Background

Transjugular intrahepatic portosystemic shunt (TIPS) creation creates a tract between hepatic and portal veins to reduce portal pressure.

Blood shunted from liver sinusoids reduces portal pressure. TIPS is a first-line treatment for portal hypertension complications in cirrhosis.

Shunt creation reduces portal pressure via portal and hepatic vein connection.

Procedure involves inserting a stent to connect portal veins to lower pressure adjacent vessels.

Reduces blood pressure in the diseased liver to prevent bleeding and fluid build-up.

Shunting portal venous flow to systemic circulation reduces portosystemic gradient effectively.

TIPS was first described in 1969 via balloon dilation between veins.

Indications

Refractory Variceal Bleeding

Refractory Ascites

Hepatorenal syndrome

Preoperative Portal Pressure Reduction

Hepatic Hydrothorax

Budd-Chiari syndrome

Contraindications

Severe and progressive liver failure

Polycystic liver disease

Severe encephalopathy

Portal and hepatic vein thrombosis

Pulmonary hypertension

Severe right-heart failure

Hepatopulmonary syndrome

Active infection

Outcomes

TIPS placement success depends on interventional radiologist skill, with data shows over 90% success at three centers.

TIPS placement controls variceal bleeding with a portosystemic gradient under 12 mm Hg.

A gradient under 12 mm Hg lowers variceal bleeding risk and is the target.
Technical failures in portal venous puncture stem from anatomical issues. Ascites reduces significantly within a month in 50-90% of cases.

Late stenosis and occlusion are linked to pseudointimal or intimal hyperplasia in stents.

Equipment required

Good ultrasound machine with linear-array probe

Fluoroscopy

Basic angiography set

Sheath and curved catheter

Guide wires

Pressure transducer

Angioplasty balloons

Patient Preparation:

General anesthesia is common for pediatric and often preferred for adults.

Midazolam and fentanyl citrate are effective for sedation. Local anesthesia achieved with 5 mL lidocaine 1% at jugular.

Impaired renal function requires pre-hydration and lower osmolality non-ionic contrast agents.

Pre-procedure imaging ensures portal and hepatic vein patency while ruling out tumors in the area.

Large-volume ascites can be drained prior to the procedure for advanced techniques like percutaneous guide wire placement.

Informed Consent:

Explain the procedure’s risks and potential complications clearly to the patient.

Patient Positioning:

The patient should be positioned in supine position with their neck turned away from the side of vein puncture.

Technique

Step 1: Venous Access and Catheter Placement

A sheath is inserted into the right internal jugular vein. Then a guiding catheter is advanced into the hepatic vein.

Step 2: Portal Vein Puncture

With help of fluoroscopy and ultrasound, a TIPS needle system is used to puncture the portal vein from the hepatic vein.

Step 3: Tract Dilation

Guidewire is advanced into the portal vein very carefully for stability.

The tract is dilated using a balloon catheter to widen the connection.

Step 4: Stent Placement

A self-expandable stent should be placed to maintain the shunt between the hepatic and portal veins.

Step 5: Hemodynamic Assessment

Finally portal pressure gradient is measured before and after TIPS creation.

Figure. Anatomy of human liver

Complications:

Inability to place the stent

Bleeding

Trauma to the liver and heart

Stent infection

Bile leak and peritonitis

Heart failure

Encephalopathy

Stent thrombosis and occlusion

Hemolytic anemia

Severe hyperbilirubinemia

Radiation injury

References

Transjugular Intrahepatic Portosystemic Shunt – StatPearls – NCBI Bookshelf

References

Transjugular Intrahepatic Portosystemic Shunt – StatPearls – NCBI Bookshelf