TIPS, Variceal Embolization, and RTO in the Management of Variceal Hemorrhage

Comprehensive Summary: TIPS, Variceal Embolization, and RTO in the Management of Variceal Hemorrhage

Presenter: Arpan Mohanty | Context: AASLD Writing Group Member – TIPS & Variceal Embolization Guidance

1. Main Clinical Topics Discussed

• Interventional radiology–guided endovascular therapies for variceal hemorrhage
• Transjugular intrahepatic portosystemic shunt (TIPS)
• Retrograde transvenous obliteration (RTO) and anterograde transvenous obliteration (ATTO)
• Variceal embolization as adjunct therapy
• Portosystemic collateral anatomy in portal hypertension
• Multidisciplinary approach to patient selection and management

2. Key Learning Points, Guidelines, and Recommendations

Anatomy & Definitions

• Collaterals within the GI tract are termed varices (esophageal, gastric, duodenal, rectal, stomal); those outside the GI tract are termed collaterals

TIPS: Technical Standards

• Preferred stent: PTFE-covered expandable stent — associated with lower stenosis/thrombosis rates and improved portal hypertensive outcomes
• Stent sizing: Begin at 8 mm diameter; progressively dilate to achieve portosystemic pressure gradient (PSPG) < 12 mmHg
• PSPG measurement: Intra-abdominal IVC pressure should be subtracted from portal pressure (right atrial pressure overestimates PSPG and is discouraged)
• If PSPG remains ≥ 12 mmHg despite maximum dilation → add non-selective beta-blockers (NSBBs)
• Portal vein thrombosis does not absolutely preclude TIPS; referral to experienced center recommended; consider case-by-case basis
• Collateral embolization at time of TIPS may be considered in patients with large spontaneous portosystemic collaterals to reduce hepatic encephalopathy (HE) risk

Contraindications

• Absolute: Congestive heart failure, severe pulmonary hypertension, severe uncontrolled hepatic encephalopathy (chronic, recurrent — not acute peri-bleed confusion), uncontrolled sepsis
• Relative: Biliary obstruction, severe coagulopathy, hepatic tumors, polycystic liver disease
• No specific MELD threshold for TIPS contraindication; most historical studies excluded Child-Turcotte-Pugh (CTP) > 13; patients > 75 years were generally excluded from trials

Post-TIPS Management

• Rifaximin 550 mg (initiated within 14 days of TIPS, maintained for 6 months) may reduce post-TIPS HE risk — considered when feasible
• For refractory encephalopathy despite lactulose + rifaximin: consider endovascular reduction of TIPS diameter; if PSPG rises > 12 mmHg, restart NSBBs

TIPS Follow-Up Protocol

• Doppler ultrasound at: 1–4 weeks → 3 months → 6 months → every 6 months thereafter
• TIPS dysfunction defined as loss of PSPG < 12 mmHg due to stenosis or thrombosis
• Trigger venography if: portal vein mean maximum flow velocity < 28 cm/s (hepatofugal flow) or < 39 cm/s (hepatopetal flow)
• Clinical suspicion warranted when worsening ascites develops

RTO/ATTO

• Performed as adjuncts to TIPS or independently
• Primarily indicated for non-esophageal varices, particularly gastric varices

3. Specific Clinical Data and Study Results Cited