Selection of a TIPS stent for management of portal hypertension in liver cirrhosis: An evidence-based review

Table 1 Transjugular intrahepatic portosystemic shunt for the prevention of variceal rebleeding: An overview of meta-analyses

Ref.	Design	No. trials	Comparative arms	Target population	Efficacy of TIPS	Encephalopathy	Survival or death
Zheng et al[6]	Meta-analysis of RCTs	12	TIPS vs endoscopic treatment	Variceal rebleeding in cirrhosis	Variceal rebleeding: TIPS was lower (P < 0.00001)	The frequency of HE: TIPS was higher (P < 0.00001)	Death due to all causes: NS
Khan et al[7]	Meta-analysis of RCTs	22	Portosystemic shunts (surgical or TIPS) vs endoscopic therapy	Variceal rebleeding in cirrhosis	Rebleeding: shunt was lower	Acute or chronic HE: shunt was higher	Mortality: NS
Burroughs et al[8]	Meta-analysis of RCTs	13	TIPS vs endoscopic treatment	Variceal rebleeding in cirrhosis	Recurrent bleeding: TIPS was lower	Encephalopathy: TIPS was higher	Survival: NS
Papatheodoridis et al[9]	Meta-analysis of RCTs	11	TIPS vs endoscopic treatment	Variceal rebleeding	Variceal rebleeding: TIPS was lower (P < 0.001)	Encephalopathy: TIPS was higher (P < 0.001)	Overall mortality: NS; sensitivity analyses: NS
Luca et al[10]	Meta-analysis of RCTs	11	TIPS vs endoscopic treatment with or without propranolol	Recurrent bleeding in cirrhosis	Recurrent bleeding: TIPS was lower	Encephalopathy: TIPS was higher	Death due to all causes: NS; death due to bleeding: NS

HE: Hepatic encephalopathy; NS: Not significant; RCT: Randomized controlled trial; TIPS: Transjugular intrahepatic portosystemic shunt.

Table 2 Transjugular intrahepatic portosystemic shunt for the treatment of refractory ascites: An overview of meta-analyses

Ref.	Design	No. trials	Comparative arms	Target population	Efficacy of TIPS	Encephalopathy	Survival or death
Chen et al[25]	Meta-regression and Trial Sequential Meta-analysis	6	TIPS vs large-volume paracentesis	Refractory ascites in liver cirrhosis	Ameliorate refractory ascites: TIPS was better (P < 0.05)	Frequency of HE: TIPS was higher (P < 0.01)	Overall mortality: NS; subgroup mortality (patients with better hepatic and renal function): TIPS was lower (P < 0.05)
Salerno et al[26]	Meta-analysis of individual patient data	4	TIPS vs large-volume paracentesis	Refractory ascites in liver cirrhosis	Tense ascites recurrence: TIPS was lower (P < 0.0001)	Average number of HE episodes: TIPS was higher (P = 0.006)	Transplant-free survival: TIPS was better (P = 0.035)
Saab et al[27]	Meta-analysis of RCTs	5	TIPS vs paracentesis	Refractory ascites in liver cirrhosis	Re-accumulation of ascites: TIPS was lower (P < 0.01)	Frequency of HE: TIPS was higher (P < 0.01)	30-d mortality: NS; 24-mo mortality: NS
D'Amico et al[28]	Meta-analysis of RCTs	5	TIPS vs paracentesis	Refractory ascites in liver cirrhosis	Recurrence of ascites: TIPS was lower (P < 0.05)	Frequency of HE: TIPS was higher (P < 0.05)	Mortality: NS
Albillos et al[29]	Meta-analysis of RCTs	5	TIPS vs paracentesis	Refractory ascites in liver cirrhosis	Ascites recurrence: TIPS was lower (P < 0.05)	Risk of HE: TIPS was greater	Overall mortality: NS; subgroup mortality (patients with recidivant ascites): TIPS was lower (P < 0.05)
Deltenre et al[30]	Meta-analysis of RCTs	5	TIPS vs large-volume paracentesis	Refractory ascites in liver cirrhosis	Control of ascites: TIPS was better (P < 0.001)	HE: TIPS was higher (P < 0.001)	Survival: NS

HE: Hepatic encephalopathy; NS: Not significant; RCT: Randomized controlled trial; TIPS: Transjugular intrahepatic portosystemic shunt.

Table 3 Comparison of outcome after transjugular intrahepatic portosystemic shunt between covered and bare stents: An overview of comparative studies

Ref.	Period	Target population	No. patients (covered/bare)	Efficacy of TIPS (covered/bare)	Shunt dysfunction or patency (covered/bare)	Post-TIPS encephalopathy (covered/bare)	Survival or death (covered/bare)
Luca et al[45]	2003.1-2010.2	Cirrhotic patients with non-tumoural PVT	70 (57/13)	NA	12-mo shunt dysfunction rate: 21%/38%; 24-mo shunt dysfunction rate: 29%/85%	NA	NA
Sommer et al[58]	2001.2-2011.1	Patients with elective TIPS procedures	174 (58/116)	Clinical success rate: ascites: 90.5%/81.3%; ascites + bleeding: 85.7%/73.7%; bleeding: 90.0%/86.2% (NS)	12-mo primary shunt patency rate: 62.4%/43.9% (P < 0.05)	Overall rate: 36.5%/37.5% (NS)	12-mo survival rate: 79.1%/75.6%; overall survival time: 835.25 ± 823.0 (9–3200)/805.6 ± 868.4 (6–3290) d (NS)
Clark et al[59]	2001-2010	Patients with PH	246 (176/70)	NA	Overall shunt dysfunction rate: 22%/ 57% (P = 0.05)	NA	Survival time: 33/31 mo (P = 0.5)
Maleux et al[60]	1992-2006	Cirrhotic patients with refractory ascites	222 (126/96)	Rate of clinically significant residual ascites 1 mo after TIPS: 35.5%/55.6% (P = 0.003)	1-yr shunt dysfunction rate: 19%/49% (P < 0.0001)	1-yr rate: 22%/56% (P < 0.0001)	6-mo survival rate: 73.2%/62.8%; 1-yr survival rate: 65.5%/55.0% (P = 0.0071)
Wu et al[61]	2007.4-2009.4	Patients with PH	60 (30/30)	Number of rebleeding: 1/6 (P = 0.04)	Number of shunt dysfunction: 0/9 (P = 0.002)	Number: 5/6 (P = 0.74)	Number of death: 0/4 (P = 0.038)
Bandi et al[62]	2006.3-2009.3	Patients with PH	66 (33/33)	Clinical relapse number (rate): 8 (26%)/15 (45%) (P < 0.05)	Number of shunt dysfunction: 5/15 (P < 0.05)	Overall rate: 22%/33% (NS)	Overall survival rate: 66%/37% (P < 0.05)
Jung et al[63]	1996.6-2006.2	Patients who received de novo TIPS	81 (51/30)	Bleeding group: 3-mo clinical success rate: 100%/58% (P = 0.03); 12-mo clinical success rate: 67%/18% (P = 0.046). Ascites group: 3-mo clinical success rate: 77%/70% (P = 0.2); 12-mo clinical success rate: 64%/33% (P = 0.18)	3-mo primary patency rate: 94%/63% (P = 0.03); 6-mo primary patency rate: 67%/ 8% (P = 0.47); 12-mo primary patency rate: 38%/24% (P = 0.65)	Overall rate: 15%/14% (P = 0.7)	Bleeding group: 30-d mortality rate: 40%/33% (P = 0.69); overall mortality rate: 40%/50% (P = 0.57). Ascites group: 30-d mortality rate: 6%/27% (P = 0.13); overall mortality rate: 13%/55% (P = 0.02)
Pan et al[64]	2001.1- 2005.12	Patients with variceal bleeding and refractory ascites	128 (57/71)	NA	30-d shunt dysfunction rate: 1.8%/4.2% (P = 0.4); 6-mo shunt dysfunction rate: 5.2/25.3% (P = 0.003); 1-yr shunt dysfunction rate: 5.2%/30.9% (P = 0.004); overall shunt dysfunction rate: 8.7%/40.8% (P = 0.004)	NA	6-mo mortality rate: 10.5%/16.9% (P = 0.3); 1-yr mortality rate: 14%/23.9% (P = 0.2); overall mortality rate: 21.1%/35.2% (P = 0.08)
Tripathi et al[65]	1991.7- 2004.12	Patients with variceal bleeding, ascites, portal hypertensive gastropathy, hepatic hydrothorax	473 (157/316)	2-yr cumulative rebleeding rate: 6%/17% (P < 0.05)	2-yr cumulative shunt dysfunction rate: 11%/74% (P < 0.001); overall shunt dysfunction rate: 8%/48%	2-yr cumulative rate: 23%/38% (P < 0.05)	2-yr cumulative mortality rate: 49%/50%
Gandini et al[66]	1994.1- 2003.11	Patients with BCS	13 (7/6)	Clinical relapse rate: 100%/0%	6-mo primary patency rate: 100%/16.7%; 12-mo primary patency rate: 85.7%/0% (P < 0.001, Log-Rank)	Overall rate: 0%/0%	NA
Barrio et al[67]	1998.9-2002.5	Cirrhotic patients with PH related complications	70 (20/50)	Rate of clinical recurrence of portal hypertension related complications: 0%/22% (P = 0.085)	6-mo shunt dysfunction rate: 0%/32%; 12-mo shunt dysfunction rate: 0%/82% (P = 0.03, Log-Rank)	1-mo rate: 41%/20%; 3-mo rate: 44%/34%; 9-mo rate: 44%/40% (P = 0.5, Log-Rank)	6-mo survival rate: 67%/88%; 12-mo survival rate: 67%/81% (P = 0.11, Log-Rank)
Bureau et al[68,69]	2000.2-2002.4	Patients with cirrhosis and uncontrolled bleeding, recurrent bleeding, or refractory ascites	80 (39/41)	Clinical relapse rate: 7.7%/29.3%	1-yr primary patency rate: 85.6%/46.6%; 2-yr primary patency rate: 80.2%/18.6% (P = 0.0005, Log-Rank)	1-yr rate: 22%/41% (P = 0.0586)	1-yr survival rate: 70.9%/59.5%; 2-yr survival rate: 64.5%/40.5%

BCS: Budd-Chiari syndrome; NA: Not available; NS: Not significant; PH: Portal hypertension; PVT: Portal vein thrombosis; TIPS: Transjugular intrahepatic portosystemic shunt.

Table 4 Outcome of transjugular intrahepatic portosystemic shunt with covered stents: An overview of case series

Ref.	Period	n	Indication for TIPS	Liver function	Follow-up time1	Patients with shunt dysfunction (n)	Cumulative shunt dysfunction or patency rate	HE (n)	No. Pts death (n)
Sajja et al[70]	2001.1- 2011.12	59	Ascites (16), variceal bleeding (31), both (12)	MELD score: 12.5	654 ± 341 (253-1584) d	6-mo: 8; overall: 14	NA	15	7
Wu et al[71]	NA	114	Pure esophageal variceal disruption hemorrhage (92), pure refractory cirrhotic ascites (8), esophageal variceal disruption hemorrhage with refractory ascites (14)	CPC A/B/C: 29/68/34	NA	16	1-yr dysfunction rate: 13.3%; 2-yr dysfunction rate: 24.8%	23	NA
Wu et al[72]	2008.1- 2011.12	150	Gastroesophageal variceal bleeding (134), refractory ascites (16)	CPC A/B/C: 30/81/39	24.1 ± 8.8 mo	17	NA	23	18
Rössle et al[73]	2000.4-2004.10	100	Variceal bleeding (41); refractory ascites, hydrothorax, or hepatorenal syndrome (59)	CPC A/B/C: 21/58/21	22 ± 15 (0.8-47) mo	6-mo: 6; 1-yr: 7; 2-yr: 11; overall: 16	NA	NA	22
Vignali et al[74]	2001.2-2003.12	114	Variceal bleeding (49), refractory ascites (52), hypertensive gastropathy (10), BCS (1), hepatorenal syndrome (2)	CPC A/B/C: 8/60/46	11.9 ± 10.2 (0-38) mo	15	6-mo dysfunction rate: 8.1%; 1-yr dysfunction rate: 20.1%; 2-yr dysfunction rate: 24.1%	27	35
Maleux et al[75]	2000.8-2003.5	56	Upper variceal bleeding (18), refractory ascites (23), variceal bleeding with refractory ascites (10), refractory ascites with hydrothorax (4), hydrothorax (1)	CPC A/B/C: 8/13/35	337 (4-962) d	1	NA	10	30-d: 3; overall: 16
Charon et al[76]	2000.7-2003.1	100	Variceal bleeding (81), refractory ascites (19)	CPC A/B/C: 20/46/34	261 (45-837) d	11	1-yr patency rate: 84%	Acute: 13	45
Hausegger et al[77]	1999.9-2002.3	71	Refractory ascites (44), recurrent esophageal bleeding (27)	CPC A/B/C: 10/43/18	NA	9	6-mo patency rate: 87.4%; 1-yr patency rate: 80.8%	18	30-d: 7; overall: 20

¹Data are expressed as absolute mean ± SD (range) or mean (range). BCS: Budd-Chiari syndrome; CPC: Child-Pugh class; HE: Hepatic encephalopathy; MELD: Model for end-stage liver disease; NA: Not available.