Download PDF
Rofo 2018; 190(08): 701-711
DOI: 10.1055/a-0628-7347
Review
© Georg Thieme Verlag KG Stuttgart · New York

Transjugulärer intrahepatischer portosystemischer Stentshunt (TIPS): Pathophysiologische Grundlagen, gegenwärtige Indikationen und Ergebnisse mit Review der Literatur

Article in several languages: English | deutsch
Holger Strunk
  Department of Radiology, Medical School & Hospital, University of Bonn, Germany
,
Milka Marinova
  Department of Radiology, Medical School & Hospital, University of Bonn, Germany
› Author Affiliations
Further Information

Publication History

27 December 2017

20 April 2018

Publication Date:
25 July 2018 (online)

Also available at
   Permissions and Reprints

Zusammenfassung

Hintergrund Der transjuguläre intrahepatische portosystemische Shunt (TIPS) ist eine nicht operative Intervention zur Druckentlastung des Pfortadersystems. Technische Entwicklungen der letzten Jahre und erweiterte zugrundeliegende pathophysiologische Kenntnisse haben die Indikationen zur TIPS-Platzierung geändert. Im vorliegenden Review soll daher auf den gegenwertigen Kenntnisstand eingegangen werden.

Methode Dazu werden anhand der Literatur gegenwärtige Indikationen im Hinblick auf pathophysiologische Grundlagen, Indikationen und Ergebnisse aufgezeigt und diskutiert.

Ergebnisse Etablierte Indikationen für einen TIPS waren und sind die akute, endoskopisch nicht kontrollierbare Varizenblutung und die Re-Blutung innerhalb von 5 Tagen. Neu in die europäischen Empfehlungen aufgenommen wurde der Einsatz des TIPS in der Behandlung der akuten Ösophagus- und gastroösophagealen Varizenblutung als sogenannter „early TIPS“. Zur sekundären Blutungsprävention wird ein TIPS erst nach Versagen der Erstlinientherapie angegeben. Neuere Studien zeigen jedoch, dass durch die TIPS-Implantation eine Verlängerung des blutungsfreien Intervalls sowie Reduzierung der Mortalität möglich ist. Bei therapie-refraktärem Aszites wird ein TIPS nur bei den Patienten empfohlen, die nicht auf die Behandlung mit NSBB ansprechen, obwohl Studien gezeigt haben, dass durch den TIPS, verglichen mit der Paracentese, die glomeruläre Filtrationsrate steigt, der Aszites besser kontrolliert und das Überleben verbessert werden kann. Weitere mögliche Indikationen sind der Einsatz des TIPS beim Budd-Chiari-Syndrom, bei der akuten Pfortaderthrombose, beim Hydrothorax, dem hepatopulmonalen und hepatorenalen Syndrom (Typ 2), bei Patienten mit einer transfusionspflichtigen portalen hypertensiven Gastropathie sowie zur Prophylaxe von Komplikationen vor geplanten abdominellen operativen Eingriffen, selten bei Blutungen durch ektope Varizen oder bei Chylothorax bzw. chylösen Aszites.

Schlussfolgerung Der TIPS ist ein mittlerweile etabliertes Verfahren mit einer neuen Indikation als „early-TIPS“. Obwohl der bisherigen Therapie durch Ligation und Betablockern klar überlegen, steht er in den europäischen Empfehlungen bei der sekundären Prävention einer Blutung nur an zweiter Stelle, ebenso wie beim therapie-refraktären Aszites.

Kernaussagen 

  • Neben bereits anerkannten Indikationen ist der Einsatz als „early-TIPS“ bei der akuten Ösophagus- und gastroösophagealen Varizenblutung neu in den europäischen Empfehlungen.

Zitierweise

  • Strunk H, Marinova M, . Transjugular Intrahepatic Portosystemic Shunt (TIPS): Pathophysiologic Basics, Actual Indications and Results with Review of the Literature. Fortschr Röntgenstr 2018; 190: 701 – 711

Key words

TIPS - porto-systemic shunt - stent-grafts - esophageal varices - transhepatic - ascites
 

  • References

  • 1 Rossle M, Richter GM, Noldge G. et al. New non-operative treatment for variceal haemorrhage.[letter]. Lancet 1989; 2: 153
    PubMedSearch in Google Scholar
  • 2 Bureau C, Pagan JC, Layrargues GP. et al. Patency of stents covered with polytetrafluoroethylene in patients treated by transjugular intrahepatic portosystemic shunts: long-term results of a randomized multicentre study. Liver Int 2007; 27: 742-747
    CrossrefPubMedSearch in Google Scholar
  • 3 Henderson JM. Surgery versus transjugular intrahepatic portal systemic shunt in the treatment of severe variceal bleeding. Clin Liver Dis 2006; 10: 599-612 , ix
    CrossrefPubMedSearch in Google Scholar
  • 4 Rossle M. TIPS: 25 years later. J Hepatol 2013; 59: 1081-1093
    CrossrefPubMedSearch in Google Scholar
  • 5 Trebicka J, von Heydebrand M, Lehmann J. et al. Assessment of response to beta-blockers by expression of betaArr2 and RhoA/ROCK2 in antrum mucosa in cirrhotic patients. J Hepatol 2016; 64: 1265-1273
    CrossrefPubMedSearch in Google Scholar
  • 6 Villanueva C, Albillos A, Genesca J. et al. Development of hyperdynamic circulation and response to beta-blockers in compensated cirrhosis with portal hypertension. Hepatology 2016; 63: 197-206
    CrossrefPubMedSearch in Google Scholar
  • 7 Berres ML, Lehmann J, Jansen C. et al. Chemokine (C-X-C motif) ligand 11 levels predict survival in cirrhotic patients with transjugular intrahepatic portosystemic shunt. Liver Int 2016; 36: 386-394
    CrossrefPubMedSearch in Google Scholar
  • 8 Allegretti AS, Ortiz G, Cui J. et al. Changes in Kidney Function After Transjugular Intrahepatic Portosystemic Shunts Versus Large-Volume Paracentesis in Cirrhosis: A Matched Cohort Analysis. Am J Kidney Dis 2016; 68: 381-391
    CrossrefPubMedSearch in Google Scholar
  • 9 Tan HK, James PD, Sniderman KW. et al. Long-term clinical outcome of patients with cirrhosis and refractory ascites treated with transjugular intrahepatic portosystemic shunt insertion. J Gastroenterol Hepatol 2015; 30: 389-395
    CrossrefPubMedSearch in Google Scholar
  • 10 de Franchis R. Expanding consensus in portal hypertension: Report of the Baveno VI Consensus Workshop: Stratifying risk and individualizing care for portal hypertension. J Hepatol 2015; 63: 743-752
    CrossrefPubMedSearch in Google Scholar
  • 11 Boyer TD, Haskal ZJ. The Role of Transjugular Intrahepatic Portosystemic Shunt (TIPS) in the Management of Portal Hypertension: update 2009. Hepatology 2010; 51: 306
    CrossrefPubMedSearch in Google Scholar
  • 12 Garcia-Pagan JC, Caca K, Bureau C. et al. Early use of TIPS in patients with cirrhosis and variceal bleeding. N Engl J Med 2010; 362: 2370-2379
    CrossrefPubMedSearch in Google Scholar
  • 13 Garcia-Pagan JC, Di Pascoli M, Caca K. et al. Use of early-TIPS for high-risk variceal bleeding: results of a post-RCT surveillance study. J Hepatol 2013; 58: 45-50
    CrossrefPubMedSearch in Google Scholar
  • 14 Thabut D, Rudler M, Lebrec D. Early TIPS with covered stents in high-risk patients with cirrhosis presenting with variceal bleeding: Are we ready to dive into the deep end of the pool?. J Hepatol 2011; 55: 1148-1149
    CrossrefPubMedSearch in Google Scholar
  • 15 Deltenre P, Trepo E, Rudler M. et al. Early transjugular intrahepatic portosystemic shunt in cirrhotic patients with acute variceal bleeding: a systematic review and meta-analysis of controlled trials. Eur J Gastroenterol Hepatol 2015; 27: e1-e9
    CrossrefPubMedSearch in Google Scholar
  • 16 Hernández-Gea V, Bureau C. Practice makes better: TIPS procedures in referral centers [editorial]. Hepatology 2017; 67: 473-475
    PubMedSearch in Google Scholar
  • 17 Sauerbruch T, Mengel M, Dollinger M. et al. Prevention of Rebleeding From Esophageal Varices in Patients With Cirrhosis Receiving Small-Diameter Stents Versus Hemodynamically Controlled Medical Therapy. Gastroenterology 2015; 149: 660-668 .e1
    CrossrefPubMedSearch in Google Scholar
  • 18 Salerno F, Camma C, Enea M. et al. Transjugular intrahepatic portosystemic shunt for refractory ascites: a meta-analysis of individual patient data. Gastroenterology 2007; 133: 825-834
    CrossrefPubMedSearch in Google Scholar
  • 19 Garcia-Pagan JC, Heydtmann M, Raffa S. et al. TIPS for Budd-Chiari syndrome: long-term results and prognostics factors in 124 patients. Gastroenterology 2008; 135: 808-815
    CrossrefPubMedSearch in Google Scholar
  • 20 Rossle M, Grandt D. TIPS: an update. Best Pract Res Clin Gastroenterol 2004; 18: 99-123
    PubMedSearch in Google Scholar
  • 21 Kori I, Bar-Zohar D, Carmiel-Haggai M. et al. Budd-Chiari syndrome and acute portal vein thrombosis: management by a transjugular intrahepatic portosystemic shunt (TIPS) and portal vein interventions via a TIPS. J Gastrointest Surg 2006; 10: 417-421
    CrossrefPubMedSearch in Google Scholar
  • 22 Ferro C, Rossi UG, Bovio G. et al. Transjugular intrahepatic portosystemic shunt, mechanical aspiration thrombectomy, and direct thrombolysis in the treatment of acute portal and superior mesenteric vein thrombosis. Cardiovasc Intervent Radiol 2007; 30: 1070-1074
    CrossrefPubMedSearch in Google Scholar
  • 23 Brensing KA, Textor J, Perz J. 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: 288-295
    CrossrefPubMedSearch in Google Scholar
  • 24 Tsauo J, Weng N, Ma H. et al. Role of Transjugular Intrahepatic Portosystemic Shunts in the Management of Hepatopulmonary Syndrome: A Systemic Literature Review. J Vasc Interv Radiol 2015; 26: 1266-1271
    CrossrefPubMedSearch in Google Scholar
  • 25 Tsauo J, Shin JH, Han K. et al. Transjugular Intrahepatic Portosystemic Shunt for the Treatment of Chylothorax and Chylous Ascites in Cirrhosis: A Case Report and Systematic Review of the Literature. J Vasc Interv Radiol 2016; 27: 112-116
    CrossrefPubMedSearch in Google Scholar
  • 26 Boyer TD. Transjugular intrahepatic portosystemic shunt: current status. Gastroenterology 2003; 124: 1700-1710
    CrossrefPubMedSearch in Google Scholar
  • 27 Clark TW. Stepwise placement of a transjugular intrahepatic portosystemic shunt endograft. Tech Vasc Interv Radiol 2008; 11: 208-211
    CrossrefPubMedSearch in Google Scholar
  • 28 Fidelman N, Kwan SW, LaBerge JM. et al. The transjugular intrahepatic portosystemic shunt: an update. Am J Roentgenol 2012; 199: 746-755
    CrossrefPubMedSearch in Google Scholar
  • 29 Boyvat F, Aytekin C, Harman A. et al. 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: 857-861
    CrossrefPubMedSearch in Google Scholar
  • 30 Boyvat F, Harman A, Ozyer U. et al. Percutaneous sonographic guidance for TIPS in Budd-Chiari syndrome: direct simultaneous puncture of the portal vein and inferior vena cava. Am J Roentgenol 2008; 191: 560-564
    CrossrefPubMedSearch in Google Scholar
  • 31 Chen S, Li X, Wei B. et al. Recurrent variceal bleeding and shunt patency: prospective randomized controlled trial of transjugular intrahepatic portosystemic shunt alone or combined with coronary vein embolization. Radiology 2013; 268: 900-906
    CrossrefPubMedSearch in Google Scholar
  • 32 Lakhoo J, Bui JT, Zivin SP. et al. Root Cause Analysis of Rebleeding Events following Transjugular Intrahepatic Portosystemic Shunt Creation for Variceal Hemorrhage. J Vasc Interv Radiol 2015; 26: 1444-1453
    CrossrefPubMedSearch in Google Scholar
  • 33 Blue RC, Lo GC, Kim E. et al. Transjugular Intrahepatic Portosystemic Shunt Flow Reduction with Adjustable Polytetrafluoroethylene-Covered Balloon-Expandable Stents Using the “Sheath Control” Technique. Cardiovasc Intervent Radiol 2016; 39: 935-939
    CrossrefPubMedSearch in Google Scholar
  • 34 Rossi P, Salvatori FM, Fanelli F. et al. Polytetrafluoroethylene-covered nitinol stent-graft for transjugular intrahepatic portosystemic shunt creation: 3-year experience. Radiology 2004; 231: 820-830
    CrossrefPubMedSearch in Google Scholar
  • 35 Yang Z, Han G, Wu Q. et al. Patency and clinical outcomes of transjugular intrahepatic portosystemic shunt with polytetrafluoroethylene-covered stents versus bare stents: a meta-analysis. J Gastroenterol Hepatol 2010; 25: 1718-1725
    CrossrefPubMedSearch in Google Scholar
  • 36 Perarnau JM, Le Gouge A, Nicolas C. et al. Covered vs. uncovered stents for transjugular intrahepatic portosystemic shunt: a randomized controlled trial. J Hepatol 2014; 60: 962-968
    CrossrefPubMedSearch in Google Scholar
  • 37 Pan JJ, Chen C, Caridi JG. et al. Factors predicting survival after transjugular intrahepatic portosystemic shunt creation: 15 years’ experience from a single tertiary medical center. J Vasc Interv Radiol 2008; 19: 1576-1581
    CrossrefPubMedSearch in Google Scholar
  • 38 Brensing KA, Horsch M, Textor J. et al. Hemodynamic effects of propranolol and nitrates in cirrhotics with transjugular intrahepatic portosystemic stent-shunt. Scand J Gastroenterol 2002; 37: 1070-1076
    CrossrefPubMedSearch in Google Scholar
  • 39 Tzeng WS, Wu RH, Lin CY. et al. Prediction of mortality after emergent transjugular intrahepatic portosystemic shunt placement: use of APACHE II, Child-Pugh and MELD scores in Asian patients with refractory variceal hemorrhage. Korean J Radiol 2009; 10: 481-489
    CrossrefPubMedSearch in Google Scholar
  • 40 Harrod-Kim P, Saad WE, Waldman D. Predictors of early mortality after transjugular intrahepatic portosystemic shunt creation for the treatment of refractory ascites. J Vasc Interv Radiol 2006; 17: 1605-1610
    CrossrefPubMedSearch in Google Scholar
  • 41 Ferral H, Vasan R, Speeg KV. et al. Evaluation of a model to predict poor survival in patients undergoing elective TIPS procedures. J Vasc Interv Radiol 2002; 13: 1103-1108
    CrossrefPubMedSearch in Google Scholar
  • 42 Schepke M, Roth F, Fimmers R. et al. Comparison of MELD, Child-Pugh, and Emory model for the prediction of survival in patients undergoing transjugular intrahepatic portosystemic shunting. Am J Gastroenterol 2003; 98: 1167-1174
    CrossrefPubMedSearch in Google Scholar
  • 43 Ripamonti R, Ferral H, Alonzo M. et al. Transjugular intrahepatic portosystemic shunt-related complications and practical solutions. Semin Intervent Radiol 2006; 23: 165-176
    Thieme ConnectPubMedSearch in Google Scholar
  • 44 Riggio O, Nardelli S, Moscucci F. et al. Hepatic encephalopathy after transjugular intrahepatic portosystemic shunt. Clin Liver Dis 2012; 16: 133-146
    CrossrefPubMedSearch in Google Scholar
  • 45 Riggio O, Angeloni S, Salvatori FM. et al. Incidence, natural history, and risk factors of hepatic encephalopathy after transjugular intrahepatic portosystemic shunt with polytetrafluoroethylene-covered stent grafts. Am J Gastroenterol 2008; 103: 2738-2746
    CrossrefPubMedSearch in Google Scholar
  • 46 Masson S, Mardini HA, Rose JD. et al. Hepatic encephalopathy after transjugular intrahepatic portosystemic shunt insertion: a decade of experience. QJM 2008; 101: 493-501
    CrossrefPubMedSearch in Google Scholar
  • 47 Luca A, Miraglia R, Maruzzelli L. et al. Early Liver Failure after Transjugular Intrahepatic Portosystemic Shunt in Patients with Cirrhosis with Model for End-Stage Liver Disease Score of 12 or Less: Incidence, Outcome, and Prognostic Factors. Radiology 2016; 280: 622-629
    CrossrefPubMedSearch in Google Scholar
  • 48 Wannhoff A, Hippchen T, Weiss CS. et al. Cardiac volume overload and pulmonary hypertension in long-term follow-up of patients with a transjugular intrahepatic portosystemic shunt. Aliment Pharmacol Ther 2016; 43: 955-965
    CrossrefPubMedSearch in Google Scholar
  • 49 Monescillo A, Martinez-Lagares F, Ruiz-del-Arbol L. et al. Influence of portal hypertension and its early decompression by TIPS placement on the outcome of variceal bleeding. Hepatology 2004; 40: 793-801
    CrossrefPubMedSearch in Google Scholar
  • 50 Qi X, Tian Y, Zhang W. et al. Covered TIPS for secondary prophylaxis of variceal bleeding in liver cirrhosis: A systematic review and meta-analysis of randomized controlled trials. Medicine (Baltimore) 2016; 95: e5680
    CrossrefPubMedSearch in Google Scholar
  • 51 Holster IL, Tjwa ET, Moelker A. et al. Covered transjugular intrahepatic portosystemic shunt versus endoscopic therapy + beta-blocker for prevention of variceal rebleeding. Hepatology 2016; 63: 581-589
    CrossrefPubMedSearch in Google Scholar
  • 52 Bai M, Qi XS, Yang ZP. et al. TIPS improves liver transplantation-free survival in cirrhotic patients with refractory ascites: an updated meta-analysis. World J Gastroenterol 2014; 20: 2704-2714
    CrossrefPubMedSearch in Google Scholar
  • 53 Bureau C, Thabut D, Oberti F. et al. Transjugular Intrahepatic Portosystemic Shunts With Covered Stents Increase Transplant-Free Survival of Patients With Cirrhosis and Recurrent Ascites. Gastroenterology 2017; 152: 157-163
    CrossrefPubMedSearch in Google Scholar
  • 54 Gaba RC, Parvinian A, Casadaban LC. et al. Survival benefit of TIPS versus serial paracentesis in patients with refractory ascites: a single institution case-control propensity score analysis. Clin Radiol 2015; 70: e51-e57
    CrossrefPubMedSearch in Google Scholar