Efficacy and safety of transjugular intrahepatic portosystemic shunt in the treatment of nongastric extraesophageal variceal bleeding

Role of emergency transjugular intrahepatic portosystemic shunts

Transjugular intrahepatic portosystemic shunts (TIPS) is a highly effective treatment for bleeding esophageal varices, with control of the bleeding in over 90% of the patients. TIPS is recommended as "rescue" treatment if primary hemostasis cannot be obtained with endoscopic and pharmacological therapy, or if uncontrollable early rebleeding occurs within 48 hours. TIPS is also a very effective technique for patients presenting with severe refractory bleeding gastric and ectopic varices, cases where endoscopic techniques are less effective. Emergency TIPS should be considered early in patients with refractory variceal bleeding once medical treatment and sclerotherapy fail, before the clinical condition worsens. Every effort should be made to stabilize the patient before TIPS, including the use of tamponade tubes and aggressive correction of coagulopathy. Patients with acute variceal bleeding with a Child-Pugh score > 12, Apache score II > 18 points, hemodynamically unstable, receiving vasopressors and coagulopathy, and/or bilirrubin > 6 mg/dL have a high risk of early death after TIPS. Expedite liver transplantation after emergency TIPS should be considered for high-risk patients.

Transjugular intrahepatic portosystemic shunt

The transjugular intrahepatic portosystemic shunt (TIPS) is an interventional treatment resulting in decompression of the portal system by creation of a side-to-side portosystemic anastomosis. Since its introduction 16 years ago, more than 1,000 publications have appeared demonstrating broad acceptance and increasing clinical use. This review summarizes our present knowledge about technical aspects and complications, follow-up of patients and indications. A technical success rate near 100% and a low occurrence of complications clearly depend on the skills of the operator. The follow-up of the TIPS patient has to assess shunt patency, liver function, hepatic encephalopathy and the possible development of hepatocellular carcinoma. Shunt patency can best be monitored by duplex sonography and can avoid routine radiological revision. Short-term patency may be improved by anticoagulation, while such a treatment does not influence long-term patency. Stent grafts covered with expanded polytetrafluoroethylene show promising long-term patency comparable with that of surgical shunts. With respect to the indications of TIPS, much is known about treatment of variceal bleeding and refractory ascites. The thirteen randomized studies that are available to date show that survival is comparable in patients receiving TIPS or endoscopic treatment for acute or recurrent variceal bleeding. Another group comprises patients with refractory ascites and related complications, such as hepatorenal syndrome and hepatic hydrothorax. It has been demonstrated that TIPS improves these complications. Five randomized studies comparing TIPS with paracentesis and one study comparing TIPS with the peritoneo-venous shunt showed good response of ascites but controversial results on survival. In addition, TIPS has been successfully applied to patients with Budd-Chiari syndrome, portal vein thrombosis, before liver transplantation, and for the treatment of ectopic variceal bleeding.