Drug-eluting beads TACE is safe and non-inferior to conventional TACE in HCC patients with TIPS

DEB-TACE versus cTACE for unresectable HCC with B1-type bile duct invasion after successful biliary drainage: A propensity score matching analysis

BACKGROUND

Transarterial chemoembolization (TACE) is the standard treatment for intermediate-stage hepatocellular carcinoma (HCC). Given the lack of specific recommendations for conventional TACE (cTACE) and drug-eluting bead TACE (DEB-TACE) in patients having unresectable HCC with tumor infiltrating the common hepatic duct or the first-order branch of the bile ducts (B1-type bile duct invasion; B1-BDI) after biliary drainage, we retrospectively compared the safety and efficacy of DEB-TACE with cTACE in this patient population.

MATERIALS AND METHODS

Using data from five tertiary medical centers (January 2017-December 2021), we compared complications, overall survival (OS), time to progression (TTP), and tumor response rate between patients having unresectable HCC with B1-BDI who underwent DEB-TACE or cTACE after successful biliary drainage. X-tile software calculated the pre-TACE total bilirubin (TBil) cutoff value, indicating optimal timing for sequential TACE after drainage. Propensity score matching (PSM) was performed.

RESULTS

The study included 108 patients with unresectable HCC (B1-BDI) who underwent DEB-TACE and 114 who received cTACE as initial treatment. After PSM (n = 53 for each group), the DEB-TACE group had a longer TTP (8.9 vs. 6.7 months, p = 0.038) and higher objective response rate (64.2% vs. 39.6%, p = 0.011) than did the cTACE group, although OS was comparable (16.7 vs. 15.3 months, p = 0.115). The DEB-TACE group exhibited fewer post-procedural increments in the mean albumin-bilirubin score, TBil, and alanine aminotransferase (ALT), along with a significantly lower incidence of serious adverse events within 30 days (hepatic failure, ALT increase, and TBil increase) than the cTACE group (all p < 0.05). The pre-TACE TBil cutoff value was 99 μmol/L; patients with higher values (>99 μmol/L) had poorer OS in both groups (p < 0.05).

CONCLUSION

DEB-TACE is safe and effective after successful biliary drainage in unresectable HCC with B1-BDI, potentially better than cTACE in terms of liver toxicity, TTP, and ORR. Lowering TBil below 99 μmol/L through successful drainage may create ideal conditions for sequential TACE.

Transjugular Intrahepatic Portosystemic Shunt for Advanced Hepatocellular Carcinoma With Main Portal Vein Tumor Thrombus-Related Symptomatic Portal Hypertension

Background and aims

The safety and efficacy of transjugular intrahepatic portosystemic shunt (TIPS) in the treatment of symptomatic portal hypertension (SPH) caused by hepatocellular carcinoma (HCC) with portal vein tumor thrombus (PVTT) of main trunk remains unclear. The purpose of this study was to initially explore the safety and efficacy of TIPS for SPH caused by HCC with PVTT of main trunk.

Methods

This retrospective study analyzed 16 patients who underwent TIPS for SPH caused by HCC with PVTT of main trunk. The evaluated outcomes were technical success rate, SPH control rate, stent patency rate, overall survival (OS), and complications.

Results

From July 2018 to February 2023, sixteen consecutive HCC patients with PVTT of main trunk and SPH were retrospectively identified. Technical success was 93.75 %. All patients had complete or partial remission of clinical symptoms, and there were no incidents of acute variceal rebleeding and re-exacerbation of ascites during follow-up. There had no intraoperative TIPS-related complications occurred. One patient developed mild hepatic encephalopathy after TIPS placement during the follow-up period. During follow-up, 13 of 16 patients died of advanced HCC progression, the median OS was 10.0 months, and the cumulative OS of 0.5-, 1-, and 2 years were 66.67 %, 45.00 %, and 11.25 %, respectively.

Conclusions

TIPS for SPH caused by HCC with PVTT of main trunk may be safe and effective.

Development of a predictive nomogram for postembolization syndrome after transcatheter arterial chemoembolization of hepatocellular carcinoma

Post-embolization syndrome (PES) is a frequent complication after receiving transcatheter arterial chemoembolization (TACE) in patients with hepatocellular carcinoma (HCC), but only a few studies have focused on the factors influencing PES in those patients. In this study, the impact factors of PES were explored and a nomogram was constructed to predict the occurrence of PES in HCC patients with TACE. This was a retrospective cohort study of HCC patients who underwent TACE obtained from the third affiliated Hospital of Kunming Medical University between January 1, 2020, and September 1, 2022. T‑test and Chi‑square test were used to search for factors influencing PES occurrence, and then the nomogram was further established based on multivariable logistic regression analysis. Validation of the predictive nomogram was also evaluated by calibration curve, concordance index (C-index), and receiver operating characteristic (ROC) curves. The enrolled patients (n = 258) were randomly assigned to the primary cohort (n = 180) and validation cohort (n = 78) in a 7:3 ratio. Among 180 patients in the primary cohort, 106 (58.89%) experienced PES. TACE types (P = 0.015), embolization degree (P = 0.008), and tumor number (P = 0.026) were identified as predictors by the logistic regression analysis and were used to develop the predictive nomogram. The internally validated and externally validated C-indexes were 0.713 and 0.703, respectively. The calibration curves presented good consistency between actual and predictive survival. Types of embolic agents, embolization degree, and tumor number were found to be the predictors of PES after TACE. The nomogram could reliably predict PES in HCC patients with TACE. This predictive model might be considered for clinical practice.

Current Evidence on Local Therapies in Advanced Adrenocortical Carcinoma

International guidelines emphasise the role of local therapies (LT) for the treatment of advanced adrenocortical carcinoma (ACC). However, large studies are lacking in this field. Therefore, we performed a review of the literature to synthesise current evidence and develop clinical guidance. PubMed database was searched for systematic literature. We identified 119 potentially relevant articles, of which 21 could be included in our final analysis. All were retrospective and reported on 374 patients treated with LT for advanced ACC (12 studies on radiotherapy, 3 on transarterial chemoembolisation and radioembolisation, 4 on image-guided thermal ablation [radiofrequency, microwave ablation, and cryoablation, and two studies reporting treatment with several different LT]). Radiotherapy was frequently performed with palliative intention. However, in most patients, disease control and with higher dosage also partial responses could be achieved. Data for other LT were more limited, but also point towards local disease control in a significant percentage of patients. Very few studies tried to identify factors that are predictive on response. Patients with a disease-free interval after primary surgery of more than 9 months and lesions<5 cm might benefit most. Underreporting of toxicities may be prevalent, but LT appear to be relatively safe overall. Available evidence on LT for ACC is limited. LT appears to be safe and effective in cases with limited disease and should be considered depending on local expertise in a multidisciplinary team discussion.

Impact of particle size of multivesicular liposomes on the embolic and therapeutic effects in rabbit VX2 liver tumor

Transcatheter arterial chemoembolization (TACE) is usually considered more efficacious in the local treatment of parenchyma-sparing hepatocellular carcinoma (HCC). At present, embolic agents commonly used in TACE, include DC pellets, Hepasphere, Lipiodol, etc. Except that iodine oil is a viscous fluid embolic agent, other solid microsphere particles used clinically range from 70 to 700 µm, among which 100 to 300 µm is the most commonly used. With the technology development of micro-invasive interventional therapy, the specific distal embolization through TACE to occlude tumor arterial blood supply in patients with HCC is also required more accurately. Effective terminal embolization is considered to be a preferred option for TACE therapy due to significantly improving the survival rate of patients and preserving liver function. In this article, we prepared the multifunctional multivesicular liposomes (IVO-DOX-MVLs) (<100 µm) that can simultaneously encapsulate ioversol and doxorubicin based on the high-phase transition temperature (Tm) lipid ingredients, and evaluated its local artery embolization and therapeutic effect in rabbit VX-2 tumor model. The influence of particle size on occlusion and therapeutic effect of MVLs on rabbit VX-2 liver tumor models were well evaluated, including the tumor volume change, tumor growth rate, and necrosis rate, which were evaluated by magnetic resonance (MR). MVL samples with average particle size distribution of 50-60 µm exhibited fewer off-target embolization. Through TACE, IVO-DOX-MVLs were directly transported to the tumor tissues, playing roles of embolization performance, CT imaging effect, and local tumor killing effect. The feasibility of MVLs as a multifunctional embolic agent in its clinical application can be further improved by optimization of lipid composition and preparation process.

Risks and benefits of TIPS in HCC and other liver malignancies: a literature review

BACKGROUND

Transjugular intrahepatic portosystemic shunt (TIPS) is a well-validated treatment option for clinically significant portal hypertension (CSPH) in the context of liver cirrhosis. Its high efficacy and safety in the management of treatment-refractory ascites and variceal bleeding have been extensively proven. Contraindications for TIPS include severe right heart failure, hepatic encephalopathy, and sepsis. However, the role of liver malignancy in TIPS is debatable. Mostly, primary liver malignancies such as hepatocellular carcinoma (HCC) emerge from advanced liver diseases. Coexisting portal hypertension in HCC often results in limited treatment options and a poor prognosis. Previous studies have shown that TIPS implantation in patients with HCC is technically feasible and is usually not associated with major adverse events. Furthermore, TIPS may help in bridging the time to liver transplantation in early HCC and allow for locoregional treatment in advanced HCC. However, several studies suggest that seeding tumour cells to the lungs by TIPS placement might worsen the prognosis.

CONCLUSIONS

TIPS placement in patients with coexisting liver malignancy remains a case-by-case decision, and there is no profound evidence allowing general recommendations. This review aims to provide a state-of-the-art overview of the potential risks and benefits of TIPS placement in patients with liver malignancies.

Comparison of the Treatment Response of Drug-Eluting Bead Transarterial Chemoembolization and Conventional Transarterial Chemoembolization in Patients With Hepatocellular Carcinoma

Introduction Hepatocellular carcinoma (HCC) is a common primary hepatic cancer. Its early diagnosis can aid in its treatment by curative means such as surgery or ablation. Advanced-stage diagnosis limits these treatment options, and such cases can be treated with transarterial chemoembolization (TACE). Conventional transarterial chemoembolization (cTACE) and drug-eluting bead transarterial chemoembolization (DEB-TACE) are usually used, and follow-up response is evaluated using modified Response Evaluation Criteria in Solid Tumors (mRECIST) criteria. This study was done to compare the treatment response of cTACE and DEB-TACE in patients with HCC. Materials and methods A retrospective review of electronic medical records of all patients diagnosed with HCC from January 2021 to August 2022 who underwent cTACE or DEB-TACE was undertaken at the Department of Interventional Radiology, Indus Hospital and Health Network. Both male and female patients aged 18 years or above with Child-Pugh class A and B were included. DEB-TACE or cTACE was performed by a fellowship-trained interventional radiologist, and the response was evaluated at six weeks follow-up using mRECIST criteria. Results A total of 129 patients were included in this study, with a mean age of 54.1 ± 10.8 years. The mean size of HCC was 3.1 ± 1.7 cm. Seventy-eight (60.5%) patients underwent cTACE, and 51 (39.5%) underwent DEB-TACE. Out of the 78 patients who underwent cTACE, complete response (CR) was found in 28 (35.9%), partial response (PR) was found in 33 (42.3%), stable disease (SD) was found in 12 (15.4%), and progressive disease (PD) was found in five (6.4%) patients. Of the 51 patients who underwent DEB-TACE, CR was found in 13 (25.5%), PR was found in 20 (39.2%), SD was found in 11 (21.6%), and PD was found in seven (13.7%) patients. Conclusion The response rate of TACE in the form of complete or partial response was higher with a lower frequency of stable or progressive disease. cTACE has a high response rate as compared to DEB-TACE.

The Role of Transjugular Intrahepatic Portosystemic Shunt (TIPS) in Treating Portal Hypertension in Patients with Hepatocellular Carcinoma

Liver cancer is very frequent, and hepatocellular carcinoma (HCC) accounts for the majority of liver cancer cases. Its growing incidence has been greatly affected by the increasing prevalence of metabolic-associated fatty liver disease (MAFLD). The latter is a new epidemic in our era. In fact, HCC is often generated from noncirrhotic liver and its treatment benefits from surgical and nonsurgical approaches, potentially bridged by transjugular intrahepatic portosystemic shunt (TIPS) use. TIPS use is an effective treatment for portal hypertension complications, but its application in patients with HCC and clinically significant portal hypertension (CSPH) remains controversial due to concerns about tumor rupture, dissemination, and increased toxicity. The technical feasibility and safety of TIPS use in HCC patients have been evaluated in several studies. Despite concerns about intraprocedural complications, retrospective studies have shown high success rates and low complication rates in TIPS placement for HCC patients. TIPS use in combination with locoregional treatments, such as transarterial chemoembolization (TACE) or transarterial radioembolization (TARE), has been explored as a treatment option for HCC patients with portal hypertension. These studies have shown improved survival rates in patients undergoing TIPS in combination with locoregional treatments. However, the efficacy and toxicity of TACE in combination with TIPS use require careful evaluation, as changes in venous and arterial flow can affect treatment outcomes and complications. The results from studies evaluating the impact of TIPS on systemic therapy and surgical options are also promising. In conclusion, the TIPS is a sufficiently safe, useful item available for physicians treating complications of portal hypertension. Moreover, a TIPS can be used in combination with locoregional therapy in HCC patients. Systemic chemotherapy can also benefit of the use of TIPS placement. A complex interplay affects TIPS use with surgery. The latter needs further data. The TIPS is a useful and safe add-on treatment, changing the natural course of HCC progression. Its use is regulated by a sophisticated physiologic and pathophysiologic flow of evidence.

Creating and Testing a Model to Predict Postoperative Discomfort in Patients with Hepatocellular Carcinoma Receiving Transarterial Chemoembolisation

Background: Abdominal pain is a frequent adverse event in patients with hepatocellular carcinoma (HCC) after transarterial chemoembolisation (TACE). However, there remains uncertainty regarding the determinants of post-TACE pain. Objectives: We aimed to create and verify a prediction model for postoperative pain in patients with HCC after TACE treatment. Methods: This prospective study included all patients with HCC undergoing TACE in our hospital. According to the time of treatment, the dataset was divided into two cohorts (development and validation) in a 3: 2 ratio. After TACE, the participants used a visual analog scale to quantify their pain level at rest over a 24-hour period. The age, gender, tumor location, tumor size and number, medication administration route, and presence of portal vein tumor thrombosis (PVTT) were recorded in all patients. Results: In total, 137 (mean age: 60.3 ± 10.1 years; 78.1% male) and 91 (mean age: 61.1 ± 10.5 years; 73.6% male) patients were included in the development and validation cohorts, respectively. Furthermore, 46.0% and 39.6% of the patients experienced acute moderate to severe pain after TACE in the development and validation cohorts, respectively. The tumor location, the drug delivery method, and the presence of PVTT were independently associated with post-TACE pain, all of which were combined to develop a prediction model based on a logistic equation. The discrimination of this risk score was satisfactory in both the development (area under the curve (AUC): 0.693, 95% confidence interval (CI): 0.609 to 0.769, P < 0.001) and validation (AUC: 0.652, 95% CI: 0.544 to 0.748, P = 0.002) cohorts. There was no significant difference between the two cohorts (difference: 0.042, 95% CI: -0.081 to 0.164, P = 0.506). The risk score had good specificity for predicting post-TACE pain in both the development (83.8% (95% CI: 73.4% to 91.3%)) and validation (76.4% (95% CI: 63.0% to 86.8%)) cohorts. Conclusions: The presence of PVTT, the tumor location, and the drug administration method were risk factors for post-TACE discomfort. A prediction model based on these risk factors was useful for identifying patients who were vulnerable to post-TACE pain. However, further studies are required to validate these findings and optimize the model’s performance.

Identifying optimal candidates for post-TIPS patients with HCC undergoing TACE: a multicenter observational study

OBJECTIVE

To develop a prognostic model for post-transjugular intrahepatic portosystemic shunt (TIPS) patients with hepatocellular carcinoma (HCC) beyond the Milan criteria treated by transarterial chemoembolization (TACE).

DESIGN

Between January 2013 and January 2020, 512 patients with HCC beyond the Milan criteria who underwent TACE after TIPS were retrospectively recruited from 15 tertiary centers. Patients were randomly sorted into a training set (n = 382) and a validation set (n = 130). Medical data and overall survival were assessed. A prediction model was developed using multivariate Cox regression analyses. Predictive performance and discrimination were evaluated and compared with other prognostic models.

RESULTS

Vascular invasion, log₁₀(AFP), 1/creatinine, extrahepatic spread, and log₁₀(ALT) were the most significant prognostic factors of survival. These five parameters were included in a new VACEA score. This score was able to stratify patients in the training set into four distinct risk grades whose median overall survival were 25.2, 15.1, 8.9, and 6.2 months, respectively. The 6-month, 1-year, 2-year, and 3-year AUROC values and C-index of the VACEA model were 0.819, 0.806, 0.779, 0.825, and 0.735, respectively, and higher than those of other seven currently available models in both the training and validation sets, as well as in different subgroups.

CONCLUSION

The VACEA score could stratify post-TIPS patients with HCC beyond the Milan criteria treated by TACE and help to identify candidates who benefit from this treatment.

KEY POINTS

• Vascular invasion, AFP, creatinine, extrahepatic spread, and ALT were independent significant prognostic factors of survival for HCC patients who underwent TACE after TIPS. • Our new model, named VACEA score, can accurately predict prognosis at the individual level and stratify patients into four distinct risk grades. • The VACEA model showed better prognostic discrimination and calibration than other current TACE-/TIPS-specific models Graphical abstract.

Mini-ALPPS-based multidisciplinary treatment leading to long-term survival in a patient with a large HCC: A case report

Background

The future liver remnant (FLR) induced by stage I associated liver partition and portal vein ligation for staged hepatectomy (ALPPS) in hepatocellular carcinoma (HCC) might be limited due to liver fibrosis/cirrhosis or incomplete liver parenchymal transection.

Case presentation

A 51-year-old male with hepatitis B liver fibrosis was diagnosed with a large HCC (13.5 cm × 12.5 cm × 13.8 cm). The FLR of the patient was insufficient to permit one-stage tumor resection. Therefore, the two-stage ALPPS surgery was planned. Stage I ALPPS was performed with incomplete liver parenchymal transection due to bleeding (which is why we called it Mini-ALPPS). On postoperative day (POD) 18, CT revealed that the FLR hypertrophy was poor. The FLR/standard liver volume (SLV) had only increased from 22.00% to 34.63%. Salvage transhepatic arterial chemoembolization (TACE) was performed on POD 22 days to control possible tumor progression during the waiting period and to further facilitate FLR growth. About 16 days later, a CT reassessment of FLR revealed a 42.5% FLR/SLV. A right hepatectomy was then uneventfully performed. Although HCC recurred after 586 days, the patient survived for more than 1,920 days after stage II ALPPS.

Discussion

Damage control during a difficult conventional stage I ALPPS was important. TACE during the interstage and postoperative periods of this Mini-ALPPS was safe and beneficial. A multidisciplinary based on Mini-ALPPS treatment could provide patients long-term survival; however, Mini-ALPPS should not be selected as the primary solution for such patients today, as some other minimally invasive and effective strategies are available.

Ferroptosis and its interaction with tumor immune microenvironment in liver cancer

Exploring effective systemic treatments for liver cancer is still a great challenge worldwide. As a novel form of regulated cell death, ferroptosis has been paid more and more attention in the cancer research field. In recent years, targeting ferroptosis has become an encouraging strategy for liver cancer treatment. Cancer cells can be directly killed by inducing ferroptosis; in contrast, ferroptosis can also ameliorate the tumor immunosuppressive microenvironment and sensitize cancers to immunotherapy. Here, we summarize fully current progress in the iron homeostasis in the liver, the internal association between imbalanced iron homeostasis and ferroptosis in liver carcinogenesis and development, as well as ferroptosis-related regulators in liver cancer. Furthermore, we discuss thoroughly the interaction between ferroptosis and tumor immune microenvironment. Finally, we provide certainly a future insight on the potential value of ferroptosis in the immunotherapy of liver cancer.

Propensity score matching analysis of efficacy of drug-eluting beads (DEB)-TACE loaded with different drugs in the treatment of hepatocellular carcinoma

OBJECTIVE

To evaluate the efficacy of drug-eluting beads transarterial chemoembolization (DEB-TACE) in the treatment of hepatocellular carcinoma (HCC) by propensity score matching (PSM) technique.

METHODS

The clinical data of HCC patients treated with DEB-TACE in the First Affiliated Hospital of Zhengzhou University from June 2017 to June 2020 as well as their 36-month-follow-up data were retrospectively analyzed. The subjects were matched in pairs based on baseline data and laboratory indicators using the PSM method and divided into a pirarubicin group (n = 34), raltitrexed group (n = 34), and arsenic trioxide group (n = 34). Clinical efficacy was evaluated according to mRECIST criteria. The levels of alpha fetal protein (AFP), carcinoma embryonic antigen (CEA) and carbohydrate antigen-125 (CA125) in serum were detected by enzyme-linked immunosorbent assay (ELISA). The progression-free survival (PFS) and overall survival (OS) were recorded by outpatient, inpatient, and telephone follow-up. Adverse reactions were counted.

RESULTS

After PSM, no significant differences were seen in gender, age, tumor burden, Child-Pugh grade, portal vein tumor thrombus or TACE frequency among the three groups (all P>0.05). The ORR rate of the pirarubicin group and arsenic trioxide group at both 3^rd and 6^th month post-operation was significantly higher than that of the raltitrexed group (all P<0.05). Before and 1 month after treatment, there were no significant differences in the aspartate aminotransferase (AST), alanine aminotransferase (ALT), or total bilirubin (TBIL) levels between the three groups (all P>0.05). Before treatment, no significant differences were observed in AFP, CEA, or CA125 levels among the three groups (all P>0.05). After treatment, the levels of AFP in the pirarubicin group and arsenic trioxide group were lower than those in the raltitrexed group (both P<0.05), but there were no significant differences in CEA and CA125 levels (all P>0.05). There were no significant differences in PFS and OS among the three groups (all P>0.05), and the incidence of fever, abdominal pain, and myelosuppression showed no significant differences among the three groups (all P>0.05).

CONCLUSION

The efficacies of DEB-TACE loaded with pirarubicin, raltitrexed, or arsenic trioxide in treating HCC were generally comparable, and the survival benefit of patients was similar. The short-term efficacy of the pirarubicin group and arsenic trioxide group was slightly better than that of the raltitrexed group.

Evaluation of Transarterial Chemoembolization Protocol with Drug-Eluting Beads in Combination with Lipiodol for Hepatocellular Carcinoma: A Single-Center Controlled Study

Objectives

To evaluate the efficacy and safety of transarterial chemoembolization (TACE) with drug-eluting beads (DEB-TACE) and lipiodol (DEB-Lipiodol TACE) in the treatment of unresectable hepatocellular carcinoma (HCC) patients.

Materials and Methods

The medical records of consecutive unresectable HCC patients who underwent DEB-TACE or DEB-Lipiodol TACE from June 2016 to July 2021 were retrospectively evaluated. Therapeutic response, overall survival (OS), progression-free survival (PFS), and adverse events (AEs) were compared among the groups.

Results

Three hundred and twenty-seven patients were enrolled in the study, including 293 patients in the DEB-TACE group and 34 patients in the DEB-Lipiodol TACE group. The objective response rate in the DEB-Lipiodol TACE group was 17.6%, significantly higher than that in the DEB-TACE group (5.8%, P=0.011). Similarly, DEB-Lipiodol TACE group also had a higher disease control rate (91.2% vs 68.6%, P=0.006). Median OS was 13 months (95% CI: 11.0 months and 15.0 months) and 22 months (95% CI: 17.3 months and 26.7 months) in the DEB-TACE group and DEB-Lipiodol TACE group, respectively (P=0.041). Meanwhile, median PFS was 7 months (95% CI: 5.2 months and 8.8 months) in the DEB-TACE group and 12 months (95% CI: 7.9 months and 16.1 months) in the DEB-Lipiodol TACE group (P=0.174). There was no statistically significant difference in AEs incidence among the two groups (P > 0.05).

Conclusions

DEB-Lipiodol TACE was safe, well tolerated, and had a better efficacy compared with DEB-TACE in unresectable HCC patients.

The role of transjugular intrahepatic portosystemic shunt in patients with portal hypertension: advantages and pitfalls

Transjugular intrahepatic portosystemic shunt (TIPS) is an effective interventional procedure to relieve portal hypertension, which is a main mechanism for the development of complications of liver cirrhosis (LC), such as variceal hemorrhage, ascites, and hepatorenal syndrome. However, the high incidence of adverse events after TIPS implementation limits its application in clinical practice. Esophageal variceal hemorrhage is one of the major indications for TIPS. Recently, preemptively performed TIPS has been recommended, as several studies have shown that TIPS significantly reduced mortality as well as rebleeding or failure to control bleeding in patients who are at high risk of treatment failure for bleeding control with endoscopic variceal ligation and vasoactive drugs. Meanwhile, recurrent ascites is another indication for TIPS with a proven survival benefit. TIPS may also be considered as an effective treatment for other LC complications, usually as an alternative therapy. Although there are concerns about the development of hepatic encephalopathy and hepatic dysfunction after TIPS implementation, careful patient selection using prognostic scores can lead to excellent outcomes. Assessments of cardiac and renal function prior to TIPS may also be considered to improve patient prognosis.