Transjugular intrahepatic portosystemic shunt (TIPS) is an important therapy for complications of portal hypertension in cirrhotic patients, especially in patients with variceal bleeding or refractory ascites. First TIPS in patients was reported by Richter et al¹ in 1990. In 1992, the first TIPS in patient was successfully performed in China.² Clinical articles about TIPS application then published successively by Xu et al² from China Medical University, Zhang et al³ from PLA General Hospital, and Li YanHao from Sun Yat-Sen University of Medical Sciences.^2–4 During this period, TIPS was gradually spread across China with the tireless efforts of interventional radiology experts and formed so-called TIPS fever in China. However, as the following studies found that the medium and long-term effect of TIPS was not very promising compared with endoscopic therapy, the number of TIPS procedures decreased dramatically. The rate of shunt dysfunction at 1, 2, and 5 years after operation was up to 5%–64%, 33%–70%, and 60%–85%, respectively, and restenosis or occlusion of the shunt was the primary cause for the poor clinical effect of TIPS.⁵ Although the recurrent bleeding rate after TIPS treatment was significantly lower than that of endoscopic treatment (10%–25% vs 35%–50%), the incidence of hepatic encephalopathy was obviously increased compared to endoscopic treatment (30% vs 15%). In addition, there was no advantage in survival rate, quality of life and economic benefits.⁶ Therefore, TIPS was treated as a transitional treatment option before liver transplantation, and the “TIPS fever” diminished quickly. This disinterest in TIPS was easily notable from the number of research papers published in Chinese journals indexed by China National Knowledge Infrastructure (CNKI) each year (Fig. 1). As the advent of covered stents, exciting research results about “early-TIPS” and the strategy of selecting appropriate patients for TIPS treatment, the efficacy of TIPS has been significantly improved. Since 2008, the number of TIPS operations has begun to rise again in China.

In China, the volume of TIPS is rapidly rising in recent years. There were about 7,300 TIPS procedures been conducted in 2016, and this number can reach to 8,300 in 2017. Chinese expert consensus on TIPS for treatment of cirrhotic portal hypertension was established and updated in the year of 2004, 2014, and 2017 (Fig. 2).^7–9 Now, TIPS procedures are mainly carried out in the following centers: Xijing Hospital in Xian, West China Hospital in Chengdu, Nanfang Hospital in Guangzhou, Nanjing Drum Tower Hospital in Nanjing, and several hospitals in Beijing and Shenyang. Hospitals that can independently implement TIPS have developed from several top-grade medical centers to some prefecture-level city hospitals (Fig. 3). Most of TIPS procedures were conducted as secondary prophylaxis for esophageal and gastric variceal hemorrhage after the failure of standard medical treatment. A few TIPS are also conducted as salvage treatment in an emergent situation or as early-TIPS.

TIPS stent selection

The major concern after TIPS procedure is how to ensure the patency of the TIPS stent. Until the VIATORR® TIPS stent graft (Gore Medical, Flagstaff, AZ, USA) was approved in 2015 October in China, the Fluency® (Bard Peripheral Vascular, Tempe, AZ, USA) fully covered stent was used in most TIPS (Fig. 2). To achieve a similar effect of partially covered VIATORR® stent, the Fluency® stent was often used in combination with a bare metal stent. A series of studies focused on the different combination of full covered stent and bare stent were published.^10–12 Due to a higher cost of VIATORR® stent and user preference, the Fluency® stent is still widely used. However, with the proven efficacy and safety of VIATORR® stent available in the literature, the proportion of VIATORR® stent in China has been increasing. In regards to the selection of TIPS stent diameter, a randomized controlled study found that 8 mm covered TIPS stents do not compromise shunt function, but halved the risk of spontaneous overt HE and reduced hepatic impairment in preventing variceal rebleeding compared with 10 mm stents.¹³ Therefore, 8 mm TIPS stents seem to be a preferred TIPS treatment option for the prevention of variceal rebleeding in China.

TIPS indications

As more and more high-quality research papers have emerged, TIPS indications have expanded dramatically worldwide, and TIPS indications in China also have expanded in line with international trends. According to Chinese expert consensus on TIPS, the TIPS indications mainly include following items.

China is a country with high incidence of hepatitis; therefore, the incidence of cirrhosis due to chronic liver disease will not change significantly. However, by 2030 with successful immunization for HBV, the main etiology of the cirrhosis will shift from hepatitis to chronic alcohol consumption and non-alcoholic fatty liver disease.²⁰ With the effectiveness of VIATORR® stents and better-designed TIPS access kits, the challenges and complications of TIPS can be further reduced. With less complexity of TIPS procedure, more physicians can perform TIPS procedures. It is somewhat predictable that the number of TIPS treatments will increase significantly shortly. Accordingly, more multicenter randomized controlled trials will be initiated and performed. Although the future of TIPS looks bright, there are many challenges that the Chinese interventional doctors need to focus and overcome such as patient selection for TIPS treatment and methods of reduction of TIPS complications.

This review was invited and edited by Edward Wolfgang Lee, MD, PhD (UCLA).

No potential conflict of interest relevant to this article was reported.