The Role of Transjugular Intrahepatic Portosystemic Shunt (TIPS) in the Management of Portal Hypertension

AASLD PRACTICE GUIDELINES
AASLD Practice Guidelines: The Role of Transjugular Intrahepatic Portosystemic Shunt (TIPS) in the Management of Portal Hypertension
Thomas D. Boyer1 and Ziv J. Haskal2

abrir aquí para acceder al documento NGC AHRQ completo, pdf de 16 páginas:
http://www.aasld.org/practiceguidelines/Documents/Bookmarked%20Practice%20Guidelines/TIPS%20Update%20Nov%202009.pdf

Preamble
These recommendations provide a data-supported approach.
They are based on the following: (1) formal review and analysis of recently published world literature on the topic (Medline search); (2) The American College of
Physicians’ Manual for Assessing Health Practices and Designing Practice Guideline1; (3) policy guidelines, including the American Association for the Study of Liver
Diseases’ Policy Statement on Development and use of Practice Guidelines and the American Gastroenterological Associations’ Policy Statement on the Use of Medical
Practice Guidelines2; and (4) the authors’ years of experience in the care of patients with portal hypertension and use of TIPS in the management of these disorders. These recommendations are fully endorsed by the AASLD and the Society for Interventional Radiology.

Intended for use by physicians, these recommendations suggest preferred approaches to the diagnostic, therapeutic, and preventative aspects of care. They are intended to be flexible, in contrast to standards of care, which are inflexible policies designed to be followed in every case. Specific recommendations are based on relevant published information.

In an attempt to characterize the quality of evidence supporting recommendations, the Practice Guidelines Committee of the American Association for the Study of Liver Diseases requires a grade to be assigned and reported with each recommendation
(Table 1).

Introduction
TIPS has been in use for more than 20 years to treat the complications of portal hypertension and TIPS have been created in thousands of patients with liver disease worldwide.

3–6 Despite the extensive use of TIPS to treat the complications of portal hypertension there initially was a lack of consensus on which patients should receive a TIPS as compared to other forms of therapy. In 1995 a conference sponsored by the National Institutes of Health concluded that TIPS was effective in the acute control and prevention of recurrent bleeding from varices but it was unclear when TIPS should be used as compared to medical and surgical therapy for these complications of portal hypertension. In addition, the efficacy of TIPS to control
refractory ascites or treat the Budd-Chiari syndrome was unclear but promising.7
Since then, more than one thousand patients have been enrolled in multiple controlled
trials comparing TIPS to endoscopic and pharmacologic therapy in the prevention of rebleeding from varices and to large volume paracentesis in the treatment of refractory cirrhotic ascites. Further, about a 1,000 papers have been published on TIPS in the English literature alone. This body of work allows for more definitive recommendations about in whom and when to use TIPS in the treatment of the complications of portal hypertension.

The guidelines are divided into two large categories.
The first category is a review of the technical aspects of the procedure, its complications and the data on which patients are most at risk for an adverse outcome following a TIPS. The second category is a review of the indications for TIPS. The use of TIPS for primary prevention of variceal bleeding and in the control of acute bleeding are discussed first. Next the two indications for TIPS that have been subjected to controlled trials (prevention of recurrent bleeding from varices and refractory ascites) will be discussed and guidelines developed. Lastly, all of the
other indications for TIPS that have been described in the literature but have not been subjected to controlled trials will be discussed and guidelines created.

To prepare these guidelines, a Medline search was performed from 1966 to 2009. A total of 1143 articles were found under the subject heading “transjugular intrahe-...

abrir aquí para acceder al documento NGC AHRQ completo, pdf de 16 páginas:
http://www.aasld.org/practiceguidelines/Documents/Bookmarked%20Practice%20Guidelines/TIPS%20Update%20Nov%202009.pdf