Anesthetic techniques and perioperative outcomes in patients undergoing transjugular intrahepatic portosystemic shunt: a retrospective cohort study

Background Portal hypertension is a common clinical manifestation of liver cirrhosis. Transjugular intrahepatic portosystemic shunt (TIPS) is a high-risk procedure that reduces portal pressure and the risk of complications, such as variceal bleeding and refractory ascites. However, there is no consensus regarding the optimal anesthetic technique for this procedure. This study aimed to describe the anesthetic techniques used and the perioperative outcomes in a high-complexity center. Methods A retrospective observational study was conducted in adults undergoing TIPS under general anesthesia between January 2015 and July 2025. Demographic, clinical, anesthetic variables, and postoperative outcomes were collected. Patients were grouped according to the anesthetic technique used: balanced general anesthesia (BGA) or total intravenous anesthesia (TIVA). Descriptive statistics were applied, and comparisons were made between groups. Results A total of 155 patients were included; 92.9% received BGA and 7.1% received TIVA. Most patients were ASA III, predominantly Chil-Pugh B, with a median MELD score of 11 (IQR 9.5–14). Variceal bleeding was the main indication for TIPS (69.7%), and 46% of the procedures were urgent, reflecting the cohort's high clinical complexity. Invasive arterial monitoring was used in 79.4% of the cases, while central venous catheters were used in only 7.9%. No statistically significant differences were observed between the anesthetic techniques regarding vasoactive requirements, transfusions, ICU admission, or postoperative complications. However, there was a non-significant trend toward a lower post-TIPS portosystemic gradient in the TIVA group (5 vs. 8 mmHg). Postoperative hepatic encephalopathy occurred in 39.4% of patients. In-hospital mortality was 17.4%, with a median survival of 51 days among deceased patients. Conclusion Balanced anesthesia was the most frequently used anesthetic technique. Advanced monitoring beyond invasive blood pressure monitoring was uncommon. Although TIVA showed a non-significant trend toward lower post-TIPS portosystemic gradients, no differences were observed in major clinical outcomes. A high rate of ICU admission and in-hospital mortality reflect patients' baseline comorbid status rather than the anesthetic technique used. This study presents data from one of the largest cohorts reported in Latin-American population, highlighting the relevance of its findings and the importance of prospective studies with individualized anesthetic strategies to guide future protocols.