TIPS in the Treatment of Variceal Bleeding

2017 ◽  
Vol 01 (04) ◽  
pp. 265-271
Author(s):  
Joseph Morrison ◽  
Andrew Lipnik ◽  
Ron Gaba
Keyword(s):  
Variceal Bleeding ◽  
Selection Criteria ◽  
Gastric Varices ◽  
Portosystemic Shunt ◽  
Variceal Hemorrhage ◽  
Life Threatening ◽  
Intrahepatic Portosystemic Shunt ◽  
Patient Selection Criteria ◽  
Early Tips

AbstractVariceal bleeding is a life-threatening complication of portal hypertension. In recent years, transjugular intrahepatic portosystemic shunt (TIPS) creation has cemented a role in the management of acute refractory bleeding and recurrent variceal hemorrhage. This article aims to review the use of TIPS in patients with variceal bleeding, with a focus on accepted procedure indications, patient selection criteria, TIPS technique, clinical outcomes, and contemporary issues, such as early TIPS in acute variceal hemorrhage, the role of adjuvant embolotherapy, and TIPS utility for gastric varices.

scholarly journals Emergent Transjugular Intrahepatic Portosystemic Shunt Creation in Acute Variceal Bleeding

2020 ◽  
Vol 37 (01) ◽  
pp. 003-013
Author(s):  
Mithil B. Pandhi ◽  
Andrew J. Kuei ◽  
Andrew J. Lipnik ◽  
Ron C. Gaba
Keyword(s):  
Transjugular Intrahepatic Portosystemic Shunt ◽  
Portosystemic Shunt ◽  
Pharmacologic Therapy ◽  
Variceal Hemorrhage ◽  
Gastroesophageal Varices ◽  
Portal Decompression ◽  
Intrahepatic Portosystemic Shunt ◽  
History Of ◽  
Early Tips

AbstractEmergent transjugular intrahepatic portosystemic shunt (TIPS) creation is most commonly employed in the setting of acute variceal hemorrhage. Given a propensity for decompensation, these patients often require a multidisciplinary, multimodal approach involving prompt diagnosis, pharmacologic therapy, and endoscopic intervention. While successful in the majority of cases, failure to medically control initial bleeding can prompt interventional radiology consultation for emergent portal decompression via TIPS creation. This article discusses TIPS creation in emergent, acute variceal hemorrhage, reviewing the natural history of gastroesophageal varices, presentation and diagnosis of acute variceal hemorrhage, pharmacologic therapy, endoscopic approaches, patient selection and risk stratification for TIPS, technical considerations for TIPS creation, adjunctive embolotherapy, and the role of salvage TIPS versus early TIPS in acute variceal hemorrhage.

scholarly journals Spontaneous portosystemic shunts in liver cirrhosis: new approaches to an old problem

2020 ◽  
Vol 13 ◽  
pp. 175628482096128 ◽  
Author(s):  
Judit Vidal-González ◽  
Sergi Quiroga ◽  
Macarena Simón-Talero ◽  
Joan Genescà
Keyword(s):  
Liver Cirrhosis ◽  
Hepatic Encephalopathy ◽  
Portosystemic Shunt ◽  
Venous System ◽  
Variceal Hemorrhage ◽  
Portal Venous System ◽  
Portal Flow ◽  
Portosystemic Shunts ◽  
Intrahepatic Portosystemic Shunt

Portal hypertension is the main consequence of liver cirrhosis, leading to severe complications such as variceal hemorrhage, ascites or hepatic encephalopathy. As an attempt to decompress the portal venous system, portal flow is derived into the systemic venous system through spontaneous portosystemic shunts (SPSSs), bypassing the liver. In this review, we aim to provide an overview of the published reports in relation to the prevalence and physiopathology behind the appearance of SPSS in liver cirrhosis, as well as the complications derived from its formation and its management. The role of SPSS embolization is specifically discussed, as SPSSs have been assessed as a therapeutic target, mainly for patients with recurrent/persistent hepatic encephalopathy and preserved liver function. Furthermore, different aspects of the role of SPSS in liver transplantation, as well as in candidates for transjugular intrahepatic portosystemic shunt are reviewed. In these settings, SPSS occlusion has been proposed to minimize possible deleterious effects, but results are so far inconclusive.

scholarly journals Transjugular Intrahepatic Portosystemic Shunt (TIPS): Pathophysiologic Basics, Actual Indications and Results with Review of the Literature

2018 ◽  
Vol 190 (08) ◽  
pp. 701-711 ◽  
Author(s):  
Holger Strunk ◽  
Milka Marinova
Keyword(s):  
Transjugular Intrahepatic Portosystemic Shunt ◽  
Endoscopic Therapy ◽  
Secondary Prophylaxis ◽  
Portosystemic Shunt ◽  
Refractory Ascites ◽  
Variceal Hemorrhage ◽  
Line Therapy ◽  
Intrahepatic Portosystemic Shunt ◽  
Pugh Class ◽  
Early Tips

Background Transjugular intrahepatic portosystemic shunt (TIPS) is a non-selective portosystemic shunt created using endovascular techniques. During recent years technical improvements and new insights into pathophysiology have modified indications for TIPS placement. In this article we therefore want to discuss current knowledge. Method A literature review was performed to review and discuss the pathophysiology, indications and results of the TIPS procedure. Results Established TIPS indications are persistent bleeding despite combined pharmacological and endoscopic therapy and rebleeding during the first five days. A new indication in the European recommendations is early TIPS placement within 72 hours, ideally within 24 hours, in patients bleeding from esophageal or gastroesophageal varices at high risk for treatment failure (e. g. Child-Pugh class C < 14 points or Child-Pugh class B with active bleeding) after initial pharmacological and endoscopic therapy. For prevention of recurrent variceal hemorrhage in the recommendations, covered TIPS placement is the treatment of choice only after failed first-line therapy, although numerous TIPS studies show a prolonged time to rebleeding and a reduction of mortality. Similarly for secondary prophylaxis in patients with refractory ascites, covered TIPS placement may be considered only if the patient continues to be intolerant to NSBBs and is an appropriate TIPS candidate even though studies show that the TIPS procedure controls ascites, improves survival and renal function better than paracentesis. Potential indications for TIPS implantation are Budd-Chiari syndrome, acute portal vein thromboses, hydrothorax, hepatopulmonary and hepatorenal syndrome (Typ 2), portal hypertensive gastropathy (PHG) and prophylaxis of complications of abdominal surgery, very rarely bleeding in ectopic varices or in patients with chylothorax or chylous ascites. Conclusion TIPS placement is an established procedure with a new indication as “early TIPS”. In the European recommendations it is only the second-line therapy for prevention of recurrent variceal hemorrhage and for secondary prophylaxis in patients with refractory ascites although several studies showed a clear benefit of the TIPS procedure compared to ligation and NSBBs. Key Points  Citation Format

Early Transjugular Intrahepatic Portosystemic Shunt (TIPS) Placement in Patients with Cirrhosis and Variceal Bleeding

2017 ◽  
Vol 01 (04) ◽  
pp. 272-276 ◽  
Author(s):  
Brett Fortune ◽  
Mark Sands ◽  
Maria Bayona-Molano ◽  
Baljendra Kapoor ◽  
Min Lang
Keyword(s):  
Transjugular Intrahepatic Portosystemic Shunt ◽  
Variceal Bleeding ◽  
Portosystemic Shunt ◽  
Decompensated Cirrhosis ◽  
Proper Patient Selection ◽  
Rescue Treatment ◽  
Increased Risk ◽  
Intrahepatic Portosystemic Shunt ◽  
Pugh Class ◽  
Early Tips

AbstractThe placement of a transjugular intrahepatic portosystemic shunt (TIPS) has been traditionally used as a rescue treatment for uncontrolled or recurrent acute variceal bleeding (AVB) in patients with cirrhosis. However, more contemporary studies are revealing that early or ‘pre-emptive’ TIPS placement (performed within 24–72 h of AVB presentation) significantly controls bleeding, prevents rebleeding, and improves survival in selected patients when compared with standard pharmacological and endoscopic therapies. Furthermore, the use of early TIPS did not translate to an increased risk of hepatic encephalopathy (HE) for this population. Proper patient selection for early TIPS is paramount, as the procedure is unlikely to benefit patients with advanced decompensated cirrhosis (Child–Turcotte–Pugh [CTP] class C, score > 13) or patients who do not carry high risk with only mild hepatic dysfunction (Child-Turcotte-Pugh class A). Finally, while the current results for early TIPS are promising, further prospective studies are needed to confirm these findings before early TIPS can be widely adopted.

scholarly journals The role of pre-emptive Transjugular Intrahepatic Portosystemic Shunt in acute variceal bleeding: a literature review

2021 ◽  
Vol 12 ◽  
pp. 204062232199577
Author(s):  
Charelle Manning ◽  
Amera Elzubeir ◽  
Syed Alam
Keyword(s):  
Transjugular Intrahepatic Portosystemic Shunt ◽  
Variceal Bleeding ◽  
Standard Of Care ◽  
Portosystemic Shunt ◽  
Emergency Setting ◽  
Acute Variceal Bleeding ◽  
Variceal Bleed ◽  
Intrahepatic Portosystemic Shunt ◽  
History Of

The development of portal hypertension has serious implications in the natural history of liver cirrhosis, leading to complications such as ascites, hepatic encephalopathy and variceal bleeding. The management of acute variceal bleeding has improved in the last two decades, but despite the advances in endoscopic methods the overall prognosis remains poor, particularly within a subgroup of patients with more advanced disease. The role of Transjugular Intrahepatic Portosystemic Shunt (TIPSS) is a well-established method of achieving haemostasis by immediate portal decompression; however, its use in an emergency setting as a rescue strategy is still associated with high mortality. It has been shown that ‘early’ use of TIPSS as a pre-emptive strategy in a patient with acute variceal bleed in addition to the standard of care confers superior survival outcomes in a subgroup of patients at high risk of treatment failure and death. The purpose of this review is to appraise the literature around the indications, patient selection, utility, complications and economic considerations of pre-emptive TIPSS.

scholarly journals Transjugular Intrahepatic Portosystemic Shunt In COVID-19 Patient: A Case Report

2020 ◽  
Author(s):  
Daniel Simões de Oliveira ◽  
José Ragide Jamal Rímoli ◽  
Leonardo Guedes Moreira Valle ◽  
Bárbara Burza Benini ◽  
Luiz Tenório de Brito Siqueira
Keyword(s):  
Case Report ◽  
Pulmonary Function ◽  
Transjugular Intrahepatic Portosystemic Shunt ◽  
Variceal Bleeding ◽  
Emergency Situation ◽  
Gastric Varices ◽  
Portosystemic Shunt ◽  
Life Saving ◽  
Intrahepatic Portosystemic Shunt ◽  
Transplant Candidates

Abstract Transjugular intrahepatic portosystemic shunt (TIPS) should be considered in all liver transplant candidates, besides being a life-saving procedure in bleeding from esophageal or gastric varices. In this case, we describe the management of a patient with diagnosis of coronavirus (COVID-19) with variceal bleeding in an emergency situation with worsening of pulmonary function.

Therapies: Drugs, Scopes and Transjugular Intrahepatic Portosystemic Shunt - When and How?

2015 ◽  
Vol 33 (4) ◽  
pp. 524-533 ◽  
Author(s):  
Juan G. Abraldes ◽  
Puneeta Tandon
Keyword(s):  
High Risk ◽  
Transjugular Intrahepatic Portosystemic Shunt ◽  
Variceal Bleeding ◽  
Portosystemic Shunt ◽  
Variceal Hemorrhage ◽  
Band Ligation ◽  
First Choice ◽  
Intrahepatic Portosystemic Shunt ◽  
Endoscopic Band Ligation ◽  
Β Blockers

Variceal bleeding is the most serious complication of portal hypertension. All cirrhotic patients should be screened endoscopically for varices which are present in about 30% of compensated and 60% of decompensated patients at diagnosis. In patients without varices, endoscopy surveillance should be continued every 2 years. Patients with high-risk varices (moderate or large in size, or with red color signs, or in Child-Pugh C patients) should be treated with a nonselective β-blocker to prevent bleeding (propranolol, nadolol or carvedilol). Endoscopic banding ligation is also effective for the prevention of first bleeding, and it is the first choice in patients with contraindications or intolerance to β-blockers. Acute variceal hemorrhage still has a high mortality rate (around 15%) and requires intensive care management and conservative blood transfusion policy. Treatment is based on the combined use of vasoactive drugs, endoscopic band ligation and prophylactic antibiotics. Failures are best managed by transjugular intrahepatic portosystemic shunt (TIPS). Balloon tamponade or specifically designed covered esophageal stents can be used as a bridge to definitive therapy in unstable patients. Early, preemptive TIPS might be the first choice in patients at high risk of failure (Child-Pugh B with active bleeding or Child-Pugh C up to 13 points). Patients surviving a variceal bleeding are at high risk of rebleeding. A combination of β-blockers and endoscopic band ligation is the most effective therapeutic approach. Preliminary data suggest that the addition of simvastatin increases survival in these patients.

scholarly journals Endovascular Treatment for Variceal Hemorrhage: TIPS, BRTO, and Combined Approaches

2018 ◽  
Vol 35 (03) ◽  
pp. 169-184 ◽  
Author(s):  
Mithil Pandhi ◽  
Ramzy Khabbaz ◽  
Ron Gaba ◽  
Andrew Lipnik
Keyword(s):  
Portal Hypertension ◽  
Patient Selection ◽  
Transjugular Intrahepatic Portosystemic Shunt ◽  
Multidisciplinary Approach ◽  
Gastric Varices ◽  
Portosystemic Shunt ◽  
Variceal Hemorrhage ◽  
Optimal Management ◽  
Basic Technique ◽  
Intrahepatic Portosystemic Shunt

AbstractVariceal hemorrhage is a feared complication of portal hypertension, with high rates of morbidity and mortality. Optimal management requires a thoughtful, multidisciplinary approach. In cases of refractory or recurrent esophageal hemorrhage, endovascular approaches such as transjugular intrahepatic portosystemic shunt (TIPS) have a well-defined role. For hemorrhage related to gastric varices, the optimal treatment remains to be established; however, there is increasing adoption of balloon-occluded retrograde transvenous obliteration (BRTO). This article will review the concept, history, patient selection, basic technique, and outcomes for TIPS, BRTO, and combined TIPS + BRTO procedures for variceal hemorrhage.

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