2026 Webinar: Pre-emptive TIPS for Variceal Bleeding (ondemand)-TIPS Webinar

Video Transcription

Video Summary

The ASLD webinar focused on preemptive transjugular intrahepatic portosystemic shunt (TIPS) in patients with cirrhosis presenting with variceal bleeding. A complex clinical case of a 72-year-old male with alcohol-related cirrhosis, prior varices managed with carvedilol, ascites control, and subsequent acute variceal hemorrhage was presented. The patient initially received band ligation without preemptive TIPS but later suffered fatal massive rebleeding.<br /><br />Dr. Juana Valdez advocated for early TIPS placement, citing randomized trials demonstrating significant reductions in rebleeding and mortality in high-risk patients defined by Child-Pugh B (score 8–9) with active bleeding or Child-Pugh C (<14 points). She emphasized the importance of individualized decisions, potential benefits of under-dilated smaller diameter TIPS (6mm), and the possibility of delayed placement beyond the ideal 72-hour window. Risks include hepatic encephalopathy and liver function worsening.<br /><br />Conversely, Dr. Marika Rudler highlighted uncertainties, such as variability in Child-Pugh scoring, difficulty confirming active bleeding endoscopically, and lack of data on older patients, alcohol abstinence status, and safety in emergency settings. Concerns about hepatic encephalopathy risk in elderly patients and paucity of evidence in non-elective scenarios were noted.<br /><br />Panelists discussed challenges in patient selection, balancing liver scores at admission versus pre-admission, impact of comorbidities like renal and cardiac function, and nuances in radiologic management (e.g., collateral embolization, TIPS size). The presence of hepatic encephalopathy was not an absolute contraindication in emergency but requires careful management.<br /><br />Transplant candidacy influenced decision-making, favoring TIPS to bridge to transplant. The evolving patient demographics, including increasing metabolic liver disease and obesity in North America, add complexity to guidelines largely based on European and Asian cohorts.<br /><br />Overall, the panel emphasized the need for personalized, multidisciplinary approaches incorporating clinical status, comorbidities, and patient preferences. Several knowledge gaps remain, including optimal timing, management in older or non-abstinent patients, and long-term outcomes, underscoring the need for further research in diverse populations.

Keywords

preemptive TIPS

variceal bleeding

cirrhosis

Child-Pugh score

hepatic encephalopathy

band ligation

alcohol-related liver disease

transjugular intrahepatic portosystemic shunt

acute variceal hemorrhage

multidisciplinary management

liver transplantation