Practice makes better: TIPS procedures in referral centers
Authors: Virginia Hernández‐Gea, Christophe Bureau
Journal: Hepatology (2017)

Potential conflict of interest: Virginia Hernández‐Gea and Christophe Bureau receive speaker fees from GORE. See Article on Page 690 The transjugular intrahepatic portosystemic shunt (TIPS) procedure is a percutaneous imaging‐guided procedure that effectively reduces portal pressure by diverting blood from portal to systemic circulation. Since it was first described by Rösch et al. in 1971,1 the TIPS technique has evolved, improved, and become a widespread treatment for portal hypertension complications, primarily variceal bleeding and refractory ascites. It is a challenging procedure, although in skilled hands its technical success rate exceeds 90%.2 Technical success implies a learning curve that is crucial in special situations, including the presence of a thrombosis in the portal vein axis or in the suprahepatic veins, "difficult" anatomy, and so forth. Expertise has been previously linked to improved outcomes and a significant reduction in technical failures and complications,3 reinforcing the idea of a learning curve effect in the context of the TIPS procedure. Moreover, a TIPS may be placed under emergency conditions (i.e., variceal bleeding) and/or in very fragile patients (i.e., refractory ascites), increasing the risk of mortality in an already life‐threatening situation. Management of these patients requires achieving hemodynamic stability through very careful fluid replacement, protection of liver and renal function, and the prevention of complications, all of which require management in a specialized multidisciplinary unit with experienced medical staff (hepatologists, endoscopists, radiologists, surgeons, and intensive care physicians). Indeed, after controlling the hemorrhage, the priority should be the identification of patients at high risk of experiencing treatment failure and rebleeding, as preemptive TIPS placements improve outcomes in these patients.4 Based on these two factors, the learning curve, and the challenges of managing patients with cirrhosis who require TIPS placement, one may think that transferring such patients to centers with experience in TIPS placement or to multidisciplinary units that specialize in the management of patients with cirrhosis should improve outcomes. Studies evaluating the impact of expertise in the outcomes of patients undergoing TIPS placement are scarce; this is the matter that Sarwar et al. address in this issue of Hepatology.5 The authors evaluated data from all 5529 patients requiring TIPS procedures who were recorded in the national readmission database in 2013 and analyzed the impact of the volume of TIPS procedures on in‐patient mortality. The centers were differentiated based on the number of TIPS procedures performed each year in a random but valid way (very low [1‐4/year], low [5‐9/year], medium [10‐19/year], high [20‐29/year], and very high [≥30/year]). The results show that, in agreement with the threshold of ≥20 TIPS procedures performed yearly already used to define experienced physicians,6 centers that performed more than 20 TIPS procedures per year had lower in‐patient mortality rates. Remarkably, all of the high‐volume TIPS centers were also metropolitan teaching hospitals where multidisciplinary management of the patients may also have influenced outcomes. The beneficial effect on mortality rates was twice as high in centers performing ≥20 procedures per year compared with centers performing <20 procedures per year, even when adjusting for variables associated with high mortality (age, variceal bleeding, infections, and coagulopathy). The same impact of volume on mortality was observed when adjusting for elective and emergent scenarios, reinforcing that the important factor is the volume of TIPS placements and not the indications for them. These results echo the evidence from more than 100 articles already published demonstrating that volume and/or experience impacts mortality, particularly in the cases of major surgical7 and percutaneous cardiovascular interventions.9 Based on this evidence, regionalization policies have been adopted worldwide to move patients to centers of expertise. Although the study has the strength of a large sample size, its conclusions are based on administrative claims data that limit the clinical information available and obscure knowledge of the real causes of the higher mortality rate. Importantly, factors responsible for differences in outcomes, such as a more accurate selection of patients, reasons for TIPS placements, liver function, and periprocedural management may have affected the results. In fact, the study failed to demonstrate that the magnitude of the effect was related to the procedure itself and/or a combination of other variables associated with expertise and specialized management. Indeed, high‐volume centers have overcome the learning curve for technical feasibility, and expertise may certainly result in a better selection of candidates and a better quality of care before and after procedures, including the management of complications. It is also true that, while often associated with quality, volume does not always reflect quality, and patients treated by low‐volume physicians may have had higher mortality rates independently of the volumes of the hospitals. Even if other potential reasons underlie the association between mortality and volume, these results support the implementation of regionalization policies, with the main aim of improving global quality and outcomes in patients with decompensated cirrhosis requiring TIPS placement. Based on the available data, centers that perform more than 20 TIPS placements per year are expected to have the best results and should be considered centers of excellence. However, to guarantee excellent management of patients, high‐volume centers need to be fully equipped to assist patients in the postintervention period, especially when complications occur. In other words, instead of expanding the number of facilities performing the procedures, efforts should be focused on enhancing access to centers of excellence and developing systems to evaluate quality to ensure the best possible outcomes. In conclusion, this study demonstrates that patients treated at high‐volume centers (≥20 procedures/year) experience better perioperative outcomes compared with their counterparts undergoing TIPS procedures at low‐volume institutions. The implementation of programs aimed at directing patients to high‐volume facilities and better equipping those facilities to meet increased demands appears to be a promising strategy for increasing survival rates among patients with cirrhosis.