Outcomes of Transjugular Intrahepatic Portosystemic Shunt Procedures in a Very-Low-Volume Institution: A Retrospective Single-Center Study

Abstract

Purpose

This study aimed to evaluate the outcomes of transjugular intrahepatic portosystemic shunt (TIPSS) procedures performed in a very-low-volume center over 4 years, focusing on procedural success, complication rates, and clinical effectiveness in managing portal hypertension and related complications.

Materials and Methods

A retrospective analysis was conducted of those who underwent TIPSS at our institution from October 2020 to October 2024. Inclusion criteria were no prior TIPSS or liver surgery and available follow-up data. Data collected included patient demographics, portal hypertension etiology, and procedural details. Success was assessed in technical, hemodynamic, and clinical categories, with complication and readmission rates analyzed.

Results

Ten patients (six male, four female; median age 45.5 years, range 12–74) underwent TIPSS between October 2020 and October 2024. TIPSS indications included refractory ascites (40%) and variceal bleeding (60%), with all procedures elective except one emergency case for acute variceal bleeding. Technical success was achieved in 90%, with one unsuccessful shunt placement in a patient due to extensive hepatic vein and vena cava thrombosis. The mean portosystemic pressure gradient (PSG) decreased from 27 ± 3.32 to 8.56 ± 1.74 mm Hg, with hemodynamic success achieved in all patients (PSG ≤ 12 mm Hg). Clinical success was observed with no rebleeding or large-volume paracentesis required within 30 days postprocedure.

Conclusion

TIPSS can be effectively performed in a very-low-volume center, yielding favorable outcomes with manageable complications, provided it is conducted by experienced physicians following proper protocols.

 

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Keywords

portal hypertension - portosystemic shunt - encephalopathy - variceal bleeding - ascites

Introduction

Cirrhosis, causing portal hypertension, is a major global health concern, ranking as the 11th leading cause of death. It is primarily attributed to alcohol abuse, chronic viral hepatitis infections, and the prevalence of obesity.[1] [2] Transjugular intrahepatic portosystemic shunt (TIPSS) is an established nonsurgical bypass reducing the portal pressure and managing the complications of portal hypertension, such as the variceal bleeding and refractory ascites, via the created connection between the portal and hepatic venous circulations. This shunt allows a portion of the portal venous blood flow to bypass the liver and lowers the portal pressure.[3] [4] [5] [6]

TIPSS was invented by the great entrepreneurs of the interventional radiology society in the 1960s to reduce portal pressure.[3] [7] [8] The primary indications for TIPSS are refractory or recurrent ascites and the secondary prevention of variceal hemorrhage related to chronic liver disease. Less common indications could be portal hypertensive gastropathy, hepatic hydrothorax, and hepatorenal syndrome.[4] Hospitalization rates for cirrhosis and portal hypertension have been increasing over the past decade, which causes a rising demand for TIPSS procedures.

The success of TIPSS procedures is influenced by a range of factors, including the expertise of the interventionist and the number of procedures performed at a given center. Studies have indicated that hospitals with higher procedural volumes report lower complication rates and improved survivals compared to lower-volume institutions, mainly attributed to the practice-makes-perfect hypothesis.[9] Despite the reported advantages in the literature performing TIPSS in a high-volume center, plenty of institutions perform TIPSS successfully with low annual numbers. Considering the potential complications of this complex and technically challenging procedure, including hepatic encephalopathy (HE), shunt dysfunction, hepatic failure, biliary duct injury, and intra-abdominal hemorrhage, the effectiveness and safety of TIPSS in low-volume centers remain less explored.[10] [11]

The present study aims to evaluate the outcomes of TIPSS procedures performed in a single very low-volume center over 4 years. By analyzing the procedural success rates, complication rates, and patient survival, this retrospective study seeks to provide insights into the feasibility of performing TIPSS in a setting with a limited procedural volume. These findings could have important implications for the future of TIPSS in low-volume centers.

 

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Materials and Methods

This retrospective study was conducted at our institution to evaluate the outcomes of TIPSS procedures performed on patients with portal hypertension between October 2020 and October 2024. The study has been approved by the Institutional Human Research Ethics Committee (İ09-717-24). Informed consent was secured from all patients, and patients' data were anonymized.

The study population consists of 10 patients who underwent TIPSS procedures at our institution during a period of 4 years. The inclusion criteria required for the patients were naive for a TIPSS procedure, having no history of liver surgery, and having documented follow-up data. Treatment decisions regarding the proceeding with TIPSS were made by our institutional multidisciplinary team, comprising gastroenterologists, transplant surgeons, and interventional radiologists. Patients whose shunt placement could not be completed due to technical challenges or other related factors were excluded from the postprocedural analysis.

Patient demographics (age, gender), preprocedural data, including etiology of cirrhosis, clinical measures (Model for End-Stage Liver Disease and Child–Pugh scores), and indications for TIPSS procedure were collected from the institutional database.

Procedural data were recorded, including technical success rates, intraprocedural complications, and immediate hemodynamic success based on pressure measurements. The interventional radiologists obtained pressure measurements, including the portal venous pressure (PVP) and the right atrial pressure (RAP), both before (TIPSSpre) and immediately after shunt placement (TIPSSpost) under general anesthesia during expiratory arrest. The portosystemic pressure gradient (PSG) was calculated as the difference between PVP and RAP. Pressure changes were determined by subtracting TIPSSpost values from TIPSSpre values.

Postprocedural data encompassed early complications occurring within the first 30 days following the procedure, clinical success measured by early outcomes within the initial 30 days, and readmission rates, defined as hospital admissions related to the TIPSS procedure following discharge. Readmissions were further classified into early readmissions between 30 and 90 days postprocedure and late readmissions after 90 days.

TIPSS Technique

In TIPSS procedures, we perform different portosystemic catheterization techniques, integrating our expertise in interventional radiology and diagnostic imaging. Patient selection is strategically based on anatomical variations identified through preprocedural ultrasound (US) or computed tomography scans, allowing for a customized approach tailored to each patient's unique vascular anatomy. Our preferred initial approach is the percutaneous US-guided direct intrahepatic portosystemic shunt technique whenever feasible ([Fig. 1]).[12] [13] If this is unsuccessful or anatomically unfavorable, we proceed with a US–fluoroscopy-guided TIPSS or the conventional transjugular technique. We usually begin with a percutaneous US-guided method because it reduces the financial burden on the public health care system by eliminating the need for a dedicated TIPSS set. The procedure can be completed with a standard 6Fr to 7Fr long sheath over a stiff 0.035” guidewire, allowing for portosystemic shunt creation with low-profile devices. We prefer using balloon-expandable graft stents (Bentley, Germany) from 8 to 10 mm in diameter, working with a compatible 6Fr or 7Fr sheath. These graft stents are often combined with a self-expandable or balloon-expandable bare stent (EV3, Boston Scientific) on the portal vasculature side, as previously described in the literature.[14] [15] [16] For the percutaneous transjugular US—with fluoroscopy-guided—as well as classical TIPSS creation, we aim to perform a technique described in detail in the literature ([Fig. 2]).[5] [7] [8] [17] [18] Post-TIPSS Medication and Follow-Up Screening Protocol

Fig. 1 A direct intrahepatic portosystemic shunt (DIPS) procedure in a patient with Budd–Chiari syndrome and intrahepatic portal vein thrombosis. (A) The introducer sheath, inserted through the right internal jugular vein, is positioned in the inferior vena cava (arrowhead). (B) Using real-time ultrasound guidance, a percutaneous needle is advanced from the portal vein, passing through the intrahepatic parenchyma toward the inferior vena cava (circle). (C) Following the puncture, the wire is guided through the percutaneous needle into the right atrium (arrow), confirming its proper placement within the inferior vena cava. (D) The angiogram obtained after transjugular intrahepatic portosystemic shunt (TIPSS) deployment confirms the proper positioning and appropriate length of the stent. (E) Color Doppler ultrasound performed at the 6-month follow-up demonstrates a patent stent with regular flow.

Fig. 2 A transjugular intrahepatic portosystemic shunt (TIPSS) procedure. (A) A vascular sheath is introduced through the right internal jugular vein, providing access to the hepatic venous system. (B) Following the puncture of the portal vein through the hepatic parenchyma, a guidewire is advanced through the needle into the portal vein, ensuring correct positioning for the creation of the shunt. (C) A balloon catheter is used to dilate the intrahepatic tract. (D) Final angiography confirms adequate flow through the TIPSS following stent placement.

We typically perform an US within the first week, usually in the initial days following the procedure, followed by assessments at the first month, third month, and sixth months, and subsequently every 6 to 12 months thereafter. Patients' genetic backgrounds are evaluated to identify potential genetic disorders that may predispose them to thrombogenicity. A therapeutic dose of low molecular weight heparin (LMWH), adjusted according to the patient's body weight, is generally prescribed for the first month, followed by a prophylactic dose until the third month. After this period, life-long aspirin at 100 mg is recommended. Alternatively, a therapeutic dose of LMWH may be prescribed for 1 month, followed directly by life-long aspirin at 100 mg, depending on the patient's individual needs.

 

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Statistical Analysis

All statistical analyses were completed using IBM SPSS Version 20 software. Categorical variables were expressed as frequencies and percentages, while quantitative variables were described as means with standard deviations or medians with interquartile ranges, depending on whether the data followed a normal or nonparametric distribution. The Shapiro–Wilk test was used to assess the normality of data distribution. A paired t-test was conducted to evaluate the significance of the reduction in PSG before and after the TIPSS procedure. A p-value of less than or equal to 0.05 was considered statistically significant.

 

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Results

A total of 10 patients underwent TIPSS procedures at our institution between January 2020 and December 2024, with two procedures performed in each of the first 2 years and three procedures in each of the subsequent 2 years. The study included six male and four female patients, with a median age of 45.5 years (range: 12–74 years). The clinical characteristics of the patients are presented in [Table 1]. All patients were diagnosed with portal hypertension and had indications for TIPSS, including refractory ascites (n = 40%) and variceal bleeding (n = 60%). All cases were performed under elective conditions except for one emergent TIPSS procedure due to acute variceal bleeding.

Table 1 Demographic and clinical characteristics of patients

	n = 10	%
Age (y)[b]  Minimum–Maximum	45.5 (37.5) 12–74
Male	6	60
Etiology of cirrhosis  Alcohol  Nonalcoholic fatty liver disease  Viral hepatitis  Budd–Chiari syndrome  Cryptogenic	1 1 2 3 3	10 10 20 30 30
Liver function status  MELD score[a]  Child–Pugh Score[b]	10.8 ± 2.25 7 (3)
Indication for TIPSS  Variceal bleeding   Actively bleeding varices  Refractory ascites	6 1 4	60 10 40

Abbreviations: MELD, Model for End-Stage Liver Disease; TIPSS, transjugular intrahepatic portosystemic shunt.

^a Mean ± standard deviation.

^b Median (interquartile range).

Procedural success was evaluated in three categories—technical, hemodynamic, and clinical—as previously described elsewhere[19] ([Table 2]).

Table 2 Procedural data and postprocedural outcomes

	n = 10	%
Technical success[a] Intraprocedural complications  Morbidity   Bleeding   Infections   Vascular injury   Biliary complications  Mortality Hemodynamic success[a] Clinical success[a]  Early clinical outcomes (the first 30 days postprocedure) Early complications (the first 30 days postprocedure)   Shunt thrombosis-occlusion/stent migration   Hepatic encephalopathy   Biliary complications   Exitus[b]  Early readmission (30–90 days period)   Intimal hyperplasia   Shunt occlusion[c]   Stent migration  Hepatic encephalopathy[c]   Late readmission (after 90 days)   Intimal hyperplasia   Shunt occlusion   Stent migration	9 1 1 1 0 0 0 0 9 9 3 0 2 0 1 2 0 2 0 1 3 2 1 0	90% 10% 10% 10% 0% 0% 0% 0% 100% 100% 33.3% 0% 22.2% 0 11.1% 25% 0% 25% 0% 12.5% 37.5% 25% 12.5% 0%

^a Success was evaluated in 3 categories—technical, hemodynamic, and clinical.

^b Nonprocedure-related mortality due to hypovolemic shock occurred in the patient presented with acute variceal bleeding before the procedure.

^c Stent occlusion and hepatic encephalopathy developed in the same patient in the second month following the procedure.

Note: The boldfaced values in represent the key outcome measures, the rates of technical, hemodynamic, and clinical success rates.

In 90% of cases, technical success was achieved, with successful shunt placement in 9 procedures. Shunt placement could not be completed in one patient presenting with refractory ascites related to Budd–Chiari syndrome, characterized by thrombosis in all hepatic veins and the inferior vena cava. Despite multiple attempts, hepatic vein catheterization could not be achieved due to the severity of the thrombosis. Intraprocedural complications are categorized into two main divisions: morbidity, including bleeding, infections, vascular injury, or biliary complications, and mortality, which can occur during the TIPSS procedure. Only one instance of mild bleeding was observed at the puncture site, which did not lead to any decrease in blood counts or warrant blood transfusion, and no mortality was reported in any of the patients.

The mean PVP before the procedure was 37.44 ± 2.74 mm Hg, decreasing to 20.11 ± 1.45 mm Hg postprocedure. Hemodynamic success, defined as a reduction in PSG ≤ 12 mm Hg, was achieved in all patients (100%) ([Table 3]). The mean PSG before the procedure was 27 ± 3.32 mm Hg, which decreased to 8.56 ± 1.74 mm Hg postprocedure. Additionally, all patients experienced a reduction in pressure gradient exceeding 25%, with individual reductions ranging from 56.5 to 76.0%. The average decrease in pressure gradient across our cohort was approximately 68.1% ([Fig. 3]).

Table 3 Pressure measurements

	TIPSSpre	TIPSSpost
Portal venous pressure (PVP) (mm Hg) Minimum–Maximum Right atrial pressure (RAP) (mm Hg) Minimum–Maximum Portosystemic pressure gradients (PSG) (mm Hg) Minimum–Maximum	37.44 ± 2.74[a] 34–42 10.44 ± 1.24[a] 9–12 27 ± 3.32[a] 23–33	20.11 ± 1.45[a] 18–22 11.56 ± 1.67[a] 10–15 8.56 ± 1.74[a] 6–11

Abbreviation: TIPSS, transjugular intrahepatic portosystemic shunt.

^a Mean ± standard deviation.

Fig. 3 Illustrates the portosystemic pressure gradient for nine patients, comparing pre- and postprocedure values. The solid navy line represents preprocedure pressures, while the postprocedure values are indicated by a dotted navy line. The red dashed line marks the 12 mm Hg threshold, highlighting the target for successful pressure reduction. Each patient's pressure reduction percentage is labeled in red, demonstrating a consistent decrease across the cohort.

Regarding the assessment of clinical success, which is defined as a complete or partial response following TIPSS for the specific indication (the first 30 days postprocedure), for the refractory ascites subgroup (3 patients), ascites control was achieved in all cases following the procedure, with no need for large-volume paracentesis within 30 days postprocedure. For the refractory variceal bleeding subgroup (6 patients), the TIPSS procedure was performed electively, and successful bleeding control was achieved in all cases, with no episodes of rebleeding requiring intervention reported within 30 days postprocedure to the last control. In one patient presenting with acute variceal bleeding, in whom endoscopic ligation had failed to control the bleeding, an emergent TIPSS procedure was performed. Although hemostasis was achieved postprocedure, the patient subsequently experienced hypovolemic shock and expired in the intensive care unit the day after the procedure.

Among the eight patients who underwent elective TIPSS, two developed grade 1 to 2 HE (HE was graded as per the West–Haven criteria)[20] in 1 month after discharge, which resolved with conventional medical treatment. No other early complications, such as stent thrombosis/occlusion, stent migration, or biliary complication, were recorded within the first 30 days postprocedure ([Table 2]).

Shunt occlusion was diagnosed in two patients during the second month following the procedure. In one of these patients, shunt revision was successfully performed. The other patient was hospitalized due to concurrent stent occlusion, HE, and acute renal failure associated with hyperuricemia. During follow-up, the patient's condition deteriorated, resulting in mortality in the intensive care unit. Apart from these, no early readmissions requiring additional intervention were reported.

During follow-up, two patients developed stent stenosis due to intimal hyperplasia at the 6th and 22nd months. Transjugular catheterization followed by percutaneous transluminal angioplasty (PTA) resulted in successful recanalization. Another patient, a 12-year-old migrant with Budd–Chiari syndrome and concomitant malnutrition, showing poor adherence to medical therapy, developed shunt occlusion at the sixth-month follow-up. Imaging confirmed the occlusion, the patient declined further treatment and voluntarily withdrew from follow-up. Aside from these three cases (37.5%), no late readmissions were recorded ([Tables 2] and [4]).

Table 4 Clinical follow-up summary for each patient

Patient number	Age	Etiology/Indication	Reintervention[a]	Follow-up period[a]	Outcome
1	65	Cryptogenic/Refractory ascites	2 / Shunt occlusion – revision	3	Alive
2	74	Nonalcoholic fatty liver disease/Refractory ascites	X	5	Alive
3	20	Budd–Chiari syndrome/Variceal bleeding	2 / Shunt occlusion - X	3	Exitus
4	51	Cryptogenic/Refractory ascites	6 / Intimal hyperplasia - PTA	17	Alive
5	56	Alcohol/Variceal bleeding	X	18	Non-procedure-related exitus - HCC
6	12	Budd–Chiari syndrome/Variceal bleeding	6 / Shunt occlusion - X	6	Voluntarily withdrew from follow-up
7	72	Viral hepatitis/Acute variceal bleeding	X	0	Nonprocedure-related exitus - hypovolemic shock
8	13	Cryptogenic/Variceal bleeding	22 / Intimal hyperplasia - PTA	46	Alive
9	40	Viral hepatitis/Variceal bleeding	X	20	Alive

Abbreviations: HCC, hepatocellular carcinoma; PTA, percutaneous transluminal angioplasty.

^a Reintervention times and follow-up period are expressed in months, with an “X” indicating patients who did not require any reintervention.

Except for the patient who expired from hypovolemic shock on the first day postprocedure due to pre-TIPSS acute variceal bleeding, the follow-up periods for patients in our cohort were 3 to 46 months. No procedure-related mortality was recorded ([Table 4]).

Procedural fluoroscopy time measurements were obtained from the angiography suite's procedure reports. The mean duration of the TIPSS procedure was 147 ± 59 minutes (range: 61–246 minutes).

 

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Discussion

This study presents the outcomes of TIPSS procedures performed at a very low-volume center over a 4-year period, providing valuable insights into the feasibility, safety, and efficacy of TIPSS in a smaller clinical setting. Despite the challenges associated with lower procedural volumes, our cohort achieved technical, clinical, and hemodynamic success rates comparable to those reported in higher-volume centers.

The American College of Radiology's (ACR) practice parameters establish various indicators to assess the safety and efficacy of the TIPSS procedure. Within these primary outcomes, success is further categorized into three subdivisions, which are technical, hemodynamic, and clinical success.[19] Cannella et al demonstrated that to have the best results in these three categories, operators should always follow the prior guidelines and expert opinions.[21] Our study aimed to evaluate our results based on these success thresholds defined by the ACR guidelines, which are compatible with our final results.

Technical success is effectively placing a shunt between the portal and hepatic veins. Although our technical success rate was 90%, we encountered only one incomplete shunt placement in a patient with Budd–Chiari syndrome and extensive hepatic vein with concomitant vena cava thrombosis. Guidelines define a 95% threshold for technical success when both the portal and hepatic veins are patent.[19] Our 90% success rate is close to this threshold; however, considering the extensive thrombosis in the vena cava and hepatic veins of the patient with unsuccessful shunt placement, this case does not entirely meet the criteria for having a technical failure. Both Hamid et al, who reported an 84.2% technical success rate in 19 patients over 7.5 years,[22] and Perello et al, who achieved a 98% technical success rate in 132 patients over 14 years,[23] conducted their studies in low-volume centers. While Perello et al's outcomes exceeded the 95% technical success threshold recommended by current guidelines, the results from Hamid et al are comparable to our study's 90% success rate. Additionally, in terms of procedure duration, a study by Barrera Gutierrez et al, involving 154 patients at a single medium-volume center, reported a mean TIPSS procedure time of 169 minutes, which is comparable to the findings of our study.[24]

Hemodynamic success was defined as a reduction in PSG to ≤ 12 mm Hg, with a threshold of 90%.[19] Although high-volume centers are generally associated with favorable outcomes, large cohort studies, such as the one by Büttner et al, which reported a 77.9% hemodynamic success rate across 835 TIPSS procedures over 25 years in a very high-volume institution,[4] and another by Tripathi et al, which observed an 83.9% success rate in 472 patients over 10 years in a high-volume center,[25] demonstrate that even in these settings, success rates may fall short of the threshold recommended by current guidelines. Also, a meta-analysis reported an overall pooled hemodynamic success rate of 86.7%.[26] Notably, the findings from our study demonstrate that TIPSS procedures were highly effective in lowering portal pressure in this small cohort. All patients (100%) in this cohort achieved a reduction in PSG exceeding 25% and reached levels below 12 mm Hg, with an average reduction in PSG of 68.1%. These results not only exceed established benchmarks but also show that low-volume centers can achieve strong hemodynamic outcomes when procedures are guided by standardized protocols and performed by experienced operators.

Clinical success is assessed by observing a complete or partial response to TIPSS for the specific indication, consistent with clinical assessments. Guidelines specify threshold values of 90% for variceal bleeding control and 50 to 90% for ascites management. Regarding clinical outcomes in our cohort, ascites control was successful in all patients within the refractory ascites subgroup. Given appropriate clinical and medical support, there was no requirement for large-volume paracentesis within 30 days postprocedure. Correspondingly, bleeding control was maintained in the refractory variceal bleeding subgroup, with no rebleeding episodes requiring intervention in the early postprocedural period. Similarly, in a study by Perello et al, the clinical success rate was reported as 85% in patients treated for variceal bleeding and 95% in those with refractory ascites or hydrothorax, demonstrating favorable outcomes across multiple indications in a low-volume center.[23]

Besides, the intraprocedural complication rate was 5%, with only one instance of mild bleeding observed at the puncture site, which did not lead to any decrease in blood counts or warrant blood transfusion. Notably, among the patients who underwent the TIPSS procedure, no procedure-related mortality occurred in our cohort. This outcome underscores the procedural safety in our cohort, as no immediate procedural complications were encountered among these patients. One patient with acute variceal bleeding experienced substantial blood loss before the procedure and underwent emergent TIPSS. Although the procedure successfully achieved hemostasis, the patient subsequently developed hypovolemic shock and expired in the intensive care unit shortly after the procedure. This case represents a nonprocedural mortality, highlighting the elevated risks associated with emergent TIPSS in critically ill patients and indicating the importance of thorough risk assessment. The above data were in line with most prior reports.[27] [28] In a nonrandomized comparative study of emergency TIPSS and esophageal transection for uncontrolled variceal hemorrhage, Jalan et al reported a 30-day mortality of 42% in the TIPSS group.[29]

TIPSS procedures are associated with major and minor complications.[19] Among minor complications, which have an overall rate of 4%, transient contrast-induced renal failure and encephalopathy controlled by medical therapy are commonly observed. Regarding the early complications in our cohort, we have reached similar results in line with previous reports, and they were classified as minor complications. Only two patients (22.2%) developed grade 1 to 2 HE within the first month after discharge, responding very well to conventional medical management. Guidelines define a 40% threshold for encephalopathy controlled by medical therapy.[19] In a Korean multicenter study involving 230 patients across 13 university hospitals, HE developed in 23.6% of cases, with most cases being managed conservatively.[30] Pateria et al reported an encephalopathy rate of 26%, with all cases managed medically, in a 12-year study of 53 patients. This rate remains within the guideline-recommended range, supporting the manageable risk profile of TIPSS-related HE even in low-volume centers.[31] Encephalopathy in our study also remains consistent with the reported range of 15 to 48% in the literature.[32] The overall reported rate of major complications is 3%, with specific issues including hemoperitoneum, stent malposition, hemobilia, hepatic infarction, renal failure requiring chronic dialysis, and severe encephalopathy. Fortunately, none of the patients in our study developed major complications, including grade 3 or 4 HE. It is known that severe encephalopathy, which necessitates hospitalization, rates are directly influenced by patient selection, as with all portosystemic diversion techniques. In patients with advanced or refractory ascites, severe encephalopathy occurs in approximately 30 to 40% of cases.[33] [34] Conversely, in patients selected for elective procedures with Child–Pugh class A or B liver conditions, the incidence is considerably lower, appearing in only 3 to 10% of cases.[35] [36]

Clinical readmissions following a successful TIPSS procedure represent another critical aspect of this complex intervention, significantly burdening the gastroenterology outpatient clinic. This burden, associated with the clinical course of the disease, may not always be accurately quantified. Regarding readmissions due to shunt-related complications (early readmissions [30–90 days period after procedure]: 25%; late readmissions [after 90 days]: 37.5%), two patients experienced shunt occlusion within the second month after the procedure; in one, shunt revision was successfully achieved, while the other faced additional complications, including acute renal failure and HE, ultimately resulting in mortality, which underscores the importance of close postprocedural monitoring, particularly in low-volume settings. A unique challenge arose in a 12-year-old patient with Budd–Chiari syndrome, developing shunt occlusion by the sixth month, most probably due to poor socioeconomic conditions and weak adherence to the best medical therapy. Despite efforts encouraging the recanalization, the patient declined further intervention and chose to discontinue follow-up. This case emphasizes the importance of ongoing patient engagement, particularly in complex, chronic conditions requiring sustained care. Additionally, two cases of stent stenosis due to intimal hyperplasia were noted at the 6th and 22nd months, successfully treated with PTA.

Recent large-scale analyses have highlighted the significant impact of annual procedural volume on TIPSS outcomes. A study analyzing 5,529 adult TIPSS cases—of which 63% were performed at hospitals with 1 to 4 TIPSS per year, 21% at hospitals with 5 to 9, 9% at hospitals with 10 to 19, 4% at hospitals with 20 to 29, and only 3% at hospitals performing ≥ 30 procedures annually—demonstrated a clear inverse relationship between institutional TIPSS volume and inpatient mortality. Specifically, centers performing more than 20 procedures annually were associated with significantly lower mortality. Furthermore, the unadjusted mortality rates were nearly double in low-volume hospitals compared to high-volume ones, both in elective (7.9% vs. 3.1%) and emergent (14.2% vs. 7.5%) cases.[9] These findings underscore the volume–outcome relationship and raise concerns about procedural safety and efficacy in low-volume settings. Contrary to these concerns, our study contributes to the growing body of literature suggesting that very low-volume centers can still achieve favorable outcomes under specific circumstances. Notably, Sarwar et al reported that hospitals performing more than 20 TIPSS procedures per year with the lowest associated mortality rates were exclusively metropolitan teaching centers.[9] Although our institution qualifies as a very low-volume center based on its annual TIPSS volume, it is a metropolitan tertiary university hospital where experienced interventional radiologists perform procedures following standardized multidisciplinary protocols. Our outcomes are comparable to those reported by high-volume institutions, indicating that while procedural volume is a significant factor, institutional infrastructure, multidisciplinary collaboration, and operator expertise play a crucial role in achieving successful results and may help bridge the outcome gap between low- and high-volume centers.

Our study acknowledges several limitations, the most important of which is its retrospective design. Second, the small sample size limits the generalizability of our findings. Third, the single-center nature of this study restricts its applicability to other institutions, as procedural outcomes may differ based on varying levels of staff expertise and institutional protocols. Lastly, the limited follow-up period hinders a comprehensive evaluation of long-term outcomes and late complications, which are crucial to understanding the full efficacy and safety profile of TIPSS. Future studies should investigate TIPSS outcomes in low-volume centers with larger patient populations obtained over a more extended period and across more diverse clinical settings. Multicenter collaborations would further clarify the influence of procedural volume on TIPSS outcomes, ultimately supporting the development of refined guidelines to optimize TIPSS practices in low-volume institutions.

 

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Conclusion

In conclusion, this study demonstrates that TIPSS can be successfully performed in a very low-volume center with outcomes that align closely with the results reported in the literature, including higher-volume institutions. Despite the technical challenges and potential complications associated with TIPSS, the technical, hemodynamic, and clinical success rates and the safety profile observed in our cohort suggest that TIPSS is a feasible and effective option even in institutions with a limited procedural volume. These findings highlighted the importance of establishing standardized protocols and ensuring skilled personnel achieve favorable outcomes in low-volume centers. Future research with larger cohorts, including low-volume centers with multicenter collaborations, is warranted to elucidate further the factors contributing to TIPSS success and to optimize procedural approaches in low-volume institutions.

 

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Conflict of Interest

None declared.

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Publication History

Article published online:
30 July 2025