Patient selection, referral pathway, and TIPS techniques
This is the second of three blogs focused on the benefits of early transjugular intrahepatic portosystemic shunt (TIPS) procedures for patients suffering from portal hypertension. Read part 1, “Evidence and literature” of the blog post series here and part 3, “Facility protocol” here.
Cook Medical sponsored a webcast discussion between specialists in interventional radiology and hepatology on the need for early transjugular intrahepatic portosystemic shunt (TIPS) procedures in patients who suffer from portal hypertension.
The programme 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 in 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.
Acute variceal bleeding
According to Dr. Hernández-Gea, when a patient is suffering from acute variceal bleeding, there are two main treatment options:
- Rescue (salvage) TIPS to stop bleeding or multiple re-bleeding episodes and return the patient to a non-emergent scenario
- Pre-emptive TIPS to prevent failure of bleeding and stabilise a high-risk patient
Patients selected to undergo rescue TIPS include those who are intubated with heavy drug support and massive, uncontrolled bleeding, or patients experiencing a failure of bridge therapy (balloon tamponade or oesophageal stent). ‘This is a very critical scenario where the mortality is very high’, she said.
Dr. Hernandez-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 study (Graham & Smith, Gastroenterol, 1981) 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 only two scores that will help guide physicians on determining which patients should receive pre-emptive TIPS: those with HVPG greater than 20 mmHG or those with clinical criteria such as Child-Pugh C scores less than 14 points and Child B plus active bleeding at endoscopy.
Based on recent literature (Nicoara-Farcau O, et al. Gastroenterol, 2021), 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’, she said.
Patients with Child B without bleeding do not benefit from pre-emptive TIPS. Patients with a Child B greater than 7 have the greatest survival benefit undergoing pre-emptive TIPS.
In an American study evaluating 5,529 patients (Sarwar A, et al. Hepatology, 2018), 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 centres of expertise.
All participants are paid consultants of Cook Medical.
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