Abstract
The trans jugular intrahepatic Porto systemic shunt (TIPS) is no longer viewed as a salvage therapy or a bridge to liver transplantation and is currently indicated for a number of conditions related to portal hypertension with positive results in survival. Moreover, the availability of self-expandable polytetrafluoroethylene (PTFE)-covered endoprostheses has dramatically improved the long-term patency of TIPS. However, since the last updated International guidelines have been published (year 2009) new evidence have come, which have open the field to new indications and solved areas of uncertainty. On this basis, the Italian Association of the Study of the Liver (AISF), the Italian College of Interventional Radiology—Italian Society of Medical Radiology (ICIR-SIRM), and the Italian Society of Anesthesia, Analgesia and Intensive Care (SIAARTI) promoted a Consensus Conference on TIPS. Under the auspices of the three scientific societies, the consensus process started with the review of the literature by a scientific board of experts and ended with a formal consensus meeting in Bergamo on June 4th and 5th, 2015. The final statements presented here were graded according to quality of evidence and strength of recommendations and were approved by an independent jury. By highlighting strengths and weaknesses of current indications to TIPS, the recommendations of AISF-ICIR-SIRM-SIAARTI may represent the starting point for further studies.
Keywords
Introduction
Portal hypertension (PH) is one of the major complications of cirrhosis. The trans jugular intrahepatic porto systemic shunt (TIPS) has been an established procedure in the treatment of the complications of portal hypertension, including bleeding oesophageal varices, refractory ascites, hepatic hydrothorax, type-2 hepatorenal syndrome, and more recently, Budd–Chiari syndrome and veno-occlusive disease. However, despite these broad applications, many clinical aspects remain controversial. The multispecialistic contribute to patient selection and TIPS management have led the Italian hepatologic community to produce a consensus statements aimed to the reassessment of the technical and clinical aspects.
Methods
The goal of this document was to provide clinical guidelines for the proper management of TIPS. Promoter of this “Consensus Guidelines” was the Italian association for the Study of Liver (AISF). The Consensus was endorsed by: ICIR (Italian College of Interventional Radiology), SIRM (Italian Society of Medical Radiology) and SIAARTI (Italian Society of Anesthesia, Analgesia and Intensive Care).
According to the PNLG (National Plan for GuideLines), the promoter identified a Scientific Board of Experts. The Scientific Board defined methodology, goals and acted as developer and reviewer.
The methodology chosen involved the following steps:
- 1.The Promoters and the Scientific Board selected the main topics of interest: 1. Technique, contraindications, and untoward effects of TIPS, 2. G.I bleeding, 3. Ascites, 4. Vascular disorders, 5. Liver transplantation, 6. Rare indications.
- 2.For each topic a working party was identified by both the Promoters and the Scientific Board, and was composed by a group of at least four experts guided by a chairman. The chairman, together with the promoters and the Scientific Board, selected the relevant clinical questions aiming at focusing on the clinical practice and controversial areas. The questions were circulated within the working groups to refine the topics and to avoid duplications. The members of the working parties were identified on the basis of competence, role, expertise and publication/research in the field of end stage liver diseases and liver transplantation.
- 3.Each working group independently carried out a systematic literature search and review, between October 2014 and May 2015, using Medline/Pub Med to support definitions and statements. Each recommendation was graded according with the Oxford grading system (Appendix 1 in Supplementary material).
- 4.The working groups elaborated the proposed statements, graded according with the selected grading system. They prepared the statements together with the presentation of the literature review for each topic during phone conferences, group meetings and mailing exchange before the Consensus Conference (between February and May 2015).
- 5.The jury members were nowhere involved in the selection, preparation and discussion of the topics and statements prior to the Consensus Conference.
- 6.All the promoters, members of the Scientific board, working groups, and Jury invited to participate to the Consensus conference were asked to declare any potential conflict of interests.
- 7.On June 4th and 5th, 2015 a Consensus Meeting was held in Bergamo. The consensus group consisted of a total of 102 participants (promoters, Scientific Board, Working Groups, and Jury). The jury was selected among Hepatologists, Radiologists, Surgeons, Methodologists, Intensive care physicians, epidemiologists, patient representatives and ethicists. During the first sessions the chairman of each group presented the selected topics and the proposed statements. A general discussion was held in order to refine the. At the end of the general session each group met independently to re-elaborate the final statements to be presented in the voting session according to the advices received by the jury. The final general session consisted in the presentation of the statement by the chairman of each working group, followed by a public vote from the jury. The agreement was reached if over 73% of the voters agreed upon a two-levels score (Agree, Disagree).
- 8.The format of this document, drafted by the writing committee, includes the questions, the statements, the quality comments by the working group chairmen, the percentage of agreement of the jury and the selected references.
SESSION 1—TIPS placement technique
Although no clear definition of technical skills and relative learning curve exists, only a physician with elevated knowledge in both hepatic and cardiopulmonary hemodynamic, should perform TIPS placement [
1
, 2
, 3
, 4
, 5
, 6
, - Boyvat F.
- Aytekin C.
- Harman A.
- et al.
Transjugular intrahepatic portosystemic shunt creation in Budd–Chiari syndrome: percutaneous ultrasound-guided direct simultaneous puncture of the portal vein and vena cava.
Cardiovascular and Interventional Radiology. 2016; 29 ([Internet] Available from: http://www.ncbi.nlm.nih.gov/pubmed/16810460 [cited 15 February 2016]): 857-861
7
].Tabled
1
| Steps required for proper TIPS placement |
|---|
| 1. Creation of a vascular access by the puncture of the internal jugular vein, which must be performed under US guidance [2] . |
| 2. Catheterization of one of the hepatic veins, which can be also punctured percutaneously under real time US guidance when its ostium is not easily accessible [3] . When hepatic veins are occluded (Budd-Chiari syndrome), portal vein branches can be reached by direct puncture from the inferior vena cava 4 , 5 , 6 ,
Transjugular intrahepatic portosystemic shunt creation in Budd–Chiari syndrome: percutaneous ultrasound-guided direct simultaneous puncture of the portal vein and vena cava. Cardiovascular and Interventional Radiology. 2016; 29 ([Internet] Available from: http://www.ncbi.nlm.nih.gov/pubmed/16810460 [cited 15 February 2016]): 857-861 7 , 8 , 9 ,
Transjugular intrahepatic portosystemic shunt for portal vein thrombosis with and without cavernous transformation. Alimentary Pharmacology & Therapeutics. 2006; 23 ([Internet] Available from: http://www.ncbi.nlm.nih.gov/pubmed/16556179 [cited 15 February 2016]): 767-775 10 ,
Transjugular intrahepatic portosystemic shunt placement in patients with cirrhosis and concomitant portal vein thrombosis. Cardiovascular and Interventional Radiology. 2016; 29 ([Internet] Available from: http://www.ncbi.nlm.nih.gov/pubmed/16850140 [cited 15 February 2016]): 785-790 11 . |
| 3. Puncture through the liver parenchyma of one of the main branches of portal vein with or without real time ultrasound guidance [12] . |
| 4. Measurement of the porto-systemic pressure gradient (PPG) by a digital recording system properly set-up for venous pressure 13 , 14 . Inferior vena cava and not right atrium blood pressure should be subtracted to portal vein pressure to calculate the gradient [15] .
Right atrial pressure is not adequate to calculate portal pressure gradient in cirrhosis: a clinical-hemodynamic correlation study. Hepatology. 2010; 51 ([Internet] Available from: http://www.ncbi.nlm.nih.gov/pubmed/20512998http://www.ncbi.nlm.nih.gov/pubmed/9609767 [cited 15 February 2016]): 2108-2116 |
| 5. Balloon dilatation of the parenchymal tract between the hepatic (or inferior vena cava) and portal veins. |
| 6. Deployment of the stent within the parenchymal tract. |
| 7. Hemodynamic assessment of the resultant PPG reduction followed by further balloon dilatation of the lumen to reach the desired target of pressure gradient 14 , 16 . PPG measurement upon recovery from deep sedation should be considered at least in patients with variceal bleeding as an indication 14 , 17 . |
The use of bare metal stents to perform TIPS has been associated with high rates of dysfunction and recurrence of portal hypertension complications [
[14]
]. Stents covered with polytetrafluoroethylene (PTFE—endoprostheses), have proven to warrant long-term patency [[18]
]. Dysfunctions occurring with the use of new generation TIPS sets (early thrombosis, later stenosis) appear to be highly dependent upon the operative skills and the accuracy of placement technique [- Bureau C.
- Pagan J.C.G.
- Layrargues G.P.
- et al.
Patency of stents covered with polytetrafluoroethylene in patients treated by transjugular intrahepatic portosystemic shunts: long-term results of a randomized multicentre study.
Liver International. 2007; 27 ([Internet] Available from: http://www.ncbi.nlm.nih.gov/pubmed/17617116 [cited 15 February 2016]): 742-747
19
, 20
, - Perarnau J.-M.
- Baju A.
- D’alteroche L.
- et al.
Feasibility and long-term evolution of TIPS in cirrhotic patients with portal thrombosis.
European Journal of Gastroenterology & Hepatology. 2010; 22 ([Internet] Available from: http://www.ncbi.nlm.nih.gov/pubmed/20308910 [cited 15 February 2016]): 1093-1098
21
]. Clinical and technical indications, success rates (>90%) and complications (<5%) of TIPS should be monitored periodically in each Center [- Qi X.-S.
- Bai M.
- Yang Z.-P.
- et al.
Selection of a TIPS stent for management of portal hypertension in liver cirrhosis: an evidence-based review.
World Journal of Gastroenterology. 2014; 20 ([Internet] Available from: http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=4047332&tool=pmcentrez&rendertype=abstract [cited 15 February 2016]): 6470-6480
22
, - Krajina A.
- Hulek P.
- Fejfar T.
- et al.
Quality improvement guidelines for transjugular intrahepatic portosystemic shunt (TIPS).
Cardiovascular and Interventional Radiology. 2012; 35 ([Internet] Available from: http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=3501161&tool=pmcentrez&rendertype=abstract [cited 7 January 2016]): 1295-1300
23
].- Marquardt S.
- Rodt T.
- Rosenthal H.
- et al.
Impact of anatomical, procedural, and operator skill factors on the success and duration of fluoroscopy-guided transjugular intrahepatic portosystemic shunt.
Cardiovascular and Interventional Radiology. 2015; 38 ([Internet] Available from: http://www.ncbi.nlm.nih.gov/pubmed/25501265 [cited 15 February 2016]): 903-912
Statements: technical coinsideration and patients selection
1.1. Where should a TIPS procedure be performed and who should do it?
Tabled
1
| Statement 1.1 |
| 1.1a. TIPS should only be performed in tertiary care Centres by interventional radiologists or specially trained physicians experienced in: (a) portal vein catheterization either through a hepatic vein or the inferior vena cava; (b) assessment and interpretation of invasive hepatic and cardiopulmonary hemodynamic; (c) trans catheter embolization, and (d) management of procedural complications (5, D) 15 ,
Right atrial pressure is not adequate to calculate portal pressure gradient in cirrhosis: a clinical-hemodynamic correlation study. Hepatology. 2010; 51 ([Internet] Available from: http://www.ncbi.nlm.nih.gov/pubmed/20512998http://www.ncbi.nlm.nih.gov/pubmed/9609767 [cited 15 February 2016]): 2108-2116 24 , 25 , 26 . |
| 1.1b. The decision to perform a TIPS should be reached by an expert team made of one hepatologist (clinical indication) and an interventional radiologist (technical feasibility); in high risk patients, the decision to place a TIPS should be based on liver transplantation candidacy and a transplant surgeon should also be involved in the evaluation period (5, D) 24 , 27 . |
| 1.1c. Clinical and technical indications, success rates (>90%) and complications (<5%) of TIPS should be monitored periodically in each Center (5, D) 22 ,
Quality improvement guidelines for transjugular intrahepatic portosystemic shunt (TIPS). Cardiovascular and Interventional Radiology. 2012; 35 ([Internet] Available from: http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=3501161&tool=pmcentrez&rendertype=abstract [cited 7 January 2016]): 1295-1300 23 .
Impact of anatomical, procedural, and operator skill factors on the success and duration of fluoroscopy-guided transjugular intrahepatic portosystemic shunt. Cardiovascular and Interventional Radiology. 2015; 38 ([Internet] Available from: http://www.ncbi.nlm.nih.gov/pubmed/25501265 [cited 15 February 2016]): 903-912 |
Votation 1.1: Votes in Favour: 96%.
1.2. Which imaging studies are needed prior to TIPS placement?
Tabled
1
| Statement 1.2 |
| Doppler ultrasonography (Doppler-US) and cross sectional liver imaging by computed tomography (CT) or magnetic resonance (MR) are appropriate to identify anomalies in liver anatomy, to rule out intrahepatic masses, to assess both portal and hepatic vein anatomy and patency and to plan the procedural approach (5, D) 22 ,
Quality improvement guidelines for transjugular intrahepatic portosystemic shunt (TIPS). Cardiovascular and Interventional Radiology. 2012; 35 ([Internet] Available from: http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=3501161&tool=pmcentrez&rendertype=abstract [cited 7 January 2016]): 1295-1300 24 , 25 . |
Votation 1.2: Votes in Favour: 100%.
Comment: Before TIPS placement, a vascular and anatomical study of the liver should be performed in order to assess both technical feasibility and anatomical contraindications to the creation of the shunt. To this end, there is no evidence to support the use of CT or MR rather than Doppler US [
22
, - Krajina A.
- Hulek P.
- Fejfar T.
- et al.
Quality improvement guidelines for transjugular intrahepatic portosystemic shunt (TIPS).
Cardiovascular and Interventional Radiology. 2012; 35 ([Internet] Available from: http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=3501161&tool=pmcentrez&rendertype=abstract [cited 7 January 2016]): 1295-1300
24
, 25
].1.3. Which are the techniques to access the portal vein for TIPS placement?
Tabled
1
| Statement 1.3 |
| 1.3a. The internal jugular vein is the first-choice peripheral vascular access for TIPS placement. For anatomical reasons, the right internal jugular vein is preferred (5, D) [2] . |
| 1.3b. US-guided puncture of the vessel is needed in order to decrease the complications (1a, A) [2] . |
| 1.3c. In case of unsuccessful trans jugular catheterization of the hepatic vein, a US-guided percutaneous puncture of the hepatic vein can be performed (4, C) [3] . |
| 1.3d. In absence of available hepatic veins, a direct puncture from the inferior vena cava can be performed (4, C) 4 , 5 , 6 .
Transjugular intrahepatic portosystemic shunt creation in Budd–Chiari syndrome: percutaneous ultrasound-guided direct simultaneous puncture of the portal vein and vena cava. Cardiovascular and Interventional Radiology. 2016; 29 ([Internet] Available from: http://www.ncbi.nlm.nih.gov/pubmed/16810460 [cited 15 February 2016]): 857-861 |
| 1.3.e. The portal vein should be punctured under real time ultrasound guide to reduce complications due to capsule perforation or accidental puncture of arteries, ectasic bile ducts and masses (cysts, haemangioma, tumours) along the parenchymal tract of TIPS (5,D) 7 , 9 ,
Transjugular intrahepatic portosystemic shunt for portal vein thrombosis with and without cavernous transformation. Alimentary Pharmacology & Therapeutics. 2006; 23 ([Internet] Available from: http://www.ncbi.nlm.nih.gov/pubmed/16556179 [cited 15 February 2016]): 767-775 10 ,
Transjugular intrahepatic portosystemic shunt placement in patients with cirrhosis and concomitant portal vein thrombosis. Cardiovascular and Interventional Radiology. 2016; 29 ([Internet] Available from: http://www.ncbi.nlm.nih.gov/pubmed/16850140 [cited 15 February 2016]): 785-790 12 . |
Votation 1.3: Votes in Favour: 100%.
1.4. Which is the technique for measuring the porto-systemic pressure gradient (PPG)?
Tabled
1
| Statement 1.4 |
| 1.4a. Baseline and post procedural porto-systemic pressure gradient (PPG) should be calculated subtracting the inferior vena cava pressure (measured at the level of the hepatic vein and TIPS outflow level, respectively) to the portal vein pressure (2b, B) 14 , 15 .
Right atrial pressure is not adequate to calculate portal pressure gradient in cirrhosis: a clinical-hemodynamic correlation study. Hepatology. 2010; 51 ([Internet] Available from: http://www.ncbi.nlm.nih.gov/pubmed/20512998http://www.ncbi.nlm.nih.gov/pubmed/9609767 [cited 15 February 2016]): 2108-2116 |
| 1.4b. Deep sedation with propofol and remifentanil adds substantial variability and uncertainty to PPG measurements. This limitation needs to be considered whenever hemodynamic measurements are obtained under this condition (2b, B) [28] . |
| 1.4c. Reduction of PPG to less than 12 mmHg should be achieved when the indication is bleeding from oesophageal varices (1b, A) [14] . This is still an uncertain hemodynamic target in patients with refractory ascites (5, D) 24 , 25 . |
Votation 1.4: Votes in Favour: 100%.
Comment: PPG value after TIPS placement can be underestimated in deep sedated patients: repetition of PPG measurement a few days following the procedure is advisable in case of incomplete clinical response particularly in bleeding patients. [
14
, 28
].1.5. Which types of device are available for TIPS?
Tabled
1
| Statement 1.5 |
| 1.5. Dedicated ePTFE-covered stents should be preferred over bare stents in order to reduce the risk of shunt dysfunction (1b, A) 18 ,
Patency of stents covered with polytetrafluoroethylene in patients treated by transjugular intrahepatic portosystemic shunts: long-term results of a randomized multicentre study. Liver International. 2007; 27 ([Internet] Available from: http://www.ncbi.nlm.nih.gov/pubmed/17617116 [cited 15 February 2016]): 742-747 19 , 20 ,
Feasibility and long-term evolution of TIPS in cirrhotic patients with portal thrombosis. European Journal of Gastroenterology & Hepatology. 2010; 22 ([Internet] Available from: http://www.ncbi.nlm.nih.gov/pubmed/20308910 [cited 15 February 2016]): 1093-1098 29 ,
Comparison of transjugular intrahepatic portosystemic shunt dysfunction in PTFE-covered stent-grafts versus bare stents. European Journal of Radiology. 2005; 55 ([Internet] Available from: http://www.ncbi.nlm.nih.gov/pubmed/15950109 [cited 15 February 2016]): 120-124 30 ,
Patency and clinical outcomes of transjugular intrahepatic portosystemic shunt with polytetrafluoroethylene-covered stents versus bare stents: a meta-analysis. Journal of Gastroenterology and Hepatology. 2010; 25 ([Internet] Available from: http://www.ncbi.nlm.nih.gov/pubmed/21039832 [cited 15 February 2016]): 1718-1725 31 .
Two-stage transjugular intrahepatic porta-systemic shunt for patients with cirrhosis and a high risk of portal-systemic encephalopathy patients as a bridge to orthotopic liver transplantation: a preliminary report. Transplantation Proceedings. 2016; 38 ([Internet] Available from: http://www.ncbi.nlm.nih.gov/pubmed/16504703 [cited 10 February 2016]): 204-208 |
Votation 1.5: Votes in Favour: 100%.
Comment: Two RCTS [
32
, 33
] and a meta-analysis [- Riggio O.
- Ridola L.
- Angeloni S.
- et al.
Clinical efficacy of transjugular intrahepatic portosystemic shunt created with covered stents with different diameters: results of a randomized controlled trial.
Journal of Hepatology. 2010; 53 ([Internet] Available from: http://www.ncbi.nlm.nih.gov/pubmed/20537753 [cited 8 February 2016]): 267-272
[29]
] of six studies (one prospective and five retrospective) comparing TIPS placement with PTFE-covered stents and bare stents for portal hypertension related complications showed that the covered stent was superior in terms of shunt dysfunction (HR=0.28; 95% CI 0.20–0.35).- Barrio J.
- Ripoll C.
- Bañares R.
- et al.
Comparison of transjugular intrahepatic portosystemic shunt dysfunction in PTFE-covered stent-grafts versus bare stents.
European Journal of Radiology. 2005; 55 ([Internet] Available from: http://www.ncbi.nlm.nih.gov/pubmed/15950109 [cited 15 February 2016]): 120-124
1.6. Which is the proper stent diameter for TIPS?
Tabled
1
| Statement 1.6 |
| 1.6a. A step-wise procedure based on the progressive dilation of 10-mm diameter covered stents by using balloon catheters of increasing diameter might be used. The extent of dilation can be considered acceptable when the target PPG is reached (in case of variceal bleeding) (1a, A) [14] or an adequate clinical response is obtained (in case of refractory/recidivant ascites) (4, C) 14 , 25 , 31 ,
Two-stage transjugular intrahepatic porta-systemic shunt for patients with cirrhosis and a high risk of portal-systemic encephalopathy patients as a bridge to orthotopic liver transplantation: a preliminary report. Transplantation Proceedings. 2016; 38 ([Internet] Available from: http://www.ncbi.nlm.nih.gov/pubmed/16504703 [cited 10 February 2016]): 204-208 32 . |
| 1.6b There is not enough evidence to support the use of 10-mm rather than 8-mm nominal diameter PTFE-covered stents aiming to achieve a better control of portal hypertension complications (5, D) 33 ,
Clinical efficacy of transjugular intrahepatic portosystemic shunt created with covered stents with different diameters: results of a randomized controlled trial. Journal of Hepatology. 2010; 53 ([Internet] Available from: http://www.ncbi.nlm.nih.gov/pubmed/20537753 [cited 8 February 2016]): 267-272 34 . |
Votation 1.6: Votes in Favour: 100%.
Comment: A randomized, single centre, open label, active control trial [
[33]
], which was aimed to demonstrate a potential benefit of 8-mm in comparison to 10-mm covered stents in reducing the risk of post-TIPS encephalopathy, was early interrupted after enrolling 39% of the calculated sample size (45 of 114 patients) due to the apparent worse control of ascites in patients treated with smaller stent grafts. Despite that, most operators perform TIPS using a 10mm stent dilated to 8mm (with subsequent calibration up to 10mm depending on post-procedure portocaval gradient) [- Riggio O.
- Ridola L.
- Angeloni S.
- et al.
Clinical efficacy of transjugular intrahepatic portosystemic shunt created with covered stents with different diameters: results of a randomized controlled trial.
Journal of Hepatology. 2010; 53 ([Internet] Available from: http://www.ncbi.nlm.nih.gov/pubmed/20537753 [cited 8 February 2016]): 267-272
3
, 33
, - Riggio O.
- Ridola L.
- Angeloni S.
- et al.
Clinical efficacy of transjugular intrahepatic portosystemic shunt created with covered stents with different diameters: results of a randomized controlled trial.
Journal of Hepatology. 2010; 53 ([Internet] Available from: http://www.ncbi.nlm.nih.gov/pubmed/20537753 [cited 8 February 2016]): 267-272
34
]. A step-wise procedure based on the progressive dilatation of 10mm diameter stents at TIPS positioning or at delayed time points during follow up can be also applied in ascitic patients with the goal to achieve a portal-pressure gradient <12mmHg [14
, 25
] and or an adequate clinical response [31
, - Wróblewski T.
- Rowiński O.
- Ziarkiewicz-Wróblewska B.
- et al.
Two-stage transjugular intrahepatic porta-systemic shunt for patients with cirrhosis and a high risk of portal-systemic encephalopathy patients as a bridge to orthotopic liver transplantation: a preliminary report.
Transplantation Proceedings. 2016; 38 ([Internet] Available from: http://www.ncbi.nlm.nih.gov/pubmed/16504703 [cited 10 February 2016]): 204-208
32
].1.7. Is there a need for US-Doppler follow-up immediately after TIPS placement?
Tabled
1
| Statement 1.7 |
| Doppler-US follow up surveillance should not be routinely performed in properly placed ePTFE-covered stents (4, C) 35 , 36 ,
Role of ultrasound surveillance of transjugular intrahepatic portosystemic shunts in the covered stent era. Journal of Vascular and Interventional Radiology. 2006; 17 ([Internet] Available from: http://www.ncbi.nlm.nih.gov/pubmed/16923976 [cited 8 February 2016]): 1297-1305 37 ,
Comparison study of Doppler ultrasound surveillance of expanded polytetrafluoroethylene-covered stent versus bare stent in transjugular intrahepatic portosystemic shunt. Journal of Clinical Ultrasound. 2010; 38 ([Internet] Available from: http://www.ncbi.nlm.nih.gov/pubmed/20533444 [cited 8 February 2016]): 353-360 38 ,
Is sonographic surveillance of polytetrafluoroethylene-covered transjugular intrahepatic portosystemic shunts (TIPS) necessary? A single centre experience comparing both types of stents. Clinical Radiology. 2008; 63 ([Internet] Available from: http://www.ncbi.nlm.nih.gov/pubmed/18774362 [cited 16 February 2016]): 1142-1148 39 . |
Votation 1.7: Votes in Favour: 87%.
Comment: A single evaluation within the first 7days should be performed when bare metal stents are implanted, technical difficulties occurred or in case of incomplete clinical response. The evaluation of flow direction in the intrahepatic portal vein branches is a reliable qualitative indicator of TIPS malfunction [
35
, 36
, - Carr C.E.
- Tuite C.M.
- Soulen M.C.
- et al.
Role of ultrasound surveillance of transjugular intrahepatic portosystemic shunts in the covered stent era.
Journal of Vascular and Interventional Radiology. 2006; 17 ([Internet] Available from: http://www.ncbi.nlm.nih.gov/pubmed/16923976 [cited 8 February 2016]): 1297-1305
38
, - Pan J.-J.
- Chen C.
- Geller B.
- et al.
Is sonographic surveillance of polytetrafluoroethylene-covered transjugular intrahepatic portosystemic shunts (TIPS) necessary? A single centre experience comparing both types of stents.
Clinical Radiology. 2008; 63 ([Internet] Available from: http://www.ncbi.nlm.nih.gov/pubmed/18774362 [cited 16 February 2016]): 1142-1148
39
].1.8–11. Sedation and patient monitoring
Tabled
1
| Statement 1.8 |
| Monitored anesthesia care (MAC) should be administered by an anaesthesiologist (4, C) [40] . |
Votation 1.8: Votes in Favour: 100%
Tabled
1
| Statement 1.9 |
| Monitored anesthesia care (MAC) and moderate sedation should be adopted as routine procedures during TIPS (4, C) [24] . |
Votation 1.9: Votes in Favour: 96%
Tabled
1
| Statement 1.10 |
| Propofol and remifentanil, which enable a fast recovery after sedation in cirrhotic patients, represent the first choices for sedation or GA (2b, B) 41 , 42 , 43 , 44 .
Gastroenterologist-administered propofol versus meperidine and midazolam for advanced upper endoscopy: a prospective, randomized trial. Gastroenterology. 2002; 123 ([Internet] Available from: http://www.ncbi.nlm.nih.gov/pubmed/12105827 [cited 15 February 2016]): 8-16 |
Votation 1.10: Votes in Favour: 100%
Tabled
1
| Statement 1.11 |
| 1.11a. All patients undergoing general Anesthesia or deep or moderate sedation require continuous monitoring of vital parameters (level of consciousness, ventilation, oxygenation status, and hemodynamic variables) (2a, B) [40] . |
| 1.11b. Patients who have received GA or MAC shall receive appropriate post-Anesthesia care (2b,B) [45] . |
| 1.11c. Discharge of the patients should be upon anaesthesiologist care (4, C) [45] . |
Votation 1.11: Votes in Favour: 100%
Comment: Patients undergoing TIPS placement often present with critical conditions (liver dysfunction, large amount of ascites, recent haemorrhagic shock) with a mental status that can indeed influence the cooperation and the tolerance of the procedure. Moreover TIPS positioning can be an uncomfortable and prolonged procedure requiring analgesics and sedatives administration, which could facilitate the transition to (GA) with or without intention, and could precipitate adverse physiological responses in particularly frail patients [
[45]
].The choice between GA and MAC depends on the patient physical conditions, mental state and ability to collaborate during the procedure. In the absence of randomized controlled trials, GA with endotracheal intubation represents the ideal option for critical patients who are at risk for aspiration during the procedure [
46
, - DeGasperi A.
- Corti A.
- Corso R.
- et al.
Transjugular intrahepatic portosystemic shunt (TIPS): the anesthesiological point of view after 150 procedures managed under total intravenous anesthesia.
Journal of Clinical Monitoring and Computing. 2009; 23 ([Internet] Available from: http://www.ncbi.nlm.nih.gov/pubmed/19844796 [cited 15 February 2016]): 341-346
47
, 48
]. Chronic liver diseases are associated with variable and non-uniform reductions in drug-metabolizing activities. These conditions make it difficult to define the ideal dosages of drugs in cirrhotic patients. To avoid respiratory depression and to reduce their hemodynamic impact, anaesthetic and analgesic drugs used during TIPS placement should be easily titratable and/or rapidly antagonized [22
, - Krajina A.
- Hulek P.
- Fejfar T.
- et al.
Quality improvement guidelines for transjugular intrahepatic portosystemic shunt (TIPS).
Cardiovascular and Interventional Radiology. 2012; 35 ([Internet] Available from: http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=3501161&tool=pmcentrez&rendertype=abstract [cited 7 January 2016]): 1295-1300
40
]. The anaesthetist, depending on the type, will define the frequency of monitoring and its invasiveness and amount of medication administered, the length of the procedure, and the general condition of the patient. Particular attention should be given to monitoring oxygenation, ventilation, circulation, level of consciousness and temperature [45
, 49
].1.12. Which are the contraindications to TIPS positioning?
Tabled
1
| Statements 1.12 |
| 1.12a. The absence of vascular accesses represents the only technical contraindication to TIPS positioning (4, C) [3] . |
| 1.12b. The presence of portal vein thrombosis resulting in a portal cavernoma is not an absolute contraindication in presence of a “portal” landing zone with adequate flow and calibre to receive the device (4, C)* 9 ,
Transjugular intrahepatic portosystemic shunt for portal vein thrombosis with and without cavernous transformation. Alimentary Pharmacology & Therapeutics. 2006; 23 ([Internet] Available from: http://www.ncbi.nlm.nih.gov/pubmed/16556179 [cited 15 February 2016]): 767-775 10 *see statements on PVT
Transjugular intrahepatic portosystemic shunt placement in patients with cirrhosis and concomitant portal vein thrombosis. Cardiovascular and Interventional Radiology. 2016; 29 ([Internet] Available from: http://www.ncbi.nlm.nih.gov/pubmed/16850140 [cited 15 February 2016]): 785-790 |
| 1.12c. Clinical contraindications to TIPS placement are: |
|
Votation 1.12: Votes in Favour: a–b 87%, c 96%.
Comment: Relative technical contraindications are anatomical conditions associated with a reduction in technical success rate or with an increased 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 contraindications. Indeed, in the context of a life threatening condition such as acute variceal bleeding (with a trickier assessment of liver failure), a broader range can be adopted (Child C score <14).
1.13. How to prevent post-TIPS complications (contrast induced nephropathy—CIN)?
Tabled
1
| Statement 1.13 |
| 1.13a. Fluid hydration with normal saline should be considered in patients at risk of renal impairment when undergoing TIPS placement (3, B) |
| 1.13b. The efficacy of NAC or other drugs in reducing the incidence of CIN remains unproven and their use cannot be recommended (1a, A). |
Votation 1.13: Votes in Favour 100%.
Comment: Contrast-induced nephropathy (CIN) identifies an acute renal failure developed after administration of radio contrast in the absence of other identifiable cause. It is defined as an absolute increase of serum creatinine of 0.5mg/d or of 25% from baseline. The rate of CIN is extremely low in patients with eGFR>60ml/min. It increases in patients with pre-existing renal impairment, diabetes, many intra-arterial contrast procedures and eGFR<45ml/m [
51
, 52
]. A cautious use of saline should be made in patients treated by TIPS for recurrent ascites with covert diastolic dysfunction, due to the increased risk of cardiac overload after the procedure.1.14. Is antibiotic prophylaxis required for the prevention of TIPS-related infectious complications?
Tabled
1
| Statement 1.14 |
| 1.14a. Routine antibiotic prophylaxis should not be performed prior to TIPS placement (4, C) [53] .
Risk factors and prevention of early infection after implantation or revision of transjugular intrahepatic portosystemic shunts: results of a randomized study. Digestive Diseases and Sciences. 1998; 43 ([Internet] Available from: http://www.ncbi.nlm.nih.gov/pubmed/9724157 [cited 15 February 2016]): 1708-1713 |
| 1.14b. If long or complex TIPS placement procedure is anticipated (portal vein thrombosis, multiple stenting, trans parietal punctures, etc.), antibiotic prophylaxis (single dose of ceftriaxone or ampicillin/sulbactam) should be considered (5,D) 54 ,
Prevention of infectious complications after transjugular intrahepatic portosystemic shunt in cirrhotic patients with a single dose of ceftriaxone. Hepato-Gastroenterology. 2016; 46 ([Internet] Available from: http://www.ncbi.nlm.nih.gov/pubmed/10370679 [cited 15 February 2016]): 1126-1130 55 ,
Transjugular intrahepatic portosystemic shunt for hepatitis C virus-related portal hypertension after liver transplantation. Clinical Transplantation. 2016; 26 ([Internet] Available from: http://www.ncbi.nlm.nih.gov/pubmed/22360603 [cited 15 February 2016]): 699-705 56 ,
Prophylactic antibiotic guidelines in modern interventional radiology practice. Seminars in Interventional Radiology. 2010; 27 ([Internet] Available from: http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=3324205&tool=pmcentrez&rendertype=abstract [cited 15 February 2016]): 327-337 57 .
Bacteremia and endotipsitis following transjugular intrahepatic portosystemic shunting. World Journal of Hepatology. 2011; 3 ([Internet] Available from: http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=3124881&tool=pmcentrez&rendertype=abstract [cited 15 February 2016]): 130-136 |
Votation 1.14: Votes in Favour: 100%.
Comment: Early events: Bacteriemia after TIPS (defined by fever >38.5°C, or leucocytosis >15.0003 and positive blood cultures) ranges between 2–25% (54–56, 58) and in a prospective RCT was not influenced by antibiotic prophylaxis [
[53]
]. A longer duration of procedure, multiple stenting and the maintenance of a central venous line are associated with a higher risk of infection after TIPS. In patients with uncomplicated procedure, the trans jugular venous access should be removed at the end of the intervention [- Deibert P.
- Schwarz S.
- Olschewski M.
- et al.
Risk factors and prevention of early infection after implantation or revision of transjugular intrahepatic portosystemic shunts: results of a randomized study.
Digestive Diseases and Sciences. 1998; 43 ([Internet] Available from: http://www.ncbi.nlm.nih.gov/pubmed/9724157 [cited 15 February 2016]): 1708-1713
53
, - Deibert P.
- Schwarz S.
- Olschewski M.
- et al.
Risk factors and prevention of early infection after implantation or revision of transjugular intrahepatic portosystemic shunts: results of a randomized study.
Digestive Diseases and Sciences. 1998; 43 ([Internet] Available from: http://www.ncbi.nlm.nih.gov/pubmed/9724157 [cited 15 February 2016]): 1708-1713
57
]. A single dose of long acting cephalosporin reduces the incidence of bacterial infection (20–2.6%) justifying its use in anticipated complex procedures [- Mizrahi M.
- Roemi L.
- Shouval D.
- et al.
Bacteremia and endotipsitis following transjugular intrahepatic portosystemic shunting.
World Journal of Hepatology. 2011; 3 ([Internet] Available from: http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=3124881&tool=pmcentrez&rendertype=abstract [cited 15 February 2016]): 130-136
[54]
]. Late events: Endotipsitis is defined by the presence of sustained bacteriemia associated with the evidence of thrombus or vegetations inside the TIPS. This clinical condition is rare (1%). Early endotipsitis (<120days 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 [- Gulberg V.
- Deibert P.
- Ochs A.
- et al.
Prevention of infectious complications after transjugular intrahepatic portosystemic shunt in cirrhotic patients with a single dose of ceftriaxone.
Hepato-Gastroenterology. 2016; 46 ([Internet] Available from: http://www.ncbi.nlm.nih.gov/pubmed/10370679 [cited 15 February 2016]): 1126-1130
[58]
]. In patients with uncontrolled or recurrent infection liver transplant should be considered [- Navaratnam A.M.
- Grant M.
- Banach D.B.
Endotipsitis: a case report with a literature review on an emerging prosthetic related infection.
World Journal of Hepatology. 2015; 7 ([Internet] Available from: http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=4388999&tool=pmcentrez&rendertype=abstract [cited 15 February 2016]): 710-716
[59]
]. There is no evidence for adopting long-term prophylaxis for the prevention of endotipsitis.1.15. Are blood products routinely required during TIPS placement?
Tabled
1
| Statement 1.15 |
| 1.15a. Fresh frozen plasma, or pro-haemostatic agents are not required in cirrhotic patients undergoing TIPS, irrespective of INR value (2a, C) 60 , 61 .
Paucity of studies to support that abnormal coagulation test results predict bleeding in the setting of invasive procedures: an evidence-based review. Transfusion. 2005; 45 ([Internet] Available from: http://www.ncbi.nlm.nih.gov/pubmed/16131373 [cited 15 February 2016]): 1413-1425 |
| 1.15b. Although the threshold of platelet count needed to ensure normal primary haemostasis in cirrhosis is not clearly defined, the 50 × 109/l cut-off can be utilized for platelets infusion before TIPS (4, C) [62] . |
Votation 1.15: Votes in Favour: 100%.
Comment: A specific evaluation of the bleeding risk in patients undergoing TIPS has never been reported. In cirrhotics, routine coagulation tests cannot define the coagulation status and the bleeding risk. Several observational and randomized placebo-controlled studies have shown that prothrombin time (PT) is a poor predictor of peri- or post-operative bleeding in patients with cirrhosis [
60
, 61
, - Segal J.B.
- Dzik W.H.
Paucity of studies to support that abnormal coagulation test results predict bleeding in the setting of invasive procedures: an evidence-based review.
Transfusion. 2005; 45 ([Internet] Available from: http://www.ncbi.nlm.nih.gov/pubmed/16131373 [cited 15 February 2016]): 1413-1425
63
]. In most invasive procedures, a 50×109/l platelets cut-off is utilized for defining the need for blood product to correct preoperative laboratory values. However, the proper cut-off number for platelets has never been identified (even though a number >60×109/l has been proven adequate, but in experimental models only [- Bendtsen F.
- D’Amico G.
- Rusch E.
- et al.
Effect of recombinant factor VIIa on outcome of acute variceal bleeding: an individual patient based meta-analysis of two controlled trials.
Journal of Hepatology. 2014; 61 ([internet] Available from: http://www.ncbi.nlm.nih.gov/pubmed/24713188 [cited 16 February 2016]): 252-259
62
, 64
]. Close monitoring for evidence of bleeding during the procedure rather than a prophylactic attitude represents the most adequate approach.- Giannini E.G.
- Greco A.
- Marenco S.
- et al.
Incidence of bleeding following invasive procedures in patients with thrombocytopenia and advanced liver disease.
Clinical Gastroenterology and Hepatology. 2010; 8 (quiz e109. [Internet] Available from: http://www.ncbi.nlm.nih.gov/ubmed/20601131 [cited 15 February 2016]): 899-902
Cardiac dysfunction
1.16. Which is the role of pulmonary arterial hypertension (PAH) and how to perform a pre-TIPS cardiac assessment and?
Tabled
1
| Statement 1.16 |
| 1.16a. Doppler echocardiography (ECHO) is suggested IN ALL CANDIDATES TO TIPS (5, D) 65 ,
Cirrhotic cardiomyopathy: a cardiologist’s perspective. World Journal of Gastroenterology. 2014; 20 ([Internet] Available from: http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=4229515&tool=pmcentrez&rendertype=abstract [cited 15 February 2016]): 15492-15498 66 ,
Diastolic dysfunction is a predictor of poor outcomes in patients with cirrhosis, portal hypertension, and a normal creatinine. Hepatology. 2013; 58 ([Internet] Available from: http://www.ncbi.nlm.nih.gov/pubmed/23703953 [cited 15 February 2016]): 1732-1741 67 , 68 ,
LEFT ventricular function assessed by echocardiography in cirrhosis: relationship to systemic hemodynamics and renal dysfunction. Journal of Hepatology. 2013; 58 ([Internet] Available from: http://www.ncbi.nlm.nih.gov/pubmed/22989573 [cited 15 February 2016]): 51-57 69 . |
| 1.16b. A systolic pulmonary artery pressure (sPAP) > 50 mmHg at ECHO or history of congestive heart failure, tricuspid regurgitation and cardiomyopathy justify the execution of a right heart catheterization (RHC) to confirm and properly define pulmonary hypertension (PAH): |
|
Votation 1.16. Votes in Favour: 100%.
Comment: New-onset chronic cardiac dysfunction have been recognized in cirrhotic patients in the absence of known cardiac disease, irrespective of the aetiology of cirrhosis and related, at least in part, to the hyper dynamic circulation [
68
, - Nazar A.
- Guevara M.
- Sitges M.
- et al.
LEFT ventricular function assessed by echocardiography in cirrhosis: relationship to systemic hemodynamics and renal dysfunction.
Journal of Hepatology. 2013; 58 ([Internet] Available from: http://www.ncbi.nlm.nih.gov/pubmed/22989573 [cited 15 February 2016]): 51-57
75
]. The disease is generally unapparent at rest and becomes manifest under pharmacogical or physical stress as infection, haemorrhage, large volume paracentesis, and exercise. Left ventricular (diastolic) dysfunction may be a significant factor in the development of ascites and hepatorenal syndrome [65
, - Gassanov N.
- Caglayan E.
- Semmo N.
- et al.
Cirrhotic cardiomyopathy: a cardiologist’s perspective.
World Journal of Gastroenterology. 2014; 20 ([Internet] Available from: http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=4229515&tool=pmcentrez&rendertype=abstract [cited 15 February 2016]): 15492-15498
66
, - Ruíz-del-Árbol L.
- Achécar L.
- Serradilla R.
- et al.
Diastolic dysfunction is a predictor of poor outcomes in patients with cirrhosis, portal hypertension, and a normal creatinine.
Hepatology. 2013; 58 ([Internet] Available from: http://www.ncbi.nlm.nih.gov/pubmed/23703953 [cited 15 February 2016]): 1732-1741
68
, - Nazar A.
- Guevara M.
- Sitges M.
- et al.
LEFT ventricular function assessed by echocardiography in cirrhosis: relationship to systemic hemodynamics and renal dysfunction.
Journal of Hepatology. 2013; 58 ([Internet] Available from: http://www.ncbi.nlm.nih.gov/pubmed/22989573 [cited 15 February 2016]): 51-57
77
, - Rabie R.N.
- Cazzaniga M.
- Salerno F.
- et al.
The use of E/A ratio as a predictor of outcome in cirrhotic patients treated with transjugular intrahepatic portosystemic shunt.
The American Journal of Gastroenterology. 2009; 104 ([Internet] Available from: http://www.ncbi.nlm.nih.gov/pubmed/19532126 [cited 15 February 2016]): 2458-2466
78
] as well as pulmonary arterial hypertension (PAH, defined as mPAP ≥25mmHg). This condition is not infrequent in cirrhotic patients with portal hypertension (up to 16% in transplant candidates).- Cazzaniga M.
- Salerno F.
- Pagnozzi G.
- et al.
Diastolic dysfunction is associated with poor survival in patients with cirrhosis with transjugular intrahepatic portosystemic shunt.
Gut. 2007; 56 ([Internet] Available from: http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=1954837&tool=pmcentrez&rendertype=abstract [cited 15 February 2016]): 869-875
The incidence of cardiac dysfunction after TIPS is unknown and no reliable predictors are available at the individual patient level. Pulmonary oedema occurs in 10-12% of patients receiving TIPS for ascites and some cases of ascites recurrence after TIPS may be due to heart failure rather than portal hypertension [
66
, - Ruíz-del-Árbol L.
- Achécar L.
- Serradilla R.
- et al.
Diastolic dysfunction is a predictor of poor outcomes in patients with cirrhosis, portal hypertension, and a normal creatinine.
Hepatology. 2013; 58 ([Internet] Available from: http://www.ncbi.nlm.nih.gov/pubmed/23703953 [cited 15 February 2016]): 1732-1741
68
, - Nazar A.
- Guevara M.
- Sitges M.
- et al.
LEFT ventricular function assessed by echocardiography in cirrhosis: relationship to systemic hemodynamics and renal dysfunction.
Journal of Hepatology. 2013; 58 ([Internet] Available from: http://www.ncbi.nlm.nih.gov/pubmed/22989573 [cited 15 February 2016]): 51-57
75
, 77
, - Rabie R.N.
- Cazzaniga M.
- Salerno F.
- et al.
The use of E/A ratio as a predictor of outcome in cirrhotic patients treated with transjugular intrahepatic portosystemic shunt.
The American Journal of Gastroenterology. 2009; 104 ([Internet] Available from: http://www.ncbi.nlm.nih.gov/pubmed/19532126 [cited 15 February 2016]): 2458-2466
78
].- Cazzaniga M.
- Salerno F.
- Pagnozzi G.
- et al.
Diastolic dysfunction is associated with poor survival in patients with cirrhosis with transjugular intrahepatic portosystemic shunt.
Gut. 2007; 56 ([Internet] Available from: http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=1954837&tool=pmcentrez&rendertype=abstract [cited 15 February 2016]): 869-875
From the haemodynamic stand point, liver transplantation shares similarities with TIPS. Data from liver transplantation indicate that severe pulmonary arterial hypertension is an absolute contraindication because of poor outcome [
71
, 72
, 73
]. In this setting, moderate or severe PAH is expected when sPAP by ECHO is >50mmHg. Therefore, a sPAP greater than 50mmHg at ECHO represents the cut-off point for executing a RHC. At RHC, a mPAP greater than 45mmHg represents a contraindication to TIPS [24
, 70
, 71
, 72
, 73
, 74
, 79
].- Krowka M.J.
- Fallon M.B.
- Kawut S.M.
- et al.
International Liver Transplant Society practice guidelines: diagnosis and management of hepatopulmonary syndrome and portopulmonary hypertension.
Transplantation. 2016; 100 ([Internet] Available from: http://www.ncbi.nlm.nih.gov/pubmed/27326810 [cited 15 February 2016]): 1440-1452
1.17. Is there a risk for hepatic encephalopathy after TIPS?
Tabled
1
| Statement 1.17 |
| TIPS is associated to an increased incidence of severe HE. (1a) Thus, the risk factors for HE should be always considered before TIPS placement (A)(Table 1). |
Votation 1.17: Votes in Favour: 100%.
Table 1Main risk factors for post-TIPS HE.
|
a Child A risk of HE close to 0, in Child B up to 33%, in Child C up to 89%.
Comment: Hepatic encephalopathy (HE) is one of the major complications of TIPS. Notwithstanding, scarce are the studies directly aiming at the assessment of HE in relation to TIPS placement. Bearing in mind these limitations, 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% [
[80]
] and that of de-novo, covert HE around 35% [- Riggio O.
- Angeloni S.
- Salvatori F.M.
- et al.
Incidence, natural history, and risk factors of hepatic encephalopathy after transjugular intrahepatic portosystemic shunt with polytetrafluoroethylene-covered stent grafts.
The American Journal of Gastroenterology. 2008; 103 ([Internet] Available from: http://www.ncbi.nlm.nih.gov/pubmed/18775022 [cited 15 February 2016]): 2738-2746
14
, 26
, 81
, - Nolte W.
- Wiltfang J.
- Schindler C.
- et al.
Portosystemic hepatic encephalopathy after transjugular intrahepatic portosystemic shunt in patients with cirrhosis: clinical, laboratory, psychometric, and electroencephalographic investigations.
Hepatology. 1998; 28 ([Internet] Available from: http://www.ncbi.nlm.nih.gov/pubmed/9794904 [cited 15 February 2016]): 1215-1225
82
, - Berlioux P.
- Robic M.A.
- Poirson H.
- 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; 59 ([Internet] Available from: http://www.ncbi.nlm.nih.gov/pubmed/24620380 [cited 15 February 2016]): 622-629
83
, 84
, 85
, - Kim H.K.
- Kim Y.J.
- Chung W.J.
- et al.
Clinical outcomes of transjugular intrahepatic portosystemic shunt for portal hypertension: Korean multicenter real-practice data.
Clinical and Molecular Hepatology. 2014; 20 ([Internet] Available from: http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=3992326&tool=pmcentrez&rendertype=abstract [cited 15 February 2016]): 18-27
86
, - Bai M.
- Qi X.-S.
- Yang Z.-P.
- et al.
TIPS improves liver transplantation-free survival in cirrhotic patients with refractory ascites: an updated meta-analysis.
World Journal of Gastroenterology. 2014; 20 ([Internet] Available from: http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=3949280&tool=pmcentrez&rendertype=abstract [cited 15 February 2016]): 2704-2714
87
, 88
].- Riggio O.
- Masini A.
- Efrati C.
- et al.
Pharmacological prophylaxis of hepatic encephalopathy after transjugular intrahepatic portosystemic shunt: a randomized controlled study.
Journal of Hepatology. 2005; 42 ([Internet] Available from: http://www.ncbi.nlm.nih.gov/pubmed/15826716 [cited 15 February 2016]): 674-679
1.18. Is there a need for routine prophylaxis of hepatic encephalopathy post TIPS placement?
Tabled
1
| Statement 1.18 |
| 1.18a. Prophylaxis of post-TIPS HE with either lactulose or rifaximin is not routinely recommended (1b) [88] .
Pharmacological prophylaxis of hepatic encephalopathy after transjugular intrahepatic portosystemic shunt: a randomized controlled study. Journal of Hepatology. 2005; 42 ([Internet] Available from: http://www.ncbi.nlm.nih.gov/pubmed/15826716 [cited 15 February 2016]): 674-679 |
| 1.18b. Stent lumen reduction or occlusion is effective in case of persistent overt post-TIPS HE (2b, B) 89 ,
Management of refractory hepatic encephalopathy after insertion of TIPS: long-term results of shunt reduction with hourglass-shaped balloon-expandable stent-graft. American Journal of Roentgenology. 2009; 193 ([Internet] Available from: http://www.ncbi.nlm.nih.gov/pubmed/19933667 [cited 15 February 2016]): 1696-1702 90 .
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; 60 ([Internet] Available from: http://www.ncbi.nlm.nih.gov/ubmed/25042402 [cited 15 February 2016]): 715-735 |
Votation 1.18: Votes in Favour: 100%.
Comment: The diagnosis and the treatment of post-TIPS overt and covert HE is not different from that of overt or covert HE occurring independently of the procedure and should be performed according to the joint EASL/AASLD guidelines. Stent lumen reduction/occlusion should be performed only in case of persistent overt HE [
89
, - Fanelli F.
- Salvatori F.M.
- Rabuffi 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.
American Journal of Roentgenology. 2009; 193 ([Internet] Available from: http://www.ncbi.nlm.nih.gov/pubmed/19933667 [cited 15 February 2016]): 1696-1702
90
, - Vilstrup H.
- Amodio P.
- Bajaj J.
- 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; 60 ([Internet] Available from: http://www.ncbi.nlm.nih.gov/ubmed/25042402 [cited 15 February 2016]): 715-735
91
].- Bai M.
- Qi X.
- Yang Z.
- et al.
Predictors of hepatic encephalopathy after transjugular intrahepatic portosystemic shunt in cirrhotic patients: a systematic review.
Journal of Gastroenterology and Hepatology. 2011; 26 ([Internet] Available from: http://www.ncbi.nlm.nih.gov/pubmed/21251067 [cited 15 February 2016]): 943-951
SESSION 2: TIPS for portal hypertension complications: portal hypertension-related bleeding in cirrhotic patients
The management of bleeding complications differs according to severity of the underlying liver disease and the stage of PH, ranging from primary prophylaxis of variceal bleeding to treatments aimed at controlling acute variceal bleeding or to prevent rebleeding. HVPG measurements in these settings has clearly been established as a clinically relevant diagnostic and prognostic tool [
[92]
]. The management of PH-related bleeding in cirrhotic patients includes endoscopic techniques, vasoactive drugs (somatostatin and vasopressin analogues), and TIPS.- de Franchis R.
Expanding consensus in portal hypertension report of the Baveno VI Consensus Workshop: stratifying risk and individualizing care for portal hypertension.
Journal of Hepatology. 2015; 63 ([Internet] Available from: http://www.ncbi.nlm.nih.gov/pubmed/26047908 [cited 15 February 2016]): 743-752
2.1. Is TIPS indicated for primary prophylaxis of first variceal bleeding?
Tabled
1
| Statement 2.1. |
| 2.12 TIPS is not indicated for the prophylaxis of first variceal bleeding (1a,A) |
Votation: 2.1 Votes in Favour 100%).
Comment: The incidence of first bleeding in cirrhotic patients with oesophageal varices (EV) ranges from 5% to 15% per year and the associated mortality is about 15–20%. A meta-analysis of shunt surgery trials has conclusively shown an unacceptable burden of mortality and HE [
[93]
] in primary prophylaxis. Until RCTs are available for TIPS in this setting, results from derivative surgery must be extrapolated to percutaneous shunting as primary prophylaxis [[24]
].2.2. How should acute bleeding treatment failure be managed?
Tabled
1
| Statement 2.2 |
| 2.2a. Persistent bleeding and rebleeding taking place within the first five days from the index bleeding, despite appropriate combined pharmacological and endoscopic treatments, should be managed by covered-TIPS (2b,B). |
Votation 2.2 Votes in Favour 91%.
Comment: Variceal bleeding is unresponsive to initial combined pharmacological and endoscopic treatments in 10–20% of cirrhotic patients. If treatment failure leads to mild bleeding and the patient is stable, a further endoscopic haemostasis may be attempted. In case of severe bleeding, derivative treatment must be considered [
92
, - de Franchis R.
Expanding consensus in portal hypertension report of the Baveno VI Consensus Workshop: stratifying risk and individualizing care for portal hypertension.
Journal of Hepatology. 2015; 63 ([Internet] Available from: http://www.ncbi.nlm.nih.gov/pubmed/26047908 [cited 15 February 2016]): 743-752
94
, - Sanyal A.J.
- Freedman A.M.
- Luketic V.A.
- et al.
Transjugular intrahepatic portosystemic shunts for patients with active variceal hemorrhage unresponsive to sclerotherapy.
Gastroenterology. 1996; 111 ([Internet] Available from: http://www.ncbi.nlm.nih.gov/pubmed/8698192 [cited 15 February 2016]): 138-146
95
, - Azoulay D.
- Castaing D.
- Majno P.
- et al.
Salvage transjugular intrahepatic portosystemic shunt for uncontrolled variceal bleeding in patients with decompensated cirrhosis.
J Hepatol [Internet]. 2001; 35 ([Internet] Available from: http://www.ncbi.nlm.nih.gov/pubmed/11690704 [cited 15 February 2016]): 590-597
96
, 97
]. Both TIPS and surgical shunts are extremely effective in controlling variceal bleeding (control rate approaching 95%). TIPS represents the first choice due to the intolerable surgical risk in decompensated cirrhotic patients [18
, - Bureau C.
- Pagan J.C.G.
- Layrargues G.P.
- et al.
Patency of stents covered with polytetrafluoroethylene in patients treated by transjugular intrahepatic portosystemic shunts: long-term results of a randomized multicentre study.
Liver International. 2007; 27 ([Internet] Available from: http://www.ncbi.nlm.nih.gov/pubmed/17617116 [cited 15 February 2016]): 742-747
98
]. Regrettably, following development of systemic complications or deterioration of liver function, mortality remains high even when TIPS is applied as a rescue therapy. Prognostic scores are helpful in the decision-making in order to accelerate TIPS referral in high-risk subjects [- Henderson J.M.
- Boyer T.D.
- Kutner M.H.
- et al.
Distal splenorenal shunt versus transjugular intrahepatic portal systematic shunt for variceal bleeding: a randomized trial.
Gastroenterology. 2006; 130 ([Internet] Available from: http://www.ncbi.nlm.nih.gov/pubmed/16697728 [cited 15 February 2016]): 1643-1651
[99]
] before a further deterioration of the patient’s clinical status occurs, affecting the outcome of derivative treatments. In more compromised cases it is advisable to perform TIPS in accordance with the liver transplantation team.- Patch D.
- Nikolopoulou V.
- McCormick A.
- et al.
Factors related to early mortality after transjugular intrahepatic portosystemic shunt for failed endoscopic therapy in acute variceal bleeding.
Journal of Hepatology. 1998; 28 ([Internet] Available from: http://www.ncbi.nlm.nih.gov/pubmed/9551684 [cited 15 February 2016]): 454-460
2.3. Which is the role of “early TIPS” in acute bleeding high-risk patients?
Tabled
1
| Statement 2.3 |
| Early TIPS (within 72 h, ideally ≤24 h from bleeding, and after initial combined pharmacological and endoscopic therapy) is effective in controlling bleeding from EV, GOV1* and 2 in patients at high risk of treatment failure defined as: |
|
| GOV1* and 2: gastro-oesophageal varices type 1 and 2. |
Votation 2.3 Votes in Favour 100%.
Comment: Available RCTs support the role of TIPS in patients with a high risk of treatment failure. Patients with HVPG levels >20mmHg recorded within 24h from bleeding [
[100]
] or in a Child-Pugh class C (<14 points) or actively bleeding at index endoscopy and in Child-Pugh class B [- Abraldes J.G.
- Villanueva C.
- Bañares R.
- et al.
Hepatic venous pressure gradient and prognosis in patients with acute variceal bleeding treated with pharmacologic and endoscopic therapy.
Journal of Hepatology. 2008; 48 ([Internet] Available from: http://www.ncbi.nlm.nih.gov/pubmed/18093686 [cited 15 February 2016]): 229-236
[101]
] have been suggested to have a poor outcome. In such high-risk subjects [[101]
] receiving TIPS within 72h from bleeding, failure to control bleeding or to prevent rebleeding and mortality were significantly lower (3% vs. 45% and 13% vs. 39% at 1year, respectively) without an increased risk of HE [102
, 103
, - Thabut D.
- Rudler M.
- Lebrec D.
Early TIPS with covered stents in high-risk patients with cirrhosis presenting with variceal bleeding: are we ready to dive into the deep end of the pool?.
Journal of Hepatology. 2011; 55 ([Internet] Available from: http://www.ncbi.nlm.nih.gov/pubmed/21708107 [cited 15 February 2016]): 1148-1149
104
]. However, in recent surveillance studies, a survival benefit was not observed [102
, 105
], although it approached statistical significance in one [- Rudler M.
- Cluzel P.
- Corvec T.L.
- et al.
Early-TIPSS placement prevents rebleeding in high-risk patients with variceal bleeding, without improving survival.
Alimentary Pharmacology & Therapeutics. 2014; 40 ([Internet] Available from: http://www.ncbi.nlm.nih.gov/pubmed/25230051 [cited 15 February 2016]): 1074-1080
[101]
].2.4. Which is the role of TIPS in failure of secondary prophylaxis of variceal bleeding?
Tabled
1
| Statement 2.4 |
| In patients rebleeding despite an appropriate combined therapy (pharmacological* + endoscopic treatment**): |
| 2.4a. Covered TIPS is the treatment of choice to prevent EV rebleeding (2b,B). |
| 2.4b. TIPS may be used as a bridge treatment in patients eligible/listed for liver transplantation (4,C). |
| 2.4c. TIPS is effective in the prevention of bleeding recurrence from GV and should be considered in this setting (2b,B). |
| 2.4d. Balloon-Occluded Retrograde Trans venous Obliteration (BRTO) may be employed for uncontrolled bleeding or rebleeding from gastric varices (GV), in the presence of contraindication(s) to TIPS, and/or more compromised liver function (5,D). |
| 2.4e. TIPS can be considered in patients with transfusion-dependent Portal Hypertensive Gastropathy (PHG), when NSBBs and/or endoscopic treatments fail (4,C). |
| 2.4f. TIPS with or without embolization of the feeding vessel(s) may be employed for uncontrolled bleeding or rebleeding from ectopic varices (4,C). |
| *NSBBs with or without 5-ISMN. |
| **Oesophageal varices: endoscopic variceal ligation (EVL); Gastric varices: glue injection |
Votation 2.4 Votes in Favour 95%.
Comment: Patients surviving a first variceal bleeding episode have a two-year rebleeding risk of over 60% [
100
, - Abraldes J.G.
- Villanueva C.
- Bañares R.
- et al.
Hepatic venous pressure gradient and prognosis in patients with acute variceal bleeding treated with pharmacologic and endoscopic therapy.
Journal of Hepatology. 2008; 48 ([Internet] Available from: http://www.ncbi.nlm.nih.gov/pubmed/18093686 [cited 15 February 2016]): 229-236
106
]. First-line therapy (FLT) is based on both NSBBs and EVL. RCT comparing TIPS to FLT, even if inhomogeneous, agreed that TIPS is highly effective in preventing rebleeding, although with a significantly burden of HE, but it did not improve overall mortality [107
, 108
, - Papatheodoridis G.V.
- Goulis J.
- Leandro G.
- et al.
Transjugular intrahepatic portosystemic shunt compared with endoscopic treatment for prevention of variceal rebleeding: a meta-analysis.
Hepatology. 1999; 30 ([Internet] Available from: http://www.ncbi.nlm.nih.gov/pubmed/10462365 [cited 15 February 2016]): 612-622
109
].- Zheng M.
- Chen Y.
- Bai J.
- et al.
Transjugular intrahepatic portosystemic shunt versus endoscopic therapy in the secondary prophylaxis of variceal rebleeding in cirrhotic patients: meta-analysis update.
Journal of Clinical Gastroenterology. 2016; 42 ([Internet] Available from: http://www.ncbi.nlm.nih.gov/pubmed/18344888 [cited 15 February 2016]): 507-516
The lack of survival benefit following TIPS may be dependent on clinical deterioration in patients with recurrent bleeding and sequential treatments. Hemodynamic non-responders to secondary FLT should be considered earlier for TIPS. Preliminary, albeit uncontrolled, data indicate that allocation of these patients to TIPS reduces rebleeding rate and bleeding-associated mortality [
5
, 97
, 106
, 110
, - García-Pagán J.C.
- Villanueva C.
- Albillos A.
- et al.
Nadolol plus isosorbide mononitrate alone or associated with band ligation in the prevention of recurrent bleeding: a multicentre randomised controlled trial.
Gut. 2009; 58 ([Internet] Available from: http://www.ncbi.nlm.nih.gov/pubmed/19218249 [cited 15 February 2016]): 1144-1150
111
, 112
, - Matos R.C.
- Lapaque N.
- Rigottier-Gois L.
- et al.
Enterococcus faecalis prophage dynamics and contributions to pathogenic traits.
PLoS Genetics. 2013; 9 ([Internet] Available from: http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=3675006&tool=pmcentrez&rendertype=abstract [cited 15 February 2016]): e1003539
113
].- Sauerbruch T.
- Mengel M.
- Dollinger M.
- et al.
Prevention of rebleeding from esophageal varices in patients with cirrhosis receiving small-diameter stents versus hemodynamically controlled medical therapy.
Gastroenterology. 2015; 149 (e1. [Internet] Available from: http://www.ncbi.nlm.nih.gov/pubmed/25989386 [cited 16 February 2016]): 660-668
Bleeding episodes from GV occur at lower HVPG levels and tend to be worse in respect to those occurring from EV and require significantly more transfusions [
[114]
]. Although the available literature on GV bleeding is not as robust as the one for EV, all studies comparing TIPS vs. cyanoacrylate in bleeding GV demonstrated a significantly higher success rate in the TIPS group, with a greater burden of HE in derived subjects [14
, 115
, - Tripathi D.
- Therapondos G.
- Redhead D.N.
- et al.
Transjugular intrahepatic portosystemic stent-shunt and its effects on orthotopic liver transplantation.
European Journal of Gastroenterology & Hepatology. 2002; 14 ([Internet] Available from: http://www.ncbi.nlm.nih.gov/pubmed/12172401 [cited 15 February 2016]): 827-832
116
, - Mahadeva S.
- Bellamy M.C.
- Kessel D.
- et al.
Cost-effectiveness of N-butyl-2-cyanoacrylate (histoacryl) glue injections versus transjugular intrahepatic portosystemic shunt in the management of acute gastric variceal bleeding.
American Journal of Gastroenterology. 2003; 98 ([Internet] Available from: http://www.ncbi.nlm.nih.gov/pubmed/14687818[cited 15 February 2016]): 2688-2993
117
, - Procaccini N.J.
- Al-Osaimi A.M.S.
- Northup P.
- et al.
Endoscopic cyanoacrylate versus transjugular intrahepatic portosystemic shunt for gastric variceal bleeding: a single-center U.S. analysis.
Gastrointestinal Endoscopy. 2009; 70 ([Internet] Available from: http://www.ncbi.nlm.nih.gov/pubmed/19559425 [cited 15 February 2016]): 881-887
118
, - 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 ([Internet] Available from: http://www.ncbi.nlm.nih.gov/pubmed/17661241 [cited 15 February 2016]): 679-685
119
, 120
, 121
, 122
, - Stanley A.J.
- Jalan R.
- Ireland H.M.
- et al.
A comparison between gastric and oesophageal variceal haemorrhage treated with transjugular intrahepatic portosystemic stent shunt (TIPSS).
Alimentary Pharmacology & Therapeutics. 1997; 11 ([Internet] Available from: http://www.ncbi.nlm.nih.gov/pubmed/9042990 [cited 15 February 2016]): 171-176
123
]; In patients with large gastro renal shunts and contraindications to TIPS (e.g. elderly patients or patients with refractory encephalopathy or more compromised liver function) BRTO may be considered for the treatment of GV bleeding [- Kochhar G.S.
- Navaneethan U.
- Hartman J.
- et al.
Comparative study of endoscopy vs. transjugular intrahepatic portosystemic shunt in the management of gastric variceal bleeding.
Gastroenterology Reports. 2015; 3 ([Internet] Available from: http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=4324874&tool=pmcentrez&rendertype=abstract [cited 15 February 2016]): 75-82
124
, 125
, - Saad W.E.A.
- Darcy M.D.
Transjugular intrahepatic portosystemic shunt (TIPS) versus balloon-occluded retrograde transvenous obliteration (BRTO) for the management of gastric varices.
Seminars in Interventional Radiology. 2011; 28 ([Internet] Available from: http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=3312168&tool=pmcentrez&rendertype=abstract [cited 15 February 2016]): 339-349
126
, 127
, 128
].- 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.
Journal of Vascular and Interventional Radiology. 2014; 25 ([Internet] Available from: http://www.ncbi.nlm.nih.gov/pubmed/24468043 [cited 15 February 2016]): 355-361
PHG is mainly detected in patients with more advanced liver disease and in those previously receiving endoscopic haemostatic treatment for EV and GV (prevalence 11–80%) [
129
, 130
]. Incidence of acute bleeding and related mortality are quite low (3% and 12.5% at three years, respectively) [- Mezawa S.
- Homma H.
- Ohta H.
- et al.
Effect of transjugular intrahepatic portosystemic shunt formation on portal hypertensive gastropathy and gastric circulation.
American Journal of Gastroenterology. 2001; 96 ([Internet] Available from: http://www.ncbi.nlm.nih.gov/pubmed/11316163 [cited 15 February 2016]): 1155-1159
131
, - Salerno F.
- Merli M.
- Riggio O.
- Cazzaniga M.
- Valeriano V.
- Pozzi M.
- et al.
Randomized controlled study of TIPS versus paracentesis plus albumin in cirrhosis with severe ascites.
Hepatology. 2004; 40 ([Internet] Available from: http://www.ncbi.nlm.nih.gov/pubmed/15349901 [cited 12 February 2016]): 629-635
132
, 133
]. Therefore, TIPS is unlikely to be proposed to these subjects. Nonetheless, patients in whom PHG causes both chronic and significant blood losses (requiring repeated transfusions), could be considered for TIPS [- Primignani M.
- Carpinelli L.
- Preatoni P.
- et al.
Natural history of portal hypertensive gastropathy in patients with liver cirrhosis. The New Italian Endoscopic Club for the study and treatment of esophageal varices (NIEC).
Gastroenterology. 2000; 119 ([Internet] Available from: http://www.ncbi.nlm.nih.gov/ubmed/10889167 [cited 15 February 2016]): 181-187
134
, 135
].GAVE is a rare finding in patients with PH (2%-3% incidence), which is not the leading pathogenic mechanism. Accordingly, GAVE is unresponsive to derivative treatment [
135
, 136
, - Ward E.M.
- Raimondo M.
- Rosser B.G.
- et al.
Prevalence and natural history of gastric antral vascular ectasia in patients undergoing orthotopic liver transplantation.
Journal of Clinical Gastroenterology. 2016; 38 ([Internet] Available from: http://www.ncbi.nlm.nih.gov/pubmed/15492609[cited 15 February 2016]): 898-900
137
].- Spahr L.
- Villeneuve J.P.
- Dufresne M.P.
- et al.
Gastric antral vascular ectasia in cirrhotic patients: absence of relation with portal hypertension.
Gut. 1999; 44 ([Internet] Available from: http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=1727493&tool=pmcentrez&rendertype=abstract [cited 15 February 2016]): 739-742
Ectopic varices account for only 2–5% of variceal bleeding in cirrhosis. They bear a 4-fold increased bleeding risk compared to EV with a mortality rate as high as 40% [
[138]
]. In case of uncommon bleeding sites (such as ectopic varices and stomas), local endoscopic treatment is often either impossible or ineffective. Several uncontrolled studies have indicated that TIPS placement is effective in preventing rebleeding from ectopic varices [- Saad W.E.A.
- Lippert A.
- Saad N.E.
- et al.
Ectopic varices: anatomical classification, hemodynamic classification, and hemodynamic-based management.
Techniques in Vascular and Interventional Radiology. 2013; 16 ([Internet]Available from: http://www.ncbi.nlm.nih.gov/pubmed/23830673 [cited 15 February 2016]): 158-175
127
, 139
, 140
, - Vidal V.
- Joly L.
- Perreault P.
- et al.
Usefulness of transjugular intrahepatic portosystemic shunt in the management of bleeding ectopic varices in cirrhotic patients.
Cardiovascular and Interventional Radiology. 2016; 29 ([Internet] Available from: http://www.ncbi.nlm.nih.gov/pubmed/16284702 [cited 15 February 2016]): 216-219
141
, - Deipolyi A.R.
- Kalva S.P.
- Oklu R.
- et al.
Reduction in portal venous pressure by transjugular intrahepatic portosystemic shunt for treatment of hemorrhagic stomal varices.
American Journal of Roentgenology. 2014; 203 ([Internet] Available from: http://www.ncbi.nlm.nih.gov/pubmed/25148174 [cited 15 February 2016]): 668-673
142
]; it should be considered that ectopic varices are known to rebleed despite a reduction of PCG below 12mmHg following TIPS [127
, 139
, 141
, - Deipolyi A.R.
- Kalva S.P.
- Oklu R.
- et al.
Reduction in portal venous pressure by transjugular intrahepatic portosystemic shunt for treatment of hemorrhagic stomal varices.
American Journal of Roentgenology. 2014; 203 ([Internet] Available from: http://www.ncbi.nlm.nih.gov/pubmed/25148174 [cited 15 February 2016]): 668-673
142
, 143
]. Therefore, TIPS also allows embolization of the feeding vessel(s) and facilitates re-interventions in case of rebleeding. In this setting derivative surgery could still play a crucial role if TIPS is not technically feasible (Supplementary materials—Appendix 4).SESSION 3: TIPS for portal hypertension complications
3.1. Is TIPS more effective than conservative/medical treatment (large volume paracentesis plus albumin infusion±diuretics) to treat refractory ascites (defined according the International Club of Ascites criteria) or recidivant ascites (3 episodes of tense ascites in 1year)?
Tabled
1
| Statement 3.1 |
| 3.1a. TIPS is more effective than conservative/medical treatment to resolve refractory/recidivant ascites, greatly reducing the need of paracentesis (1a, A). |
| 3.1b. TIPS should be considered in all patients with refractory/recidivant ascites (1a, A). |
| 3.1c. In selected patients with refractory/recidivant ascites and without general contraindications (*) TIPS improves transplant-free survival (1a, A). |
| 3.1d. In patients who are eligible for liver transplant, TIPS should be planned in agreement with a Transplant Centre (5,D). |
| 3.1e. At present, in patients with ascites “early TIPS” is not indicated. The concept of “early TIPS” needs further definition (5,D) |
| *see statement 1.12. |
Votation 3.1. Votes in Favour 100%.
Comment: Efficacy: To date 6 RCTs performed with bare stents and including 390 patients and a meta-analysis have been conducted to compare TIPS and large volume paracentesis in patients with refractory/recurrent ascites [
75
,