Transjugular intrahepatic portosystemic shunt

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A transjugular intrahepatic portosystemic shunt (TIPS) is a treatment for portal hypertension in which a direct communication is formed between a hepatic vein and a branch of the portal vein, thus bypassing the liver. A successful endpoint is a portosystemic gradient of <12 mmHg.

Indications

Many patients have end stage liver disease. Indications include

variceal bleeding (preventative in recurrent cases)
variceal bleeding (for treatment in acute setting⁵)
refractory ascites, hepatic hydrothorax
portal ~~hypertensive~~ hypertensive gastropathy
hepatorenal syndrome
lower gastrointestinal and stomal varices
malignant compression of hepatic or portal veins
Budd-Chiari syndrome

Relative contraindications

severeright heart failure
cavernous transformation of the portal vein
severe rapidly ~~progressive hepatic~~ progressive hepatic failure
multi-cystic hepatic disease
severe hepatic encephalopathy
main portal vein occlusion
polycystic kidney disease
hypervascular hepatic tumour

Complications

blockage: TIPS occlusion. A portovenogram with re-stenting is indicated when there is recurrent bleeding and decreased doppler flow on follow up.
uncontrollable hepatic encephalopathy
hepatic venous stenosis
haemorrhage (haemoperitoneum, intrahepatic haematoma, subcapsular haematoma
sepsis secondary to infection ⁶
unintentional arterial access ^7,8

Methods to assess patency

colour Doppler¹
CT angiography ⁴
portography with portal manometry

See: TIPS evaluation

Factors affecting poor survival ⁵

hyponatremia
hyperbilirubinemia
elevated serum ALT
advanced liver disease
coexisting renal insufficiency

Image 7 DSA (angiography) (TIPS) ( create )

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