Rethinking TIPS: From clinical insight to device innovation

The mind, like a parachute, performs best when is open. James Dewar The aphorism captures an enduring truth about scientific progress: innovation rarely advances through rigid adherence to established clinical frameworks that have progressively crystallized into dogma. Rather, it flourishes when clinicians and researchers remain open to challenging assumptions that have long guided medical practice. In Hepatology, a compelling example is the development of the under-dilated transjugular intrahepatic portosystemic shunt (U-TIPS) strategy, conceived within the scientific community of the Italian Association for the Study of the Liver. Clinician-driven innovation begins with dissatisfaction. When experienced practitioners recognize that conventional protocols do not consistently produce the desired outcomes, new questions arise. Why do some patients deteriorate despite technically successful procedures? Could a different strategy yield a better balance between benefits and risks? What if the underlying assumptions guiding our interventions are not entirely correct? Such questions, when pursued systematically, can reshape entire fields. TIPS is widely regarded as the most effective therapy for severe complications of portal hypertension, supported by decades of evidence and a central role in current guidelines [ 1–6 ]; accordingly, its application deserves critical appraisal. Before addressing technical aspects, the discussion should be anchored to the goals of TIPS: controlling variceal bleeding and recurrent/refractory ascites, preventing further decompensation, preserving hepatic, neurocognitive, and cardiac function, and improving quality of life. These patient-centered outcomes, not procedural metrics, should guide decision-making.