Management of portal hypertension severe complications

Portal hypertension is a clinical syndrome characterized by an increase in the portal pressure gradient, defined as the gradient between the portal vein at the site downstream of the site of obstruction and the inferior vena cava. The most frequent cause of portal hypertension is cirrhosis. In patients with cirrhosis, portal hypertension is the main driver of cirrhosis progression and development of hepatic decompensation (ascites, variceal hemorrhage, and hepatic encephalopathy), which defines the transition from compensated to decompensated stage. In decompensated patients, treatments aim at lowering the risk of death by preventing further decompensation and/or development of acute-on-chronic liver failure. Decompensated patients often pose a complex challenge which typically requires a multidisciplinary approach. The aims of the present review are to discuss the current knowledge regarding interventional treatments for patients with portal hypertension complications as well as to highlight useful information to aid hepatologists in their clinical practice. Specifically, we discuss indications and contraindications of transjugular intra-hepatic portosystemic shunt (TIPS) and balloon-occluded transvenous retrograde obliteration (BRTO) for the treatment of gastro-esophageal variceal hemorrhage in patients with decompensated cirrhosis (first section), we review the use of interventional treatments in patients with hepatic vein obstruction (Budd-Chiari syndrome) and in those with portal vein thrombosis (second section), and we briefly comment on the most frequent applications of selective splenic embolization in patients with and without underlying cirrhosis (third section)