Transjugular intrahepatic portosystemic shunts and portal hypertension-related complications

Table 1 Contraindications to transjugular intrahepatic portosystemic shunts placement according to current American Association for the Study of Liver Diseases guidelines

Absolute	Relative
Congestive heart failure	Hepatoma especially if central
Multiple hepatic cysts	Obstruction of all hepatic veins
Uncontrolled systemic infection or sepsis	Portal vein thrombosis
Unrelieved biliary obstruction	Severe coagulopathy (INR > 5)
Severe pulmonary hypertension	Thrombocytopenia of < 20000/cm3
	Moderate pulmonary hypertension

Table 2 Results of 3 trials comparing early transjugular intrahepatic portosystemic shunts placement and standard treatment (combined pharmacologic and endoscopic therapy) in high-risk acute variceal bleeding

Findings	Ref.
	Monescillo et al[44], 2004		García-Pagán et al[45], 2010		Garcia-Pagán et al[46], 2012
	Early TIPS	Standard care	Early TIPS	Standard care	Early TIPS	Standard care
Patients	26	26	32	31	45	30
Treatment failure1	12%	50%	3%	45%	7%	50%
Early rebleeding (< 5 d)	4%	12%	3%	13%	2%	13%
1-yr mortality rate	31%	65%	14%	39%	14%3	30%
Development of hepatic encephalopathy2	31%	35%	25%	39%	51%	50%

¹Failure to control acute bleeding and/or development of variceal re-bleeding;

²Not significant in all 3 trials;

³The P value is 0.056..

Table 3 Results of 6 randomized controlled trials comparing transjugular intrahepatic portosystemic shunts and large volume paracentesis for refractory ascites

Ref.	Number of patients		Complete resolution of ascites within 6 mo1			Treatment failure2			Survival at 2 yr			Newly developed or severe encephalopathy
	TIPS	LVP	TIPS	LVP	P-value	TIPS	LVP	P-value	TIPS	LVP	P-value	TIPS	LVP	P-value
Lebrec et al[98] 1996	13	12	38%	0%	< 0.05	NR			29%	60%	0.03	45%	0%	< 0.05
Rössle et al[100], 2000	29	31	52%	16%	0.001	10%	48%	0.001	58%	32%	0.11	23%	13%	NS
Ginès et al[97], 2002	35	35	NR			49%	83%	0.003	26%	30%	0.51	60%	34%	0.03
Sanyal et al[102], 2003	52	57	NR			42%	84%	< 0.001	35%	33%	0.84	38%	21%	0.058
Salerno et al[101], 2004	33	33	60%3	3%	< 0.001	21%	57%	0.001	59%	29%	0.021	61%	39%	NS
Narahara et al[99], 2011	30	30	30%	0%	< 0.005	13%	80%	< 0.001	64%	35%	< 0.005	67%	17%	< 0.001

¹By intention-to-treat analysis;

²Needed frequent paracentesis or other treatment modalities to control ascites;

³Evaluated at 1 year after randomization. NR: Not reported; NS: Not significant. LVP: Large volume paracentesis; TIPS: Transjugular intrahepatic portosystemic shunts.

Table 4 Case series of transjugular intrahepatic portosystemic shunts for refractory hepatic hydrothorax

Ref.	No. of patients	Child-Pugh or MELD score	Efficacy (complete/partial response)	30-d mortality	1-yr survival	Predictor of mortality
Strauss et al[112], 1994	5	C: 5	80%/20%	NR	NR	NR
Gordon et al[113], 1997	24	B/C: 5/19	58%/21%	21%	NR	Child C
						Non-response
Jeffries et al[114], 1998	12	A/B/C: 1/5/6	42%/17%	25%	NR	Age > 65
Siegerstetter et al[115], 2001	40	B/C: 24/16	71%/11%	NR	64%	Age > 60
Spencer et al[116], 2002	21	B/C: 7/14	63%/11%	29%	NR	Multiple comorbidities
Wilputte et al[117], 2007	28	B/C: 12/16	57%/11%	14%	41%	Child-Pugh score
Dhanasekaran et al[118], 2010	73	MELD < 15: 32.8%	59%/20.5%1	19%	48%	Pre-TIPS MELD score Non-response
		MELD > 15: 67.2%	60%/15%2

¹At 1-mo post TIPS;

²At 6-mo post-TIPS. NR: Not reported; TIPS: Transjugular intrahepatic portosystemic shunts.