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Diagnostic and Interventional Imaging (2015) xxx, xxx—xxx

CONTINUING EDUCATION PROGRAM: FOCUS. . .

Transjugular intrahepatic portosystemic shunt for acute variceal gastrointestinal bleeding: Indications, techniques and outcomes R. Loffroy ∗, S. Favelier , P. Pottecher , L. Estivalet , P.Y. Genson , S. Gehin , D. Krausé , J.-P. Cercueil Department of vascular, oncologic and interventional radiology, Le2i UMR CNRS 6306, University of Dijon School of Medicine, Bocage Teaching Hospital, 14, rue Paul-Gaffarel, BP 77908, 21079 Dijon cedex, France

KEYWORDS Portal hypertension; Cirrhosis; Variceal bleeding; Transjugular intrahepatic portosystemic shunt; Embolization

Abstract Acute variceal bleeding is a life-threatening condition that requires a multidisciplinary approach for effective therapy. The transjugular intrahepatic portosystemic shunt (TIPS) procedure is a minimally invasive image-guided intervention used for secondary prevention of bleeding and as salvage therapy in acute bleeding. Emergency TIPS should be considered early in patients with refractory variceal bleeding once medical treatment and endoscopic sclerotherapy fail, before the clinical condition worsens. Furthermore, admission to specialized centers is mandatory in such a setting and regional protocols are essential to be organized effectively. This procedure involves establishment of a direct pathway between the hepatic veins and the portal veins to decompress the portal venous hypertension that is the source of the patient’s bleeding. The procedure is technically challenging, especially in critically ill patients, and has a mortality of 30%—50% in the emergency setting, but has an effectiveness greater than 90% in controlling bleeding from gastro-esophageal varices. This review focuses on the role of TIPS in the setting of variceal bleeding, with emphasis on current indications and techniques for TIPS creation, TIPS clinical outcomes, and the role of adjuvant embolization of varices. © 2015 Éditions franc ¸aises de radiologie. Published by Elsevier Masson SAS. All rights reserved.

∗

Corresponding author. E-mail address: [email protected] (R. Loffroy).

http://dx.doi.org/10.1016/j.diii.2015.05.005 2211-5684/© 2015 Éditions franc ¸aises de radiologie. Published by Elsevier Masson SAS. All rights reserved.

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Acute variceal bleeding is a common clinical emergency and is caused most often by cirrhosis-related portal hypertension. Less common causes include splenic vein thrombosis, hepatic veno-occlusive disease, and primary biliary cirrhosis. It is defined as visible bleeding from an esophageal or gastric varix at the time of endoscopy, the presence of large esophageal varices with recent stigmata of bleeding or fresh blood visible in the stomach with no other source of bleeding identified [1]. The frequency of gastroesophageal varices in cirrhosis varies from 30% to 70% with bleeding occurring in approximately one-third of patients [2]. Twenty percent of cirrhotics with acute variceal hemorrhage die within 6 weeks [3]. The rebleeding rates range from 30% to 40% at 6 weeks and the mortality from rebleeding reaches 30% [4]. Gastro-esophageal varices account for approximately 80% of all cases of variceal bleeding [2,5]. The precipitating cause for bleeding, presumably an acute rise in portal pressure and subsequent variceal rupture, remains uncertain but several factors have been implicated including raised intra-abdominal pressure, presence of bacterial infection, continued excess alcohol consumption and postprandial increase in splanchnic blood flow. Predictive factors for variceal bleeding include a hepatic venous pressure gradient (HVPG) of > 20 mmHg [6,7], the presence of large varices with red signs [8] and underlying severe liver disease (Child-Pugh grade C) [2]. Optimal management of variceal bleeding requires a multidisciplinary approach, involving a team of gastroenterologists, hepatologists, critical care physicians, surgeons, and interventional radiologists. The principal components of therapy include airway maintenance, hemodynamic stabilization, control of the variceal bleeding, and alteration of the hemodynamic effects of portal hypertension. Treatment options for the management of acute variceal bleeding include endoscopic therapy, use of vasoactive drugs, balloon tamponade and esophageal transaction. These various methods, either alone or in combination, are effective in controlling acute variceal bleeding in 80%—90% of patients. Patients who do not respond to these measures are referred for rescue therapies, which include transjugular intrahepatic portosystemic shunt (TIPS) and surgical portosystemic shunts with or without splenectomy. Because of the higher mortality of surgery in the acute setting, TIPS is the favored rescue procedure for uncontrolled variceal bleeding [6]. The purpose of this review article is to briefly describe the different therapeutic options available to control acute variceal bleeding and then to focus on the role of TIPS as a primary therapy to control acute variceal bleeding, particularly as a rescue therapy following failure of endoscopic approaches. The technical aspects and outcomes in such a setting will be discussed.

Indications and contraindications Indications TIPS is indicated in the treatment of uncontrollable variceal bleeding as well as in the management of recurrent variceal bleeding in patients who have failed endoscopic and medical therapy, refractory ascites, Budd-Chiari syndrome or hepatic veno-occlusive disease, and hepatic hydrothorax. Other less

Table 1 Level of evidence of indications for transjugular intrahepatic portosystemic shunt (TIPS). Indication

Best available level of evidence

Secondary prevention of variceal bleeding Refractory ascites Refractory acute variceal bleeding Portal hypertensive gastropathy Hepatorenal syndromes Budd-Chiarri syndrome Hepatic hydrothorax Hepatic veno-occlusive disease Hepatopulmonary syndrome

1A 1A 1B 2B 2B 4 4 4 4

Levels of evidence: 1A: systematic review of randomized controlled trials; 1B: individual randomized control trial; 2B: individual cohort study; 4: case series.

common indications include the poorly understood entities of portal (congestive) gastropathy and the hepatorenal syndrome [9—14]. TIPS may also be performed as a bridge to liver transplantation in the cirrhotic patient (Table 1). The causes of gastrointestinal bleeding in a patient with portal hypertension may be variceal rupture, portal hypertension gastropathy, postsclerotherapy ulcers, peptic ulcer disease, hemorrhagic gastritis, and Mallory-Weiss tear. TIPS is generally accepted as a second-line therapy after failure of endoscopic and medical therapy of bleeding from gastro-esophageal varices [15].

Primary prophylaxis of variceal bleeding Bleeding from esophageal varices is a common and severe complication of portal hypertension. Prevention of the initial bleeding can be achieved in a number of cases by endoscopic variceal ligation or ␤-blocker treatment. However, TIPS has never been tested in this situation as previous experience with surgical portacaval shunts has clearly demonstrated that this approach is associated with higher morbidity and mortality rates [16]. Bleeding from gastric varices is often severe and difficult to control, particularly when fundal varices are involved. The first-line treatment is endoscopic sclerotherapy with cyanoacrylate [17]. TIPS has been used in a number of uncontrolled trials in patients in whom endoscopic therapy failed [18,19]. A recent controlled trial has shown that TIPS is more efficient than cyanoacrylate in prevention of rebleeding (secondary prophylaxis) from large gastric varices [20]. This interesting finding must be confirmed by other groups and after a long-term follow-up. It should be mentioned that due to the large size of fundal varices, the risk of rupture is still present even at a low portacaval gradient (< 12 mmHg) after TIPS [21]. This is probably best explained by the relationship between the variceal tension (and therefore the risk of rupture) and the variceal

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TIPS for variceal gastrointestinal bleeding size. For this reason, it is now recommended to embolize gastric varices at the time of TIPS placement [16,22].

Acute variceal bleeding

3 Table 2 Contraindications to placement of a transjugular intrahepatic portosystemic shunt (TIPS). Absolute

Relative

Primary prevention of variceal bleeding

Hepatocellular carcinoma, especially central Obstruction of all hepatic veins Portal vein thrombosis

When an initial bleeding occurs, it is usually controlled with less invasive endoscopic treatment and/or pharmacological therapy. In rare cases bleeding remains uncontrollable, and TIPS has been used as a rescue treatment with good results for bleeding control. However, prognosis relies on the general condition of the patient, the value of the liver function reserve, and the associated co-morbidities [23—26]. However, a recent randomized controlled trial evaluated the use of emergent TIPS as compared to standard medical therapy in patients with severe portal hypertension and a Pugh score of 7 to 13 [27]. Treatment failure was more frequent in the medical group (50% versus 12%) and the survival rate was better in the TIPS group (11 versus 38%). This approach could justify the use of TIPS early after bleeding episodes in patients with moderate or severe liver failure and severe portal hypertension. Current evidence supports the use of TIPS as a ‘‘rescue’’ treatment for patients with bleeding esophageal varices who failed pharmacological and endoscopic treatments, and not as a primary form of treatment.

are related to liver disease and not to portal hypertension [44,45].

Secondary prophylaxis of variceal bleeding

Contraindications

The strongest evidence in favor of performing a TIPS procedure exists for the secondary prevention of variceal bleeding. A total of 12 randomized controlled trials have been published on this topic, describing results for 948 patients, 472 of whom received a TIPS [28—39]. Recent meta-analyses [40,41] found a more than threefold decrease in the risk of recurrent bleeding after insertion of a TIPS compared with various forms of endoscopic therapy (Table 1). Rates of rebleeding after insertion of TIPS ranged from 9% to 40.6%. Conversely, continued endoscopic therapy resulted in a 20.5—60.6% rate of rebleeding. All-cause mortality rates were found to be similar between the TIPS and endoscopic therapy groups. However, there was a more than twofold increase in the rate of development of hepatic encephalopathy after a TIPS procedure [28—39].

Absolute contraindications to TIPS include right heart failure and pulmonary arterial hypertension. TIPS is of unclear survival benefit in patients with severe liver failure (ChildPugh class C cirrhosis, model for end-stage liver disease score > 22, serum bilirubin > 3 mg/dL). Other relative contraindications include hepatic encephalopathy (which may worsen following TIPS creation), polycystic liver disease (technically challenging with a high incidence of hemorrhagic complications), active sepsis (poor outcomes), and chronic organized portal vein thrombosis (technically challenging for successful TIPS creation) (Table 2). Acute portal vein thrombus is not a contraindication for TIPS; however, it necessitates extensive stenting to prevent shunt occlusion [46].

Ectopic varices

Pre-tips work-up

Varices may develop anywhere along the digestive tract in patients with portal hypertension (duodenum, jejunum, colon, rectum, stomies) and may bleed. Local treatments are either impossible or associated with a high rate of rebleeding. The best approach is the TIPS procedure, which can be combined with embolization of the varices [42,43].

Portal hypertensive gastropathy These gastric lesions rarely induce problematic bleeding. Anecdotal case reports suggest that TIPS may control bleeding in these patients [44].

Gastric antral vascular ectasia Chronic bleeding from gastric antral vascular ectasia may be difficult to manage. However, TIPS does not help to control bleeding, probably because these vascular lesions

Congestive heart failure Severe tricuspid regurgitation Severe pulmonary hypertension Multiple hepatic cysts Uncontrolled systemic infection or sepsis Unrelieved biliary obstruction

Moderate pulmonary hypertension Severe coagulopathy (INR > 5) Thrombocytopenia of < 20,000 cells/cm3 Hepatic encephalopathy

Patients who are actively bleeding and/or intubated may be unable to give informed consent for the procedure. In such instances, informed consent must be obtained from the health care proxy after a discussion of the specifics of the procedure that includes the risks, expectations, and benefits. Comprehensive blood work must be obtained, including a complete blood count, renal function parameters, liver function tests, the serum ammonia level, and a coagulation profile. Any coagulopathy should be corrected with the administration of fresh frozen plasma and platelets. Blood bank samples should be sent for type and cross match, and at least 2 U of blood should be available for transfusion [47]. Endoscopy should be performed before TIPS consultation both to confirm variceal bleeding and to attempt endoscopic management. Any prior imaging studies (ultrasound, computed tomography, and magnetic resonance imaging) should be reviewed to confirm portal vein patency and to assess

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the presence of gastro-esophageal varices and other portosystemic shunts that may compete with the TIPS. The location of the portal vein bifurcation should be determined on prior imaging, as an extrahepatic portal vein bifurcation occurs in 25% of patients and accessing an extrahepatic portal vein during TIPS carries a high mortality. Imaging may also demonstrate the presence of splenic vein thrombosis (TIPS is not the treatment of choice for isolated gastric variceal bleeding due to splenic vein thrombosis), ascites, and general hepatic morphology. If there is large-volume ascites, preprocedural paracentesis should be performed. If no imaging is available, Doppler ultrasound assessment of the portal vein should be performed before initiating the TIPS procedure. Although the role of antibiotics during a TIPS procedure is controversial, it is a common practice at our institution to give antibiotics at the time of TIPS procedure. All patients with cirrhosis and gastrointestinal bleeding have been shown to be at an increased risk of bacterial infection [48,49] and thus prophylactic antibiotics should be administered. Several meta-analyses have demonstrated a reduction in bacterial infections and improved survival attributed to the use of short-term prophylactic antibiotics [50]. No consensus exists as to which antibiotic should be given but as the majority of studies used quinolones [51,52], these are generally recommended, for 5—7 days, intravenous initially and then orally. The procedure is performed under general anesthesia and thus an emergency consultation with anesthesia is initiated as soon as TIPS is considered. Although the above studies illustrate the efficacy and applicability of TIPS in the setting of uncontrolled variceal bleeding, there remains a debate about the best time to undertake the procedure. Although a convenient definition of uncontrolled variceal bleeding can be taken as failure of two endoscopic treatments, this does not necessarily mean this is the correct selection criterion for TIPS insertion. Patients who are Child’s A and whose bleeding does not appear life-threatening may be managed by balloon tamponade followed by further sessions of endoscopic band ligation and generally do not require TIPS. Conversely, patients with advanced liver disease who have had a single massive bleed and have unsuccessful endoscopic treatment on one occasion and require balloon tamponade, may be better treated by TIPS early rather than undergoing a second endoscopic therapy session. Monescillo et al. [53] showed that early insertion of TIPS might confer extra benefit. The basis of this is probably due to reducing the duration or risk of hypotension that is likely to be detrimental for patients with decompensated liver disease.

Technical aspects of tips creation Available Sets Three types of TIPS sets are commercially available. Two sets, made by Cook Medical (Bloomington, IN), include the ‘‘Ring TIPS set’’ and the ‘‘Rosch-Uchida TIPS set’’. The Ring set has a 16-Gauge curved Colapinto needle, while the Rosch-Uchida set has 16-Gauge curved blunt cannula through which a 5-French catheter with an inner needle is advanced to access the portal vein. After advancing the

Table 3 Procedural steps of transjugular intrahepatic portosystemic shunt (TIPS) creation. Step 1 Step 2 Step 3

Step 4

Step 5 Step 6 Step 7

Step 8

Venous access Hepatic venography Wedged hepatic venography and measurement of portosystemic gradient Accessing the portal vein, portography, measurement of portal venous pressure Dilatation of the parenchymal tract Deployment of a stent across the parenchymal tract Portography and measurement of portosystemic gradient Ancillary procedures as embolization of varices

catheter (together with the needle), the needle is removed and the catheter is slowly withdrawn while maintaining suction in the catheter. There is also a Cope version of the Ring set, which uses a 20- to 21-Gauge-long needle. Another set is made by AngioDynamics (Queensbury, NY) and has a hollow 21-Gauge needle that is passed through a hollow, curved cannula [54].

Conventional procedural steps As previously said, the procedure is usually performed under general anesthesia with endotracheal intubation. Commonly used methods for creation of a TIPS have been recently reviewed in detail elsewhere (Table 3) [55]. The different steps of TIPS creation are summarized in Fig. 1. Most practitioners prefer to create the shunt from the right hepatic vein approach. However, portal vein access can be obtained from any hepatic vein or even from the inferior vena cava in patients with complete occlusion of the hepatic veins. Many practitioners use blocked-catheter or balloon occlusion hepatic venography using contrast medium or carbon dioxide to show the course and direction of flow in the portal veins [54,56]. Fluoroscopically guided needle passes are made in the hepatic parenchyma followed by aspiration on the TIPS needle through a syringe. A flush of blood in the syringe indicates that the tip of the needle is located in a vascular structure. Contrast material is then injected through the needle to determine whether access to a portal vein branch has been gained. If the site of portal vein entry is deemed large enough and without severe angulation in the expected course of the shunt, a 0.035-inch guidewire is introduced through the needle into the portal vein. A hydrophilic-coated guidewire or a floppy-tip non-hydrophilic guidewire can be used; in difficult cases, a micro-guidewire and microcatheter combination may be helpful. Once transportal access to the splenic or superior mesenteric vein with a guidewire is secured, a 5-French catheter is introduced into the splenic or superior mesenteric vein,

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Figure 1. Conventional transjugular intrahepatic portosystemic shunt (TIPS) creation technique; a and b: right hepatic venography: contrast injection through a sheath placed in the right hepatic vein demonstrates a patent right hepatic vein; c: catheter-blocked transhepatic portogram using iodinated contrast material shows course of portal veins; d and e: accessing the portal vein with a Colapinto needle: the needle is advanced either anteriorly (if the right hepatic vein has been selectively catheterized) or posteriorly (if the catheter is within the middle hepatic vein) for accessing the right portal vein. The needle is slowly withdrawn while maintaining suction with a syringe that is attached to the needle hub. Once an intravascular location is confirmed, contrast material is injected through Colapinto needle confirming needle position within portal vein before passage of guidewire; f: direct portography via a 5-French marked pigtail catheter helping to choose the right length of stent to be used; g, h and i: dilatation of a tract through the hepatic parenchyma that is interposed between the hepatic and portal veins; j, k, l and m: deployment of a 10-mm Viatorr® stent-graft (W.L. Gore) diameter. The stent is deployed, so the bare portion of the stent lies in the portal vein and the junction between the bare and covered portion lies at the portal vein entry site. The stent should extend to the hepatic vein-inferior vena cava junction and is secondary dilated; n and o: portal venogram obtained after TIPS insertion shows flow through polytetrafluoroethylene (PTFE)-covered stent.

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and a stiff guidewire is left in place. Portal venography and pressure measurement can be performed at this point. A portosystemic pressure gradient is calculated as the pressure difference between the portal vein and the right atrium. The parenchymal track is then dilated with an angioplasty balloon to allow passage of the TIPS sheath into the portal vein. Catheterization of the portal vein with the 10French TIPS sheath is required to place the PTFE-covered stent-graft (Viatorr® , W.L. Gore). This step might prove to be technically challenging because of ‘‘buckling’’ of the sheath in the right atrium. A variety of maneuvers can be tried to advance the sheath, including employment of a partially deflated angioplasty balloon, the stiff plastic tapered sheath introducer, or the TIPS needle itself. In some difficult cases, a TIPS can be created by deploying an uncovered metal stent first, through which the TIPS sheath can usually be advanced into the portal vein. In these cases, the PTFE-covered stent is deployed within the bare-metal stent. When using PTFE-covered stents, care should be taken to leave the uncovered caudal portion of the stent in the portal vein, whereas the covered portion of the stent should be in the parenchymal tract and in the hepatic vein. The cranial end of the stent should extend to the junction of the hepatic vein and the inferior vena cava. Overlapping stents of the same diameter are often used to achieve the desired shunt length and to reduce severe angulation within the shunt. A 10-mm stent diameter is typically chosen for adult patients, whereas 8-mm stents are more often used in the pediatric population. Once stents are deployed, trans-TIPS portal venography and pressure measurements in the main portal vein and the right atrium are repeated. The post-TIPS portosystemic pressure gradient is calculated. A post-TIPS portosystemic pressure gradient under 12 mmHg in patients with a history of variceal bleeding should be achieved to prevent a rebleeding episode [57]. A threshold portosystemic pressure gradient value for patients receiving a TIPS for refractory ascites has been a subject of some debate. Society of Interventional Radiology and American Association for the Study of Liver Disease guidelines [58] recommend reducing the portosystemic pressure gradient to under 8 mmHg, whereas other investigators [59] suggested that a threshold value below 12 mmHg may provide adequate ascites control. Gradients below 5 mmHg have been associated with an increase in the risk of liver failure and severe hepatic encephalopathy requiring an intervention, such as TIPS reduction [60].

Endovascular alternative technique One of the technical challenges in creating a TIPS involves cannulation and catheterization of an adequate portal vein branch. The reason for this challenge is the fact that portal vein is not visualized on the fluoroscopic images. Transhepatic portal venography helps assess the approximate course of the vein, but the 2D nature of venography prevents precise localization of the portal vein. This inability to visualize the portal vein often leads to multiple needle passes within the liver parenchyma that may result in hepatic artery, bile duct, and liver capsule injuries, which in turn may have dire consequences. One of the most commonly used technical variants of a TIPS technique is the direct intrahepatic portacaval shunt (DIPS). DIPS was first described in 2001 by

Petersen et al. [61]. The hallmark of the DIPS procedure is the use of the caudate lobe as the parenchymal tract to create a side-to-side shunt between the inferior vena cava and the portal vein. The conventional DIPS method relies on direct needle guidance using an intravascular ultrasound probe introduced via the femoral vein approach [62]. A TIPS needle is introduced from the jugular approach and is visualized sonographically as it passes from the inferior vena cava into the portal vein. The remainder of the procedure is similar to the creation of a conventional TIPS. Intravascular ultrasound skills are not required to master the DIPS technique. DIPS can be performed using transabdominal ultrasound by guiding a needle through a large intraparenchymal portal vein branch to the inferior vena cava [63]. A left lobe approach through the left portal vein is preferred in this technique because it avoids the intercostal approach to the liver right lobe. Once the inferior vena cava is cannulated, a guidewire is advanced into the cava and is snared from the jugular approach. The resulting stable through-and-through guidewire access is used to introduce a guiding sheath from the jugular approach and dilate the parenchymal track to the portal vein. The sheath is then advanced into the portal vein, and its location within the portal vein can be confirmed sonographically. A second catheter and guidewire are then manipulated into the splanchnic venous system followed by removal of the through-and-through guidewire and introduction of a stent. The quoted advantages of the DIPS procedure are the lack of hepatic vein as shunt outflow (and therefore lack of hepatic vein stenosis), real-time imaging guidance during advancement of the needle into the portal vein, decreased radiation by use of ultrasound during portal vein access, and decreased procedural time [61]. Limited data suggest that DIPS has a high technical success rate and long-term patency similar to that of the TIPS procedure [64].

Embolization of varices Embolization of the esophageal varices at the time of the TIPS is easily accomplished but its routine application has been also controversial. Embolization after TIPS has been reported in some series in 24 to 48% of patients [65,66]. Currently, it is not clear whether the combination of TIPS and variceal embolization is more effective than TIPS alone. Some authors recommend transjugular embolization of the varices to increase the effect of the shunt with respect to acute hemostasis [65,66], and other authors do not perform any embolization during the TIPS procedure [67]. Patients with a history of variceal bleeding may benefit from selective catheterization and embolization of gastro-esophageal varices. A large retrospective study by Tesdal et al. [22] showed that patients who underwent variceal embolization at the time of TIPS were significantly less likely (84% vs. 61% at 2 years; 81% vs. 53% at 4 years) to develop recurrent variceal bleeding than patients who had only a TIPS procedure. In our clinical practice, we perform embolization of varices only if we observe persistent contrast flow into the varices in the control portography after TIPS. Variceal embolization is also indicated for patients with recurrent esophageal bleeding despite a patent shunt [65]. The varices may be embolized with coils, cyanoacrylate glue, onyx,

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Figure 2. Variceal embolization before transjugular intrahepatic portosystemic shunt (TIPS) revision in a patient with acute variceal bleeding; a and b: TIPS portogram through a calibrated catheter positioned in the portal vein demonstrates complete TIPS obstruction and opacification of gastro-esophageal varices; c and d: the varices were successfully embolized with Onyx® through a 3-French microcatheter; e and f: angiography after shunt revision with uncovered nitinol stent plus polytetrafluoroethylene (PTFE)-covered stent (Fluency® , Bard) shows TIPS patency and disappearance of varices.

vascular occluder as well as with sclerosants such as sodium tetradecyl sulfate (Fig. 2).

Follow-up Patients are usually admitted to a unit that can provide close monitoring for a minimum of 6 hours after the procedure. Laboratory parameters including complete blood count, coagulation panel, serum creatinine level, and liver function tests are checked regularly. Urine output and mental status are tracked as well. A liver ultrasound with Doppler is commonly obtained on the day after the TIPS procedure to show shunt patency. Flow in PTFE-covered stents is usually difficult to detect sonographically during the first 72 hours after placement because of retention of small air bubbles within the graft material. Adjunct diagnostic measures, such as detection of hepatopetal flow in the main portal vein and hepatofugal flow in the branch portal veins, suggest TIPS patency and appropriate functioning. Patients with a suspected TIPS dysfunction should undergo TIPS venography. If the original TIPS was created using a bare-metal stent, placement of a covered stent is likely to improve long-term shunt patency [68]. Other commonly used measures include balloon angioplasty within the stents and the placement of additional stents in patients to extend cranial or caudal length of the stent. Hepatic encephalopathy refractory to medical management or

progressive hepatic dysfunction after TIPS placement might require endovascular shunt reduction. A commonly used technique involves shunt catheterization by two parallel guidewires followed by simultaneous deployment of two stents within the shunt. One of the stents is a covered endograft through which blood flow will be conducted, whereas the second device is a balloon-expandable bare-metal stent, the diameter of which determines the ultimate shunt diameter. Usually, the bare-metal stent is placed along the cephalic aspect of the covered stent. This allows continued access to the balloon-expandable stent if further reduction is necessary [69,70].

Outcomes Survival Acute variceal bleeding that is poorly controlled with endoscopic therapy is generally well controlled with TIPS, which has success in this respect that ranges from 90% to 100%. However, TIPS is associated with a mortality of 27%—50% [25,71,72]. Increased mortality is related to a Child C clinical status, hemodynamic instability at the time of the TIPS procedure, and the presence of other co-morbidities. In general, an early TIPS intervention allows for better control of bleeding with decreased mortality. Patients with a high HVPG (> 20 mmHg) and acute variceal bleeding have a

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R. Loffroy et al. Table 4

Potential complications after transjugular intrahepatic portosystemic shunt (TIPS) placement.

Acute complications

Chronic complications

Minor or moderate

Life-threatening

Stent displacement Neck hematoma Arrhythmia Shunt thrombosis Hepatic vein obstruction

Hemobilia Hemoperitoneum Cardiac failure Liver ischemia Sepsis

better survival with TIPS than with endoscopic therapy [53]. Most of the deaths of patients after emergency TIPS are related to hepatic failure, multiorgan failure, and sepsis, often accompanied by variceal and non-variceal bleeding. A minority of the deaths is related to isolated recurrent variceal bleeding [19,73]. Early death occurring within 30 days is most commonly caused by multiorgan failure, and late death after 30 days is most commonly related to liver failure [73]. Many studies reporting on emergency TIPS for the ‘‘rescue’’ treatment of acute esophageal varices bleeding have shown low survival rates and significantly higher mortality rates than patients undergoing elective TIPS. Rajan et al. [74] reported 123 patients who were acutely bleeding at the time of TIPS creation. Of these, 42 (34.1%) died within 30 days of TIPS creation, compared with 16 of 97 patients (16.5%) undergoing elective TIPS creation. As an independent predictor of mortality, bleeding at the time of TIPS creation was associated with odds of death that were 2.9 times greater than those associated with elective TIPS placement. Similar findings have been reported by Helton et al. [75], who reported 56% in-hospital mortality for patients who were actively bleeding or hemodynamically unstable at the time of the TIPS versus 5.5% following non-emergent procedures. The reported mortality associated with TIPS varies widely because the inclusion criteria, timing of the TIPS, and the severity of liver disease varies in the different published series. Many of the reports combine the results of patients actively bleeding during TIPS with those of the patients who were stable during the procedure. Several reports describing different prognostic factors associated with mortality after TIPS have been published. Prognostic factors are not intended to predict outcome or management on individual basis or to deny a patient a potentially lifesaving intervention, but are useful as guidelines for prognostic purposes, to develop appropriate expectations, and to weigh different therapeutic options. Final decisions are based on the individual patient needs and overall clinical condition [53,76]. Many of these prognostic factors correlate well with the mortality of patients undergoing elective TIPS. In patients with acute variceal bleeding, however, these predictors may fail because the hepatic reserve and renal function are difficult to evaluate in the acute setting [53]. Events such as bleeding, infection, and high-dose diuretic therapy may affect the renal and liver function in a transient way. No single prognostic criterion has been demonstrated to be able to help to accurately select those patients with a very high risk of dying [77]. However, several selection criteria have been recently described as more experience has been obtained over the years in regards to the emergency TIPS procedure [78].

Portal vein thrombosis Congestive heart failure Progressive liver failure Chronic recurrent encephalopathy Stent dysfunction

Complications The TIPS procedure may lead to a number of potentially significant adverse events (Table 4). Technical complications sustained at the time of TIPS placement can include transcapsular puncture, which may occur in as many as 33% of cases. The capsular perforation leads to significant intraperitoneal hemorrhage 1—2% of the time. Clinically significant hemobilia is also rarely observed after the procedure. The stent can be placed too far into the inferior vena cava or even into the right atrium at the cranial end or far into the main portal vein at the caudal end of the shunt in up to 20% of patients. On occasion, stents may migrate on or shortly after placement because of catheter and balloon manipulation [58]. Diversion of portal venous flow through the shunt diminishes the metabolic filtering effect of the hepatic parenchyma, leading to new or worsened encephalopathy in 30—46% of patients [40,41]. Chronic recurrent disabling hepatic encephalopathy can occur in 5—10% and may lead to a complete loss of the patient’s autonomy. Several pre-TIPS parameters have been tested to predict post-TIPS hepatic encephalopathy (Table 4) [40,41]. Deterioration of hepatic function in approximately 10% of patients [41], and occasionally hepatorenal syndrome [79], may also be observed. TIPS stenosis and occlusion used to be quite common before wide acceptance of PTFE-covered stents (Viatorr® , W.L. Gore). The most common site of shunt stenosis is at the hepatic venous end. The culprit of midstent stenosis is thought to be intimal hyperplasia within the bare-metal stent due to contact between traversed biliary radicles and stent lumen [58]. The incidence of stenosis due to hyperplasia within the stent ranged from 18% to 78% [58] for bare-metal stents, which led to recurrence of portal hypertension complications and required frequent invasive procedures for reconstitution of flow. The introduction of PTFE-covered stent-grafts led to dramatic improvement in long-term TIPS patency. A randomized controlled trial published in 2007 [80] established a PTFE-covered stent as the preferred device for TIPS. In that study, 80 patients were randomized to receive either a covered (n = 39) or a bare (n = 41) metal stent and were followed for 2 years after TIPS placement. Compared with patients treated with a bare-metal stent, patients with a PTFE-covered stent had a significantly lower rate of TIPS dysfunction (15% vs. 44%), a higher rate of primary patency (76% vs. 36%), a lower rate of clinical relapse (10% vs. 29%), and were less likely to develop encephalopathy (33% vs. 49%). On the basis of these data, a PTFE-covered stent became the standard of care device for de novo TIPS. Patients who have a bare-metal stent TIPS should undergo shunt revision with

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TIPS for variceal gastrointestinal bleeding a PTFE-covered stent in the event of shunt dysfunction (Fig. 2) [58].

Conclusion The role of TIPS in the management of acute variceal bleeding that is refractory to endoscopic therapy is well established. Although it is highly effective in controlling bleeding, the mortality with emergency TIPS is high. Early elective intervention is the key to achieving better results. The best available evidence supports the use of TIPS in secondary prevention of variceal bleeding and in refractory ascites, although TIPS is also used for other indications, such as Budd-Chiari syndrome, hepatic hydrothorax, and acute variceal bleeding. The TIPS procedure was revolutionized by the introduction of covered stents, which dramatically improved long-term shunt patency. A number of potential technical challenges related to creation of a TIPS led to the development of endovascular portosystemic shunt variants, such as DIPS, which may play a larger role in the future treatment of patients with complications of portal hypertension.

Take-home messages • Bleeding from esophageal varices is a common and severe complication of portal hypertension. • The transjugular intrahepatic portosystemic shunt (TIPS) procedure is a minimally invasive imageguided intervention used for secondary prevention of bleeding and as salvage therapy in acute bleeding. • The procedure is technically challenging, especially in critically ill patients, and has a mortality of 30%—50% in the emergency setting, but has greater than 90% effectiveness in controlling bleeding from gastro-esophageal varices. • The introduction of PTFE-covered stent-grafts led to dramatic improvement in long-term TIPS patency. • The best available evidence supports the use of TIPS in secondary prevention of variceal bleeding and in refractory ascites, although TIPS is also used for other indications, such as Budd-Chiari syndrome, hepatic hydrothorax, and acute variceal bleeding.

Disclosure of interest The authors declare that they have no conflicts of interest concerning this article.

References [1] Jalan R, Hayes PC. UK Guidelines on the management of variceal haemorrhage in cirrhotic patients. Br Soc Gastroenterol Gut 2000;46:III1—15. [2] The North Italian Endoscopic Club for the Study and Treatment of Esophageal Varices. Prediction of the first variceal hemorrhage in patients with cirrhosis of the liver and esophageal varices. A prospective multicenter study. N Engl J Med 1988;319:983—9. [3] D’Amico G, Pagliaro L, Bosch J. The treatment of portal hypertension: a metaanalytic review. Hepatology 1995;22:332—54.

9 [4] DeDombal FT, Clark JR, Clamp SE, Malizia G, Kofwal MR, Morgan AG. Prognostic factors in upper GI bleeding. Endoscopy 1986;18(Suppl. 2):6—10. [5] Gores GJ, Wiesner RH, Dickson ER, Zinsmeister AR, Jorgensen RA, Langworthy A. Prospective evaluation of esophageal varices in primary biliary cirrhosis: development, natural history, and influence on survival. Gastroenterology 1989;96:1552—9. [6] McAvoy NC, Hayes PC. The use of transjugular intrahepatic portosystemic stent shunt in the management of acute oesophageal variceal haemorrhage. Eur J Gastroenterol Hepatol 2006;18:1135—41. [7] Moitinho E, Escorsell A, Bandi JC, Salmeron JM, Garcia-Pagan JC, Rodes J, et al. Prognostic value of early measurement of portal pressure in acute variceal bleeding. Gastroenterology 1999;117:626—31. [8] Beppu K, Inokuchi K, Koyanagi N, Nakayama S, Sakata H, Kitano S, et al. Prediction of variceal hemorrhage by esophageal endoscopy. Gastrointest Endosc 1981;27:213—8. [9] Hernandez-Guerra M, Turnes J, Rubinstein P, Olliff S, Elias E, Bosch J, et al. PTFE-covered stents improve TIPS patency in Budd-Chiari syndrome. Hepatology 2004;40:1197—202. [10] Dhanasekaran R, West JK, Gonzales PC, Subramanian R, Parekh S, Spivey JR, et al. Transjugular intrahepatic portosystemic shunt for symptomatic refractory hepatic hydrothorax in patients with cirrhosis. Am J Gastroenterol 2010;105:635—41. [11] Siegerstetter V, Deibert P, Ochs A, Olschewski M, Blum HE, Rossle M. Treatment of refractory hepatic hydrothorax with transjugular intrahepatic portosystemic shunt: longterm results in 40 patients. Eur J Gastroenterol Hepatol 2001;13:529—34. [12] Spencer EB, Cohen DT, Darcy MD. Safety and efficacy of transjugular intrahepatic portosystemic shunt creation for the treatment of hepatic hydrothorax. J Vasc Interv Radiol 2002;13:385—90. [13] Brensing KA, Textor J, Perz J, Schiedermaier P, Raab P, Strunk H, et al. Long-term outcome after transjugular intrahepatic portosystemic stent-shunt in non-transplant cirrhotics with hepatorenal syndrome: a phase II study. Gut 2000;47:288—95. [14] Martinez-Palli G, Drake BB, Garcia-Pagan JC, Barbera JA, Arguedas MR, Rodriguez-Roisin R, et al. Effect of transjugular intrahepatic portosystemic shunt on pulmonary gas exchange in patients with portal hypertension and hepatopulmonary syndrome. World J Gastroenterol 2005;11:6858—62. [15] Krajina A, Hulek P, Fejfar T, Valek V. Quality Improvement Guidelines for Transjugular Intrahepatic Portosystemic Shunt (TIPS). Cardiovasc Intervent Radiol 2012;35:1295—300. [16] Pomier-Layrargues G, Bouchard L, Lafortune M, Bissonnette J, Guérette D, Perreault P. The transjugular intrahepatic portosystemic shunt in the treatment of portal hypertension: current status. Int J Hepatol 2012;2012:167868. [17] Irani S, Kowdley K, Kozarek R. Gastric varices: an updated review of management. J Clin Gastroenterol 2011;45:133—48. [18] Barange K, Peron JM, Imani K, Otal P, Payen JL, Rousseau H, et al. Transjugular intrahepatic portosystemic shunt in the treatment of refractory bleeding from ruptured gastric varices. Hepatology 1999;30:1139—43. [19] Chau TN, Patch D, Chan YW, Nagral A, Dick R, Burroughs AK. Salvage transjugular intrahepatic portosystemic shunts: gastric fundal compared with esophageal variceal bleeding. Gastroenterology 1998;114:981—7. [20] Lo GH, Liang HL, Chen WC, Chen MH, Lai KH, Hsu PI, et al. A prospective, randomized controlled trial of transjugular intrahepatic portosystemic shunt versus cyanoacrylate injection in the prevention of gastric variceal rebleeding. Endoscopy 2007;39:679—85. [21] Tripathi D, Therapondos G, Jackson E, Redhead DN, Hayes PC. The role of the transjugular intrahepatic portosystemic

Please cite this article in press as: Loffroy R, et al. Transjugular intrahepatic portosystemic shunt for acute variceal gastrointestinal bleeding: Indications, techniques and outcomes. Diagnostic and Interventional Imaging (2015), http://dx.doi.org/10.1016/j.diii.2015.05.005

+Model DIII-629; No. of Pages 11

ARTICLE IN PRESS

10

[22]

[23]

[24]

[25]

[26] [27]

[28]

[29]

[30]

[31]

[32]

[33]

[34]

[35]

[36]

[37]

R. Loffroy et al. stent shunt (TIPSS) in the management of bleeding gastric varices: clinical and haemodynamic correlations. Gut 2002;51: 270—4. Tesdal IK, Filser T, Weiss C, Holm E, Dueber C, Jaschke W. Transjugular intrahepatic portosystemic shunts: adjunctive embolotherapy of gastroesophageal collateral vessels in the prevention of variceal rebleeding. Radiology 2005;236:360—7. Azoulay D, Castaing D, Majno P, Saliba F, Ichaï P, Smail A, et al. Salvage transjugular intrahepatic portosystemic shunt for uncontrolled variceal bleeding in patients with decompensated cirrhosis. J Hepatol 2001;35:590—7. D’Amico G, Luca A. TIPS is a cost effective alternative to surgical shunt as a rescue therapy for prevention of recurrent bleeding from esophageal varices. J Hepatol 2008;48:387—90. Sanyal AJ, Freedman AM, Luketic VA, Purdum PP, Shiffman ML, Tisnado J, et al. Transjugular intrahepatic portosystemic shunts for patients with active variceal hemorrhage unresponsive to sclerotherapy. Gastroenterology 1996;111:138—46. Vangeli M, Patch D, Burroughs AK. Salvage tips for uncontrolled variceal bleeding. J Hepatol 2002;37:703—4. Garcıa-Pagan JC, Caca K, Bureau C, Laleman W, Appenrodt B, Luca A, et al. Early use of TIPS in patients with cirrhosis and variceal bleeding. N Engl J Med 2010;362:2370—9. Rossle M, Haag K, Ochs A, Sellinger M, Noldge G, Perarnau JM, et al. The transjugular intrahepatic portosystemic stent-shunt procedure for variceal bleeding. N Engl J Med 1994;330:165—71. Cello JP, Ring EJ, Olcott EW, Koch J, Gordon R, Sandhu J, et al. Endoscopic sclerotherapy compared with percutaneous transjugular intrahepatic portosystemic shunt after initial sclerotherapy in patients with acute variceal hemorrhage: a randomized, controlled trial. Ann Intern Med 1997;126:858—65. Sanyal AJ, Freedman AM, Luketic VA, Purdum PP, 3rd, Shiffman ML, et al. Transjugular intrahepatic portosystemic shunts compared with endoscopic sclerotherapy for the prevention of recurrent variceal hemorrhage: a randomized, controlled trial. Ann Intern Med 1997;126:849—57. Cabrera J, Maynar M, Granados R, Gorriz E, Reyes R, PulidoDuque JM, et al. Transjugular intrahepatic portosystemic shunt versus sclerotherapy in the elective treatment of variceal hemorrhage. Gastroenterology 1996;110:832—9. Sauer P, Theilmann L, Stremmel W, Benz C, Richter GM, Stiehl A. Transjugular intrahepatic portosystemic stent shunt versus sclerotherapy plus propranolol for variceal rebleeding. Gastroenterology 1997;113:1623—31. Jalan R, Forrest EH, Stanley AJ, Redhead DN, Forbes J, Dillon JF, et al. A randomized trial comparing transjugular intrahepatic portosystemic stent-shunt with variceal band ligation in the prevention of rebleeding from esophageal varices. Hepatology 1997;26:1115—22. Merli M, Salerno F, Riggio O, de Franchis R, Fiaccadori F, Meddi P, et al. Transjugular intrahepatic portosystemic shunt versus endoscopic sclerotherapy for the prevention of variceal bleeding in cirrhosis: a randomized multicenter trial. Hepatology 1998;27:48—53. Sauer P, Benz C, Thelmann L, Richter G, Stremmel W, Stiehl A. Transjugular intrahepatic portosystemic stent shunt (TIPS) vs. endoscopic banding in the prevention of variceal rebleeding: final results of a randomized study. Gastroenterology 1997;113:1623—31. Garcia-Villarreal L, Martinez-Lagares F, Sierra A, Guevara C, Marrero JM, Jiménez E, et al. Transjugular intrahepatic portosystemic shunt versus endoscopic sclerotherapy for the prevention of variceal rebleeding after recent variceal hemorrhage. Hepatology 1999;29:27—32. Pomier-Layrargues G, Villeneuve JP, Deschenes M, Deschenes M, Bui B, Perreault P, et al. Transjugular intrahepatic

[38]

[39]

[40]

[41]

[42]

[43]

[44]

[45]

[46]

[47]

[48]

[49]

[50]

[51]

[52]

portosystemic shunt (TIPS) versus endoscopic variceal ligation in the prevention of variceal rebleeding in patients with cirrhosis: a randomised trial. Gut 2001;48:390—6. Narahara Y, Kanazawa H, Kawamata H, Tada N, Saitoh H, Matsuzaka S, et al. A randomized clinical trial comparing transjugular intrahepatic portosystemic shunt with endoscopic sclerotherapy in the long-term management of patients with cirrhosis after recent variceal hemorrhage. Hepatol Res 2001;21:189—98. Gulberg V, Schepke M, Geigenberger G, Holl J, Brensing KA, Waggershauser T, et al. Transjugular intrahepatic portosystemic shunting is not superior to endoscopic variceal band ligation for the prevention of variceal rebleeding in cirrhotic patients: a randomized controlled trial. Scand J Gastroenterol 2002;37:338—43. Burroughs AK, Vangeli M. Transjugular intrahepatic portosystemic shunt versus endoscopic therapy: randomized trials for secondary prophylaxis of variceal bleeding: an updated metaanalysis. Scand J Gastroenterol 2002;37:249—52. Zheng M, Chen Y, Bai J, Zeng Q, You J, Jin R, et al. Transjugular intrahepatic portosystemic shunt versus endoscopic therapy in the secondary prophylaxis of variceal rebleeding in cirrhotic patients: meta-analysis update. J Clin Gastroenterol 2008;42:507—16. Vangeli M, Patch D, Terreni N, Tibballs J, Watkinson A, Davies N, et al. Bleeding ectopic varices—treatment with transjugular intrahepatic portosystemic shunt (TIPS) and embolisation. J Hepatol 2004;41:560—6. Vidal V, Joly L, Perreault P, Bouchard L, Lafortune M, Pomier-Layrargues G. Usefulness of transjugular intrahepatic portosystemic shunt in the management of bleeding ectopic varices in cirrhotic patients. Cardiovasc Intervent Radiol 2006;29:216—9. Kamath PS, Lacerda M, Ahlquist DA, McKusick MA, Andrews JC, Nagorney DA. Gastric mucosal responses to intrahepatic portosystemic shunting in patients with cirrhosis. Gastroenterology 2000;118:905—11. Spahr L, Villeneuve JP, Dufresne MP, Tasse D, Bui B, Willems B, et al. Gastric antral vascular ectasia in cirrhotic patients: absence of relation with portal hypertension. Gut 1999;44:739—42. Fidelman N, Kwan SW, LaBerge JM, Gordon RL, Ring EJ, Kerlan Jr RK. The transjugular intrahepatic portosystemic shunt: an update. AJR Am J Roentgenol 2012;199:746—55. Kravetz D, Bosch J, Arderiu M, Pilar Pizcueta M, Rodes J. Hemodynamic effects of blood volume restitution following a hemorrhage in rats with portal hypertension due to cirrhosis of the liver: influence and extent of portalsystemic shunting. Hepatology 1989;9:808—14. Bernard B, Cadranel JF, Valla D, Escolano S, Jarlier V, Opolon P. Prognostic significance of bacterial infection in bleeding cirrhotic patients: a prospective study. Gastroenterology 1995;108:1828—34. Goulis J, Armonis A, Patch D, Sabin C, Greenslade L, Burroughs AK. Bacterial infection is independently associated with failure to control bleeding in cirrhotic patients with gastrointestinal hemorrhage. Hepatology 1998;27:1207—12. Bernard B, Grange JD, Khac EN, Amiot X, Opolon P, Poynard T. Antibiotic prophylaxis for the prevention of bacterial infections in cirrhotic patients with gastrointestinal bleeding: a meta analysis. Hepatology 1999;29:1655—61. Blaise M, Pateron D, Trinchet JC, Levacher S, Beaugrand M, Pourriat JL. Systemic antibiotic therapy prevents bacterial infection in cirrhotic patients with gastrointestinal haemorrhage. Hepatology 1994;20:34—8. Selby WS, Norton ID, Pokorny CS, Bern RA. Bacteriaemia and bacterascites after endoscopic sclerotherapy for bleeding esophageal varices and prevention by intravenous

Please cite this article in press as: Loffroy R, et al. Transjugular intrahepatic portosystemic shunt for acute variceal gastrointestinal bleeding: Indications, techniques and outcomes. Diagnostic and Interventional Imaging (2015), http://dx.doi.org/10.1016/j.diii.2015.05.005

+Model DIII-629; No. of Pages 11

ARTICLE IN PRESS

TIPS for variceal gastrointestinal bleeding

[53]

[54]

[55]

[56]

[57]

[58]

[59]

[60]

[61]

[62]

[63]

[64] [65] [66]

cefotaxime: a randomised control trial. Gastrointest Endosc 1994;40:680—4. Monescillo A, Martinez-Lagares F, Ruiz-del-Arbol L, Sierra A, Guevara C, Jimenez E, et al. Influence of portal hypertension and its early decompression TIPSS placement on the outcome of variceal bleeding. Hepatology 2004;40:793—801. Loffroy R, Estivalet L, Cherblanc V, Favelier S, Pottecher P, Hamza S, et al. Transjugular intrahepatic portosystemic shunt for the management of acute variceal hemorrhage. World J Gastroenterol 2013;19:6131—43. Clark TWI. Stepwise placement of a transjugular intrahepatic portosystemic shunt endograft. Tech Vasc Interv Radiol 2008;11:208—11. Caporossi JM, Vidal V, Jacquier A, Reyre A, Flavian A, Muller C, et al. Balloon occlusion versus wedged hepatic venography using iodinated contrast for targeting the portal vein during TIPS. Diagn Interv Imaging 2015;96:357—63. Garcia-Tsao G, Groszmann RJ, Fisher RL, Conn HO, Atterbury CE, Glickman M. Portal pressure, presence of gastroesophageal varices and variceal bleeding. Hepatology 1985;5:419—24. Boyer TD, Haskal ZJ. American Association for the Study of Liver Disease Practice Guidelines: the role of transjugular intrahepatic portosystemic shunt creation in the management of portal hypertension. J Vasc Interv Radiol 2005;16:615—29. Casado M, Bosch J, Garcia-Pagan JC, Bru C, Banares R, Bandi JC, et al. Clinical events after transjugular intrahepatic portosystemic shunt: correlation with hemodynamic findings. Gastroenterology 1998;114:1296—303. Chung HH, Razavi MK, Sze DY, Frisoli JK, Kee ST, Dake MD, et al. Portosystemic pressure gradient during transjugular intrahepatic portosystemic shunt with Viatorr stent graft: what is the critical low threshold to avoid medically uncontrolled low pressure gradient related complications? J Gastroenterol Hepatol 2008;23:95—101. Petersen B, Uchida BT, Timmermans H, Keller FS, Rosch J. Intravascular US-guided direct intrahepatic portacaval shunt with a PTFE-covered stentgraft: feasibility study in swine and initial clinical results. J Vasc Interv Radiol 2001;12:475—86. Petersen B, Binkert C. Intravascular ultrasoundguided direct intrahepatic portacaval shunt: midterm follow-up. J Vasc Interv Radiol 2004;15:927—38. Boyvat F, Aytekin C, Harman A, Ozin Y. Transjugular intrahepatic portosystemic shunt creation in Budd-Chiari syndrome: percutaneous ultrasound-guided direct simultaneous puncture of the portal vein and vena cava. Cardiovasc Intervent Radiol 2006;29:857—61. Petersen BD, Clark TWI. Direct intrahepatic portocaval shunt. Tech Vasc Interv Radiol 2008;11:230—4. Lopera JE. Role of emergency transjugular intrahepatic portosystemic shunts. Semin Intervent Radiol 2005;22:253—65. Sahagun G, Benner KG, Saxon R, Barton RE, Rabkin J, Keller FS, et al. Outcome of 100 patients after transjugular intrahepatic portosystemic shunt for variceal bleeding. Am J Gastroenterol 1997;92:1444—52.

11 [67] Bizollon T, Dumortier J, Jouisse C, Rode A, Henry L, Boillot O, et al. Transjugular intrahepatic portosystemic shunt for refractory variceal bleeding. Eur J Gastroenterol Hepatol 2001;13:369—75. [68] Jirkovsky V, Fejfar T, Safka V, Hulek P, Krajina A, Chovanec V, et al. Influence of the secondary deployment of expanded polytetrafluoroethylene-covered stent grafts on maintenance of transjugular intrahepatic portosystemic shunt patency. J Vasc Interv Radiol 2011;22:55—60. [69] Sze DY, Hwang GL, Kao JS, Frisoli JK, Kee ST, Razavi MK, et al. Bidirectionally adjustable TIPS reduction by parallel stent and stent-graft deployment. J Vasc Interv Radiol 2008;19:1653—8. [70] Fanelli F, Salvatori FM, Rabuffi P, Boatta E, Riggio O, Lucatelli P, et al. Management of refractory hepatic encephalopathy after insertion of TIPS: long-term results of shunt reduction with hourglass-shaped balloon-expandable stent-graft. AJR Am J Roentgenol 2009;193:1696—702. [71] Banares R, Casado M, Rodriguez-Laiz JM, Camunez F, Matilla A, Echenagusia A, et al. Urgent transjugular intrahepatic portosystemic shunt for control of acute variceal bleeding. Am J Gastroenterol 1998;93:75—9. [72] Gerbes AL, Gülberg V, Waggershauser T, Holl J, Reiser M. Transjugular intrahepatic portosystemic shunt (TIPS) for variceal bleeding in portal hypertension: Comparison of emergency and elective interventions. Dig Dis Sci 1998;43:2463—9. [73] LaBerge JM, Somberg KA, Lake JR, Gordon RL, Kerlan Jr RK, Ascher NL, et al. Two-year outcome following transjugular intrahepatic portosystemic shunt for variceal bleeding: results in 90 patients. Gastroenterology 1995;108:1143—51. [74] Rajan DK, Haskal ZJ, Clark TW. Serum bilirubin and early mortality after transjugular intrahepatic portosystemic shunts: results of a multivariate analysis. J Vasc Interv Radiol 2002;13:155—61. [75] Helton WS, Belshaw A, Althaus S, Park S, Coldwell D, Johansen K. Critical appraisal of the angiographic portacaval shunt (TIPS). Am J Surg 1993;165:566—71. [76] McCormick PA, Dick R, Panagou EB, Chin JK, Greenslade L, McIntyre, et al. Emergency transjugular intrahepatic portasystemic stent shunting as salvage treatment for uncontrolled variceal bleeding. Br J Surg 1994;81:1324—7. [77] Bosch J. Salvage transjugular intrahepatic portosystemic shunt: is it really life-saving? J Hepatol 2001;35:658—60. [78] Ferral H, Patel NH. Selection criteria for patients undergoing transjugular intrahepatic portosystemic shunt procedures: current status. J Vasc Interv Radiol 2005;16:449—55. [79] D’Amico G, Luca A, Morabito A, Miraglia R, D’Amico M. Uncovered transjugular intrahepatic portosystemic shunt for refractory ascites: a metaanalysis. Gastroenterology 2005;129: 1282—93. [80] Bureau C, Pagan JC, Layrargues GP, Metivier S, Bellot P, Perreault P, et al. Patency of stents covered with polytetrafluoroethylene in patients treated by transjugular intrahepatic portosystemic shunts: long-term results of a randomized multicenter study. Liver Int 2007;27:742—7.

Please cite this article in press as: Loffroy R, et al. Transjugular intrahepatic portosystemic shunt for acute variceal gastrointestinal bleeding: Indications, techniques and outcomes. Diagnostic and Interventional Imaging (2015), http://dx.doi.org/10.1016/j.diii.2015.05.005