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Transjugular intrahepatic portosystemic shunt (TIPS): current indications and strategies to improve the outcomes

Abstract

Transjugular intrahepatic portosystemic shunt (TIPS) represents a very effective treatment of complications of portal hypertension. Established indications to TIPS in cirrhotic patients include portal hypertensive bleeding and refractory ascites. Over the years additional indications have been proposed, such as the treatment of vascular disease of the liver, hepatic hydrothorax, hepatorenal syndrome and bleeding from ectopic varices. Indications under evaluation include treatment of portal hypertension prior to major abdominal surgery and treatment of portal vein thrombosis. In spite of these advances, there are still uncertainties regarding the appropriate workup for patients to be scheduled for TIPS. Moreover, prevention and management of post-TIPS complications including hepatic encephalopathy and heart failure are still suboptimal. These issues are particularly relevant considering aging in TIPS candidates in Western countries. Correct selection of patients is mandatory to prevent complications which may eventually frustrate the good hemodynamic results and worsen the patient’s quality of life or even life expectancy. The possible role of small diameter TIPS to prevent post-procedural complications is discussed.

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Abbreviations

PH:

Portal hypertension

HVPG:

Hepatic venous pressure gradient

TIPS:

Trans-jugular intrahepatic portosystemic shunt

PCG:

Portal caval gradient

HE:

Hepatic encephalopathy

IGV:

Isolated gastric varices

GOV:

Gastroesophageal varices

GAVE:

Gastric antral vascular ectasia

HRS:

Hepatorenal syndrome

PVT:

Portal vein thrombosis

BCS:

Budd–Chiari syndrome

SOS:

Sinusoidal obstruction syndrome

MELD:

Model for end-stage liver disease

PV:

Portal vein

PTFE:

Polytetrafluoroethylene

CHE:

Cover hepatic encephalopathy

MHE:

Minimal hepatic encephalopathy

LVEF:

Left ventricular ejection fraction

sPAP:

Systolic pulmonary arterial pressure

mPAP:

Mean pulmonary artery pressure

PCWP:

Pulmonary capillary wedge pressure

PFO:

Patent foramen ovale

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Correspondence to Fabio Marra.

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Dr. Schepis and Dr. Vizzutti have received grant support (FS), lecture fees (FV and FS) from Gore. Dr. Fabio Marra received travel Grants from Alfasigma. Dr. Fabrizio Fanelli received support and lecture fees from Gore. No other potential conflict of interest related to this article was reported.

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Vizzutti, F., Schepis, F., Arena, U. et al. Transjugular intrahepatic portosystemic shunt (TIPS): current indications and strategies to improve the outcomes. Intern Emerg Med (2020). https://doi.org/10.1007/s11739-019-02252-8

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Keywords

  • Hepatic encephalopathy
  • Heart failure
  • Variceal bleeding
  • Ascites