LIVER ASSOCIATION GUIDANCE RECOMMEND EARLIER TIPS

The American Association for the Study of Liver Diseases (AASLD), the Advancing Liver Therapeutic Approaches group (ALTA) and European Association for the Study of the Liver (EASL) suggest TIPS earlier in the treatment algorithm and a multidisciplinary approach that includes gastroenterology and hepatology.1-3

Multidisciplinary Team for TIPS

ALTA1
EASL2
AASLD3
ALTA1

Before TIPS creation, we recommend that a gastroenterologist or hepatologist should be involved in the initial decision to place an emergent or nonemergent TIPS with subsequent consultation by an interventional radiologist or other proceduralist with competency in TIPS. If center expertise is not available, we recommend referral to an expert center. Additional specialty consultations (eg, transplant surgery, cardiology, critical care, hematology, nephrology) may be considered on a case-by-case basis. [LOE 5]a

In patients with cirrhosis undergoing TIPS, a multidisciplinary approach, rather than an absolute MELD cut-off value, is recommended to centers with adequate experience in these areas. [LOE 2a]a

EASL2

A hepato-gastroenterologist should be involved in the initial decision to place an elective TIPS with subsequent consultation by a proceduralist who has competency in TIPS creation. If center expertise is not available, referral to an expert center is recommended. [LOE 5, strong recommendation, strong consensus] a

The MELD score remains the most accurate predictive model and should thus be used to assess liver function and post-TIPS survival. A multidisciplinary approach, rather than an absolute MELD cut-off, is recommended to assess TIPS candidacy. [LOE 2, strong recommendation, strong consensus]a

AASLD3

Management of ectopic varices should be determined by a multidisciplinary team consisting of hepatologists, gastroenterologists, interventional radiologists, and surgeons. [Guidance]a

PATIENT SELECTION

General
TIPS for treatment of ascites
TIPS for treatment of variceal bleeding
General

EASL2: The medical evaluation prior to elective TIPS creation in patients with cirrhosis should include an attentive history and physical exam focused on the presence or history of overt hepatic encephalopathy and signs of cardiopulmonary dysfunction. Laboratory evaluation should, at minimum, include INR, platelet count, haemoglobin and comprehensive metabolic panel enabling assessment of bleeding risk, degree of hepatic dysfunction, renal function and calculation of prognostic scores, such as MELD and/or Child-Pugh scores. Other prognostic scores (eg, FIPS, MOTS) may also be considered. [LOE 5, strong recommendation, consensus]a

Risk assessment for HE should include assessment of history prior and control/response to treatment of overt HE, severity of liver dysfunction, hyponatremia, advanced age, sarcopenia, renal failure, and presence of large spontaneous portosystemic shunts. [LOE 2, strong recommendation, strong consensus] a

ALTA 1: In patients undergoing elective TIPS, we recommend the following:

  • Contrast-enhanced multiphasic cross-sectional imaging (CT/MRI) to assist with TIPS planning.
  • Comprehensive echocardiography to assess for abnormalities in cardiac structure, function and right ventricular systolic pressure. [LOE 2a] a

ALTA 1: In patients with cirrhosis undergoing emergent TIPS, best clinical judgement should be applied. We suggest at least a liver ultrasound with Doppler to evaluate the patency of the portal venous system and consideration of a limited (bedside) echocardiogram, evaluating left ventricular ejection fraction and right ventricular systolic pressure. [LOE 3] a

TIPS for treatment of ascites

ALTA1: For carefully selected patients with cirrhosis and refractory ascites, TIPS is recommended over LVP to prevent recurrent ascites. [LOE 1a] a

For carefully selected patients with cirrhosis and refractory ascites, TIPS is recommended over LVP to improve transplant-free survival. [LOE 1a] a

In patients not fulfilling a strict definition of refractory ascites but requiring at least 3 LPV for tense ascites in a year despite optimal medical therapy, we recommend that TIPS creation should be considered. [LOE 1a] a

EASL2: In patients with cirrhosis receiving repeated large volume paracenteses despite optimal medical therapy, a TIPS should be discussed early to improve patient outcomes. [LOE 1, strong recommendation, strong consensus] a

AASLD5: Careful patient selection is the key to the success of TIPS in the management of RA (ascites that recurs after LVP despite standard treatment).

Given its ability to reduce the portal pressure effectively, TIPS in well‐selected patients with RA has been shown to be better than repeated LVP in the control of ascites. Survival advantage with TIPS insertion in patients with RA is reported in recent studies, including a meta‐analysis. This may be especially true for younger patients with low Model for End‐Stage Liver Disease (MELD) scores, those who received a smaller diameter covered stent, and those who had a complete response to TIPS with total elimination of ascites.

TIPS for treatment of variceal bleeding

ALTA1: For acute variceal hemorrhage, we recommend TIPS creation in the following scenarios:

  • Pre-emptive TIPS in patients who have been banded successfully but who meet high-risk criteria for rebleeding. High-risk criteria are CTP class C (10 - 13 points) or CTP class B > 7 points with active bleeding at endoscopy. TIPS should be performed within 72 hours of admission in patients without contraindications to TIPS. [LOE 1c] a
  • Rescue TIPS in patients who have been banded successfully but who rebleed at any time during admission (after endoscopy). [LOE 2a] a
  • Salvage TIPS should be performed emergently for patients in whom endoscopic band ligation cannot be performed because of profuse bleeding or bleeding persists at endoscopy despite endoscopic band ligation. [LOE 2b] a

EASL2: In patients with cirrhosis and bleeding from esophageal varices or type 1 gastro-esophageal varices, Child-Pugh class B > 7 with active bleeding during initial endoscopy despite vasoactive drug use, or Child-Pugh class C < 14, or documented HVPG >/= 20 mmHg at the time of bleeding, should be used to define high-risk patients who may obtain a survival benefit from a pre-emptive TIPS. [LOE 1, strong recommendation, strong consensus] a

A pre-emptive TIPS should be offered within the first 72 hours to improve survival in patients with cirrhosis and PH-related bleeding, fulfilling high-risk criteria. [LOE 1, strong recommendation, strong consensus] a

AASLD3: In patients with acute esophageal variceal hemorrhage, preemptive “early” TIPS with PTFE-covered stents within 72 hours (ideally < 24 hours) of initial upper endoscopy should be considered in patients who meet any of the following criteria: Child-Pugh class C 10–13 points or Child-Pugh class B 8–9 points with active bleeding at initial endoscopy despite concomitant treatment with vasoactive agents.

AASLD4: In patients with Child-Pugh class B score > 7 and active bleeding on endoscopy or Child-Pugh class C score 10–13, preemptive TIPS creation (within 72 hours and ideally within 24 hours of initial upper endoscopy) should be recommended in absence of absolute contraindications to TIPS. If TIPS is not locally available, transfer to a center with the capacity to intervene should be considered.

TIPS should be considered in patients with uncontrolled Acute Variceal Hemorrhage (AVH) (“salvage” TIPS) or who rebleed despite vasoactive therapy and Endoscopic Variceal Ligation (EVL) (“rescue” TIPS).

ALTA1: When placing a TIPS for variceal hemorrhage, we recommend a goal Portal System Gradient (PSG) of < 12 mmHg or 50% - 60% decrease from initial. We do not recommend using shunt diameter as a procedural end point. [LOE 2b] a

AASLD3: In patients whose PSG does not decrease below 12 mm Hg despite maximum dilation of TIPS (10 mm), NSBBs should be added to further decrease portal pressure.

OTHER CONSIDERATIONS

Hepatic Encephalopathy
Sarcopenia
Liver Transplant
Hepatic Encephalopathy

EASL2: The main risk factors are a history of overt HE, the presence of minimal (covert) HE, impaired liver or renal function, hyponatremia, sarcopenia, advanced age and the presence of large portosystemic shunts. It is noteworthy that these conditions are also risk factors for HE in patients with cirrhosis outside the setting of TIPS.

EASL2: Following TIPS creation, overt HE should be classified clinically based on West Haven criteria as part of regular follow-up. [LOE 4, strong recommendation, strong consensus] a

In patients with cirrhosis with a history of HE, rifaximin should be considered for prophylaxis of HE already before non-urgent TIPS placement. [LOE 2, strong recommendation, strong consensus] a

ALTA1: We recommend counseling patients that TIPS is associated with a risk of overt HE in approximately 25% - 50% of recipients [LOE 1b] a. Patient-specific risk factors for the development of post-TIPS overt HE include prior history of overt HE, advanced age, advanced liver dysfunction (CTP class C), hyponatremia, renal dysfunction, and sarcopenia. [LOE 2a] a

We recommend avoiding elective TIPS in patients with cognitive impairment and limited family or social support. [LOE 3] a

AASLD3: In patients with large spontaneous portal systemic collaterals, collateral embolization at the time of TIPS placement may be considered because it may decrease the risk of hepatic encephalopathy.

ALTA1: In patients undergoing elective TIPS for ascites and/or hepatic hydrothorax, embolization of SPSS > 6 mm may be considered to reduce the risk of post-TIPS hepatic encephalopathy.

Sarcopenia

EASL2: Sarcopeniab seems to be a key predictor for post-TIPS HE, independent of usual prognostic criteria. However, observations have shown that a TIPS may improve nutritional status and sarcopenia.

AASLD6: TIPS placement for standard indications (eg, ascites, acute variceal bleeding) may offer an indirect benefit of improving muscle mass.

Liver Transplant

ALTA1: In patients with cirrhosis undergoing elective or emergent TIPS, there is insufficient evidence to recommend universal pre-procedure liver transplant evaluation. [LOE 5] a

EASL2: LT should be considered but routine pre-procedure LT evaluation is not recommended owing to insufficient evidence. Collaboration between the TIPS centre and the transplant centre is essential during the pre-TIPS evaluation to anticipate the potential need for LT on a case-by-case basis.

a Levels of Evidence for Therapeutic Studies. From the Centre for Evidence-Based Medicine, http://www.cebm.net
b Sarcopenia is a risk for patients with liver disease and not an indication for a TIPS procedure.

  1. Boike, Justin R. et al. North American practice-based recommendations for transjugular intrahepatic portosystemic shunts in portal hypertension. Clinical Gastroenterology and Hepatology, Volume 20, Issue 8, 1636 - 1662.e36.
  2. European Association for the Study of the Liver. EASL clinical practice guidelines on TIPS. Journal of Hepatology 2025;83(1):177-210.
  3. Lee EW, Eghtesad B, Garcia-Tsao G, et al. AASLD practice guidance on the use of TIPS, variceal embolization, and retrograde transvenous obliteration in the management of variceal hemorrhage. Hepatology 2024;79(1):224-250.
  4. Kaplan D, Ripoll C, Thiele M, et al. AASLD Practice Guidance on risk stratification and management of portal hypertension and varices in cirrhosis. Hepatology 2024;79(5):1180-1211.
  5. Biggins SW, Angeli P, Garcia-Tsao G, Ginès P, Ling SC, Nadim MK, Wong F, Kim WR. Diagnosis, evaluation, and management of ascites, spontaneous bacterial peritonitis and hepatorenal syndrome: 2021 Practice Guidance by the American Association for the Study of Liver Diseases. Hepatology 2021;74(2):1014-1048. Erratum in: Hepatology. 2024;80(5):E89.
  6. Lai JC, Tandon P, Bernal W, Tapper EB, Ekong U, Dasarathy S, Carey EJ. Malnutrition, frailty, and sarcopenia in patients with cirrhosis: 2021 Practice Guidance by the American Association for the Study of Liver Diseases. Hepatology 2021;74(3):1611-1644. Erratum in: Hepatology. 2021;74(6):3563.

This information is intended for education and awareness only. Patients should consult their physician for information on the risks associated with the devices and surgical procedures discussed in this website. All surgical procedures carry potential health risks. Not all patients will be candidates for treatment with these devices, and individual outcomes may vary. Always follow physician advice on your post-surgery care and recovery.

IFU Consult instructions

Refer to Instructions for Use at eifu.goremedical.com for a complete description of all applicable indications, warnings, precautions and contraindications for the markets where this product is available. RXOnly

INDICATIONS FOR USE IN THE U.S.: The GORE® VIATORR® TIPS Endoprosthesis is indicated for use in the de novo and revision treatment of portal hypertension and its complications such as variceal bleeding, gastropathy, ascites which recurs despite conventional treatment, and/or hepatic hydrothorax. 

INDICATIONS FOR USE IN CANADA: The GORE® VIATORR® TIPS Endoprosthesis with Controlled Expansion is indicated for use in the treatment of portal hypertension and its complications such as variceal bleeding and ascites which recurs despite conventional treatment.

CONTRAINDICATIONS: There are no known contraindications for this device.

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