Transjugular Intrahepatic Portosystemic Shunt Creation With Embolization or Obliteration for Variceal Bleeding
Introduction
In the 4 decades since the conceptual and experimental advent of percutaneous portosystemic shunting by Rösch et al1 and the first clinical report of minimally invasive portal decompression and variceal occlusion for treatment of variceal bleeding by Colapinto et al,2 transjugular intrahepatic portosystemic shunt (TIPS) creation and variceal embolization have developed into widely employed and firmly accepted techniques for the management of variceal hemorrhage in patients with cirrhosis.3 Though commonly used in current clinical practice, these interventions have evolving indications, applications, and evidential support, and can be labor intensive, technically demanding, time consuming, and intellectually taxing pursuits for Interventional Radiology (IR) operators involved in the care of patients with portal hypertension. In order to address such challenges, this article presents an overview of a single IR physician’s clinical and technical approach to TIPS creation and variceal therapy—including strategies, tactics, tips, tricks, pitfalls, and evidence—based on experience gained in having performed numerous such procedures, partaken in clinical research in the field, and appraised the medical literature in this space. This article focuses on the aspects of patient evaluation and selection, procedure technique, and clinical outcomes as they pertain to portal venous decompression and variceal embolotherapy, whereas details of the medical, endoscopic, and surgical management of variceal bleeding, as well as purely obliterative interventional approaches to variceal treatment, are beyond the scope of the current topic, and would not be discussed.
Section snippets
History and Physical Examination
Standard historical information related to gastrointestinal bleeding, including onset, character, amount, and time course are relevant. Patients may be screened for symptoms of liver disease—such as jaundice—to help support a variceal bleeding source. Blood transfusion requirements should be noted. Additional historical information that may influence the decision to pursue TIPS includes number of prior variceal bleeding events, history of hepatic encephalopathy, and history of heart failure or
Procedure Indications
The following are the currently accepted indications for TIPS creation in the context of variceal bleeding well defined by clinical practice guidelines of both Hepatology and IR societies16, 17, 18, 19:
- (1)
The prevention of recurrent variceal hemorrhage in patients who demonstrate intolerance or resistance to medical and endoscopic treatment.17, 18 This is a common procedure indication at the author’s institution.
- (2)
Rescue therapy in cases of refractory (medically or endoscopically uncontrollable or
Patient Stabilization
Acute variceal hemorrhage requires aggressive resuscitation. Initial management calls for fluid and blood product infusion and hemodynamic stabilization, and vasoactive agents may be administered to achieve and maintain hemostasis. Use of variceal balloon tamponade via a Sengstaken-Blakemore tube can function as a temporizing measure in extreme cases.25 Any coagulopathy or thrombocytopenia should be corrected.26 Airway protection via endotracheal intubation may be warranted in the setting of
Rationale and Evidence
The role of ancillary embolotherapy at the time of TIPS creation is a matter of debate. Embolic occlusion should theoretically limit variceal filling or recanalization and reduce the incidence of recurrent hemorrhage due to shunt dysfunction.46 However, because expanded polytetrafluoroethylene covered stent-grafts confer high patency and a low incidence of shunt dysfunction, the likelihood for variceal recanalization is low and the need for routine embolization is uncertain.35, 47 Additionally,
Overcoming Technical Challenges
TIPS creation and variceal embolization or obliteration can pose some significant technical challenges. Potential technical difficulties—such as wedged venography–related liver injury, nontarget biliary or arterial puncture, stent malposition, and device (eg, coil) migration—have been previously discussed in a prior publication by the author,32 although others are listed later, with recommendations to help overcome the hitches.
- (1)
Unsuccessful portal venous entry: Successful transhepatic portal
Clinical Follow-Up
After TIPS procedures, patients undergo inpatient monitoring for at least 24 hours. Liver function tests and the coagulation profile are assessed daily until downtrending. At the author’s institution, patients are followed both in an outpatient Hepatology clinic and also in an outpatient IR clinic after hospital discharge. All patients with TIPS undergo Doppler ultrasound surveillance of shunt patency at 1-month, 3-month, and subsequent 6-month intervals postprocedure. In cases of TIPS created
Expected Outcomes
In the covered stent-graft era, overall rebleeding rates after TIPS performed for variceal hemorrhage are low, approximating to 5%-10%.20, 21, 35, 67 A discussion of general clinical outcomes for specific TIPS indications is noted later (but does not represent a systematic literature review).
Conclusions
TIPS creation with variceal embolization or obliteration plays an important role in the contemporary management of variceal hemorrhage. These procedures are supported by robust evidence as secondary prevention of bleeding and as salvage therapy in acute hemorrhage for varices at different sites. The data supporting early TIPS creation in high-risk patients are promising, though limited, and the role of adjuvant embolotherapy remains controversial. Attentive consideration of patient evaluation,
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