Transjugular intrahepatic portosystemic shunt

Transjugular intrahepatic portosystemic shunt (TIPS) is a treatment for portal hypertension in which direct communication is formed between a hepatic vein and a branch of the portal vein, thus allowing some proportion of portal flow to bypass the liver. The target portosystemic gradient after TIPS formation is <12 mmHg.

Indications

• acute variceal bleeding when pharmacologic therapy and endoscopic sclerotherapy have failed ¹¹
• recurrent variceal bleeding (as a preventative procedure)
• ascites refractory to medical management in patients that require frequent drainage or do not tolerate repeated drainage ¹¹
• hepatic hydrothorax that cannot be adequately managed with salt restriction and diuresis ¹¹
• portal hypertensive gastropathy
• hepatorenal syndrome 
• lower gastrointestinal and stomal varices
• malignant compression of hepatic or portal veins
• Budd-Chiari syndrome of moderate level disease not responsive to anticoagulation ¹¹

Contraindications

Absolute contraindications

• severe chronic liver disease or rapidly progressive acute liver failure, as the diseased or injured liver may not tolerate the diversion of nutrient portal blood flow ¹⁰
• severe encephalopathy resistant to medical management, as diversion of unfiltered blood will worsen it ¹⁰
• severe right heart failure as the flow diversion from a TIPS will increase pre-load ¹⁰
• uncontrolled sepsis as there is a substantially increased risk of stent infection ¹⁰

Relative contraindications

• right heart failure
• cavernous transformation of the portal vein
• cystic hepatic disease
• occlusive main portal vein thrombus
• polycystic kidney disease
• hepatic malignancy or haemangioma ¹⁰

Procedure details

1. Ultrasound-guided vascular access gained typically via the right internal jugular vein (other approaches are possible if this is contraindicated) with a vascular sheath inserted into the right atrium for initial pressure measurement.
2. An angiographic catheter is advanced into a chosen hepatic vein (typically the right hepatic vein), and hepatic venography is performed.
3. Curved TIPS puncture needle is advanced into the hepatic vein with its surrounding sheath.
4. For the typical case of right-hepatic-vein to right-portal-vein branch stent, the TIPS puncture needle is rotated anteriorly and advanced inferiorly through the liver parenchyma to the anticipated location of the portal vein branch.
5. Portal venogram is performed with contrast injected through the TIPS puncture needle to confirm portal vein cannulation.
6. Guidewire is advanced through the needle and manipulated into the splenic or mesenteric vein to ensure portal vein access is not lost as the liver will be moving craniocaudally with respiration.
7. Angiographic catheter is advanced into portal vein for portal pressure measurement, and venography can be repeated to visualise varicies.
8. The tract created through the liver parenchyma is dilated using a balloon catheter.
9. Vascular sheath is advanced through the tract and 2cm into the portal vein branch.
10. Stent is deployed over the sheath.
11. Portal pressures are measured to assess if the desired reduction in portosystemic gradient is achieved (stent dilation is possible immediately and in the future to increase flow diversion).
12. Venography can be repeated to confirm variceal bleeding has ceased with portal pressure reduction.

Complications

Acute complications

• haemorrhage (haemoperitoneum, intrahepatic haematoma, subcapsular haematoma)
• hepatic infarction
• gallbladder puncture
• sepsis secondary to infection ⁶
• vascular access sites haematoma
• unintentional arterial access ^7,8
• acute kidney injury

Long-term complications

• uncontrollable hepatic encephalopathy
• recurrence of portal hypertension with sequelae
• hepatic venous stenosis
• stent occlusion: portovenogram with re-stenting is indicated when there is recurrent bleeding and decreased Doppler flow on follow-up
• stent migration
• stent infection

* Since the introduction of PTFE (polytetrafluoroethylene) stents, stent-related complications are extremely rare ¹².

Methods to assess patency

• colour Doppler ¹
• CT angiography ⁴
• portography with portal manometry

See: TIPS evaluation.

Factors affecting poor survival

These include ⁵:

• hyponatremia
• hyperbilirubinemia
• elevated serum ALT
• advanced liver disease
• coexisting renal insufficiency

See also

• liver and biliary interventional procedures