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transjugular intrahepatic portosystemic shunt (TIPS)

Interventional radiology technique. Indications: - useful for relieving portal pressure in patients with - hepatic cirrhosis - gastric varices - esophageal varices - refractory ascites - *control refractory hemorrhage in candidates for liver transplantation Clinical significance: - useful for patients who are poor surgical candidates - success rate in control of esophageal varices is > 90% Procedure: - angiographic placement of an expandandable metallic stent from a branch of the hepatic vein through the hepatic parenchyma into a branch of the portal vein - rifaximin 600 mg bid starting 14 days prior to procedure & continuing for 6 months prevents hepatic encephalopathy [7] Complications: 1) shunt occlusion (50% in 1 year) 2) increased risk of hepatic encephalopathy 15-25% (3-5% severe) [2] 3) morbidity of 20% & early mortality of 5% Notes: - there is little evidence that TIPS improves mortality - preemptive TIPS in patients with cirrhois & acute variceal hemorrhage improves survival [6] - recurrence of variceal bleeding after TIPS is almost always caused by stenosis or occlusion of the shunt

General

vascular surgery

References

  1. Manual of Medical Therapeutics, 28th ed, Ewald & McKenzie (eds), Little, Brown & Co, Boston, 1995, pg 352
  2. Journal Watch 20(3):22, 2000
  3. Chalasani N et al Determinants of mortality in patients with advanced cirrhosis after transjugular intrahepatic portosystemic shunting. Gastroenterology 118:138, 2000 PMID: 10611162
  4. Medical Knowledge Self Assessment Program (MKSAP) 11, 14, 17. American College of Physicians, Philadelphia 1998, 2006, 2015
  5. American Association for the Study of Liver Diseases. Boyer TD, Haskal ZJ The Role of Transjugular Intrahepatic Portosystemic Shunt (TIPS) in the Management of Portal Hypertension: update 2009. Hepatology. 2010 Jan;51(1):306. PMID: 19902484
  6. Hernandez-Gea V, Procopet B, Giraldez A et al. Preemptive-TIPS improves outcome in high-risk variceal bleeding: An observational study. Hepatology 2018 Jul 16; PMID: 30014519 https://aasldpubs.onlinelibrary.wiley.com/doi/abs/10.1002/hep.30182
  7. Bureau C, Thabut D, Jezequel C et al. The use of rifaximin in the prevention of overt hepatic encephalopathy after transjugular intrahepatic portosystemic shunt: A randomized controlled trial. Ann Intern Med 2021 Feb 2; PMID: 33524293 https://www.acpjournals.org/doi/10.7326/M20-0202