The role of transjugular intrahepatic portosystemic shunt in the management of portal hypertension†

TIPS, transjugular intrahepatic portosystemic shunt; MELD, model for end-stage liver disease; HVPG, hepatic venous pressure gradient; PTFE, polytetrafluoroethylene; PHG, portal hypertensive gastropathy; GAVE, gastric antral vascular ectasia; LVP, large volume paracentesis; HRS, hepatorenal syndrome; BCS, Budd-Chiari syndrome. The recommendations in this article provide a data-supported approach. They are based on the following: (1) a formal review and analysis of recently published world literature on the topic (as listed in MEDLINE); (2) the American College of Physicians' A Manual for Assessing Health Practices and Designing Practice Guidelines1; (3) policy guidelines, including the American Association for the Study of Liver Diseases' Policy Statement on Development and Use of Practice Guidelines and the American Gastroenterological Association's Policy Statement on the Use of Medical Practice Guidelines2; and (4) the authors' years of experience in the care of patients with portal hypertension and use of transjugular intrahepatic portosystemic shunt in the management of these disorders. These recommendations are fully endorsed by the American Association for the Study of Liver Diseases and the Society for Interventional Radiology. Intended for use by physicians, these recommendations suggest preferred approaches to the diagnostic, therapeutic, and preventative aspects of care. They are intended to be flexible, in contrast to standards of care, which are inflexible policies designed to be followed in every case. Specific recommendations are based on relevant published information. In an attempt to characterize the quality of evidence supporting recommendations, the Practice Guidelines Committee of the American Association for the Study of Liver Diseases requires a grade to be assigned and reported with each recommendation (Table 1). Transjugular intrahepatic portosystemic shunt (TIPS) has been in use for more than 20 years to treat the complications of portal hypertension, and TIPS have been created in thousands of patients with liver disease worldwide.3-6 Despite the extensive use of TIPS to treat the complications of portal hypertension, there initially was a lack of consensus regarding which patients should receive TIPS instead of other forms of therapy. A 1995 conference sponsored by the National Institutes of Health concluded that TIPS was effective in the acute control and prevention of recurrent bleeding from varices, but it was unclear when TIPS should be used instead of medical and surgical therapy for these complications of portal hypertension. In addition, the efficacy of TIPS to control refractory ascites or treat Budd-Chiari syndrome was unclear but promising.7 Since then, more than 1,000 patients have been enrolled in multiple controlled trials comparing TIPS with endoscopic and pharmacological therapy in the prevention of rebleeding from varices and with large-volume paracentesis in the treatment of refractory ascites associated with cirrhosis. Furthermore, approximately 1,000 papers have been published on TIPS in the English literature alone. This body of work allows for more definitive recommendations about in whom and when to use TIPS in the treatment of the complications of portal hypertension. The guidelines are divided into two large categories. The first category is a review of the technical aspects of the procedure, its complications, and the data on which patients are most at risk for an adverse outcome following TIPS. The second category is a review of the indications for TIPS. The use of TIPS for primary prevention of variceal bleeding and the control of acute bleeding are discussed first. Next, the two indications for TIPS that have been subjected to controlled trials (prevention of recurrent bleeding from varices and refractory ascites) are discussed, and guidelines are developed. Lastly, all of the other indications for TIPS that have been described in the literature but have not been subjected to controlled trials are discussed, and guidelines are created. To prepare these guidelines, a MEDLINE search was performed on papers published between 1966 and 2004. Nine hundred eight papers were found under the subject heading “transjugular intrahepatic portosystemic shunt.” Controlled trials and large series were sought. Recently published papers were also used as a source of references missed by the MEDLINE search, as were the personal files of the two authors. 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