Role Of Transjugular Intrahepatic Portosystemic Shunt Research Articles

The Role of Transjugular Intrahepatic Portosystemic Shunt for the Management of Ascites in Patients with Decompensated Cirrhosis.

The development and progression of ascites represent a crucial event in the natural history of patients with cirrhosis, predisposing them to other complications and carrying a heavy impact on prognosis. The current standard of care for the management of ascites relies on various combinations of diuretics and large-volume paracenteses. Periodic long-term albumin infusions on top of diuretics have been recently shown to greatly facilitate the management of ascites. The insertion of a transjugular intrahepatic portosystemic shunt (TIPS), an artificial connection between the portal and caval systems, is indicated to treat patients with refractory ascites. TIPS acts to decrease portal hypertension, thus targeting an upstream event in the pathophysiological cascade of cirrhosis decompensation. Available evidence shows a significant benefit on ascites control/resolution, with less clear results on patient survival. Patient selection plays a crucial role in obtaining better clinical responses and avoiding TIPS-related adverse events, the most important of which are hepatic encephalopathy, cardiac overload and failure, and liver failure. At the same time, some recent technical evolutions of available stents appear promising but deserve further investigations. Future challenges and perspectives include (i) identifying the features for selecting the ideal candidate to TIPS; (ii) recognizing the better timing for TIPS placement; and (iii) understanding the most appropriate role of TIPS within the framework of all other available treatments for the management of patients with decompensated cirrhosis.

The role of TIPS in the management of liver transplant candidates.

Transjugular intrahepatic portosystemic shunt (TIPS) implantation is used for treatment of several complications in patients with liver cirrhosis. Recent studies have identified a survival benefit for patients on the waiting list after TIPS implantation, but the optimal time point for TIPS implantation prior to orthotopic liver transplantation (OLT) has not been established. This study retrospectively assessed patients undergoing TIPS implantation before or after listing for OLT at the Medical University of Vienna. n = 98 patients with TIPS on the waiting list between January 1993 and December 2013 were identified (n = 73 (74.5%) pre-listing TIPS, n = 25 (25.5%) post-listing TIPS). A matched control group at the time of OLT without TIPS (n = 60) was included. More patients with post-listing TIPS (28.0%, 7/25) showed clinical improvement and went off-list than patients with pre-listing TIPS (8.2%, 6/73, p = .0119). A similar proportion of patients with pre-listing TIPS (19.2%, 14/73) and post-listing TIPS (20.0%, 5/25) died on the OLT waiting list. Transplant surgery time was similar in patients with and without TIPS: 348(±13) vs. 337(±10) minutes (p = .5139). Estimated 1-year post-transplant survival was similar across all groups (pre-listing TIPS: 76.2%, post-listing TIPS: 86.0%, no TIPS: 91.2%, log-rank p = .1506). TIPS should be considered in all liver transplant candidates, since it can obviate the need for OLT and optimize bridging to OLT.

Covered TIPS for secondary prophylaxis of variceal bleeding in liver cirrhosis: A systematic review and meta-analysis of randomized controlled trials.

In the era of bare stents, transjugular intrahepatic portosystemic shunt (TIPS) is the second-line choice of therapy for the prevention of variceal rebleeding in liver cirrhosis. In the era of covered stents, the role of TIPS should be re-evaluated. The aim of the study was to compare the outcomes of covered TIPS versus the traditional first-line therapy (i.e, drug plus endoscopic therapy) for the prevention of variceal rebleeding in liver cirrhosis. All relevant randomized controlled trials were searched via the PubMed, EMBASE, and Cochrane Library databases. Hazard ratios (HRs) and odds ratios (ORs) with 95% confidence intervals (CIs) and P values were calculated for the cumulative risk and overall risk, respectively. Heterogeneity among studies was also calculated. Three of 111 retrieved papers were eligible. Among them, the proportion of patients who were switched from drug plus endoscopic therapy to TIPS was 16% to 25%. The risk of bias was relatively low in all included randomized controlled trials. Meta-analyses demonstrated that the covered TIPS group had a similar overall survival (HR = 0.84, 95% CI = 0.55-1.28, P = 0.41; OR = 1.00, 95% CI = 0.59-1.69, P = 0.99), a significantly lower risk of variceal rebleeding (HR = 0.30, 95% CI = 0.18-0.48, P < 0.00001; OR = 0.24, 95% CI = 0.12-0.46, P < 0.0001), and a similar risk of hepatic encephalopathy (HR = 1.35, 95% CI = 0.72-2.53, P = 0.36; OR = 1.28, 95% CI = 0.54-3.04, P = 0.57). In most of meta-analyses, the heterogeneity among studies was not statistically significant. Compared with drug plus endoscopic therapy, covered TIPS had a significant benefit of preventing from variceal rebleeding, but did not increase the overall survival or risk of hepatic encephalopathy.

Transjugular intrahepatic portosystemic shunt for acute variceal gastrointestinal bleeding: Indications, techniques and outcomes.

Acute variceal bleeding is a life-threatening condition that requires a multidisciplinary approach for effective therapy. The transjugular intrahepatic portosystemic shunt (TIPS) procedure is a minimally invasive image-guided intervention used for secondary prevention of bleeding and as salvage therapy in acute bleeding. Emergency TIPS should be considered early in patients with refractory variceal bleeding once medical treatment and endoscopic sclerotherapy fail, before the clinical condition worsens. Furthermore, admission to specialized centers is mandatory in such a setting and regional protocols are essential to be organized effectively. This procedure involves establishment of a direct pathway between the hepatic veins and the portal veins to decompress the portal venous hypertension that is the source of the patient's bleeding. The procedure is technically challenging, especially in critically ill patients, and has a mortality of 30%-50% in the emergency setting, but has an effectiveness greater than 90% in controlling bleeding from gastro-esophageal varices. This review focuses on the role of TIPS in the setting of variceal bleeding, with emphasis on current indications and techniques for TIPS creation, TIPS clinical outcomes, and the role of adjuvant embolization of varices.

Outcomes of TIPS for Treatment of Gastroesophageal Variceal Hemorrhage.

Variceal hemorrhage is a life-threatening complication of cirrhosis that requires a multidisciplinary approach to management. The transjugular intrahepatic portosystemic shunt (TIPS) procedure is a minimally invasive image-guided intervention used for secondary prevention of bleeding and as salvage therapy in acute hemorrhage. This review focuses on the role of TIPS in the setting of variceal hemorrhage, with emphasis on the pathophysiology and conventional management of variceal hemorrhage, current and emerging indications for TIPS creation, TIPS clinical outcomes, and the role of adjuvant embolotherapy.

Transjugular intrahepatic portosystemic shunts and portal hypertension-related complications.

Portal hypertension (PH) plays an important role in the natural history of cirrhosis, and is associated with several clinical consequences. The introduction of transjugular intrahepatic portosystemic shunts (TIPS) in the 1980s has been regarded as a major technical advance in the management of the PH-related complications. At present, polytetrafluoroethylene-covered stents are the preferred option over traditional bare metal stents. TIPS is currently indicated as a salvage therapy in patients with bleeding esophageal varices who fail standard treatment. Recently, applying TIPS early (within 72 h after admission) has been shown to be an effective and life-saving treatment in those with high-risk variceal bleeding. In addition, TIPS is recommended as the second-line treatment for secondary prophylaxis. For bleeding gastric varices, applying TIPS was able to achieve hemostasis in more than 90% of patients. More trials are needed to clarify the efficacy of TIPS compared with other treatment modalities, including cyanoacrylate injection and balloon retrograde transvenous obliteration of gastric varices. TIPS should also be considered in bleeding ectopic varices and refractory portal hypertensive gastropathy. In patients with refractory ascites, there is growing evidence that TIPS not only results in better control of ascites, but also improves long-term survival in appropriately selected candidates. In addition, TIPS is a promising treatment for refractory hepatic hydrothorax. However, the role of TIPS in the treatment of hepatorenal and hepatopulmonary syndrome is not well defined. The advantage of TIPS is offset by a risk of developing hepatic encephalopathy, the most relevant post-procedural complication. Emerging data are addressing the determination the optimal time and patient selection for TIPS placement aiming at improving long-term treatment outcome. This review is aimed at summarizing the published data regarding the application of TIPS in the management of complications related to PH.

Role of transjugular intrahepatic portosystemic shunt in prevention and treatment of variceal bleeding in liver cirrhosis

In patients with liver cirrhosis,variceal bleeding is a common fatal complication of portal hypertension. Varices are present in almost half of patients with cirrhosis at the time of diagnosis. Since transjugular intrahepatic portosystemic shunt(TIPS) was first applied clinically in 1988,the relevant information about TIPS has been continually updated and perfected by lots of clinical trials. The role of TIPS in the prevention and treatment of variceal bleeding in cirrhotic patients with portal hypertension,including primary prevention of variceal bleeding,treatment of acute variceal bleeding,and prevention of rebleeding,is reviewed. TIPS is an effective treatment for variceal bleeding in cirrhotic patients with portal hypertension. Along with the technical development,TIPS will be available for more and more patients and will play an increasingly important role in the prevention and treatment of variceal bleeding among cirrhotic patients with portal hypertension.

Improving Survival in Patients with Decompensated Cirrhosis

About 60% of patients with decompensated disease have oesophageal varices. One third of these patients will experience variceal bleed. Each bleeding episode compromises the decompensated state and is associated with a 20% to 30% mortality. Bleeding from ectopic varices is rare but is generally massive and life threatening. The first two articles, “Clinicopathological features and treatment of ectopic varices with portal hypertension” and “Application of endoscopy in improving survival of cirrhotic patients with acute variceal hemorrhage” discuss the management of variceal bleeding in cirrhotic patients. “Improved survival with the patients with variceal bleed” is a review article on how new treatment modalities have improved the outlook of patients with bleeding oesophageal varices. The hepatorenal syndrome (HRS) signifies advanced liver failure and is a bad prognostic factor in patients with decompensated cirrhosis. Management of this condition is discussed in “Management of renal failure and ascites in patients with cirrhosis”. One of the features of decompensated liver disease is the occurrence of recurrent or resistant ascites. Transjugular intrahepatic portosystemic shunt (TIPS) is an effective therapy for refractory ascites and HRS at the expense of hepatic encephalopathy and may offer an effective bridge to liver transplantation, by improving short and medium term survivals, as discussed in “Role of TIPS in improving survival of patients with decompensated liver disease”. Bacterial infection is responsible for up to a quarter of the deaths of patients with decompensated liver disease. “Prevention and management of bacterial infections in cirrhosis” discuss the high index of suspicion that is needed to prevent bacterial infections in patients with decompensated cirrhosis. These patients are immunologically compromised, and prophylactic antibiotics can prevent fatal septicemia and HRS in those with gastrointestinal bleeding. Current thoughts on how to deal with the neuropsychiatric complication of cirrhosis are discussed in “Management of hepatic encephalopathy”. Cardiomyopathy, hepatopulmonary syndrome, portopulmonary hypertension and right-sided hydrothorax complications that are often overlooked in patients with decompensated liver disease are discussed in “Management of cardiopulmonary complications of cirrhosis”. Decompensated liver cirrhosis has been traditionally considered as a prototype of hemorrhagic coagulopathy, and routinely performed coagulation profile is abnormal in the majority of these patients. In “Management of coagulopathy in patients with decompensated liver disease”, the authors discussed recent thoughts on coagulation in end-stage liver disease. The related article entitled “Determination of ADAMTS13 and its clinical significance for ADAMTS13 supplementation therapy to improve the survival of patients with decompensated liver cirrhosis” reviews the role of the deficiency of the metalloproteinase ADAMTS13 in end-stage liver cirrhosis in inducing platelet clumping or thrombi and how the resulting sinusoidal microcirculatory disturbances causes further liver damage and is closely related to further deterioration of liver function, hepatic encephalopathy, hepatorenal syndrome, and intractable ascites in advanced liver cirrhosis. Fresh frozen plasma (FFP) is a source of ADAMTS13. Liver cirrhosis is the common end stage of persistent liver injury. In the Asia Pacific region, these injuries commonly result from chronic hepatitis B and C infections as well as alcohol. The following two articles, “Treatment of hepatitis B in decompensated liver cirrhosis and treatment of decompensated alcoholic liver disease” address the management of hepatitis B and alcoholic liver disease in end stage liver disease. Pharmacotherapy in patients with decompensated liver disease is not without complications and side effects and might compromise the decompensated state. The article entitled “Prescribing medications in patients with decompensated liver cirrhosis” addresses the above conundrum. A common complication of liver cirrhosis is liver cancer, and treatment of this condition is challenging in patients with liver decompensation to say the least. The paper entitled “Screening for hepatocellular carcinoma” discusses early detection of liver cancer in these patients so that appropriate management can be arranged. Finally, liver transplantation for end-stage liver failure is discussed in “Indications and contraindications for liver transplantation”. Deepak Amarapurkar Rajiv Jalan Richard Guan Paul Kwo

Transjugular intrahepatic portosystemic shunt in the management of complications of portal hypertension

Transjugular intrahepatic portosystemic shunt (TIPS) is a commonly used approach for managing many complications of portal hypertension. It is an attractive option due to its relative ease of creation (> 90% success rate) and the availability at most hospitals of an interventional radiologist capable of performing the procedure. TIPS is the preferred approach to control acutely bleeding esophageal or gastric varices that cannot be controlled with medical management. It is also now preferred to surgical shunts for preventing rebleeding in patients who rebleed despite adequate medical management. TIPS is more effective than large-volume paracentesis in controlling refractory cirrhotic ascites, with possibly a slight survival benefit but also increased encephalopathy. TIPS should be used to control refractory ascites in patients who cannot be managed with large-volume paracentesis. The role of TIPS in the treatment of hepatorenal syndrome is unclear; currently only patients with type 2 hepatorenal syndrome should be considered candidates for TIPS.

Transjugular intrahepatic portosystemic shunt. Experiences at a liver transplantation center.

Transjugular intrahepatic portosystemic shunt (TIPS) placement is an established therapy for portal hypertension that leads to variceal bleeding or refractory ascites. We present experiences of the role of TIPS at a liver transplantation center. One hundred and ten patients were referred to the Radiological Department for TIPS placement. One of the 110 patients had recurrent cirrhosis after liver transplantation with refractory ascites. Function of the TIPS was controlled with Doppler US at 1 day, 1 week, 4 weeks and 4 months after TIPS placement and subsequently every 3 months. Shunt insufficiency was supposed when the blood flow velocity within the stent tract was under 50 cm/s and was an indication for TIPS revision. TIPS was placed in 101 patients. After TIPS placement, 10 patients underwent liver transplantation. While waiting for the new liver, none of them developed variceal rebleeding, ascites or other complications of portal hypertension. Two of the 101 patients had episodes of rebleeding. The frequency of patients undergoing TIPS revision within the first year after TIPS placement was 67.5%, within the second year 38.0% and within the third year 24.4%. The revisions led to sufficient reduction of the portosystemic pressure gradient. In some liver transplant candidates, TIPS can be useful in minimizing the risk of complications of portal hypertension during the waiting time for a liver transplantation. TIPS can be monitored by Doppler US and revised if occlusion occurs.

Role of TIPS as a Bridge to Hepatic Transplantation in Budd-Chiari Syndrome

To investigate the role of transjugular intrahepatic portosystemic shunt (TIPS) as a bridge to transplantation for patients with Budd-Chiari syndrome (BCS). Eight patients (five women, three men) with a mean age of 49.8 years (range, 20-61 years) were diagnosed with BCS by means of computed tomography, hepatic venography, and liver biopsy. One patient had acute liver failure, with subacute or chronic failure in seven. TIPS placement was attempted in all eight patients. Clinical follow-up and portograms were obtained in all patients until death or transplantation. TIPS placement was completed in seven of eight patients (87.5%). During the follow-up period, TIPS occlusion occurred in four patients. TIPS revision in this patient, although successful, was complicated by hemorrhage and multiorgan failure, and the patient died. Assisted patency rate, excluding the technical failure, was 100%. Mean follow-up in the six survivors with TIPS was 342 days (range, 19-660 days). All six survivors had complete resolution of their ascites. Albumin levels improved an average of 0.43 g/dL (range, 0.3-1.4 g/dL). Bilirubin levels improved in five of six patients (83%), decreasing by an average of 5.6 mg/dL (range, 3.0-15.2 mg/dL). Of the six survivors, three underwent elective liver transplantation, one is awaiting transplantation, and one has been removed from the transplantation list because of clinical improvement. One patient was a candidate for transplantation but declined to be put on the list. Hepatic synthetic dysfunction improves markedly after TIPS placement in patients with BCS. Significant improvement in ascites can also occur. TIPS can be an effective bridge to transplantation for patients with BCS.

Role of TIPS in portal hypertension: variceal bleeding and ascites

The transjugular intrahepatic portosystemic shunt (TIPS) has become established as a valuable therapy for the management of the complications of portal hypertension. Despite promising results, it is still a relatively new technique under active investigation. The technical success rate for TIPS placement, that is, the frequency with which a functioning shunt can be placed without acute complications, is greater than 95% in the hands of experienced operators. However, some of the initial enthusiasm surrounding the introduction of TIPS has been appropriately tempered by awareness of its longer-term limitation of shunt insufficiency and complications of hepatic encephalopathy and liver failure. The indications for TIPS represent a work in progress and have been formulated through expert consensus at several conferences, including a workshop sponsored by the National Digestive Diseases Advisory Board in 1994. This review focuses on the principles underlying the use of TIPS and the two major indications for its placement: variceal bleeding and refractory ascites in patients with cirrhosis and portal hypertension.

8 Transjugular intrahepatic portosystemic shunts (TIPS)

Transjugular intrahepatic portosystemic shunt (TIPS) is a procedure recently introduced for the management of complications of portal hypertension. TIPS can be placed in the liver with relative ease by a skilled radiologist with a low risk of mortality. The major complications following the procedure are infection, especially in patients undergoing emergency TIPS, intra-abdominal haemorrhage from capsular punctures, and long-term problems related to encephalopathy and stenosis of the shunt. Encephalopathy is more of a problem in older patients with wide diameter shunts. Stenosis of the shunt is related to pseudo-intimal hyperplasia, probably related to transection of bile ductules during placement of the shunt. In view of the high rate of encephalopathy and stenosis following the shunt, a careful follow-up of all patients, including ultrasonographic and angiographic examination of the shunt, is mandatory. TIPS is used predominantly for the control of acute variceal haemorrhage, prevention of recurrent variceal bleeding, and refractory ascites when conventional treatment has failed. However, the role of TIPS in the management of complications of portal hypertension still awaits the outcome of clinical trials.

Pre-Liver Transplant: Tips Versus Distal Splenorenal Shunt

Recurrent variceal bleeding in liver transplant candidates with end-stage liver disease can complicate or even prohibit a subsequent transplant procedure (OLT). Endoscopic sclero-therapy and medical therapy are considered as first-line management with surgical shunts reserved for refractory situations. Surgical shunts can be associated with a high mortality in this population and may complicate subsequent OLT. The transjugular intrahepatic portosystemic shunt (TIPS) has been recommended in these patients as a bridge to OLT. This is a new modality that has not been compared with previously established therapies such as the distal splenorenal shunt (DSRS). In this study we report our experience with 35 liver transplant recipients who had a previous TIPS (18 patients) or DSRS (17 patients) for variceal bleeding. The TIPS group had a significantly larger proportion of critically ill and Child-Pugh C patients. Mean operating time was more prolonged in the DSRS group (P=0.014) but transfusion requirements were similar. Intraoperative portal vein blood flow measurements averaged 2132±725 ml/min in the TIPS group compared with 1120±351ml/min in the DSRS group (P<0.001). Arterial flows were similar. Mean ICU and hospital stays were similar. There were 3 hospital mortalities in the DSRS group and none in the TIPS group (P=0.1). We conclude that TIPS is a valuable tool in the management of recurrent variceal bleeding prior to liver transplantation. Intra0Perative hemodynamic measurements suggest a theoretical advantage with TIPS. In a group of patients with advanced liver disease we report an outcome that is similar to patients treated with DSRS prior to liver transplantation. The role of TIPS in the treatment of nontransplant candidates remains to be clarified.

Transjugular intrahepatic portosystemic shunts.

Management of bleeding esophageal varices due to portal hypertension has traditionally relied on endoscopic sclerotherapy and operative intervention with placement of a portosystemic shunt. Although percutaneous decompression of portal hypertension was investigated 25 years ago, it was not clinically feasible until recently. With the advent of intravascular stents, the technique of creating a transjugular intrahepatic portosystemic shunt (TIPS) can now be effectively applied to treat the complications of portal hypertension, including variceal hemorrhage and refractory ascites. Since its introduction in 1989, TIPS has enjoyed widespread clinical application. The initial results with this procedure are encouraging and suggest that it is an effective means of reducing the frequency of variceal hemorrhage in patients with portal hypertension. The long-term patency rate and frequency of complications, however, have not been clearly defined. Similarly, the role of TIPS in the treatment of refractory ascites, Budd-Chiari syndrome, and hepatorenal syndrome remains unclear because sufficient data do not yet exist to support its general use in these settings.

A Comparison Of Treatment With Transjugular Intrahepatic Portosystemic Shunt Or Distal Splenorenal Shunt In The Management Of Variceal Bleeding Prior To Liver Transplantation

Recurrent variceal bleeding in liver transplant candidates with end-stage liver disease can complicate or even prohibit a subsequent transplant procedure (OLT). Endoscopic sclerotherapy and medical therapy are considered as first-line management with surgical shunts reserved for refractory situations. Surgical shunts can be associated with a high mortality in this population and may complicate subsequent OLT. The transjugular intrahepatic portosystemic shunt (TIPS) has been recommended in these patients as a bridge to OLT. This is a new modality that has not been compared with previously established therapies such as the distal splenorenal shunt (DSRS). In this study we report our experience with 35 liver transplant recipients who had a previous TIPS (18 patients) or DSRS (17 patients) for variceal bleeding. The TIPS group had a significantly larger proportion of critically ill and Child-Pugh C patients. Mean operating time was more prolonged in the DSRS group (P = 0.014) but transfusion requirements were similar. Intraoperative portal vein blood flow measurements averaged 2132 +/- 725 ml/min in the TIPS group compared with 1120 +/- 351 ml/min in the DSRS group (P < 0.001). Arterial flows were similar. Mean ICU and hospital stays were similar. There were 3 hospital mortalities in the DSRS group and none in the TIPS group (P = 0.1). We conclude that TIPS is a valuable tool in the management of recurrent variceal bleeding prior to liver transplantation. Intraoperative hemodynamic measurements suggest a theoretical advantage with TIPS. In a group of patients with advanced liver disease we report an outcome that is similar to patients treated with DSRS prior to liver transplantation. The role of TIPS in the treatment of nontransplant candidates remains to be clarified.

A Comparison Of Treatment With Transjugular Intrahepatic Portosystemic Shunt Or Distal Splenorenal Shunt In The Management Of Variceal Bleeding Prior To Liver Transplantation

Recurrent variceal bleeding in liver transplant candidates with end-stage liver disease can complicate or even prohibit a subsequent transplant procedure (OLT). Endoscopic sclerotherapy and medical therapy are considered as first-line management with surgical shunts reserved for refractory situations. Surgical shunts can be associated with a high mortality in this population and may complicate subsequent OLT. The transjugular intrahepatic portosystemic shunt (TIPS) has been recommended in these patients as a bridge to OLT. This is a new modality that has not been compared with previously established therapies such as the distal splenorenal shunt (DSRS). In this study we report our experience with 35 liver transplant recipients who had a previous TIPS (18 patients) or DSRS (17 patients) for variceal bleeding. The TIPS group had a significantly larger proportion of critically ill and Child-Pugh C patients. Mean operating time was more prolonged in the DSRS group (P = 0.014) but transfusion requirements were similar. Intraoperative portal vein blood flow measurements averaged 2132 +/- 725 ml/min in the TIPS group compared with 1120 +/- 351 ml/min in the DSRS group (P < 0.001). Arterial flows were similar. Mean ICU and hospital stays were similar. There were 3 hospital mortalities in the DSRS group and none in the TIPS group (P = 0.1). We conclude that TIPS is a valuable tool in the management of recurrent variceal bleeding prior to liver transplantation. Intraoperative hemodynamic measurements suggest a theoretical advantage with TIPS. In a group of patients with advanced liver disease we report an outcome that is similar to patients treated with DSRS prior to liver transplantation. The role of TIPS in the treatment of nontransplant candidates remains to be clarified.

Review article: the transjugular intrahepatic portosystemic shunt (TIPS) in the treatment of portal hypertension.

The transjugular intrahepatic portosystemic shunt (TIPS) is a non-surgical intrahepatic shunt connecting the hepatic and portal veins. The shunt can be inserted successfully in more than 90% of patients and it effectively decompresses the portal venous circulation. Serious complications, such as intraperitoneal bleeding, occur but they are uncommon. The role of TIPS in the treatment of portal hypertension is currently being evaluated. There are few controlled data available to compare TIPS with established treatment such as drugs, injection sclerotherapy, endoscopic banding or shunt surgery. TIPS has also been used to treat ascites, the Budd-Chiari syndrome and cirrhotic hydrothorax. Concerns over the long-term patency and the true incidence of encephalopathy following TIPS raise doubts about its long-term efficacy. Controlled trials are required to demonstrate the cost-effectiveness of TIPS for individual indications before it is widely adopted. TIPS may find its most immediate application in the emergency treatment of active variceal haemorrhage refractory to standard medical and endoscopic therapy, as there is no satisfactory treatment currently available for this high-risk group. TIPS may also have a role in patients awaiting liver transplantation who bleed from varices. Long-term patency should not be an issue in this patient group and portal decompression may reduce blood transfusion requirements during transplant surgery.