Copyright ©The Author(s) 2020.
World J Gastroenterol. Oct 7, 2020; 26(37): 5561-5596
Published online Oct 7, 2020. doi: 10.3748/wjg.v26.i37.5561
Table 1 Summary of the randomised controlled trials on early (preemptive) transjugular intrahepatic portosystemic shunt
Ref.No. of pts (TIPS/control)Primary inclusion criteriaPrimary and secondary end-pointsRebleeding (%; TIPS/control)1-yr survival (%; TIPS/control)HE (%; TIPS/control)
Monescillo et al[13]26/26HVPG > 20 mmHgPrimary: sensivity and specificity of HVPG cutoff value (20 mmHg) in predicting TFS, and assessment of TFS as well as short- and long-term survival; secondary: transfusional needs, ICU stay, complications during the first week of treatment, and causes of death12/5062/3531/35
Garcia-Pagán et al[14]32/31Child–Pugh class C disease (a score of 10 to 13) or class B disease but with active bleeding at diagnostic endoscopyPrimary: failure to control bleeding and failure to prevent clinically significant variceal rebleeding within 1 yr; secondary: mortality at 6 wk and at 1 yr, failure to control acute bleeding, early rebleeding, rate of rebleeding between 6 wk and 1 yr, other complications of portal hypertension, the number of days in the ICU, days spent in the hospital, and the use of alternative treatments3/5086/6125/39
Lv et al[20]84/45Child–Pugh class C disease (a score of 10 to 13) or class B disease (with or without active bleeding at diagnostic endoscopy)Primary: TFS; secondary: failure to control bleeding or rebleeding, new or worsening ascites, overt HE, and other complications of portal hypertension11/3462/3535/36
Dunne et al[21]29/29Child–Pugh class C disease (a score of 10 to 13) or class B disease (with or without active bleeding at diagnostic endoscopy); inability to control bleeding at index endoscopy was considered an exclusion criteriaPrimary: 1-yr survival; secondary: survival at 6 wk, early rebleeding (within 6 wk) and late rebleeding (between 6 wk and 1 yr), and the development of HE24/3479/7641/17
Table 2 Summary of the randomised controlled trials on transjugular intrahepatic portosystemic shunt in patients with ascites
Ref.No. of pts (LVP/TIPS)Definition of ascites for inclusionExclusion criteriaPrimary and secondary outcomes and mean follow-up time (LVP/TIPS) in monthsImprovement in ascites (%; LVP/TIPS)HE (%; LVP/TIPS)Survival (%; LVP/TIPS)
Lebrec et al[49]12/13Despite adequate diuretics and sodium restriction: (1) Weight loss < 200 g/d in 5 d or (2) > 2 episodes of tense ascites in 4 mthAge > 70 yr, severe extra-hepatic diseases, HCC, pulmonary hypertension, HE, bacterial infection, severe alcoholic hepatitis, portal or hepatic vein obstruction or thrombosis, obstruction of biliary tract, obstruction of hepatic artery, serum creatinine >1.7 mg/dLPrimary: Recurrence of ascites; secondary: Overall survival, HE, hemodynamic, liver; and renal function; Follow-up: 12.4/7.50/386/1560/29
Rossle et al[80]31/29Definition reported in 1996 by IAC (45% patients had recidivant ascites)Overt HE, serum bilirubin > 5 mg/dL, serum creatinine > 3 mg/dL, PVT, hepatic hydrothorax, advanced cancer, failure of LVP (ascites persisting after LVP or need for LVP > once per week)Primary: TFS; secondary: Recurrence of ascites, liver and renal function, HE; Follow-up: 44/4543/8413/2332/58
Gines et al[81]35/35Definition reported in 1996 by IACAge > 18 or > 75 yr; serum bilirubin > 10 mg/dL; prothrombin time < 40% (INR 2.5); platelet count < than 40000/mm3; serum creatinine > 3 mg/dL, HCC, complete portal vein thrombosis; cardiac or respiratory failure; organic renal failure; bacterial infection; chronic HEPrimary: TFS; secondary: Recurrence of ascites, liver and renal function, HE, GI, bleeding, HRS; Follow-up: 10.8/9.517/5134/6030/26
Sanyal et al[82]57/52Definition reported in 1996 by IACCauses of ascites other than cirrhosis, advanced liver failure (serum bilirubin bilirubin > 5 mg/dL, PT INR > 2), incurable cancers or nonhepatic diseases that were likely to limit life expectancy to 1 yr, congestive heart failure, acute renal failure, parenchymal renal disease, PVT; bacterial infections, overt HE, florid alcoholic hepatitis, HCC, GI hemorrhage within 6 wk of randomisationPrimary: Recurrence of ascites and TFS; secondary: Overall survival, HE, GI bleeding, liver and renal function, quality of life; Follow-up: 38/4116/5821/3833/35
Salerno et al[83]33/33Definition reported in 1996 by IAC (32% patients had recidivant ascites)Age > 72 yr, recurrent overt HE, serum bilirubin > 6 mg/dL, serum creatinine > 3 mg/dL, CTP score> 11, complete PVT; HCC; GI bleeding within 15 d of randomisation, serious cardiac or pulmonary dysfunctions, bacterial infection, SAAG gradient < 11 g/LPrimary: TFS; secondary: Recurrence of ascites, HE, GI bleeding, liver and renal function, HRS; Follow-up: 15/2142/7939/6129/59
Narahara et al[88]30/30Definition reported in 1996 by IACAge > 70 yr, chronic HE, HCC and other malignancies, complete portal vein thrombosis with cavernomatous transformation, bacterial infection, severe cardiac or pulmonary disease, organic renal diseasePrimary: Overall survival; secondary: Recurrence of ascites, HE; Follow-up: 13/2730/8717/6730/43
Bureau et al[92]33/29At least 2 LVPs within a minimum interval of 3 wkAge < 18 and > 70 yrs, patients who had required > 6 LVPs within the previous 3 mo; patients on transplant waiting list, congestive heart failure, history or presence of pulmonary hypertension, complete PVT, recurrent overt HE, HCC, severe liver failure (prothrombin index < 35%, total bilirubin > 100 mmol/L or CTP score > 12), serum creatinine > 250 mmol/L, uncontrolled sepsisPrimary: 1-yr liver TFS; secondary: Ascites recurrence and treatment failure, overt HE, PHT-related complications, other complications of cirrhosis, and the number of days in hospital during a 1-yr period after inclusion; Follow-up: 10.4 /11.5At 1-yr follow-up, total number of paracentesis in the TIPS and LVP group were 32 and 320, respectively35/3552/93
Table 3 Complications associated with transjugular intrahepatic portosystemic shunt placement and prevention or management strategies
Carotid artery puncture during internal jugular vein accessUsing ultrasound and fluoroscopic guidance for jugular venous access
Right atrial perforationAvoid keeping the large 10-F sheath in the right atrium after the procedure
Capsular laceration during wedged hepatic venographyUsing closed bag system for CO2 delivery/gentle injection of iodinated contrast
Hepatic capsular transgression or extrahepatic portal venous punctureUsing guidance for portal venous access
Non-target TIPS stent insertion into biliary tract or hepatic arteryUsing guidance (USG/IVUS/CBCT) for portal venous access, confirm successful puncture with contrast injection
TIPS stent migrationCareful stent deployement and maintaining wire access across the stent until satisfactory, positioning is confirmed with portal venography, in case retrieval is needed
Early shunt occlusionPositioning the proximal end of the stent till the hepatico-caval junction; thrombectomy, thrombolysis and restenting can be done for establishing flow
Hernia incarcerationPre-TIPS hernia repair; alternatively, keeping a high index of suspicion after TIPS and prompt referral to a surgeon for management