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Patient Selection for a TIPS Procedure

Updated: Sep 17

Transjugular intrahepatic portosystemic shunt (TIPS) procedures for the treatment of ascites and variceal bleeding can be emergent and lengthy. Interventional radiologists Dr. Peter Bream and Dr. Peder Horner discuss their TIPS practices, the ideal patient, as well as TIPS alternatives and adjunctive therapy.

We’ve provided the highlight reel below, but you can listen to the full podcast here or on the BackTable App


The BackTable Brief

  • Working at UNC, Dr. Bream receives most of his patient referrals from hepatologists at his academic institution. He treats a large liver failure and cirrhosis population, performing TIPS for the main indications of ascites and variceal bleeding. Dr. Horner works in private practice and treats conditions such as non-alcoholic steatohepatitis and cirrhosis as well as high acuity, high alcoholic livers with variceal hemorrhages. Both Dr. Bream and Dr. Horner avoid emergent TIPS procedures if possible.

  • Although it is known that older age is a risk factor for hepatic encephalopathy, Dr. Bream and Dr. Horner do not have pre-determined age cut-offs for TIPS procedures. Instead, they emphasize functional status. Dr. Horner discusses the importance of determining the risk to benefit ratio from weekly paracentesis or thoracentesis vs TIPS, which can always be reversed.

  • If possible, Dr. Horner and Dr. Bream prefer BRTO over TIPS as initial treatment. If TIPS is the treatment of choice, Dr. Horner and Dr. Bream both embolize varices with coils if these additional varices can be visualized.



Disclaimer: The opinions expressed by participants of the BackTable Podcast belong solely to the participants, and do not necessarily reflect the views of BackTable.


Inside a TIPS Practice


Dr. Bream and Dr. Horner discuss what they are treating with TIPS and how they acquire patients.


[Michael Barraza]

I'd like to start maybe by having you each tell us what your TIPS practice looks like. Overall, I'm mostly treating patients with acute or recent variceal bleeding. Tell us what you're mainly doing these for and where you're getting most of your patients.


[Peter Bream]

We're a transplant center at UNC, so we have a large liver failure population, a large cirrhosis population. We work very closely with the hepatologists and the transplant surgeons here. That's where most of our patients come from. We do a fair amount of TIPS for both of the main indications, for ascites and for variceal bleeding—mainly esophageal variceal bleeding that's refractory to GI management, but also for gastric varices as well, although it's not as robust. We usually end up doing an antegrade obliteration of the varices, along with the TIPS, if we're dealing with gastric varices that do not have a splenorenal shunt. In my previous practice, we rarely ever did an emergent TIPS in the middle of the night… We had a pretty strong former colleague that felt like the mortality on those were so high that you needed to get the patient stabilized, maybe put in a Minnesota tube, or a Blakemore tube, transfuse them, do the full work up with the Echo, looking at the right heart, and making sure that the TIPS is going to be safe, rather than just barrel in there with somebody that's bleeding out in the middle of the night.

[Peder Horner]

We're a private practice. My scenario is more community-based hospital, so we got some big ones and some smaller ones. It really depends on where we are, and the indications, because some of the more refractory ascites cases I can do at one hospital where's there a big liver population of non-alcoholic steatohepatitis, cirrhosis, or your cryptogenics. Then there are peripheral folks in the smaller hospital, sometimes very high acuity, high alcoholic livers with variceal hemorrhages and what not. We try not to TIPS in the middle of the night either. I don't think anyone likes to do that, but I think it does come up sometimes when all other situations and options have been exhausted.



The Ideal TIPS Patient


Older patients are at greater risk of hepatic encephalopathy after TIPS. Dr. Bream and Dr. Horner discuss age, functional status, pre-existing conditions such as coagulopathy and thrombocytopenia, and patient goals in determining treatment approach.


[Michael Barraza]

So talking about elective TIPS, say for ascites or anything like that, do you have an age cut off? I know literature says age greater than 65 is a known risk for encephalopathy after a TIPS, but a healthy 68 year old with bad ascites, I don't know.


[Peter Bream]

I don't think I've been referred somebody who the hepatologist felt would be too old for a TIPS. They wouldn't refer them, if their functional status was so low.


[Peder Horner]

I think the oldest I've done is 80. Encephalopathy is an issue with those older people for sure. You look at the meta analysis, like Salerno, etc., and all those from the 2000s, you'll see that age over 60 is known to be an independent risk factor for worse HE.


[Michael Barraza]

What about for patients with mild intermittent encephalopathy? How do you approach those patients? I guess for ascites it's more complicated, but for bleeding risk, that just seems like a challenge.


[Peter Bream]

I think it's definitely a challenge. This is the opportunity during your clinic appointment to talk about these things and talk about the risks, then weigh the risk benefit ratio from weekly paracentesis or weekly thoracentesis. You can always reverse a TIPS, you can always occlude it, you can narrow it. You just have to have a frank discussion with the referring clinician and the patient and talk about these things so if they do occur, you have a plan B.


[Michael Barraza]

You see every now and then somebody with coagulopathy or thrombocytopenia, and I know what our SIR guidelines say about correcting or not doing it above or below a certain number. But, a lot of these patients just have chronic coagulopathy. How do you guys approach that?


[Peder Horner]

You want your INR and your platelets to be tuned up as best you can. Certainly giving some platelets before or during the procedure is fine, if they're on the low side, or even some FFP. With the advent of the ICE catheter, we can reduce the number of sticks and passes with the needle, especially in those coagulopathic patients. Gone are the days when you have to stick until you get the portal vein because that's where you might get into trouble.


[Michael Barraza]

In the setting of life threatening, acute variceal bleeding, you don't always have time to get your full work up. What if anything in these patients is a deal breaker? Do you have a meld limit for acute bleeding?


[Peter Bream]

You just have to take every single one of these cases on a case by case basis and look at the full picture. Again, throw in, is there a possibility to do an obliteration instead of a decompression? I think the literature's pretty clear on this, that melds greater than what, 15, 17, 18, are problematic. Again, it goes in with the whole discussion about encephalopathy and things like that. You've got to weigh all these risks because they can go into fulminant liver failure pretty quick.


[Peder Horner]

Absolutely. You also have to take into account the discussion with the family, their values, and where they are with the whole process. A lot of the people I see in this situation needing urgent TIPS for variceal hemorrhages are 30 or 40 year olds, and they still have families. I think to say no, I'm not going to do this because your meld is too high… they won’t accept that. Most families that I've come across, they want something more.


BRTO and Other Alternatives to TIPS


Dr. Bream and Dr. Horner discuss alternatives to TIPS, such as BRTO, and adjunctive techniques for TIPS including embolization.


[Peter Bream]

BRTOs have become a huge part of our practice and cases where we might have done TIPS in the past, we're now doing BRTOs.


[Peder Horner]

My colleagues and I have switched to almost like a BRTO first, in approach to hemorrhage. If they've got gastric varices, if you've got a big shunt, we'll BRTO first. We don't even talk about TIPS. I really think that approach has been very helpful in our practice, and it's been pretty cool getting to share that with some of the GI docs. Some of them are, again, smaller community hospitals and they're not aware of the other options out there besides TIPS.


[Michael Barraza]

Are you guys approaching BRTO like the Japanese do, or are you doing it strictly for gastric varices in the setting of a splenorenal shunt?


[Peter Bream]

I would say mainly for us, if they have a splenorenal shunt, we're considering a sclerosing type of procedure to start with. There’s two camps. There's the western camp of diversion or decompression, and then you have the eastern camp, mainly the Japanese and the Asian, that have the sclerosant, or the obliteration side. As I've thought about this over the years, I start to think of these gastric varices being very similar to an arteriovenous malformation, where if you do not get rid of the actual varix—let’s say you just coil a couple of the inflows—it will recruit other vessels. There are so many vessels in this area that could be potentially recruited, and if you can't get directly into the varix and at least reflux sclerosant up into the varix, then you may really be treating it now, but you're not treating it down the road.


[Michael Barraza]

One last question about BRTO, are you guys strictly doing them for gastric varices or are you occasionally doing them for patients with esophageal varices?


[Peder Horner]

Mine are usually for gastric varices. I just don't see the splenorenal shunt in the esophageal camp, I really don't.


[Peter Bream]

I've done it before for small bowel varices. You have another route where it's going up through the duodenum and actually I’ve done more of an antegrade approach to those, trying to sclerose the varix that may be in the duodenum. I've only had to do that a couple of times, though. That's kind of unusual.


[Peder Horner]

I’ve had a couple patients over the last year where they've had stomal varices. They were very high functioning people, did not want any kind of risk of hepatic encephalopathy, so we actually did transhepatic portal vein access. Then, we went down to the varices and sclerosed them just like a BRTO. Those have worked really, really well so far. I'm out about a year now.


[Peter Bream]

Whether we stick them directly or go transhepatic…I can tell you that my practices have varied on that. When I first started doing those we were just coiling, and then as I got more facile with Sotradecol, I was doing more obliteration. I can't tell you which is better, but I can tell you that just blocking the portal venous flow and getting that main channel that's coming from the portal vein is dramatic for these patients.


[Michael Barraza]

Regarding alternative and adjunctive techniques that you use during a TIPS, when, if ever, are you guys embolizing varices in addition to placing the TIPS?


[Peder Horner]

I've always embolized varices if I see them. That's just how I was trained. Someone told me recently that you can't bill for embolization, and so, I don't really care, but if I see big varices, I usually still embolize them with coils.


[Peter Bream]

We would say do a hand injection of 10 ccs of contrast with the catheter in the splenic vein, and if you did not see any varices, you wouldn't embolize them. If you did a power injection, you're going to reflux up anyway, and you get false positive. We felt like that was enough to prove they were not filling anymore, but if you did see them filling, you would embolize them at that time. I've kind of used that. That's not very scientific, but it works.


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Podcast Participants:

Dr. Peder Horner is a practicing interventional radiologist in the Denver, CO area.

Dr. Peter Bream is a practicing interventional radiologist and professor with the University of North Carolina at Chapel Hill School of Medicine.

Host Dr. Michael Barraza is a practicing interventional radiologist with Radiology Alliance in Nashville.


Cite this podcast:

BackTable, LLC (Producer). (2019, June 16). Ep. 44 – TIPS Procedure Techniques: East vs. West [Audio podcast]. Retrieved from https://www.backtable.com/podcasts


Medical Disclaimer:

The Materials available on the BackTable Blog are for informational and educational purposes only and are not a substitute for the professional judgment of a healthcare professional in diagnosing and treating patients. The opinions expressed by participants of the BackTable Podcast belong solely to the participants, and do not necessarily reflect the views of BackTable.

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