New Indications for TIPSs: What Do We Know So Far?

Abstract

Since 1988, transjugular intrahepatic portosystemic shunt (TIPS) has been an effective therapy for portal hypertension in many settings. Thanks to continuous technical improvements and a wiser selection of patients, excellent results have been achieved with this therapeutic strategy. The historical indications for TIPS placement, in the context of liver cirrhosis, such as refractory ascites and variceal bleeding are now well established and known. However, in recent years, new indications are emerging. These have been investigated and approved in some studies but are not yet included in guidelines and clinical practice. This review aims to highlight what is new for the role of TIPS in portal vein thrombosis (especially in patients awaiting liver transplantation), in recurrent ascites and not only refractory ascites, as a neoadjuvant therapy before abdominal surgery and, finally, in the setting of noncirrhotic portal hypertension. All these new aspects are addressed in this review with a critical approach based on the literature revision and clinical practice. Future research is needed to explore and validate the new role of TIPS in these scenarios. Since 1988, transjugular intrahepatic portosystemic shunt (TIPS) has been an effective therapy for portal hypertension in many settings. Thanks to continuous technical improvements and a wiser selection of patients, excellent results have been achieved with this therapeutic strategy. The historical indications for TIPS placement, in the context of liver cirrhosis, such as refractory ascites and variceal bleeding are now well established and known. However, in recent years, new indications are emerging. These have been investigated and approved in some studies but are not yet included in guidelines and clinical practice. This review aims to highlight what is new for the role of TIPS in portal vein thrombosis (especially in patients awaiting liver transplantation), in recurrent ascites and not only refractory ascites, as a neoadjuvant therapy before abdominal surgery and, finally, in the setting of noncirrhotic portal hypertension. All these new aspects are addressed in this review with a critical approach based on the literature revision and clinical practice. Future research is needed to explore and validate the new role of TIPS in these scenarios. The transjugular intrahepatic portosystemic shunt (TIPS) is an artificial channel within the liver that establishes communication between the inflow portal vein and the outflow hepatic vein. The first successful TIPS insertions were performed in 1988 at the University of Freiburg, and it has since become the standard of care for certain complications of liver cirrhosis.1Rössle M. Richter G.M. Nöldge G. Palmaz J.C. Wenz W. Gerok W. New non-operative treatment for variceal haemorrhage.Lancet. 1989 Jul 15; 2: 153Abstract PubMed Scopus (74) Google Scholar However, it was not a process without its setbacks. TIPS dysfunction due to thrombosis or intimal hyperplasia and subsequent graft stenosis or complete occlusion limited the use of bare grafts by leading to a clinical relapse of portal hypertensive (PH) complications.2Eesa M. Clark T. Transjugular intrahepatic portosystemic shunt: state of the art.Semin Roentgenol. 2011 Apr; 46: 125-132Crossref PubMed Scopus (20) Google Scholar Polytetrafluoroethylene (PTFE)-covered stent graft reduced the rates of TIPS dysfunction, and it was the single most important factor allowing the widespread use of TIPS in the clinical practice. Currently, refractory ascites (RefA) and variceal bleeding are routine indications for TIPS placement in the context of liver cirrhosis. Importantly, PTFE-covered stent grafts allowed new indications to emerge as well. However, there is currently no recommendation in the clinical practice guidelines for or against using TIPS in these clinical settings. Therefore, this review aimed to highlight what is new for the role of TIPS in portal vein thrombosis (PVT; especially in patients awaiting liver transplantation), in recurrent ascites (RecA), or as neoadjuvant therapy before abdominal surgery, and finally, in the setting of noncirrhotic PH. All these new aspects are addressed in this review with a critical approach based on the literature revision and clinical practice. Future research is needed to explore and validate the role of TIPS in these new scenarios (Figure 1). TIPS is an intrahepatic shunt that connects the portal circulation to the systemic one, reducing the pressures that insist on the portal system. It is an interventional radiology procedure, which should be performed only in third-level centers that have matured experience of the procedure and possible complications. The classic procedure consists of the catheterization of one of the hepatic veins, achieved by puncturing the internal jugular vein under ultrasound guidance. The hepatic parenchyma is punctured until one of the main branches of the portal vein is reached. Then, it is possible to measure the portosystemic pressure gradient between the portal circulation (indirectly) and the inferior vena cava. Finally, through balloon dilatation, the channel is created where the stent is positioned, which can be further dilated as needed. To date, there are no recent international guidelines on the placement of TIPS. Based on the European guidelines on decompensated cirrhosis and the Italian consensus on the positioning of TIPS, it is possible to derive the following3European Association for the Study of the LiverEASL Clinical Practice Guidelines for the management of patients with decompensated cirrhosis.J Hepatol. 2018 Aug; 69: 406-460Abstract Full Text Full Text PDF PubMed Scopus (1520) Google Scholar,4Fagiuoli S. Bruno R. Debernardi Venon W. TIPS on TIPS Full Text Full Text PDF PubMed Scopus Google The classic indications for the placement of TIPS are as ascites, as it the of ascites and hepatic treatment of with and variceal TIPS within in patients, such as with with or with treatment in patients for liver in or are not of or with TIPS placement with or without to ascites there are no and on this of and in patients with ascites or with the indications of the with cirrhosis However, it should be that TIPS is a procedure that in patients with in patients with liver cirrhosis. 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