Role of early transjugular intrahepatic portosystemic stent-shunt in acute variceal bleeding: An update of the evidence and future directions

Table 2 Summary of current Guidelines regarding early transjugular intrahepatic portosystemic stent-shunt

Ref.	Guidelines	e-TIPSS recommendations
[40]	Baveno VI Consensus Workshop (2015)	An early TIPSS (p-TIPSS) with PTFE-covered stents within 72 h (ideally < 24 h) must be considered in patients bleeding from EV, GOV1 and GOV2 at high risk of treatment failure [e.g., Child-Pugh class C < 14 points or Child-Pugh class B with active bleeding) after initial pharmacological and endoscopic therapy (1b; A)]. Criteria for high-risk patients should be refined.
[41]	American Association for the Study of Liver Diseases (2017)	In patients at high risk of failure or rebleeding (CTP class C cirrhosis or CTP class B with active bleeding on endoscopy) who have no contraindications for TIPSS, an “early” (pre-emptive) TIPSS within 72 h from EGD/EVL may benefit selected patients.
[42]	The European Association for the Study of the Liver (2018)	Early pre-emptive covered TIPSS (placed within 24–72 h) can be suggested in selected high-risk patients, such as those with Child class C with score < 14 (I; 2). However, the criteria for high-risk patients, particularly Child B with active bleeding, remains debatable and needs further study. Up to 10%–15% of patients have persistent bleeding or early rebleeding despite treatment with vasoactive drugs plus variceal ligation, and prophylactic antibiotics. TIPSS should be used as the rescue therapy of choice in such cases (I; 1).
[43]	British Society of Gastroenterology (2020)	In patients who have Child’s C disease (C10-13) or MELD ≥ 19, and bleeding from oesophageal varices or GOV1 and GOV2 gastric varices and are hemodynamically stable, early or pre-emptive TIPSS can be considered within 72 h of a variceal bleed where local resources allow (weak recommendation, moderate quality of evidence). However, large multi-centre randomised controlled trials are necessary to determine whether patients with Child’s B disease and active bleeding or with MELD 12-18 benefit from early pre-emptive TIPSS.

PTFE: Polytetrafluoroethylene; p-TIPSS: Pre-emptive transjugular intrahepatic portosystemic shunt; EV: Oesophageal varices, GOV: Gastro-oesophageal varices; CTP: Child-Turcotte-Pugh; EGD: Oesophago-gastro-duodenoscopy; EVL: Endoscopic variceal ligation; MELD: Model for end-stage liver disease.