What are the contraindications to TIPS creation?
A pre-TIPS total bilirubin level >3 mg/dL, refractory coagulopathy with an international normalized ratio >1.8, a Child-Pugh score >12, and a serum creatinine level >1.9 mg/dL all have been found to be associated with poor outcomes in studies. However, model for end-stage liver disease (MELD) score prior to TIPS has been shown to be the best single predictive index of mortality following TIPS. Most investigators feel that a MELD of ≤18 is associated with improved long-term survival. TIPS creation that is performed on an emergent basis is also associated with high mortality, and hemodynamic stabilization with transfusions, other medical interventions, and balloon tamponade of gastroesophageal varices are therefore preferred before the TIPS procedure. A functioning TIPS can be associated with new or worsened hepatic encephalopathy, so the presence of moderate to severe encephalopathy at baseline that is not readily treatable with medications may be a contraindication. Severe cardiac or renal dysfunction is also a contraindication, since shunting of portal flow to the systemic circulation would cause an increase in systemic volume that could result in congestive heart failure.