What is TIPS (Transjugular Intrahepatic Portosystemic Shunt)?

Transjugular Intrahepatic Portosystemic Shunt (TIPS)

TIPS is an interventional procedure that creates a bypass within the liver by placing a metal stent between the portal and hepatic veins, reducing portal pressure to treat complications of portal hypertension such as refractory variceal bleeding and ascites. 1

Procedure Details

• TIPS is performed by an interventional radiologist or hepatologist who inserts a wire through the jugular vein in the neck, then threads it through the liver under X-ray guidance to create a connection between the portal and hepatic veins 1
• The procedure typically takes 90-120 minutes and is performed under general anesthesia or deep sedation 1
• Covered stents are preferred over bare metal stents due to superior patency rates 2
• The stent creates a direct pathway for blood to flow from the portal vein to the hepatic vein, effectively bypassing the liver and reducing portal pressure 1

Main Indications

• Acute variceal bleeding unresponsive to standard treatments (endoscopic banding and drug therapy) 1, 3
• Prevention of variceal rebleeding in patients who have bled again despite standard endoscopic and medical therapies 1, 2
• Refractory or recurrent ascites where fluid accumulation persists despite paracentesis or diuretics 1, 3, 2
• Hepatic hydrothorax unresponsive to conventional therapy 1, 3
• Budd-Chiari syndrome in selected patients at specialist centers that also offer liver transplantation 1
• Portal vein thrombosis in selected patients at specialized centers 1, 2
• Bridge to liver transplantation in patients with end-stage liver disease and complications of portal hypertension 4, 5

Pre-Procedure Evaluation

• Comprehensive pre-procedure assessment 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

Contraindications

• Bilirubin >50 μmol/L 3, 2
• Platelets <75×10^9 3, 2
• Pre-existing encephalopathy 3, 2
• Active infection 3, 2
• Severe cardiac failure 3, 2
• Severe pulmonary hypertension 3, 2
• Porto-pulmonary hypertension requires careful evaluation as TIPS may worsen this condition 3

Complications

• Short-term complications (occur in <5% of patients):

  • Bleeding 1, 2
  • Infection 1, 2
  • Heart failure 1, 2
  • Liver failure 1, 2
  • Kidney failure 1, 2
  • Fever 1
  • Damage to blood vessels and bile ducts 1

• Long-term complications:

  • Hepatic encephalopathy affects approximately one-third of patients 1, 3, 2, 4
  • Shunt dysfunction requiring revision (67.5% in first year, 38% in second year, 24.4% in third year) 5
  • Potential for overshunting leading to hepatic decompensation 6

Post-Procedure Monitoring

• Doppler ultrasound is recommended:
  • One week after TIPS implantation in patients with prothrombotic conditions 2
  • Regular follow-up at 6-12 month intervals 2
  • When shunt insufficiency is suspected (blood flow velocity within stent <50 cm/s) 5

Special Considerations

• Centers performing TIPS should handle a minimum of 10 cases annually, with complex cases reserved for centers doing at least 20 cases per year 1
• In cases of overshunting complications, TIPS reduction techniques can be considered before complete occlusion 6
• The role of early or pre-emptive TIPS (within 72 hours of stabilized acute variceal bleeding) remains under investigation, particularly in high-risk patients (Child's C disease or MELD ≥19) 1, 3, 2
• TIPS can be particularly valuable in liver transplant candidates to minimize complications of portal hypertension during the waiting period 4, 5
• TIPS in liver transplant recipients (for recurrent portal hypertension) is associated with lower clinical response rates and higher complications compared to non-transplant patients 7

Management of TIPS Complications

• Hepatic encephalopathy usually responds to simple measures and medical therapy, but in severe cases, it may be necessary to reduce the diameter of or occlude the TIPS 3
• TIPS revision is effective in maintaining sufficient reduction of the portosystemic pressure gradient when shunt dysfunction occurs 5