The most common indications to perform a TIPS procedure are to control esophageal variceal bleeding and management of refractory ascites. The procedure is performed either in an emergency situation (active variceal bleeding) or as an elective procedure (recurrent bleed after failed medical and endoscopic therapy or for the management of ascites).
1. The Role of Transjugular Intrahepatic Portosystemic Shunt in Patients with Variceal Bleeding
a. Patients with Acute Variceal Hemorrhage
Acute variceal hemorrhage is a medical emergency. Patients are treated in intensive care units with aggressive medical management. A diagnostic endoscopy is should be performed within 12 hours of admission. Endoscopic variceal ligation or sclerotherapy is the treatment of choice if varices are confirmed as the source of bleeding. TIPS procedure is indicated in patients who fail endoscopic and vasoactive treatment.
Patients with a Child-Pugh class C, HPVG greater than 20 mm Hg and bleeding varices during diagnostic endoscopy are considered to be at high risk of failing standard therapy. Garcia-Pagan and coworkers demonstrated that application of early TIPS (within 72hrs of admission) in this subgroup of patients resulted in a significant improvement in patient survival and a significant decrease in rebleeding rates.
There are few poor prognostic factors for early TIPS, which should be kept in mind while deciding for management. These are: APACHE II score >18, ascites (moderate or severe), need for emergent mechanical ventilation, elevated serum creatinine, elevated PT (>17 sec) INR, elevated bilirubin (>3mg/dl) and activated partial thromboplastin time (aPTT). Presence of these factors indicates high 6 week mortality, so TIPS is not advised if any of these is present. Such patients should be offered alternative treatments like balloon-occluded retro-grade transvenous obliteration [BRTO] or direct embolization of varices.
b. Patients Who Have Survived a Bleeding Episode and Require Treatment to Prevent Rebleeding
In a patient who has survived an episode of acute variceal bleed, risk of rebreeding is high, ranging between 50-60%. In this clinical category there are two groups of patients: 1) those who have undergone TIPS procedure, 2) those who responded well to medical and endoscopic therapy. Patients who have undergone TIPS procedure require close observation of the shunt, but do not require medicines to prevent rebleeding. Patient who responded to medical and endoscopic therapy require continued prophylactic therapy with nonselective beta-blockers. In the latter group, either TIPS or surgical shunts are indicated for those who rebleed despite optimal medical and endoscopic treatment. TIPS performed in this clinical setting are either emergent or elective; thus, these patients have better prognosis in general.
There are at least five prognostic scores described to determine the survival prognosis of these patients undergoing TIPS. Of these Child-Pugh score and Model for End-stage Liver Disease (MELD) score are most commonly used. The Child-Pugh score is very old and has disadvantage of having two subjective parameters: ascites and degree of encephalopathy. Still it has stood the test of time and is very effective in predicting outcome of TIPS patients. In Child-Pugh score, class C patient with a score of 12 or higher is at very high risk of having an early death after a TIPS procedure. MELD score was originally developed by Malinchoc and coworkers. It was tested and modified into what we now call MELD score. In MELD score, score >18 is associated with an unfavourable prognosis with significantly lower 3-month survival rates.
2. Role of TIPS in Patients with Ascites
Ascites is a common complication of cirrhosis and its development indicates a poor prognosis. The standard treatment of ascites in cirrhotic patient is medical management, which includes fluid and sodium restriction and the administration of diuretics. However medical therapy fails in 5% to 10% of patients. TIPS and large-volume paracentesis (LVP) are used as therapeutic options in these patients. Studies have shown that TIPS is better than LVP to control the accumulation of fluid. TIPS performed in cirrhotic patients with ascites is always elective.
MELD score is used for determining prognosis after TIPS procedure in cirrhotic patients with ascites. Score >18 indicate poor prognosis and TIPS should be withheld unless the patient is liver transplant candidate. In patients with MELD score >24, TIPS should not be performed because of 40-60% 30-day mortality rate. Kim and coworkers developed new MELD-Na score, which includes serum sodium in formula. This score appears to be more precise than standard MELD score for predicting outcomes in patients undergoing elective TIPS – especially in patients undergoing TIPS for management of ascites because these patients have well-known derangement in handling of serum sodium. MELD-Na score >15 predict poor outcome. These patients should continue with LVP, creation of Denver Shunt or placement of tunnelled peritoneal drain; especially if they are not suitable liver transplant candidates.
If you come across a patient who requires TIPS procedure, refer Dr Milan Jolapara – Dev Interventional Clinic for the best treatment and care.
Dr Milan Jolapara is consultant Interventional Neuroradiologist and Peripheral Vascular Interventionist in Ahmedabad, Gujarat.
MD (Radiology), DM (Neuroradiology and Intervention)