Review article: update on the role of transjugular intrahepatic portosystemic stent-shunt (TIPSS) in the management of complications of portal hypertension.

In the 8 years since its introduction into clinical practice, initial enthusiasm for the transjugular intrahepatic portosystemic stent-shunt (TIPSS) has been tempered by a more critical appraisal of its role in the management of portal hypertension. TIPSS has established its role as a rescue procedure for variceal haemorrhage uncontrolled by endoscopic means and as a treatment for ectopic or recurrent variceal bleeding. Randomized trials comparing TIPSS with endoscopic methods in the secondary prophylaxis of oesophageal variceal haemorrhage have shown reduced rebleeding after TIPSS but no effect on survival. Its exact role in this situation awaits further assessment, including quality of life and cost analyses, and consideration of the current limited availability of the technique. Experience of TIPSS in patients with refractory ascites or hepatorenal syndrome has been disappointing. Little data currently exist, but results of further randomized studies comparing TIPSS with paracentesis for refractory ascites are awaited. Ideally these should be multicentre studies, and should include quality of life data for this poor prognostic group. Development of shunt insufficiency remains a major problem and occurs in approximately 50% patients at 1 year. The need for continued shunt surveillance by Doppler sonography and direct portography is the major limitation of TIPSS, but hopefully the development of covered stents will address this problem.