What are the requirements for a Transjugular Intrahepatic Portosystemic Shunt (TIPS) procedure?

Requirements for Transjugular Intrahepatic Portosystemic Shunt (TIPS) Procedure

TIPS procedures require careful patient selection, comprehensive pre-procedure evaluation, and should be performed in centers with appropriate expertise performing at least 10 cases annually to minimize complications and optimize outcomes. 1

Patient Selection and Indications

TIPS is indicated for the following conditions:

Primary Indications

• Variceal bleeding

  • Refractory to endoscopic and drug therapy (Baveno 6 criteria) 1
  • Early/pre-emptive TIPS for patients with Child's C disease (C10-13) or MELD ≥19 with bleeding from esophageal or GOV1/GOV2 gastric varices 1

• Refractory or recurrent ascites in selected patients 1

• Refractory hepatic hydrothorax 1

Secondary Indications

• Budd-Chiari syndrome when patients fail to respond to medical therapy with anticoagulation or hepatic vein interventions 1
• Portal vein thrombosis (not an absolute contraindication, though cavernoma has high failure rate) 1
• Hepatorenal syndrome (considered experimental) 1

Contraindications

Absolute Contraindications

• Child-Pugh score >13 for salvage TIPS 1
• Severe right-sided heart failure
• Severe tricuspid regurgitation
• Severe pulmonary hypertension

Relative Contraindications

• Hepatic factors:

  • Bilirubin >50 μmol/L 1
  • Platelet count <75×10⁹/L 1
  • Pre-existing hepatic encephalopathy 1
  • Presence of covert hepatic encephalopathy 1

• Cardiac factors:

  • Severe left ventricular dysfunction 1
  • Severe pulmonary hypertension 1

• Other factors:

  • Active infection 1
  • Significant intrinsic renal disease (stage 4/5) 1
  • Age >65 years (increases risk of encephalopathy) 1

Pre-Procedure Evaluation Requirements

Mandatory Assessments

1. Multidisciplinary team discussion for all elective TIPS 1

2. Cross-sectional imaging prior to TIPS 1

3. Cardiac evaluation:

   • Cardiac history and examination
   • 12-lead ECG
   • NT-proBNP measurement
   • Echocardiogram if any abnormalities detected 1

4. Hepatic encephalopathy screening:

   • At least two of the following: 1
     • Psychometric Hepatic Encephalopathy Score (PHES)
     • Stroop testing
     • Critical Flicker Frequency
     • Spectral Enhanced or quantitative EEG

5. Nutritional and functional assessment 1

6. Laboratory tests:

   • Liver function tests
   • Kidney function tests
   • Coagulation profile (thromboelastography preferred over INR) 1
   • Complete blood count

Procedural Requirements

Technical Requirements

• Stent type: PTFE-covered stents (superior patency rates) 1
• Portal pressure gradient measurement:
  • Pre- and post-stent deployment 1
  • Target reduction: <12 mmHg or ≥20% of baseline for variceal bleeding 1

Facility Requirements

• Center expertise: Minimum 10 TIPS cases annually 1
• For complex TIPS: Centers performing at least 20 cases annually 1

Personnel Requirements

• Multidisciplinary team:

  • Hepatology team experienced with portal hypertension
  • Interventional radiologists
  • Intensivists familiar with portal hypertension
  • Anesthesiologists experienced with interventional radiology procedures 1
  • Fully trained interventional support staff (nurses capable of invasive pressure measurements, radiographers)

• Additional support services:

  • Nephrology with access to renal replacement therapy
  • Microbiology
  • Cardiology
  • Networked communication with liver transplant services 1

Post-Procedure Monitoring

• Immediate post-procedure: Monitor for complications (fever, pain, hemodynamic changes)
• Short-term follow-up: Doppler ultrasound within 7 days for patients with prothrombotic conditions 1
• Long-term follow-up: Doppler ultrasound at 6-12 month intervals or with HCC surveillance 1

Common Pitfalls and Complications

Complications to Monitor

• Minor (<10%): Fever, hemobilia 1
• Major (<5%): Hemoperitoneum, biliary peritonitis, hepatic infarction, renal failure, liver failure, heart failure 1
• Mortality: <2% 1
• Hepatic encephalopathy: Occurs in approximately one-third of patients 1

Important Considerations

• For patients eligible for liver transplantation, TIPS for ascites should only be undertaken after discussion with the regional transplant center 1
• Flow reduction may be necessary in cases of severe post-TIPS hepatic encephalopathy 2
• Careful patient selection is crucial to prevent post-TIPS complications including liver failure, encephalopathy, and cardiac decompensation 3

By adhering to these requirements, the risk of complications can be minimized and outcomes optimized for patients undergoing TIPS procedures.