North American Practice-Based Recommendations for Transjugular Intrahepatic Portosystemic Shunts in Portal Hypertension

Complications of portal hypertension, including ascites, gastrointestinal bleeding, hepatic hydrothorax, and hepatic encephalopathy, are associated with significant morbidity and mortality. Despite few high-quality randomized controlled trials to guide therapeutic decisions, transjugular intrahepatic portosystemic shunt (TIPS) creation has emerged as a crucial therapeutic option to treat complications of portal hypertension. In North America, the decision to perform TIPS involves gastroenterologists, hepatologists, and interventional radiologists, but TIPS creation is performed by interventional radiologists. This is in contrast to other parts of the world where TIPS creation is performed primarily by hepatologists. Thus, the successful use of TIPS in North America is dependent on a multidisciplinary approach and technical expertise, so as to optimize outcomes. Recently, new procedural techniques, TIPS stent technology, and indications for TIPS have emerged. As a result, practices and outcomes vary greatly across institutions and significant knowledge gaps exist. In this consensus statement, the Advancing Liver Therapeutic Approaches group critically reviews the application of TIPS in the management of portal hypertension. Advancing Liver Therapeutic Approaches convened a multidisciplinary group of North American experts from hepatology, interventional radiology, transplant surgery, nephrology, cardiology, pulmonology, and hematology to critically review existing literature and develop practice-based recommendations for the use of TIPS in patients with any cause of portal hypertension in terms of candidate selection, procedural best practices and, post-TIPS management; and to develop areas of consensus for TIPS indications and the prevention of complications. Finally, future research directions are identified related to TIPS for the management of portal hypertension. Complications of portal hypertension, including ascites, gastrointestinal bleeding, hepatic hydrothorax, and hepatic encephalopathy, are associated with significant morbidity and mortality. Despite few high-quality randomized controlled trials to guide therapeutic decisions, transjugular intrahepatic portosystemic shunt (TIPS) creation has emerged as a crucial therapeutic option to treat complications of portal hypertension. In North America, the decision to perform TIPS involves gastroenterologists, hepatologists, and interventional radiologists, but TIPS creation is performed by interventional radiologists. This is in contrast to other parts of the world where TIPS creation is performed primarily by hepatologists. Thus, the successful use of TIPS in North America is dependent on a multidisciplinary approach and technical expertise, so as to optimize outcomes. Recently, new procedural techniques, TIPS stent technology, and indications for TIPS have emerged. As a result, practices and outcomes vary greatly across institutions and significant knowledge gaps exist. In this consensus statement, the Advancing Liver Therapeutic Approaches group critically reviews the application of TIPS in the management of portal hypertension. Advancing Liver Therapeutic Approaches convened a multidisciplinary group of North American experts from hepatology, interventional radiology, transplant surgery, nephrology, cardiology, pulmonology, and hematology to critically review existing literature and develop practice-based recommendations for the use of TIPS in patients with any cause of portal hypertension in terms of candidate selection, procedural best practices and, post-TIPS management; and to develop areas of consensus for TIPS indications and the prevention of complications. Finally, future research directions are identified related to TIPS for the management of portal hypertension. Portal hypertension, defined as increased pressure in the portal venous system, can lead to major clinical complications including ascites, gastrointestinal hemorrhage, hepatic hydrothorax (HH), and hepatic encephalopathy (HE), all associated with significant morbidity and mortality.1Runyon B.A. American Association for the Study of Liver DiseasesIntroduction to the revised American Association for the Study of Liver Diseases Practice Guideline management of adult patients with ascites due to cirrhosis 2012.Hepatology. 2013; 57: 1651-1653Crossref PubMed Scopus (483) Google Scholar Although medical therapies and liver transplantation (LT) are effective treatments in many scenarios, transjugular intrahepatic portosystemic shunt (TIPS) creation is a crucial therapeutic option (Supplementary Figure 1). In North America, the decision to perform TIPS is determined by specialists in gastroenterology and hepatology who treat patients with portal hypertension, but TIPS creation is performed by interventional radiology (IR). This is in contrast to other parts of the world (eg, Europe) in which hepatologists primarily perform TIPS. Although TIPS creation is effective for management of complications of portal hypertension,2Lv Y. Zuo L. Zhu X. et al.Identifying optimal candidates for early TIPS among patients with cirrhosis and acute variceal bleeding: a multicentre observational study.Gut. 2019; 68: 1297-1310Crossref PubMed Scopus (57) Google Scholar, 3Garcia-Pagan J.C. Caca K. Bureau C. et al.Early use of TIPS in patients with cirrhosis and variceal bleeding.N Engl J Med. 2010; 362: 2370-2379Crossref PubMed Scopus (794) Google Scholar, 4Bureau C. Thabut D. Oberti F. et al.Transjugular intrahepatic portosystemic shunts with covered stents increase transplant-free survival of patients with cirrhosis and recurrent ascites.Gastroenterology. 2017; 152: 157-163Abstract Full Text Full Text PDF PubMed Scopus (205) Google Scholar, 5Dhanasekaran R. West J.K. Gonzales P.C. et al.Transjugular intrahepatic portosystemic shunt for symptomatic refractory hepatic hydrothorax in patients with cirrhosis.Am J Gastroenterol. 2010; 105: 635-641Crossref PubMed Scopus (0) Google Scholar, 6Song T. Rossle M. He F. et al.Transjugular intrahepatic portosystemic shunt for hepatorenal syndrome: a systematic review and meta-analysis.Dig Liver Dis. 2018; 50: 323-330Abstract Full Text Full Text PDF PubMed Scopus (41) Google Scholar, 7Mezawa S. Homma H. Ohta H. et al.Effect of transjugular intrahepatic portosystemic shunt formation on portal hypertensive gastropathy and gastric circulation.Am J Gastroenterol. 2001; 96: 1155-1159Crossref PubMed Google Scholar it is associated with several risks, including deterioration in liver function, new onset or worsening HE,8Trivedi P.S. Rochon P.J. Durham J.D. et al.National trends and outcomes of transjugular intrahepatic portosystemic shunt creation using the nationwide inpatient sample.J Vasc Interv Radiol. 2016; 27: 838-845Abstract Full Text Full Text PDF PubMed Google Scholar and changes in cardiopulmonary and renal hemodynamics (Supplementary Figure 1).9Busk T.M. Bendtsen F. Poulsen J.H. et al.Transjugular intrahepatic portosystemic shunt: impact on systemic hemodynamics and renal and cardiac function in patients with cirrhosis.Am J Physiol Gastrointest Liver Physiol. 2018; 314: G275-G286Crossref PubMed Scopus (24) Google Scholar Over the past decade there have been important advancements in TIPS devices, procedural techniques, and immense growth in the literature supporting the role of TIPS in the management of portal hypertension.10Miraglia R. Maruzzelli L. Di Piazza A. et al.Transjugular intrahepatic portosystemic shunt using the new Gore Viatorr controlled expansion endoprosthesis: prospective, single-center, preliminary experience.Cardiovasc Intervent Radiol. 2019; 42: 78-86Crossref PubMed Scopus (36) Google Scholar,11RiChard J. Thornburg B. New techniques and devices in transjugular intrahepatic portosystemic shunt placement.Semin Intervent Radiol. 2018; 35: 206-214Crossref PubMed Scopus (6) Google Scholar However, there are few high-quality randomized controlled trials (RCTs) of TIPS use. New indications for TIPS placement also have emerged, including treatment of portal vein thrombosis (PVT), which require rigorous assessment. As a result, practices and outcomes vary greatly across institutions and significant knowledge gaps exist. The goals and objectives of the Advancing Liver Therapeutic Approaches consensus conference were to convene a multidisciplinary group of North American experts from hepatology, IR, transplant surgery, nephrology, cardiology, pulmonology, and hematology to critically review existing literature and develop practice-based recommendations for the use of TIPS in persons with any cause of portal hypertension in terms of candidate selection, procedural best practices, and post-TIPS management across 7 key topic areas: general considerations for TIPS, TIPS in the management of ascites/HH, TIPS in the management of variceal bleeding, novel indications for TIPS, cardiopulmonary considerations of TIPS including management of hepatopulmonary syndrome, renal considerations of TIPS including management of hepatorenal syndrome (HRS), and HE and TIPS. A consensus-building process was conducted consistent with standards described in the Appraisal of Guidelines for Research and Evaluation II12Brouwers M.C. Kho M.E. Browman G.P. et al.AGREE II: advancing guideline development, reporting and evaluation in health care.CMAJ. 2010; 182: E839-E842Crossref PubMed Scopus (1813) Google Scholar and used a modified Delphi approach to achieve consensus (Supplementary Methods section).13Dalkey N. Helmer O. An experimental application of the DELPHI method to the use of experts.Manage Sci. 1963; 9: 458-467Crossref Google Scholar Practice-based recommendations were developed by 30 Advancing Liver Therapeutic Approaches group members with extensive experience in the management of portal hypertension and the use of TIPS, who participated in the consensus conference held on October 23, 2020. The target users are gastroenterologists, hepatologists, and subspecialty physicians who refer for TIPS and/or provide care for patients undergoing TIPS. PubMed, EMBASE, and Cochrane were queried for English language articles published between January 1, 1990, and July 1, 2020. The target population was persons with any cause of portal hypertension undergoing TIPS. Terms were chosen through input from participants and by consultation with a medical librarian (Supplementary Methods section). We considered peer-reviewed articles in the following order of relevance: RCTs, systematic reviews and meta-analyses, and observational studies. For select topics in which studies were limited, case reports were included. Between August 2020 and October 2020, literature for each topic was discussed iteratively by workgroups of physicians with expertise in the identified topics. The level of evidence for all consensus statements was graded using the Oxford Centre for Evidence-based Medicine Levels of Evidence.14Howick J. Chalmers I. Glasziou P. et al.The 2011 Oxford CEBM levels of evidence. University of Oxford, Oxford Centre for Evidence-Based Medicine, Oxford, UK2011Google Scholar The literature search yielded 2116 articles, with 703 reports remaining after titles and abstracts were screened for relevance (Supplementary Methods section). An additional 81 articles not captured by the literature search were included on the basis of panel agreement of relevance. A total of 105 clinical statements were developed for assessment throughout the 2 iterations of the Delphi survey. All panelists completed all survey items. After 2 iterations of the Delphi survey, 87 statements met the standardized definition for consensus (Supplementary Methods section and Supplementary Table 1). The recommendations are outlined in Tables 1, 2, and 3. The following text provides brief rationale supporting these recommendations. Expanded rationale, where indicated, are available in the Supplementary Discussion section.Table 1Clinical Consensus Statements for TIPS Planning, Procedural Best Practices, and Care of the TIPS Recipient Independent of Indication for TIPSQuestionStatementLevel of evidencePre-TIPS considerationsQuestion 1. Who should be involved in the decision to place a TIPS and what other preprocedure consultations are recommended?Before TIPS creation, we recommend that a gastroenterologist or hepatologist should be involved in the initial decision to place an emergent or nonemergent TIPS with subsequent consultation by an interventional radiologist or other proceduralist with competency in TIPS. If center expertise is not available, we recommend referral to an expert center. Additional specialty consultations (eg, transplant surgery, cardiology, critical care, hematology, nephrology) may be considered on a case-by-case basis.5Question 2. What services should be readily available at centers where TIPS is performed and what referral pathways should be established for a higher level of care?For all patients undergoing TIPS creation, we recommend that TIPS should occur at a center with available IR, gastroenterology/hepatology, cardiology, pulmonary surgery, hematology, nephrology, and critical care services to provide an adequate level of support for patient management before and after TIPS. In patients requiring a higher level of care, such as possible liver transplant candidates, or in whom the need for further IR expertise is indicated (eg, extensive portal vein thrombosis), we recommend referral to centers with adequate experience in these areas.5Question 3. Is there a MELD threshold above which elective TIPS should not be considered?In patients with cirrhosis undergoing TIPS, a multidisciplinary approach, rather than an absolute MELD cut-off value, is recommended to assess TIPS candidacy.2aQuestion 4. What imaging and/or preprocedural evaluation is required before TIPS creation?Q4a. In patients undergoing elective TIPS, we recommend the following:• Contrast-enhanced multiphasic cross-sectional imaging (CT/MRI) to assist with TIPS planning.• Comprehensive echocardiography to assess for abnormalities in cardiac structure, function, and right ventricular systolic pressure.2aQ4b. In patients with cirrhosis undergoing emergent TIPS, best clinical judgement should be applied. We suggest at least a liver ultrasound with Doppler to evaluate the patency of the portal venous system and consideration of a limited (bedside) echocardiogram, evaluating left ventricular ejection fraction and right ventricular systolic pressure.3Question 5. What are absolute contraindications (medical and anatomic) to elective TIPS creation?The absolute contraindications to elective TIPS include the following:• Severe congestive heart failure (ACC/AHA stage C or D HF)• Severe untreated valvular heart disease (AHA/ACC stage C or D VHD)• Moderate–severe pulmonary hypertension (based on invasive measurements) despite medical optimization• Uncontrolled systemic infection• Refractory overt HE• Unrelieved biliary obstruction• Lesions (eg, cysts) or tumors in the liver parenchyma that preclude TIPS creation2aQuestion 6. Should all patients being considered for TIPS undergo evaluation for liver transplantation before TIPS creation?In patients with cirrhosis undergoing elective or emergent TIPS, there is insufficient evidence to recommend universal preprocedure liver transplant evaluation.5TIPS procedural considerationsQuestion 7: Who should perform TIPS creation?We recommend that TIPS creation should be performed by a credentialed, board-certified interventional radiologist or a certified provider with equivalent training and procedural competencyaAccording to radiology professional society guidelines, TIPS placement must be performed by a physician with board certification or accredited training as well as sufficient experience with TIPS procedures. In the absence of certification or accredited training, TIPS placement can be performed by a competent proceduralist defined as one who has performed a sufficient number of TIPS procedures under supervision (minimum threshold, 5), in addition to other endovascular techniques (ie, minimum of 100 angiograms, 50 angioplasties, 10 stent placements, and 5 embolizations), has achieved expected procedure completion thresholds, and has obtained appropriate privileges at their center.385Question 8. Which type of stent is recommended for TIPS creation?For patients undergoing TIPS placement, we recommend the use of an ePTFE-lined stent graft (1b) with controlled expansion, which allows the surgeon to tailor the amount of portosystemic shunting based on the indication, target gradient, and patient comorbidities (2b).1b and 2bQuestion 9. Should coagulopathy be corrected before TIPS placement?Because of insufficient evidence, we do not recommend a specific target INR or platelet threshold when placing a TIPS in a patient with cirrhosis.2bQuestion 10. Should periprocedural antibiotics be used routinely in TIPS creation?There are no studies to show that the routine use of antibiotics during TIPS placement decreases infectious complications and their use should depend on patient and local risk factors.5Question 11. Should TIPS creation be performed using general anesthesia or is deep or conscious sedation appropriate?The use of general anesthesia, deep sedation, or conscious sedation all may be appropriate for TIPS placement and their use will vary depending on the patient risk factors and local practices.5Question 12. Is the use of intravascular ultrasound recommended to assist with the portal vein puncture?For patients undergoing TIPS creation, although there is insufficient evidence to recommend the universal use of intravascular ultrasound guidance, it may facilitate efficient portal access in certain situations. Its use will depend on equipment availability and surgeon preference.3bQuestion 13. What is the optimal location from which to measure the systemic venous pressure at the time of TIPS creation (hepatic vein, IVC, right atrium)?We recommend the use of the free hepatic vein or IVC pressure as the systemic pressure when measuring the portosystemic gradient before and after TIPS placement.2aQuestion 14. Are there specific technical factors that should be considered to ensure that TIPS placement does not adversely influence liver transplant candidacy?Q14a. In patients undergoing TIPS placement who are potentially eligible for liver transplant, we recommend positioning the stent as to not interfere with the portal and hepatic vein anastomoses, presuming that this does not detrimentally affect TIPS function or patency. This positioning includes leaving a segment of unstented main portal vein and not extending the TIPS stent into the right atrium.5Q14b. Liver transplant candidacy should not be impacted by placement of TIPS.2aCare of the post-TIPS patientQuestion 15. What is the recommended duration of intensive postprocedure monitoring?After TIPS creation, we recommend that all patients undergo in-hospital overnight observation at minimum. The level of care during post-TIPS observation should be dictated by the patient’s condition, indication for TIPS, and intraprocedural technical complexity.5Question 16. What early laboratory testing and/or imaging is recommended after TIPS creation and at what interval?Q16a. In all patients undergoing TIPS creation, routine laboratory tests (complete blood count, comprehensive metabolic panel, and PT/INR) should be obtained on the day after TIPS creation. Hemoglobin/hematocrit laboratory tests may be obtained on the same day of TIPS creation, depending on institution and/or surgeon discretion.5Q16b. Predischarge imaging is not indicated in most patients undergoing TIPS creation.5Question 17. Should TIPS venography and intervention be based on ultrasound, clinical findings, or both?Q17a. In patients who have undergone TIPS creation for management of varices, either Doppler ultrasound findings suggesting TIPS dysfunction or persistence or recurrence of portal hypertensive complications should prompt TIPS venography and manometry ± intervention. Ultrasound findings suggesting TIPS dysfunction include alterations in intrahepatic portal vein direction of flow, abnormal flow velocities within the TIPS, and persistent (eg, >6 weeks after TIPS) or recurrent ascites.2bQ17b. In patients who have undergone TIPS creation for management of ascites and/or hepatic hydrothorax, persistence or recurrence of portal hypertensive complications should prompt TIPS venography and manometry ± intervention. Medical decision making should be individualized in patients with well-controlled ascites and/or hepatic hydrothorax and ultrasound findings suggesting TIPS dysfunction.2bQ17c. In select patients, scheduled TIPS venography with intervention is suggested in the early (1–2 months) post-TIPS period. An example of such a scenario would be TIPS creation in a patient with portal vein thrombosis.5Question 18. What are the optimal techniques for increasing or decreasing TIPS flow when intervention is required?Q18a. In patients in whom further decrease in portal pressure is desired, we recommend stepwise dilatation of TIPS to its maximum diameter. If it is already at maximum diameter, other interventions to decrease portal pressure (eg, nonselective β-blockers, parallel TIPS creation) should be evaluated.5Q18b. In patients in whom an increase in portal pressure is desired, there is insufficient evidence to recommend a specific technique to reduce portosystemic shunting through a TIPS.5Question 19. Who should see patients with TIPS in follow-up evaluation?In patients who have undergone TIPS creation, we recommend that a gastroenterologist or hepatologist and a competent proceduralist (eg, interventional radiologist) should follow-up the patient to ensure ongoing management of chronic liver disease, postprocedural complications, and to determine any need for potential device revision.5ACC, American College of Cardiology; AHA, American Heart Association; CT, computed tomography; ePTFE, Polytetrafluoroethylene; HE, hepatic encephalopathy; HF, heart failure; INR, international normalized ratio; IR, interventional radiology; IVC, inferior vena cava; MELD, model for end-stage liver disease; MRI, magnetic resonance imaging; PT, prothrombin time; TIPS, transjugular intrahepatic portosystemic shunt; VHD, valvular heart disease.a According to radiology professional society guidelines, TIPS placement must be performed by a physician with board certification or accredited training as well as sufficient experience with TIPS procedures. In the absence of certification or accredited training, TIPS placement can be performed by a competent proceduralist defined as one who has performed a sufficient number of TIPS procedures under supervision (minimum threshold, 5), in addition to other endovascular techniques (ie, minimum of 100 angiograms, 50 angioplasties, 10 stent placements, and 5 embolizations), has achieved expected procedure completion thresholds, and has obtained appropriate privileges at their center.38Society of Interventional Radiology Standards of Practice CommitteeAmerican College of Radiology (ACR)-Society of Interventional Radiology (SIR)-Society for Pediatric Radiology (SPR) Practice Parameter for the Creation of a Transjugular Intrahepatic Portosystemic Shunt (TIPS) - ACR-SIR-SPR TIPS.https://www.acr.org/-/media/ACR/Files/Practice-Parameters/TIPS.pdf?la=enDate: 2017Date accessed: October 23, 2020Google Scholar Open table in a new tab Table 2Clinical Consensus Statements for TIPS by IndicationQuestionStatementLevel of evidenceTIPS in ascites or HHTQuestion 1. What is the optimal technical approach to TIPS creation among patients with cirrhosis and refractory ascites?Q1a. For patients with cirrhosis and diuretic refractory or resistant ascites undergoing elective TIPS, we recommend the use of an ePTFE-covered controlled expansion stent.2bQ1b. For patients with cirrhosis and diuretic refractory or resistant ascites undergoing elective TIPS, we recommend a staged approach to TIPS creation with an initial procedural stent dilation to 8 mm followed by clinical assessment, and then subsequent progressive stent dilation to 9 mm and then 10 mm at 6-week intervals if needed to optimize clinical response.2bQuestion 2. Is TIPS associated with better outcomes (mortality, ascites control) than serial LVP for the treatment of refractory ascites?Q2a. For carefully selected patients with cirrhosis and refractory ascites, TIPS is recommended over LVP to prevent recurrent ascites.1aQ2b. For carefully selected patients with cirrhosis and refractory ascites, TIPS is recommended over LVP to improve transplant-free survival.1aQuestion 3. Is there a threshold of liver dysfunction above which TIPS for refractory ascites should be contraindicated and how should it be defined?Among patients with cirrhosis and refractory ascites, increased bilirubin, increased MELD score, and CTP class C cirrhosis are associated with increased post-TIPS complications including mortality. There is insufficient evidence to recommend a cut-off value above which any of these measures should be considered a contraindication to TIPS.1aQuestion 4. What is the impact of age on candidacy for TIPS for refractory ascites?Among patients with cirrhosis and refractory ascites, advanced age is associated significantly with post-TIPS complications including severe hepatic encephalopathy and death. There is insufficient evidence to recommend a cut-off age that should be considered a contraindication to TIPS.1aQuestion 5. What is the role of TIPS in patients with ascites that is not refractory?In patients not fulfilling a strict definition of refractory ascites but requiring at least 3 LVP for tense ascites in a year despite optimal medical therapy, we recommend that TIPS creation should be considered.1aQuestion 6. What is the role of TIPS in HHT? Is patient selection similar for patients with ascites vs patients with HHT?For patients with HHT requiring recurrent thoracentesis, we recommend that TIPS should be considered.2bQuestion 7. Is prior liver transplantation a contraindication to TIPS for refractory ascites? Is TIPS a better treatment than surgical shunt, serial LVP, or splenic artery embolization in liver transplant recipients with refractory ascites?Unlike TIPS for ascites and HHT in cirrhosis, there is insufficient evidence to support any recommendation regarding therapy (TIPS and other modalities) in liver transplant recipients with refractory ascites.2bQuestion 8. What is the expected timeline for the TIPS to be effective for reduction of ascites/HHT?In the setting of TIPS creation for ascites or hepatic hydrothorax, we recommend using a staged approach by starting with the TIPS stent with the smallest diameter with concomitant use of diuretics as tolerated. Reassessment for need to further dilate the TIPS stent should be performed every 6 weeks.2bTIPS in variceal bleedingQuestion 1. When is TIPS indicated in acute variceal hemorrhage?For acute variceal hemorrhage, we recommend TIPS creation in the following scenarios:• Pre-emptive TIPS in patients who have been banded successfully but who meet high-risk criteria for rebleeding. High-risk criteria are CTP class C (10–13 points) or CTP class B >7 points with active bleeding at endoscopy. TIPS should be performed within 72 hours of admission in patients without contraindications to TIPS.1c• Rescue TIPS in patients who have been banded successfully but who rebleed at any time during admission (after endoscopy).2a• Salvage TIPS should be performed emergently for patients in whom endoscopic band ligation cannot be performed because of profuse bleeding or bleeding persists at endoscopy despite endoscopic band ligation.2bQuestion 2. When should TIPS be used in the management of bleeding gastric fundal varices or prevention of rebleeding?Q2a. We recommend that the initial management of bleeding gastric-fundal varices should be based on center expertise. Variceal obliteration/embolization with or without TIPS should be considered for bleeding gastric-fundal varices if unable to be managed endoscopically.5Q2b. For rebleeding gastric-fundal varices after endoscopic therapy, we recommend variceal obliteration with or without TIPS creation.2bQuestion 3. What are the procedural considerations in TIPS creation for variceal hemorrhage?Q3a. When placing a TIPS for variceal hemorrhage, we recommend a goal PSG of <12 mm Hg or 50%–60% decrease from initial. We do not recommend using shunt diameter as a procedural end point.2bQ3b. In cases of TIPS creation for variceal hemorrhage, we recommend concurrent obliteration of varices.1bQuestion 4. How should patients be monitored after TIPS creation for variceal hemorrhage?Q4a. In the setting of TIPS creation for variceal bleeding, we recommend surveillance with Doppler ultrasonography 3 months after TIPS creation and every 6 months thereafter to monitor for post-TIPS stenosis or occlusion.5Q4b. If TIPS stenosis/occlusion is suspected or if patient rebleeds after TIPS creation, TIPS venogram with pressure measurements is indicated with consideration of TIPS revision.2bNovel indications for TIPSQuestion 1. Does preoperative TIPS creation in patients with portal hypertension reduce surgical complication and/or improve perioperative outcomes after nontransplant abdominal surgery?Q1a. In patients with portal hypertension requiring nontransplant surgery, there is insufficient evidence to recommend that preoperative TIPS prevents bleeding complications or the need for blood transfusion during or after invasive nontransplant surgical procedures.1bQ1b. In patients with cirrhosis without clinically significant ascites, there is insufficient evidence to recommend preoperative TIPS in abdominal surgery to prevent complications of ascites. In patients with cirrhosis with clinically significant ascites requiring abdominal surgery, a multidisciplinary team