Unsolved Questions in Salvage TIPSS: Practical Modalities for Placement, Alternative Therapeutics, and Long-Term Outcomes

Shunt dysfunction and mortality after transjugular intrahepatic portosystemic shunt (TIPS) in patients with portal hypertension

OBJECTIVES

Transjugular intrahepatic portosystemic shunt (TIPS) is a catheter-based, minimally invasive procedure to reduce portal hypertension. The aim of the study was to investigate dysfunction and mortality after TIPS and to identify factors associated with these events.

METHODS

A retrospective analysis of 834 patients undergoing TIPS implantation in a single center from 1993-2018 was performed. Cumulative incidence curves were estimated, and frailty models were used to assess associations between potentially influential variables and time to dysfunction or death.

RESULTS

1-, 2-, and 5-year mortality rates were 20.9% (confidence interval (CI) 17.7-24.1), 22.5% (CI 19.1-25.8), and 25.0% (CI: 21.1-28.8), 1-year, 2-year, and 5-year dysfunction rates were 28.4% (CI 24.6-32.3), 38.9% (CI 34.5-43.3), and 52.4% (CI 47.2-57.6). The use of covered stents is a protective factor regarding TIPS dysfunction (hazard ratio (HR) 0.47, CI 0.33-0.68) but does not play a major role in survival (HR 0.95, CI 0.58-1.56). Risk factors for mortality are rather TIPS in an emergency setting (HR 2.78, CI 1.19-6.50), a previous TIPS dysfunction (HR 2.43, CI 1.28-4.62), and an increased Freiburg score (HR 1.45, CI 0.93-2.28).

CONCLUSION

The use of covered stents is an important protective factor regarding TIPS dysfunction. Whereas previous TIPS dysfunction, emergency TIPS implantation, and an elevated Freiburg score are associated with increased mortality. Awareness of risk factors could contribute to a better selection of patients who may benefit from a TIPS procedure and improve clinical follow-up with regard to early detection of thrombosis/stenosis.

CRITICAL RELEVANCE STATEMENT

The use of covered stents reduces the risk of dysfunction after transjugular intrahepatic portosystemic shunt (TIPS). TIPS dysfunction, emergency TIPS placement, and a high Freiburg score are linked to higher mortality rates in TIPS patients.

KEY POINTS

The risk of dysfunction is higher for uncovered stents compared to covered stents. Transjugular intrahepatic portosystemic shunt dysfunction increases the risk of instantaneous death after the intervention. A higher Freiburg score increases the rate of death after the intervention. Transjugular intrahepatic portosystemic shunt implantations in emergency settings reduce survival rates.

Portosystemic shunt for variceal esophagogastric bleeding and risk of early re-bleeding. Rationale for involuntary intervention: A single-center observational controlled study

Background. Variceal esophageal-gastric bleeding is considered to be a life-threatening complication of portal hypertension in patients with cirrhosis. In some cases, only portosystemic shunt can serve as a life-saving intervention for the patient.

Aim. To justify the forced expediency of transjugular intrahepatic portosystemic shunt (TIPS) in case of ineffective drug and endoscopic hemostasis or a high risk of early recurrence of variceal bleeding.

Methods. A single-center observational controlled study was conducted to analyze the results of shunt procedure in 62 patients during the period of 2017–2023. The patients were divided into 2 groups: the main group (n = 32) with patients who underwent “early” shunt procedure in a “salvage” variant (n = 10) with continued bleeding and in a “pre-emptive” variant (n = 22) with a high risk of early recurrence of hemorrhage, and the control group (n = 30) with patients who underwent planned shunt procedure. The value of the portosystemic pressure gradient was calculated by subtracting the value of the pressure in the inferior vena cava recorded at the initial stage of the operation from the value of the initial pressure in the portal vein, measured by direct manometry. The authors compared the dynamics of the portosystemic pressure gradient in the study groups at similar stages of the intervention — initial, after embolization of the veins of portal blood flow to the varix, after shunt stenting. The study involved the analysis of mortality rates (6-week, one-year, for the entire observation period) and complications. Statistica-for-Windows 12.0 (StatSoft®, USA) and Excel (Microsoft, USA) were used to calculate descriptive statistics.

Results. Patients of both groups achieved normalization of pressure in the portal vein system and, accordingly, the portosystemic pressure gradient as a result of shunt surgery. Effective portal decompression was confirmed by their significant reduction. In the portal vein, the pressure decreased from 33.84 ± 2.70 to 20.53 ± 1.27 mmHg (t = 4.46; p < 0.001) in the main group and from 32.80 ± 3.07 to 20.10 ± 1.60 mmHg (t = 3.67; p < 0.001) in the control group. The dynamics of the portosystemic pressure gradient showed a significant decrease from 26.16 ± 2.69 to 10.06 ± 0.88 mm Hg (t = 5.69; p < 0.001) in the main group, and from 24.83 ± 2.73 to 9.67 ± 1.21 mm Hg (t = 5.08; p < 0.001) in the control group. Together with embolization of the vessels of the hepatofugal inflow of portal blood to the varices, this led to a stable and long-term cessation of variceal bleeding. When comparing the results of shunt procedure in the study groups, no significant differences were found in terms of differentiated mortality rates and complications in both the early and long-term periods. In the main group, the 6-week and one-year mortality rates accounted for 6.3% (n = 2) and 15.6% (n = 5), in the control group — 6.7% (n = 2) and 13.3% (n = 4), respectively (p = 0.917). Mortality in the main group comprised 25.0% (n = 8) over 58 months, in the control group — 23.3% (n = 7) over 60 months (p = 0.886).

Conclusion. The transjugular shunt provides a significant reduction in the portosystemic pressure gradient. “Salvage” and “pre-emptive” shunt options can prevent death and early recurrence of bleeding. Their effectiveness increases due to endovascular blockage of vessels that ensures the overflow of esophagogastric varices with portal blood.

Safety and Efficacy of TIPS as a Bridge to Liver Transplantation in Two Cases of Severely High MELD Patients With Variceal Bleeding

Transjugular intrahepatic portosystemic shunt (TIPS) is well established as a salvage therapy for refractory esophageal variceal hemorrhage (EVH). A more controversial issue is the upper limit of Model for End-Stage Liver Disease (MELD) scores at which this procedure can be performed safely. We present 2 cases of TIPS performed for EVH in patients with severely high MELD scores as a successful intervention for hemostatic and hemodynamic stabilization, and as a bridge to urgent liver transplantation. Both patients had endoscopically confirmed EVH with high blood product transfusion and vasopressor needs despite standard medical therapy. Each received narrow bore TIPS at MELD 42 and 44, respectively, with subsequent resolution of hemorrhage despite worsening synthetic liver function. Detrimental consequences of metabolic acidosis associated with minimal residual hepatic function were avoided via continuous renal replacement therapy and mechanical ventilation, with a goal to maintain cardiopulmonary stability and favorable acid base balance. Liver transplant followed TIPS 4 and 3 days, respectively, with both patients maintaining good functional status at discharge. Both cases suggest that in patients deemed otherwise appropriate for liver transplantation, a severely high MELD score alone should not preclude TIPS as salvage therapy for refractory EVH bleeds.

Where does TIPS fit in the management of patients with cirrhosis?

In this review, we summarise the current knowledge on the indications and contraindications of transjugular intrahepatic portosystemic shunt (TIPS) placement for the treatment of the complications of portal hypertension in cirrhosis, specifically variceal haemorrhage and ascites. Moreover, we discuss the role of TIPS for the treatment of portal vein thrombosis (PVT) and the prevention of complications after extrahepatic surgery ('preoperative TIPS') in patients with cirrhosis. The position of TIPS in the treatment hierarchy depends on the clinical setting and on patient characteristics. In acute variceal haemorrhage, preemptive TIPS is indicated in patients at a high risk of failing standard therapy, that is those with a Child-Pugh score of 10-13 points or Child-Pugh B with active bleeding at endoscopy, although the survival benefit in the latter group still remains to be established. Non-preemptive TIPS is a second-line therapy for the prevention of recurrent variceal haemorrhage and for the treatment of ascites. Of note, TIPS may also improve sarcopenia. Contraindications to TIPS placement, independent of clinical setting, include very advanced disease (Child-Pugh >13 points), episodes of recurrent overt hepatic encephalopathy without an identifiable precipitating factor, heart failure, and pulmonary hypertension. In patients with PVT, TIPS placement not only controls complications of portal hypertension, but also promotes portal vein recanalisation. Although the severity of portal hypertension correlates with poor outcomes after extrahepatic surgery, there is no evidence to recommend preoperative TIPS placement.