Portal Hypertension, TIPS, and RTO—Latest AASLD Guidance

🎙️ Morning Rounds: Portal Hypertension, TIPS, and RTO—Latest AASLD Guidance

This episode breaks down the critical differences between the two main endovascular strategies for managing variceal bleeding in patients with portal hypertension:

• TIPS (Transjugular Intrahepatic Portosystemic Shunt): A procedure that acts as an internal bypass to lower the overall portal pressure.

  • New Guidance: Covered stents are now standard, and smaller 8mm stents are preferred to minimize the risk of Hepatic Encephalopathy (HE).

  • Trade-Off: It reduces the risk of bleeding but increases the risk of HE (brain fog/confusion).

• RTO/ATO (Retrograde/Antegrade Transvenous Obliteration): Procedures that physically block and obliterate the specific bleeding veins (varices).

  • Key Difference: RTO/ATO increases portal pressure but is preferred for patients with pre-existing HE or heart issues, as it often improves liver function and has a lower HE risk.

  • Technological Leap: Newer methods like PARTO and CARTO (Coil/Plug-Assisted RTO) are replacing older techniques, offering a safer, faster, and more targeted approach that eliminates the need for prolonged ICU stays.

The Clinical Crossroads: We detail how specialists choose between TIPS (pressure-lowering) and RTO (obliteration) based on patient factors like underlying HE, cardiac health, and the location of the bleeding varices.