Which patients benefit the most? An update on transjugular intrahepatic portosystemic shunt

Table 1 Key points concerning transjugular intrahepatic portosystemic shunt

Technical aspects	Perform TIPS with anesthetic sedation or general anesthesia
	Use prosthesis coated with PTFE
	Measure HVPG
	Puncture the portal vein branch guided by abdominal ultrasound
	Use preferably a prosthesis of 8 mm
	Monitoring patients to assess TIPS patency, with doppler ultrasound performed at 1 week, 3 months, 6 months and then every 6 months
Indications	Refractory ascites
	Recurrent ascites that are difficult to manage
	Variceal bleeding unresponsive to pharmacological treatment combined with endoscopic therapy
	Variceal rebleeding in the first 5 days
	High risk for rebleeding (pTIPS): Child C score < 14 points or Child B with a score > 7 with active bleeding on endoscopy, in the first 72 hours after combined treatment (endoscopic and vasoactive drugs), regardless of whether they responded to initial standard therapy
	Hepatic hydrothorax
	Budd-Chiari syndrome
	Portosinusoidal vascular disorder
	Hepatorenal syndrome not associated with AKI
	To prevent future decompensation in cirrhosis
Contraindications	Absolute: Severe uncontrolled HE, systemic infection or sepsis, congestive heart failure (stage C or D, or a documented ejection fraction < 50%); severe pulmonary arterial hypertension, untreated biliary obstruction
	Relative: Very high MELD score, Child-Pugh score > 13 points, severe coagulopathy, polycystic liver disease, portal or hepatic vein occlusion and intrahepatic tumors
Complications	HE, deterioration of liver function and complications related to cardiac overload (low-risk if BNP < 40 pg/mL; NT-proBNP < 125 pg/mL; absence of a prolonged QT interval and diastolic dysfunction criteria on the echocardiogram)

TIPS: Transjugular intrahepatic portosystemic shunt; HVPG: Hepatic venous pressure gradient; PTFE: Polytetrafluoroethylene; pTIPS: Preemptive transjugular intrahepatic portosystemic shunt; MELD: Model for end stage liver diseases; HE: Hepatic encephalopathy BNP: Brain natriuretic peptide; NT-proBNP: N-terminal pro-brain natriuretic peptide; AKI: Acute kidney injury.