review of literature for transjugular intrahepatic portosystemic shunt placement and balloon occluded retrograde transvenous obliteration in management of patients with varices hemorrhage

1. TIPS Vs BRTO
Pratap Sagar Tiwari
1
Total slides : 52

2. Content
TIPS: Intro/ History/ Procedure1
BRTO: Intro/ History/ Procedure2
Role of TIPS & BRTO in VH3
TIPS Vs BRTO4

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. TIPS Vs SX in RAVH
Author Compa
rison
Number
of
patients
Child-pugh(%) Postoperative morbidity (%) Mortality
(%)
1-year
survival
(%)
2-year
survival
(%)
5-year
survival
(%)A B C VH SS HE
Khaitiyar e
t al.1
TIPS Vs
DSRS
35 Vs
32
34 Vs
31
66 Vs
69
0 26 Vs
6
69 Vs
6
43 Vs
19
6 Vs
6
83 Vs
81
80 Vs
81
NA
Henderson
et al.2
TIPS Vs
DSRS
67 Vs
73
58 Vs
56
42 Vs
44
0 11 Vs
6
82 Vs
11
51 Vs
49
1 Vs
7
93 Vs
88
88 Vs
81
61 Vs
62
Rosemurgy
et al.3
TIPS Vs
HGPCS
66 Vs
66
18 Vs
14
38 Vs
36
44 Vs
50
30 Vs
8
48 Vs
11
NA 15 Vs
20
64 Vs
74
53 Vs
68
31 Vs
47
Orloff et
al.4
TIPS Vs
PCS
78 Vs
76
21 Vs
20
50 Vs
49
29 Vs
32
41 Vs 0 84 Vs
3
61 Vs
21
22 Vs
23
55 Vs
75
49 Vs
68
20 Vs
61
1. Khaitiyar JS, Luthra SK, Prasad N, Ratnakar N, Daruwala DK. Transjugular intrahepatic portosystemic shunt versus distal splenorenal shunt – A comparative study. Hepatogastroenterology. 2000;47:492–7.
2. Henderson JM, Boyer TD, Kutner MH, Galloway JR, Rikkers LF, Jeffers LJ, et al. Distal splenorenal shunt versus transjugular intrahepatic portal systematic shunt for variceal bleeding: A randomized trial.
Gastroenterology. 2006;130:1643–51.
3. Rosemurgy AS, Frohman HA, Teta AF, Luberice K, Ross SB. Prosthetic H-graft portacaval shunts vs transjugular intrahepatic portasystemic stent shunts: 18-year follow-up of a randomized trial. J Am Coll Surg.
2012;214:445–53.
4. Orloff MJ, Vaida F, Haynes KS, Hye RJ, Isenberg JI, Jinich-Brook H. Randomized controlled trial of emergency transjugular intrahepatic portosystemic shunt versus emergency portacaval shunt treatment of acute
bleeding esophageal varices in cirrhosis. J Gastrointest Surg. 2012;16:2094–111.
SS: Shunt stenosis
The outcomes of the meta-analysis based on these 4 trials stated the superiority of
surgical shunting over TIPS.
6

7. Why not shunt surgery ?
• Indeed, surgical shunts were considered before and were compared to TIPSS as a rescue
therapy for variceal bleeding in RCTs [1,2].
1. G. D'Amico and A. Luca, “TIPS is a cost effective alternative to surgical shunt as a rescue therapy for prevention of recurrent bleeding from EV,” Journal of Hepatology, vol. 48, no. 3, pp. 387–390, 2008.
2. M. J. Orloff, “Fifty-three years' experience with randomized clinical trials of emergency portacaval shunt for bleeding esophageal varices in cirrhosis 1958-2011,” JAMA Surgery, vol. 149, no. 2, pp. 155–169, 2014.
3. M. D'Amico, A. Berzigotti, and J. C. Garcia-Pagan, “Refractory acute variceal bleeding: what to do next?” Clinics in Liver Disease, vol. 14, no. 2, pp. 297–305, 2010.
4. 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.
5. J. M. Henderson, “Salvage therapies for refractory variceal hemorrhage,” Clinics in Liver Disease, vol. 5, no. 3, pp. 709–725, 2001.
• need to be performed by experienced surgeons.
• may prevent considering a later LT[3]
• a/with a higher mortality than TIPSS [4,5]
Only bare stents were used in these studies, underestimating the benefits of TIPSS
Surgical shunts TIPSS is the first-class therapeutic for refractory variceal bleeding.
• Covered TIPS is the treatment of choice to prevent EV rebleeding
• TIPS is effective in the prevention of bleeding recurrence from GV and should be
considered in this setting. [Consensus conference on TIPS management;2017]
TIPSS can technically be done in 90-100% of cases.
7

8. 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
8

9. 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
9References are at the end of the slides

10. 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.
10

11. 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. 11

12. 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. 12

13. TIPS PROCEDURE
©2018 UpToDate
13

14. 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.
14/56

15. 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.
15

16. Post-TIPS assessment
16/56
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

17. 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.
17

18. 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.
18

19. 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. 19

20. 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
20

21. • 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).
21

22. 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. 22
Note: Use of polytetrafluoroethylene coated stents was first reported in 1995 [6]

23. 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 39% 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.
23References are present at the end of the slides.

24. Prevention of recurrent variceal bleeding:
bTIPS Vs Medical therapy + EVL
Zheng et al. 2015
12 RCT; 883 pts
• Decreased incidence of RVH;
OR=0.32, 95% CI:0.24-0.43,
P<0.00001
• Deaths due to rebleeding; OR=0.35,
95% CI:0.18-0.67, P=0.002
• Increased rate of HE; OR=2.21,
95% CI:1.61-3.03, P<0.00001
TIPS is currently the first choice to
prevent rebleeding except that TIPS is
worse than endoscopic therapy for HE.
1. Zheng M., Chen Y., Bai J., Zeng Q., You J., Jin R., et al. (2008) Transjugular intrahepatic portosystemic shunt versus endoscopic therapy
in the secondary prophylaxis of variceal rebleeding in cirrhotic patients: meta-analysis update. J Clin Gastroenterol 2009; 42: 507–16.
• Most indications for TIPS were established in the era
of bare stents.
• For example, a meta-analysis(12 HQ RCT;883 pts)
by Zheng et al[1] suggested that TIPS with bare stents
should be superior to endoscopic and
pharmacological treatment for decreasing the risk of
variceal rebleeding, but inferior in relation to HE .
24

25. 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
25References are present at the end of the slides.

26. Balloon-occluded retrograde transvenous
obliteration
Picture credit:Shou-Dong Lee, Cheng Hsin General Hospital
26

27. Transvenous obliteration
• Transvenous obliteration is an old idea that was practiced in the 1970s in
the pre TIPS era as an procedure for the MX of bleeding EV and GOV from
a percutaneous transhepatic approach.[1-5]
• These percutaneous transhepatic obliteration were mostly performed
utilizing coils, Gelfoam, and/or sclerosants (such as absolute alcohol and
30–50% glucose solution) without utilizing occlusive balloons to modulate
blood flow.[1-5]
• These procedures, utilizing current terminology, are now referred to as
PTO[6,7], which is a type of balloon-occluded antegrade transvenous
obliteration (BATO).
1. Choi YH, Yoon CJ, Park JH, Chung JW, Kwon JW, Choi GM. Balloon-occluded retrograde transvenous obliteration for gastric variceal bleeding: its feasibility compared with transjugular intrahepatic portosystemic shunt. Korean J Radiol 2003;4(2):109–116
2. Funaro AH, Ring EJ, Freiman DB, Oleaga JA, Gordon RL. Transhepatic obliteration of esophageal varices using the stainless steel coil. AJR Am J Roentgenol 1979;133(6):1123–1125
3. Scott J, Dick R, Long RG, Sherlock S. Percutaneous transhepatic obliteration of gastro-oesophageal varices. Lancet 1976;2(7976):53–55
4. Lunderquist A, Simert G, Tyle´n U, Vang J. Follow-up of patients with portal hypertension and esophageal varices treated with percutaneous obliteration of gastric coronary vein. Radiology 1977;122(1):59–63
5. Lunderquist A, Vang J. Transhepatic catheterization and obliteration of the coronary vein in patients with portal hypertension and esophageal varices. N Engl J Med 1974; 291(13):646–649
6. Lunderquist A, Vang J. Sclerosing injection of esophageal varices through transhepatic selective catheterization of the gastric coronary vein. A preliminary report. Acta Radiol Diagn (Stockh) 1974;15(5):546–550
7. Tajiri T, Onda M, Yamashita K, et al. Interventional radiology for portal hypertension. PTO.TIO. Nippon Geka Gakkai Zasshi 1996;97(1):70–77
27

28. PERCUTANEOUS TRANSHEPATIC OBLITERATION OF
G-E VARICES
• The PV was localised in both anteroposterior and lateral
planes by venography, or grey-scale ultrasound.
• Under local anaesthesia the liver is punctured during apnea in
the mid-axillary line below the costophrenic reflection by
means of a cholangiography needle with a radio-opaque
catheter.
• The needle is advanced under image guidance in the direction
of the PV.
• The needle is removed and the radio-opaque catheter gradually drawn with suction applied until blood
is freely aspirated. A test injection of contrast medium is made to confirm the position of the catheter in
the PV or one of its branches. The catheter is advanced over a guide wire as far as possible along the SV.
The portal pressure is measured and a portal venogram obtained.
Scott J, Dick R, Long RG, Sherlock S. Percutaneous transhepatic obliteration of gastro-oesophageal varices. Lancet 1976;2(7976):53–55 28/56

29. PERCUTANEOUS TRANSHEPATIC OBLITERATION OF
G-E VARICES
• The major variceal supply veins (LGV and short gastric)
are selectively catheterised and thrombosed. 30 ml of 50
% dextrose is injected to traumatise the intima of the
veins, increasing quantities of human thrombin (500-
3000 units) is injected to induce complete thrombosis,
and small pieces of gelatin foam are injected to stabilise
the thrombus.
• Contrast medium is then injected to confirm successful
obliteration, and if this had been achieved the catheter is
carefully withdrawn.
• A portal venogram is obtained to ensure complete obliteration of all variceal supply veins and PV
patency. Finally, before complete withdrawal of the catheter from the liver, the hepatic puncture wound
is plugged by an injection of gelatin foam into the subcapsular parenchyma.
Scott J, Dick R, Long RG, Sherlock S. Percutaneous transhepatic obliteration of gastro-oesophageal varices. Lancet 1976;2(7976):53–55 29

30. BRTO
2006
John Kaufman
1991-1993
Kanagawa et al
1984
Olson et al
1970
First BRTO in US, with 3%
Sotradecol [4]
Practiced and published
BRTO procedure, coining the
term ‘‘balloon-occluded
retrograde transvenous
obliteration’’ (B-RTO).[3]
Ethanolamine-oleate
Transvenous obliteration is
an old idea that was
practiced in the 1970s in
the pre-TIPS era as an
procedure for the MX of
bleeding varices from a
percutaneous transhepatic
approach.[1]
First published document of
an attempt at balloon-
occluded sclerotherapy
(absolute alcohol) of the GRS
for the MX of GVs.[2]
Term used for the procedure
was ‘‘transrenal-vein reflux
ethanol sclerosis’’.
1. Scott J, Dick R, Long RG, Sherlock S. Percutaneous transhepatic obliteration of gastro-oesophageal varices. Lancet 1976;2(7976):53–55
2. Fukatsu H, Kawamoto H, Harada R, et al. Gastric fundal varices with an exposed microcoil after the combined BRTO and PTO therapy. Endoscopy 2007;39(Suppl
1):E247–E248
3. Kanagawa H, Mima S, Kouyama H, Gotoh K, Uchida T, Okuda K. Treatment of gastric fundal varices by balloonoccluded retrograde transvenous obliteration. J
Gastroenterol Hepatol 1996;11(1):51–58
4. Saad, W. E. A. (2011). The History and Evolution of Balloon-occluded Retrograde Transvenous Obliteration (BRTO): From the United States to Japan and Back.
Seminars in Interventional Radiology, 28(03), 283–287. doi:10.1055/s-0031-1284454
30

31. Gastric Varices
1. Sarin SK, Lahoti D, Saxena SP, Murthy NS, Makwana UK. Prevalence, classification and natural history of gastric varices: a long-term followup study in 568 portal hypertension patients. Hepatology 1992;16:1343–1349. (also for table shown)
2. De Franchis RBaveno 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;63:743–752.
3. T. Kim, H. Shijo, H. Kokawa et al., “Risk factors for hemorrhage from gastric fundal varices,” Hepatology, vol. 25, no. 2, pp. 307–312, 1997.
Pic src: Mehta, G., Abraldes, J. G., & Bosch, J. (2010). Developments and controversies in the management of oesophageal and gastric varices. Gut, 59(6), 701–705.
• The Sarin classification is most commonly used for
risk stratification and MX of GV. [1] GV are present
in about 20% of pts with LC.
• GOV 1 are commonly managed following guidelines
for EV.[2]
• Cardiofundal varices (GOV2 & IGV1) bleed less
frequently. However, is often more severe, more
difficult to control and shows a ↑ risk of rec bleeding
and mortality (up to 45%) compared to EV.[1]
• In CFV, the 5-year cumulative incidence of bleeding
is 44% in the natural course, and the 1-year survival
rate is 48% in case of bleeding. [3]
31

32. Anatomy of gastric varices
A. Kim M, Lee K-Y. Understanding the pathophysiology of portosystemic shunt by simulation using an electric circuit. Biomed Res Int. 2016;2016(81):ID 2097363.7
B. Gonzalez JM, et al. Management of fundic varices. Endoscopic aspects. Rev esp enfeRm Dig 2015. 107;8, pp. 501-508
A
B
The afferent channel for gastric varix is mostly from LGV or
posterior gastric veins.[1-3] The efferent channel for most GVs
(80–85%) is the GRS, which opens into the LRV.[2,4]
1. Watanabe K, Kimura K, Matsutani S, Ohto M, Okuda K. Portal hemodynamics in patients with gastric varices: A study in 230 patients with esophageal and/or gastric varices using portal vein catheterization.
Gastroenterology. 1988;95:434–40.
2. Chikamori F, Kuniyoshi N, Shibuya S, Takase Y. Correlation between endoscopic and angiographic findings in patients with esophageal and isolated gastric varices. Dig Surg. 2001;18:176–81.
3. Kimura K, Ohto M, Matsutani S, Furuse J, Hoshino K, Okuda K. Relative frequencies of portosystemic pathways and renal shunt formation through the “posterior” gastric vein: Portographic study in 460 patients.
Hepatology. 1990;12:725–8.
4. Koito K, Namieno T, Nagakawa T, Morita K. Balloon-occluded retrograde transvenous obliteration for gastric varices with gastrorenal or gastrocaval collaterals. AJR Am J Roentgenol. 1996;167:1317–20.
32

33. Anatomy of gastric varices
• The two main infra-diaphragmatic portosystemic shunts:
the gastrocaval and gastrorenal shunts.
• The common afferent (portovenous feeders) to the GV are
LGV (also known as the coronary vein), the PGV, and the
SGV.
• The SGV and PGV arise from the SV, and the LGV arises
from the confluence of the SV and the mesenteric vein(s)
(SMV). The LGV may also arise from the proximal main
PV.
• The efferent limbs of the GV, which drain the GV into the
systemic circulation, either drain directly into the IVC (the
GRS) or into the LRV (GRS).
• The asterisk denotes a direct communication between the
SV and the shunt/left renal vein, demonstrating a SRS.
Al-Osaimi AMS, Caldwell SH. Medical and endoscopic management of gastric varices. Semin Interv Radiol 2011 ;28:273–282.
33

34. Anatomy of gastric varices
• Basic anatomy of a GV, with the portal circulation shaded
dark gray and the systemic circulation shaded light gray.
• The figure demonstrates the para- and
supradiaphragmatic portosystemic venous circulation,
representing alternative access routes to the BRTO
procedure.
• The GRS in this drawing is rudimentary.
Rt BCV,right brachiocephalic vein; Lt BCV, left
brachiocephalic vein;
Lt SV, left subclavian vein; Peric V, Pericardiol or pericardio-
phrenic vein; AzA, azygous arch; AV, azygous venous system
or azygo-paraesophageal venous system; IPV, inferior
phrenic vein: descending portion (DpIPV) and transverse
portion (TpIPV);
Saad WEA, Sze DY. Variations of balloonoccluded antegrade transvenous obliteration (BATO) and alternative/ adjunctive routes for BRTO. Semin Interv Radiol 2011;28:314–324
34

35. Anatomy of gastric varices
(B) The balloon-occlusion catheter being advanced from a transfemoral
approach and positioned and inflated in the transverse portion of the inferior
phrenic vein via the left brachiocephalic and pericardial veins ,with ultimate
filling of the GV with contrast (black).
(C) Balloon-occlusion catheter being advanced from a transfemoral approach
and positioned and inflated in the descending portion of the inferior phrenic
vein via the azygous arch and azygous-paraesophageal venous system,
ultimately filling the GV with contrast (black).
Saad WEA, Sze DY. Variations of balloonoccluded antegrade transvenous obliteration (BATO) and alternative/ adjunctive routes for BRTO. Semin Interv Radiol 2011;28:314–324
(A) The balloon-occlusion catheter being advanced from a
transfemoral approach and positioned and inflated in the
transverse portion of the inferior phrenic vein and filling of the
GV with contrast (black).
35

36. Anatomy of gastric varices
• The basic and surgical anatomy of a gastric
varix, with the portal circulation shaded gray
and the systemic circulation shaded black.
• A combined balloon-occluded antegrade
transvenous obliteration (BATO) and BRTO
access is illustrated.
• The BATO access is via a TIPS.
• The BRTO access is via the traditional
transfemororenal access.
Saad WEA, Sze DY. Variations of balloonoccluded antegrade transvenous obliteration (BATO) and alternative/ adjunctive routes for BRTO. Semin Interv Radiol 2011;28:314–324
36

37. The Kiyosue classification of GV
(a) Classification based on drainage pathway
A.Arora, S.Rajesh, Y. S.Meenakshi, B. Sureka,K.Bansal, and S. K. Sarin, “Spectrumof hepatofugal collateral pathways in portal hypertension: an illustrated radiological review,” Insights into Imaging, vol. 6, no. 5, pp.
559–572, 2015.
• Type A consists of a
portosystemic shunt as the
only drainage
• Type B: PSS along with
additional small portosystemic
collaterals
• Type C: there is presence of
multiple large PSS
• Type D consists of multiple small portosystemic collaterals as the drainage pathways
without proper shunt formation.
37

38. The Kiyosue classification of GV
(b) Classification based on the inflow pathway
A.Arora, S.Rajesh, Y. S.Meenakshi, B. Sureka,K.Bansal, and S. K. Sarin, “Spectrumof hepatofugal collateral pathways in portal hypertension: an illustrated radiological review,” Insights into Imaging, vol. 6, no. 5, pp.
559–572, 2015.
• Type 1 consists of single afferent
vein for the varices
• Type 2 has multiple afferent
vessels contributing to the
variceal formation
• Type 3 is similar to Type 2 but with additional small collateral/shunts directly
communicating with outflow tract.
38

39. Coil-assisted retrograde transvenous obliteration
39/56

40. The concept of BRTO
• The concept of BRTO involves accessing the GRS via the LRV
through the femoral or jugular route and injecting a
sclerosant agent such as ethanolamine oleate, absolute
alcohol, gelfoam, or sodium tetradecyl sulphate into the
varices after inflating a balloon in the GRS to obstruct the
shunt outflow, thereby obliterating the varices[1-4]
References are at the end of the slides
Taken from: https://articl.net/resource/balloon-occluded-retrograde-
transvenous-obliteration-brto
• In the presence of a completely thrombosed main PV, GRS act as the primary outflow of the splenic and mesenteric
veins. So, occlusion of the GRS, which is a by-product of the BRTO procedure, would potentially cause mesenteric
venous hypertension, mesenteric ischemia, and possibly thrombosis of the entire splanchnic portal venous circulation.
• Although PVT is not an absolute CI to BRTO, it is a hemodynamic dilemma that has not been investigated fully. Chronic
occlusion of the main PV with cavernous transformation may provide sufficient outflow for the portal venous system
after occluding the portosystemic shunts, and therefore it may be acceptable to proceed with the BRTO procedure with
the risks and benefits of the procedure taken into consideration.[5]
40

41. Clinical Outcomes of BRTO Procedure for the
management of Gastric Varices
In most studies, GV rebleeding rates of pts who had undergone a successful BRTO range from zero-12%
after a median follow-up of 33 to 75 wks, and rates for complete obliteration of GV range from 86-100%.
References are at the end of the slides
41

42. Clinical Outcomes of BRTO Procedures for GV
• The 30-day mortality rates range from zero to
4.1%, and the most common cause of death is
progressive liver failure.[1-9]
• Most of these complication were related with
use of ethanolamine oleate. Sodium tetradecyl
sulfate (STS) foam is also widely used for
BTRO procedure,[2,3] and complication of
BRTO has also changed. For example, STS
foam does not lead to AKI. But it could make
air embolism.
Procedural complications:
• Gross hematuria with AKI(up to 4.8%)
• Pulmonary embolism (1.5%–4.1%)
• Anaphylaxis to ethanolamine oleate (up to
5%)
• Cardiac arrhythmias (up to 1.5%)
• Rapidly declining hepatic function (5%–7%)
References are at the end of the slides 42

43. PHTN complications related to BRTO
1. Fukuda T, Hirota S, Sugimura K. Long-term results of balloon-occluded retrograde transvenous obliteration for the treatment of gastric varices and hepatic encephalopathy. J Vasc Interv Radiol. 2001; 12:327–36.
2. Ninoi T, Nishida N, Kaminou T, Sakai Y, Kitayama T, Hamuro M, et al. Balloon-occluded retrograde transvenous obliteration of gastric varices with gastrorenal shunt: long-term follow-up in 78 patients. AJR Am J Roentgenol. 2005; 184:1340–6.
3. Ninoi T, Nakamura K, Kaminou T, Nishida N, Sakai Y, Kitayama T, et al. TIPS versus transcatheter sclerotherapy for gastric varices. AJR Am J Roentgenol. 2004; 183:369–76.
4. Kanagawa H, Mima S, Kouyama H, Gotoh K, Uchida T, Okuda K. Treatment of gastric fundal varices by balloon-occluded retrograde transvenous obliteration. J Gastroenterol Hepatol. 1996; 11:51–8.
5. Sonomura T, Sato M, Kishi K, Terada M, Shioyama Y, Kimura M, et al. Balloon-occluded retrograde transvenous obliteration for gastric varices: a feasibility study. Cardiovasc Intervent Radiol. 1998; 21:27–30.
6. Kitamoto M, Imamura M, Kamada K, Aikata H, Kawakami Y, Matsumoto A, et al. Balloon-occluded retrograde transvenous obliteration of gastric fundal varices with hemorrhage. AJR Am J Roentgenol. 2002; 178:1167–74.
7. Arai H, Abe T, Shimoda R, Takagi H, Yamada T, Mori M. Emergency balloon-occluded retrograde transvenous obliteration for gastric varices. J Gastroenterol. 2005; 40:964–71.
8. Cho SK, Shin SW, Lee IH, Do YS, Choo SW, Park KB, et al. Balloon-occluded retrograde transvenous obliteration of gastric varices: outcomes and complications in 49 patients. AJR Am J Roentgenol. 2007; 189:W365–72.
9. Hiraga N, Aikata H, Takaki S, Kodama H, Shirakawa H, Imamura M, et al. The long-term outcome of patients with bleeding gastric varices after balloon-occluded retrograde transvenous obliteration. J Gastroenterol. 2007; 42:663–72.
Another most important complications a/with BRTO is the aggravation of EV. Reported rates of worsening
EV vary up to 63%, with 11% to 24% subsequent variceal bleeding rate.[1-9]
Other complications from increased PHTN after BRTO
• Development of PHG (5%–13%)
• Ascites (0%–44%)
• Hydrothorax (0%–8%).[1-9]
43

44. HCC after BRTO
Yokohama et al. The Incidence of Hepatocellular Carcinoma after Balloon-Occluded Retrograde Transvenous Obliteration. Volume 2015, Article ID 605292, 7 pages
Group A % Group B % Non BRTO %
1 YR 20.9 35.8 6.3
3 YR 41.1 80.0 19.2
5 YR 60.7 0 42.5
The study demonstrated a high incidence of HCC after BRTO in
LC pts with viral hepatitis infection. This suggested the potential
for BRTO to accelerate hepatocarcinogenesis.
• Yooyama et al investigated the incidence of HCC after BRTO in pts with
chronic viral hepatatits related CLD (HCV:66, HBV:5) .
• Group A, pts without H/O HCC before BRTO (n=40) and group B, pts
with H/O RX for HCC and DX with no HCC appearance when BRTO
was performed (n=31).
• Non-BRTO group: 51 pts with chronic viral hepatatits related and
without H/O HCC
44

45. Clinical Outcomes of the TIPS procedure for GV
• There are limited data addressing TIPS for the treatment of GV, as most TIPS studies
have included all EV with or without GV. There are 8 studies evaluating the placement
of a TIPS for bleeding GV.[1-8]
References are at the end of the slides
45/56

46. cTIPS Vs BRTO : in treatment of pt bleeding from gastric varices
Sabri et al. 2014[1] Sauk et al. 2014[2]
27 Vs 23 27 Vs 25
Technical success rate: 100% Vs 91%, p = 0.21
Major complications: 4% Vs 9%, p = 0 .344
HE: 15% Vs 0%, p = 0.12
At 12 mnths, incidence of rebleeding: 11% Vs 0%, p = 0.25
BRTO appears to be equivalent to TIPS in the short-term
for management of bleeding GV
Procedural complications: 7% Vs 12%, p = 0.463
Resolution of GV on follow-up: 60% Vs 87%, p= 0.079
Rebleeding rates: 7% Vs 12%, p = 0.463
HE: 22% Vs 0%,p = 0.012
Development of new ascites: 4% Vs 4%, p = 0.937
BRTO is an effective method in the RX of GV with
similar outcomes and complication rates as TIPS, but
with a lower rate of HE.
Single center retrospective
cTIPS versus BRTO (EO or Sotradecol foam)
Single center retrospective
cTIPS versus BRTO (foam sclerosant)
Bare stents were used in earlier studies, which, are known to have lower patency when compared to
covered stents, and likely account for the higher rebleeding rates. More recently, Sabri et al[1] and Sauk et al
[2] did a retrospective study to compare cTIPS with BRTO for MX of pts bleeding from GV.
46References are at the end of the slides

47. TIPS or BRTO ?
• As discussed from the review of the literature, both TIPS and BRTO can effectively treat
GV with low rebleeding rates, however careful pt selection is required to best treat the
pt’s individual clinical situation.
For pts with GV and severe HE or If a pt’s MELD score is high
If there is recurrent gastric variceal bleeding even after TIPS
revision
In pts in whom a TIPS placement is technically difficult
If there is a centrally located tumor and no window for the TIPS
stent to land without violating the tumor
For eg: In pts with cavernous transformation of a chronically thrombosed
main PV, a TIPS procedure could be technically difficult.
47

48. TIPS or BRTO ?
• As discussed from the review of the literature, both TIPS and BRTO can effectively treat
GV with low rebleeding rates, however careful pt selection is required to best treat the
pt’s individual clinical situation.
If there is EV in addition to GV, a TIPS procedure or BRTO after
endoscopic ligation of the EV can be performed.
For pts with GV and intractable ascites or hydrothorax, TIPS is a
better option.
If the BRTO procedure is complicated by vein rupture or balloon
rupture with subsequent clinical failure, TIPS could be placed .
48

49. Role of adjunct therapy ?
BRTOTIPS
• BRTO and TIPS are two procedures that are considered for the RX of bleeding
GV.[1,2,3]
TIPS creates a portosystemic
shunt and thus decompresses
the portal circulation
BRTO involves occlusion of a commonly
associated spontaneous portosystemic
shunt that usually causes increased PP
1. Saad W EA Al-Osaimi A M Caldwell S et al.For the Expert Panel on Interventional Radiology for the American College of Radiology ACR Appropriateness Criteria(r): Radiologic Management of Gastric Varices. Available at:
http://www.acr.org/~/media/ACR/Documents/AppCriteria/Interventional/RadiologicManagementGastricVarices.pdf.
2. Saad W E, Darcy M D. Transjugular intrahepatic portosystemic shunt (TIPS) versus balloon-occluded retrograde transvenous obliteration (BRTO) for the management of gastric varices. Semin Intervent Radiol. 2011;28(3):339–349.
3. Saad W E, Wagner C C, Lippert A. et al.Protective value of TIPS against the development of hydrothorax/ascites and upper gastrointestinal bleeding after balloon-occluded retrograde transvenous obliteration (BRTO) Am J Gastroenterol. 2013;108(10):1612–1619.
4. Kessler J, Trerotola S O. Use of the Amplatzer Vascular Plug for embolization of a large retroperitoneal shunt during transjugular intrahepatic portosystemic shunt creation for gastric variceal bleeding. J Vasc Interv Radiol. 2006;17(1):135–140.
5. Gaba R C, Bui J T, Cotler S J. et al.Rebleeding rates following TIPS for variceal hemorrhage in the Viatorr era: TIPS alone versus TIPS with variceal embolization. Hepatol Int. 2010;4(4):749–756.
6. Lunderquist A, Vang J. Transhepatic catheterization and obliteration of the coronary vein in patients with portal hypertension and esophageal varices. N Engl J Med. 1974;291(13):646–649.
The effectiveness of adjunctive variceal embolization after decompressing the portal circulation with a TIPS
is a matter of debate.
Adjunctive embolization is performed after TIPS if the varices are still visualized during the post-TIPS portal
venogram,[4,5] Variceal embolization likely helps reduce the risk of bleeding in the setting of subsequent
TIPS dysfunction as well.[6]
49

50. Prevention of recurrent variceal bleeding:
TIPS + Emb Vs TIPS alone
Tesdal et al. 2005[1] Chen et al. 2013[2] Qi et al. 2013[3]
53 Vs 42 54 Vs 52 6 studies
The 2-year and 4-year rebleeding rates
16 and 19%, Vs 39 and 47%; p = 0.02
TIPS and adjunctive embolotherapy of
gastroesophageal collateral vessels
significantly lower the rebleeding rate in
comparison to TIPS alone.
6-month rebleeding rate: 6 vs.
20%; p = 0.02
The TIPS+E regimen may reduce the risk of
RVH during the first 6 months by
preventing shunt dysfunction, which may
improve liver function.
lower incidence of RVH: OR 2.02, 95% CI
1.29-3.17, p = 0.002
Shunt dysfunction: OR 1.26, 95% CI 0.76-
2.08, p = 0.38
HE: OR 0.81, 95% CI 0.46-1.43, p = 0.4
Death: OR 0.90, 95% CI 0.55-1.47, p=
0.68
Adjunctive variceal embolization during
TIPS procedures might be beneficial in
the prevention of RVH.
bTIPS and variceal embolization Vs
bTIPS alone (RS)
mTIPS and variceal embolization Vs
mTIPS alone (MA)
cTIPS and variceal embolization Vs
cTIPS alone (PS)
50References are at the end of the slides

51. Prevention of recurrent variceal bleeding:
BRTO Vs BRTO + TIPS
Saad et al. 2013[1]
27 Vs 9
• Pre-BRTO ascites / HH resolved in7 % Vs 56 % ;P
= 0.006
• The ascites / HH free rate at 6, 12, and 24 months
58 % , 43 % ,29 % , and 100 % , 100 % , 100 %;
p= 0.01
• RVH at 6, 12, and 24 months was 9 % , 9 % , 21
% vs. 0 % , 0 % , 0 %; p= 0.03
• The 1-year survival of both groups (80 – 88 % )
was similar; p> 0.05
BRTO Vs BRTO + TIPS; (RS)
• One study directly compared the outcomes of BRTO only
versus the outcomes of combining BRTO and TIPS; this
study demonstrated the superior outcomes of combining TIPS
with BRTO instead of BRTO alone.[1]
• Moreover, when comparing the available literature, the
combined TIPS–BRTO procedure has demonstrated superior
results to TIPS alone in the MX of GV.[2-6]
1. Saad W E, Wagner C C, Lippert A. et al.Protective value of TIPS against the development of hydrothorax/ascites and upper gastrointestinal
bleeding after balloon-occluded retrograde transvenous obliteration (BRTO) Am J Gastroenterol. 2013;108(10):1612–1619.
2. Sabri S S, Abi-Jaoudeh N, Swee W. et al.Short-term rebleeding rates for isolated gastric varices managed by transjugular intrahepatic
portosystemic shunt versus balloon-occluded retrograde transvenous obliteration. J Vasc Interv Radiol. 2014;25(3):355–361.
3. Mahadeva S, Bellamy M C, Kessel D, Davies M H, Millson C E. Cost-effectiveness of N-butyl-2-cyanoacrylate (histoacryl) glue injections versus
transjugular intrahepatic portosystemic shunt in the management of acute gastric variceal bleeding. Am J Gastroenterol. 2003;98(12):2688–
2693.
4. Ninoi T, Nakamura K, Kaminou T. et al.TIPS versus transcatheter sclerotherapy for gastric varices. AJR Am J Roentgenol. 2004;183(2):369–376.
5. Choi Y H, Yoon C J, Park J H, Chung J W, Kwon J W, Choi G M. Balloon-occluded retrograde transvenous obliteration for gastric variceal
bleeding: its feasibility compared with transjugular intrahepatic portosystemic shunt. Korean J Radiol. 2003;4(2):109–116.
6. Lo G H, Liang H L, Chen W C. et al.A prospective, randomized controlled trial of transjugular intrahepatic portosystemic shunt versus
cyanoacrylate injection in the prevention of gastric variceal rebleeding. Endoscopy. 2007;39(8):679–685.
51

52. • In conclusion, there is growing evidence that embolizing or obliterating varices arising
from the portal system leads to reduced rebleed rates.
• Moreover, combining TIPS and BRTO is more effective than either procedure alone
when managing gastric varices.
52

53. 53

54. 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
54

55. 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.
55

56. References: TIPS: Bare stent Vs PTFE-covered stent
1. Casado M, Bosch J, Garcia-Pagan JC, Bru C, Banares R, Bandi JC, et al. Clinical events after transjugular intrahepatic portosystemic
shunt: correlation with hemodynamic findings. Gastroenterology 1998;114:1296–1303.
2. 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;103:2738–2746.
3. Sauerbruch T, Mengel M, Dollinger M, Zipprich A, Rossle M, Panther E, et al. Prevention of rebleeding from esophageal varices in
patients with cirrhosis receiving small-diameter stents vs. hemodynamically controlled medical therapy. Gastroenterology
2015;149:660–668.
4. Wang Q, Lv Y, Bai M, Wang Z, Liu H, He C, et al. Eight millimetre covered TIPS does not compromise shunt function but reduces
hepatic encephalopathy in preventing variceal rebleeding. J Hepatol 2017;67: 508–516.
5. Bureau C, Garcia-Pagan JC, Otal P, Pomier-Layrargues G, Chabbert V, Cortez C, et al. Improved clinical outcome using
polytetrafluoroethylene-coated stents for TIPS: results of a randomized study. Gastroenterology 2004;126:469–475.
6. Nishimine K, Saxon RR, Kichikawa K, Mendel-Hartvig J, Timmermans HA, Shim HJ, Uchida BT, Barton RE, Keller FS, Rösch J. Improved
transjugular intrahepatic portosystemic shunt patency with PTFE-covered stent-grafts: experimental results in swine. Radiology.
1995;196:341-347.
56

57. 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
57

58. 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.
58

59. References: The concept of BRTO
Taken from: https://articl.net/resource/balloon-occluded-retrograde-
transvenous-obliteration-brto
1. Kanagawa H, Mima S, Kouyama H, Gotoh K, Uchida T, Okuda K. Treatment of gastric fundal varices by
balloon-occluded retrograde transvenous obliteration. J Gastroenterol Hepatol. 1996;11:51–8.
2. Kiyosue H, Mori H, Matsumoto S, Yamada Y, Hori Y, Okino Y. Transcatheter obliteration of gastric varices:
Part-1: Anatomic classification. Radiographics. 2003;23:911–20.
3. Kiyosue H, Mori H, Matsumoto S, Yamada Y, Hori Y, Okino Y. Transcatheter obliteration of gastric varices:
Part-2: Strategy and techniques based on hemodynamic features. Radiographics. 2003;23:921–37.
4. Olson E, Yune HY, Klatte EC. Transrenal-vein reflux ethanol sclerosis of gastroesophageal varices. Am J
Roentgenol. 1984;143:627–8.
5. Al-Osaimi AMS, Sabri SS, Caldwell SH. Balloon-occluded retrograde transvenous obliteration (BRTO):
preprocedural evaluation and imaging. Semin Intervent Radiol 2011;28:288–295
59

60. References: Clinical Outcomes of BRTO Procedures for
GV
1. Ninoi T, Nakamura K, Kaminou T, Nishida N, Sakai Y, Kitayama T, et al. TIPS versus transcatheter sclerotherapy for gastric varices. AJR
Am J Roentgenol. 2004; 183:369–76. DOI: 10.2214/ajr.183.2.1830369. PMID: 15269027.
2. Sabri SS, Abi-Jaoudeh N, Swee W, Saad WE, Turba UC, Caldwell SH, et al. Short-term rebleeding rates for isolated gastric varices
managed by transjugular intrahepatic portosystemic shunt versus balloon-occluded retrograde transvenous obliteration. J Vasc
Interv Radiol. 2014; 25:355–61.
3. Sauk S, Niemeyer M, Kim SK, Korenblat K. Outcomes from balloon-occluded retrograde transvenous obliteration (BRTO) versus
transjugular intrahepatic portosystemic shunt (TIPS) in the management of isolated gastric varices: a retrospective study in single US
medical center. J Vasc Interv Radiol. 2014; 25(Suppl 3):S80.
4. Kanagawa H, Mima S, Kouyama H, Gotoh K, Uchida T, Okuda K. Treatment of gastric fundal varices by balloon-occluded retrograde
transvenous obliteration. J Gastroenterol Hepatol. 1996; 11:51–8.
5. Sonomura T, Sato M, Kishi K, Terada M, Shioyama Y, Kimura M, et al. Balloon-occluded retrograde transvenous obliteration for
gastric varices: a feasibility study. Cardiovasc Intervent Radiol. 1998; 21:27–30.
6. Kitamoto M, Imamura M, Kamada K, Aikata H, Kawakami Y, Matsumoto A, et al. Balloon-occluded retrograde transvenous
obliteration of gastric fundal varices with hemorrhage. AJR Am J Roentgenol. 2002; 178:1167–74.
7. Arai H, Abe T, Shimoda R, Takagi H, Yamada T, Mori M. Emergency balloon-occluded retrograde transvenous obliteration for gastric
varices. J Gastroenterol. 2005; 40:964–71.
8. Cho SK, Shin SW, Lee IH, Do YS, Choo SW, Park KB, et al. Balloon-occluded retrograde transvenous obliteration of gastric varices:
outcomes and complications in 49 patients. AJR Am J Roentgenol. 2007; 189:W365–72.
9. Hiraga N, Aikata H, Takaki S, Kodama H, Shirakawa H, Imamura M, et al. The long-term outcome of patients with bleeding gastric
varices after balloon-occluded retrograde transvenous obliteration. J Gastroenterol. 2007; 42:663–72.
60

61. References: Clinical Outcomes of BRTO Procedure for
the management of Gastric Varices
1. Kanagawa H, Mima S, Kouyama H, Gotoh K, Uchida T, Okuda K. Treatment of gastric fundal varices by balloon-occluded retrograde
transvenous obliteration. J Gastroenterol Hepatol. 1996; 11:51–8.
2. Sonomura T, Sato M, Kishi K, Terada M, Shioyama Y, Kimura M, et al. Balloon-occluded retrograde transvenous obliteration for
gastric varices: a feasibility study. Cardiovasc Intervent Radiol. 1998; 21:27–30.
3. Kitamoto M, et al. Balloon-occluded retrograde transvenous obliteration of gastric fundal varices with hemorrhage. AJR Am J
Roentgenol. 2002; 178:1167–74.
4. Ninoi T, et al. TIPS versus transcatheter sclerotherapy for gastric varices. AJR Am J Roentgenol. 2004; 183:369–76.
5. Arai H, Abe T, Shimoda R, Takagi H, Yamada T, Mori M. Emergency balloon-occluded retrograde transvenous obliteration for gastric
varices. J Gastroenterol. 2005; 40:964–71.
6. Cho SK, et al. Balloon-occluded retrograde transvenous obliteration of gastric varices: outcomes and complications in 49 patients.
AJR Am J Roentgenol. 2007; 189:W365–72.
7. Hiraga N, Aikata H, Takaki S, Kodama H, Shirakawa H, Imamura M, et al. The long-term outcome of patients with bleeding gastric
varices after balloon-occluded retrograde transvenous obliteration. J Gastroenterol. 2007; 42:663–72.
8. Sabri SS, et al. Short-term rebleeding rates for isolated gastric varices managed by transjugular intrahepatic portosystemic shunt
versus balloon-occluded retrograde transvenous obliteration. J Vasc Interv Radiol. 2014; 25:355–61.
9. Sauk S, Niemeyer M, Kim SK, Korenblat K. Outcomes from balloon-occluded retrograde transvenous obliteration (BRTO) versus
transjugular intrahepatic portosystemic shunt (TIPS) in the management of isolated gastric varices: a retrospective study in single US
medical center. J Vasc Interv Radiol. 2014; 25(Suppl 3):S80.
61

62. References to: Clinical Outcomes of the TIPS
Procedure for GV
1. Chau TN, Patch D, Chan YW, Nagral A, Dick R, Burroughs AK. “Salvage” transjugular intrahepatic portosystemic shunts: gastric
fundal compared with esophageal variceal bleeding. Gastroenterology. 1998; 114:981–7.
2. Barange K, Péron JM, Imani K, Otal P, Payen JL, Rousseau H, et al. Transjugular intrahepatic portosystemic shunt in the treatment of
refractory bleeding from ruptured gastric varices. Hepatology. 1999; 30:1139–43.
3. Rees CJ, Nylander DL, Thompson NP, Rose JD, Record CO, Hudson M. Do gastric and oesophageal varices bleed at different portal
pressures and is TIPS an effective treatment? Liver. 2000; 20:253–6.
4. Choi YH, Yoon CJ, Park JH, Chung JW, Kwon JW, Choi GM. Balloon-occluded retrograde transvenous obliteration for gastric variceal
bleeding: its feasibility compared with transjugular intrahepatic portosystemic shunt. Korean J Radiol. 2003; 4:109–16.
5. Ninoi T, Nakamura K, Kaminou T, Nishida N, Sakai Y, Kitayama T, et al. TIPS versus transcatheter sclerotherapy for gastric varices. AJR
Am J Roentgenol. 2004; 183:369–76.
6. Lo GH, Liang HL, Chen WC, Chen MH, Lai KH, Hsu PI, et al. A prospective, randomized controlled trial of transjugular intrahepatic
portosystemic shunt versus cyanoacrylate injection in the prevention of gastric variceal rebleeding. Endoscopy. 2007; 39:679–85.
7. Sabri SS, Abi-Jaoudeh N, Swee W, Saad WE, Turba UC, Caldwell SH, et al. Short-term rebleeding rates for isolated gastric varices
managed by transjugular intrahepatic portosystemic shunt versus balloon-occluded retrograde transvenous obliteration. J Vasc
Interv Radiol. 2014; 25:355–61.
8. Sauk S, Niemeyer M, Kim SK, Korenblat K. Outcomes from balloon-occluded retrograde transvenous obliteration (BRTO) versus
transjugular intrahepatic portosystemic shunt (TIPS) in the management of isolated gastric varices: a retrospective study in single US
medical center. J Vasc Interv Radiol. 2014; 25(Suppl 3):S80.
62

63. References to cTIPS Vs BRTO : in treatment of pt
bleeding from gastric varices
1.Sabri SS, Abi-Jaoudeh N, Swee W, Saad WE, Turba UC, Caldwell SH, et al. Short-term
rebleeding rates for isolated gastric varices managed by transjugular intrahepatic
portosystemic shunt versus balloon-occluded retrograde transvenous obliteration. J Vasc
Interv Radiol. 2014; 25:355–61.
2.Sauk S, Niemeyer M, Kim SK, Korenblat K. Outcomes from balloon-occluded retrograde
transvenous obliteration (BRTO) versus transjugular intrahepatic portosystemic shunt
(TIPS) in the management of isolated gastric varices: a retrospective study in single US
medical center. J Vasc Interv Radiol. 2014; 25(Suppl 3):S80.
63

64. References: Prevention of recurrent variceal
bleeding: TIPS + Emb Vs TIPS alone
1. Tesdal IK, Filser T, Weiss C, Holm E, Dueber C, Jaschke W. Transjugular intrahepatic portosystemic shunts: adjunctive
embolotherapy of gastroesophageal collateral vessels in the prevention of variceal rebleeding. Radiology 2005; 236:
360–7.
2. Chen S, Li X, Wei B et al. Recurrent variceal bleeding and shunt patency: prospective randomized controlled trial of
transjugular intrahepatic portosystemic shunt alone or combined with coronary vein embolization. Radiology 2013;
268: 900–6.
3. Qi, X., Liu, L., Bai, M., Chen, H., Wang, J., Yang, Z., Fan, D. (2014). Transjugular intrahepatic portosystemic shunt in
combination with or without variceal embolization for the prevention of variceal rebleeding: A meta-analysis. Journal of
Gastroenterology and Hepatology, 29(4), 688–696.

65. TIPS in HPS/SOS?
• At present, there is no sufficient evidence to support the use of TIPS for
the treatment of hepatopulmonary syndrome.
• 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 .
65

66. TIPS in refractory/recidivant ascites/HRS/HH ?
• TIPS is more effective than conservative/medical treatment to resolve
refractory/recidivant ascites, greatly reducing the need of paracentesis.
TIPS should be considered in all pts with refractory/recidivant ascites.
• TIPS is effective to treat type-II HRS associated to refractory/recidivant
ascites. Cannot be recommended in unselected patients with type-I HRS .
• TIPS can be considered in refractory hydrothorax aiming at resolution of
hydrothorax and reduction in number of thoracentesis. The effect of TIPS
on survival are still not clearly defined in RH. Thus, the final decision to
insert a TIPS should be reached on an individual pt basis after a
multidisciplinary clinical evaluation.
66

67. 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.
67

68. 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 patients with refractory ascites, kidney failure and
comorbidities.
68

69. 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.
69

70. Kim k,et al. Transjugular intrahepatic portosystemic shunts versus balloon-occluded retrograde transvenous obliteration
for the management of gastric varices: Treatment algorithm according to clinical manifestations. Gastrointestinal
Intervention 2016; 5(3): 170-176. 70