What is TIPS (Transjugular Intrahepatic Portosystemic Shunt)?

What is TIPS?

TIPS (Transjugular Intrahepatic Portosystemic Shunt) is a non-surgical procedure that creates a connection between the portal vein and hepatic vein using a metal stent to reduce portal hypertension in patients with liver disease. 1

Definition and Procedure

• TIPS involves an interventional radiologist or hepatologist placing a metal stent inside the liver by inserting a wire through the jugular vein in the neck, then threading and guiding it through the liver using X-ray guidance 1
• The procedure typically takes 90-120 minutes and is performed under general anesthesia or deep sedation 1
• The stent creates a bypass that allows blood to flow directly from the portal vein to the hepatic vein, reducing portal pressure 1

Main Indications

TIPS is recommended in the following clinical situations:

1. Acute variceal bleeding that is unresponsive to standard treatments (endoscopic banding and drug therapy) 1
2. Prevention of variceal rebleeding in non-emergency situations where patients have bled again despite standard endoscopic and medical therapies 1
3. Refractory ascites or hydrothorax where fluid accumulation persists despite other treatments like paracentesis or diuretics 1
4. Budd-Chiari syndrome in selected patients at specialist centers that also offer liver transplantation 1
5. Portal vein thrombosis in selected patients at specialized centers performing high volumes of TIPS procedures 1

Preparation and Patient Selection

Careful patient selection is critical to minimize complications. Pre-procedure evaluation includes:

• Specialized imaging of the liver and surrounding vessels 1
• Liver and kidney function tests 1
• Coagulation studies 1
• Cardiac function assessment 1
• Nutritional assessment 1
• Evaluation of encephalopathy risk 1

Complications

• Short-term complications occur in less than 5% of patients and include bleeding, infection, heart failure, liver failure, kidney failure, fever, and damage to blood vessels and bile ducts 1
• Hepatic encephalopathy affects approximately one-third of patients long-term 1
• Encephalopathy may require medical therapy or, in severe cases, reduction or occlusion of the TIPS 2
• TIPS dysfunction requiring revision occurs in 67.5% of patients within the first year, 38% in the second year, and 24.4% in the third year 3

Special Considerations

• TIPS can serve as a bridge to liver transplantation, helping manage portal hypertension complications while patients await transplant 3, 4
• Patients with Child-Pugh class C cirrhosis and those requiring urgent TIPS have higher mortality rates 4
• Centers performing TIPS should handle a minimum of 10 cases annually, with complex cases (thrombosed vessels or transplant recipients) reserved for centers doing at least 20 cases per year 1
• TIPS placement in liver transplant recipients has lower clinical response rates and higher complications compared to non-transplant patients 5

Uncertain Indications

The role of TIPS remains unclear in:

• "Early" or "pre-emptive" TIPS within 72 hours of stabilized acute variceal bleeding 1
• Patients with chronic kidney disease 1
• Idiopathic non-cirrhotic portal hypertension 1
• Prophylactic use before non-hepatic surgery 1, 6