TIPS and Liver Transplantation

Abstract

Liver transplantation is considered the only long- term solution to the inevitable mortality of end- stage liver disease. Portal hypertension associated with bleeding and ascites is commonly seen in the final stages of a multitude of liver diseases. When medical treatment fails to control the complications of portal hypertension, more invasive modalities must be considered. Before the introduction of TIPS (transjugular intrahepatic portosystemic shunt) into clinical practice, surgical decompression procedures were used to lower portal pressure in bleeding esophageal varices. Two types of shunt have been used: nonselective shunts (e.g., end-to-side or side- to-side portocaval and proximal splenorenal shunt) to decompress the entire portal system and selective shunts (e.g., distal splenorenal shunt) to decompress only the varices while maintaining blood flow to the liver. Nonselective shunts are more likely to be complicated by encephalopathy in comparison to selective shunts. Surgically created shunts effectively reduce the risk of recurrent hemorrhage, but this improvement is counterbalanced by increased morbidity from encephalopathy and death from progressive liver failure. Additionally, the overall mortality rate of patients undergoing shunt surgery is comparable to that of nonsurgical patients. TIPS compares favorably as a nonselective intrahepatic shunt and has proven to be a highly effective and safe alternative in the control of portal hypertensive complications. One main advantage over surgery is the adaptation of the shunt diameter to the portosystemic pressure gradient. Based on animal studies in dogs by Rösch et al. in 1969, the first TIPS in human was created by Richter et al. (1990). Since then, this method has been widely used as a standard tool in the treatment of portal hypertension.