Do cirrhotic patients with a high MELD score benefit from TIPS?

which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited. Editorial The aim of a transjugular intrahepatic portosystemic shunt (TIPS) is to shunt blood from the hypertensive portal vein to the hepatic vein, thereby nonsurgically decompressing the portal pressure. This procedure is generally used to treat complications related to portal hypertension, 1 with intractable variceal bleeding and refractory ascites in particular being primary indications for TIPS. 2 TIPS was initially used as a rescue therapy for controlling acute variceal bleeding that is refractory to endoscopic therapy. The combination of pharmacologic and endoscopic treatment can achieve hemostasis in most patients with acute variceal bleeding, and so this combined treatment has become accepted as the first-line therapy. 2 However, approximately 20% of patients continue to bleed despite that combined treatment, for which emergency TIPS can be considered a second-line approach. Several studies have demonstrated that TIPS can control acute intractable variceal bleeding that is resistant to pharmacologic and endoscopic treatment with reported success rates in the range of 90-100%; however , the mortality rate is high, at approximately 30% within the first month. 3 TIPS also can be regarded as a second-line therapy for the prevention of variceal rebleeding. 4 Several randomized controlled trials have demonstrated that while TIPS is more effective than endoscopic therapy for preventing variceal rebleeding, there appear to be no survival benefits from TIPS, and the incidence of complications such as hepatic encephalopathy is higher with TIPS than with endoscopic treatment. Therefore, TIPS is reserved as a second-line therapy for preventing variceal rebleeding. Furthermore , the current guidelines suggest that this procedure should not be used for preventing rebleeding in patients who have bled only once from esophageal varices, and that its use should be limited to those for whom pharmacologic and endoscopic treatments have failed. 2 Refractory ascites represent another main indication for TIPS. 5 The initial treatment of choice for patients with refractory ascites is large-volume paracentesis (LVP), which rapidly relieves abdominal tension. However, LVP does not prevent the rapid reaccumulation of ascites, since it does not correct the mechanisms underlying ascites formation. Repeated LVP is thus inevitably required, with its consequent negative effects on the patient's quality of life. Conversely, the decrease in portal pressure induced by TIPS leads to an effective control of ascites formation, resulting in a dramatic reduction in the recurrence of tense ascites. …