Interventional therapy is an emerging clinical discipline and an important part of minimally invasive medicine. It stands as the third major clinical discipline, distinct from traditional internal medicine and surgery. Interventional therapy allows the treatment of various diseases through tiny channels a few millimeters in diameter created in the skin, using advanced imaging technologies such as DSA, ultrasound, and CT, without the need for large incisions to expose the lesion. Special needles, catheters, drugs, or stents are employed to treat the affected organs and tissues. To provide cutting-edge advancements in interventional hepatology, Hepatology Digest has partnered with Dr. Xuefeng Luo from West China Hospital of Sichuan University to create the "Interventional Therapy in Hepatobiliary Diseases" column. This monthly column aims to share the latest research, convey standardized treatment concepts, and track the latest developments in interventional therapy, with the goal of benefiting experts, researchers, and frontline medical workers in the field.

In this first issue of the “Interventional Therapy in Hepatobiliary Diseases” column, Dr. Xuefeng Luo has selected the French guidelines on Transjugular Intrahepatic Portosystemic Shunt (TIPS) as the opening topic and provided a detailed interpretation. The analysis and recommendations from these guidelines have been organized into two articles, presented in two parts for readers’ reference.

Hepatology Digest: What does the new French guideline recommend for the management of perioperative complications of TIPS, and are these recommendations applicable to Chinese clinical patients?

Dr. Xuefeng Luo: The new French guidelines provide detailed assessments and preventive measures related to perioperative complications of TIPS, particularly concerning cardiac function. The guidelines emphasize that before TIPS treatment, patients must undergo comprehensive cardiac evaluations, including but not limited to checks for valvular disease, heart failure, and potential cirrhosis-associated cardiomyopathy. A previous clinical study in France found that up to 20% of patients were readmitted post-surgery due to cardiac complications, a high rate that has garnered global attention and prompted doctors to focus more on the potential cardiac risks associated with TIPS.

Our team conducted a retrospective analysis of cases from our hospital and found that the incidence of cardiac complications in Chinese patients is relatively lower. However, this does not mean that cardiac evaluations should be overlooked. On the contrary, we must adopt the evaluation methods outlined in the French guidelines, such as basic echocardiograms, electrocardiograms, BNP testing, and right heart catheterization, to fully assess the patient’s cardiac status and identify risk factors for postoperative heart failure, allowing for early intervention and risk mitigation.

Additionally, we need to establish TIPS perioperative cardiac evaluation standards tailored to Chinese patients. We should identify high-risk factors and determine the actual risk of cardiac failure post-TIPS. Although our center’s data shows a lower rate of post-TIPS cardiac failure than the 20% mentioned in the French guidelines, we should reanalyze and present these findings to inform Chinese doctors, helping them better assess and manage the risk of cardiac complications during the perioperative period.

Hepatology Digest: How does the new French guideline guide our clinical practice in terms of procedural flow, from preoperative examination to stent selection? Is this procedural flow entirely applicable to Chinese patients?

Dr. Xuefeng Luo: There are certainly aspects of the procedural flow that we can learn from. In Europe, for example, controlled stents are often used in TIPS procedures, allowing for the gradual expansion of the stent diameter to achieve an individualized pressure setting for patients. In contrast, we have long used fixed-diameter stents in China. However, we are gradually updating our practices by adopting better-controlled stents for creating the shunt. In doing so, we can learn from international standards, such as the initial choice of diameter and the criteria for expansion.

Patients with either bleeding or ascites will have different pressure targets and evaluation time points. We can initially adopt European standards to assess their suitability for our patients. If they prove unsuitable, adjustments can be made; otherwise, we may avoid unnecessary detours by following proven approaches.

However, it is important to note that TIPS procedures in Europe have some local characteristics. European centers tend to perform fewer TIPS procedures compared to the large-scale operations in Chinese hospitals. As a result, they rely more on surface ultrasound guidance for TIPS, a method seldom used in China due to the high volume of TIPS cases and our more extensive experience, which often leads us to prefer imaging evaluations. This is a notable difference between the two regions.

During my involvement in revising the European Association for the Study of the Liver (EASL) TIPS guidelines, I provided feedback on our TIPS practices in China, reflecting a mutual exchange of ideas. I believe regional guidelines should incorporate global awareness, where learning and adaptation happen in both directions.

Hepatology Digest: Children are a unique medical population. What preoperative assessments are necessary for children requiring TIPS? What should be noted during and after the procedure? How should we select and adjust the new guideline’s recommendations for Chinese pediatric patients?

Dr. Xuefeng Luo: To be frank, this is a difficult question to answer because data and experience regarding pediatric TIPS, both domestically and internationally, are relatively scarce. Globally, children needing TIPS due to complications from portal hypertension are rare. Therefore, neither the French guidelines nor the domestic consensus provides clear, strong recommendations in this area, and decisions are often made on a case-by-case basis.

From a technical standpoint, TIPS is feasible for pediatric patients, and we have had successful cases in our center. However, due to the rarity of these cases, more data is needed to support assessments, management, and treatment decisions for these patients. I hope that in the future, platforms like International Hepatology will help collect more cases in China. Even if each center has only a few cases, nationwide data aggregation could provide us with valuable insights.

This is one of the unresolved issues in the French guidelines, as they do not offer strong, high-level recommendations. As such, we need to gather more Chinese data, conduct retrospective and prospective studies, and delve deeper into evaluating, managing, and selecting pediatric patients for TIPS intervention.

Hepatology Digest: What references does the new French guideline provide for drafting TIPS guidelines in China?

Dr. Xuefeng Luo: I have participated in the drafting of relevant guidelines and consensus documents in Europe, the U.S., and Asia, including the Baveno consensus on portal hypertension and the EASL TIPS guidelines. Among the guidelines I have encountered, the multidisciplinary collaboration seen in the North American and French TIPS guidelines is particularly noteworthy.

Both of these guidelines stand out for their broad and deep multidisciplinary collaboration. They incorporate input not only from hepatologists and gastroenterologists but also from interventional radiologists, surgeons, and other specialists. Additionally, these guidelines excel in data management, providing a level of detail not often seen in guidelines crafted by single-discipline physicians.

I encourage our doctors to adopt an open-minded, inclusive approach and actively invite physicians from various specialties to participate in the development of guidelines, rather than limiting discussions within the confines of a single discipline. By bringing together the knowledge and experience of doctors from multiple disciplines, we can create more comprehensive, patient-centered, and disease-centered guidelines that are scientifically robust and effective.

French TIPS Guidelines

2024 French Guidelines: Indications and Modalities for Transjugular Intrahepatic Portosystemic Shunt (TIPS) Larrue H, Allaire M, Weil‐Verhoeven D, et al. French guidelines on TIPS: Indications and modalities. Liver International. Published online May 17, 2024. doi:10.1111/liv.15976

Section 8: Pre-Surgical TIPS

• R2.1: TIPS may be considered in cirrhotic patients requiring non-hepatic abdominal surgery to improve postoperative outcomes, especially for patients in the decompensated phase of cirrhosis (Expert opinion, strong agreement).
• R2.2: TIPS is not routinely recommended in compensated cirrhotic patients, even if they have severe portal hypertension (Expert opinion, strong agreement).
• R2.3: TIPS is not routinely recommended before cardiothoracic surgery, liver resection, endoscopic resection, or endoscopic retrograde cholangiopancreatography (ERCP), regardless of whether portal hypertension is related to cirrhosis or PSVD (Expert opinion, strong agreement).

Section 9: Clinical Follow-Up of Patients After TIPS

Given the lack of effective research data in this field, all guidelines in this chapter are based on expert consensus.

• 9R1: Outpatient TIPS is not recommended.
• 9R2: Clinical efficacy assessment is based on the effectiveness of treating and preventing complications related to portal hypertension.
• 9R3: Follow-up evaluations should be conducted every 3 months before discharge, 1 month after surgery, and every 3 months within the first year, with a focus on hepatic and cardiac decompensation.
• 9R4: Liver function should be assessed before discharge, 1 month after surgery, and every 3 months within the first year.
• 9R5: Systematic evaluation for hepatic encephalopathy should be conducted at each follow-up.
• 9R6: Renal function (creatinine clearance) should be assessed before discharge, 1 month after surgery, and every 3 months within the first year.
• 9R7.1: Endoscopic screening for esophageal varices is not recommended if the post-TIPS portal pressure gradient (PPG) is below 12 mmHg and there are no complications related to portal hypertension (e.g., bleeding, ascites).
• 9R7.2: If the post-TIPS PPG is below 12 mmHg, discontinuation of non-selective beta-blockers (NSBB) is recommended.
• 9R7.3: NSBB can be used in cases of uncorrectable TIPS failure.
• 9R7.4: Prophylactic use of furosemide can be considered to reduce the risk of cardiac decompensation after TIPS in high-risk patients.
• 9R7.5: Anticoagulant or antiplatelet therapy is not recommended for preventing TIPS failure (except in cases of vascular liver diseases, etc.).

Section 10: Technical Aspects Related to TIPS Procedure

• 10R1.1.1: Before creating the shunt, hepatic venous wedge pressure, free pressure, inferior vena cava pressure, and right atrial pressure should be measured. The hepatic venous pressure gradient (HVPG) is calculated by subtracting the free pressure from the wedge pressure (G1+, strong agreement).
• 10R1.1.2: After creating the shunt, the PPG (portal vein pressure minus inferior vena cava pressure) should be measured to guide subsequent procedures (G1+, strong agreement).
• 10R1.1.3: The post-procedure PPG (portal vein pressure minus inferior vena cava pressure) should be measured at the end of the procedure (G1+, strong agreement).
• 10R1.2: If there are any doubts about the accuracy of pressure measurements before the end of the procedure, the PPG should be verified as early as possible (Expert opinion, strong agreement).
• 10R2: Real-time ultrasound or CT fusion guidance is recommended for portal vein puncture (G2+, strong agreement).
• 10R3.1.1: Polytetrafluoroethylene (PTFE) covered stents are recommended (G1+, strong agreement).
• 10R3.1.2: The stent should initially be dilated to 8 mm and then gradually expanded based on the target PPG, patient comorbidities, and TIPS indications, if necessary, to 10 mm (G1+, strong agreement).
• 10R3.2: The stent should cover the hepatic vein-inferior vena cava junction (G2+, strong agreement).
• 10R3.3: The distal end of the stent should be positioned at the lower or upper end of the portal vein confluence to avoid increasing the difficulty of future liver transplantation (G2+, strong agreement).
• 10R4.1.1: Stent dilation should be based on hemodynamic results (G1+, strong agreement).
• 10R4.1.2: Preoperative discussions among the expert team on hemodynamic targets are recommended (Expert opinion, strong agreement).
• 10R4.2.1: For patients with portal hypertension-related bleeding, the final PPG should be less than 12 mmHg (G1+, strong agreement).
• 10R4.2.2: For patients with ascites, the final PPG should also be less than 12 mmHg (G2+, strong agreement).
• 10R5.1: Routine variceal embolization is not recommended after TIPS (G1−, strong agreement).
• 10R5.2: Variceal embolization can be considered for refractory bleeding, such as varices that continue to fill after TIPS (G2+, strong agreement).

Section 11: Shunt Follow-Up

Given the lack of effective research data in this field, all guidelines in this chapter are based on expert consensus.

• 11R1.1: Ultrasound re-examination on the second day after surgery is not recommended. It is recommended that patients undergo ultrasound every 6 months after the shunt procedure and upon recurrence of portal hypertension complications to evaluate the shunt and screen for liver cancer.
• 11R1.2: Routine venography and PPG measurement are not recommended. Venography and PPG measurement should be performed when shunt failure is suspected, based on the clinical context and initial TIPS indications.
• 11R2.1: In routine follow-up, if shunt failure is suspected or complications of portal hypertension persist or recur, shunt recanalization is recommended. After recanalization, the benefit/risk ratio should be reassessed, as in the initial shunt procedure. Gradual stent dilation is recommended, and a new covered stent can be implanted in the uncovered portion (portal vein or hepatic vein side).
• 11R2.2: When the maximum stent expansion does not achieve the target hemodynamics, further treatment depends on the specific case analysis (related treatment, liver transplantation, second shunt, etc.).
• 11R3: For patients with early severe liver failure, hepatic encephalopathy, or heart failure that is resistant to medical treatment, shunt reduction is recommended. However, specific shunt reduction techniques cannot be recommended at this time.

Section 12: TIPS and Hepatic Encephalopathy

• 12R1: Prophylactic use of rifaximin (550 mg, twice daily) is recommended 2 weeks before elective TIPS to reduce the risk of post-operative overt hepatic encephalopathy (G2+, strong agreement).
• 12R2.1: Patients who develop overt hepatic encephalopathy after TIPS should be treated with rifaximin and lactulose (Expert opinion, strong agreement).
• 12R2.2: For refractory overt hepatic encephalopathy after TIPS that does not respond to medication (lactulose and rifaximin), reduction rather than closure of the shunt should be considered, with simultaneous evaluation for liver transplantation (Expert opinion, strong agreement).

Section 13: TIPS and Liver Transplantation

• 13R1: To prevent recurrence of portal hypertension after liver transplantation, a comprehensive evaluation should be performed (including at least abdominal CT, cardiovascular examination, hemodynamic monitoring, and liver biopsy) (Expert opinion, strong agreement).
• 13R2: Post-transplant TIPS is feasible and should be decided through multidisciplinary discussions among hepatologists, radiologists, and surgeons on whether to perform TIPS or liver retransplantation (Expert opinion, strong agreement).

Section 14: TIPS in Children

• 14R1: To date, TIPS is not indicated in cirrhotic patients without complications of portal hypertension.
• 14R2: TIPS should be considered in pediatric patients with failed banding combined with NSBB or refractory bleeding, or refractory ascites (Expert opinion).
• 14R3: TIPS should be performed by specialists, and the procedure and equipment should be adapted to the specific child (Expert opinion).

Section 15: TIPS and Nutritional Support

• 15R1: Malnutrition, sarcopenia, and frailty are associated with increased comorbidities and mortality in cirrhotic patients undergoing TIPS. An evaluation for malnutrition/sarcopenia and frailty should be conducted before TIPS (G1+, strong agreement).
• 15R2: During the waiting period for TIPS, dietary management with the help of a nutritionist is recommended to alleviate malnutrition, meet the patient’s energy needs, and avoid fasting, especially overnight fasting (Expert opinion, strong agreement).
• 15R3: Nutritional status (weight change, grip strength, and frailty assessment) should be evaluated at each follow-up after TIPS (Expert opinion, strong agreement).

Section 16: TIPS and Hepatocellular Carcinoma (HCC)

• 16R1: There are no specific technical issues with TIPS in HCC patients, except to avoid placing the shunt through the tumor when curative treatment is anticipated (Expert opinion, strong agreement).
• 16R2: TIPS is not a contraindication for percutaneous radiofrequency ablation in HCC patients (Expert opinion, strong agreement).
• 16R3: TACE is not recommended after TIPS, except for patients awaiting liver transplantation (Expert opinion, strong agreement).
• 16R4: TARE is feasible in patients after TIPS, as the risk of liver damage is lower than with TACE.
• 16R5: HCC patients after TIPS can receive systemic tumor therapy. The indications and precautions are the same as for patients without TIPS (Expert opinion, strong agreement).
• 16R6: TIPS can be a treatment option for patients with tense ascites, aiming for curative treatment (e.g., percutaneous radiofrequency ablation) (Expert opinion, strong agreement).
• 16R7: TIPS can be a treatment option for HCC patients with refractory ascites or those meeting the criteria for priority TIPS (Expert opinion, strong agreement).