Role of Interventional Radiology (IR) in vascular emergencies among cirrhotic patients.

Gastrointestinal hemorrhage remains one of the most common causes of morbidity and mortality among patients with liver cirrhosis. Mostly, these patients bleed from the gastroesophageal varices. However, nonvariceal bleeding is also more likely to occur in these patients. Because of frequent co-existing coagulopathy, cirrhotics are more prone to bleed from a minor vascular injury while performing percutaneous interventions. Ultrasound-guided bedside vascular access is an essential procedure in liver critical care units. Transjugular portosystemic shunts (TIPS) with/without variceal embolization is a life-saving measure in patients with refractory variceal bleeding. Whenever feasible, balloon-assisted retrograde transvenous obliteration (BRTO) is an alternative to TIPS in managing gastric variceal bleeding, but without a risk of hepatic encephalopathy. In cases of failed or unfeasible endotherapy, transarterial embolization using various embolic agents remains the cornerstone therapy in patients with nonvariceal bleeding such as ruptured hepatocellular carcinoma, gastroduodenal ulcer bleeding, and procedure-related hemorrhagic complications. Among various embolic agents, N-butyl cyanoacrylate (NBCA) enables better vascular occlusion in cirrhotics, even in coagulopathy, making it a more suitable embolic agent in an expert hand. This article briefly entails the different interventional radiological procedures in vascular emergencies among patients with liver cirrhosis.

Transjugular Intrahepatic Portosystemic Shunt Creation in Children Weighing <10 kg Using an Unconventional Technique.

Transjugular intrahepatic portosystemic shunt (TIPS) creation is a standard therapeutic procedure for the management of complications of portal hypertension. However, in small children, this procedure is infrequently performed because of technical difficulties owing to their small size and scarce information on outcomes. This article presents the results of treatment of variceal bleeding with TIPS creation in 8 children weighing <10 kg, along with the description of the unconventional techniques and materials required. Technical and clinical success rates were 100%. Although this was a small cohort of patients, the results obtained suggest that this is a safe and technically and clinically effective treatment option for complications of portal hypertension in this age group.

TIPS: indications, Contraindications, and Evaluation.

PURPOSE OF REVIEW: This review summarizes the current and emerging indications, contraindications, and evaluation for TIPS. In the last three decades of use, there have been substantial changes and progress in this field, including the use of controlled-expansion, covered stents, which has broadened the clinical uses of TIPS. RECENT FINDINGS: Recent findings have rapidly expanded the indications for TIPS, including emerging uses in hepatorenal syndrome, hepatopulmonary syndrome and before abdominal surgery. The widespread use of controlled-expansion, covered stents has decreased rates of post-TIPS hepatic encephalopathy, opening TIPS to a larger patient population. Overall, with newer stent technology and more research in this area, the clinical utility and potential of TIPS has rapidly expanded. Going forward, a renewed focus on randomized-control trials and long-term outcomes will be a crucial element to selecting appropriate TIPS recipients and recommending emerging indications for this procedure.

Large left varicocele in a patient with portal hypertension treated via transjugular intrahepatic portosystemic shunt placement and both variceal and varicocele embolization.

BACKGROUND: Scrotal swelling from varicocele is a common complaint in adult men. Varicocele due to portosystemic collaterals is a rare presentation of portal hypertension. Imaging workup and intervention for varicocele in this case is more complex than varicocele due to absent or incompetent valves in the testicular veins and pampiniform plexus. CASE PRESENTATION: We present the case of a 53-year-old man with alcohol-related cirrhosis presented with persistent left scrotal heaviness, pain, and swelling found to have a large left varicocele. Given his history of cirrhosis, a contrast-enhanced CT of the abdomen and pelvis was obtained showing that the varices were supplied by a vessel arising from the splenic vein and draining into the left renal vein as well as gastric varices. Varicocele embolization alone is not sufficient in this case, and we treated with transjugular intrahepatic portosystemic shunt, variceal and varicocele embolization. CONCLUSION: In patients presenting with a varicocele with a history of cirrhosis/portal hypertension, cross sectional imaging of the abdomen and pelvis should be obtained prior to treatment to evaluate for the presence of varices which may be pressured by varicocele embolization. If present, consideration should be given to referral to an interventional radiologist for possible concurrent variceal embolization and TIPS placement.

Outcomes of Transjugular Intrahepatic Portosystemic Shunt and Gastric Coronary Vein Embolization for Variceal Bleeding in Cirrhotic Portal Hypertension.

Purpose: To evaluate the efficacy and safety of transjugular intrahepatic portosystemic shunt (TIPS) combined with gastric coronary vein embolization (GCVE) for cirrhotic portal hypertensive variceal bleeding and compare outcomes of first-line with second-line treatment, coil with glue, and single-covered with double stents.Methods: Fifteen patients received TIPS plus GCVE as the first-line treatment for secondary prophylaxis of variceal bleeding, and 45 received it as second-line treatment. Preoperative and postoperative quantitative variables were compared using a paired t test. The incidence of survival rate, re-bleeding, hepatic encephalopathy, and shunt dysfunction were analyzed using the Kaplan-Meier method.Results: The portal venous pressure was significantly decreased from 39.0 ± 5.0 mm Hg to 22.5 ± 4.4 mm Hg (P≤0.001) after TIPS treatment. After 1, 3, 6, 12, 18, and 24 months re-bleeding rates were 1.6%, 3.3%, 6.6%, 13.3%, 0%, and 0%, respectively. Shunt dysfunction rates were 5%, 0%, 10%, 16.6%, 1.6%, and 5%, respectively. Hepatic encephalopathy rates were 3.3%, 1.6%, 3.3%, 6.6%, 0%, and 0%, respectively. And survival rates were 100%, 100%, 100%, 96.6%, 93.3%, and 88.3% respectively. In comparative analysis, statistically significant differences were seen in re-bleeding between the first-line and second-line treatment groups (26.6% vs 24.4%, log-rank P=0.012), and survival rates between single-covered and double stent (3.7% vs 16.1%, log-rang (P=0.043).Conclusion: The results suggest that TIPS combined with GCVE is effective and safer in the treatment of cirrhotic portal hypertensive variceal bleeding. The use of TIP plus GCVE as first-line treatment, may be preferable for high-risk re-bleeding, and more than 25 mm Hg portal venous pressure with repeated variceal bleeding. However, the sample size was small. Therefore, large, randomized, controlled, multidisciplinary center studies are needed for further evaluation.

Innovation in direct intrahepatic portosystemic shunt; a developing country experience.

Anticoagulants are the first-line treatment option for patients with Budd-Chiari syndrome (BCS); however, intervention is required when this fails. Although, the ultimate treatment is liver transplant, other radiological procedures are for the management of the disease and bridge to definitive therapy. TIPS (trans jugular intrahepatic portosystemic shunt) is a method used by interventional radiologists to create a shunt between portal vein and hepatic vein. At times it is technically not possible, in such cases, direct intrahepatic portosystemic shunt (DIPS) is performed. This patient underwent a successful DIPS procedure for BCS along with balloon dilatation (venoplasty) for inferior vena cava (IVC) stenosis.

[An excerpt from the 2023 AASLD practice guidelines: TIPS, variceal embolization, and retrograde transvenous embolization for the treatment of variceal hemorrhage].

This is the American Association for the Study of Liver Diseases (AASLD) comprehensive guideline on the application of endovascular interventional radiological procedures in the treatment of variceal bleeding, which supplements Risk Stratification and Management of Portal Hypertensive Bleeding in Cirrhosis by describing recent advances in invasive surgery. Transjugular intrahepatic portosystemic shunt (TIPS) dates back to the 80s of the 20th century, and over the past few years, several new technical improvements have been made to TIPS stents. Another major treatment for gastric variceal bleeding in North America is the use of different forms of retrograde transvenous embolization. This guideline is intended to provide healthcare professionals with an in-depth understanding of the use of TIPS and/or variceal embolization/occlusion in the treatment of variceal bleeding, with the goal of facilitating multidisciplinary discussions on treatment strategies among hepatologists, gastroenterologists, interventional radiologists, and surgeons. Additionally, it provides a data-based approach to the endovascular treatment of variceal bleeding. However, it differs from the AASLD guidelines by being supported by a systematic review of the literature, a formal rating of the quality of the evidence, and the strength of the recommendations. Consequently, this guideline was developed by a consensus of an expert panel under the supervision of the AASLD Practice Guidelines Committee and provides guidance statements based on a comprehensive review and analysis of the literature on the relevant topic. Importantly, the AASLD Practice Guidelines Committee selected this topic because, for the most part, there are not a sufficient number of randomized controlled trials on this topic to provide meaningful systematic reviews and meta-analyses.

Intravascular Ultrasound Guidance for TIPS Procedures: A Review.

The most challenging and time-consuming step of TIPS procedures is obtaining appropriate portal vein (PV) access. Given the lack of real-time direct target visualization, conventional fluoroscopic guidance requires multiple passes, contributing to complications. In comparison, intravascular ultrasound (IVUS) guidance during TIPS procedures provides direct visualization of hepatic structures and real-time guidance for PV puncture. IVUS guidance during TIPS creation improves procedural metrics such as radiation dose, contrast agent volume, procedure time, and technical success rate and is particularly beneficial in technically challenging cases (e.g., in patients portal vein thrombosis, small or variant portal vein anatomy, Budd-Chiari syndrome, or liver masses). The purpose of this review is to summarize current IVUS technology, describe the technical aspects of IVUS-guided TIPS creation, and discuss the clinical indications for and benefits of using IVUS for TIPS creation, while presenting available evidence supporting the technique's use. Given the improved safety profile and overall success rate in comparison with conventional guidance methods, IVUS guidance has the future potential to become the standard practice for TIPS placement.

Subjective Difficulty Scale in Liver Transplantation: A Prospective Observational Study.

The predictive value of a subjective difficulty scale (DS) after surgical procedures is unknown. The objective of this study was to evaluate the prognostic value of a DS after liver transplantation (LT) and to identify predictors of difficulty. Surgeons prospectively evaluated the difficulty of 441 consecutive liver transplantations from donation after brain death at the end of the surgery by using a DS from 0 to 10 ("the easiest to the hardest you can imagine"). DS was associated with severe morbidity. The risk of graft loss at 1 year remained unchanged from 0 to 6 but increased beyond 6. Graft survival and patient survival of group with DS 7-10 was significantly impaired compared to groups with DS: 0-3 or DS: 4-6 but were significantly impaired for the group with DS: 7-10. Independent predictors of difficult LT (DS ≥ 7) were annular segment 1, transjugular intrahepatic portosystemic shunt, retransplantation beyond 30 days, portal vein thrombosis, and ascites. Of them, ascites was a borderline non-significant covariate (p = .04). Vascular complications occurred more often after difficult LT (20.5% vs. 5.9%), whereas there was no difference in the other types of complications. DS can be used to tailor monitoring and anticipate early complications. External validation is needed.

[Emphasis on the prevention and treatment of hepatic vascular diseases].

Portal hypertension, as a common and complex hepatic vascular disease, is a key pathophysiological link in many events of acute cirrhosis decompensation and the progression of multiple organ failure. The most effective measure to reduce portal hypertension is a transjugular intrahepatic portosystemic shunt (TIPS). Maintaining liver function, reducing complications, and improving patients' quality of life and survival time are positively impacted by early TIPS insertion. Patients with cirrhosis have a risk of portal vein thrombosis (PVT) that is 1 000 times higher than that of the normal population. Hepatic sinusoidal obstruction syndrome has a severe clinical course and a high mortality risk. The primary treatment approaches for PVT and HSOS are anticoagulation and TIPS. The innovative magnetic anastomosis vascular technique significantly shortens the anhepatic time and restores normal liver function in patients following liver transplantation.

Precision medicine in variceal bleeding: Are we there yet?

Variceal bleeding is one of the most feared complications of portal hypertension in patients with cirrhosis because of its deleterious impact on prognosis. Adequate management of patients at risk of developing variceal bleeding includes the prevention of the first episode of variceal bleeding and rebleeding, and is crucial in modifying prognosis. The presence of clinically significant portal hypertension is the main factor determining the risk of development of varices and other liver-related decompensations; therefore, it should be carefully screened for and monitored. Treating patients with clinically significant portal hypertension based on their individual risk of portal hypertension-related bleeding undoubtedly improves prognosis. The evaluation of liver haemodynamics and liver function can stratify patients according to their risk of bleeding and are no question useful tools to guide therapy in an individualised manner. That said, recent data support the idea that tailoring therapy to patient characteristics may effectively impact on prognosis and increase survival in all clinical scenarios. This review will focus on evaluating the available evidence supporting the use of individual risk characteristics for clinical decision-making and their impact on clinical outcome and survival. In primary prophylaxis, identification and treatment of patients with clinically significant portal hypertension improves decompensation-free survival. In the setting of acute variceal bleeding, the risk of failure and rebleeding can be easily predicted, allowing for early escalation of treatment (i.e. pre-emptive transjugular intrahepatic portosystemic shunt) which can improve survival in appropriate candidates. Stratifying the risk of recurrent variceal bleeding based on liver function and haemodynamic response to non-selective beta-blockers allows for tailored treatment, thereby increasing survival and avoiding adverse events.

[Gastroesophageal variceal bleeding in cirrhotic patients: the possibilities of effective hemostasis]. / Varikoznye pishchevodno-zheludochnye krovotecheniia pri tsirroze pecheni: vozmozhnosti éffektivnogo gemostaza.

AIM: To improve the results of treatment of gastroesophageal variceal bleeding (GEVB) in cirrhotic patients with thrombocytopenia. MATERIAL AND METHODS: A total experience of the clinic includes 338 GEVB patients, endoscopic variceal ligation (EVL) and transjugular intrahepatic portosystemic shunt (TIPS) were performed in 162 and 157 cases respectively. Nevertheless, just the efficacy of initial pharmacological hemostatic therapy was analyzed. RESULTS: Administration of serotonin adipinate 30-50 mg/day during 3-5 days in addition to standard initial therapy allowed us to achieve permanent hemostasis during initial treatment if EVL was impossible. Serotonin adipinate induces thrombocytes' adhesion and improves fibrin clot strength. This therapy markedly decreases mortality (33.3% vs 46.7%), incidence of recurrent bleeding (46.4% vs 60.0%). Also it contributes successful hemostasis with endoscopic ligation and effective portal decompression by TIPS procedure.

Eight millimetre covered TIPS does not compromise shunt function but reduces hepatic encephalopathy in preventing variceal rebleeding.

BACKGROUND & AIMS: Currently, there are no recommendations in guidelines concerning the preferred diameter of stents for transjugular intrahepatic portosystemic shunt (TIPS), owing to the lack of adequate evidence. We therefore compared 8mm stents with 10mm stents, to evaluate whether 8mm stents would achieve similar shunt function, with less hepatic encephalopathy (HE) and better liver function. METHODS: Cirrhotic patients were randomly assigned to receive TIPS with an 8mm or 10mm covered stent to prevent variceal rebleeding. The primary endpoint was shunt dysfunction. All-cause rebleeding, orthotopic liver transplantation (OLT)-free survival, their composite endpoint, overt HE (overall and spontaneous) and liver function were designated as the secondary endpoints. RESULTS: From July 2012 to January 2014, 64 and 63 patients were allocated to the 8mm and 10mm groups, respectively. During a median follow-up of 27months in both arms, dysfunction rates (16% vs. 16% at two years, p=0.62), two-year rebleeding (16% vs. 17%, p=0.65), OLT-free survival (95% vs. 86%, p=0.37), and the composite endpoint (p=0.62) were not statistically different between the groups. Despite a marginal decrease in overall overt HE, there were significantly fewer spontaneous overt HE incidents in the 8mm group within two years (27% vs. 43%, p=0.03), with a risk reduction of 47%. Notably, patients receiving 8mm stents also developed less hepatic impairment. CONCLUSIONS: TIPS with 8mm covered stents showed similar shunt function to TIPS with 10mm stents, but halved the risk of spontaneous overt HE and reduced hepatic impairment. Therefore, 8mm TIPS stents should be preferred for the prevention of variceal rebleeding in cirrhotic patients. Lay summary: The optimal diameter for transjugular intrahepatic portosystemic shunt (TIPS) remained uncertain. This study showed that TIPS with 8mm covered stents did not compromise shunt patency, or influence the efficacy of variceal rebleeding prevention compared to TIPS with 10mm stents, but reduced the risk of spontaneous overt hepatic encephalopathy and the incidence of severe encephalopathy. Moreover, liver function reserve was also better in the 8mm stents group, suggesting that 8mm TIPS stents should be preferred for the prevention of variceal rebleeding in cirrhotic patients.

Advances and challenges in cirrhosis and portal hypertension.

BACKGROUND: Liver cirrhosis is the fourth cause of death in adults in Western countries, with complications of portal hypertension being responsible for most casualties. In order to reduce mortality, development of accurate diagnostic methods for early diagnosis, effective etiologic treatment, improved pharmacological therapy for portal hypertension, and effective therapies for end-stage liver failure are required. DISCUSSION: Early detection of cirrhosis and portal hypertension is now possible using simple non-invasive methods, leading to the advancement of individualized risk stratification in clinical practice. Despite previous assumptions, cirrhosis can regress if its etiologic cause is effectively removed. Nevertheless, while this is now possible for cirrhosis caused by chronic hepatitis C, the incidence of cirrhosis due to non-alcoholic steatohepatitis has increased dramatically and effective therapies are not yet available. New drugs acting on the dynamic component of hepatic vascular resistance are being studied and will likely improve the future management of portal hypertension. CONCLUSION: Cirrhosis is now seen as a dynamic disease able to progress and regress between the compensated and decompensated stages. This opinion article aims to provide the author's personal view of the current major advances and challenges in this field.

[Transjugular intrahepatic portosystemic shunt for esophagogastric variceal bleeding in liver cirrhosis: intended population and timing].

Esophagogastric variceal bleeding is a life-threatening complication of cirrhotic portal hypertension. Transjugular intrahepatic portosystemic shunt (TIPS) is an effective method for the treatment and prevention of esophagogastric variceal bleeding; however, right timing of TIPS and selection of appropriate candidates for TIPS are of vital importance in improving patients' survival rate and reducing mortality rate. This article reviews the intended population and right timing of TIPS for the treatment and prevention of esophagogastric variceal bleeding in liver cirrhosis.

Current diagnosis and management of post-transjugular intrahepatic portosystemic shunt refractory hepatic encephalopathy.

Transjugular intrahepatic portosystemic shunt has evolved into an important option for management of complications of portal hypertension. The use of polytetrafluoroethylene covered stents enhances shunt patency. Hepatic encephalopathy (HE) remains a significant problem after TIPS placement. The approach to management of patients with refractory hepatic encephalopathy typically requires collaboration between different specialties. Patient selection for TIPS requires careful evaluation of risk factors for HE. TIPS procedure-related technical factors like stent size, attention to portosystemic pressure gradient reduction and use of adjunctive variceal embolization maybe important. Conservative medical therapy in combination with endovascular therapies often results in resolution or substantial reduction of symptoms. Liver transplantation is, however, the ultimate treatment.

Role of Transjugular Intrahepatic Portosystemic Shunts in the Management of Hepatopulmonary Syndrome: A Systemic Literature Review.

PURPOSE: To evaluate the role of transjugular intrahepatic portosystemic shunt (TIPS) creation in the management of hepatopulmonary syndrome (HPS). MATERIALS AND METHODS: A MEDLINE (PubMed) search from January 1990 to April 2015 was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. The search was restricted to the English language and human subjects. Inclusion criteria were patients with HPS who underwent TIPS creation for any indication. Exclusion criteria was age < 18 years. RESULTS: Ten studies consisting of 12 patients with HPS were included. Eight patients had very severe HPS, 2 had severe HPS, and 2 had moderate HPS. Transjugular intrahepatic portosystemic shunt creation was technically successful in all patients, without complications. Mean portosystemic pressure gradients before and after the procedure were 18.2 mm Hg (range, 10-30 mm Hg) and 6.5 mm Hg (range, 3-15 mm Hg), respectively. The mean duration of follow-up was 9.3 months (range, 0.75-36 mo). Improvement in oxygenation occurred in 9 patients but was not sustained after 4 months in 2 patients. In the remaining 3 patients, oxygenation remained unchanged; it worsened after 4 months in 1 patient. Four patients underwent liver transplantation. Two patients died of multiple organ dysfunction syndrome and 1 died of sepsis. The remaining patients were alive and well at the time of last follow-up. CONCLUSIONS: Transjugular intrahepatic portosystemic shunt creation shows promise in the management of HPS. Future prospective studies are warranted.

Management of refractory hepatic hydrothorax.

PURPOSE OF REVIEW: Treatment of hepatic hydrothorax is challenging because of its rapid symptomatic recurrence. This review will focus on potential therapeutic approaches to hepatic hydrothorax. RECENT FINDINGS: Hepatic hydrothorax is refractory to salt restriction and diuretics in approximately 25% of cases. Primary management options for these patients include serial thoracenteses, transjugular intrahepatic portosystemic shunt (TIPS) placement, and insertion of an indwelling pleural catheter (IPC). Response rate to TIPS, being the first choice whenever possible, is about 80%. IPC is emerging as a feasible alternative in patients who require frequent therapeutic thoracenteses, particularly if TIPS is contraindicated. Pleurodesis is not advocated because of the low likelihood of a pleural symphysis owing to the rapid re-accumulation of pleural fluid. The only cure for hepatic hydrothorax, a defined complication of end-stage liver disease, is liver transplantation. SUMMARY: No single treatment option for refractory hepatic hydrothorax is ideal. However, in patients with contraindications to or who are awaiting liver transplantation, TIPS seems the most beneficial therapy, whereas IPC promises to be an alternative second-line consideration.

A streamlined controlled-expansion covered tapered stent for TIPS in the treatment of PHT.

Transjugular intrahepatic portosystemic shunt (TIPS) relieves cirrhotic complications by reducing portacaval pressure gradient (PCG), but it lacks precision in achieving a targeted post-TIPS PCG simply through diameter adjustment of equal diameter stents. This study aimed to present a controlled-expansion, streamlined, and covered tapered stent, and examined its effects on pressure reduction compared with equal- diameter stents. Twenty-four patients who underwent standardized 8-mm stent TIPS implantation at West China Hospital from December 2017 to February 2021 were included in the current study. Virtual equal-diameter stent graft with different diameter and streamlined tapered stents were created in the post-TIPS 3-dimentional models reconstructed based on computed tomography angiography data. The numerical simulation showed that only two patients achieved targeted post-TIPS PCG consistent with the clinical invasive measurement. When 6-mm and 10-mm equal-diameter stents were employed, simulated post-TIPS PCGs for most patients remained outside the safe range, and recirculating flow was observed at the stent-portal vein anastomosis. In contrast, the use of the new streamlined taper stent resulted in post-TIPS PCGs within the 10-12 mmHg range for 17 out of 24 patients, with no recirculating flow observed at the anastomotic sites. In conclusion, the streamlined tapered stent could pose an effective solution to the problem that the big jump depressurization between two different equal-diameter stents and it would improve the hemodynamics in the region near the PV-stent anchorage. Therefore, the streamlined tapered stent may present a superior alternative for TIPS procedure.

TEN-YEAR OUTCOMES OF TIPS FOR BUDD-CHIARI SYNDROME: SYSTEMATIC REVIEW AND META-ANALYSIS.

BACKGROUND: Budd-Chiari syndrome (BCS) results from the obstruction of the hepatic venous flow, usually at the level of the hepatic vein or inferior vena cava. When left untreated, it can progress with several complications, including liver cirrhosis. Transjugular intrahepatic portosystemic shunt (TIPS) appears to be effective in a subgroup of BCS patients. OBJECTIVE: To perform a systematic review and meta-analysis of TIPS effectiveness in BCS treatment, considering the survival rate, reduction in portosystemic pressure, need for liver transplantation, technical failure, and shunt dysfunction for up to 10 years of follow-up. METHODS: We evaluated 17 studies published in PubMed, Science Direct, Web of Science, and SCOPUS databases, which used TIPS as a treatment for BCS, comprising 618 subjects between 18 and 78 years old. We assessed the bias risk by the NOS, NHI, and JBI scales for cohort stu-dies, before-after studies, and case series, respectively. We conducted the meta-analyses by extracting the number of events and the total patients evaluated to perform the proportion meta-analyses using the R software ("meta" package - version 4.9-6). RESULTS: The pooled results (95%CI) showed a 19% (25.9-12.5%) rate of portosystemic pressure reduction, 6% (1-12%) rate for the need for liver transplants despite the use of TIPS, 2% (1-6%) technical failure rate, 30% (18-46%) shunt dysfunction rate, and 88% (81-93%) for the mean frequency of patients alive between 1 and 10 years after the procedure. We stratified survival rate and found an 86% (74-93%) prevalence of living subjects during less than five years, 92% (83-97%) at five years, and a 77% frequency (68-83%) of patients alive ten years after the TIPS placement. CONCLUSION: TIPS is an effective treatment for BCS, providing a high 10-year frequency of living patients and a significant decrease in portosystemic pressure. The need for liver transplants after TIPS and the technical failure rate is low.