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Transjugular Intrahepatic Portosystemic Shunt: Challenges and Perspectives

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A special issue of Journal of Clinical Medicine (ISSN 2077-0383). This special issue belongs to the section "Gastroenterology & Hepatopancreatobiliary Medicine".

Deadline for manuscript submissions: closed (20 July 2023) | Viewed by 17036

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Dr. Lorenzo Ridola

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Guest Editor

Department of Translational and Precision Medicine, "Sapienza" University of Rome, Latina, Italy
Interests: portal hypertension; cirrhosis; hepatic encephalopathy; sarcopenia; TIPS
Special Issues, Collections and Topics in MDPI journals

Dr. Silvia Nardelli

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Guest Editor

Department of Clinical Medicine, Centre for the Diagnosis and Treatment of Portal Hypertension, “Sapienza” University of Rome, Rome, Italy
Interests: hepatic encephalopathy; minimal hepatic encephalopathy; spontaneous portal-systemic shunts; transjugular intrahepatic portosystemic shunt; cirrhosis; portal hypertension; sarcopenia

Dr. Stefania Gioia

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Guest Editor

Department of Translational and Precision Medicine, Sapienza University of Rome, 00185 Rome, Italy
Interests: hepatic encephalopathy; minimal hepatic encephalopathy; spontaneous portal-systemic shunts; transjugular intrahepatic portosystemic shunt; cirrhosis; portal hypertension; sarcopenia

Special Issue Information

Dear Colleagues,

Transjugular intrahepatic portosystemic shunts have been part of the therapeutic armamentarium for the resolution of complications related to portal hypertension for years. At first, its use was limited to patients with relapsed esophagogastric variceal hemorrhage or refractory ascites, but over the years, the indications have changed regarding the timing of the procedure, and it has also been extended to other indications, such as congestive transfusion-dependent gastropathy despite standard medical and endoscopic therapy, Budd Chiari syndrome, and portal vein recanalization in the case of portal thrombosis, and it has also been used in selected cases of non-cirrhotic portal hypertension. The aim of this collection will be to provide a systematic and critical analysis of the state of the art, of the gray areas, and of the challenges and the treatment prospects of this procedure.

Dr. Lorenzo Ridola
Dr. Silvia Nardelli
Dr. Stefania Gioia
Guest Editors

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Keywords

hepatic encephalopathy
spontaneous portal-systemic shunts
transjugular intrahepatic portosystemic shunt
cirrhosis
portal hypertension
sarcopenia
myosteatosis
gastrointestinal bleeding
ascites
non cirrhotic portal hypertension

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Related Special Issue

Hepatic Encephalopathy: Clinical Challenges and Opportunities in Journal of Clinical Medicine (11 articles)

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Research

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12 pages, 1475 KiB

Open AccessArticle

Long-Term Efficacy and Safety of Rifaximin in Japanese Patients with Hepatic Encephalopathy: A Multicenter Retrospective Study

by Hideto Kawaratani, Yasuteru Kondo, Ryoji Tatsumi, Naoto Kawabe, Norikazu Tanabe, Akira Sakamaki, Kazuo Okumoto, Yoshihito Uchida, Kei Endo, Takumi Kawaguchi, Tsunekazu Oikawa, Yoji Ishizu, Shuhei Hige, Taro Takami, Shuji Terai, Yoshiyuki Ueno, Satoshi Mochida, Yasuhiro Takikawa, Takuji Torimura, Tomokazu Matsuura, Masatoshi Ishigami, Kazuhiko Koike and Hitoshi Yoshiji Show full author list Hide full author list

J. Clin. Med. 2022, 11(6), 1571; https://doi.org/10.3390/jcm11061571 - 12 Mar 2022

Cited by 7 | Viewed by 4000

Abstract

Background: Rifaximin is commonly used for hepatic encephalopathy (HE). However, the effects of long-term treatment for Japanese people are limited. Therefore, this study aimed to investigate the effects and safety of long-term treatment with rifaximin on HE. Methods: A total of 215 patients with cirrhosis administered with rifaximin developed overt or covert HE, which was diagnosed by an attending physician for >12 months. Laboratory data were extracted at pretreatment and 3, 6, and 12 months after rifaximin administration. The long-term effect of rifaximin was evaluated, and the incidence of overt HE during 12 months and adverse events was extracted. Results: Ammonia levels were significantly improved after 3 months of rifaximin administration and were continued until 12 months. There were no serious adverse events after rifaximin administration. The number of overt HE incidents was 9, 14, and 27 patients within 3, 6, and 12 months, respectively. Liver enzymes, renal function, and electrolytes did not change after rifaximin administration. Prothrombin activity is a significant risk factor for the occurrence of overt HE. The serum albumin, prothrombin activity, and albumin–bilirubin (ALBI) scores were statistically improved after 3 and 6 months of rifaximin administration. Moreover, the same results were obtained in patients with Child–Pugh C. Conclusions: The long-term rifaximin treatment was effective and safe for patients with HE, including Child–Pugh C. Full article

(This article belongs to the Special Issue Transjugular Intrahepatic Portosystemic Shunt: Challenges and Perspectives)

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Review

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27 pages, 1841 KiB

Open AccessReview

Transjugular Intrahepatic Portosystemic Shunt (TIPS) for Treatment of Bleeding from Cardiofundal and Ectopic Varices in Cirrhosis

by Sarah Shalaby, Oana Nicoară-Farcău, Valeria Perez-Campuzano, Pol Olivas, Sonia Torres, Juan Carlos García-Pagán and Virginia Hernández-Gea

J. Clin. Med. 2024, 13(19), 5681; https://doi.org/10.3390/jcm13195681 - 24 Sep 2024

Viewed by 858

Abstract

Acute variceal bleeding in cirrhosis represents a critical clinical event that significantly impacts patient prognosis, with mortality rates increasing further after a second episode. This underscores the need for immediate intervention and optimal prophylaxis. The creation of a transjugular intrahepatic portosystemic shunt (TIPS) has been proven to be highly effective for managing esophageal variceal bleeding. However, the use of TIPS for managing cardiofundal gastric varices and ectopic varices remains debated due to their unique vascular anatomy and the limited data available. These varices, although less prevalent than esophageal varices, are complex and heterogeneous vascular shunts between the splanchnic venous system and the systemic veins. Indeed, while endoscopic therapy with tissue adhesives is widely endorsed for achieving hemostasis in active hemorrhage, there is no consensus regarding the optimal approach for secondary prophylaxis. Recent research emphasizes the efficacy of endovascular techniques over endoscopic treatments, such as TIPS and endovascular variceal embolization techniques. This review examines the use of TIPS in managing acute variceal bleeding in patients with cirrhosis, focusing specifically on cardiofundal gastric varices and ectopic varices, discussing optimal patient care based on the latest evidence, aiming to improve outcomes for this challenging subset of patients. Full article

(This article belongs to the Special Issue Transjugular Intrahepatic Portosystemic Shunt: Challenges and Perspectives)

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11 pages, 530 KiB

Open AccessReview

Transjugular Intrahepatic Portosystemic Shunt as a Bridge to Abdominal Surgery in Cirrhosis

by Fabio Melandro, Simona Parisse, Stefano Ginanni Corradini, Vincenzo Cardinale, Flaminia Ferri, Manuela Merli, Domenico Alvaro, Francesco Pugliese, Massimo Rossi, Gianluca Mennini and Quirino Lai

J. Clin. Med. 2024, 13(8), 2213; https://doi.org/10.3390/jcm13082213 - 11 Apr 2024

Cited by 1 | Viewed by 1509

Abstract

Abdominal surgery is associated with high postoperative mortality and morbidity in cirrhotic patients. Despite improvements in surgical techniques, clinical management, and intensive care, the outcome could be influenced by the degree of portal hypertension, the severity of hepatopathy, or the type of surgery. Preoperative transjugular intrahepatic portosystemic shunt (TIPS) placement, in addition to medical therapy, plays an important role in managing the complications of portal hypertension such as ascites, hepatic encephalopathy, variceal bleeding or portal vein thrombosis. To date, the improvement of post-surgery outcomes in cirrhotic patients after TIPS placement remains unclear. Only observational data existing in the literature and prospective studies are urgently needed to evaluate the efficacy and safety of TIPS in this setting. This review aims to outline the role of TIPS as a tool in postoperative complications reduction in cirrhotic patients, both in the setting of emergency and elective surgery. Full article

(This article belongs to the Special Issue Transjugular Intrahepatic Portosystemic Shunt: Challenges and Perspectives)

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16 pages, 1275 KiB

Open AccessReview

Transjugular Intrahepatic Portosystemic Shunt in Nonmalignant Noncirrhotic Portal Vein Thrombosis and Portosinusoidal Vascular Disorder

by Sarah Shalaby, Roberto Miraglia and Marco Senzolo

J. Clin. Med. 2024, 13(5), 1412; https://doi.org/10.3390/jcm13051412 - 29 Feb 2024

Cited by 3 | Viewed by 1294

Abstract

Transjugular intrahepatic portosystemic shunt (TIPS) emerges as a key treatment for portal hypertension (PH) complications. While international guidelines provide clear indications for its use in cirrhosis, empirical knowledge is notably scarcer in non-cirrhotic PH, particularly in nonmalignant noncirrhotic portal vein thrombosis (NNPVT) and in patients with portosinusoidal vascular disorder (PSVD). Patients afflicted by these rare diseases exhibit distinct clinical profiles compared to their cirrhotic counterparts, often characterized by a younger age, predominantly preserved hepatic functionality even in cases of severe PH, and a higher propensity for extensive splanchnic thrombosis, which intricately complicates TIPS placement, posing unique challenges for its creation. The objective of this review is to synthesize existing literature on the effectiveness, safety, specific indications, and clinical outcomes of TIPS in adult patients with NNPVT or PSVD, focusing also on the technical challenges of TIPS insertion in the presence of portal cavernoma. Full article

(This article belongs to the Special Issue Transjugular Intrahepatic Portosystemic Shunt: Challenges and Perspectives)

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12 pages, 1382 KiB

Open AccessReview

The Role of Transjugular Intrahepatic Portosystemic Shunt for the Management of Ascites in Patients with Decompensated Cirrhosis

by Giulia Iannone, Enrico Pompili, Clara De Venuto, Dario Pratelli, Greta Tedesco, Maurizio Baldassarre, Paolo Caraceni and Giacomo Zaccherini

J. Clin. Med. 2024, 13(5), 1349; https://doi.org/10.3390/jcm13051349 - 27 Feb 2024

Cited by 2 | Viewed by 1624

Abstract

The development and progression of ascites represent a crucial event in the natural history of patients with cirrhosis, predisposing them to other complications and carrying a heavy impact on prognosis. The current standard of care for the management of ascites relies on various combinations of diuretics and large-volume paracenteses. Periodic long-term albumin infusions on top of diuretics have been recently shown to greatly facilitate the management of ascites. The insertion of a transjugular intrahepatic portosystemic shunt (TIPS), an artificial connection between the portal and caval systems, is indicated to treat patients with refractory ascites. TIPS acts to decrease portal hypertension, thus targeting an upstream event in the pathophysiological cascade of cirrhosis decompensation. Available evidence shows a significant benefit on ascites control/resolution, with less clear results on patient survival. Patient selection plays a crucial role in obtaining better clinical responses and avoiding TIPS-related adverse events, the most important of which are hepatic encephalopathy, cardiac overload and failure, and liver failure. At the same time, some recent technical evolutions of available stents appear promising but deserve further investigations. Future challenges and perspectives include (i) identifying the features for selecting the ideal candidate to TIPS; (ii) recognizing the better timing for TIPS placement; and (iii) understanding the most appropriate role of TIPS within the framework of all other available treatments for the management of patients with decompensated cirrhosis. Full article

(This article belongs to the Special Issue Transjugular Intrahepatic Portosystemic Shunt: Challenges and Perspectives)

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14 pages, 1320 KiB

Open AccessReview

Role of Transjugular Intrahepatic Portosystemic Shunt in the Liver Transplant Setting

by Simone Di Cola, Lucia Lapenna, Jakub Gazda, Stefano Fonte, Giulia Cusi, Samuele Esposito, Marco Mattana and Manuela Merli

J. Clin. Med. 2024, 13(2), 600; https://doi.org/10.3390/jcm13020600 - 21 Jan 2024

Cited by 2 | Viewed by 1713

Abstract

Liver transplantation is currently the only curative therapy for patients with liver cirrhosis. Not all patients in the natural course of the disease will undergo transplantation, but the majority of them will experience portal hypertension and its complications. In addition to medical and endoscopic therapy, a key role in managing these complications is played by the placement of a transjugular intrahepatic portosystemic shunt (TIPS). Some indications for TIPS placement are well-established, and they are expanding and broadening over time. This review aims to describe the role of TIPS in managing patients with liver cirrhosis, in light of liver transplantation. As far as it is known, TIPS placement seems not to affect the surgical aspects of liver transplantation, in terms of intraoperative bleeding rates, postoperative complications, or length of stay in the Intensive Care Unit. However, the placement of a TIPS “towards transplant” can offer advantages in terms of ameliorating a patient’s clinical condition at the time of transplantation and improving patient survival. Additionally, the TIPS procedure can help preserve the technical feasibility of the transplant itself. In this context, indications for TIPS placement at an earlier stage are drawing particular attention. However, TIPS insertion in decompensated patients can also lead to serious adverse events. For these reasons, further studies are needed to make reliable recommendations for TIPS in the pre-transplant setting. Full article

(This article belongs to the Special Issue Transjugular Intrahepatic Portosystemic Shunt: Challenges and Perspectives)

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18 pages, 1702 KiB

Open AccessReview

Post-Transjugular Intrahepatic Portosystemic Shunt (TIPS) Hepatic Encephalopathy—A Review of the Past Decade’s Literature Focusing on Incidence, Risk Factors, and Prophylaxis

by Karina Holm Friis, Karen Louise Thomsen, Wim Laleman, Sara Montagnese, Hendrik Vilstrup and Mette Munk Lauridsen

J. Clin. Med. 2024, 13(1), 14; https://doi.org/10.3390/jcm13010014 - 19 Dec 2023

Cited by 3 | Viewed by 2460

Abstract

Transjugular intrahepatic portosystemic shunt (TIPS) is an established treatment for portal hypertension and its’ complications in liver cirrhosis, yet the development of hepatic encephalopathy (HE) remains a significant concern. This review covers the reported incidence, risk factors, and management strategies for post-TIPS HE over the past decade. Incidence varies widely (7–61%), with factors like age, liver function, hyponatremia, and spontaneous portosystemic shunts influencing risk. Procedural aspects, including TIPS timing, indication, and stent characteristics, also contribute. Pharmacological prophylaxis with lactulose and rifaximin shows promise, but current evidence is inconclusive. Procedural preventive measures, such as shunt embolization and monitoring portal pressure gradients, are explored. Treatment involves pharmacological options like lactulose and rifaximin, and procedural interventions like stent diameter reduction. Ongoing studies on novel predictive markers and emerging treatments, such as faecal microbiota transplant, reflect the evolving landscape in post-TIPS HE management. This concise review provides clinicians with insights into the multifaceted nature of post-TIPS HE, aiding in improved risk assessment, prophylaxis, and management for patients undergoing TIPS procedures. Full article

(This article belongs to the Special Issue Transjugular Intrahepatic Portosystemic Shunt: Challenges and Perspectives)

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12 pages, 795 KiB

Open AccessFeature PaperReview

Transjugular Intrahepatic Portosystemic Shunt Placement: Effects on Nutritional Status in Cirrhotic Patients

by Ilaria de Felice, Lorenzo Ridola, Oliviero Riggio, Jessica Faccioli, Silvia Nardelli and Stefania Gioia

J. Clin. Med. 2023, 12(22), 7029; https://doi.org/10.3390/jcm12227029 - 10 Nov 2023

Cited by 2 | Viewed by 1315

Abstract

Malnutrition is a tangible complication of cirrhosis with portal hypertension with a prevalence of up to 50%. In particular, sarcopenia and myosteatosis, defined as the alteration in muscle quantity and quality, have a negative impact on the main complications of liver disease and are associated with higher mortality in patients with cirrhosis. Recently, alterations in adipose tissue have also been described in cirrhotic patients and they seem to influence the course of liver disease. Several pieces of evidence indicate that a transjugular intrahepatic portosystemic shunt (TIPS), placed for the treatment of refractory portal hypertension, can lead to a modification of body composition consisting in the improvement of the skeletal muscle index, myosteatosis, and an increase in subcutaneous fat. These modifications of the nutritional status, even more pronounced in sarcopenic patients before TIPS, have been associated with an amelioration of cognitive impairment after TIPS as well as with an increase in the survival rate. The aim of this paper is to provide an overview of the effects of TIPS placement on nutritional status in cirrhosis focusing on its pathophysiological mechanisms and its relationship with liver-related outcomes. Full article

(This article belongs to the Special Issue Transjugular Intrahepatic Portosystemic Shunt: Challenges and Perspectives)

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17 pages, 1697 KiB

Open AccessEditor’s ChoiceReview

Transjugular Intrahepatic Portosystemic Shunt: Devices Evolution, Technical Tips and Future Perspectives

by Dario Saltini, Federica Indulti, Tomas Guasconi, Marcello Bianchini, Biagio Cuffari, Cristian Caporali, Federico Casari, Francesco Prampolini, Marco Senzolo, Antonio Colecchia and Filippo Schepis

J. Clin. Med. 2023, 12(21), 6758; https://doi.org/10.3390/jcm12216758 - 25 Oct 2023

Cited by 7 | Viewed by 1692

Abstract

Portal hypertension (PH) constitutes a pivotal factor in the progression of cirrhosis, giving rise to severe complications and a diminished survival rate. The transjugular intrahepatic portosystemic shunt (TIPS) procedure has undergone significant evolution, with advancements in stent technology assuming a central role in managing PH-related complications. This review aims to outline the progression of TIPS and emphasizes the significant influence of stent advancement on its effectiveness. Initially, the use of bare metal stents (BMSs) was limited due to frequent dysfunction. However, the advent of expanding polytetrafluoroethylene-covered stent grafts (ePTFE-SGs) heralded a transformative era, greatly enhancing patency rates. Further innovation culminated in the creation of ePTFE-SGs with controlled expansion, enabling precise adjustment of TIPS diameters. Comparative analyses demonstrated the superiority of ePTFE-SGs over BMSs, resulting in improved patency, fewer complications, and higher survival rates. Additional technical findings highlight the importance of central stent placement and adequate stent length, as well as the use of smaller calibers to reduce the risk of shunt-related complications. However, improving TIPS through technical means alone is inadequate for optimizing patient outcomes. An extensive understanding of hemodynamic, cardiac, and systemic factors is required to predict outcomes and tailor a personalized approach. Looking forward, the ongoing progress in SG technology, paired with the control of clinical factors that can impact outcomes, holds the promise of reshaping the management of PH-related complications in cirrhosis. Full article

(This article belongs to the Special Issue Transjugular Intrahepatic Portosystemic Shunt: Challenges and Perspectives)

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