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 Dr. Antonio Gaetano Rampoldi from Niguarda Hospital in Milan.
Hepatologist Dr. Hernández-Gea, an expert on portal hypertension, discussed the role of TIPS in patients with variceal bleeding. She noted that there is no indication for TIPS as a primary prophylactic treatment.
According to Dr. Hernández-Gea, when a patient has acute variceal bleeding, there are two main treatment options:
Patients selected to undergo rescue TIPS include those who are intubated with heavy drug support and massive, uncontrolled bleeding, and patients experiencing a failure of bridge therapy (balloon tamponade or esophageal stent). “This is a very critical scenario where the mortality is very high,” she said.
Dr. Hernández-Gea explained that 20% of patients with variceal bleeding will respond to the treatment but are at risk of early re-bleeding.
Therefore, preemptive TIPS must be placed in these high-risk patients as soon as possible to prevent re-bleeding, failure, and mortality. A landmark study1 showed bleeding and mortality is concentrated in the first three days, especially in the first 24–48 hours.
According to Dr. Hernández-Gea, there are three scores that will help physicians determine that patients should receive preemptive TIPS: an HVPG greater than 20 mmHG, a Child-Pugh C score less than 14, and a Child-Pugh B score greater than 7 with active bleeding at endoscopy.
Based on the study by Nicoara-Farcau O, et al.,2 patient stratification helps to clearly identify patients who will benefit from an early intervention. “We should stratify patients and go for Child B more than 7 points with active bleeding to place the TIPS,” Dr. Hernández-Gea said.
Patients with Child B without bleeding do not benefit from preemptive TIPS. Patients with a Child B greater than 7 have the greatest survival benefit undergoing preemptive TIPS.
In an American study evaluating 5,529 patients,3 mortality is correlated with the number of TIPS placements at the institution. Hospitals placing more than 20 TIPS per year have lower mortality rates. Therefore, in the best interest of the patient, said Dr. Hernández-Gea, hospitals that place only a few TIPS per year should refer these patients to centers of expertise.
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