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.
Similar content being viewed by others
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
References
Garcia-Tsao G, Bosch J (2010) Management of varices and variceal hemorrhage in cirrhosis. N Engl J Med 362:823–832
De Franchis R, Faculty BVI (2015) Expanding consensus in portal hypertension: report of the Baveno VI consensus workshop: stratifying risk and individualizing care for portal hypertension. J Hepatol 63:743–752
Rosch J, Hanafee W, Snow H et al (1971) Transjugular intrahepatic portacaval shunt. An experimental work. Am J Surg 121:588–592
Garcìa-Pagàn JC, Caca K, Bureau C et al (2010) Early use of TIPS in patients with cirrhosis and variceal bleeding. N Engl J Med 24:2370–2379
Salerno F, Cammà C, Enea M et al (2007) Transjugular intrahepatic portosystemic shunt for refractory ascites: a meta-analysis of individual patient data. Gastroenterology 133:825–834
Qi X, Jia J, Bai M et al (2015) Transjugular intrahepatic portosystemic shunt for acute variceal bleeding: a meta-analysis. J Clin Gastroenterol 49:495–505
Lv Y, Zuo L, Zhu X et al (2019) Identifying optimal candidates for early TIPS among patients with cirrhosis and acute variceal bleeding: a multicentre observational study. Gut 68:1297–1310
Azoulay D, Castaing D, Majno P et al (2001) Salvage transjugular intrahepatic portosystemic shunt for uncontrolled variceal bleeding in patients with decompensated cirrhosis. J Hepatol 35:590–597
Vangeli M, Patch D, Burroughs AK (2002) Salvage tips for uncontrolled variceal bleeding. J Hepatol 37:703–704
Sauerbruch T, Mengel M, Dollinger M et al (2015) Prevention of rebleeding from esophageal varices in patients with cirrhosis receiving small-diameter stents versus hemodynamically controlled medical therapy. Gastroenterology 149:660–668
Fagiuoli S, Bruno R, Debernardi Venon W et al (2017) Consensus conference on TIPS management: techniques, indications, contraindications. Dig Liver Dis 49:121–137
García-Pagán JC, Villanueva C, Albillos A et al (2009) Nadolol plus isosorbide mononitrate alone or associated with band ligation in the prevention of recurrent bleeding: a multicentre randomised controlled trial. Gut 58:1144–1150
Vidal V, Joly L, Perreault P et al (2006) Usefulness of transjugular intrahepatic portosystemic shunt in the management of bleeding ectopic varices in cirrhotic patients. Cardiovasc Interv Radiol 29:216–219
Castagna E, Cardellicchio A, Pulitanò R et al (2011) Bleeding ileal varices: a rare cause of chronic anemia in liver cirrhosis. Intern Emerg Med 6:271–273
Ginès P, Tito L, Arroyo V et al (1988) Randomized comparative study of therapeutic paracentesis with and without intravenous albumin in cirrhosis. Gastroenterology 94:1493–1502
Wong W, Liu P, Blendis L et al (1999) Long-term renal sodium handling in patients with cirrhosis treated with transjugular intrahepatic portosystemic shunts for refractory ascites. Am J Med 106:315–322
Colombato LA, Spahr L, Martinet JP et al (1996) Haemodynamic adaptation 2 months after transjugular intrahepatic portosystemic shunt (TIPS) in cirrhotic patients. Gut 39:600–604
Lotterer E, Wengert A, Fleig WE (1999) Transjugular intrahepatic portosystemic shunt: short-term and long-term effects on hepatic and systemic hemodynamics in patients with cirrhosis. Hepatology 29:632–639
D’Amico G, Luca A, Morabito A et al (2005) Uncovered transjugular intrahepatic portosystemic shunt for refractory ascites: a meta-analysis. Gastroenterology 129:1282–1293
Bureau C, Thabut D, Oberti F et al (2017) Transjugular intrahepatic portosystemic shunts with covered stents increase transplant-free survival of patients with cirrhosis and recurrent ascites. Gastroenterology 152:157–163
Uriz J, Ginès P, Cárdenas A et al (2000) Terlipressin plus albumin infusion: an effective and safe therapy of hepatorenal syndrome. J Hepatol 33:43–48
Wong F, Pantea L, Sniderman K (2004) Midodrine, albumin, and TIPS in selected patients with cirrhosis and type 1 hepatorenal syndrome. Hepatology 40:55–64
Testino G, Ferro C, Sumberaz A et al (2003) Type-2 hepatorenal syndrome and refractory ascites: role of transjugular intrahepatic portosystemic stent-shunt in eighteen patients with advanced cirrhosis awaiting orthotopic liver transplantation. Hepatogastroenterology 50:1753–1755
Dhanasekaran R, West JK, Gonzales PC et al (2010) Transjugular intrahepatic portosystemic shunt for symptomatic refractory hydrothorax in patients with cirrhosis. Am J Gastroenterol 105:635–641
Violi F, Corazza RG, Caldwell SH et al (2016) Portal vein thrombosis relevance on liver cirrhosis: Italian Venous Thrombotic Events Registry. Intern Emerg Med 11:1059
Luca A, Miraglia R, Caruso S et al (2011) Short- and long-term effects of the transjugular intrahepatic portosystemic shunt on portal vein thrombosis in patients with cirrhosis. Gut 60:846–852
Senzolo M, Riggio O, Primignani M (2011) Vascular disorders of the liver: recommendations from the Italian Association for the Study of the Liver (AISF) ad hoc committee. Dig Liver Dis 43:503–514
Fanelli F, Angeloni S, Salvatori FM et al (2011) Transjugular intrahepatic portosystemic shunt with expanded polytetrafluoroethylene-covered stents in non-cirrhotic patients with portal cavernoma. Dig Liver Dis 43:78–84
Pararnau JM, Baju A, D’Alteroche L et al (2010) Feasibility and long-term evolution of TIPS in cirrhotic patients with portal thrombosis. Eur J Gastroenterol Hepatol 22:1093–1098
Valentin N, Korrapati P, Constantino J et al (2018) The role of transjugular intrahepatic portosystemic shunt in the management of portal vein thrombosis: a systematic review and meta-analysis. Eur J Gastroenterol Hepatol 10:1187–1193
Tabchouri N, Barbier L, Menahem B et al (2019) Original study: transjugular intrahepatic portosystemic shunt as a bridge to abdominal surgery in cirrhotic patients. J Gastrointest Surg 23:2283–2390
Salerno F, Merli M, Cazzaniga M et al (2002) MELD score is better than Child–Pugh score in predicting 3-month survival of patients undergoing transjugular intrahepatic portosystemic shunt. J Hepatol 36:494–500
Ripamonti R, Ferral H, Alonzo M et al (2006) Transjugular intrahepatic portosystemic shunt-related complications and practical solutions. Semin Interv Radiol 23:165–176
Dariushinia SR, Haskal ZJ, Midia M et al (2016) Quality improvement guidelines for transjugular intrahepatic portosystemic shunts. J Vasc Interv Radiol 27:1–7
Boyer TD, Haskal ZJ (2005) The role of transjugular intrahepatic portosystemic shunt in the management of portal hypertension. Hepatology 41:386–400
Nolte W, Wiltfang J, Schindler C et al (1998) Portosystemic hepatic encephalopathy after transjugular intrahepatic portosystemic shunt in patients with cirrhosis: clinical, laboratory, psychometric and electroencephalographic investigations. Hepatology 28:1215–1225
Bureau C, Garcia-Pagan JC, Otal P et al (2004) Improved clinical outcome using polytetrafluoroethylene-coated stents for TIPS: results of a randomized study. Gastroenterology 126:469–475
Angeloni S, Merli M, Salvatori F et al (2004) Polytetrafluoroethylene-covered stent graft for TIPS procedure: 1-year patency and clinical results. Am J Gastroenterol 99:280–285
Cejna M, Peck-Radosavljevic M, Thurnher SA et al (2001) Creation of transjugular intrahepatic portosystemic shunts with stent-grafts: initial experiences with a polytetrafluoroethylene-covered nitinol endoprosthesis. Radiology 221:437–446
Angermayr B, Cejna M, Koeing F et al (2003) Survival in patients undergoing transjugular intrahepatic portosystemic shunt: ePTFE-covered stent-grafts versus bare stents. Hepatology 38:1043–1050
Perarnau JM, Le Gouge A, Nicolas C et al (2014) STIC-TIPS group. Covered vs. uncovered stents for transjugular intrahepatic portosystemic shunt: a randomized controlled trial. J Hepatol 60(5):962–968
Vilstrup H, Amodio P, Bajaj J et al (2014) Hepatic encephalopathy in chronic liver disease: 2014 practice guideline by the American Association for the Study of Liver Diseases and the European Association for the Study of the Liver. Hepatology 60:715–735
Ferenci P, Lockwood A, Mullen K et al (2002) Hepatic encephalopathy-definition, nomenclature, diagnosis, and quantification: final report of the working party at the 11th World Congresses of Gastroenterology, Vienna, 1998. Hepatology 35:716–721
Montagnese S, Balistreri E, Schiff S et al (2014) Cover hepatic encephalopathy: agreement and predictive validity of different indices. WJG 20:15756–15762
Campagna F, Montagnese S, Ridola L et al (2017) The animal naming test: and easy tool for the assessment of hepatic encephalopathy. Hepatology 66:198–208
Plauth M, Schetz T, Buckendal DP et al (2004) Weight gain after transjugular intrahepatic portosystemic shunt (TIPS) is associated with improvement in body composition in malnourished patients with cirrhosis and hypermetabolism. J Hepatol 40:228–233
Riggio O, Masini A, Efrati C et al (2005) Pharmacological prophylaxis of hepatic encephalopathy after transjugular intrahepatic portosystemic shunt: a randomized controlled study. J Hepatol 42(5):674–679
Casado M, Bosch J, Garcìa-Pagàn JC et al (1998) Clinical events after transjugular intrahepatic portosystemic shunt correlation with hemodynamic findings. Gastroenterology 114:1296–1303
Chung HH, Razavi MK, Sze DY et al (2008) Portosystemic pressure gradient during transjugular intrahepatic portosystemic shunt with VIATORR® stent graft: what is the critical low threshold to avoid medically uncontrolled low-pressure gradient related complications? J Gastroenterol Hepatol 23:95–101
Mullen KD (2003) Interplay of portal pressure, portal perfusion and hepatic arterial inflow in modulating expression of hepatic encephalopathy in patients with spontaneous or artificially created portosystemic shunts. Indian J Gastroenterol 22:25–27
Deng D, Liao MS, Quin JP et al (2006) Relationship between pre-TIPS hepatic hemodynamics and postoperative incidence of hepatic encephalopathy. Hepatobiliary Pancreat Dis Int 5:232–236
Wang Q, Lv Y, Bai M et al (2017) Eight millimetre covered TIPS does not compromise shunt function but reduces hepatic encephalopathy in preventing variceal rebleeding. J Hepatol 67(3):508–516
Thalheimer U, Leandro G, Samonakis DN et al (2009) TIPS for refractory ascites: a single-centre experience. J Gastroenterol 44:1089–1095
Wróblewski T, Rowiński O, Ziarkiewicz-Wróblewska B et al (2006) Two-stage transjugular intrahepatic porto-systemic shunt for patients with cirrhosis and a high risk of portal-systemic encephalopathy patients as a bridge to orthotopic liver transplantation: a preliminary report. Transplant Proc 38:204–208
Schepis F, Vizzutti F, Garcia-Tsao G et al (2018) Under-dilated TIPS associate with efficacy and reduced encephalopaty in a prospective, non-randomized study of patients with cirrhosis. Clin Gastroenterol Hepatol 16:1153–1162
Sikuler E, Kravetz D, Groszmann RJ (1985) Evolution of portal hypertension and mechanisms involved in its maintenance in a rat model. Am J Physiol 248:G618–G625
Ginès P, Berl T, Bernardi M et al (1998) Hyponatremia in cirrhosis: from pathogenesis to treatment. Hepatology 28:851–864
Zardi EM, Abbate A, Zardi DM et al (2010) Cirrhotic cardiomyopathy. J Am Coll Cardiol 56:539–549
Zardi EM, Zardi DM, Chin D et al (2016) Cirrhotic cardiomyopathy in the pre- and post- liver transplantation phase. J Cardiol 67:125–130
Albillos A, Garcia-Tsao G (2011) Classification of cirrhosis: the clinical use of HVPG measurement. Dis Markers 31:121–128
Myers RP, Lee SS (2000) Cirrhotic cardiomyopathy and liver transplantation. Liver Transpl 6:S44–S52
Merli M, Valeriano V, Funaro S et al (2002) Modifications of cardiac function in cirrhotic patients treated with transjugular intrahepatic portosystemic shunt (TIPS). Am J Gastroenterol 97:142–148
Ginès P, Uriz J, Calahorra B et al (2002) Transjugular intrahepatic portosystemic shunting versus paracentesis plus albumin for refractory ascites in cirrhosis. Gastroenterology 123:1839–1847
Kovács A, Schepke M, Heller J et al (2010) Short-term effects of transjugular intrahepatic shunt on cardiac function assessed by cardiac MRI: preliminary results. Cardiovasc Intervent Radiol 33:290–296
Huonker M, Schumacher YO, Ochs A et al (1999) Cardiac function and haemodynamics in alcoholic cirrhosis and effects of the transjugular intrahepatic portosystemic stent shunt. Gut 44:743–748
Saugel B, Mair S, Meidert AS (2014) The effects of transjugular intrahepatic porto-systemic stent shunt on systemic cardiocirculatory parameters. J Crit Care 29:1001–1005
Rodriguez-Laiz JM, Banares R, Echenagusia A et al (1995) Effects of transjugular intrahepatic portosystemic shunt (TIPS) on splanchnic and systemic hemodynamics, and hepatic function in patients with portal hypertension. Preliminary results. Dig Dis Sci 40:2121–2127
Møller S, Hove JD, Dixen U et al (2013) New insights into cirrhotic cardiomyopathy. Int J Cardiol 167:1101–1108
Braverman AC, Steiner MA, Picus D et al (1995) High-output congestive heart failure following transjugular intrahepatic portal- systemic shunting. Chest 107:1467–1469
Ramsay M (2010) Portopulmonary hypertension and right heart failure in patients with cirrhosis. Curr Opin Anaesthesiol 23:145–150
Grose RD, Nolan J, Dillon JF et al (1995) Exercise-induced left ventricular dysfunction in alcoholic and non-alcoholic cirrhosis. J Hepatol 22:326–332
Epstein SK, Ciubotaru RL, Zilberberg MD et al (1998) Analysis of impaired exercise capacity in patients with cirrhosis. Dig Dis Sci 43:1701–1707
Rabie RN, Cazzaniga M, Salerno F et al (2009) The use of E/A ratio as a predictor of outcome in cirrhotic patients treated with transjugular intrahepatic portosystemic shunt. Am J Gastroenterol 104:2458–2466
Paulus WJ, Tschope C, Sanderson JE et al (2007) How to diagnose diastolic heart failure: a consensus statement on the diagnosis of heart failure with normal left ventricular ejection fraction by the Heart Failure and Echocardiography Associations of the European Society of Cardiology. Eur Heart J 28:2539–2550
Seib GA (1934) Incidences of the patent foramen ovale cordis in adult American Whites and American Negroes. Am J Anat 55:511–525
Vizzutti F, Rega L, Arena U et al (2015) Paradoxical embolization in TIPS: take a closer look to the heart. Ann Hepatol 14:127–131
Tuennemann J, Mossner J, Hoffmeister A (2013) Acute cerebrovascular incident as a complication of TIPS procedure. Z Gastroenterol 51:381–383
Appenrodt B, Schepke M, Kuntz-Hehner S et al (2006) A patient with portal hypertension and blindness after transjugular intrahepatic porto-systemic shunt. Eur J Gastroenterol Hepatol 18:447–449
Van der Linden P, Le Moine O, Ghysels M et al (1996) Pulmonary hypertension after transjugular intrahepatic portosystemic shunt: effects on right ventricular function. Hepatology 23:982–987
Haskal ZJ, Radhakrishnan J (2008) Transjugular intrahepatic portosystemic shunt in hemodialysis-dependent patients and patients with advanced renal insufficiency: safety, caution, and encephalopathy. J Vasc Interv Rad 19:516–520
Funding
This paper was supported by Grants from University of Florence (to FM, FV and SG).
Author information
Authors and Affiliations
Corresponding author
Ethics declarations
Conflict of interest
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.
Statements of human and animal rights
This article does not contain any studies with human participants or animals performed by any of the authors.
Informed consent
Written informed consent was obtained from each patient.
Additional information
Publisher's Note
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
Electronic supplementary material
Below is the link to the electronic supplementary material.
Rights and permissions
About this article
Cite this article
Vizzutti, F., Schepis, F., Arena, U. et al. Transjugular intrahepatic portosystemic shunt (TIPS): current indications and strategies to improve the outcomes. Intern Emerg Med 15, 37–48 (2020). https://doi.org/10.1007/s11739-019-02252-8
Received:
Accepted:
Published:
Issue Date:
DOI: https://doi.org/10.1007/s11739-019-02252-8