Trans-jugular intrahepatic portosystemic stent shunting benefits and limits

Abstract

Trans-jugular intrahepatic portosystemic stent shunting (TIPSS) has been in use for many years with great results and many evolutions. The procedure essentially involves the insertion of a metal covert stent to create an Hepato-Hepatic portosystemic shunt. Over time, TIPSS has become the subject of many studies aimed at examining its clinical utility and evaluating the results of using TIPSS to manage complications related to portal hypertension. From the outset, this procedure has been met with hope and enthusiasm and give the chance to consider another possibility to treat the complications of portal hypertension without the use of surgery. Considering that TIPSS is an attractive alternative to shunt surgery because it does not require the use of general anesthesia or laparotomy, in fact this method is applicable to many patients with severe liver disease not suitable for it. TIPSS has been studied for the management of variceal bleeding, ascites, hepatic hydrothorax, hepatorenal syndrome, and other types of cirrhosis. However, some drawbacks of the TIPSS, such as shunt stenosis and hepatic encephalopathy, have also been reported in the literature. On the basis of the available evidence and the new epidemiological findings regarding liver disease, the following question may be posed: What is the place of TIPSS in current clinical practice?

Key Words: Hepatic compensation; Decompensation; Trans-jugular intrahepatic portosystemic stent-shunt; Bleeding; Ascites

Core Tip: The main topic of this article is whether trans-jugular intrahepatic portosystemic stent shunting can be considered a useful strategy for liver recompensation, following the new recommendations of the Baveno guidelines and clinical experience.

TO THE EDITOR

The new Baveno VII guidelines strongly recommend that hepatopathic patients be referred as soon as possible to an expert center for treatment, including the opportunity for trans-jugular intrahepatic portosystemic stent shunting (TIPSS) implantation. Evidence suggests that TIPSS is not effective for everyone. For example, TIPSS may be unuseful and maybe could create damage in not compensated patients (Child-Pugh C cirrhosis or model for end-stage liver disease score of > 30) and lactate levels unless liver transplantation is performed shortly[1-5]. This decision in critical patients must consider the multidisciplinary decision of different professionals (hepatologists, cardiologists, and radiologists). However, the increased expertise of interventional radiologists and cardiologists, as well as certain predictive clinical tests, has significantly reduced the incidence of complications and left room for new indications[4].

In the field of transplantation, if patients exhibit refractory bleeding, urgent treatment with TIPSS can be considered a bridge to transplantation; in patients with refractory ascites, TIPSS could allow complete compensation and consequent delisting[6]. Moreover, TIPSS should also be considered for transfusion-dependent patients and those who require weekly transfusions, we see an improvement of this and a minor necessity of transfusion, that is important for the quality of life of the patients. More Moreover, portal hypertension gastritis despite the indications to treat it with NSBBs and endoscopy, has been shown to improve after TIPS, moreover preprocedural sarcopenia is associated with a worst outcome and more risk of decompensation. In fact, Sarcopenia cannot be an indication for TIPSS[7].

Innovative indications for TIPSS are growing. For example, in cases of refractory variceal bleeding, TIPSS should be performed in less than 72 hours at specialized center. We are living in a new era in which there may be more options to treat our patients or to delist them. Hopefully, we will gain new competence and expertise to avoid most of the complications of this procedure.

CONCLUSION

In conclusion, TIPSS is a safe procedure that, despite its limitations, provides a new option for patients who are affected by severe complications of cirrhosis. These individuals could gain more time to await transplantation or may even be removed from the waiting list for recompensation. Moreover, through this approach, we can help patients with complications of cirrhosis to obtain a better quality of life. We understand that a more powerful message needed of more reference so we search more important article and review, and we see the same things, TIPSS is a benefit, with some complication, as all medical action.