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

TIPS Recommendations

All TIPS procedures should be performed using PTFE-covered stents with controlled expansion, and the portal pressure gradient must be reduced to <12 mmHg or by ≥20% of baseline for variceal bleeding. 1

Pre-Procedure Evaluation

Multidisciplinary Assessment

• All elective TIPS candidates must be discussed in a multidisciplinary team including hepatology and interventional radiology. 1
• For complex cases (portal vein thrombosis, transplant candidates), referral to experienced centers with transplant surgery, nephrology, and critical care expertise is essential. 1

Required Imaging and Testing

For elective TIPS: 1

• Contrast-enhanced multiphasic cross-sectional imaging (CT/MRI) to evaluate portal venous anatomy and liver parenchyma
• Comprehensive echocardiography assessing cardiac structure, function, and right ventricular systolic pressure
• Cardiac history, 12-lead ECG, and NT-proBNP levels 1

For emergent TIPS (acute variceal bleeding): 1

• Minimum: liver ultrasound with Doppler to assess portal vein patency
• Consider limited bedside echocardiogram for left ventricular ejection fraction and right ventricular systolic pressure
• Do not delay life-saving emergent TIPS for complete cardiac evaluation 1

Hepatic Encephalopathy Screening

All elective TIPS candidates must be screened for covert and overt encephalopathy using at least two of the following: 1

• Psychometric hepatic encephalopathy score (PHES) testing
• Stroop testing
• Critical Flicker Frequency
• Spectral Enhanced or quantitative EEG

Nutritional and Functional Assessment

Patients undergoing elective TIPS should have detailed nutritional and functional assessment, as cachexia may increase encephalopathy risk. 1

Absolute Contraindications to Elective TIPS

The following are absolute contraindications: 1

• Severe congestive heart failure (ACC/AHA Stage C or D)
• Severe untreated valvular heart disease (AHA/ACC stage C or D)
• Moderate-severe pulmonary hypertension (based on invasive measurements) despite medical optimization
• Severe left ventricular dysfunction 1
• Uncontrolled systemic infection
• Refractory overt hepatic encephalopathy
• Unrelieved biliary obstruction
• Hepatic lesions (cysts, tumors) that preclude TIPS creation
• Stage 4/5 chronic kidney disease (significant intrinsic renal disease) 1

Important Caveats:

• In acute variceal bleeding with renal dysfunction, TIPS can still be considered despite renal impairment 1
• Covert hepatic encephalopathy is a relative (not absolute) contraindication to elective TIPS 1
• Age >65 increases encephalopathy risk but is not an absolute contraindication; factor this into decision-making 1

MELD Score Considerations

Use a multidisciplinary approach rather than an absolute MELD cutoff to assess TIPS candidacy. 1 Consider the TIPS indication, patient comorbidities, and alternative treatment options when evaluating MELD score, as the score performs better for variceal bleeding than refractory ascites. 1

Procedural Recommendations

Operator Qualifications

TIPS must be performed by a credentialed, board-certified interventional radiologist or certified provider with equivalent training and procedural competency. 1

Anesthesia

General anesthesia or deep sedation using propofol is recommended for all TIPS procedures. 1 The choice between general anesthesia, deep sedation, or conscious sedation depends on patient risk factors and local practices. 1

Antibiotic Prophylaxis

Routine prophylactic antibiotics are NOT recommended except for: 1

• TIPS for variceal bleeding
• Complex procedures
• Previous biliary instrumentation

Coagulopathy Correction

• Base the decision to correct coagulopathy on thromboelastography, as INR is unreliable in liver disease 1
• Consider platelet transfusion if platelet count <50×10⁵/L 1
• There is no specific target INR or platelet threshold mandated 1

Stent Selection and Technique

Use ePTFE-covered stents with controlled expansion capability, as they have superior patency rates compared to bare metal stents. 1 Controlled expansion allows tailoring of portosystemic shunting based on indication, target gradient, and patient comorbidities. 1

Pressure Gradient Targets

• Measure portal pressure gradient between portal vein and IVC (or free hepatic vein) pre- and post-stent deployment 1
• For variceal bleeding: reduce gradient to <12 mmHg OR by ≥20% of baseline 1
• For other indications: balance efficacy against hepatic encephalopathy risk; individualize gradient reduction 1

Variceal Embolization

The role of embolization with TIPS is unclear. Base decisions on cross-sectional imaging and portography showing large varices where pressure reduction alone may be insufficient. 1

Special Populations

Portal Vein Thrombosis

• Portal vein thrombosis is NOT an absolute contraindication to TIPS 1
• Cavernoma formation is associated with significantly higher failure rates 1
• Discuss acute PVT and cirrhotic patients with PVT and variceal bleeding with experienced units 1

Transplant Candidates

• Position the stent to avoid interference with portal and hepatic vein anastomoses during future liver transplantation 1
• Universal pre-procedure liver transplant evaluation is not required for all TIPS candidates 1
• TIPS should not be delayed to complete transplant evaluation 1

Post-Procedure Surveillance

Doppler Ultrasound Monitoring

Perform Doppler ultrasound: 1

• One week after TIPS in patients with prothrombotic conditions or suspected dysfunction
• At 6-12 month intervals for routine surveillance
• Every 6 months in patients undergoing HCC surveillance

TIPS Dysfunction Criteria

Suspect shunt insufficiency when blood flow velocity within the stent tract is <50 cm/s, which indicates need for TIPS revision. 2

Venography

• Patients with prothrombotic conditions (e.g., Budd-Chiari syndrome) require careful consideration for TIPS venography 1
• Routine venography is NOT indicated in other patients 1

Management of Post-TIPS Encephalopathy

If encephalopathy develops after TIPS, manage according to standard hepatic encephalopathy guidelines. If encephalopathy persists despite medical management, consider shunt reduction, embolization, or occlusion. 1