrahepatic portosystemic shunt (TIPS) in patients with cirrhosis and acute variceal bleeding (AVB) remains controversial. This meta-analysis was conducted to evaluate the therapeutic effect of early TIPS on cirrhotic patients with AVB. MEDLINE, Embase, and Cochrane Central Register of Controlled Trials databases were searched for relevant literatures. Data from included studies were extracted, and random-effects meta-analyses were performed. Three randomized control trials and six observational studies involving 2878 participants were included. Compared with those undergoing standard treatment, patients undergoing early TIPS had a significantly lower all-cause mortality (RR, 0.64; 95% CI, 0.52-0.79). Furthermore, early TIPS was associated with a significantly reduced incidence of failure to control bleeding (RR, 0.15; 95% CI, 0.07-0.29) and rebleeding (RR, 0.40; 95% CI, 0.23-0.71), without increasing the risk of hepatic encephalopathy (RR, 1.13; 95% CI, 0.92-1.38). In a stratification analysis based on Child-Pugh classification, the survival benefit was observed in Child-Pugh B patients with active bleeding (RR, 0.53; 95% CI, 0.31-0.93) and Child-Pugh C patients (RR 0.55, 95% CI, 0.37-0.82), but not in low-risk patients (Child-Pugh A and Child-Pugh B without active bleeding) (RR, 0.93; 95% CI, 0.55-1.57). Early TIPS is a feasible therapeutic option for cirrhotic patients with AVB, especially benefiting high-risk patients in terms of improved survival. Given the current low utilization rate in clinical practice, this study favors the placement of early TIPS in a wider range of patients with cirrhosis and AVB, especially high-risk patients. • Early TIPS is associated with improved survival in high-risk patients (Child-Pugh B plus active bleeding at endoscopy or Child-Pugh C 10-13) with cirrhosis and acute variceal bleeding. • Current utilization rate of early TIPS is low in clinical practice.

Perceptions on the management of varices and on the use of albumin in patients with cirrhosis among GI specialists in Austria

SummaryBackgroundPortal hypertension (PH) causes severe complications in patients with liver cirrhosis, such as variceal bleeding and ascites; however, data on the knowledge and perceptions on guideline recommendations for the management of varices and the use of albumin is scarce.MethodsWe designed two structured surveys on (i) the management of varices and (ii) the use of albumin for Austrian physicians of specialized Gastro-Intestinal (GI) centers. The interviewed physicians were confronted spontaneously and provided ad hoc responses to the questionnaire.ResultsIn total, 158 surveys were completed. Interestingly, many specialists (30%) would recommend a follow-up gastroscopy after 1 year in patients with compensated cirrhosis without varices (i.e., overtreatment). For small varices, 81.5% would use non-selective beta blockers (NSBB) for primary prophylaxis (PP). For PP in patients with large varices, endoscopic band ligation (EBL) plus NSBB was preferred by 51.4% (i.e., overtreatment). Knowledge on the indication criteria for early TIPS (transjugular intrahepatic portosystemic shunt) was reported by 54.3%, but only 20% could report these criteria correctly. The majority (87.1%) correctly indicated a preference to use NSBB and EBL for secondary prophylaxis (SP).The majority of participating gastroenterologists reported no restrictions on the use of albumin (89.8%) in their hospitals. Of the interviewed specialists, 63.6% would use albumin in patients with SBP; however, only 11.4% would use the doses recommended by guidelines. The majority of specialists indicated using albumin at the recommended doses for hepatorenal syndrome (HRS-AKI, 86.4%) and for large volume paracentesis (LVP, 73.3%). The individual responses regarding albumin use for infections/sepsis, hyponatremia, renal impairment, and encephalopathy were heterogeneous.ConclusionThe reported management of PH and varices is mostly adherent to guidelines, but endoscopic surveillance in patients without varices is too intense and EBL is overused in the setting of PP. Knowledge on the correct use of early TIPS must be improved among Austrian specialists. Albumin use is widely unrestricted in Austria; however, albumin is often underdosed in established indications.Electronic supplementary materialThe online version of this article (10.1007/s00508-020-01769-9) contains supplementary material, which is available to authorized users.

Performance of artificial intelligence for prognostic prediction with the albumin-bilirubin and platelet-albumin-bilirubin for cirrhotic patients with acute variceal bleeding undergoing early transjugular intrahepatic portosystemic shunt.

The aim of this study was to validate and compare the prognostic performance of the albumin-bilirubin (ALBI) grade, platelet-albumin-bilirubin (PALBI) grade, Child-Pugh (CP) grade, and Model for End-Stage Liver Disease (MELD) score in predicting the 1-year variceal rebleeding probability using artificial intelligence for patients with cirrhosis and variceal bleeding undergoing early transjugular intrahepatic portosystemic shunt (TIPS) procedures. This dual-center retrospective study included two cohorts, with patients enrolled between January 2016 and September 2018 in the training cohort and January 2017 and September 2018 in the validation cohort. In the training cohort, independent risk factors associated with the 1-year variceal rebleeding probability were identified using univariate and multivariate logistic analyses. ALBI-, PALBI-, Child-Pugh-, and MELD-based nomograms and an artificial neural network (ANN) model were established and validated internally in the training cohort and externally in the validation cohort, which included patients with variceal bleeding who were treated with preventive TIPS. A total of 259 patients were included. The median follow-up periods were 24.1 and 18.9 months, and the 1-year variceal rebleeding rates were 12.3% (14/114) and 10.3% (15/145) in the training and validation cohorts, respectively. In the training cohort, all four variables were identified as independent risk factors. Four nomograms were then established and showed comparable prognostic performances after internal (C-index: 0.879, 0.829, 0.874, and 0.798) and external (C-index: 0.720, 0.719, 0.718, and 0.703) validation. The ANN demonstrated that these four variables had comparable importance in predicting the 1-year variceal rebleeding probability. None of the four variables are optimal in predicting the 1-year variceal rebleeding probability for patients with cirrhosis and variceal bleeding undergoing early TIPS.

Transjugular Intrahepatic Portosystemic Shunt for Very Severe Veno-Occlusive Disease/Sinusoidal Obstruction Syndrome (VOD/SOS) after Unmanipulated Haploidentical Hematopoietic Stem Cell Transplantation with Post-transplantation Cyclophosphamide.

Hepatic veno-occlusive disease or sinusoidal obstruction syndrome (VOD/SOS) is a threatening complication after both autologous and allogeneic hematopoietic stem cell transplantation (HSCT), with high mortality rates despite early medical treatment, including the use of defibrotide (DF). We retrospectively analyzed 185 unmanipulated haploidentical (haplo-) HSCT with post-transplantation cyclophosphamide as graft-versus-host disease prophylaxis performed consecutively between 2011 and June 2019 in a single center. Seventeen patients (9.2%) were diagnosed with VOD/SOS. Based on revised European Society for Blood and Marrow Transplantation severity criteria, the VOD/SOS cases were classified as mild in 2 patients (11.7%), moderate in 2 (11.7%), severe in 2 (11.7%), and very severe in 11 (64.9%). Thirteen patients (76%) were treated with DF, including all patients with severe or very severe VOD/SOS, except 1 patient with CNS hemorrhage. Sixteen patients (94%) were alive at day +100 after HSCT. Seven patients (41%) with very severe VOD/SOS were treated with transjugular intrahepatic portosystemic shunt (TIPS) owing to rapid clinical or analytical deterioration or refractory hepatorenal syndrome despite medical treatment, including DF. TIPS insertion was performed at a median time since VOD/SOS diagnosis of 4 days (range, 1 to 28 days) without technical complications in any case. The median hepatic venous pressure gradient before and after TIPS treatment was 24 mmHg (range, 14 to 29 mmHg) and 7 mmHg (range, 2 to 11 mmHg), respectively, with a median drop of 16 mmHg (range, 9 to 19 mmHg). Following TIPS insertion, all patients showed clinical improvement with hepatomegaly, ascites, and renal failure resolution, and all showed analytical improvement with reduced alanine aminotransferase (ALT), creatinine, and international normalized ratio values, except for patient 2, whose indication for TIPS was refractory hepatorenal syndrome with a normal ALT level. The 6 patients who had initiated DF before TIPS insertion completed 21 days of treatment. All patients met the criteria for complete remission (CR) at a median of 8 days after TIPS insertion (range, 2 to 82 days). The 100-day overall survival was 100%. For patients with rapid progressive VOD/SOS, early TIPS insertion allowed completion of DF therapy. The use of TIPS together with DF resulted in CR and no associated complications with no VOD/SOS-associated mortality despite high severity. In our experience, timely and individualized use of TIPS significantly improves outcomes of very severe VOD/SOS after haplo-HSCT. Therefore, TIPS should be promptly considered in rapidly progressive cases.

AS046 - Risk of mortality in patients with uncontrolled variceal bleeding is determined by the presence and severity of acute on chronic liver failure (ACLF) and early transjugular intrahepatic portosystemic shunt (TIPSS) reduces long term mortality

AS046 - Risk of mortality in patients with uncontrolled variceal bleeding is determined by the presence and severity of acute on chronic liver failure (ACLF) and early transjugular intrahepatic portosystemic shunt (TIPSS) reduces long term mortality

Pre-emptive (early) transjugular intrahepatic porto-systemic shunt in the treatment of high-risk acute variceal bleeding. An individual patient data meta-analysis

Pre-emptive (early) transjugular intrahepatic porto-systemic shunt in the treatment of high-risk acute variceal bleeding. An individual patient data meta-analysis

Randomised clinical trial: standard of care versus early-transjugular intrahepatic porto-systemic shunt (TIPSS) in patients with cirrhosis and oesophageal variceal bleeding.

Early-transjugular intrahepatic porto-systemic shunt (TIPSS) has been recommended in international guidelines for high-risk patients with oesophageal variceal bleeding. To validate the results of a previous randomised control trial which supports use of early-TIPSS. In a two-centre open-label parallel-group randomised control trial, patients with cirrhosis and acute variceal bleeding were recruited following haemostasis with vaso-active drugs and endoscopic band ligation. Participants were randomised to standard of care or early-TIPSS. The primary outcome was 1-year survival, secondary outcomes included early and late rebleeding, and complications of portal hypertension. Fifty-eight patients (58±11.12years; 32.7% female) were randomised. After one year, seven patients died in the standard of care group and six in the early-TIPSS group, a 1-year survival of 75.9% vs 79.3% respectively (P=0.79). Variceal rebleeding occurred in eight patients in the standard of care group compared with three patients in the early-TIPSS group (P=0.09). Not all participants randomised to early-TIPSS received the intervention in time. For those receiving TIPSS per-protocol, variceal rebleeding rates were reduced (0% vs 27.6%, P=0.04) but this had no effect on survival (76.9% vs 75.9%, P=0.91). Serious adverse events were similar in both treatment groups, except that rates of hepatic encephalopathy were higher in patients receiving TIPSS (46.1% vs 20.7%, P<0.05). Early-TIPSS reduced variceal rebleeding, increased encephalopathy but had no effect on survival in high-risk patients with oesophageal variceal bleeding. Early-TIPSS may not be feasible in many centres however, larger studies are needed. ClinicalTrials.gov reference: NCT02377141.

Emergent Transjugular Intrahepatic Portosystemic Shunt Creation in Acute Variceal Bleeding.

Emergent transjugular intrahepatic portosystemic shunt (TIPS) creation is most commonly employed in the setting of acute variceal hemorrhage. Given a propensity for decompensation, these patients often require a multidisciplinary, multimodal approach involving prompt diagnosis, pharmacologic therapy, and endoscopic intervention. While successful in the majority of cases, failure to medically control initial bleeding can prompt interventional radiology consultation for emergent portal decompression via TIPS creation. This article discusses TIPS creation in emergent, acute variceal hemorrhage, reviewing the natural history of gastroesophageal varices, presentation and diagnosis of acute variceal hemorrhage, pharmacologic therapy, endoscopic approaches, patient selection and risk stratification for TIPS, technical considerations for TIPS creation, adjunctive embolotherapy, and the role of salvage TIPS versus early TIPS in acute variceal hemorrhage.

What's new in portal hypertension?

Portal hypertension is defined as increased pressure in the portal venous system. The most common cause of portal hypertension is cirrhosis. In this setting, there is an increase in intrahepatic resistance leading to an increase in portal pressure. By increasing portal blood flow, splanchnic vasodilation further aggravates portal hypertension. New pathogenic pathways are being established which might result in new therapeutic strategies. The presence of varices at endoscopy and/or other abdominal portosystemic collaterals confirms the diagnosis of portal hypertension. The role of non-invasive and imaging tests in the diagnosis and prognosis of portal hypertension has been clarified. Non-selective beta-blockers decrease both the risk of variceal haemorrhage and hepatic decompensation. Terlipressin, somatostatin or octreotide, in combination with early endoscopic therapy, are recommended for the treatment of acute variceal haemorrhage. EarlyTransjugular intrahepatic portosystemicshunt (TIPS) is effective as salvage therapy in acute variceal bleeding in selected patients and prevents rebleeding more effectively than endoscopic and medical therapyresulting in an increased survival.

Transjugular Intrahepatic Portosystemic Shunt (TIPS) for Very Severe Veno-Occlusive Disease after Unmanipulated Haploidentical HSCT with Post-Transplant Cyclophosphamide

Background: The use of unmanipulated Haploidentical HSCT (Haplo-HSCT) with post-transplant Cyclophosphamide (PT-Cy) as GVHD prophylaxis has widely extended. Veno-occlusive disease (VOD) is a threatening complication after both autologous and allogeneic HSCT, with high mortality rates despite early medical treatment, including the use of defibrotide. The objective of this study was to describe characteristics and outcomes of patients with refractory very severe VOD after Haplo-HSCT with PT-Cy, treated with TIPS as salvage procedure. Methods: We retrospectively analysed 176 Haplo-HSCT with Cy-post consecutively performed between 2011 and May 2019 in a single centre. VOD was defined according to modified Seattle, Baltimore or revised EBMT criteria. Severity was retrospectively graded according to revised EBMT severity criteria into four categories: mild, moderate, severe and very severe. Complete response (CR) was defined as a normal total bilirubin level (&lt;2 mg/dL) or, in patients with normal bilirubin or alternative causes of hyperbilirubinemia, as normalized renal function, reduction of elevated transaminase level &lt;50%, tense ascites resolution, and no need for oxygen supplement in the absence of alternative hypoxemia causes. Results: Sixteen patients (9.1%) met the modified Seattle, Baltimore or revised EBMT diagnostic criteria for VOD. Ultrasound with Doppler ultrasonography was performed in all patients, and at least indirect signs of VOD were found in all cases. Based on revised EBMT severity criteria, there were 2 mild (12.5%), 2 moderate (12.5%), 2 severe (12.5%) and 10 very severe (62.5%) grade VOD. Twelve patients (75%) were treated with defibrotide, including all patients with very severe VOD, except one with CNS hemorrhage (Patient 1). Six patients with very severe VOD, were treated with TIPS due to rapid clinical or analytical deterioration or refractory hepatorenal syndrome, despite medical treatment including defibrotide (Table 1). All were male patients, with a median age of 31 years (range 22-36), all transplanted with myeloablative conditioning regimen. TIPS insertion was performed on a median time since VOD diagnosis of 5 days (range 1-28) without technical complications in any case. Median total bilirubin, ALT, creatinine and INR the day of procedure were 3 mg/dL (range 2.2-11.2), 1120 UI/L (range 10-2595), 2.45 mg/dL (range 2.06-3.58) and 1.96 (range 1.1-4) respectively. Median hepatic venous pressure gradient (HVPG) prior to and after TIPS was 22.5 (range 14-29) and 6.5 (range 2-10) mmHg respectively, with a median drop of 16.5 mmHg (range 9-19). Following TIPS, all patients showed clinical improvement with hepatomegaly, ascites and renal failure resolution, and all showed analytical improvement with bilirubin, creatinine and ALT values reduction, except for patient 2, whose TIPS indication was refractory hepatorenal syndrome with normal ALT levels (Figure 1). The 5 patients who had iniciated defibrotide before TIPS, completed 21 days of treatment. All patients met criteria for CR in a median of 8 days after TIPS insertion (range 2-82). The 100-day overall survival (OS) was 100%. Five patients were alive with normal liver and renal function at last follow up, and one patient died due to infection 7 months after Haplo-HSCT, with VOD in complete resolution. Conclusions: Incidence of VOD after Haplo-HSCT with PT-Cy is comparable to those reported after HLA-identical HSCT series. Most of the patients developed very severe VOD according to revised EBMT severity criteria. For patients with rapid progressive VOD, early TIPS insertion allowed completion of defibrotide therapy. The use of TIPS together with defibrotide resulted in complete response and no associated complications with a 0% of VOD associated mortality in spite of high severity. ALT values may be the best predictor of CR after TIPS procedure. In our experience, timely and individualized use of TIPS significantly improves outcome of very severe VOD after Haplo-HSCT. Therefore, TIPS should be promptly considered in rapid progressive cases. Disclosures No relevant conflicts of interest to declare.

TIPS for management of portal-hypertension-related complications in patients with cirrhosis

Portal hypertension is primarily due to liver cirrhosis, and is responsible for complications that include variceal bleeding, ascites and hepatorenal syndrome. The transjugular intrahepatic portosystemic shunt (TIPS) is a low-resistance channel between the portal vein and the hepatic vein, created by interventional radiology, that aims to reduce portal pressure. TIPS is a potential treatment for severe portal-hypertension-related complications, including esophageal and gastric variceal bleeding. TIPS is currently indicated as salvage therapy in this setting when patients fail to respond to standard endoscopic and medical treatment. More recently, early TIPS has been shown to be effective in decreasing risk of rebleeding after variceal hemorrhage and mortality in Child-Pugh B patients with active hemorrhage at endoscopy, and in Child-Pugh C patients. TIPS is also an efficient treatment for refractory ascites and hepatic hydrothorax. In contrast, the role of TIPS in the hepatorenal syndrome has not been precisely defined. The aim of this review was to specifically describe the current role of TIPS in management of portal hypertension in patients with cirrhosis.

Patient Selection in Transjugular Intrahepatic Portosystemic Shunt (TIPS) for Refractory Ascites and Associated Conditions

This review summarizes the key developments and latest evidence for transjugular intrahepatic portosystemic shunt (TIPS) for the indications of refractory ascites and related conditions, as well as factors that should be taken into consideration with regard to patient selection. Recent evidence from randomized controlled studies has suggested that the early institution of TIPS in well-selected patients with refractory ascites may confer a survival benefit. Increasing evidence is also mounting on the potential role of TIPS in improving and reversing hepatorenal syndrome. TIPS has conventionally been sought as a second-line treatment for refractory ascites. Recent evidence has suggested a potential survival benefit with early TIPS in well-compensated patients for this indication; this may lead to a paradigm shift for TIPS to be considered as primary therapy in well-selected “low-risk” patients. In hepatorenal syndrome, while evidence on TIPS is limited, multiple studies have shown a serendipitous improvement to renal function in both type 1 and 2 hepatorenal syndrome following TIPS.

Child-Pugh Classification: Time to Abandon?

The Child-Pugh classification is one of the commonest and oldest bedside tools utilized in estimating prognosis in patients with cirrhosis. However, its usage as a risk prediction tool or indeed a decision-making tool should be revisited. In this review, we discuss some inherent issues with the Child-Pugh classification and present a few contexts in which the current usage of Child-Pugh warrants reassessment, elaborating on its utility in acute variceal bleeding, specifically its role in decision-making on early transjugular intrahepatic portosystemic shunt, as well as its use in the context of hepatocellular carcinoma and drug development and dose adjustment.

Model for end-stage liver disease score and hemodynamic instability as a predictor of poor outcome in early transjugular intrahepatic portosystemic shunt treatment for acute variceal hemorrhage.

To evaluate the outcome of early transjugular portosystemic shunt (TIPS) treatment in patients with a trial-compatible high-risk variceal bleeding and secondly to disclose other predictors of early mortality. A cohort study was conducted on patients referred for a TIPS procedure with or without combined variceal embolization to control acute esophageal variceal bleeding. A total of 32 patients with Child-Pugh C score less than 14 or Child-Pugh B plus active bleeding at endoscopy, admitted for early-TIPS treatment (<72 h), were included. We noted one (3.7%) failure to control bleeding and no rebleeding during 1-year follow-up. Ten (31.3%) patients died within 6 weeks after TIPS placement. Early mortality was associated with model for end-stage liver disease (MELD) score (P=0.025), MELD score of at least 19 (P=0.008) and hemodynamic instability at time of admission (P=0.001). If hemodynamic instability is associated with a high MELD score, the 6-week mortality peaks at 77.8% (P=0.000). This study confirms the excellent survival results of early-TIPS treatment for acute variceal bleeding in a selected patient group with a low MELD score. Poor survival in hemodynamically unstable patients with high MELD scores (≥19) contests the guidelines that patients with Child-Pugh class C cirrhosis or Child-Pugh class B with active bleeding on endoscopy should deliberately receive preemptive TIPS treatment after endoscopic haemostasis.

Identifying optimal candidates for early TIPS among patients with cirrhosis and acute variceal bleeding: a multicentre observational study

ObjectivesEarly placement of transjugular intrahepatic portosystemic shunt (TIPS) has been shown to improve survival in high-risk patients (Child-Pugh B plus active bleeding at endoscopy or Child-Pugh C 10–13) with cirrhosis...

Outcomes after placement of a SX‐ELLA oesophageal stent for refractory variceal bleeding—A national multicentre study

BackgroundCurrent guidelines favour the use of bleeding stents over balloon tamponade (BT) for refractory variceal bleeding (VB) from oesophageal varices. However, data on the efficacy and safety of self‐expandable metal SX‐ELLA Danis stents (SEMS) are limited.MethodsCirrhotic patients receiving SEMS for VB at four tertiary care centres were included in this retrospective multicentre study. Rates of failure‐to‐control bleeding (within 5 days) and bleeding‐related mortality (6 weeks) were assessed.ResultsSEMS controlled VB in 79.4% (27/34) of patients. In the rest of patients, other rescue treatments including endoscopic band ligation (EBL, n = 3), SEMS renewed (n = 2) or Linton (n = 2) were applied; however, VB was only controlled in one patient. Early rebleeding within six weeks occurred in 17.6% (6/34) patients. Median SEMS dwell time was three (IQR:6) days. Overall n = 13/34 (38.2%) patients died with SEMS in situ. After SEMS removal, rebleeding and bleeding‐related death occurred in n = 7 (35%) and n = 5 (14.7%) patients respectively. Only 32.4% (10/34) patients did not experience any rebleeding within six weeks after SEMS removal. Bleeding‐related mortality was 47.1% (n = 16/34) and the median survival after SEMS placement was 2.1 months. Notably, no patient received an early transjugular intrahepatic portosystemic shunt (TIPS). The most common adverse events were stent dislocations (n = 13; 38.2%), while ulcers/necrosis of the oesophageal mucosa was seen in only four (11.8%) patients.ConclusionSEMS controlled refractory VB in most patients. However, bleeding‐related mortality remained high. While SEMS dislocations were frequent, ulcers/necrosis of the oesophagus was rare. Further studies should investigate whether the wider use of early TIPS reduces bleeding‐related mortality after SEMS placement.

Early Transjugular Intrahepatic Portosystemic Shunt Creation Compared to Endoscopy With Pharmacotherapy in the Management of Variceal Rebleeding in Cirrhotic Patients: A Comprehensive Systematic Review and Meta-Analysis: Presidential Poster Award

Introduction: The use of early or rescue transjugular intrahepatic portosystemic shunt (TIPS) has been evaluated in cirrhotic patients with a history of variceal bleeding. In this study, we aimed to perform a systematic review and meta-analysis of studies investigating the efficacy and safety of early TIPS in the management of variceal bleeding as well as comparing the use of early compared to rescue TIPS. Methods: Medical electronic databases were queried for clinical studies in which TIPS creation was compared with endoscopy and pharmacotherapy treatment in cirrhotic patients with a history of variceal bleeding. Search results were screened against predefined eligibility criteria and data were extracted to a standard data extraction form. Meta-analysis was performed using Comprehensive Meta-Analysis software and the risk of bias of included studies was assessed using the Cochrane tool and modified Newcastle-Ottawa scale Results: Thirty-four studies that enrolled 2876 cirrhotic patients (n=1453 in the TIPS group and n=1423 in the endoscopy with pharmacotherapy group) were included. Overall analysis displayed significantly reduced re-bleeding, odds ratio (OR) = 0.29, 95% confidence interval (CI) [0.22-0.38], p< 0.0001) and bleeding-related death (OR= 0.28, 95% CI [0.18-0.44], p< 0.0001) in the TIPS group. There was no significant difference in all-cause mortality between all TIPS and endoscopy with pharmacotherapy (OR= 0.93, 95% CI [0.74-1.16], p= 0.52) and there was an increased incidence of hepatic encephalopathy (OR= 1.80, 95% CI [1.41-2.28], p< 0.0001) in the TIPS group (pooled analysis of both early and rescue TIPS). Early use of TIPS did not reveal any differences in hepatic encephalopathy (OR= 1.27, 95% CI [0.9-1.7], p= 0.13) and showed a decreased mortality in high risk patients (Child-Pugh class C, Child-Pugh class B with active bleeding at endoscopy, and hepatic venous pressure gradient [HVPG] ≥20 mm Hg) when compared to rescue TIPS. Conclusion: TIPS creation decreases rebleeding at the cost of increased hepatic encephalopathy with no survival benefit. Early TIPS creation may confer better clinical outcomes in terms of comparable hepatic encephalopathy and improved survival in high-risk patients when compared to rescue TIPS.

Transjugular Intrahepatic Portosystemic Shunt (TIPS): Pathophysiologic Basics, Actual Indications and Results with Reviewof the Literature.

Transjugular intrahepatic portosystemic shunt (TIPS) is a non-selective portosystemic shunt created using endovascular techniques. During recent years technical improvements and new insights into pathophysiology have modified indications for TIPS placement. In this article we therefore want to discuss current knowledge. A literature review was performed to review and discuss the pathophysiology, indications and results of the TIPS procedure. Established TIPS indications are persistent bleeding despite combined pharmacological and endoscopic therapy and rebleeding during the first five days. A new indication in the European recommendations is early TIPS placement within 72 hours, ideally within 24 hours, in patients bleeding from esophageal or gastroesophageal varices at high risk for treatment failure (e. g. Child-Pugh class C < 14 points or Child-Pugh class B with active bleeding) after initial pharmacological and endoscopic therapy. For prevention of recurrent variceal hemorrhage in the recommendations, covered TIPS placement is the treatment of choice only after failed first-line therapy, although numerous TIPS studies show a prolonged time to rebleeding and a reduction of mortality. Similarly for secondary prophylaxis in patients with refractory ascites, covered TIPS placement may be considered only if the patient continues to be intolerant to NSBBs and is an appropriate TIPS candidate even though studies show that the TIPS procedure controls ascites, improves survival and renal function better than paracentesis. Potential indications for TIPS implantation are Budd-Chiari syndrome, acute portal vein thromboses, hydrothorax, hepatopulmonary and hepatorenal syndrome (Typ 2), portal hypertensive gastropathy (PHG) and prophylaxis of complications of abdominal surgery, very rarely bleeding in ectopic varices or in patients with chylothorax or chylous ascites. TIPS placement is an established procedure with a new indication as "early TIPS". In the European recommendations it is only the second-line therapy for prevention of recurrent variceal hemorrhage and for secondary prophylaxis in patients with refractory ascites although several studies showed a clear benefit of the TIPS procedure compared to ligation and NSBBs. · In addition to already established indications, new European recommendations suggest early TIPS placement in patients bleeding from esophageal or gastroesophageal varices at high risk for treatment failure.. · Strunk H, Marinova M, . Transjugular Intrahepatic Portosystemic Shunt (TIPS): Pathophysiologic Basics, Actual Indications and Results with Review of the Literature. Fortschr Röntgenstr 2018; 190: 701 - 711.

Cost Effectiveness of Early Insertion of Transjugular Intrahepatic Portosystemic Shunts for Recurrent Ascites

Treatment options for recurrent ascites resulting from decompensated cirrhosis include serial large-volume paracentesis and albumin infusion (LVP+A) or insertion of a transjugular intrahepatic portosystemic shunt (TIPS). Insertion of TIPSs with covered stents during early stages of ascites (early TIPS, defined as 2 LVPs within the past 3 weeks and <6 LVPs in the prior 3 months) significantly improves chances of survival and reduces complications of cirrhosis compared with LVP+A. However, it is not clear if TIPS insertion is cost effective in these patients. We developed a Markov model using the payer perspective for a hypothetical cohort of patients with cirrhosis with recurrent ascites receiving early TIPSs or LVP+A using data from publications and national databases collected from 2012 to 2018. Projected outcomes included quality-adjusted life-year (QALY), costs (2017 US dollars), and incremental cost-effectiveness ratios (ICERs; $/QALY). Sensitivity analyses (1-way, 2-way, and probabilistic) were conducted. ICERs less than $100,000 per QALY were considered cost effective. In base-case analysis, early insertion of TIPS had a higher cost ($22,770) than LVP+A ($19,180), but also increased QALY (0.73 for early TIPSs and 0.65 for LVP+A), resulting in anICER of $46,310/QALY. Results were sensitive to cost of uncomplicated TIPS insertion andtransplant, need for LVP+A, probability of transplant, and decompensated QALY. In probabilistic sensitivity analysis, TIPS insertion was the optimal strategy in 59.1% of simulations. Based on Markov model analysis, early placement of TIPSs appears to be a cost-effective strategy for management of specific patients with cirrhosis and recurrent ascites. TIPS placement should be considered early and as a first-line treatment option for select patients.

Timing of Transjugular Intrahepatic Portosystemic Shunt for Budd-Chiari Syndrome: An Italian Hepatologist's Perspective.

Budd-Chiari syndrome (BCS) management flow-chart is derived from experts' opinion and is not evidence-based. Guidelines suggest BCS management should follow a stepwise strategy: medical therapy as first-line treatment, revascularization or transjugular intrahepatic portosystemic shunt (TIPS) if no response to medical therapy, and liver transplant as rescue therapy. Recent evidence suggests that only medical therapy results in a bad long-term outcome. The biggest criticism of guidelines is the indication that BCS should receive further treatment only when hemodynamic consequences of portal hypertension become clinically evident. Recent data support that in BCS liver fibrosis could arise from chronic microvascular ischemia. A reasoning model of BCS physiopathology is that impaired hepatic vein outflow has hemodynamic consequences on portal hypertension development and causes hepatic fibrosis and liver failure through chronic ischemic damage. On this assumption is the concept that relieving liver congestion could ameliorate liver function and prevent development of BCS complications. Recently, early interventional treatment with TIPS for BCS has been reported to be effective. Early TIPS seems to be the best option for BCS management. Future multicenter controlled studies should compare the outcome of BCS treated with early interventional treatment compared with stepwise strategy.