Transjugular intrahepatic portosystemic shunt: Present status, comparison with endoscopic therapy and shunt surgery, and future prospectives

During the 13 years since its introduction into clinical practice, transjug ular intrahepatic portosystemic shunt (TIPS) has become widely accepted wor ldwide as a percutaneous, interventional procedure for treating complicatio ns of portal hypertension, An experienced, skillful team, however, is neces sary to ensure the high technical success of TIPS and to avoid its potentia l procedural complications. Presently, TIPS is used mainly for treatment of acute or recurrent hemorrhage from gastroesophageal varices refractory to endoscopic therapy. Randomized studies have shown that it is more effective than endoscopic treatment for preventing rebleeding; however, it is associ ated with a higher incidence of encephalopathy, Both treatments produce com parable survival rates. TIPS is also effective in the treatment of hepatoge nic ascites and hydrothorax and hepatorenal syndrome. In comparison with su rgical shunts, TIPS is a significantly less invasive procedure that can be done in poor surgical candidates with advanced cirrhosis. The high rate of shunt obstructions seen with TIPS mandates close surveillance and maintenan ce, rendering TIPS a multistage procedure. This is a major disadvantage of TIPS compared to surgery. Presently, both TIPS and surgical shunts have the ir place in the treatment of gastroesophageal variceal hemorrhage unrespons ive to endoscopic therapy. TIPS is most suited for class B and C patients, particularly those who are candidates for liver transplantation. Surgical s hunts should be considered for patients with well preserved liver function. Large, randomized controlled studies should be done to compare these treat ment methods. Animal experimental and early clinical studies using covered stents (stent-grafts) are promising for the prevention of shunt obstruction s and thus converting TIPS from a multistage to a one-stage procedure.