TIPS Placement: Treating Portal Hypertension in the Outpatient Setting

[Dr. Chris Beck]
Tom, if you could, will you talk about either a patient that may come through your clinic or the transplant clinic and that gets referred over for a TIPS, like a couple of different scenarios that you're like, all right, we should get this patient over to interventional radiology for potential TIPS workup. What patients like end up getting shifted over to IR for potential TIPS?

[Dr. Tom Leventhal]
Are you more interested in say outpatient or inpatient?

[Dr. Chris Beck]
I'll start out without patient outpatient considerations.

[Dr. Tom Leventhal]
Sure. I think the predominant reason that we're making referrals for TIPS is a diuretic refractory ascites or hepatic hydrothorax. I think that, like I said, we're aggressive. I think that with case management for helping to manage these patients requesting that as getting frequent labs, but we know that the natural history of cirrhosis is they'll progress and they're ultimately progressed to where they develop a kidney dysfunction, be a type of hepatorenal syndrome or a consequence or side effect of their diuretics.

I think that once we get to that point, sort of regardless of MELD, if less than 20, we're pretty quick about saying, hey, we've tried this. You're getting your paracentesis at the number of patients that I have in clinic that are getting them weekly, twice weekly. I've had some patients that needed them three times weekly and you can only do so much and we recognize that with patients is that you can recommend these lifestyle modifications of sodium avoidance, but it is what it is. They're human.

I think that it's the refractory ascites or hepatic hydrothorax that really is the big push for us to get these patients into TIPS and, I'll toot Siobhan's horn for her, we do the second most TIPS in the United States and at least that's the urban legend that's going around and I believe it because we're very assertive about referring them and our outcomes and the resolution of ascites or hepatic hydrothorax is very impressive.

Along with that, the improvement in quality of life, the ability for your patient to be more active ultimately I think prolongs life till time to transplant or else just prolongs life and so it makes a really big difference.

[Dr. Chris Beck]
All right, Siobhan, so from your perspective, I guess what I want to know, like one of the questions I have in my head is I can remember being in training, I guess I came out in 2015 and the number of TIPS that we did at the very first half of the year was 10 and the second half of the year, it was 100 and like there was like this quick ramp up and then like I was at Georgetown Transplant Center and then it just never went down, like it was like, up into the right and then leveled off. Do you remember that point in your practice when your TIPS placement went up, like was there an upward trajectory or was it a slow burnup?

[Dr. Siobhan Flanagan]
I think it was a quick change for us and I think it was twofold. Our newer hepatologists really looking to manage their patients' fluid, and that really changed the practice for us, but then also, when Northwestern's data came out on making patients transplant candidates, that really changed things for us as well and I think since then it's just been a steady rise for us in general. I don't think as much as that, 2016 or so, we were a little bit behind you guys, 2016 to early 2017, I really remember that time as being a transition point for us doing more and more TIPS.

[Dr. Chris Beck]
Tom, would you echo that sentiment that it was some of the data that came out around that time and maybe different hepatologists coming on board and were more interested in getting a little bit more aggressive with fluid management?

[Dr. Tom Leventhal]
I would. Yes, I think that aside, the early study that looked at like early TIPS for, we'll say, even variceal hemorrhage came out in 2010. Then it was like every couple years another big study looking at, inpatient mortality was reduced, things like that and it was like, okay, we know that there are certainly indications where it makes a dramatic difference, but I think then that got broadly applied to say, hey, like we can make a really big difference and understanding that there are people with portal hypertension that don't have high MELDs, but still have significant ascites and significant hepatic hydrothorax. We couldn't always weigh on transplant as being the ultimate, it was the ultimate, but it wasn't necessarily going to be feasible anytime soon if they didn't have access to say a living donor and then this was just a, hey, this is something that works that can prolong life and reduce morbidity without transplant. I think that's why we saw this ramp up.

[Dr. Chris Beck]
One of the things that often gets discussed or has been discussed is like the big push and pull between the benefits of TIPS versus the downsides. Tom, in your mind, what would you say are the top three downsides to a TIPS procedure that in your mind, you're like, this is like the worst situation that can happen post TIPS.

[Dr. Tom Leventhal]
Before you threw in that last sentence, I would have said none.

[Dr. Chris Beck]
All right.

[Dr. Tom Leventhal]
I think they're phenomenal. I just, again, it's just our practice, they just are in so many ways life-changing, right? What we worry about is refractory encephalopathy that leads to an almost comatose state. I've been practicing hepatology eight years. In that time, we talk about this, right? Because it's so rare. I can think of two patients who we actually had to close down the TIPS because of such dense refractory encephalopathy. I've ordered a lot of TIPS and my partners that have been here as long or longer than I have comparable results.

I've seen very few people go into like heart failure, right-sided heart failure because of the increase in preload. I think that's why just uniform our practices, we've got to get an up-to-date echo. We have to make sure that we're at least looking for that risk stratification. Outside of that, I don't even know if I could come up with a third risk that I would really worry about just because of how positive the outcomes overall are.

[Dr. Chris Beck]
As far as what happens at the patient's post, you said a lot of your patients now are going home same day?

[Dr. Siobhan Flanagan]
They're going home same day.

[Dr. Chris Beck]
Is that relatively new for you guys?

[Dr. Siobhan Flanagan]
We've been doing this for about 18 months now. Our protocol for this is the patient will stay up in the PACU recovery room for about four hours. Some patients who are maybe a little borderline, you're a little more concerned about them, you'll watch them for six. As long as they're doing well after the procedure, they're going home after that observation time.

[Dr. Chris Beck]
They go home same day and then-- so one, I want to, Siobhan, I want to know when they follow up with IR. Then also Tom, I would like to know like what they look like as you guys are starting to pick them up post-TIPS. Siobhan, we'll start with you.

[Dr. Siobhan Flanagan]
Yes, and IR, I see them at one-month post-procedure, but we've got a great nurse clinician support team in IR, and they're calling the patient, day after, we have a day one and a day three call just to make sure that it doesn't sound like they're having issues with encephalopathy early on that maybe they aren't even recognizing. Part of our, setup for our patients when we're meeting them in clinic is to understand what's your social and in-house support at home. Knowing that they've got someone else in the household with them is a more comforting thing than thinking about them being on their own so there's someone to really watch out for any development of encephalopathy as well.

[Dr. Chris Beck]
Cool. Do you send them home with any meds for potential encephalopathy treatment? Do they have that going home or, so I've heard some IR docs will get them these prescriptions even before the TIPS goes in or I didn't know if you guys had anything like that in place.

[Dr. Siobhan Flanagan]
Yes. I know Tom can talk to the hepatology side of that that's a desirable thing on our end to have the patient ready with those medications.

[Dr. Chris Beck]
Tom, what does it look like from your end?

[Dr. Tom Leventhal]
We made the assessment, they go in for it. I have to say, it's not that you're selling it, right? It's that you're doing the right thing medically, but when you have these discussions with patients in hepatology clinic, how long am I in the hospital after the surgery? To be able to say, no, it's a procedure, it's a day procedure, you'll probably go home the same day, it takes away a lot of reticence that they may have to go through with it, which is huge.

My guess is that the majority of patients that we're referring for TIPS are already on treatment medications for hepatic encephalopathy with either lactulose or rifaximin. Many of them already are. I certainly have had colleagues reach out afterwards, at that one-month follow-up visit where they're starting to hear through their nurse coordinators and stuff, oh, maybe there are some changes that may signify it. Not uncommon, right? That they're practicing the medicine and getting those medicines on board or else our team will take over and manage it. I feel like it's very rare that we're actually seeing a clinically significant worsening of encephalopathy after the procedure.

[Dr. Chris Beck]
Cool. Very nice. As far as after they have their TIPS, when do they get plugged back in to your clinic? Does necessarily having a TIPS mean that, oh, you need to go back and see transplant clinic, two weeks after, one month after, or do they still just stay on their regular schedule of what they normally go?

[Dr. Tom Leventhal]
They actually, they'll stay on their regular schedule and I think a lot of that has to do with the trust and I think the aggressive medical management on the IR side, seeing these patients in follow-up, I don't think happens everywhere. It might, but like in my experience, it hasn't. We feel that they are getting comprehensive care and that we know if issues come up, especially in the setting of the pandemic, virtual visits, access to the EMR, you're much more likely to get alerts from your patients, things are a little bit off. Because they had this interventional procedure, even with the known risks, it doesn't escalate our need to get them back in.

[Dr. Chris Beck]
That's great. What has the IR team done right as far as their clinic presence to make you guys feel more comfortable with, once you send them for the procedure that you understand that all that will be taken care of? I just imagine, Siobhan, maybe you guys have been very sophisticated for a long time, but I was just curious as maybe as if they've been more sophisticated in their clinic presence that's endeared them or made them more or instilled more confidence on the other side of things.

[Dr. Tom Leventhal]
Sure. I started back, I came back to the University of Minnesota in 2019 and very early on after ordering one of these, I was getting inbox alerts and messages from interventional radiology of, “oh, hey, they had their TIPS. I got their ultrasound one month post, saw them in clinic, seems like they're having lower extremity edema, are you okay with higher ordering diuretics?” It completely caught me off guard that this was even a practice that was in place, that other people were managing this stuff. I just always assumed that I'd be getting the call.

Very quickly in coming back that this was, it was, it was beyond procedural from my perspective. It was true medical management and recognition of this stuff. Then, hey, would you mind ordering the diuretics? Absolutely, that's my job. you guys don't have to worry about that, but having someone lay eyes on someone and know that and passing it along just made it so much easier and I think led to way better outcomes.

[Dr. Chris Beck]
That's great. Siobhan, from your perspective, so I also want to know like what you think is, as you've seen the practice progress and evolve, what you guys have done right? I also want to put you on the hot seat. Can you think of anything that, any missteps that y'all have had along the way that y'all have used for improvement? You know what I mean? Lessons learned.

[Dr. Siobhan Flanagan]
I'm going to have to think about that for a minute. We make plenty of mistakes in IR.

[Dr. Chris Beck]
Zero mistakes, zero mistakes.

[Dr. Siobhan Flanagan]
No, not zero mistakes. I've got to think about that for a minute.

[Dr. Chris Beck]
What are the things that you think of as you've seen like the clinic progress or those clinical presence progress, like that y'all have done right to, I guess, have a more, I'm always trying to like push the idea that like having a procedural presence is a better thing for interventional radiology. You get better outcomes. You get better referrals. You have better relationships with your colleagues. I was just curious if y'all's practice, like if you've seen that evolve and seen that relationship build because of how clinical y'all's practice has become.

[Dr. Siobhan Flanagan]
Yes, I've seen a distinct change in our service and our relationships with more than just hepatology. Our relationship with hepatology has been the model to do this with other procedures, partner with other clinicians. I would say predating 2015, there was a tumor conference, but outside of tumor conference, not nearly as much conversation and collaboration as there is today.

I know that, overall patient outcomes, they've always been good, but they've improved from regards to how quickly patients are managed with, maybe like Tom was mentioning, or you were mentioning, peripheral edema after their TIPS is placed. Maybe in the past, it was something that patients struggled with for, two or three months, but, we're talking to them early, seeing them upfront, recognizing that this is happening, and getting them the medical management they need sooner. From that standpoint, we're leaps and bounds beyond where we were before. Our whole field is wanting to progress to this more clinical practice. This has just been a good example of how that's successful and improves patient outcomes just from, the ultimate outcome of success. You've managed their portal hypertension, but just those intricacies afterwards from a symptom management standpoint.

[Dr. Tom Leventhal]
To go to the other end of the spectrum, and I think how important the relationship is, I've gotten a call from one of our IR partners to come to the IR suite, and something that was scheduled for TIPS that day is an elective outpatient procedure. They'd gotten labs that morning, they had done their assessment and they had significant concerns about, was this someone where this procedure was going to be safe on this day.

In going there, taking a look at the labs, taking a look at the patient, and having had that longitudinal relationship saying, hey, there has been a significant clinical decline. This would not be safe right now. I don't know. I don't know. Again, don't know if that happens everywhere, but it made a big difference and probably prevented a really bad outcome.

[Dr. Siobhan Flanagan]
I would say, missteps on our end probably is in line with the previous conversation, the times when before the close follow-up and collaboration, patients just not doing well with post-procedure symptoms. I would say that in the past was our biggest misstep, really the clinical management side, not the procedural management side. Even that close collaboration has resulted in us not placing TIPS in patients who may be on the day of, like Tom mentioned, aren't appropriate to have it done.

I think in the past we had one case where, the updating or echo we're pretty stringent about it'd be great to have it in the last six months because things change over time. One misstep I recall on our part was not having an updated echo. This was probably maybe seven years ago and not having an updated echo on a patient who went into a right heart failure after their TIPS.

[Dr. Chris Beck]
How many days a week do or days a month do you spend in clinic?

[Dr. Siobhan Flanagan]
I have four clinic days per month.

[Dr. Chris Beck]
Okay. You do one a week basically. Then procedural the rest of the time.

[Dr. Siobhan Flanagan]
Correct.