An Approach to Endovascular and Percutaneous Management of Transjugular Intrahepatic Portosystemic Shunt (TIPS) Dysfunction: A Pictorial Essay and Clinical Practice Algorithm

French guidelines on TIPS: Indications and modalities

Transjugular intrahepatic portosystemic shunt (TIPS) has become essential in the treatment or prevention of portal hypertension-related complications. In the early 1990s, the primary indication was refractory bleeding. It is now proposed for the treatment of ascites for the prevention of bleeding and in patients with vascular diseases of the liver. Thus, there are a growing number of patients being treated with TIPS all over the world. The broadening of indications, the involvement of multiple stakeholders, the need for an accurate selection, the positioning in relation to transplantation and the lack of standardization in pre-therapeutic assessment, in the procedure itself and in the follow-up have led the board of the French Association for the Study of the Liver to establish recommendations.

A novel score predicts mortality after transjugular intrahepatic portosystemic shunt: MOTS - Modified TIPS Score

BACKGROUND AND AIMS

The high risk for severe shunting-related post-interventional complications demands a stringent selection of candidates for transjugular intrahepatic portosystemic shunt (TIPS). We aimed to develop a simple and reliable tool to accurately predict early post-TIPS mortality.

METHODS

144 cases of TIPS implantation were retrospectively analysed. Using univariate and multivariate Cox regression analysis of factors predicting mortality within 90 days after TIPS, a score integrating urea, international normalized ratio (INR) and bilirubin was developed. The Modified TIPS-Score (MOTS) ranges from 0 to 3 points: INR >1.6, urea >71 mg/dl and bilirubin >2.2 mg/dl account for one point each. Additionally, MOTS was tested in an external validation cohort (n = 187) and its performance was compared to existing models.

RESULTS

Modified TIPS-Score achieved a significant prognostic discrimination reflected by 90-day mortality of 8% in patients with MOTS 0-1 and 60% in patients with MOTS 2-3 (p < .001). Predictive performance (area under the curve) of MOTS was accurate (c = 0.845 [0.73-0.96], p < .001), also in patients with renal insufficiency (c = 0.830 [0.64-1.00], p = .02) and in patients with refractory ascites (c = 0.949 [0.88-1.00], p < .001), which are subgroups with particular room for improvement of post-TIPS mortality prediction. The results were reproducible in the validation cohort.

CONCLUSIONS

Modified TIPS-Score is a novel, practicable tool to predict post-TIPS mortality, that can significantly simplify clinical decision making. Its practical applicability should be further investigated.

A new choice of stent for transjugular intrahepatic portosystemic shunt creation: Viabahn ePTFE covered stent/bare metal stent combination

Objectives

To compare the clinical outcomes in terms of structure and function between the insertion of a transjugular intrahepatic portosystemic shunt (TIPS) created with the Viabahn ePTFE covered stent/bare metal stent (BMS) combination and the Fluency ePTFE covered stent/BMS combination.

Methods

A total of 101 consecutive patients who received a TIPS from February 2016 to August 2018 in our center were retrospectively analyzed. Sixty-four subjects were enrolled in the Viabahn group and 37 were enrolled in the Fluency group. The geometry characteristics of the TIPS were calculated, and the associated occurrence of shunt dysfunction, survival, overt hepatic encephalopathy, and variceal rebleeding were evaluated.

Results

The technical success rate was 100%. After the insertion of the TIPS, the rate of shunt dysfunction during the first 3 months was significantly different between the Viabahn and Fluency groups (1.6% and 13.5%, respectively; p ​= ​0.024). Multivariate analysis indicated that the angle of portal venous inflow (α) was the only independent risk factor for shunt dysfunction (hazard ratio ​= ​1.060, 95% confidence interval ​= ​1.009–1.112, p ​= ​0.020). In addition, 3 months after the TIPS insertion, the α angle distinctly increased from 20.9° ​± ​14.3°–26.9° ​± ​20.1° (p ​= ​0.005) in the Fluency group but did not change significantly in the Viabahn group (from 21.9° ​± ​15.1°–22.9° ​± ​17.6°, p ​= ​0.798).

Conclusions

Shunt dysfunction was related to the α angle owing to the slight effect on the α angle after the implantation of the TIPS. The Viabahn ePTFE covered stent/BMS combination was more stable in structure and promised higher short-term stent patency compared with the Fluency ePTFE covered stent/BMS combination.

Percutaneous mechanical thrombectomy device assisted TIPS recanalization: a feasibility study

BACKGROUND

Despite improved shunt patency, transjugular intrahepatic portosystemic shunt (TIPS) occlusion remains a serious complication, and effective debulking of the existing tract is needed to restore sufficient blood flow.

PURPOSE

To evaluate the technical and clinical success of percutaneous mechanical thrombectomy in restoring patency of acutely and chronically thrombosed covered TIPS using the Aspirex®S and Rotarex®S system.

MATERIAL AND METHODS

We evaluated mechanical thrombectomy-assisted revisions in five patients between January 2012 and April 2021. Two patients had to be revised twice due to recurrent occlusion. We designated thrombosis within 10 days after shunt creation or revision as acute. Insidious deterioration of portal hypertension related symptoms for at least 6-8 weeks was recorded in chronic cases. We treated four acute and three chronic occlusions. After transjugular lesion crossing, we performed two mechanical thrombectomy device passages. If indicated, balloon dilatation, covered stent placement, or variceal embolization were added.

RESULTS

The technical success rate was 100%. No procedure-related complications occurred. In one patient with acute decompensation of Budd-Chiari syndrome and acute-on-chronic liver failure, early re-thrombosis occurred twice with patency intervals of up to eight days. In contrast, stable patency was achieved in the other four patients with documented patency intervals of at least five months and improvement of portal hypertension-related symptoms, resulting in a patient based clinical success rate of 80%.

CONCLUSION

In five patients, percutaneous mechanical thrombectomy assisted TIPS recanalization of four acute and three chronic occlusions proved to be technically feasible and safe with a high clinical success rate.

Combined Y-configured stents for revising occluded transjugular intrahepatic portosystemic shunt

PURPOSE

We aimed to determine the technical feasibility, safety and prognosis of the transjugular intrahepatic portosystemic shunt (TIPS) revision by combined Y-configured stents placement.

METHODS

We retrospectively evaluated 12 patients who received TIPS revision using Y-stenting technique between June 2015 and January 2019. The rates of technical success, complication, shunt patency, hepatic encephalopathy and mortality were described and analyzed.

RESULTS

The combined Y-configured stents were successfully placed in 11 of 12 patients (92%) without major complications. The median portosystemic pressure gradient (PPG) decreased from 23 mmHg (interquartile range, IQR, 18.5-27.5 mmHg) to 10 mmHg (IQR, 9-14 mmHg). The left internal jugular vein approach was used in 5 patients. Four patients required a shunt extension with an extra stent to resolve the stenosis at the portal venous terminus. Two patients developed hepatic encephalopathy, which was medically controlled within 3 months after the procedure. The TIPS patency and survival rates were both 100% during a median follow-up period of 10 months (IQR, 5.5-14 months).

CONCLUSION

TIPS revision by combined Y-configured stents placement was technically feasible and safe with favorable clinical outcomes.

TIPS vs. endoscopic treatment for prevention of recurrent variceal bleeding: a long-term follow-up of 126 patients

BACKGROUND

Recurrent bleeding from gastroesophageal varices is the most common life-threatening complication of portal hypertension. According to guidelines, transjugular intrahepatic portosystemic shunt (TIPS) should not be used as a first-line treatment and should be limited to those bleedings which are refractory to pharmacologic and endoscopic treatment (ET). To our knowledge, long-term studies evaluating the role of elective TIPS in comparison to ET in patients with recurrent variceal bleeding episodes are rare.

PATIENTS AND METHODS

This study was designed as a retrospective single-institution analysis of 70 patients treated with TIPS and 56 with ET. Patients were followed-up from inclusion in the study until death, liver transplantation, the last follow-up observation or until the end of our study.

RESULTS

Recurrent variceal bleeding was significantly more frequent in ET group compared to patients TIPS group (66.1% vs. 21.4%, p < 0.001; χ2-test). The incidence of death secondary to recurrent bleeding was higher in the ET group (28.6% vs. 10%). Cumulative survival after 1 year, 2 years and 5 years in TIPS group compared to ET group was 85% vs. 83%, 73% vs. 67% and 41% vs. 35%, respectively. The main cause of death in patients with cumulative survival more than 2 years was liver failure. Median observation time was 47 months (range; 2-194 months) in the TIPS group and 40 months (range; 1-168 months) in the ET group.

CONCLUSIONS

In present study TIPS was more effective in the prevention of recurrent variceal bleeding and had lower mortality due to recurrent variceal bleeding compared to ET.

Multicenter analysis of the use of transjugular intrahepatic portosystemic shunt for management of MPN-associated portal hypertension

BCR-ABL1-negative myeloproliferative neoplasms (MPNs) are clonal stem cell disorders defined by proliferation of one or more myeloid lineages, and carry an increased risk of vascular events and progression to myelofibrosis and leukemia. Portal hypertension (pHTN) occurs in 7-18% of MPN patients via both thrombotic and nonthrombotic mechanisms and portends a poor prognosis. Transjugular intrahepatic portosystemic shunt (TIPS) has been used in the management of MPN-associated pHTN; however, data on long-term outcomes of TIPS in this setting is limited and the optimal management of medically refractory MPN-associated pHTN is not known. In order to assess the efficacy and long-term outcomes of TIPS in MPN-associated pHTN, we performed a retrospective analysis of 29 MPN patients who underwent TIPS at three academic medical centers between 1997 and 2016. The majority of patients experienced complete clinical resolution of pHTN and its clinical sequelae following TIPS. One, two, three, and four-year overall survival post-TIPS was 96.4%, 92.3%, 84.6%, and 71.4%, respectively. However, despite therapeutic anticoagulation, in-stent thrombosis occurred in 31.0% of patients after TIPS, necessitating additional interventions. In conclusion, TIPS can be an effective intervention for MPN-associated pHTN regardless of etiology. However, TIPS thrombosis is a frequent complication in the MPN population and indefinite anticoagulation post-TIPS should be considered.