What is TIPS (Transjugular Intrahepatic Portosystemic Shunt)?

What is TIPS?

TIPS (Transjugular Intrahepatic Portosystemic Shunt) is an interventional radiology procedure where a metal stent is placed inside the liver to create a bypass between the portal vein and hepatic vein, reducing portal pressure in patients with complications of portal hypertension. 1

The Procedure

• An interventional radiologist or hepatologist inserts a wire through the jugular vein in the neck, threads it through the liver using X-ray guidance, and places a metal stent to create the shunt 1
• The procedure takes 90-120 minutes and is performed under general anesthesia or deep sedation 1
• The stent allows blood to flow directly from the portal vein to the hepatic vein, bypassing the high-resistance cirrhotic liver and reducing portal pressure 1
• Technical success rates exceed 90% in experienced hands 2, 3

Primary Indications

Acute Variceal Bleeding:

• TIPS is strongly recommended for gastro-esophageal variceal bleeding that fails endoscopic and drug therapy 4
• It achieves excellent hemostasis (95% success rate) with low rebleeding rates (<20%) 2
• Early or pre-emptive TIPS within 72 hours should be considered in high-risk patients (Child's C disease or MELD ≥19) 4

Secondary Prevention of Variceal Rebleeding:

• TIPS is recommended for prevention of variceal rebleeding when patients have bled again despite standard endoscopic and medical therapies 1
• It is particularly useful for bleeding from varices inaccessible to endoscopy 2

Refractory Ascites:

• TIPS is recommended for refractory or recurrent ascites where fluid accumulation persists despite paracentesis or diuretics 1, 4
• TIPS is more effective than large volume paracentesis in controlling refractory ascites and may confer a survival advantage 5

Other Indications:

• Hepatic hydrothorax (though further comparative studies are needed) 4
• Budd-Chiari syndrome in selected patients at specialist centers 1
• Portal vein thrombosis in selected patients at specialized high-volume centers 1

Absolute Contraindications

• Bilirubin >50 μmol/L 4
• Platelets <75×10^9 4
• Pre-existing hepatic encephalopathy 4
• Active infection 4
• Severe cardiac failure 4
• Severe pulmonary hypertension 4

Pre-Procedure Evaluation

Careful patient selection is critical to minimize complications. 1 The workup 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 (occurring in <5% of patients):

• Bleeding, infection, heart failure, liver failure, kidney failure, fever, and damage to blood vessels and bile ducts 1

Long-term complications:

• Hepatic encephalopathy affects approximately one-third of patients 1, 4
• In most cases, encephalopathy responds to simple measures and medical therapy, but severe cases may require reducing the diameter of or occluding the TIPS 4
• Stent dysfunction requiring reintervention is a major drawback, though covered stents have dramatically improved patency rates 2, 6

Volume Requirements and Expertise

• Centers performing TIPS should handle a minimum of 10 cases annually 1
• Complex cases (thrombosed vessels or transplant recipients) should be reserved for centers performing at least 20 cases per year 1

Common Pitfalls

• Do not use TIPS for primary prophylaxis of variceal bleeding - it is not indicated and exposes patients to unnecessary risks 2
• Patients with severe liver dysfunction (high MELD scores) tend to die post-TIPS despite a functioning shunt, making careful patient selection vital 5
• All patients requiring TIPS for complications of cirrhosis should be referred for consideration of liver transplantation 5
• The presence of porto-pulmonary hypertension requires careful evaluation as TIPS may worsen pulmonary hypertension 4