Role of tips in liver disease

1. Role of TIPS in liver diseases
Pratap Sagar Tiwari
1
Total slides : 38

2. • Note: This is for academic purpose only. All credit goes to the
respective authors and researchers. References included.

3. Algorithm for the MX of AVH in pts with LC
*Any of the following: varix spurting blood, varices with overlying clot or with white nipple sign, varices and no other lesion that would explain hemorrhage.
**A short-term course (10 days) of PPI may reduce the size of post-banding ulcers.
Zanetto A, et al. Management of acute variceal hemorrhage. F1000Research 2019, 8(F1000 Faculty Rev):966
3/56

4. Algorithm for the MX of AVH in pts with LC
***Excluding pts >75 years old or who have HCC outside Milan criteria, creat of at least 3 mg/dL, previous combination pharmacological plus endoscopic treatment to prevent re-
bleeding, bleeding from isolated gastric or ectopic varices, recurrent HE, pulmonary HTN, or heart failure or a combination of these.
†Patient should not be discharged on prophylactic antibiotic (consider discontinuing at same time as vasoactive drugs).
Zanetto A, et al. Management of acute variceal hemorrhage. F1000Research 2019, 8(F1000 Faculty Rev):966
4

5. Role of TIPS
Guidelines[1,2,3] recommend TIPS placement in the following pts at the time of acute
VH:
1. Rescue TIPS in pts with persistent bleeding or early re-bleeding despite treatment
with vasoconstrictors plus EVL.
2. Early (within 24 to 72 hours) pre-emptive TIPS can be considered in high-risk pts
(Child C with score < 14) without CI to TIPS.
High risk pt: HVPG≥ 20 mmHg or those with active bleeding at endoscopy.[5]
The feasibility of using MELD was evaluated in a retrospective cohort[4]. Among the 206 pts who
received early TIPS, those with MELD of at least 19 had a significant survival benefit.
1. de Franchis R, Baveno VI Faculty: Expanding consensus in portal hypertension: Report of the Baveno VI Consensus Workshop: Stratifying risk and individualizing care for portal hypertension. J Hepatol. 2015;
63(3): 743–52.
2. European Association for the Study of the Liver: EASL Clinical Practice Guidelines for the management of patients with decompensated cirrhosis. J Hepatol. 2018; 69(2): 406–60.
3. Garcia-Tsao G, Abraldes JG, Berzigotti A, et al.: Portal hypertensive bleeding in cirrhosis: Risk stratification, diagnosis, and management: 2016 practice guidance by the American Association for the study of liver
diseases. Hepatology. 2017; 65(1): 310–35.
4. Lv Y, Zuo L, Zhu X, et al.: Identifying optimal candidates for early TIPS among patients with cirrhosis and acute variceal bleeding: a multicentre observational study. Gut. 2019; 68(7): 1297–1310.
5. Monescillo A, Martínez-Lagares F, Ruiz-del-Arbol L, et al. Influence of portal hypertension and its early decompression by TIPS placement on the outcome of variceal bleeding. Hepatology 2004; 40:793.
5

6. 1960s
Inadvertent portal access during
transjugular cholangiography
1969
Rosch [1] discussed the potential of a
“radiologic portocaval shunt”
1982
Colapinto [2] creates the first
human balloon dilated TIPS
1988
Richeter [3] creates the first
human Palmaz stent TIPS
Early to mid-
1990s
Widespread clinical use with self-
expanding bare stents
HISTORY OF TIPS
1. Rösch J, HanafeeWN, SnowH. Transjugular portal venography and radiologic portacaval shunt: an experimental study. Radiology 1969;92(5):1112–1114
2. Colapinto RF, Stronell RD, Gildiner M, et al. Formation of intrahepatic portosystemic shunts using a balloon dilatation catheter: preliminary clinical experience. AJR AmJ Roentgenol 1983;140(4): 709–714
3. Richter GM, Palmaz JC, Noldge G, et al. The transjugular intrahepatic portosystemic stent-shunt (TIPSS): a new nonoperative percutaneous procedure. Radiologie 1989;29:406–411
6

7. Mid- to late-
1990s
Animal experimentation using
silicone and e-PTFE coated stents to
improve TIPS patency [1-3]
2001
Procedure endpoint defined as a
reduction in PSG to <12 mm Hg
Early 2000s
• Early human e-PTFE covered stent-graft experience[4-7]
• Defining TIPS candidacy by prognostic parameters (e.g.,
MELD)
2005
AASLD places practice guidelines on the
“role of TIPS in the MX of PHTN”
2009
AASLD adds BCS as an additional
indication & considers e-PTFE
covered stent grafts as standard of
practice
HISTORY OF TIPS
7References are at the end of the slides

8. Transjugular intrahepatic portosystemic shunt
(TIPSS): Introduction
• TIPS involve creation of a low-resistance channel between
the hepatic vein and the intrahepatic portion of the
portal vein (usually the right branch) using angiographic
techniques.
• The tract is kept patent by deployment of an expandable
metal stent across it, thereby allowing blood to return to
the systemic circulation.
• A TIPS is placed to reduce portal pressure in pts with
complications related to PHTN.[1,2]
1. Colombato L. The role of transjugular intrahepatic portosystemic shunt (TIPS) in the management of portal hypertension.
J Clin Gastroenterol. 2007 Nov-Dec. 41 Suppl 3:S344-51.
2. Gaba RC, Omene BO, Podczerwinski ES, Knuttinen MG, Cotler SJ, Kallwitz ER, et al. TIPS for Treatment of Variceal
Hemorrhage: Clinical Outcomes in 128 Patients at a Single Institution over a 12-Year Period. J Vasc Interv Radiol. 2011
Dec 16. Pic src: Sankar K, edt al. Transjugular Intrahepatic Portosystemic Shunts. JAMA. 2017;317(8):880.
8

9. Transjugular intrahepatic portosystemic shunt
©2018 UpToDate
• Creation of a vascular access by the puncture of the IJV, which
must be performed under US guidance.
• Catheterization of one of the HVs, which can be also punctured
percutaneously under real time US guidance when its ostium is
not easily accessible. When HVs are occluded (BCS), PV branches
can be reached by direct puncture from the IVC.
• Puncture through the liver parenchyma of one of the main
branches of PV with or without real time USG guidance .
• Measurement of the porto-systemic pressure gradient (PPG)
by a digital recording system properly set-up for venous pressure.
IVC and not RA BP should be subtracted to PV pressure to
calculate the gradient.
S. Fagiuoli, R. Bruno, and V. W. Debernardi, “Consensus conference on TIPS management: Techniques, indications, contraindications,”
Digestive and Liver Disease, vol. 49, no. 2, pp. 121–137, 2017. 9

10. Transjugular intrahepatic portosystemic shunt
©2018 UpToDate
• Balloon dilatation of the parenchymal tract between the hepatic
(or IVC) and PVs.
• Deployment of the stent within the parenchymal tract.
• Hemodynamic assessment of the resultant PPG reduction
followed by further balloon dilatation of the lumen to reach the
desired target of pressure gradient.
• Reduction of PPG to <12 mm Hg should be achieved when the
indication is bleeding from EV.
S. Fagiuoli, R. Bruno, and V. W. Debernardi, “Consensus conference on TIPS management: Techniques, indications, contraindications,”
Digestive and Liver Disease, vol. 49, no. 2, pp. 121–137, 2017. 10

11. TIPS PROCEDURE
• Intravenous heparin is given for prevention of shunt thrombosis (bolus dose of
2500–5000 U followed by constant infusion for 1–2 weeks, targeted at an aPTT of 60–
80 seconds.
• A color Doppler USG is obtained 24 hours after the procedure to show shunt patency.
• It is usually repeated one week later if it is an uncovered stent or one month later if
it is covered. After that, if there are no complications, the USG is repeated 3 months
later and then every 6 months until the clinical outcome.
11/56

12. Are blood products routinely required during
TIPS placement?
• FFP, or pro-haemostatic agents are not required in cirrhotic pts
undergoing TIPS, irrespective of INR value (1,2).
• Although the threshold of platelet count needed to ensure normal
primary haemostasis in cirrhosis is not clearly defined, the 50X109/L cut-
off can be utilized for platelets infusion before TIPS (3).
1. Bosch J, Thabut D, Albillos A, Carbonell N, Spicak J, Massard J, et al. Recombinant factor VIIa for variceal bleeding in patients with advanced cirrhosis: A randomized, controlled trial. Hepatology. 2008
May;47(5):1604–14.
2. Segal JB, Dzik WH. Paucity of studies to support that abnormal coagulation test results predict bleeding in the setting of invasive procedures: an evidence-based review. Transfusion. 2005 Sep;45(9):1413–25.
3. Tripodi A, Primignani M, Chantarangkul V, Lemma L, Jovani M, Rebulla P, et al. Global hemostasis tests in patients with cirrhosis before and after prophylactic platelet transfusion. Liver Int. 2013 Mar;33(3):362–7.
12

13. Post-TIPS assessment
13/56
LOREM
IPSUM
>50 cm/s, ideally between 90 to 150 cm/s, but
acceptable from 50 to 200~250 cm/s.
Velocity in the shunt device
Patency and flow direction in HVs
(esp. the segment between the device and the IVC, of
which we should determine the velocity)
Direction of flow in PV: Hepatopetal
Direction of main IHPV branches: retrograde/
stagnant.
Flow direction in PV & branches
If the flow in SV is hepatofugal before TIPS, should
be hepatopetal post-TIPS in a normal functionating
device.
Flow direction in Splenic Vein
>30 cm/s. Note that it should ↑ significantly
after TIPS (>50%).
Velocity of the mid PV
Reduction in the caliper of the collaterals;
(paraumbilical, left gastric, SRS).
Evaluation of the collateral vessels
Stent configuration / position

14. EARLY EVENTS: Bacteriemia
• Bacteriemia after TIPS (defined by fever >38.5°C, or leucocytosis >15.000 / ul and
positive blood cultures) ranges between 2-25%(2-4,6) and in a prospective RCT was not
influenced by antibiotic prophylaxis (1)
• A longer duration of procedure, multiple stenting and the maintenance of a
central venous line are a/with a higher risk of infection after TIPS.
• In pts with uncomplicated procedure, the transjugular venous access should be
removed at the end of the intervention (1,5).
• A single dose of long acting cephalosporin ↓ the incidence of bacterial infection
(20% to 2.6%) justifying its use in anticipated complex procedures (2).
1. Deibert P, Schwarz S, Olschewski M, Siegerstetter V, Blum HE, Rössle M. Risk factors and prevention of early infection after implantation or revision of transjugular intrahepatic portosystemic shunts: results of a
randomized study. Dig Dis Sci. 1998 Aug;43(8):1708–13.
2. Gulberg V, Deibert P, Ochs A, Rossle M, Gerbes AL. Prevention of infectious complications after transjugular intrahepatic portosystemic shunt in cirrhotic patients with a single dose of
ceftriaxone.Hepatogastroenterology. Jan;46(26):1126–30.
3. Ghinolfi D, De Simone P, Catalano G, Petruccelli S, Coletti L, Carrai P, et al. Transjugular intrahepatic portosystemic shunt for hepatitis C virus-related portal hypertension after liver transplantation. Clin Transplant.
Jan;26(5):699–705.
4. Moon E, Tam MDBS, Kikano RN, Karuppasamy K. Prophylactic antibiotic guidelines in modern interventional radiology practice. Semin Intervent Radiol. 2010 Dec;27(4):327–37.
5. Mizrahi M, Roemi L, Shouval D, Adar T, Korem M, Moses A, et al. Bacteremia and “Endotipsitis” following transjugular intrahepatic portosystemic shunting. World J Hepatol. 2011 May 27;3(5):130–6.
6. Navaratnam AM, Grant M, Banach DB. Endotipsitis: A case report with a literature review on an emerging prosthetic related infection. World J Hepatol. 2015 Apr 8;7(4):710–6.
14

15. LATE EVENTS: Endotipsitis
• Defined by the presence of sustained bacteriemia a/with the evidence of thrombus or
vegetations inside the TIPS. This clinical condition is rare (1%).
• Early endotipsitis (< 120 days of the procedure) is usually related to Gram-positive
organisms and the antibiotic therapy must be long-lasting (at least 3 months) to avoid
recurrence (1).
• In pts with uncontrolled or recurrent infection LT should be considered(2).
• There is no evidence for adopting long-term prophylaxis for the prevention of
endotipsitis.
1. Navaratnam AM, Grant M, Banach DB. Endotipsitis: A case report with a literature review on an emerging prosthetic related infection. World J Hepatol. 2015 Apr 8;7(4):710–6.
2. Kochar N, Tripathi D, Arestis NJ, Ireland H, Redhead DN, Hayes PC. Tipsitis: incidence and outcome-a single centre experience. Eur J Gastroenterol Hepatol. 2010 Jun;22(6):729–35.
3. Sanyal AJ, Reddy KR. Vegetative infection of transjugular intrahepatic portosystemic shunts. Gastroenterology. 1998;115:110-115.
The term “endotipsitis” was proposed by Sanyal and Reddy[3], who defined it as: (1) the presence of continuous
bacteremia indicating an infectious focus in continuity with the venous circulation and (2) failure to find an alternate
source of infection despite an extensive search.
15

16. Hepatic encephalopathy
• HE is one of the major complications of TIPS. The incidence of overt episodic or
recurrent HE post-TIPS varies between 15 and 67% in a 2-year follow-up. The
incidence of persistent overt HE is around 8% (1) and that of covert HE around
35% (2-9,12,13).
• Prophylaxis of post-TIPS HE with either lactulose or rifaximin is not routinely
recommended (9).
• Stent lumen reduction or occlusion is effective in case of persistent overt post-
TIPS HE (10,11).
References are present at the end of the slides. 16

17. Contraindications to TIPS positioning
• The absence of vascular accesses represents the only technical CI to TIPS (1).
• The presence of PVT resulting in a portal cavernoma is not an absolute CI in presence
of a “portal” landing zone with adequate flow and calibre to receive the device (2,3)
1. Gazzera C, Fonio P, Gallesio C, Camerano F, Doriguzzi Breatta A, Righi D, et al. Ultrasound-guided transhepatic puncture of the hepatic veins for TIPS placement. Radiol Med. 2013 Apr;118(3):379–85.
2. Senzolo M, Tibbals J, Cholongitas E, Triantos CK, Burroughs AK, Patch D. Transjugular intrahepatic portosystemic shunt for portal vein thrombosis with and without cavernous transformation. Aliment Pharmacol
Ther. 2006 Mar 15;23(6):767–75.
3. Van Ha TG, Hodge J, Funaki B, Lorenz J, Rosenblum J, Straus C, et al. Transjugular intrahepatic portosystemic shunt placement in patients with cirrhosis and concomitant portal vein thrombosis. Cardiovasc
Intervent Radiol. Jan;29(5):785–90.
4. Chiva T, Ripoll C, Sarnago F, Rincón D, Gómez-Camarero J, Galindo E, et al. Characteristic haemodynamic changes of cirrhosis may influence the diagnosis of portopulmonary hypertension. Liver Int. 2015
Feb;35(2):353–61.
S. Fagiuoli, “Consensus conference on TIPS management" 2017
Clinical contraindications to TIPS placement are:
• Advanced liver disease (CP > 11, serum bilirubin > 5 mg/dl, MELD >18) (4).
• Severe organic renal failure (serum creat > 3 mg/dl)
• Heart failure
• Severe porto-pulmonary HTN (mPAP>45mmHg)
• Recurrent or persistent overt HE grade > 2 (WH scale) despite adequate RX
• Uncontrolled sepsis
17

18. • Relative technical CIs are anatomical conditions a/with a reduction in
technical success rate or with an ↑ risk of complications, such as liver
tumours, the presence of multiple hepatic cysts.
The clinical appropriateness of TIPS positioning should be evaluated on a
case-by-case basis according with the relevance of the indication and the
presence of general CIs. Indeed, in the context of a life-threatening
condition such as AVH, a broader range can be adopted (CP C score < 14).
18

19. TIPS: Bare stent Vs PTFE-covered stent
• A major complication after TIPS insertion using bare stent grafts is the
development of HE, which can occur in up to 50% of pts.[1,2]
• The incidence of this complication can be significantly reduced to about 18% with
the use of PTFE-covered stent grafts of 8 mm,[3] a result confirmed by a recent
RCT comparing 8 mm and 10mm stent grafts.[4]
• Dysfunction of TIPS with bare stent grafts because of stent thrombosis and
stenosis can develop in up to 80% of cases.[1] This complication has been
significantly reduced with the use of PTFE-covered stents.[5]
References are present at the end of the slides. 19
Note: Use of polytetrafluoroethylene coated stents was first reported in 1995 [6]

20. TIPS: Covered Vs Bare
Bureau et al. 2015[2] Perarnau et al. 2015[3]
39 Vs 41 66 Vs 71
After median follow-up of 300 days;
Shunt dysfunction: 13% Vs 44%,P < 0.001.
HE @1 yr: 21% Vs 41% (NS).
The 1-year and 2-year survival rates: 70.9 % and 64.5 %
Vs 59.5 % and 40.5 % (NS)
The use of CS improves shunt patency without increasing
the risk of HE.
Median follow-up :23.6 and 21.8 months, respectively.
Shunt dysfunction :RR= 0.60; 95% CI:0.38-0.96, p=0.032.
The 2-year rate of shunt dysfunction: 44.0% vs. 63.6% .
Risk of HE: 0.89; 95% CI: 0.53-1.49,NS
2-year survival: 70% vs. 67.5%, NS
CS provided a significant 40% reduction in dysfunction
compared to BS. No significant difference with regard to
HE or death.
Multi center single blind RCT
Stent diameter data: NA
Multi center single blind RCT
CS: 10.5 ± 0.9 versus BS: 11.7 ± 0.8 mm
In the recent meta-analysis by Qi et al[1], covered stents not only significantly
improved the shunt patency, but also significantly ↓the risk of death. Additionally,
the risk of HE was not ↑ by the use of covered stents.
20References are present at the end of the slides.

21. Prevention of recurrent variceal bleeding:
cTIPS Vs Medical therapy + EVL
Sauerbruch et al. 2015 Luo et al. 2015 Holster et al. 2016
92 Vs 95 37 Vs 36 37 Vs 35
RVH within 2 yrs: 7% Vs 26%; p =
0.002
HE: 18% vs 8%; p = 0.05.
No difference in survival curve.
TIPS was more straightforward and
prevented RVH more effectively, but
did not improve the survival.
The 2-year probability of remaining free
of RVH: 77.8% Vs 42.9%; p = 0.002
HE; no sig differences; p = 0.53.
The 2-year survival: 72.9% Vs 57.2% ;p
= 0.23
TIPS had a significantly lower risk of
RVH, but a similar risk of HE and
death.
Median follow‐up of 23 months,
RVH: 0% vs 29 %; p = 0.001
Mortality: 32% vs. 26%; p = 0.418
Early HE: 35% vs. 14%; p = 0.035
TIPS had a significantly lower risk
of RVH, but the risk of HE and
death was not sig different.
Multicenter prospective RCT
Germany
Multicenter prospective RCT
Netherlands
Single center prospective RCT
China
21References are present at the end of the slides.

22. TIPS in refractory/recidivant ascites
• TIPS decompresses the portal system by shunting an intrahepatic portal branch into a
hepatic vein. Its insertion accentuates perpheral arterial vasodilation in the short term.
• However, within 4–6 weeks its result is an improvement in effective volaemia and
renal function, ultimately leading to an increase in renal sodium excretion.
• TIPS induced natriuresis can be delayed by advanced age and reduced pre-TIPS GFR,
and prevented by intrinsic kidney disease.
• TIPS may also exert beneficial effects on nitrogen balance and nutrition and quality
of life.
22

23. TIPS in refractory/recidivant ascites
• It must be underlined that the indication for TIPS insertion in the studies was the
prevention or treatment of recurrent bleeding, which may restrict the relevance of
these results in patients with refractory ascites.
• Dysfunction of TIPS with bare stent grafts because of stent thrombosis and stenosis
can develop in up to 80% of cases.
• This complication has been significantly reduced to about 18% with the use of
polytetrafluoroethylene (PTFE)-covered stent grafts of 8 mm.
23

24. TIPS in refractory/recidivant ascites
• The final messages can be summarised as follow:
i) TIPS controlled ascites better than LVP
ii)TIPS is followed by a greater incidence of HE. However, discrepant results were
obtained with respect to survival.
• Thus, currently available data suggest that TIPS improves survival compared to LVP
in pts with recurrent ascites, but it does not in those with refractory ascites.
24

25. TIPS IN HRS
• TIPS was used in the MX of HRS1 and HRS2 more than a decade ago.
• As PHTN is the initiator of the hemodynamic changes that ultimately lead to renal VC and ↓
GFR, it is not surprising that lowering the PP will improve renal function.
• The effect of TIPS insertion on improving UNa excretion and renal function in
cirrhotic pts with refractory ascites is well documented.
25

26. TIPS IN HRS
Studies evaluated the effect of TIPS insertion in pts with HRS and preserved liver
function as evidenced by a CP score < 12.[1,2]
• Reversal of HRS occurred in almost 50% within 3 months from TIPS insertion.[1,2]
• An important observation from the studies is the slow and delayed recovery of renal
function following TIPS (within 2-4 wks), unlike VC therapy, in which responders have
faster recovery of renal function (1-2 wks).
• HE was a common complication. Another drawback of TIPS insertion in T1HRS pts is
the fact that most of these pts have advanced liver disease with a S bilirubin >5 mg/dL,
a known absolute CI for TIPS, limiting the utility of TIPS in this group.[3]
• Nevertheless, the results of the studies suggest that TIPS insertion is a reasonable
alternative in pts not candidates for VC therapy.
1. Guevara M, Ginès P, Bandi JC, et al. Transjugular intrahepatic portosystemic shunt in hepatorenal syndrome: effects on renal function and vasoactive systems. Hepatology 1998;28(2):416–422
2. Brensing KA, Textor J, Perz J, et al. Long term outcome after transjugular intrahepatic portosystemic stent-shunt in nontransplant cirrhotics with hepatorenal syndrome: a phase II study. Gut 2000;47(2):288–295
3. Rössle M, Gerbes AL. TIPS for the treatment of refractory ascites, hepatorenal syndrome and hepatic hydrothorax: a critical update.Gut 2010;59(7):988–1000 26

27. TIPS IN HRS: VC PLUS TIPS
• VC therapy in conjunction with TIPS was evaluated in studies.
• The first study included 14 T1HRS pts who received oral midodrine, octreotide, and
albumin, followed by TIPS insertion in stable pts who responded to the VC therapy.[1]
• All 5 pts who received combination therapy were alive 6-30 months following TIPS,
with only 1 pt requiring LT 13 months later. On the other hand, responders to VC who
did not receive TIPS either died (3 pts) or required a LT (2 pts).
• The second study, which included 11 T2HRS cases MX with sequential terlipressin and
TIPS, also showed improvement of kidney function following TIPS. [2]
1. Wong F, Pantea L, Sniderman K. Midodrine, octreotide, albumin,and TIPS in selected patients with cirrhosis and type 1 hepatorenal syndrome. Hepatology 2004;40(1):55–64
2. Alessandria C, Venon WD, Marzano A, Barletti C, Fadda M, Rizzetto M. Renal failure in cirrhotic patients: role of terlipressin in clinical approach to hepatorenal syndrome type 2. Eur J Gastroenterol Hepatol
2002;14(12):1363–1368
However, due to the small number of cases and limited applicability of TIPS in pts with
advanced cirrhosis, it is hard to utilize this combination TX on large no of pts.
27

28. Thirty-Day and 90-Day Survival following RX
of HRS by Treatment Modality
Sorry for no ref 28/67

29. Hepatic hydrothorax
• The efficacy of TIPS in HH has been reported in several retrospective nonrandomized
studies and case reports [1-8] .
1. Siegerstetter V, Deibert P, Ochs A, Olschewski M, Blum HE, Rössle M: Treatment of refractory hepatic hydrothorax with transjugular intrahepatic portosystemic shunt: longterm results in 40 patients. Eur J Gastro
enterol Hepatol 2001; 13: 529–534.
2. Strauss RM, Martin LG, Kaufman SL, et al: Transjugular intrahepatic portal systemic shunt for the management of symptomatic cirrhotic hydrothorax. Am J Gastroenterol 1994; 92: 1520–1522.
3. Gordon FD, Anastopoulos HT, Crenshaw W, et al: The successful treatment of symptomatic,refractory hepatic hydrothorax with transjugular intrahepatic portosystemic shunt. Hepatology 1997; 25: 1366–1369.
4. Jeffries MA, Kazanjian S, Wilson M, et al: Transjugular intrahepatic portosystemic shunts and liver transplantation in patients with refractory hepatic hydrothorax. Liver Transpl Surg 1998; 4: 416–423.
5. Chalasani N, Clark WS, Martin LG, et al: Determinants of mortality in patients with advanced cirrhosis after transjugular intrahepatic portosytemic shunting. Gastroenterology 2000;118:138–144.
6. Spencer EB, Cohen DT, Darey MD: Safety and efficacy of transjugular intrahepatic portosystemic shunt creation for the treatment of hepatic hydrothorax. J Vasc Interv Radiol 2002; 13: 385–390.
7. Wilputte JY, Goffette P, Zech F, et al: The outcome after transjugular intrahepatic portosystemic shunts (TIPS) for hepatic hydrothorax is closely related to liver dysfunction: a long-term study in 28 patients. Acta
Gastroenterol Belg 2007; 70: 6–10.
8. Dhanasekaran R, West JK, Gonzales PC, et al: Transjugular intrahepatic portosystemic shunt for symptomatic refractory hepatic hydrothorax in patients with cirrhosis. Am J Gastroenterol 2010; 105: 635–641.

30. TIPS IN HH
• The most recently published and largest series to date was reported by Dhanasekaran and
colleagues in 2010.[1]
• In their study 73 pts with refractory HH had a TIPS placed. 59% of pts had a complete
response, 20% had a partial response, and 21% had no response to TIPS placement.
• The short-term survival rates at 30, 60, and 90 days were 81, 78, and 72%,
respectively.
• The long-term survival rates at 1, 3, and 5 years were 48, 26, and 15%, respectively.
1. Dhanasekaran R, West JK, Gonzales PC, et al. Transjugular intrahepatic portosystemic shunt for symptomatic refractory hepatic hydrothorax in patients with cirrhosis. Am J Gastroenterol 2010; 105(3):635–641

31. TIPS in NCIPH ?
• TIPS can be considered in NCIPH, applying the same indications utilized for the
management of portal hypertensive complications.
• Caution is needed in pts with refractory ascites, kidney failure and comorbidities.
31

32. TIPS in EHPVO
• For pts who have a favourable anatomy including patency of intrahepatic LPV in the
Rex recessus, patency of SMV, the first choice of treatment without doubt is the
meso-Rex bypass, as this operation results in a physiologic restoration of normal BF to
the liver.[1-3]
• This operation, however, has not been widely used owing to its complexity and high
technique demanding. In addition, meso-Rex bypass may be unfeasible in some pts
owing to anatomic issues or lack of useable vessels . [3,4]
• Surgical portosystemic shunts have historically been the primary option for reducing
PP with recurrent VH or in whom endoscopic and medical RX have failed.[3]
1. Shneider BL, Bosch J, de Franchis R, et al. Portal hypertension in children: expert pediatric opinion on the report of the Baveno v Consensus Workshop on Methodology of Diagnosis and Therapy in Portal Hypertension.
Pediatr Transplant 2012;16:426–37.
2. Lautz TB, Keys LA, Melvin JC, et al. Advantages of the meso-Rex bypass compared with portosystemic shunts in the management of extrahepatic portal vein obstruction in children. J Am Coll Surg 2013;216:83–9.
3. Giouleme O, Theocharidou E. Management of portal hypertension in children with portal vein thrombosis. J Pediatr Gastroenterol Nutr 2013;57:419–25.
4. Superina R, Shneider B, Emre S, et al. Surgical guidelines for the management of extra-hepatic portal vein obstruction. Pediatr Transplant 2006;10:908–13. 32

33. TIPS in EHPVO
• Studies have demonstrated that TIPS was equally effective compared with surgical
portosystemic shunts—both ↓ the incidence of variceal rebleeding and improving
growth impairment.[1]
• The advantage that TIPS offer over surgical portosystemic shunts is its mini-
invasiveness, but short-term patency of TIPS is a large concern. Because of the use of
ePTFE-covered stentgrafts, a significant improvement in patency rates and a ↓ in
reintervention rate have, however, been reported.[2-4]
• Therefore, TIPS procedure, if feasible, could represent a less-invasive alternative to
traditional surgical portosystemic shunting or a valuable RX option if surgery and
endoscopic treatment failed and an anatomy unsuitable for meso-Rex bypass.
1. Kato T, Romero R, Koutouby R, et al. Portosystemic shunting in children during the era of endoscopic therapy: improved postoperative growth parameters. J Pediatr Gastroenterol Nutr 2000;30:419–25.
2. Di Giorgio A, Agazzi R, Alberti D, et al. Feasibility and efficacy of transjugular intrahepatic portosystemic shunt (TIPS) in children. J Pediatr Gastroenterol Nutr 2012;54:594–600.
3. Zurera LJ, Espejo JJ, Lombardo S, et al. Safety and efficacy of expanded polytetrafluoroethylene-covered transjugular intrahepatic portosystemic shunts in children with acute or recurring upper gastrointestinal
bleeding. Pediatr Radiol 2015;45:422–9.
4. Yang Z, Han G, Wu Q, et al. Patency and clinical outcomes of transjugular intrahepatic portosystemic shunt with polytetrafluoroethylene-covered stents versus bare stents: a meta-analysis. J Gastroenterol Hepatol
2010;25:1718–25.
33

34. TIPS in BCS ?
• In BCS pts, in a stepwise approach, TIPS with covered stent is indicated in case of
failure of anticoagulation (and angioplasty when feasible), represented by persistent
ascites, AKI or elevated transaminases .
• Listing for LT should be considered in case of a prognostic index score greater than 7
in pts candidate to TIPS for BCS.
• When TIPS is attempted to treat hyper acute BCS with ALF presentation, the listing
process for LT should not be delayed.
BCS-TIPS PI (only for patients who underwent TIPS procedure): age × 0.08 + bilirubin × 0.16 + INR × 0.63[1].
1. Garcia-Pagán JC, Heydtmann M, Raffa S, Plessier A, Murad S, Fabris F, Vizzini G, Gonzales Abraldes J, Olliff S, Nicolini A, et al. TIPS for Budd-Chiari syndrome: long-term
results and prognostics factors in 124 patients. Gastroenterology. 2008;135:808–815.
34

35. TIPS in PVT ?
• TIPS is feasible in pts with PVT with and without cirrhosis, but it bears higher
failure and complication rates when portal cavernoma, fibrous transformation of the
main portal vein or intrahepatic branches thrombosis, are present .
• Extension of the TIPS stent into the portal or SMV should be considered when
recanalization of PV/SMV is incomplete and the pt is not a LT candidate.
• TIPS can be considered to treat PVT in both cirrhotic and non-cirrhotic pts with
progression of thrombosis despite adequate anticoagulant treatment, or when
there is an absolute CI to anticoagulation, or with no response after a maximum of 6
months of anticoagulation treatment.
35

36. TIPS IN POPH
• In general, the use of TIPS is CI in moderate to severe POPH.

37. TIPS IN HPS
• Portal decompression with TIPS has been attempted in a small number of cases.
• However, convincing evidence for sustained improvement is lacking and TIPS should
be considered an experimental treatment.
• At present, there is no sufficient evidence to support the use of TIPS for the
treatment of hepatopulmonary syndrome.

38. TIPS in SOS
• TIPS is not indicated in Sinusoidal Occlusion Syndrome in Bone Marrow
Transplanted Patients, but may be considered in individual basis in Solid Organ
Transplant Recipient as stand-alone treatment or as bridge to liver transplantation in a
setting of multidisciplinary evaluation .
38

39. End of slides

40. References: History
1. Saxon RR, Mendel-Hartvig J, Corless CL, et al. Bile duct injury as a major cause of stenosis and occlusion in transjugular intrahepatic
portosystemic shunts: comparative histopathologic analysis in humans and swine. J Vasc Interv Radiol 1996;7(4):487–497
2. Nishimine K, Saxon RR, Kichikawa K, et al. Improved transjugular intrahepatic portosystemic shunt patency with PTFE-covered stent-
grafts: experimental results in swine. Radiology 1995; 196(2):341–347
3. Haskal ZJ, Davis A, McAllister A, Furth EE. PTFE-encapsulated endovascular stent-graft for transjugular intrahepatic portosystemic shunts:
experimental evaluation. Radiology 1997;205(3): 682–688
4. Barrio J, Ripoll C, Bañares R, et al. Comparison of transjugular intrahepatic portosystemic shunt dysfunction in PTFE-covered stent-grafts
versus bare stents. Eur J Radiol 2005;55(1):120–124
5. Charon JP, Alaeddin FH, Pimpalwar SA, et al. Results of a retrospective multicenter trial of the Viatorr expanded polytetrafluoroethylene-
covered stent-graft for transjugular intrahepatic portosystemic shunt creation. J Vasc Interv Radiol 2004;15(11):1219–1230
6. Maleux G, Nevens F, Wilmer A, et al. Early and long-term clinical and radiological follow-up results of expanded-polytetrafluoroethylene-
covered stent-grafts for transjugular intrahepatic portosystemic shunt procedures. Eur Radiol 2004;14(10):1842–1850
7. Hausegger KA, Karnel F, Georgieva B, et al. Transjugular intrahepatic portosystemic shunt creation with the Viatorr expanded
polytetrafluoroethylene-covered stent-graft. J Vasc Interv Radiol 2004;15(3):239–248
8. Angeloni S, Merli M, Salvatori FM, et al. Polytetrafluoroethylenecovered stent grafts for TIPS procedure: 1-year patency and clinical
results. Am J Gastroenterol 2004;99(2):280–285
40

41. References: Hepatic encephalopathy
1. Riggio O, Angeloni S, Salvatori FM, De Santis A, Cerini F, Farcomeni A, et al. Incidence, natural history, and risk factors of hepatic encephalopathy after transjugular intrahepatic
portosystemic shunt with polytetrafluoroethylene-covered stent grafts. Am J Gastroenterol. 2008 Nov;103(11):2738–46.
2. Nolte W, Wiltfang J, Schindler C, Münke H, Unterberg K, Zumhasch U, et al. Portosystemic hepatic encephalopathy after transjugular intrahepatic portosystemic shunt in patients
with cirrhosis: clinical, laboratory, psychometric, and electroencephalographic investigations. Hepatology. 1998 Nov;28(5):1215–25.
3. Berlioux P, Robic MA, Poirson H, Métivier S, Otal P, Barret C, et al. Pre-transjugular intrahepatic portosystemic shunts (TIPS) prediction of post-TIPS overt hepatic encephalopathy:
the critical flicker frequency is more accurate than psychometric tests. Hepatology. 2014 Feb;59(2):622–9.
4. Salerno F, Cammà C, Enea M, Rössle M, Wong F. Transjugular intrahepatic portosystemic shunt for refractory ascites: a meta-analysis of individual patient data. Gastroenterology .
2007 Sep;133(3):825–34.
5. Chalasani N, Clark WS, Martin LG, Kamean J, Khan MA, Patel NH, et al. Determinants of mortality in patients with advanced cirrhosis after transjugular intrahepatic portosystemic
shunting. Gastroenterology. 2000 Jan;118(1):138–44.
6. Kim HK, Kim YJ, Chung WJ, Kim SS, Shim JJ, Choi MS, et al. Clinical outcomes of transjugular intrahepatic portosystemic shunt for portal hypertension: Korean multicenter real-
practice data. Clin Mol Hepatol. 2014 Mar;20(1):18–27.
7. Bai M, Qi X-S, Yang Z-P, Yang M, Fan D-M, Han G-H. TIPS improves liver transplantation-free survival in cirrhotic patients with refractory ascites: an updated meta-analysis. World J
Gastroenterol. 2014 Mar 14;20(10):2704–14.
8. D’Amico G, Luca A, Morabito A, Miraglia R, D’Amico M. Uncovered transjugular intrahepatic portosystemic shunt for refractory ascites: a meta-analysis. Gastroenterology. 2005
Oct;129(4):1282–93.
9. Riggio O, Masini A, Efrati C, Nicolao F, Angeloni S, Salvatori FM, et al. Pharmacological prophylaxis of hepatic encephalopathy after transjugular intrahepatic portosystemic shunt:
a randomized controlled study. J Hepatol. 2005 May;42(5):674–9.
10. Fanelli F, Salvatori FM, Rabuffi P, Boatta E, Riggio O, Lucatelli P, et al. Management of refractory hepatic encephalopathy after insertion of TIPS: long-term results of shunt
reduction with hourglass-shaped balloon-expandable stent-graft. AJR Am J Roentgenol. 2009 Dec;193(6):1696–702.
11. Vilstrup H, Amodio P, Bajaj J, Cordoba J, Ferenci P, Mullen KD, et al. 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. 2014 Aug;60(2):715–35.
12. Casado M, Bosch J, García-Pagán JC, Bru C, Bañares R, Bandi JC, et al. Clinical events after transjugular intrahepatic portosystemic shunt: correlation with hemodynamic findings.
Gastroenterology. 1998 Jun;114(6):1296–303.
13. Rössle M, Gerbes AL. TIPS for the treatment of refractory ascites, hepatorenal syndrome and hepatic hydrothorax: a critical update. Gut. 2010 Jul;59(7):988–1000.
41

42. References: TIPS: Covered Vs Bare
1. Qi X, et al. Covered versus bare stents for transjugular intrahepatic portosystemic shunt: an updated meta-analysis of
randomized controlled trials. Therap Adv Gastroenterol. 2017 Jan; 10(1): 32–41.
2. Bureau C., Garcia-Pagan J., Otal P., Pomier-Layrargues G., Chabbert V., Cortez C., et al. (2004) Improved clinical outcome using
polytetrafluoroethylene-coated stents for TIPS: results of a randomized study. Gastroenterology 126: 469–475.
3. Perarnau J., Le Gouge A., Nicolas C., D’Alteroche L., Borentain P., Saliba F., et al. (2014) Covered vs. uncovered stents for
transjugular intrahepatic portosystemic shunt: a randomized controlled trial. J Hepatol 60: 962–968
42

43. References: Prevention of recurrent variceal
bleeding: cTIPS Vs Medical therapy + EVL
1. Sauerbruch T., Mengel M., Dollinger M., Zipprich A., Rossle M., Panther E., 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.e1–668.e1.
2. Luo X., Wang Z., Tsauo J., Zhou B., Zhang H., Li X. (2015) Advanced cirrhosis combined with portal vein thrombosis: a randomized
trial of tips versus endoscopic band ligation plus propranolol for the prevention of recurrent esophageal variceal bleeding. Radiology
276: 286–293.
3. Holster I., Tjwa E., Moelker A., Wils A., Hansen B., Vermeijden J., et al. (2016) Covered transjugular intrahepatic portosystemic shunt
versus endoscopic therapy + β-blocker for prevention of variceal rebleeding. Hepatology 63: 581–589.
43