Part 1 – Evidence and literature

Cook Medical sponsored a webinar discussion between specialists in interventional radiology and hepatology on the need for early transjugular intrahepatic portosystemic shunt (TIPS) procedures in patients with portal hypertension. The program was moderated by Dr. David Patch from the Royal Free Hospital in London and Prof. Otto M. van Delden from Amsterdam University Medical Center. Speakers included Prof. Bernhard Gebauer, director of the interventional radiology department at Charité Campus Virchow Clinic in Berlin; Dr. Virginia Hernández-Gea from the Liver Unit at Hospital Clínic-IDIBAPS in Barcelona; and Prof. Antonio Gaetano Rampoldi from Niguarda Hospital in Milan.

The first study on preemptive TIPS for acute variceal bleeding (AVB) was published in 2004. In the article, titled “Influence of portal hypertension and its early decompression by TIPS placement on the outcome of variceal bleeding,”¹ researchers determined hemodynamically stable patients who have received standard care should receive TIPS implementation within 72 hours following a diagnostic endoscopy. “These patients are at a high risk of recurrent bleeding,” Prof. Gebauer explained. “If you tried to implant TIPS under emergency conditions, then it might be very difficult to get a successful TIPS implementation in these patients.” According to this study, failure of treatment for patients with a hepatic venous pressure gradient (HVPG) of greater than or equal to 20 mmHg who did not receive an early TIPS procedure was 50%, while for those who did receive TIPS, it was 12%.

Dr. Hernández-Gea discussed a 1981 study titled, “The course of patients after variceal hemorrhage,”³ which showed mortality due to bleeding concentrates in the first three days. This outcome was also confirmed in a recent meta-analysis.⁴ “If we place the TIPS with the aim of preventing bleeding, preventing failure, and decreasing mortality, we have to prove that as soon as possible,” she said.

“If we place the TIPS with the aim of preventing bleeding, preventing failure, and decreasing mortality, we have to prove that as soon as possible.” – Dr. Hernández-Gea

Dr. Hernández-Gea pointed to several randomized clinical trials and observational studies that evaluated the efficacy of preemptive TIPS. Almost all the studies used clinical criteria to identify patients at high risk, which is easy and allows any hospital to make this classification. This high-risk population concentrates in patients with Child-Pugh C<14. Additionally, a survival benefit was observed in Child-Pugh B patients with active bleeding but not in those without active bleeding.⁵

According to Dr. Rampoldi, early TIPS is a concept often connected only to variceal bleeding, but literature has also demonstrated benefits from an early intervention in cases of refractory ascites. “There are not clear guidelines yet on this,” he said, “but, we should already think about TIPS after the first paracentesis.” He explained that the literature indicates that, following TIPS, ascites is more successfully controlled in cases of patients with low frequency of paracentesis. TIPS is also associated with improved survival.

TIPS for ascites may also help patients with nutritional deficits as well as sarcopenia. It is a complicated situation, according to Dr. Patch. He explained that, often, these patients are sarcopenic because of ascites, “so attempts to improve their sarcopenia are actually just delaying things when you need TIPS in order for them to eat and build up their muscle.” He explained that a lack of muscle puts the patient at risk of developing encephalopathy. Dr. Hernández-Gea added that it’s important to consider TIPS after the first instance of paracentesis and to perform the procedure once the refractory ascites has been assessed. “If we wait too much, the patient is going to be sarcopenic with bad nutritional status,” she said. Dr. Patch fully agreed, “Early TIPS with bleeding, the definition of diuretic ascites, actually almost predefined a fairly sarcopenic patient. So, we actually need to think of early TIPS for ascites as well as bleeding.”

“We actually need to think of early TIPS for ascites as well as bleeding.” – Dr. David Patch

Not all Child-Pugh B patients with active bleeding will benefit from preemptive TIPS.

All participants are paid consultants of Cook Medical at the time of the webinar recording.

References

1. Monescillo A, Martínez-Lagares F, Ruiz-del-Arbol L, et al. Influence of portal hypertension and its early decompression by TIPS placement on the outcome of variceal bleeding. Hepatology. 2004;40(4):793-801. doi: 10.1002/hep.20386.
2. García-Pagán JC, Caca K, Bureau C, et al. Early use of TIPS in patients with cirrhosis and variceal bleeding. N Engl J Med. 2010;362(25):2370-2379.
3. Graham DY, Smith JL. The course of patients after variceal hemorrhage. Gastroenterol. 1981;80(4):800-809.
4. Nicoara-Farcau O, Han G, Rudler M, et al. Effects of early placement of transjugular portosystemic shunts in patients with high-risk acute variceal bleeding: a meta-analysis of individual patient data. Gastroenterol. 2021;160(1):193-205.e10. doi: 10.1053/j.gastro.2020.09.026.
5. Lv Y, Zuo L, Zhu X, et al. Identifying optimal candidates for early TIPS among patients with cirrhosis and acute variceal bleeding: A multicentre observational study. J Hepatol. 2019;68:1297-1310.