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Transjugular intrahepatic portosystemic shunting
CHAPTER
76E
Transjugular intrahepatic portosystemic shunting: indications and technique Michael Darcy OVERVIEW In the 20 years since its introduction, transjugular intrahepatic portosystemic shunting (TIPS) has gone from being a procedure reserved for desperate circumstances to one that is now routinely used to manage some complications of portal hypertension. The broader utilization of TIPS has been accompanied by changes in the indications and techniques, influenced by greater experience and better knowledge of outcomes.
INDICATIONS Variceal Bleeding Bleeding gastroesophageal varices not controlled by medical or endoscopic means was the original indication for which TIPS was devised, and this is still the primary indication. TIPS can routinely decompress the portal system to drop the portosystemic gradient (PSG) and will lead to immediate cessation of bleeding in 95% of patients (Fig. 76E.1). A number of randomized trials have compared TIPS to best medical management (Cabrera et al, 1996; Cello et al, 1997; Garcia-Villarreal et al, 1999; Gulberg et al, 2002b; Jalan et al, 1997; Merli et al, 1998; Pomier-Layrargues et al, 2001; Rössle et al, 1997; Sanyal et al, 1997; Sauer et al, 1997). These have demonstrated that TIPS provides better long-term control of variceal bleeding. In these studies, recurrent bleeding occurred in 18% to 56% of patients in the sclerotherapy cohorts versus only 9% to 23% of patients in the TIPS arms. Not only were these differences statistically significant for the primary outcome, the crossover rate from endoscopy to TIPS was 5% to 28%, but only 0% to 7% of the TIPS patients crossed over to endoscopic treatment. Despite the improved control of bleeding, TIPS did not yield a survival benefit in most of these studies. One possible explanation for this is that by shunting portal blood flow from the liver, some deterioration in liver function occurs, and this might offset the improved survival related to control of hemorrhage. Alternatively, it is possible that the studies simply did not follow patients long enough to demonstrate the survival benefit. In most of the randomized trials, the survival in the TIPS group was longer than the medical therapy group but not long enough to achieve statistical significance; perhaps longer follow-up might have yielded a significant difference. Better stratification of patients might also have yielded different results, as evidenced by one randomized trial (Monescillo et al, 2004) that stratified patients according to early measurement of their hepatic venous pressure gradient (HVPG) and then randomized high-risk patients (HVPG >20 mm Hg) to medical management or early TIPS placement. Not only did 1180
the TIPS group have fewer episodes of recurrent bleeding, both the in-hospital and 1 year mortality rates (11% and 38%) were significantly lower than in the non-TIPS cohort (38% and 65%). One caveat regarding many of the randomized trials is that most were done using bare metal stents to create the shunt. Thus, within 6 to 12 months, the majority of the shunts in the TIPS group had stenosed. The current standard of care is to use stent grafts (polytetrafluoroethylene-covered stents) for TIPS procedures. These newer stent grafts have much improved patency and yield even better control of variceal bleeding than the bare metal TIPS (Angeloni et al, 2004; Angermayr et al, 2003; Bureau et al, 2007; Tripathi et al, 2006). Although more studies need to be done with stent grafts, at least one randomized trial (Garcia-Pagan et al, 2010) showed significantly better 1-year survival for TIPS performed with these improved stents compared with medical management (86% vs. 60%, P < .01). The main downfall to TIPS is the development of new hepatic encephalopathy or exacerbation of existing encephalopathy, which occurs in 20% to 31% of cases (Boyer & Haskal, 2010). It is for this reason that TIPS is still recommended only after failure of medical management and not as front-line therapy for variceal bleeding. Interestingly, despite improved patency, the stent-graft TIPS has actually been associated with a lower incidence of encephalopathy compared with bare-stent TIPS (Bureau et al, 2007; Tripathi et al, 2006). This is another reason why the randomized trials comparing TIPS to medical management need to be repeated with the newer stent grafts.
Gastric Varices and Gastropathy Gastric varices are also frequently seen in patients with portal hypertension and are actually associated with a higher rate of hemorrhage-related mortality compared with bleeding from esophageal varices (Garcia-Tsao & Bosch, 2010). TIPS can also provide good control of bleeding related to this condition, although the efficacy compared to endoscopic management is less clear. One large retrospective study comparing TIPS to endoscopic cyanoacrylate injection failed to demonstrate a benefit for TIPS in either control of bleeding or survival (Procaccini et al, 2009). However, another trial (Lo et al, 2007) that randomized patients to either TIPS or variceal obliteration with endoscopic cyanoacrylate injection showed that rebleeding was significantly less frequent in the TIPS group (11% vs. 38%, P = .014). TIPS has also been used to treat portal hypertensive gastropathy, but data are sparse, and no randomized trials have evaluated the use of TIPS for this condition. Some investigators believe that TIPS is less effective for this condition, and several
76E
Transjugular intrahepatic portosystemic shunting: indications and technique Michael Darcy OVERVIEW In the 20 years since its introduction, transjugular intrahepatic portosystemic shunting (TIPS) has gone from being a procedure reserved for desperate circumstances to one that is now routinely used to manage some complications of portal hypertension. The broader utilization of TIPS has been accompanied by changes in the indications and techniques, influenced by greater experience and better knowledge of outcomes.
INDICATIONS Variceal Bleeding Bleeding gastroesophageal varices not controlled by medical or endoscopic means was the original indication for which TIPS was devised, and this is still the primary indication. TIPS can routinely decompress the portal system to drop the portosystemic gradient (PSG) and will lead to immediate cessation of bleeding in 95% of patients (Fig. 76E.1). A number of randomized trials have compared TIPS to best medical management (Cabrera et al, 1996; Cello et al, 1997; Garcia-Villarreal et al, 1999; Gulberg et al, 2002b; Jalan et al, 1997; Merli et al, 1998; Pomier-Layrargues et al, 2001; Rössle et al, 1997; Sanyal et al, 1997; Sauer et al, 1997). These have demonstrated that TIPS provides better long-term control of variceal bleeding. In these studies, recurrent bleeding occurred in 18% to 56% of patients in the sclerotherapy cohorts versus only 9% to 23% of patients in the TIPS arms. Not only were these differences statistically significant for the primary outcome, the crossover rate from endoscopy to TIPS was 5% to 28%, but only 0% to 7% of the TIPS patients crossed over to endoscopic treatment. Despite the improved control of bleeding, TIPS did not yield a survival benefit in most of these studies. One possible explanation for this is that by shunting portal blood flow from the liver, some deterioration in liver function occurs, and this might offset the improved survival related to control of hemorrhage. Alternatively, it is possible that the studies simply did not follow patients long enough to demonstrate the survival benefit. In most of the randomized trials, the survival in the TIPS group was longer than the medical therapy group but not long enough to achieve statistical significance; perhaps longer follow-up might have yielded a significant difference. Better stratification of patients might also have yielded different results, as evidenced by one randomized trial (Monescillo et al, 2004) that stratified patients according to early measurement of their hepatic venous pressure gradient (HVPG) and then randomized high-risk patients (HVPG >20 mm Hg) to medical management or early TIPS placement. Not only did 1180
the TIPS group have fewer episodes of recurrent bleeding, both the in-hospital and 1 year mortality rates (11% and 38%) were significantly lower than in the non-TIPS cohort (38% and 65%). One caveat regarding many of the randomized trials is that most were done using bare metal stents to create the shunt. Thus, within 6 to 12 months, the majority of the shunts in the TIPS group had stenosed. The current standard of care is to use stent grafts (polytetrafluoroethylene-covered stents) for TIPS procedures. These newer stent grafts have much improved patency and yield even better control of variceal bleeding than the bare metal TIPS (Angeloni et al, 2004; Angermayr et al, 2003; Bureau et al, 2007; Tripathi et al, 2006). Although more studies need to be done with stent grafts, at least one randomized trial (Garcia-Pagan et al, 2010) showed significantly better 1-year survival for TIPS performed with these improved stents compared with medical management (86% vs. 60%, P < .01). The main downfall to TIPS is the development of new hepatic encephalopathy or exacerbation of existing encephalopathy, which occurs in 20% to 31% of cases (Boyer & Haskal, 2010). It is for this reason that TIPS is still recommended only after failure of medical management and not as front-line therapy for variceal bleeding. Interestingly, despite improved patency, the stent-graft TIPS has actually been associated with a lower incidence of encephalopathy compared with bare-stent TIPS (Bureau et al, 2007; Tripathi et al, 2006). This is another reason why the randomized trials comparing TIPS to medical management need to be repeated with the newer stent grafts.
Gastric Varices and Gastropathy Gastric varices are also frequently seen in patients with portal hypertension and are actually associated with a higher rate of hemorrhage-related mortality compared with bleeding from esophageal varices (Garcia-Tsao & Bosch, 2010). TIPS can also provide good control of bleeding related to this condition, although the efficacy compared to endoscopic management is less clear. One large retrospective study comparing TIPS to endoscopic cyanoacrylate injection failed to demonstrate a benefit for TIPS in either control of bleeding or survival (Procaccini et al, 2009). However, another trial (Lo et al, 2007) that randomized patients to either TIPS or variceal obliteration with endoscopic cyanoacrylate injection showed that rebleeding was significantly less frequent in the TIPS group (11% vs. 38%, P = .014). TIPS has also been used to treat portal hypertensive gastropathy, but data are sparse, and no randomized trials have evaluated the use of TIPS for this condition. Some investigators believe that TIPS is less effective for this condition, and several