Transjugular intrahepatic portosystemic shunt in cirrhosis: An exhaustive critical update

Abstract

More than five decades after it was originally conceptualized as rescue therapy for patients with intractable variceal bleeding, the transjugular intrahepatic portosystemic shunt (TIPS) procedure continues to remain a focus of intense clinical and biomedical research. By the impressive reduction in portal pressure achieved by this intervention, coupled with its minimally invasive nature, TIPS has gained increasing acceptance in the treatment of complications of portal hypertension. The early years of TIPS were plagued by poor long-term patency of the stents and increased incidence of hepatic encephalopathy. Moreover, the diversion of portal flow after placement of TIPS often resulted in derangement of hepatic functions, which was occasionally severe. While the incidence of shunt dysfunction has markedly reduced with the advent of covered stents, hepatic encephalopathy and instances of early liver failure continue to remain a significant issue after TIPS. It has emerged over the years that careful selection of patients and diligent post-procedural care is of paramount importance to optimize the outcome after TIPS. The past twenty years have seen multiple studies redefining the role of TIPS in the management of variceal bleeding and refractory ascites while exploring its application in other complications of cirrhosis like hepatic hydrothorax, portal hypertensive gastropathy, ectopic varices, hepatorenal and hepatopulmonary syndromes, non-tumoral portal vein thrombosis and chylous ascites. It has also been utilized to good effect before extrahepatic abdominal surgery to reduce perioperative morbidity and mortality. The current article aims to review the updated literature on the status of TIPS in the management of patients with liver cirrhosis.

Keywords: Early transjugular portosystemic shunt, Preemptive transjugular intrahepatic portosystemic shunt, Portal hypertension, Esophageal varices, Gastric varices, Refractory ascites

Core Tip: Covered transjugular intrahepatic portosystemic shunt has proven effective in ameliorating the symptoms associated with cirrhosis and portal hypertension in a subset of patients. However, hepatic encephalopathy (HE) and deterioration of liver function remain a concern. The meticulous selection of patients is the most fruitful measure to improve patient outcomes. While patients having preserved hepatic and renal functions and without any prior history of, HE and cardiopulmonary disease are ideal candidates, patients with high liver disease severity scores, poor cardiac reserve, and risk of HE should be considered for transjugular intrahepatic portosystemic shunt only as a last resort or a bridge to transplant. With the advent of controlled expansion stent, and improvements in patient selection criteria, the incidence of HE and early liver failure is expected to reduce further.