Transjugular intrahepatic portosystemic shunt and non-selective beta-blockers act as friends or foe in decompensated cirrhosis: A comparative review

Abstract

The management of portal hypertension and its complications, such as variceal bleeding, in patients with cirrhosis often involves the use of nonselective beta-blockers (NSBBs) and a transjugular intrahepatic portosystemic shunt (TIPS). Both treatment modalities have demonstrated efficacy; however, each presents distinct challenges and benefits. NSBBs, including propranolol, nadolol, and carvedilol, effectively reduce portal pressure, but are associated with side effects such as bradycardia, hypotension, fatigue, and respiratory issues. Additionally, NSBBs can exacerbate conditions such as refractory ascites, hepatorenal syndrome, and hepatic encephalopathy. In contrast, TIPS effectively reduces the incidence of variceal rebleeding, controlling refractory ascites. However, it is associated with a significant risk of hepatic encephalopathy, shunt dysfunction, and procedure-related complications including bleeding and infection. The high cost of TIPS, along with the need for regular follow-up and potential re-intervention, poses additional challenges. Furthermore, patient selection for TIPS is critical, as inappropriate candidates may experience suboptimal outcomes. Future studies comparing NSBBs and TIPS should focus on refining the patient selection criteria, enhancing procedural techniques, optimising combination therapies, and conducting long-term outcome studies. Personalised treatment approaches, cost-effectiveness analyses, and improved patient education and support are essential for maximising the use of these therapies.

Key Words: Transjugular intrahepatic portosystemic shunt; Liver cirrhosis; Variceal bleeding; Nonselective beta-blockers; Portal hypertension

Core Tip: The management of portal hypertension in decompensated cirrhosis often involves nonselective beta-blockers (NSBBs) and a transjugular intrahepatic portosystemic shunt (TIPS). Although NSBBs effectively reduce portal pressure and prevent variceal bleeding, they can cause significant side effects, negatively impacting adherence. Conversely, TIPS provides rapid relief from variceal bleeding but carries risks such as hepatic encephalopathy and other complications. However, both treatments require careful patient selection and monitoring. Future strategies should focus on optimising patient management, enhancing procedural techniques, and integrating personalised approaches to improve outcomes in patients with cirrhosis.

INTRODUCTION

Decompensated cirrhosis is a critical stage of liver disease, characterised by acute deterioration of hepatic function and the onset of life-threatening complications such as variceal bleeding, ascites, hepatic encephalopathy, and hepatorenal syndrome (HRS)[1,2]. According to Kim et al[1], this disease often results in the death of at least 85% of patients who do not receive a liver transplant within the first five years after presentation. Portal hypertension, a hallmark of decompensated cirrhosis, is a major driver of these complications, with an elevated portal pressure leading to variceal bleeding and other severe sequelae[2,3]. Notably, Garcia-Tsao[3] posited that the median survival rate of patients diagnosed with portal hypertension in decompensated cirrhosis was < 24 months.

The management of portal hypertension and its complications remains a significant challenge in clinical practice. Nonetheless, several treatment options are available, which vary across surgical procedures, such as the insertion of the transjugular intrahepatic portosystemic shunt (TIPS)[4]; medication regimens including the use of diuretics, lactulose, and rifaximin; and nonselective beta-blockers (NSBBs) such as propranolol[5], endoscopic band ligation, and liver transplantation. However, one of the most straightforward interventions involves lifestyle changes in terms of dietary intervention, weight moderation, and ultimately, cessation of alcohol consumption[6].

NSBBs, such as propranolol and carvedilol, have long been established as first-line therapies for reducing portal pressure and preventing variceal bleeding[7]. These medications decrease cardiac output and induce splanchnic vasoconstriction, thereby reducing portal venous pressure. However, their use is often limited by the significant side effects associated with NSBBs, including bradycardia, hypotension, and exacerbation of conditions such as refractory ascites and hepatic encephalopathy. NSBB therapy adherence is further complicated by the need for lifelong treatment and regular monitoring[8].

In contrast, TIPS offers a more invasive but effective approach for managing portal hypertension by creating a shunt between the portal and hepatic veins, thereby reducing portal pressure[9,10]. While TIPS is highly effective in controlling variceal bleeding and refractory ascites, it is associated with risks such as hepatic encephalopathy, shunt dysfunction, and procedure-related complications[10]. The high cost of TIPS, along with the need for specialised expertise and ongoing follow-up, further complicate its use.

Despite the widespread use of both NSBBs and TIPS, there is a lack of consensus regarding the optimal approach for managing portal hypertension in decompensated cirrhosis[11,12]. The choice between these therapies often depends on patient-specific factors, including the severity of liver disease, presence of comorbidities, and the risk of complications. Moreover, the comparative efficacy, safety, and long-term outcomes of NSBBs and TIPS have not yet been fully elucidated, particularly in the context of modern advancements in both pharmacological and interventional therapies.

This study aimed to provide a comprehensive comparative review of NSBBs and TIPS in the management of decompensated cirrhosis, focusing on their mechanisms of action, efficacy, safety profiles, and challenges in clinical practice. By analysing the latest evidence, we sought to clarify the roles of these therapies in different clinical scenarios and highlight the areas where further research is required to optimise patient outcomes. This study also reviews the mechanisms and indications of NSBBs and TIPS, followed by a comparative analysis of their efficacy and complications. Finally, we discuss future research directions, including the potential for personalised treatment approaches and the integration of emerging therapies.

NSBBS

Following the discovery of propranolol more than three decades ago, NSBBs have emerged as a crucial first-line intervention therapy for the management of decompensated cirrhosis. Several randomised control trials (RCTs) have demonstrated significantly positive outcomes for the efficacy of NSBBs in preventing both primary and secondary bleeding episodes from esophagogastric and portal hypertensive gastropathy[13-16]. Moreover, the administration of NSBBs in patients with cirrhosis has been associated with reduced bacterial translocation, reduced spontaneous bacterial peritonitis, and increased overall survival, independent of bleeding events[17,18].

The primary mechanism of NSBBs relies on their ability to affect beta-1 and beta-2 receptors in the myocardium and splanchnic vascular beds, respectively[19]. Through alterations in the beta-1 receptors, NSBBs can significantly decrease cardiac output and contractility. In contrast, beta-2 receptors, in turn, can cause vasoconstriction of the portal veins, primarily due to the unopposed activity of alpha-1 adrenergic receptors in the splanchnic vascular bed, resulting in a net reduction in the portal vein[19]. As indicated earlier, intrahepatic vascular resistance caused by distortions in hepatic anatomy is the primary cause of portal hypertension. Bhathal and Grossman[20] posited that almost 40 percent of this resistance could be functionally reversed by manipulating the specific locations of contractile elements found in the hepatic vascular landscape, thus modulating portal hypertension.

Recent studies have highlighted the abundance of alpha-1 adrenergic receptors in the systemic and splanchnic vascular anatomy of smooth muscles across the genitourinary tract. Thus, Al-Ghamdi[19] analysed the hypothesis that antagonisation of these receptors could reduce intrahepatic vascular tone and attenuate portal pressure. A subsequent trial by Albillos et al[21] involving the administration of propranolol combined with prazosin, an established alpha-1 blocker, in 28 patients compared with the administration of propranolol in addition to isosorbide-5-mononitrate in a 28-member cohort for three months showed a more significant reduction in the hepatic venous pressure gradient in the former than in the latter. However, this cohort was also associated with more hypotensive events and lower tolerance than the latter[21].

Thus, carvedilol, an NSBB composed of a mixture (racemic) of potent NSBBs and a weak alpha-1-receptor, was proposed. This new NSBB has been highlighted to be twice as potent as propranolol for beta-receptor blocking[22]. Several comparative trials comparing the outcomes of propranolol and carvedilol showed a > 20 percent decrease in the hepatic venous pressure gradient[23-25]. Rodrigues et al[26] outline the mechanisms of action for NSBB.

Challenges associated with NSBBs

NSBBs such as propranolol, nadolol, and carvedilol are pivotal in managing portal hypertension and preventing variceal bleeding in patients with cirrhosis. However, its use is associated with challenges and limitations that can affect patient outcomes and treatment adherence.

One of the primary challenges associated with the use of NSBBs is their cardiovascular side effects. NSBBs can cause significant bradycardia (slow heart rate) and hypotension (low blood pressure), which are particularly important in patients with advanced liver disease, who often have compromised cardiovascular systems[21,27]. These side effects can lead to poor medication tolerance and patients frequently report fatigue and dizziness, which can substantially affect their quality of life. This discomfort often results in poor adherence to the prescribed regimen, undermining the effectiveness of the treatment[27].

The use of NSBB medications has been known to exacerbate preexisting respiratory conditions such as asthma and chronic obstructive pulmonary disease (COPD). The nonselective action of these beta-blockers on beta-receptors can lead to bronchoconstriction, further complicating the management of patients with concurrent respiratory disorders[28]. In certain circumstances, NSBBs can worsen circulatory dysfunction. For instance, in patients undergoing large-volume paracentesis to manage ascites, NSBBs may exacerbate paracentesis-induced circulatory dysfunction[21]. In addition, NSBBs can worsen the condition of patients with refractory ascites, making their use problematic in this subgroup of patients with advanced liver disease.

Furthermore, NSBBs are associated with an increased risk of HRS[29]. Some studies have suggested that these medications can increase the risk of HRS owing to their impact on renal blood flow and systemic vasoconstriction. This risk is particularly concerning given the already precarious renal function in many patients with decompensated cirrhosis[29]. Hepatic encephalopathy, a common complication of cirrhosis, is aggravated by NSBBs. These drugs can further reduce hepatic perfusion, potentially worsen liver function, and lead to increased encephalopathy. These side effects necessitate careful monitoring and therapeutic adjustments to balance the benefits and risks of NSBBs.

However, patient adherence to NSBB therapy remains a significant challenge[29]. The side effects and lifelong nature of the therapy can lead to poor adherence, which reduces the prophylactic effectiveness of the treatment and increases the risk of variceal rebleeding. Ensuring patient compliance with NSBB therapy requires extensive patient education and support, which can be resource-intensive.

Moreover, individual variability in the response to NSBBs further complicates their use. Not all patients achieve adequate reduction in portal pressure with NSBBs, necessitating additional therapies or alternative treatments such as TIPS[30]. This variability underscores the need for personalised treatment plans and regular monitoring to adjust therapy as needed. The effective use of NSBBs requires regular monitoring of heart rate and blood pressure to ensure appropriate dosing. This requirement can be challenging to meet in resource-limited settings, and adds to the overall burden of managing patients with cirrhosis. The need for frequent adjustments and close follow-up can strain healthcare resources and may not be feasible in all healthcare environments.

TIPS

Qi et al[31] attributed portal hypertension to the incidence of non-neoplastic portal vein thrombosis with an incidence rate of 10%-23%, leading to increased venous pressure and reduced blood flow to the liver[31,32]. Non-neoplastic portal vein thrombosis has also been associated with poor outcomes following liver transplantation, mortality, reduced blood flow, and contraindications to liver transplantation[33]. Moreover, Englesbe et al[34] and Sarin et al[35] reported a six-week mortality rate in almost 20% of patients with cirrhosis presenting with variceal bleeding, and its aetiology was attributed to increased portal vein pressure.

Currently, no consensus guidelines have elucidated the optimal prophylactic treatment for patients presenting with cirrhosis-induced variceal bleeding and portal vein thrombosis[36]. Current evidence suggests that this patient cohort has been associated with significant long-term complications and challenges in eradicating variceal bleeding in the long term[34]. However, several standard treatment interventions, including endoscopic band ligation and NSBBs, have been used to achieve immediate haemostasis and prevent re-bleeding[12]. Therefore, TIPS is recommended in patients who fail to respond to either of the two standard treatments[12].

Challenges associated with TIPS

One of the primary challenges of TIPS is the risk of hepatic encephalopathy[37,38]. This condition occurs in a significant proportion of patients following the procedure because of the shunting of blood away from the liver, which reduces the ability of the liver to detoxify harmful substances. This can lead to the build-up of toxins in the bloodstream, affecting brain function and resulting in symptoms ranging from mild confusion to severe cognitive impairment. Managing hepatic encephalopathy often requires additional medications and frequent monitoring, in addition to the complexity of post-TIPS care[38]. Shunt dysfunction is a major issue associated with TIPS complication. Over time, the shunt can become occluded or stenotic, leading to the loss of its therapeutic effect, necessitating regular surveillance with imaging studies such as doppler ultrasound to monitor shunt patency[39,40]. When dysfunction is detected, interventions such as angioplasty or shunt revision, which can be invasive and expensive, may be required. The need for ongoing surveillance and potential reinterventions places a significant burden on both patients and the healthcare system.

Procedure-related complications also pose a challenge for the use of TIPS. These complications include bleeding, infection, and injury to adjacent organs such as the bile ducts or hepatic arteries[41]. This procedure requires considerable expertise and is typically performed at specialist centres. The complexity of TIPS and the potential for severe complications highlight the importance of experienced interventional radiologists performing the procedure[41,42]. Another concern is the high cost of TIPS. The procedure requires follow-up care and potential re-interventions can be expensive, making TIPS less accessible in resource-limited settings and placing a financial strain on the patients and healthcare systems. The cost-effectiveness of TIPS is often weighed against its benefits, particularly in patients with advanced liver disease or those at high risk of complications[42].

Patient selection is crucial for the success of TIPS, but remains challenging. Identifying patients who will benefit the most from TIPS requires careful consideration of various factors, including liver function, portal hypertension severity, and other comorbidities[11]. Inappropriate patient selection can lead to suboptimal outcomes including higher rates of complications and mortality. Developing clear and evidence-based criteria for patient selection is essential to maximise the benefits of TIPS while minimising its risks[11]. Furthermore, the effect of TIPS on liver function is of significant concern. Although this procedure can effectively reduce portal hypertension, it can also compromise liver perfusion, potentially worsening liver function in some patients. This is particularly problematic in patients with a compromised liver function. A balance between reducing portal pressure and maintaining adequate liver function is difficult to achieve and requires careful management.

Finally, long-term data on the outcomes of patients who undergo TIPS are needed. While short-term benefits, such as reduced variceal bleeding and ascites control, are well-documented, the long-term impact on survival and quality of life is unclear. Ongoing research and long-term studies are needed to elucidate the full range of outcomes associated with TIPS and refine patient management strategies accordingly.

COMPARISON OF NSBBS AND TIPS

Evidence supporting TIPS for secondary prophylaxis

Historically, most evidence supporting TIPS for the secondary prevention of variceal bleeding comes from studies using bare metal stents, as illustrated in a meta-analysis by Miao et al[43]. One significant study compared endoscopic variceal ligation (EVL) with uncovered TIPS in 80 patients with cirrhosis who had variceal bleeding. The study found that TIPS significantly reduced the incidence of variceal rebleeding but did not improve the two-year survival rate[44]. Another trial compared drug therapies, including propranolol and isosorbide-5-mononitrate, with uncovered TIPS in patients with child-Pugh class B or C cirrhosis after the first episode of variceal bleeding. The trial revealed similar survival rates between the two groups. However, the TIPS group experienced more hepatic encephalopathy and required a higher number of re-interventions owing to in-stent thrombosis and other complications[11].

Transition to covered stents

Owing to the high incidence of in-stent thrombosis with bare-metal stents, there has been a shift toward the use of covered stents. Data on early treatment with covered TIPS vs endoscopic therapy combined with beta-blockers for acute variceal bleeding are limited, but promising. Two notable studies indicated a survival benefit in selected high-risk populations, specifically in patients with child-Pugh class C or child-Pugh class B disease with active bleeding observed during diagnostic endoscopy[11]. However, these studies suggest that TIPS benefits may depend on early intervention and appropriate patient selection.

Recent uncontrolled studies and the need for further research

One uncontrolled study investigated the use of early TIPS for secondary prevention after controlling initial bleeding episodes. The study did not find a survival benefit of early TIPS compared to a historical cohort treated with EVL, highlighting the need for further research to refine patient selection criteria[45]. These findings underscore the importance of additional studies to determine the optimal criteria for selecting patients who would benefit most from TIPS for the secondary prevention of variceal bleeding[46].

Mechanism and indications

NSBBs and TIPS are used to manage portal hypertension and prevent variceal rebleeding. However, they have distinct mechanisms and indications. NSBBs, such as propranolol and nadolol, reduce portal pressure by decreasing cardiac output and inducing splanchnic vasoconstriction. They are primarily used to prevent initial and recurrent variceal bleeding[3]. Conversely, TIPS involves creating a channel within the liver to connect the portal vein to the hepatic vein, significantly reducing portal pressure and managing complications such as refractory ascites and hydrothorax.

Efficacy and survival

NSBBs effectively lower the risk of variceal bleeding; however, their effects on survival remain unclear. Clinical guidelines recommend these treatments in patients with high-risk varices[9]. TIPS has shown high efficacy in controlling variceal bleeding and improving survival, particularly in patients with refractory ascites or those at a high risk of rebleeding. However, TIPS is associated with a high risk of hepatic encephalopathy and requires careful patient selection[11].

Side-effects and complications

The side effects of NSBBs include bradycardia, hypotension, fatigue, asthma exacerbation, and COPD. They can also worsen paracentesis-induced circulatory dysfunction and refractory ascites, limiting their use in certain patients[16]. TIPS, although effective, is associated with risks such as hepatic encephalopathy, shunt dysfunction, and procedure-related complications. The high cost and need for specialised expertise further complicate its use. Table 1 shows a direct Comparison of NSBBs and TIPS.

Table 1 Comparisons between nonselective beta-blockers and transjugular intrahepatic portosystemic shunt.

Aspect	NSBBs	TIPS
Mechanism of action	Decreases cardiac output and induces splanchnic vasoconstriction to lower the portal pressure	Creates a channel between the portal and hepatic veins to reduce the portal pressure
Primary indications	Prevention of first and recurrent variceal bleeding	Management of portal hypertension complications such as variceal bleeding, refractory ascites, and hepatic hydrothorax
Efficacy	Effective in reducing variceal bleeding risk	Highly effective in controlling variceal bleeding and managing refractory ascites
Procedure	Non-invasive medications	Minimally invasive procedures performed by interventional radiologists
Side-effects	Bradycardia, hypotension, fatigue, exacerbation of asthma or COPD, paracentesis-induced circulatory dysfunction, and potential worsening of ascites	Risk factors of hepatic encephalopathy, shunt dysfunction, infection, and procedure-related complications
Survival impact	This can improve the survival of patients with high-risk varices	It can improve survival, particularly in patients with refractory ascites or those at a high risk of variceal rebleeding
Cost	Relatively low-cost as it involves medication	Expensive; Higher costs are attributed to the need for interventional procedures and possible subsequent shunt revisions
Follow-up and maintenance	Regular monitoring of heart rate, blood pressure, and dose adjustments may be necessary	Regular follow-up for shunt patency may require repeat imaging or interventions to maintain shunt function
Impact on hepatic encephalopathy	They can help reduce the incidence of hepatic encephalopathy when used appropriately	This involves a higher risk of postprocedural hepatic encephalopathy
Combination therapy	These are often combined with endoscopic treatment to achieve better outcomes	This may be combined with NSBBs to manage residual varices or incomplete portal decompression after the procedure
Clinical guidelines	American Association for the Study of Liver Diseases and the European Association for the Study of the Liver recommend it for the prevention of variceal bleeding	The American Association for the Study of Liver Diseases and the European Association for the Study of the Liver recommend this for managing refractory complications of portal hypertension

NSBBs: Nonselective beta-blockers; TIPS: Transjugular intrahepatic portosystemic shunt; COPD: Chronic obstructive pulmonary disease.

FUTURE DIRECTIONS AND RECOMMENDATIONS IN THE COMPARISON BETWEEN TIPS AND NSBBS

The management of complications arising from portal hypertension in patients with cirrhosis often involves the use of NSBBs or TIPS. Both treatment modalities have demonstrated efficacy but have distinct advantages and limitations. Future research in this field should focus on refining the patient selection criteria, enhancing procedural techniques, and optimising combination therapies to improve patient outcomes.

Refining patient selection and early intervention

One of the most critical areas for future research is the development of more precise patient selection criteria. Current guidelines recommend TIPS for patients with refractory ascites or recurrent variceal bleeding. However, more nuanced stratification tools are required. Therefore, this study recommends conducting randomised controlled trials to evaluate the benefits of early TIPS initiation (within 72 hours of admission) in high-risk patients, particularly those with child-Pugh class B or C cirrhosis and active bleeding on endoscopy. These trials could help identify subgroups of patients who derive the most benefit from early intervention and bolster the findings detailed in the prospective studies by García-Pagán et al[45], Ruiz-Blard et al[46], Rudler et al[47], Lv et al[48,49], and García-Pagán et al[50]. Additionally, the development of biomarkers such as serum ammonia levels, inflammatory markers (e.g., interleukin-6 and tumour necrosis factor-α), and genetic polymorphisms could improve risk stratification and help predict complications such as hepatic encephalopathy. By integrating these biomarkers with clinical parameters (e.g., model for end-stage liver disease score and hepatic venous pressure gradient), more accurate risk stratification tools can be created to guide treatment decisions.

Optimizing combination therapies

Combining NSBBs with TIPS has shown promise in some studies, suggesting that a multifaceted approach may provide superior outcomes compared with either therapy alone[51,52]. Future clinical trials should explore the efficacy and safety of combination therapies in various patient populations, particularly those with refractory ascites or recurrent variceal bleeding. These trials should assess whether combining NSBBs with TIPS can reduce the risk of rebleeding and hepatic encephalopathy while improving survival. Furthermore, the potential synergistic effects of NSBBs with other vasoactive agents, such as alpha-1 blockers (e.g., prazosin) or nitric oxide donors, should be investigated. Such combinations could offer a pharmacological alternative to invasive procedures such as TIPS, particularly in patients who are unsuitable candidates for the shunting procedure.

Advancements in TIPS technology

Technological advancements in TIPS, particularly in the use of covered stents, have improved outcomes by reducing shunt dysfunction. Future research should focus on the development of next-generation stents, including drug-eluting stents, which may further reduce the risk of complications such as hepatic encephalopathy and shunt occlusion. In addition, minimally invasive techniques such as image-guided navigation systems can improve the precision of shunt placement and reduce procedure-related complications. Studies should also explore the long-term outcomes of these innovations, including their impact on shunt patency and the need for repeated interventions. By enhancing procedural techniques, we can minimise risks and improve the overall efficacy of TIPS.

Long-term outcome studies and patient-centred care

Although the short-term benefits of NSBBs and TIPS are well-documented, more comprehensive long-term studies are required to understand their impact on overall survival, quality of life, and healthcare costs. Large multicentre longitudinal cohort studies should follow patients for at least 5-10 years to provide robust data on the durability of these treatments. These studies should also incorporate patient-reported outcome measures to evaluate the impact of NSBBs and TIPS on patient quality of life, including symptoms such as fatigue, cognitive function, and physical activity levels. By focusing on patient-centred outcomes, we can better understand the real-world impacts of these therapies and tailor treatment plans according to individual needs.

Addressing hepatic encephalopathy

Hepatic encephalopathy remains a significant challenge after TIPS, and future research should investigate strategies to mitigate this risk. Adjunctive therapies, such as rifaximin, lactulose, or ammonia-lowering agents (e.g., L-ornithine and L-aspartate), can be evaluated in RCTs to determine their efficacy in reducing the incidence of post-TIPS hepatic encephalopathy. Additionally, the role of gut microbiome modulation through probiotics or faecal microbiota transplantation should be explored as a potential strategy to reduce ammonia production and lower the risk of encephalopathy. Identifying patients at a higher risk of this complication pre-procedure using biomarkers or genetic profiling could also help tailor interventions more effectively.

Cost-effectiveness and resource allocation

The high cost of TIPS, including the procedure itself and the need for follow-up care, makes it imperative to conduct thorough cost-effectiveness analyses. Future research should compare the long-term costs and benefits of TIPS vs NSBBs, considering not only medical expenses but also indirect costs such as lost productivity and quality-adjusted life years. These analyses will help health care providers and policymakers make informed decisions regarding resource allocation, particularly in resource-limited settings. Implementation studies should also evaluate the feasibility of integrating TIPS and NSBBs into routine clinical practice, identify barriers to their adoption, and propose strategies for improving access to these therapies.

Personalised medicinal approaches

The future management of portal hypertension in cirrhosis will be based on personalised medicine. Genetic profiling may play a key role in predicting individual responses to NSBBs and TIPS. For example, polymorphisms in beta-adrenergic receptors or genes involved in hepatic fibrosis can influence treatment outcomes and thus guide personalised therapeutic decisions. Machine learning models that integrate clinical, biochemical, and imaging data can help predict treatment responses and complications, enabling clinicians to tailor therapies according to individual patient profiles. By leveraging these advanced technologies, more precise and effective treatment strategies can be developed.

Enhancing patient education and support

Finally, improving patient education and support is crucial for optimising outcomes. Educational interventions, including digital health tools, such as mobile apps or telemedicine platforms, could enhance patient adherence to NSBB therapy and manage the expectations of those undergoing TIPS. Multidisciplinary care teams comprising hepatologists, interventional radiologists, nurses, and dietitians should be established to provide comprehensive care to patients with decompensated cirrhosis. Research should assess the impact of these teams on patient outcomes and satisfaction, ensuring that care is both effective and patient-centred.

The comparison between NSBBs and TIPS in the management of portal complications in patients with cirrhosis highlights the distinct benefits and challenges associated with each modality. NSBBs are a cornerstone in reducing portal pressure and preventing variceal bleeding but are often associated with significant cardiovascular and respiratory side effects, exacerbation of HRS, and hepatic encephalopathy. Variability in patient responses and the need for regular monitoring and dose adjustments further complicate their use. Despite their effectiveness, poor patient adherence due to the lifelong nature of the therapy and its side effects remains a significant hurdle. TIPS, while effective in reducing variceal rebleeding and managing refractory ascites, poses challenges, such as a high risk of hepatic encephalopathy, shunt dysfunction, and procedure-related complications. The high cost of the procedure and need for specialised expertise and follow-up care add to the complexity of its management. Patient selection is critical as inappropriate candidates may not benefit optimally and may experience higher complication rates.

CONCLUSION

Future research should focus on refining the patient selection criteria to identify which patients are most likely to benefit from each treatment modality. Advancements in TIPS technology such as the development of better stent materials and more precise imaging techniques are required to reduce complications and improve outcomes. Optimising combination therapies that leverage the strengths of both NSBBs and TIPS could provide superior outcomes compared to either treatment alone. Long-term studies are essential to understand the durability of TIPS and long-term adherence to NSBB therapy and to provide insights into overall survival, quality of life, and healthcare costs. Additionally, the development of personalised treatment plans based on patient characteristics, including genetic factors, disease severity, and comorbidities, could lead to more effective and safer outcomes. Cost-effectiveness analyses should compare the long-term costs and benefits of TIPS versus NSBBs, considering not only medical expenses, but also patient quality of life and productivity. Enhancing patient education and support to improve adherence to NSBB therapy and managing the expectations of those undergoing TIPS are crucial. By addressing these challenges and focusing on personalised and cost-effective care, healthcare providers can optimise the management of pulmonary hypertension complications in patients with cirrhosis. This will lead to improved patient outcomes, reduced complications, and a more efficient use of healthcare resources.