Transjugular intrahepatic portosystemic shunt (TIPS) is an effective intervention for managing major complications of cirrhosis including refractory ascites, hydrothorax, and variceal bleed. The impact of advanced age on outcomes of TIPS has not been studied comprehensively. Therefore, we aimed to study optimal advanced age cutoff in context of MELD score for patients undergoing TIPS.

A single-center retrospective analysis of all adult patients with cirrhosis, who underwent TIPS between 2002 and 2020 was performed. Univariate and multivariate analyses were conducted to determine the development of hepatic encephalopathy (HE) and mortality at 30 days and 1 year. The impact of various age groups (55, 60, 65, and 70 years) and MELD score cutoffs on mortality were elucidated.

A total of 225 patients were included. No significant associations were found between advanced age and short-term mortality (p = 0.410), short-term development of HE (p = 0.846), or secondary post-TIPS outcomes such as rebleed or need for paracentesis. However, advanced age was associated with significant differences in post TIPS mortality (p = 0.026) and inpatient development of HE (p = 0.032) at 1-year. These associations were confirmed in multivariate models. Area under the covariate adjusted receiver operating curve (AUROC) identified optimal age and MELD cutoffs as 60 years and 15 for 1-year mortality, respectively. An optimal age cutoff of 54 was identified for 1-year HE.

Advanced age is strongly associated with 1-year mortality and 1-year development of HE post-TIPS. Poorer post-TIPS outcomes were further observed in patients with higher MELD. Therefore, during selection of advanced age patients for TIPS, MELD score should be considered for better long-term outcomes.

Transjugular intrahepatic portosystemic shunt (TIPS) has an important role in the therapy of complications of portal-hypertension-related ascites. Various guidelines now indicate that TIPS is indicated for refractory ascites (RA), but TIPS for recurrent nonrefractory ascites (RNRA) achieved better clinical results.

To compare the clinical outcomes of TIPS for RA and RNRA in patients with complications related to portal hypertension.

There were 863 patients divided into two main categories who underwent TIPS between September 2016 and September 2021. In category 1, patients had ascites without cirrhotic gastrointestinal bleeding. The patients were divided into group A (RNRA, n = 183) and group B (RA, n = 217). In category 2, patients had ascites and cirrhotic gastrointestinal bleeding. The patients were divided into group C (RNRA, n = 328) and group D (RA, n = 135). The clinical outcomes were probability of total hepatic impairment, incidence of hepatic encephalopathy (HE) and mortality.

The symptoms of ascites disappeared or were relieved within 1 week in group A compared with group B (P = 0.032), and in group C compared with group D (P = 0.027). By the end of follow-up, there were significant differences in the rate of RA in group A compared with group B (P = 0.016), and in group C compared with group D (P = 0.012). The probability of total hepatic impairment was significantly different in group A compared with group B (P = 0.024), and in group C compared with group D (P = 0.019). The total incidence of HE was significantly different in group A compared with group B (P = 0.008), and in group C compared with group D (P = 0.004). The 6-month, and 1-, 2- and 3-year survival rates were significantly different between groups A and B (all P < 0.05), and between groups C and D (all P < 0.05).

TIPS has a good therapeutic effect on ascites related to cirrhotic portal hypertension, and early TIPS for RNRA can prolong survival, and prevent progression to RA.

TIPS is the most effective treatment for portal hypertension. Patient selection remains important to achieving optimal post-TIPS outcomes. The study evaluates 1-year mortality factors in cirrhotic patients receiving TIPS.

87 cirrhotic patients received a TIPS between 2015 - 2021. Predictors of 1-year and overall mortality were assessed by estimating cumulative incidence functions and Grey's test to adjust for liver transplantation as a risk competing with mortality. Variables with p < 0.05 were checked for collinearity and included in the multivariate Cox proportional hazards model. Model discrimination was evaluated by calculating the area under the ROC curve.

87 patients were included (68% men; 22% ≥70 years). ALD was the primary cirrhosis cause. Most patients were Child-Pugh class B, MELD-Na score was 13.6 ± 6.0 points. The most frequent indication for TIPS was bleeding (51.7%), followed by refractory ascites (42.5%). The variables positively associated with mortality in univariate analysis were ascites, clinically overt sarcopenia and MELD-Na score, while ongoing nutritional supplementation improved survival. In the multivariate analysis, only clinically overt sarcopenia and MELD-Na score remained independently associated with mortality. A MELD-Na/sarcopenia model demonstrated a good discrimination, AUROC: 0.86 (95% CI 0.77 - 0.95).

MELD-Na score, and sarcopenia were significantly associated with 1-year survival in cirrhotic patients who received TIPS.

The objective of our study was to develop a nomogram to predict post-transjugular intrahepatic portosystemic shunt (TIPS) survival in patients with cirrhosis based on CT images.

This retrospective cohort study included patients who had received TIPS operation at the Wenzhou Medical University First Affiliated Hospital between November 2013 and April 2017. To predict prognosis, a nomogram and Web-based probability were developed to assess the overall survival (OS) rates at 1, 3, and 5 years based on multivariate analyses. With deep learning algorithm, the automated measurement of liver and spleen volumes can be realized. We assessed the predictive accuracy and discriminative ability of the nomogram using the concordance index (C-index), receiver operating characteristic (ROC) curve, calibration curve, and decision curve analysis (DCA).

Age, total bilirubin, and spleen volume-to-platelet ratio (SVPR) were identified as the independent risk factors for OS. The nomogram was constructed based on the above risk factors. The C-index (0.80, 0.74, 0.70), ROC curve (area under curve: 0.828, 0.761, 0.729), calibration curve, and DCA showed that nomogram good at predictive value, stability, and clinical benefit in the prediction of 1-, 3-, 5-year OS in patients with TIPS creation.

We constructed a nomogram for predicting prognosis in patients with TIPS creation based on risk factors. The nomogram can help clinicians in identifying patients with poor prognosis, eventually facilitating earlier treatment and selecting suitable patients before TIPS.

This study developed the first nomogram based on SVPR to predict the prognosis of patients treated with TIPS. The nomogram could help clinician in non-invasive decision-making.

Transjugular intrahepatic portosystemic shunt (TIPS) is a procedure typically utilized to treat refractory ascites and variceal bleeding. However, TIPS can lead to significant complications, most commonly hepatic encephalopathy (HE). Advanced age has been described as a risk factor for HE, as the elderly population tends to have decreased cognitive reserve and increased sarcopenia. We conducted a systematic review and meta-analysis of the available literature to summarize the association between advanced age and risk of adverse events after undergoing TIPS.

A comprehensive search strategy to identify reports of specific outcomes (HE, 30-day and 90-day mortality, and 30-day readmission due to HE) in elderly patients after undergoing TIPS was developed in Embase (Embase.com, Elsevier). We compared outcomes and performed separate data analyses for patients aged < 70 vs. > 70 years and patients aged < 65 vs. > 65 years.

Six studies with a total of 1,591 patients met our inclusion criteria and were included in the final meta-analysis. Three studies divided patients by age < 65 vs. > 65 years, with a total of 816 patients who were 54% male. The remaining three studies divided patients by age < 70 vs. > 70 years, with a total of 775 patients who were 63% male. Results demonstrated a significantly lower risk of post-TIPS HE (risk ratio (RR): 0.42, confidence interval (CI): 0.185 - 0.953, P = 0.03, I2 = 49%), 30-day mortality (RR: 0.37, CI: 0.188 - 0.74, P = 0.005, I2 = 0%), and 90-day mortality (RR: 0.35, CI: 0.24 - 0.49, P = 0.001, I2 = 0%) in patients aged > 70 vs. < 70 years, as well as a trend towards lower risk of 30-day readmission due to HE. There was no significant difference in post-TIPS HE, 30-day or 90-day mortality, or 30-day readmission due to HE between patients aged < 65 vs. > 65 years.

Age > 70 years is associated with significantly higher rates of HE and 30-day and 90-day mortality rates in patients after undergoing TIPS, as well as a trend towards higher 30-day readmission due to HE.

Complications of portal hypertension, including ascites, gastrointestinal bleeding, hepatic hydrothorax, and hepatic encephalopathy, are associated with significant morbidity and mortality. Despite few high-quality randomized controlled trials to guide therapeutic decisions, transjugular intrahepatic portosystemic shunt (TIPS) creation has emerged as a crucial therapeutic option to treat complications of portal hypertension. In North America, the decision to perform TIPS involves gastroenterologists, hepatologists, and interventional radiologists, but TIPS creation is performed by interventional radiologists. This is in contrast to other parts of the world where TIPS creation is performed primarily by hepatologists. Thus, the successful use of TIPS in North America is dependent on a multidisciplinary approach and technical expertise, so as to optimize outcomes. Recently, new procedural techniques, TIPS stent technology, and indications for TIPS have emerged. As a result, practices and outcomes vary greatly across institutions and significant knowledge gaps exist. In this consensus statement, the Advancing Liver Therapeutic Approaches group critically reviews the application of TIPS in the management of portal hypertension. Advancing Liver Therapeutic Approaches convened a multidisciplinary group of North American experts from hepatology, interventional radiology, transplant surgery, nephrology, cardiology, pulmonology, and hematology to critically review existing literature and develop practice-based recommendations for the use of TIPS in patients with any cause of portal hypertension in terms of candidate selection, procedural best practices and, post-TIPS management; and to develop areas of consensus for TIPS indications and the prevention of complications. Finally, future research directions are identified related to TIPS for the management of portal hypertension.

An increased risk of complications of TIPS in patients older than 65 years of age has been described, but data is limited. The objective of this study was to determine if the rate of complications post-TIPS differs in patients 65 or younger, compared to those older than 65 years of age.

A retrospective chart review was performed for all patients who underwent TIPS procedure at Banner-University Medical Center Phoenix, from 2010 to 2018, specifically focusing on complications and outcomes post-TIPS. In total, 402 patients were included in this analysis. Complications included portosystemic encephalopathy, post-TIPS infection, acute kidney injury requiring hemodialysis, hemorrhage, respiratory complications, need for transplant, or death.

A total of 402 patients were included and divided into two groups: 300 (74.6%) were 65 years or younger (ages 53 ± 9), and 102 were older than 65 years (70 ± 5 (p < 0.001)). There were no statistically significant differences between age groups when comparing portosystemic encephalopathy, post-TIPS infection, acute kidney injury, respiratory complications, need for transplant, or death.

In this large, single-center cohort, there was no statistically significant difference in the rate of complications of TIPS between the two age groups. Based on our results, TIPS procedure is an equally safe option for properly selected patients with complications of portal hypertension, regardless of age.

More than five decades after it was originally conceptualized as rescue therapy for patients with intractable variceal bleeding, the transjugular intrahepatic portosystemic shunt (TIPS) procedure continues to remain a focus of intense clinical and biomedical research. By the impressive reduction in portal pressure achieved by this intervention, coupled with its minimally invasive nature, TIPS has gained increasing acceptance in the treatment of complications of portal hypertension. The early years of TIPS were plagued by poor long-term patency of the stents and increased incidence of hepatic encephalopathy. Moreover, the diversion of portal flow after placement of TIPS often resulted in derangement of hepatic functions, which was occasionally severe. While the incidence of shunt dysfunction has markedly reduced with the advent of covered stents, hepatic encephalopathy and instances of early liver failure continue to remain a significant issue after TIPS. It has emerged over the years that careful selection of patients and diligent post-procedural care is of paramount importance to optimize the outcome after TIPS. The past twenty years have seen multiple studies redefining the role of TIPS in the management of variceal bleeding and refractory ascites while exploring its application in other complications of cirrhosis like hepatic hydrothorax, portal hypertensive gastropathy, ectopic varices, hepatorenal and hepatopulmonary syndromes, non-tumoral portal vein thrombosis and chylous ascites. It has also been utilized to good effect before extrahepatic abdominal surgery to reduce perioperative morbidity and mortality. The current article aims to review the updated literature on the status of TIPS in the management of patients with liver cirrhosis.

The management of patients with refractory ascites (RA) is challenging, particularly at higher age. Transjugular intrahepatic portosystemic shunt (TIPS) is an established treatment for RA, but safety data in elderly patients are rare. Our aim was to evaluate the safety and feasibility of TIPS in elderly patients with RA.

Overall, 160 consecutive cirrhotic patients receiving a TIPS for RA at Hannover Medical School between 2012 and 2018 were considered for this retrospective analysis. Periinterventional complications such as acute-on-chronic liver failure (ACLF) as well as survival were compared between patients <65 and ≥65 years. Propensity score matching was conducted to match elderly TIPS patients and patients treated with paracentesis.

A number of 53 out of the 160 patients were ≥65 years (33%). Periinterventional course in those ≥65 years appeared to be slightly more complicated than in <65 years as reflected by a significantly longer hospital stay (p = 0.030) and more ACLF-episodes (21% vs. 9%; p = 0.044). 28-day mortality was similar between both groups (p = 0.350), whereas survival of the younger patients was significantly higher at 90 days (p = 0.029) and numerically higher at 1 year (p = 0.171). In the multivariate analysis age ≥65 years remained an independent predictor for 90-day mortality (HR: 2.58; p = 0.028), while it was not associated with 28-day and 1-year survival. Importantly, after matching for potential confounders 1-year survival was similar in elderly patients if treated with TIPS or paracentesis (p = 0.419).

TIPS placement in elderly patients with RA appears to be slightly more complicated compared to younger individuals, but overall feasible and at least not inferior to paracentesis.

Ascites, a common complication of liver cirrhosis, eventually becomes refractory to diuretic therapy and sodium restriction in ∼10% of patients. Multiple pathogenetic factors are involved in the development of refractory ascites, which ultimately lead to renal hypoperfusion and avid sodium retention. Therefore, renal dysfunction commonly accompanies refractory ascites. Management includes continuation of sodium restriction, which needs frequent reviews for adherence; and regular large volume paracentesis of 5 L or more with albumin infusions to prevent the development of paracentesis-induced circulatory dysfunction. In the appropriate patients with reasonable liver reserve, the insertion of a transjugular intrahepatic portosystemic stent shunt (TIPS) can be considered, especially if the patient is relatively young and has no previous hepatic encephalopathy or anatomical contraindications, and no past history of renal or cardiopulmonary disease. Response to TIPS with ascites clearance can lead to nutritional improvement. Devices such as an automated low-flow ascites pump may be available in the future for ascites treatment. Patients with refractory ascites and poor liver function and/or renal dysfunction, should be referred for liver transplant, as this will eliminate the portal hypertension and liver dysfunction. Renal dysfunction prior to liver transplant largely improves after transplant without affecting post-transplant survival.