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Boyer T, Haskal Z, American Association for the Study of Liver Disease (AASLD). AASLD practice guidelines: the role of transjugular intrahepatic portosystemic shunt (TIPS) in the management of portal hypertension. Hepatology. 2010 Jan;51(1):1-16. [127 references] |
Disease/Condition(s)
Complications of portal hypertension:
Guideline Category
Assessment of Therapeutic EffectivenessEvaluationManagementPreventionRisk AssessmentTreatment
Guideline Objective(s)
To provide a data-supported approach to the use of transjugular intrahepatic portosystemic shunt (TIPS) in the management of the complications of portal hypertension
Interventions and Practices Considered
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Methods Used to Collect/Select the Evidence
Hand-searches of Published Literature (Primary Sources)Hand-searches of Published Literature (Secondary Sources)Searches of Electronic Databases
Description of Methods Used to Collect/Select the Evidence
A MEDLINE search was performed from 1966 to 2009. A total of 1143 articles were found under the subject heading "transjugular intrahepatic portosystemic shunt." Controlled trials and large series were sought during this search. Recently published papers were also used as a source of references missed by the MEDLINE search, and the personal files of the two authors were also used as a source of references.
Methods Used to Assess the Quality and Strength of the Evidence
Expert ConsensusWeighting According to a Rating Scheme (Scheme Given)
Rating Scheme for the Strength of the Evidence
Grade I: Randomized controlled trials
Grade II-1: Controlled trials without randomization
Grade II-2: Cohort or case-control analytic studies
Grade II-3: Multiple time series, dramatic uncontrolled experiments
Grade III: Opinions of respected authorities, descriptive epidemiology
Methods Used to Analyze the Evidence
Review of Published Meta-AnalysesSystematic Review with Evidence Tables
Cost Analysis
A cost-effectiveness analysis of a randomized controlled trial comparing transjugular intrahepatic portosystematic shunt (TIPS) (bare metal Wallstents) to distal splenorenal shunt (DSRS) reported costs of both in- and out-patient care. The average yearly cost over a 5 year period were $16,363 for TIPS patients and $13,492 for the DSRS patients. These yearly costs are similar to what has been reported for pharmacologic and endoscopic management of patients with bleeding varices. TIPS was slightly more cost effective than DSRS at year five ($61,000 per life saved) but difference was felt not to be significant. Using covered rather than bare walls stents was estimated to increase the cost-effectiveness of TIPS only slightly. The authors conclude that TIPS is as effective as DSRS in the prevention of variceal rebleeding and may be slightly more cost-effective.
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Major Recommendations
Recommendations are followed by quality of evidence ratings (Grades I, II-1, II-2, II-3, III) which are defined at the end of the "Major Recommendations" field.
The Procedure: Pre-TIPS Evaluation and Contraindications, Mortality
Complications; TIPS in the Transplant Candidate
Indications
Primary Prevention of Variceal Bleeding; Acutely Bleeding Esophageal Varices Refractory to Medical Treatment; Esophageal Variceal Rebleeding; Bleeding from Gastric Varices; Prevention of Bleeding From Portal Hypertensive Gastropathy (PHG) and Gastric Antral Vascular Ectasia (GAVE)
Cirrhotic Ascites; Refractory Hepatic Hydrothorax; Hepatorenal Syndrome (HRS)
Budd-Chiari Syndrome (BCS); Veno-occlusive Disease or Sinusoidal Obstruction Syndrome (SOS); Hepatopulmonary Syndrome
Conclusions
TIPS is an important part of the current armamentarium used to treat the complications of portal hypertension. Most fellowship-trained interventional radiologists are capable of creating a TIPS in a patient with patent hepatic and portal veins. Creation of a TIPS ranks among the more complex procedures performed by interventional radiologists, and it is important that each physician monitor their success and complication rates. As with any complex intervention, the decision to create a TIPS should be reached by a gastroenterologist or hepatologist who is experienced in the management of these patients in concert with an interventional radiologist. Pre-TIPS evaluation includes routine tests of liver and kidney function as well as Doppler ultrasound, contrast-enhanced abdominal computed tomography (CT), or magnetic resonance imaging (MRI) of the liver. Once a TIPS is created, it cannot be forgotten. The patient requires frequent monitoring by Doppler ultrasound and clinic visits to look for the development of TIPS dysfunction. The use of polytetrafluoroethylene (PTFE)-covered stents reduces the risk of TIPS dysfunction, but this will not eliminate the need for continued surveillance.
TIPS will effectively prevent rebleeding from varices and decrease the need for repeat thoracentesis in patients with hepatic hydrothorax or for large-volume paracentesis in patients with refractory ascites. However, TIPS will increase the incidence of hepatic encephalopathy and will not improve survival in any of these patients. Hence, TIPS should not be considered as primary therapy for any complication of portal hypertension with the exception of bleeding gastric or ectopic varices. In all other situations, TIPS should only be created when the patient has failed other forms of medical therapy (i.e., pharmacological or endoscopic therapy, diuretics, or repeated large-volume paracentesis or thoracentesis). In patients with good liver function and recurrent bleeding from varices despite medical treatment, a surgical shunt or TIPS appear to be equivalent therapies. Which patients with BCS are best managed by TIPS remains undefined, although creation of a TIPS in select patients appears to be of benefit. Creation of a TIPS for the treatment of hepatorenal syndrome (HRS) or hepatopulmonary syndrome is of unproven benefit and should be considered investigatory.
Definitions:
Quality of Evidence
Grade I: Randomized controlled trials
Grade II-1: Controlled trials without randomization
Grade II-2: Cohort or case-control analytic studies
Grade II-3: Multiple time series, dramatic uncontrolled experiments
Grade III: Opinions of respected authorities, descriptive epidemiology
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Potential Benefits
Potential Harms
Complications of Transjugular Intrahepatic Portosystemic Shunt (TIPS)
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Contraindications
Absolute Contraindications to Placement of a Transjugular Intrahepatic Portosystemic Shunt (TIPS)
Relative Contraindications to Placement of a TIPS
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Qualifying Statements
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Bibliographic Source(s)
Guideline Developer(s)
American Association for the Study of Liver Diseases - Nonprofit Research Organization
Composition of Group That Authored the Guideline
Primary Authors: Thomas D. Boyer, Liver Research Institute, University of Arizona School of Medicine, Tucson, AZ; Ziv J. Haskal, Division of Vascular and Interventional Radiology, University of Maryland Medical School, Baltimore, MD
Committee Members: Jayant A. Talwalkar, MD, MPH (Chair); Anna Mae Diehl, MD (Board Liaison); Jeffrey H. Albrecht, MD; Amanda DeVoss, MMS, PA-C; Jose Franco, MD; Stephen A. Harrison, MD; Kevin Korenblat, MD; Simon C. Ling, MBChB; Lawrence U. Liu, MD; Paul Martin, MD; Kim M. Olthoff, MD; Robert S. O'Shea, MD; Nancy Reau, MD; Adnan Said, MD; Margaret C. Shuhart, MD, MS; and Kerry N. Whitt, MD
Financial Disclosures/Conflicts of Interest
Drs. Boyer and Haskal were paid consultants for W. L. Gore and Associates, Inc., the manufacturer of a polytetrafluoroethylene (PTFE)-covered stent used for transjugular intrahepatic portosystemic shunts (TIPS).
Guideline Status
This is the current release of the guideline.
This guideline updates a previous version: Boyer TD, Haskal ZJ. The role of transjugular intrahepatic portosystemic shunt in the management of portal hypertension. Hepatology 2005 Feb;41(2):386-400.
Guideline Availability
Electronic copies: Available in Portable Document Format (PDF) from the American Association for the Study of Liver Diseases Web site .
Print copies: Available from the American Association for the Study of Liver Diseases, 1729 King Street, Suite 200; Alexandria, VA 22314; Phone: 703-299-9766; Web site: www.aasld.org ; e-mail: aasld@aasld.org.
Availability of Companion Documents
This guideline is available as a Personal Digital Assistant (PDA) download via the APPRISOR™ Document Viewer fromwww.apprisor.com .
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