From the Guidelines
The procedure for a Transjugular Intrahepatic Portosystemic Shunt (TIPS) involves the placement of a bespoke metal tube (stent) inside the liver by inserting a wire through the jugular vein in the neck, then threading and guiding it through the liver under general anaesthetic or deep sedation.
Key Steps in the TIPS Procedure
- The procedure is typically performed by an interventional radiologist or hepatologist and takes approximately 90-120 minutes in uncomplicated cases 1.
- PTFE-covered stents are recommended as they are associated with better patency rates than bare stents 1.
- The portal pressure gradient should be measured pre- and post-stent deployment, and reduced to <12 mmHg or by >=20% of baseline in the case of variceal bleeding 1.
- A Doppler ultrasound is recommended a week after TIPS implantation in patients with prothrombotic conditions, and in other patients where TIPS dysfunction is suspected 1.
Indications for TIPS
- The main indications for TIPS are to treat bleeding from swollen veins in the gullet (varices) and excessive fluid build-up in the abdomen or stomach (ascites) 1.
- TIPS can also be used to treat other complications of portal hypertension, such as hepatic hydrothorax and hepatic encephalopathy 1.
Complications of TIPS
- The main complications of the procedure include bleeding, infection, heart failure, liver failure, kidney failure, fever, damage to blood vessels and bile ducts, and occur in less than 5% of patients 1.
- Long-term complications such as hepatic encephalopathy (HE) affect one-third of patients, but can be managed with medical therapy or by blocking off the TIPS 1.
Follow-up Care
- Patients with prothrombotic conditions require follow-up with Doppler ultrasound and careful consideration for TIPS venography 1.
- Regular follow-up with Doppler ultrasound is recommended at 6-12 monthly intervals to monitor TIPS function and detect any potential complications 1.
From the Research
Procedure Overview
The Transjugular Intrahepatic Portosystemic Shunt (TIPS) procedure is used to treat complications of portal hypertension, including:
- Recurrent or refractory variceal bleeding
- Refractory ascites
- Acute variceal bleed
- Hepatic hydrothorax
- Hepatorenal syndrome 2 The procedure involves creating a shunt between the portal and hepatic veins to reduce portal pressure.
Patient Selection and Indications
Patient selection for TIPS is crucial, and the procedure is typically performed on patients with:
- Severe portal hypertension complications
- Cirrhosis
- Hypercoagulability complicated by Budd-Chiari syndrome
- Acute portal vein thrombosis 3 The indications for TIPS include:
- Treatment or secondary prevention of variceal bleeding
- Refractory ascites
- Mesenteric ischemia due to acute portal vein thrombosis
- Acute liver failure 3
Procedure Techniques
The TIPS procedure can be performed using different techniques, including:
- Transjugular intrahepatic portosystemic shunt (TIPS)
- Direct intrahepatic portocaval shunt (DIPS)
- Transjugular transcaval intrahepatic portosystemic shunt (TTIPS) 4 The choice of technique depends on the patient's anatomy and the presence of any contraindications.
Outcomes and Complications
The outcomes of TIPS can be good, with improved survival and reduced complications of portal hypertension 3, 5 However, the procedure is not without complications, including:
- Transient encephalopathy
- Ischemic hepatitis
- Acute renal failure
- Bleeding 3 Careful patient selection and monitoring can help minimize the risk of complications.