Endothelial cells lining transjugular intrahepatic portasystemic shunts originate in hepatic sinusoids: implications for pseudointimal hyperplasia

Liver transplantation and hepatocellular carcinoma: is TIPS deleterious? A multicentric retrospective study of the ARCHET research group with propensity score matching

PURPOSE

A transjugular intrahepatic portosystemic shunt (TIPS) before the liver transplantation (LT) has been considered a contraindication in cases of hepatocellular carcinoma (HCC) because of the risk of tumour growth. We aimed to assess the impact of TIPS on incidental HCC and oncological outcomes in transplanted patients with pre-existing HCC.

METHODS

All consecutive transplanted patients for cirrhosis who had a previous TIPS with or without HCC were included. Between 2007 and 2014, 1912 patients were transplanted. We included 122 (6.3%) patients having TIPS before LT. A 1:3 matched cohort of 366 patients (18.9%) having LT without previous TIPS was selected using a propensity score. Incidental HCC rate and risk factor of HCC recurrence were evaluated using multivariate analysis with a competing risk model.

RESULTS

Before LT, in the TIPS group, 27 (22.1%) had an HCC vs. 81 (22.1%) in the control group (p = 1). The incidental HCC rate was similar: 10.5% (10/95) in the TIPS group vs. 6.3% (18/285) in the control group (p = 0.17). Recurrence occurred in 1/27 (3.7%) patient in the TIPS group and in 7/81 (8.6%) patients in the control group, without significant difference (p = 0.51). After multivariate regression, patient's gender (p < 0.01) was significantly associated with HCC recurrence while a tumour within Milan criteria (p = 0.01, sHR: 0.17 [0.04; 0.7]) and an incidental HCC (p<0.01) were found to be protector factors against HCC recurrence.

CONCLUSION

TIPS did not worsen the prognosis of transplanted patients for HCC. TIPS should no longer be contraindicated for oncological reasons in patients with HCC waiting for an LT.

Transjugular intrahepatic portal shunt in the treatment of portal hypertension due to cirrhosis: single center experience

Aim

To investigate clinical efficacy of transjugular intrahepatic portal shunt (TIPS) for the treatment of cirrhotic portal hypertension.

Methods

71 cases of patients with cirrhotic portal hypertension and esophageal and gastric variceal bleeding hospitalized from January 2014 to June 2017 were enrolled and treated with TIPS. The change of portal pressure and serum biochemical indexes before and after TIPS were compared, and re-hemorrhage rate, ascites incidence, complications, and survival rate were calculated.

Results

71 patients (male/female 47/24, aged 29–77 years, average 48.9 ± 9.8 years) with cirrhotic portal hypertension received TIPS. The success rate of TIPS was 93% (66/71). During 1–24 months (mean 12.5 ± 7 months) follow-up of 66 patients, 61 cases survived and 5 cases died. The portal pressure decreased significantly from 40.48 ± 3.15 cmH2O to 23.59 ± 4.41 cmH2O after TIPS (P < 0.05). During the follow-up, the incidence of hepatic encephalopathy was 12.1%, the incidence of re-hemorrhage was 18.2%, and there were 4 cases of stent dysfunction, with 1 case of bare stent and 3 cases of dual stent.

Conclusion

TIPS is an effective procedure for the treatment of cirrhotic portal hypertension complications, since it can reduce portal pressure and significantly alleviate ascites. Liver function is impaired in short-term after TIPS, but TIPS has no significant effect on liver function in middle-term.

TIPS Is Not Associated with a Higher Risk of Developing HCC in Cirrhotic Patients: A Systematic Review and Meta-analysis

Background and Aims: The association between portal-systemic shunt and hepatocellular carcinoma (HCC) development in patients who have cirrhosis is still controversial. This systematic review with meta-analysis was performed to systematically clarify the potential role of portal-systemic shunt in the development of HCC. Methods: The PubMed, Embase, and Cochrane Library databases were searched for potentially eligible literature. Meta-analysis with random-effects model was performed to combine the incidence rates of HCC after portal-systemic shunt. Finally, seven studies were included. In the present review, we mainly focused on 859 patients (365 in the transjugular intrahepatic portal-systemic shunt (TIPS) group and 494 in the non-TIPS group) from five studies to analyze incidence rates after TIPS. Results: At the end of follow-up, there were 66 (18%, 66/365) patients who developed HCC after TIPS intervention and 63 (13%, 63/494) patients who developed HCC after non-TIPS treatments. Pooled estimates with random-effects model did not demonstrate a significant increase of incidence of HCC after TIPS (risk ratio: 1.37 [confidence interval (CI): 0.96 to 1.97]; p = 0.08) compared with non-TIPS treatments. Subgroup analyses for those patients with transplanted liver also did not detect a significant difference between the TIPS group and non-TIPS group (risk ratio: 1.10 [CI: 0.59 to 2.07]; p = 0.75). Conclusions: Current evidence suggests that portal-systemic shunt is not associated with a higher risk of HCC development in cirrhotic patients.

Transjugular intrahepatic porto-systemic shunt is a risk factor for liver dysplasia but not hepatocellular carcinoma: a retrospective study of explanted livers

BACKGROUND

Conflicting data exist regarding the risk for hepatocellular carcinoma after transjugular intrahepatic porto-systemic shunt (TIPS) insertion in cirrhotic patients.

METHODS

We retrospectively analysed histopathological data from 214 patients who were transplanted in our Institution including 68 patients who underwent TIPS placement before transplantation. Pathological lesions from explanted livers, including incidental hepatocellular carcinoma, small cell dysplasia and large cell dysplasia were recorded.

RESULTS

Pathological lesions were found in 36.4% of explanted livers. TIPS insertion was an independent risk factor for pathological lesion (HR = 2.11, p < 0.05), concurrently with age (HR = 1.10 per year, p < 0.001) and viral aetiology of cirrhosis (HR = 3.05, p < 0.001). When considering the different type of lesions, TIPS insertion was not associated with an increased risk for hepatocellular carcinoma but was an independent risk factor for liver dysplasia (HR = 2.15, p = 0.042).

CONCLUSION

Although a direct relationship between TIPS insertion and hepatocellular carcinoma risk was not demonstrated in this study, the increased frequency of liver dysplasia observed in TIPS-bearing explanted livers deserves further prospective investigations with adequate follow-up.

MRI-monitored intra-shunt local agent delivery of motexafin gadolinium: towards improving long-term patency of TIPS

Background

Transjugular intrahepatic portosystemic shunt (TIPS) has become an important and effective interventional procedure in treatment of the complications related to portal hypertension. Although the primary patency of TIPS has been greatly improved due to the clinical application of cover stent-grafts, the long-term patency is still suboptimal. This study was to investigate the feasibility of using magnetic resonance imaging (MRI)-monitored intra-shunt local agent delivery of motexafin gadolinium (MGd) into shunt-vein walls of TIPS. This new technique aimed to ultimately inhibit shuntstenosis of TIPS.

Methodology

Human umbilical vein smooth muscle cells (SMCs) were incubated with various concentrations of MGd, and then examed by confocal microscopy and T1-map MRI. In addition, the proliferation of MGd-treated cells was evaluated. For in vivo validation, seventeen pigs underwent TIPS. Before placement of the stent, an MGd/trypan-blue mixture was locally delivered, via a microporous balloon, into eleven shunt-hepatic vein walls under dynamic MRI monitoring, while trypan-blue only was locally delivered into six shunt-hepatic vein walls as serve as controls. T1-weighted MRI of the shunt-vein walls was achieved before- and at different time points after agent injections. Contrast-to-noise ratio (CNR) of the shunt-vein wall at each time-point was measured. Shunts were harvested for subsequent histology confirmation.

Principal Findings

In vitro studies confirmed the capability of SMCs in uptaking MGds in a concentration-dependent fashion, and demonstrated the suppression of cell proliferation by MGds as well. Dynamic MRI displayed MGd/blue penetration into the shunt-vein walls, showing significantly higher CNR of shunt-vein walls on post-delivery images than on pre-delivery images (49.5±9.4 vs 11.2±1.6, P<0.01), which was confirmed by histology.

Conclusion

Results of this study indicate that MRI-monitored intra-shunt local MGd delivery is feasible and MGd functions as a potential therapeutic agent to inhibit the proliferation of SMCs, which may open alternative avenues to improve the long-term patency of TIPS.

Using transjugular intrahepatic portosystemic shunts for complications of cirrhosis

Transjugular intrahepatic portosystemic shunt (TIPS) decompresses the portal venous system. TIPS has been used to manage the complications of portal hypertension in cirrhosis, including variceal hemorrhage and refractory ascites. The uncoated TIPS stents are limited by stent stenosis; however, the introduction of coated stents has decreased this. With the introduction of coated stents, we must reevaluate the utility of TIPS in the management of complications of portal hypertension.

Transjugular intrahepatic portosystemic shunt with an autologous endothelial progenitor cell seeded stent: a porcine model

RATIONALE AND OBJECTIVES

To evaluate the efficacy of a self-expanding metal stent seeded with autologous endothelial progenitor cells (EPCs) for preventing in-stent stenoses in transjugular intrahepatic portosystemic shunt (TIPS) in a swine model.

MATERIALS AND METHODS

TIPS was performed in 18 young adult pigs, using a self-expanding nitinol stent (control, n = 8) and an autologous EPC-seeded stent (treatment, n = 10). All pigs were sacrificed at 2 weeks post-TIPS procedure. Portography was performed immediately before the euthanasia. Gross, microscopic, and immunohistochemistry of the TIPS tract specimens were examined. The proliferative response of the shunt was quantified histologically.

RESULTS

TIPS was performed successfully in 16 swine, 2 animals died during the procedure. Another pig died of unknown causes 2 days post-procedure. At day 14 follow-up, portography and necropsy of the 15 remaining swine demonstrated that five shunts occluded and one shunt was stenotic (80%) in the control group (n = 6). Five shunts remained patent, two shunts were stenosed (50%, 70%), and the remaining two shunts were occluded in the treatment group (n = 9). The patency rate was significantly lower in the control group than in the treatment group, 0% versus 55.6% (P = .03). Histological analyses showed a significantly greater pseudointimal hyperplasia in the TIPS track of the control group than that of the treatment group (P < .05). Intact endothelium was documented in the lumina of all the EPC-implanted stent group.

CONCLUSIONS

The EPC-seeded metal stent is feasibly fabricated in vitro and improves the patency in TIPS in a porcine model.

The natural history of parallel transjugular intrahepatic portosystemic stent shunts using uncovered stent: the role of host-related factors

OBJECTIVES

Parallel shunts (PS) are used in the management of transjugular intrahepatic portosystemic stent-shunt (TIPS) insufficiency, a major limitation of the technique. This study describes the natural history of PS, and uses them as a model to assess the role of host factors in the development of primary shunt insufficiency.

METHODS

Out of 338 patients with TIPS, 40 (11.8%) patients required insertion of a PS. Baseline and follow-up data of these patients were collected. Regular shunt surveillance involved biannual clinic visits and transjugular portography.

RESULTS

The non-PS group (group 1; n = 298) and the PS group (group 2; n = 40) had similar baseline demographic and disease characteristics. Index shunts of both groups and the PS produced a significant portal pressure gradient drop (P < 0.001), which was less in the index shunts of Group 2 (P < 0.02 for both). PS had similar cumulative shunt patency rates to those of the index shunts of Group 1, and both were greater than those of index shunts in Group 2 (P < 0.001 for both). The intervention rate (number of interventions/number of check portograms x 100) was similar for PS and the index shunts of Group 1 (38.7% and 43% respectively), but was significantly higher in the index shunts of Group 2 (85.6%; P < 0.01 for both). In Group 1 and Group 2, 144 patients (48.3%) and 21 patients (52.5%) died during follow-up after a median period of 23.4 and 8.9 months respectively.

CONCLUSIONS

These findings do not support the hypothesis that shunt insufficiency is related to host factors.

Dacron-covered stent-grafts in transjugular intrahepatic portosystemic shunts: initial experience

PURPOSE

To retrospectively review the authors' experience with use of a Dacron-covered stent-graft in transjugular intrahepatic postosystemic shunts (TIPS).

MATERIALS AND METHODS

The need for internal review board approval was waived. Informed consent was obtained from all patients. The study was compliant with the Health Insurance Portability and Accountability Act. A retrospective analysis was performed of 16 patients who received a Dacron-covered stent-graft during revision or de novo creation of TIPS. There were 13 men and three women aged 44-80 years (mean age, 61 years). Primary unassisted and assisted patency rates and secondary patency rates were estimated. The primary unassisted patency of patients who underwent de novo placement of stent-grafts (n = 10) was compared with that of patients with stent-grafts placed during shunt revision (n = 6); in all patients, stent-grafts were placed within stents. Primary unassisted patency was also compared between patients in whom the covered stent was confined to the parenchymal tract (n = 7) and those in whom the stent extended 1 cm or more into the portal vein (n = 9). Patency was estimated with the Kaplan-Meier method, and group comparisons were performed with the log-rank test.

RESULTS

Primary unassisted patency rates following stent-graft placement at 4, 12, and 24 months (+/- standard error) were 64% +/- 14, 54% +/- 15, and 40% +/- 16, respectively. The rates for primary assisted patency were 78% +/- 12, 67% +/- 14, and 67% +/- 14 and those for secondary patency were 91% +/- 9, 81% +/- 12, and 54% +/- 23. At 12 months, primary unassisted patency with de novo stent-graft placement was 90% +/- 9, whereas that with stent-grafts placed during TIPS revision was 17% +/- 15 (P = .005). At 12 months, the primary unassisted patency in patients with stent-grafts confined to the parenchymal tract was 75% +/- 22, and that of patients with stent-grafts extending at least 1 cm into the portal vein was 40% +/- 17 (P = .21).

CONCLUSION

In this small series, satisfactory long-term patency was observed among patients in whom Dacron-covered stent-grafts were placed during revision or de novo creation of TIPS. More favorable outcomes were observed when the stent-graft was placed during de novo TIPS creation and when the device was confined to the parenchymal tract.

Bile leakage during transjugular intrahepatic portosystemic shunt creation: in vitro effect of bile on growth and function of human umbilical vein endothelium

PURPOSE

To evaluate the effect of bile on growth and proliferation of human umbilical vein endothelium cultured in vitro, with a view toward clarifying the effect of bile leakage during transjugular intrahepatic portosystemic shunt creation.

MATERIALS AND METHODS

This study was approved by the ethical review committee, and written informed consent was obtained from all mothers. Endothelial cells (ECs) were collected from human umbilical veins and cultured in vitro. After 24-48 hours in culture, ECs were distributed into groups supplemented with the following concentrations of bile in the culture medium: 0%, 5.0%, 10.0%, 15.0%, 20.0%, and 25.0%. The cells were harvested 5 days after supplementation with bile. The morphologic features, von Willebrand factor (vWF) level, tetrazolium salt (MTT) assay value of light absorption, total protein level, and nitric oxide synthase (NOS) activity of the ECs were evaluated.

RESULTS

All explanted cells were identified as ECs by using the vWF test. Compared with ECs in the control group without bile, ECs in culture medium with a bile concentration of 5.0%, 10.0%, or 15.0% showed no marked morphologic changes, whereas ECs in culture medium with a bile concentration of 20.0% or 25.0% were reduced greatly in number and looked markedly immature. The MTT value of light absorption, total protein level, and vWF secretion were significantly decreased (P < .05 for all) in ECs in culture medium with 25.0% bile compared with these parameters in ECs in culture medium without bile, although these parameters did not significantly differ between the ECs in culture medium of 5.0% or 10.0% bile and the ECs in culture medium without bile. Compared with NOS activity in ECs when no bile was present in the culture medium, NOS activity in ECs was significantly decreased at all bile concentrations (P < .05).

CONCLUSION

Low concentrations of bile do not markedly inhibit cell growth; the inhibiting effect of bile on ECs progresses with an increase in bile concentration.

Patients with cirrhosis and bare-stent TIPS may have increased risk of hepatocellular carcinoma

A trend toward a higher incidence of hepatocelullar carcinoma (HCC) in patients with cirrhosis treated with bare-stent transjugular intrahepatic portosystemic shunt (TIPS) has been observed in previous studies. To assess the influence of TIPS as a risk factor for developing HCC, we have compared the incidence of HCC in two retrospective cohorts of patients. The TIPS cohort (n = 138) included patients with cirrhosis who underwent TIPS placement for the treatment of portal hypertension-related complications; the non-TIPS cohort was composed of patients admitted at the hospital at the same time of TIPS insertion who were individually matched 1:1 according to age, sex, Child-Turcotte-Pugh class, and cause of cirrhosis. A stratified Cox model was used to assess risk of HCC development. The median time of follow-up was similar in TIPS and non-TIPS cohorts (30.3 [range, 7.8-119.5] and 31.4 [range, 7.8-110.8] months, respectively). The cumulative probability of developing HCC at 1, 3, and 5 years was 3%, 24%, and 34% for the TIPS cohort and 1%, 6%, and 25%, for the non-TIPS cohort, respectively (Breslow test = 5.23, P = .022). The adjusted hazard ratio was 1.52 (95% confidence interval, 1.06-2.19; P = .02). Hepatitis C virus infection and age were independent predictors of HCC development in patients without TIPS. In conclusion, patients with cirrhosis who are treated with TIPS may have a higher incidence of HCC. This observation suggests the need for a strict HCC surveillance program for these patients, especially if they are not expected to undergo a short- or medium-term liver transplantation.

[Increased long-term permeability of transjugular intrahepatic portosystemic shunt (TIPS) in 218 cirrhotic patients, with strict monitoring]

OBJECTIVE

To measure the impact of strict monitoring on long term permeability of TIPS.

METHODS

From November 1991 to December 2002, 208 patients (152 men and 66 women managed for the placing of a TIPS following failure with sclerotherapy or refractory ascites were included. The permeability of the prosthesis was controlled on the surgical piece. Revision of the TIPS was performed at the same time as the diagnosis of obstruction using trans-jugular angiography. The TIPS permeability was classified into 3 categories: primary permeability (duration of permeability recorded up until any intervention); assisted primary permeability (duration of continuous permeability with or without percutaneous intervention); secondary permeability (total duration of permeability with or without treated occlusion).

RESULTS

Among the 218 patients in the study, 108 had been monitored for less than one year (49.5%), 29 for between 1 and 2 years (13.5%), 27 between 2 and 3 years (12.5%), 16 between 3 and 4 years (7.5%), 15 between 4 and 5 years (7%) and 23 for more than 5 years (10%). The mean follow-up period was of 24.1 +/- 27.2 months (median: 13.7). Current survival of these patients was of 81.2 +/- 2.9% at 1 year, 62.9 +/- 4.2% at 3 years and 52 +/- 4.9% at 5 years. Thirty-four patients were lost to follow-up (16%), after a mean follow-up of 22.9 +/- 26.7 months (median: 9.7). All these patients exhibited a permeable TIPS during their last control. One hundred and thirty-five patients (62%) had never presented obstruction of the TIPS, with a mean follow-up of 19.5 +/- 26.2 months (median: 7.4); 83 patients (38%) exhibited 117 episodes of obstruction; 24 two episodes, 7 three and 3 more than three; 4 exhibited thrombosis provoked by an invalidating encephalopathy and contraindicating transplantation, 2 of them following a first episode of thrombosis. The current primary, primary assisted and secondary permeability rates were respectively: 67.7 +/- 3 and 514 +/- 3.7%, 79.9 +/- 2.3% and 69.3 +/- 3.4%, 94.4 +/- 1.8% and 91 +/- 2.6% at 1 and 3 years (p = 0.0001, Log Rank = 65.3). Univariate analysis revealed a relationship between the onset of an episode of early or late obstruction and the patients' age at the time the TIPS was inserted, Child's score before, and the pre- and post-surgical gradient. In multivariate analysis, none of these elements reached significance.

CONCLUSION

Although the use of TIPS in the treatment of portal hypertension follows the course of development of all surgery towards minimally invasive methods, it should not be considered as a surgical portal shunt or as a permanent treatment: long-term permeability is only obtained with strict and regular monitoring and the possibility of rapid intervention in the case of obstruction.

Improved clinical outcome using polytetrafluoroethylene-coated stents for TIPS: results of a randomized study

BACKGROUND & AIMS

A 50% dysfunction rate at 1 year is one of the main drawbacks of the transjugular intrahepatic portosystemic shunt procedure. Preliminary experimental and clinical studies suggest that the use of stents covered with polytetrafluoroethylene could tremendously decrease this risk.

METHODS

Eighty patients with cirrhosis and uncontrolled bleeding (n = 23), recurrent bleeding (n = 25), or refractory ascites (n = 32) were randomized to be treated by transjugular intrahepatic portosystemic shunts with either a polytetrafluoroethylene-covered stent (group 1; 39 patients) or a usual uncovered prosthesis (group 2; 41 patients). Follow-up Doppler ultrasound was scheduled at day 7, at 1 month, and then every 3 months for 2 years. Angiography and portosystemic pressure gradient measurements were performed 6, 12, and 24 months after the transjugular intrahepatic portosystemic shunt procedure and whenever dysfunction was suspected. Dysfunction was defined as a >50% reduction of the lumen of the shunt at angiography or a portosystemic pressure gradient >12 mm Hg.

RESULTS

After a median follow-up of 300 days, 5 patients (13%) in group 1 and 18 (44%) in group 2 experienced shunt dysfunction (P < 0.001). Clinical relapse occurred in 3 patients (8%) in group 1 and 12 (29%) in group 2 (P < 0.05). Actuarial rates of encephalopathy were 21% in group 1 and 41% in group 2 at 1 year (not significant). Estimated probabilities of survival were 71% and 60% at 1 year and 65% and 41% at 2 years in groups 1 and 2, respectively (not significant).

CONCLUSIONS

The use of polytetrafluoroethylene-covered prostheses improves transjugular intrahepatic portosystemic shunt patency and decreases the number of clinical relapses and reinterventions without increasing the risk of encephalopathy.

Portal hypertensive bleeding

Portal hypertension bleeding is a common and serious complication of cirrhosis. All patients with cirrhosis should undergo endoscopy and be evaluated for possible causes of current or future portal hypertensive bleeding. Possible causes of bleeding include esophageal varices, gastric varices, and PHG. Patients with esophageal varices at high risk of bleeding should be treated with nonselective beta-blockers for primary prevention of variceal hemorrhage. HVPG measurements represent the optimal way to monitor the success of pharmacologic therapy. EVL may be used in those with high-risk varices who do not tolerate beta-blockers. When active bleeding develops, simultaneous and coordinated attention must be given to hemodynamic resuscitation, prevention and treatment of complications, and active control of bleeding. In cases of acute esophageal variceal (Fig. 5) and PHG bleeding, terlipressin, somatostatin, or octreotide should be started. Endoscopic treatment is provided for those with bleeding esophageal varices. If first-line therapy fails, TIPS or surgery may need to be performed. Unlike esophageal variceal or PHG bleeding, there is no established optimal treatment for gastric variceal bleeding. Individual and specific treatment modalities for acute gastric variceal bleeding must be calculated carefully after considering side effects.

Transjugular intrahepatic portosystemic shunt with an autologous vein-covered stent: results in a swine model

PURPOSE

To investigate the feasibility, safety, and efficacy of an autologous vein-covered stent (AVCS) to prevent shunt stenosis in a porcine transjugular intrahepatic portosystemic shunt (TIPS) model.

MATERIALS AND METHODS

TIPS were created with an AVCS in 12 healthy domestic swine and with a bare stent in 10 additional swine. Tissue response was compared with use of venography, histology, and computerized morphometry analysis 2 weeks after implantation. Differences between AVCS and noncovered stents (established by a t-test), as well as regional differences within a single stent (established by an f test), were considered significant at P <.05.

RESULTS

Twenty of 22 TIPS procedures were technically successful. Ten of 12 shunts with an AVCS (83%) and two of 10 with bare stents (20%) remained patent (<50% diameter narrowing) at euthanasia 2 weeks later (P <.01). Histologic evaluation of harvested bare stents showed marked intimal hyperplasia (IH), composed of smooth muscle cells, myofibroblasts, and fibroblasts. In contrast, the AVCS were remarkably free of IH and thromboses. In patent TIPS in both groups, endothelial coverage of the luminal surface was present histologically. IH accounted for 57% (26.27/45.79) of total stent cross-sectional lumen area in the control group and 21% (8.34/39.54) in the AVCS group (P <.01), with no intrashunt differences (P >.05).

CONCLUSION

Based on short-term follow-up, AVCS significantly improved TIPS patency by prevention of both IH and in-stent thrombosis. TIPS created with an AVCS was feasible and safe in our porcine model.

Esophageal varices. II. TIPS (transjugular intrahepatic portosystemic shunt) and surgical therapy

The role of surgery in the prevention and treatment of variceal hemorrhage is reviewed. Types of available surgery, their physiologic basis, and literature supporting their use are discussed in the context of the natural history of variceal hemorrhage. The evolution of transjugular intrahepatic portosystemic shunt (TIPS) as a treatment modality for variceal hemorrhage is reviewed. The effects of TIPS on portal and systemic hemodynamics and clinical usefulness in the management of variceal hemorrhage are discussed. A treatment algorithm for the integrated use of the various treatments is provided.