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Transjugular IntrahepaticPortosystemic Shunt (TIPSS)
Clinical Policy Bulletins Medical Clinical Policy Bulletins
Policy History
Last Revi
ew
05/07/2019
Effective: 06/18/199
Next Review:
02/27/2020
Review Hi
story
Definitions
Additional Information
Number: 0259
Policy *Please see amendment for Pennsylvania Medicaidat the end
of this CPB.
Aetna considers transjugular intrahepatic portosystemic shunt
(TIPSS) medically
necessary in members with bleeding gastric, esophageal or
ectopic (including
anorectal, intestinal, and stomal) varices, moderate Budd-Chiari
syndrome and who
have failed to respond to anticoagulation, portal hypertensive
gastropathy with
recurrent bleeding despite the use of beta-blockers, severe
refractory ascites, and
refractory hepatic hydrothorax (see background section for
selection criteria).
Aetna considers polyflorotetraethylene (PTFE)-coated stents
medically necessary
for TIPSS.
Aetna considers TIPSS experimental and investigational for all
other indications
including any of the following conditions because the
effectiveness of TIPSS for
these conditions has not been proven:
Cirrhosis-related chylothorax; or
Controlling bleeding from gastro antral vascular ectasia in
persons with
cirrhosis; or
Correction of hypersplenism and thrombocytopenia; or
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Hepatopulmonary syndrome; or
Hepatorenal syndrome; or
Initial therapy for acute variceal hemorrhage; or
Initial therapy to prevent first or recurrent variceal
hemorrhage; or
Portal hypertension associated with polycystic liver disease or
Caroli
disease; or
Portal-mesenteric venous thrombosis; or
Pre-hepatic portal hypertension; or
Pre-operative reduction in portal hypertension before liver
transplantation;
or
Prevention of re-bleeding in cirrhotic individuals with
cavernous
transformation of the portal vein; or
Prophylaxis of variceal hemorrhage; or
Pulmonary hypertension; or
Sinusoidal obstruction syndrome (veno-occlusive disease).
Background
Transjugular intrahepatic portosystemic shunt (TIPSS) has been
shown in a
number of clinical studies to be an option in the treatment of
acute variceal bleeding
that can not be successfully controlled with sclerotherapy and
for treatment of
recurrent variceal bleeding that can not be successfully
controlled with medical
management or sclerotherapy.
Transjugular intrahepatic portosystemic shunt does not involve
an incision; rather, a
catheter is placed percutaneously into the jugular vein through
which a permanent
intrahepatic shunt is created between the hepatic and portal
veins. Blood flow is
diverted around the diseased liver, thus easing portal
hypertension. It is usually
performed in the angiography or interventional radiology
laboratory under
intravenous anesthesia.
The efficacy of TIPSS as the initial treatment of variceal
bleeding or in the
prevention of secondary variceal bleeding has not been
established.
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The American Association for the Study of Liver Diseases (AASLD)
practice
guidelines on the role of TIPSS creation in the management of
portal hypertension
has a number of recommendations, including the following (Boyer
and Haskal,
2005):
The use of TIPSS to treat hepatopulmonary syndrome can not
be
recommended (grade II-3).
The use of TIPSS to treat sinusoidal obstruction syndrome can
not be
recommended (grade II-3).
TIPSS is effective in the control of hepatic hydrothorax, but it
should be used
only in patients whose effusion can not be controlled by
diuretics and sodium
restriction (grade II-3).
TIPSS is effective in the prevention of rebleeding from gastric
and ectopic
varices (including intestinal, stomal, and anorectal varices)
and is the
preferred approach for the prevention of rebleeding in this
group of
patients (grade II-3).
Grade II-3 refers to multiple time series, dramatic uncontrolled
experiments.
Pan et al (2008) identified factors predictive of survival after
TIPSS creation. Log-
rank tests were used to compare the cumulative survival
functions among groups of
patients who underwent TIPSS creation for various indications.
Thirty-day mortality
after TIPSS creation was examined by logistic regression. Cox
proportional-
hazards analyses were performed to analyze the cumulative 90-day
and 1-year
survival. Selected variables such as creatinine, bilirubin, and
International
Normalized Ratio (INR) were assessed with respect to survival.
The study included
352 patients, of whom 229 (65.1 %) were male. The mean age at
the time of
TIPSS creation was 53.6 years (range of 21 to 82). A Model for
End-stage Liver
Disease (MELD) score greater than 15 was significantly
associated with poor
survival (p < 0.05) at 30 days, 90 days, and 1 year after
TIPSS creation.
Independently, a serum total bilirubin level greater than 2.5
mg/dL, an INR greater
than 1.4 (p < 0.05), and a serum creatinine level greater
than 1.2 mg/dL were
predictive of poor survival. Finally, age greater than 70 years
was associated with
poor survival at 90 days and 1 year after TIPSS creation (p <
0.05). The authors
concluded that the choice to create a TIPSS in individuals whose
MELD score is
greater than 15 and/or whose age is greater than 70 years should
involve a careful
consideration of risk/benefit ratio, taking into account the
finding that such patients
have significantly poorer survival after TIPSS creation.
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Garcia-Pagán et al (2008) reported the long-term results and
prognostics factors in
124 patients with Budd-Chiari syndrome (BCS) who were treated
with TIPSS.
Subjects were followed until death, orthotopic liver
transplantation (OLT), or last
clinical evaluation. Prior to treatment with TIPSS, BCS patients
had a high MELD
and high Rotterdam BCS prognostic index (98 % of patients at
intermediate-risk or
high-risk) indicating severity of liver dysfunction. However, 1-
and 5-year OLT-free
survival were 88 % and 78 %, respectively. In the high-risk
patients, 5-year OLT-
free survival was much better than that estimated by the
Rotterdam BCS index (71
% versus 42 %, respectively). In the whole population,
bilirubin, age, and INR for
prothrombin time independently predicted 1-year OLT-free
survival. A prognostic
score with a good discriminative capacity (area under the curve,
0.86) was
developed from these variables. Seven out of 8 patients with a
score greater than
7 died or underwent transplantation versus 5 out of 114 patients
with a score of less
than 7. The authors concluded that long-term outcome for
patients with severe
BCS treated with TIPSS is excellent even in high-risk patients,
suggesting that
TIPS may improve survival. Furthermore, these researchers
identified a small
subgroup of BCS patients with poor prognosis despite TIPSS who
might benefit
from early OLT.
Murad et al (2008) noted that the clinical outcome of a covered
versus uncovered
TIPSS for patients with BCS is as yet largely unknown. These
investigators
compared patency rates of bare and polytetrafluoroethylene
(PTFE)-covered
stents, and examined clinical outcome using 4 prognostic indices
(Child-Pugh
score, Rotterdam BCS index, modified Clichy score and MELD). A
total of 23
TIPSS procedures were performed on 16 patients. The primary
patency rate at 2
years was 12 % using bare and 56 % using covered stents (p =
0.09). These
researchers found marked clinical improvement at 3 months
post-TIPSS as
determined by a drop in median Child-Pugh score (10 to 7, p =
0.04), Rotterdam
BCS index (1.90 to 0.83, p = 0.02) and modified Clichy score
(7.77 to 2.94, p =
0.003), but not in MELD (18.91 to 17.42, p = 0.9). Survival at 1
and 3 years post-
TIPSS was 80 % (95 % confidence interval [CI]: 59 to 100 %) and
72 % (95 % CI:
48 to 96 %). Four patients (25 %) died and 1 required liver
transplantation. The
authors concluded that a TIPSS using PTFE-covered stents shows
better patency
rates than bare stents in BCS. Moreover, TIPSS leads to an
improvement in
important prognostic indicators for the survival of patients
with BCS.
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Corso et al (2008) evaluated the safety and effectiveness of
TIPSS in the treatment
of patients affected by BCS. A total of 15 patients (7 male and
8 female subjects,
age range of 7 to 52 years) with BCS uncontrolled by medical
therapy were treated
with TIPSS placement. In 7 cases BCS was idiopathic, in 4 it was
caused by
myeloproliferative disorders and in 4 by other disorders. One
patient also had
portal vein thrombosis. In 5/15 cases TIPSS was created through
a transcaval
approach. Eight patients (53.4 %) received a bare stent, and 7
(46.6 %) received a
stent graft. The follow-up lasted a median of 29.4 (range of 3.2
to 68) months.
Technical success was achieved in all patients without major
complications.
Transjugular intrahepatic portosystemic shunt was very effective
in decreasing the
portosystemic pressure gradient from 26.2 +/- 5.8 to 10 +/- 6.2
mmHg. All patients
but 2 were alive at the time of writing. Acute leukemia was the
cause of the single
early death and was unrelated to the procedure. The patient with
portal vein
thrombosis underwent thrombolysis before TIPSS, but the vein
occluded again after
3 weeks, and the patient died 6 months later. The other patients
showed significant
improvements in liver function, ascites and symptoms related to
portal
hypertension. Primary patency was 53.3 %, and primary assisted
patency was
93.3 %. No patient required or was scheduled for liver
transplantation. The
authors concluded that TIPSS is an effective and safe treatment
for BCS and may
be considered a valuable alternative to traditional surgical
portosystemic shunting
or liver transplantation.
Amarapurkar and associates (2008) assessed patterns of
obstruction, etiological
spectrum and non-surgical treatment in patients with BCS. A
total of 49
consecutive cases were prospectively evaluated. All patients
with refractory ascites
or deteriorating liver function were, depending on morphology of
inferior vena cava
(IVC) and/or hepatic vein (HV) obstruction, triaged for
radiological intervention, in
addition to anti-coagulation therapy. Asymptomatic patients,
patients with diuretic-
responsive ascites and stable liver function, and patients
unwilling for surgical
intervention were treated symptomatically with anti-coagulation.
Mean duration of
symptoms was 41.5 +/- 11.2 (range of 1 to 240) months. Hepatic
vein thrombosis
(HVT) was present in 29 (59.1 %), IVC thrombosis in 8 (16.3 %),
membranous
obstruction of IVC in 2 (4 %) and both IVC-HV thrombosis in 10
(20.4 %) cases. Of
35 cases tested for hyper-coagulability, 27 (77.1 %) were
positive for 1 or more
hyper-coagulable states. Radiological intervention was
technically successful in
37/38 (97.3 %): IVC stenting in 7 (18.9 %), IVC balloon
angioplasty in 2 (5.4 %),
combined IVC-HV stenting in 2 (5.4 %), HV stenting in 11 (29.7
%), TIPSS in 13
(35.1 %) and combined TIPSS-IVC stenting in 2 (5.4 %).
Complications
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encountered in follow-up: death in 5, re-stenosis of the stent
in 5 (17.1 %), hepatic
encephalopathy in 2 and hepatocellular carcinoma in 1 patient.
Of 9 patients
treated medically, 2 showed complete resolution of HVT. The
authors concluded
that in their series, HVT was the predominant cause of BCS. In
the last 5 years
with the availability of sophisticated tests for
hyper-coagulability, etiologies were
defined in 85.7 % of cases. Non-surgical management was
successful in most
cases.
Current guidelines from the AASLD on TIPSS (Boyer and Haskal,
2010) indicated
that Teflon-coated stents are preferred over bare stents to
lower the risk of shunt
dysfunction. This position is supported by a number of studies
of PTFE-covered
stents in TIPSS.
Tripathi et al (2006) assessed the shunt function and clinical
efficacy of PTFE-
covered stents in a single center. A total of 316 patients with
uncovered stents
before the introduction of covered stents (group 1) and 157
patients with the Viatorr
Gore PTFE-covered stents at the time of TIPSS creation (group 2)
were studied.
The mean follow-up was 22.8 +/- 25.4 and 13.1 +/- 12.5 months,
respectively (p <
0.01). Shunt insufficiency was greater in group 1 [54 % versus 8
% at 12 months;
relative hazard (RH) 8.6; 95 % CI: 4.8 to 15.5; p < 0.001].
The incidence of variceal
re-bleeding was greater in group 1 (11 % versus 6 % at 12
months; RH 2.4; 95 %
CI: 1.1 to 5.1; p < 0.05). T he incidence of hepatic
encephalopathy was greater in
group 1 (32 % versus 22 % at 12 months; RH 1.5; 95 % CI: 1.1 to
2.3; p < 0.05).
Mortality was similar in the two groups. The authors concluded
that the Viatorr type
of PTFE-covered stent results in vastly improved patency
compared with uncovered
stents, with reduced rates of variceal re-bleeding and hepatic
encephalopathy. This
type of covered stent has the potential for superior clinical
efficacy compared with
uncovered stents.
Saad et al (2010) compared functional and anatomic outcomes of
TIPSs created
with the specialized Viatorr stent versus a Wallstent/Fluency
stent combination.
Retrospective review of patients who underwent TIPS creation
with stent-grafts was
conducted over a 54-month period ending in June 2008. Patients
were divided into
3 groups: (i) Viatorr only, (ii) Fluency only, and (iii)
combined Viatorr/Fluency, the
latter of which was included in the overall evaluation but
excluded from the
comparative analysis between the Viatorr and Fluency groups.
Patient
demographics, Child-Pugh scores, and PSG reduction were
compared. Patencies
were calculated using the Kaplan-Meier method and compared. A
total of 126
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TIPSs created with stent-grafts were found: 28 with Fluency
stents, 93 with Viatorr
devices, and 5 combined. No significance in demographic factors
or PSGs was
found among groups (p > 0.05). Major encephalopathy rates
were 3.6 % and 4.3 %
in the Fluency and Viatorr groups, respectively (p = 1.000).
Hemodynamic success
rates were 93 % and 98 % in the Fluency and Viatorr groups,
respectively (p =
0.099). The primary unassisted patency rates at 6, 9, and 12
months were 87 %,
81 %, and 81 %, respectively, in the Fluency group and 95 %, 93
%, and 89 %,
respectively, in the Viatorr group (p = 0.03). Portal and
hepatic end stenoses were
the causes of TIPS narrowing in the Fluency and Viatorr groups,
respectively. The
authors concluded that the Wallstent/Fluency stent combination
is associated with a
1-year patency rate greater than 80 %, with no significant
difference versus the
Viatorr stent regarding technical and hemodynamic success and
encephalopathy
rate. However, the Viatorr stent is associated with improved
patency (89 %) versus
this bare stent/stent-graft combination.
In a meta-analysis, Yang et al (2010) compared the patency and
clinical outcomes
of TIPS with PTFE-covered stent-grafts versus bare stents.
Pertinent studies were
retrieved through PubMed (1950 to 2010), MEDLINE (1950 to 2010),
and reference
lists of key articles. Outcome measures were primary patency,
risk of
encephalopathy and survival. Time-to-event data analysis was
used to calculate
the overall hazard ratios (HR). A total of 6 studies were
identified including a total
of 1,275 patients (346 TIPS with PTFE-covered stent-grafts and
929 TIPS with bare
stents). Pooled shunt patency data from 4 eligible studies
suggested a significant
improvement of primary patency in patients who were treated with
PTFE-covered
stent-grafts (HR = 0.28, 95 % CI: 0.20 to 0.35). Pooled
encephalopathy data
from 3 eligible studies suggested a significant reduction of
risk in the PTFE-covered
group (HR = 0.65, 95 % CI: 0.45 to 0.86). Pooled survival data
from 4 eligible
studies also suggested a significant decrease of mortality in
the PTFE-covered
group (HR = 0.76, 95 % CI: 0.58 to 0.94). No statistical
heterogeneity was
observed between studies for either outcome. The authors
concluded that this meta-
analysis showed that the use of PTFE-covered stent-grafts
clearly improves shunt
patency without increasing the risk of hepatic encephalopathy
and with a trend
towards better survival.
Wu et al (2010) examined the outcome of a modified TIPSS
(MTIPSS) in the
treatment of the BCS. A total of 11 patients with severe BCS
were selected for
MTIPS treatment -- 3 patients had an acute history (less than 2
months) and 8 had
a subacute or a chronic course of the disease. All patients were
associated with
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variceal bleeding and massive ascites. The diagnosis of BCS was
established by
duplex sonography, computed tomography scan, magnetic resonance
imaging,
angiography of hepatic veins and inferior vena cava, and liver
biopsy. The shunt
was established using conventional self-expandable stents with
diameter of 10 cm
in all patients. The mean follow-up was 60.55 +/- 42.76 months.
The shunt
reduced the portosystemic pressure gradient from 30.32 +/- 7.69
to 9.08 +/- 3.43
mmHg and improved the portal flow velocity from 11.24 +/- 2.75
to 52.16 +/- 13.68
cm/s. Clinical symptoms as well as the biochemical test results
improved
significantly during 3 weeks after shunt treatment except for 1
death caused by
hepatic failure. Ten patients are alive without clinical
symptoms. Three revisions
in 2 patients were needed during the follow-up. The inflation of
stenosised shunt
was performed in 1 patient, and the inflation of stenosised
shunt and the re-
implantation of stent in another patient. The other 8 patients
had no revisions. The
authors concluded that MTIPSS provides an excellent outcome in
patients with
BCS. It may be regarded as an option for the acute and long-term
managements of
these patients.
The AASLD's guideline on the role of TIPSS in the management of
portal
hypertension (Boyer and Haskal, 2005) stated that the decision
to create a TIPSS
in a patient with BCS should be based on the severity of
disease, and only patients
with moderate disease appear to be reasonable candidates for a
TIPSS. Patients
with BCS and mild disease can be managed medically, whereas
those with more
severe disease or acute hepatic failure are best managed by
liver transplantation.
Furthermore, the use of TIPSS to treat sinusoidal obstruction
syndrome or
hepatopulmonary syndrome can not be recommended.
The AASLD's 2009 updated guidelines on the role of TIPS in the
management of
portal hypertension (Boyer and Haskal, 2010) has the following
recommendations:
The use of TIPS in the management of portal hypertensive
gastropathy
should be limited to those who have recurrent bleeding despite
the use of
betablockers. Evidence-II-3.
TIPS is ineffective in controlling bleeding from gastro antral
vascular
ectasia in patients with cirrhosis and should not be used in
this situation.
Evidence-II-3.
TIPS will decrease the need for repeated large volume
paracentesis in
patients with refractory cirrhotic ascites. However, given the
uncertainty as
to the effect of TIPS creation on survival and the increased
risk of
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encephalopathy, TIPS should be used in those patients who are
intolerant of
repeated large volume paracentesis. Evidence-I.
TIPS is effective in the control of hepatic hydrothorax, but it
only should be
used in patients whose effusion can not be controlled by
diuretics and
sodium restriction. Evidence-II-3.
TIPS is of investigatory use for the treatment of HRS,
especially type 1,
pending the publication of controlled trials. Evidence-II-3.
The decision to create a TIPS in a patient with Budd-Chiari
syndrome should
be based on the severity of their disease and only those with
moderate
disease and who have failed to respond to anticoagulation appear
to be
reasonable candidates for a TIPS. Evidence-II-3.
Patients with Budd-Chiari syndrome and mild disease can be
managed
medically whereas those with more severe disease or acute
hepatic failure
are best managed by liver transplantation. Evidence-II-3.
The use of TIPS to treat sinusoidal obstruction syndrome
(veno-occlusive
disease) can not be recommended. Evidence-II-3.
The use of TIPS to treat hepatopulmonary syndrome is not
recommended.
Evidence-II-3.
García-Pagán et al (2010) stated that patients with cirrhosis in
Child-Pugh class C
or those in class B who have persistent bleeding at endoscopy
are at high-risk for
treatment failure and a poor prognosis, even if they have
undergone rescue
treatment with a TIPSS. These researchers evaluated the earlier
use of TIPSS in
such patients; they randomly assigned, within 24 hours after
admission, 63 patients
with cirrhosis and acute variceal bleeding who had been treated
with vasoactive
drugs plus endoscopic therapy to treatment with a PTFE-covered
stent within 72
hours after randomization (early-TIPSS group, n = 32) or
continuation of vasoactive-
drug therapy, followed after 3 to 5 days by treatment with
propranolol or nadolol and
long-term endoscopic band ligation (EBL), with insertion of a
TIPSS if
needed as rescue therapy (pharmacotherapy-EBL group, n = 31).
During a median
follow-up of 16 months, re-bleeding or failure to control
bleeding occurred in 14
patients in the pharmacotherapy-EBL group as compared with 1
patient in the
early-TIPSS group (p = 0.001). The 1-year actuarial probability
of remaining free of
this composite end point was 50 % in the pharmacotherapy-EBL
group versus 97 %
in the early-TIPSS group (p < 0.001). Sixteen patients died
(12 in the
pharmacotherapy-EBL group and 4 in the early-TIPSS group, p =
0.01). The
1-year actuarial survival was 61 % in the pharmacotherapy-EBL
group versus 86 %
in the early-TIPSS group (p < 0.001). Seven patients in the
pharmacotherapy-EBL
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group received TIPSS as rescue therapy, but 4 died. The number
of days in the
intensive care unit and the percentage of time in the hospital
during follow-up were
significantly higher in the pharmacotherapy-EBL group than in
the early-TIPSS
group. No significant differences were observed between the 2
treatment groups
with respect to serious adverse events. The authors concluded
that in these
patients with cirrhosis who were hospitalized for acute variceal
bleeding and at high-
risk for treatment failure, the early use of TIPSS was
associated with significant
reductions in treatment failure and in mortality.
In an editorial that accompanied the afore-mentioned study,
Afdhal and Curry
(2010) state that additional clinical trials of adequate size
should be carried out to
confirm these findings and to examine the effect of a rapid
reduction in portal
pressure on disease progression in patients with cirrhosis of
other causes.
Qi and colleagues (2014) conducted a meta-analysis to compare
the incidence of
shunt dysfunction, variceal re-bleeding, encephalopathy, and
death between
patients treated with TIPS alone and those treated with TIPS
combined with
variceal embolization. All relevant studies were searched via
PubMed, EMBASE,
and Cochrane Library databases. Odds ratios (ORs) with 95 % CIs
were pooled.
Heterogeneity among studies and publication bias were assessed.
A total of 6
articles were included in this study. Type of stents was covered
(n = 2), bare (n =
2), mixed (n = 1), and unknown (n = 1). Varices were
angiographically embolized
by coils in 6 studies. Additional liquids agents were employed
in 3 studies.
Compared with TIPS alone group, TIPS combined with variceal
embolization group
had a significantly lower incidence of variceal re-bleeding (OR
= 2.02, 95 % CI:
1.29 to 3.17, p = 0.002), but a similar incidence of shunt
dysfunction (OR = 1.26, 95
% CI: 0.76 to 2.08, p = 0.38), encephalopathy (OR = 0.81, 95 %
CI: 0.46 to 1.43, p
= 0.47), and death (OR = 0.90, 95 % CI: 0.55 to 1.47, p = 0.68).
Neither any
significant heterogeneity nor proof of publication bias among
studies was found in
all meta-analyses. The authors concluded that adjunctive
variceal embolization
during TIPS procedures might be beneficial in the prevention of
variceal re-
bleeding. However, they stated that given the heterogeneity of
type of stents,
embolic agents, type of varices, and indications of variceal
embolization among
studies, additional well-designed randomized controlled trials
with larger sample
size and use of covered stents should be warranted to confirm
these findings.
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Qi et al (2015) performed a meta-analysis to compare the
outcomes of TIPS to
those of medical/endoscopic therapy for acute variceal bleeding
in cirrhotic
patients. The PubMed, EMBASE, and Cochrane Library databases
were searched
for all relevant comparative studies. Odds ratios and HR with 95
% CIwere pooled
for dichotomous and time-dependent variables, respectively.
Subgroup analyses
were performed according to the type of study design (randomized
or non-
randomized studies), source of bleeding (esophageal or gastric
varices), type of
stent (covered or bare stent), and patient selection (high risk
or unselected
patients). A total of 6 papers were eligible. Transjugular
intrahepatic portosystemic
shunt was superior to medical/endoscopic therapy in decreasing
the incidence of
treatment failure (OR = 0.22; 95 % CI: 0.11 to 0.44), improving
overall survival (HR
= 0.55; 95 % CI: 0.38 to 0.812), and decreasing the incidence of
bleeding-related
death (OR = 0.19; 95 % CI: 0.06 to 0.59). Although TIPS did not
significantly
decrease the incidence of re-bleeding (OR = 0.27; 95 % CI: 0.06
to 1.29), it
became significantly greater in the subgroup meta-analyses of
randomized studies
(OR = 0.09; 95 % CI: 0.03 to 0.32) than in those of
non-randomized studies (OR =
0.76; 95 % CI: 0.40 to 1.45; subgroup difference, p = 0.003),
and in the subgroup
meta-analyses of studies including high-risk patients (OR =
0.06; 95 % CI: 0.01 to
0.23) than in those including low-risk patients (OR = 0.83; 95 %
CI: 0.44 to 1.56;
subgroup difference, p = 0.0007). In addition, TIPS did not
significantly increase
the incidence of post-treatment hepatic encephalopathy (OR =
1.37; 95 % CI: 0.63
to 2.99). The authors concluded that with the exception of the
benefit of prevention
from treatment failure, TIPS with covered stents might improve
the overall survival
of high-risk patients with acute variceal bleeding.
Deltenre and colleagues (2015) stated that there is conflicting
evidence on the
benefit of early TIPSS on the survival of patients with acute
variceal bleeding
(AVB). These researchers evaluated the effect of early TIPSS on
patient
prognosis. They performed a meta-analysis of studies evaluating
early TIPSS in
cirrhotic patients with AVB. A total of 4 studies were included.
Early TIPSS was
associated with fewer deaths [OR = 0.38, 95 % CI: 0.17 to 0.83,
p =0.02], with
moderate heterogeneity between studies (p = 0.15, I = 44 %).
Early TIPSS was not
significantly associated with fewer deaths among Child-Pugh B
patients (OR =
0.35, 95 CI: 0.10 to 1.17, p = 0.087) nor among Child-Pugh C
patients (OR = 0.34,
95 % CI: 0.10 to 1.11, p = 0.074). There was no heterogeneity
between studies in
the Child-Pugh B analysis (p = 0.6, I = 0 %), but there was a
high heterogeneity in
the Child-Pugh C analysis (p = 0.06, I = 60 %). Early TIPSS was
associated with
lower rates of bleeding within 1 year (OR = 0.08, 95 % CI: 0.04
to 0.17, p < 0.001)
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both among Child-Pugh B patients, (OR = 0.15, 95 % CI: 0.05 to
0.47, p = 0.001)
and among Child-Pugh C patients (OR = 0.05, 95 % CI: 0.02 to
0.15, p < 0.001),
with no heterogeneity between studies. Early TIPSS was not
associated with
higher rates of encephalopathy (OR = 0.84, 95 % CI: 0.50 to
1.42, p = 0.5). The
authors concluded that cirrhotic patients with AVB treated with
early TIPSS had
lower death rates and lower rates of clinically significant
bleeding within 1 year
compared with patients treated without early TIPSS. Moreover,
they stated that
additional studies are needed to identify the potential risk
factors leading to a poor
prognosis after early TIPSS in patients with AVB and to
determine the impact of the
degree of liver failure on the patient's prognosis.
An UpToDate review on “Transjugular intrahepatic portosystemic
shunts:
Indications and contraindications” (Sanyal and Bajaj, 2016)
states that TIPS should
not be used for:
Correction of hypersplenism and thrombocytopenia
Portal hypertension associated with polycystic liver disease or
Caroli disease
Pre-hepatic portal hypertension
Primary prophylaxis of variceal hemorrhage
Pulmonary hypertension and hepatopulmonary syndrome
Lahat and associates (2018) stated that portal hypertension
(PHTN) increases the
risk of non-hepatic surgery in cirrhotic patients. This first
systematic review
analyzed the place of TIPS in preparation for non-hepatic
surgery in such patients.
Medline, Embase, and Scopus databases were searched from 1990 to
2017 to
identify reports on outcomes of non-hepatic surgery in cirrhotic
patients with PHTN
prepared by TIPS. Feasibility of TIPS and the planned surgery,
and the short- and
long-term outcomes of the latter were assessed. A total of 19
studies (64 patients)
were selected; TIPS was indicated for past history of variceal
bleeding and/or
ascites in 22 (34 %) and 33 (52 %) patients, respectively. The
planned surgery was
gastro-intestinal (GI) tract cancer in 38 (59 %) patients,
benign digestive or pelvic
surgery in 21 (33 %) patients and others in 4 (6 %) patients.
The TIPS procedure
was successful in all, with a zero mortality rate. All patients
could be operated
within a median delay of 30 days from TIPS (mortality rate = 8
%; overall morbidity
rate = 59.4 %). One year overall survival (OS) was 80 %. The
authors concluded
that TIPS allows non-hepatic surgery in cirrhotic patients
deemed non-operable due
to PHTN. Moreover, they stated that further evidence in larger
cohort of patients is
essential for wider applicability.
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Cirrhosis-Related Chylothorax
Lutz and associates (2013) reported on the case of a 59-year old
woman with
severe dyspnea due to a large chylothorax. She was known to have
liver cirrhosis
but no ascites. There was no history of trauma, cardiac function
was normal and
thorough diagnostic work-up did not reveal any signs of
malignancy. In summary,
no other etiology of the chylothorax than portal hypertension
could be found.
Therapy with diuretics as well as parenteral feeding failed to
relieve symptoms.
After a TIPSS had successfully been placed, pleural effusion
decreased
considerably. Eight months later, TIPSS revision had to be
performed because of
stenosis, resulting in remission from chylothorax. This case
showed that even in
the absence of ascites, chylothorax might be caused by portal
hypertension and
that TIPSS can be an effective treatment option. However, the
authors noted that
“The success of the TIPSS placement in this patient confirmed
the hepatic origin of
the chylothorax. It has been suggested that in liver cirrhosis,
chyle flow increases
substantially due to increased formation of hepatic lymph and
due to portal
hypertension. Since drainage into the venous system is limited
by a valve at the
junction of the thoracic duct and the subclavian vein, pressure
in the lymphatic
vessels is increased, leading to an elevated risk of spontaneous
rupture. Thus, in
this patient, such a spontaneous leak might have persisted as
long as portal
hypertension was high, maintaining the pleural effusion via
small gaps in the
diaphragm as in hepatic hydrothorax, which occurs in about 5 %
to 12 % of liver
cirrhosis patients. A recent review described a clinical
response rate of about 70 %
in 198 patients with hepatic hydrothorax after TIPS placement.
However, controlled
studies are still missing. No case of chylothorax was described
in these patients”.
Tsauo and colleagues (2016) stated that cirrhosis-related
chylothorax and chylous
ascites are rare conditions. The pathophysiologic mechanism of
cirrhosis-related
chylous fluid collections is believed to be excessive lymph flow
resulting from portal
hypertension. These investigators reported the case of a 61-year
old man with
cirrhosis-related chylothorax treated successfully with a TIPSS.
They also
performed a systematic review of the literature, which revealed
9 additional cases
of chylothorax or chylous ascites treated successfully with a
TIPSS. The authors
concluded that these cases showed that TIPS creation may be safe
and effective
for the treatment of chylous fluid collections in patients with
cirrhosis. These
preliminary findings need to be validated by well-designed
studies.
Furthermore, an UpToDate review on “Management of chylothorax”
(Heffner, 2016)
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does not mention TIPSS as a management tool.
Covered Stents for Transjugular Intrahepatic Portosystemic
Shunt
In a meta-analysis of randomized controlled trials (RCTs), Qi
and co-workers
(2017) compared the outcomes of covered stents (CS) versus bare
stents (BS) for
TIPS. PubMed, Embase, and Cochrane Library databases were
searched to
identify the relevant RCTs; OS, shunt patency, and hepatic
encephalopathy (HE)
were the major end-points; HRs with 95 % CIs were calculated.
Heterogeneity was
calculated. Cochrane risk of bias tool was employed. A total of
119 papers were
identified. Among them, 4 RCTs were eligible. Viatorr CS alone,
Fluency CS
alone, and Viatorr plus Fluency CS were employed in 1, 2, and 1
RCTs,
respectively. Risk of bias was relatively low. Meta-analyses
demonstrated that the
CS group had significantly higher probabilities of OS (HR =
0.67, 95 % CI: 0.50 to
0.90, p = 0.008) and shunt patency (HR = 0.42, 95 % CI: 0.29 to
0.62, p < 0.0001)
than the BS group. Additionally, the CS group might have a lower
risk of HE than
the BS group (HR = 0.70, 95 % CI: 0.49 to 1.00, p = 0.05). The
heterogeneity
among studies was not statistically significant in the
meta-analyses. The authors
concluded that compared with BS, CS for TIPS may improve the OS.
These
researchers stated that in the era of CS, the indications for
TIPS may be further
expanded.
In a meta-analysis, Triantafyllou and colleagues (2018)
reviewed
polytetrafluoroethylene-CS grafts versus BS in TIPS procedure.
Systematic search
of literature databases was done from January 1990 till April
2017, using pre-
decided keywords. Outcome measures studied were primary-patency
(PP) at 1
year (defined as absence of shunt insufficiency at 1 year),
re-bleeding (RE), new-
onset HE (new-onset or worsening encephalopathy following the
procedure), and
survival at 1 year (SU). Odds ratio (OR) was calculated for each
outcome variable.
Between-study heterogeneity was assessed by the I2 statistics
and χ2 Q-test. A
total of 14 studies (4 RCTs, 2 prospective non-randomized, and 8
retrospective)
were included with 2,519 patients (1,548 patients in BS group
and 971 patients in
CS group). Three-quarter outcome measures showed significantly
better results
with CS; PP was pooled from 13 studies and showed an OR = 4.75
(95 % CI: 3.32
to 6.79; p < 0.00001; I2 = 44 %) in favor of CS; RE was
pooled from 6 studies with
OR = 0.37 (95 % CI: 0.24 to 0.56; p < 0.00001; I2 = 0 %) in
favor of CS; SU was
pooled from 11 studies with OR = 1.85 (95 % CI: 1.44 to 2.38;
p < 0.00001; I2 = 0 %)
in favor of CS. On subset analysis for RCTs, 3 outcome variables
favored CS with
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minimal heterogeneity [PP: OR = 4.18 (95 % CI: 2.66 to 6.55;
p < 0.00001; I2 = 0 %);
RE: OR = 0.43 (95 % CI: 0.25 to 0.72; p < 0.001; I2 = 0
%); SU: OR = 1.85 (95 % CI:
1.44 to 2.38, p < 0.00001; I2 = 0 %)]; HE showed no
difference between 2 stents on
the overall and subset pooled analysis. Overall: OR = 0.86 (95
% CI: 0.68 to 1.08; p
= 0.19; I2 = 4 %). Only RCTs: OR = 0.91 (95 % CI: 0.63 to
1.32, p = 0.63; I2 = 0 %).
The authors concluded that CS is associated with better primary
patency and
survival and lesser rate of re-bleeding than BS in patients
undergoing TIPS
procedure. Furthermore, there was no difference in new-onset
HE.
Portal Vein Thrombosis
In a retrospective analysis, Goykhman et al (2010) reviewed
their experience with
TIPSS and analyzed the results with emphasis on patient
selection and indication
(conventional versus atypical). All cases were managed by a
single-center multi-
disciplinary team comprising liver surgery and transplantation,
hepatology, imaging,
interventional radiology and intensive care). Between August
2003 and December
2009, a total of 34 patients (mean age of 51, range of 27 to 76
years) were treated
with TIPSS. The cause of portal hypertension was cirrhosis (n =
23), hyper-
coagulability complicated by BCS (n = 6), and acute portal vein
thrombosis (PVT; n
= 5). Clinical indications for TIPSS included treatment or
secondary prevention of
variceal bleeding (n = 10), refractory ascites (n = 18),
mesenteric ischemia due to
acute portal vein thrombosis (n = 5), and acute liver failure (n
= 1). Transjugular
intrahepatic portosystemic shunt was urgent in 18 cases (53 %)
and elective in 16.
Three deaths occurred following urgent TIPSS. The overall
related complication
rate was 32 %: trasient encephalopathy (n = 6), ischemic
hepatitis (n = 2), acute
renal failure (n = 2) and bleeding (n = 1). Long-term results of
TIPSS were defined
as good in 25 cases (73 %), fair in 4 (12 %) and failure in 5
(15 %). In 3 of 5
patients with mesenteric ischemia following acute portal vein
thrombosis, surgery
was obviated. Revision of TIPSS due to stenosis or thrombosis
was needed in 7
cases (20 %). The authors concluded that TIPSS is safe and
effective.
Furthermore, they noted that while its benefit for patients with
portal hypertension is
clear, the role of TIPSS in treatment of portal-mesenteric
venous thrombosis needs
further evaluation.
Valentin and colleagues (2018) stated that the role of TIPS in
the management of
PVT remains controversial. These investigators performed a
systematic review and
meta-analysis to examine the role of TIPS for the management of
PVT in adult
patients with liver disease. Multiple databases were searched
through April 2017.
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Data were gathered to estimate the rates of technical success,
portal vein re-
canalization, portal patency, HE, and mean change in portal
pressure gradient in
patients with PVT who underwent TIPS; estimates were pooled
across studies
using the random effects model. A total of 18 studies were
included in the analysis.
The pooled technical success rate was 86.7 % [95 % CI: 78.6 to
92.1 %]. Rate of
portal vein re-canalization was 84.4 % (95 % CI: 78.4 to 89.0
%). The rate of
complete re-canalization was 73.7 % (95 % CI: 64.3 to 81.3 %).
Portal patency
was 86.9 % (95 % CI: 79.7 to 91.8 %). Mean change in portal
pressure gradient
was 14.5 mmHg (95 % CI: 11.3 to 17.7 mmHg); HE was 25.3 % (95 %
CI: 19.2 to
32.6 %). The number of major adverse events (AEs) reported
across studies was
low. The majority of the analyses were not associated with
substantial
heterogeneity. The authors concluded that the use of TIPS in the
management of
PVT was feasible and effective in achieving a significant and
sustainable reduction
in clot burden with a low risk of major complications; and TIPS
should be
considered as a viable therapeutic option in patients with PVT.
Moreover, these
researchers stated that given the limited amount of randomized,
comparative
studies reported, additional studies are needed to evaluate the
safety and efficacy
of TIPS as a treatment modality in PVT, in comparison to other
therapeutic options,
such as anti-coagulation.
Prevention of Re-Bleeding in Cirrhotic Individuals with
Cavernous Transformation of the Portal Vein
Zuo and associates (2019) examined the role of early overt HE
(OHE) as a clinical
marker of prognosis in cirrhosis with a TIPS and evaluated the
relationship between
recurrence of OHE and survival after TIPS. From January 2012 to
December 2013,
a retrospective study of consecutive patients with cirrhosis and
a TIPS was
performed at a single institution. A total of 304 patients (196
men; mean age of 52
years) were enrolled during the study period. The mean MELD
score was 11.6;
and time-dependent Cox regression was applied to estimate the
predictive ability of
early OHE (within 3 months after TIPS) and the effect of its
frequency on survival.
During a median follow-up of 28.3 months, 115 patients
experienced OHE after the
TIPS procedure; of these, 54 had at least 2 OHE episodes.
Long-term survival
worsened in patients with early OHE (HR = 2.75; 95 % CI: 1.75 to
4.32; p < 0.001).
When early OHE was further divided into early-recurrent and
single OHE, death
was more common in patients with early-recurrent OHE (p <
.001) than in patients
with early-single OHE (p = 0.24). After adjustment by MELD
score, ascites, serum
albumin, indication for TIPS, and age, patients with
early-recurrent OHE had a
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lower probability of survival (HR = 2.91; 95 % CI: 1.04 to 4.89;
p < 0.001).
Furthermore, landmark and propensity score analyses confirmed
the predictive
value of early-recurrent OHE. The authors concluded that early
recurrence of OHE
was associated with an increased risk of mortality for patients
with cirrhosis who
underwent TIPS.
Li and colleagues (2019) compared the effectiveness of TIPS and
endoscopic
variceal ligation (EVL) plus propranolol in reducing re-bleeding
and improving
survival rate in cirrhotic patients with cavernous
transformation of the portal vein
(CTPV). Cirrhotic patients with CTPV and variceal bleeding
history treated for a
second prophylaxis of recurrent variceal bleeding between June
2010 and July
2016 were identified and classified based on the treatment that
they received (TIPS
or EVL + propranolol). Patients' demographics and clinical data
were recorded.
The PRISM method was applied to compare the re-bleeding and
long-term survival
rate. A total of 51 patients were included, 25 of them were
treated with TIPS and
26 received EVL + propranolol during the study period. The mean
follow-up
duration was 21 months in the TIPS group (range of 1 to 47
month) and 27 months
in the EVL + propranolol group (range of 6 to 73 month). The
recurrent variceal
bleeding free probability was increased remarkable in the TIPS
group compared
with the EVL + propranolol group (p = 0.047); 3 (14.29 %)
patients died in the TIPS
group, and 1 (3.85 %) in the EVL+ propranolol group; however,
there were no
significant differences in the survival rate (p = 0.305); and HE
occurred in 14.29 %
(3 of 21) of patients in the TIPS group, and 3.85 % (1 of 26) in
the EVL +
propranolol group (p = 0.202). The authors concluded that the
effectiveness of
TIPS appeared to be greater in preventing re-bleeding in
patients with CTPV
comparing with EVL + propranolol in on this study, without
improving survival. The
higher rate of HE in the TIPS group was a concern; these
findings need to be
further investigated.
An UpToDate review on chronic portal vein thrombosis in adults
(Sanyal, et al.,
2019) stated: "Transjugular intrahepatic portosystemic shunting
(TIPS) has been
shown to be technically feasible in some cases of extrahepatic
portal vein
thrombosis, such as patients without cavernous transformation in
whom the
thrombosed vein can be accessed, dilated, and stented, and it
may be considered
in selected cases with symptoms related to portal hypertension
that fail to respond
to other treatments. However, the ability to adequately
decompress the portal vein
is unpredictable. In addition, although TIPS may be technically
feasible in patients
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with cavernous transformation, it is unlikely to adequately
decompress the liver.
When performed, it is advisable to perform a thorough assessment
for
prothrombotic states and consider anticoagulation after the
bleeding is controlled."
Appendix
Selection Criteria of TIPSS for the Treatment of Varices and
Ascites
Aetna considers transjugular intrahepatic portosystemic shunt
(TIPSS) medically
necessary in members who meet any of the following criteria:
Surgery is contraindicated and the member requires bleeding
control from
varices; or
The member has failed sclerotherapy and has acute bleeding from
varices;
or
The member has failed sclerotherapy and has had 2 or more
episodes of re-
bleeding requiring a transfusion during a 2-week period; or
The member has severe debilitating ascites or hepatic
hydrothorax
refractory to medical management (e.g., oral diuretics and
sodium
restriction; and repeated large-volume paracentesis); or
The member is a liver transplant candidate who requires bleeding
control
from varices.
CPT Codes / HCPCS Codes / ICD-10 Codes
Information in the [brackets] below has been added for
clarificationpurposes. Codes requiring a 7th character are
represented by "+":
Code Code Description
CPT codes covered if selection criteria are met:
37182 Insertion of transvenous intrahepatic portosystemic
shunt(s) (TIPS)
(includes venous access, hepatic and portal vein
catheterization,
portography with hemodynamic evaluation, intrahepatic tract
formation/dilatation, stent placement and all associated
imaging
guidance and documentation)
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Code Code Description
37183 Revision of transvenous intrahepatic portosystemic
shunt(s) (TIPS)
(includes venous access, hepatic and portal vein
catheterization,
portography with hemodynamic evaluation, intrahepatic tract
recanulization/dilatation, stent placement and all associated
imaging
guidance and documentation)
HCPCS codes covered if selection criteria are met:
C1874 Stent, coated/covered, with delivery system [PTFE
coated]
C1875 Stent, coated/covered, without delivery system [PTFE
coated]
ICD-10 codes covered if selection criteria are met:
I82.0 Budd-Chiari syndrome [moderate with failed response to
anticoagulation] [not covered for sinusoidal obstruction
syndrome or
veno-occlusive disease]
I85.00 Esophageal varices without bleeding
I85.01 Esophageal varices with bleeding [not covered for
prophylaxis of
variceal hemorrhage]
I85.10 Secondary esophageal varices without bleeding
I85.11 Secondary esophageal varices with bleeding [not covered
for
prophylaxis of variceal hemorrhage]
I86.4 Gastric varices
I86.8 Varicose veins of other specified sites
J90 Pleural effusion, not elsewhere classified [hepatic
hydrothorax]
K31.89 Other diseases of stomach and duodenum [portal
hypertensive
gastropathy with recurrent bleeding despite the use of
beta-blockers]
K64.0 - K64.9 Hemorrhoids and perianal venous thrombosis
K74.0 Hepatic fibrosis
K74.3 - K74.69 Other and unspecified cirrhosis of liver
K76.6 Portal hypertension
K92.0 Hematemesis
K92.1 Melena
K92.2 Gastrointestinal hemorrhage, unspecified
R18.0 - R18.8 Ascites
ICD-10 codes not covered for indications listed in the CPB (not
all-inclusive):
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Code Code Description
D69.3 - D69.6 Thrombocytopenia
D73.1 Hypersplenism
I27.20 - I27.29 Other secondary pulmonary hypertension
I27.2 Other secondary pulmonary hypertension
I81 Portal vein thrombosis [portal-mesenteric venous
thrombosis]
I89.8 Other specified noninfective disorders of lymphatic
vessels and lymph
nodes [chirrhosis-related chylothorax]
K31.811 Angiodysplasia of stomach and duodenum with bleeding
[with cirrhosis]
K55.011 - K55.1 Acute and chronic vascular disorders of
intestine [portal-mesenteric
venous thrombosis]
K76.5 Hepatic veno-occlusive disease [Sinusoidal obstruction
syndrome]
K76.6 Portal hypertension
K76.7 Hepatorenal syndrome
K76.81 Hepatopulmonary syndrome
Q44.6 Cystic disease of liver [Caroli disease]
Z76.82 Awaiting organ transplant status [preoperative reduction
in portal
hypertension before liver transplantation]
The above policy is based on the following references:
1. Ring EJ, Lake JR, Roberts JP, et al. Using transjugular
intra-hepatic
portosystemic shunts to control variceal bleeding before
liver
transplantation. Ann Int Med. 1992;116(4):304-309.
2. Rossle M, Haag K, Ochs A, et al. The transjugular
intrahepatic
portosystemic stent-shunt procedure for variceal bleeding. N Eng
J Med.
1994;330(3):165-171.
3. LaBerge JM, Ring EJ, Gordon RL, et al. Creation of
transjugular intrahepatic
portosystemic shunts with the Wallstent endoprosthesis: Results
in 100
patients. Radiol. 1993;187(2):413-420.
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4. Jalan R, Redhead DN, Hayes PC. Transjugular intrahepatic
portasystemic
stent-shunt in the treatment of variceal haemorrhage. Br J Surg.
1995;82
(9):1158-1164.
5. Brown RS Jr, Lake JR. Transjugular intrahepatic portosystemic
shunt as a
form of treatment for portal hypertension: Indications and
contraindications. Adv Intern Med. 1997;42:485-504.
6. Stanley AJ, Redhead DN, Hayes PC. Review article: Update on
the role of
transjugular intrahepatic portosystemic stent-shunt (TIPSS) in
the
management of complications of portal hypertension. Aliment
Pharmacol
Ther. 1997;11(2):261-272.
7. Svoboda P, Kantorova I, Brhelova H, et al. Recent position of
transjugular
intrahepatic portosystemic shunt in the treatment of portal
hypertension.
Hepatogastroenterology. 1997;44(15):647-655.
8. Kamath PS, McKusick MA. Transjugular intrahepatic
portosystemic shunts
(TIPS). Baillieres Clin Gastroenterol. 1997;11(2):327-349.
9. Carr-Locke DL, Branch SM, Byrne WJ, et al. Technology
assessment status
evaluation: Transvenous intrahepatic portosystemic shunt
(TIPS).
Gastrointestinal Endoscopy. 1998;47(6):584-587.
10. National Institutes of Health (NIH). Consensus Development
Conference
Statement: Transjugular Intrahepatic Portosystemic Shunt.
Bethesda, MD:
NIH; 1996.
11. Miller-Catchpole R. Transjugular intrahepatic portosystemic
shunt (TIPS).
Diagnostic and Therapeutic Technology Assessment. JAMA.
1995;273
(23):1824-1830.
12. Burroughs AK, Patch D. Transjugular intrahepatic
portosystemic shunt.
Semin Liver Dis. 1999;19(4):457-473.
13. Rosch J, Keller FS. Transjugular intrahepatic portosystemic
shunt: Present
status, comparison with endoscopic therapy and shunt surgery,
and future
prospectives. World J Surg. 2001;25(3):337-456.
14. Bizollon T, Dumortier J, Jouisse C, et al. Transjugular
intra-hepatic
portosystemic shunt for refractory variceal bleeding. Eur J
Gastroenterol
Hepatol. 2001;13(4):369-375.
15. Ong JP, Sands M, Younossi ZM. Transjugular intrahepatic
portosystemic
shunts (TIPS): A decade later. J Clin Gastroenterol.
2000;30(1):14-28.
16. Gow PJ, Chapman RW. Modern management of oesophageal
varices.
Postgrad Med J. 2001;77(904):75-81.
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17. Rossle M. Prevention of rebleeding from oesophageal-gastric
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Copyright Aetna Inc. All rights reserved. Clinical Policy
Bulletins are developed by Aetna to assist in administering
plan
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advice. This Clinical Policy Bulletin contains only a partial,
general description of plan or program benefits and does not
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outcomes. Participating providers are independent contractors
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Copyright © 2001-2019 Aetna Inc.
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AETNA BETTER HEALTH® OF PENNSYLVANIA
Amendment to Aetna Clinical Policy Bulletin Number:
Transjugular
Intrahepatic Portosystemic Shunt (TIPSS)
There are no amendments for Medicaid.
www.aetnabetterhealth.com/pennsylvania revised 05/07/2019
http://www.aetnabetterhealth.com/pennsylvania
Prior Authorization Review Panel MCO Policy
SubmissionTransjugular Intrahepatic Portosystemic Shunt (TIPSS)CPT
Codes / HCPCS Codes / ICD-10 Codes ReferencesAmendment to Aetna
Clinical Policy Bulletin Number: Transjugular Intrahepatic
Portosystemic Shunt (TIPSS)