Transjugular intrahepatic portosystemic shunt
Transjugular intrahepatic portosystemic shunt (TIPS) is a treatment for portal hypertension in which direct communication is formed between a hepatic vein and a branch of the portal vein, thus allowing some proportion of portal flow to bypass the liver. The target portosystemic gradient after TIPS formation is <12 mmHg.
- acute variceal bleeding when pharmacologic therapy and endoscopic sclerotherapy have failed 12
- recurrent variceal bleeding (as a preventative procedure)
- ascites refractory to medical management in patients that require frequent drainage or do not tolerate repeated drainage 12
- hepatic hydrothorax that cannot be adequately managed with salt restriction and diuresis 12
- portal hypertensive gastropathy
- hepatorenal syndrome
- lower gastrointestinal and stomal varices
- malignant compression of hepatic or portal veins
- Budd-Chiari syndrome of moderate level disease not responsive to anticoagulation 12
It is arguable that there are no absolute contraindications 10. However, practices among interventional radiologists vary. Some generally accepted absolute contraindications are:
- severe chronic liver disease or rapidly progressive acute liver failure, as the diseased or injured liver may not tolerate the diversion of nutrient portal blood flow 11
- severe encephalopathy resistant to medical management, as diversion of unfiltered blood will worsen it 11
- severe right heart failure as the flow diversion from a TIPS will increase pre-load 11
- uncontrolled sepsis as there is a substantially increased risk of stent infection 11
- right heart failure
- cavernous transformation of the portal vein
- cystic hepatic disease
- occlusive main portal vein thrombus
- polycystic kidney disease
- hepatic malignancy or haemangioma 11
- Ultrasound-guided vascular access gained typically via the right internal jugular vein (other approaches are possible if this is contraindicated) with a vascular sheath inserted into the right atrium for initial pressure measurement.
- An angiographic catheter is advanced into a chosen hepatic vein (typically the right hepatic vein), and hepatic venography is performed.
- Curved TIPS puncture needle is advanced into the hepatic vein with its surrounding sheath.
- For the typical case of right-hepatic-vein to right-portal-vein branch stent, the TIPS puncture needle is rotated anteriorly and advanced inferiorly through the liver parenchyma to the anticipated location of the portal vein branch.
- Portal venogram is performed with contrast injected through the TIPS puncture needle to confirm portal vein cannulation.
- Guidewire is advanced through the needle and manipulated into the splenic or mesenteric vein to ensure portal vein access is not lost as the liver will be moving craniocaudally with respiration.
- Angiographic catheter is advanced into portal vein for portal pressure measurement, and venography can be repeated to visualise varicies.
- The tract created through the liver parenchyma is dilated using a balloon catheter.
- Vascular sheath is advanced through the tract and 2cm into the portal vein branch.
- Stent is deployed over the sheath.
- Portal pressures are measured to assess if the desired reduction in portosystemic gradient is achieved (stent dilation is possible immediately and in the future to increase flow diversion).
- Venography can be repeated to confirm variceal bleeding has ceased with portal pressure reduction.
- haemorrhage (haemoperitoneum, intrahepatic haematoma, subcapsular haematoma)
- hepatic infarction
- gallbladder puncture
- sepsis secondary to infection 6
- vascular access sites haematoma
- unintentional arterial access 7,8
- acute kidney injury
- uncontrollable hepatic encephalopathy
- recurrence of portal hypertension with sequelae
- hepatic venous stenosis
- stent occlusion: portovenogram with re-stenting is indicated when there is recurrent bleeding and decreased Doppler flow on follow-up
- stent migration
- stent infection
* Since the introduction of PTFE (polytetrafluoroethylene) stents, stent-related complications are extremely rare 12.
Methods to assess patency
- colour Doppler 1
- CT angiography 4
- portography with portal manometry
See: TIPS evaluation.
Factors affecting poor survival
These include 5:
- elevated serum ALT
- advanced liver disease
- coexisting renal insufficiency
- 1. Kliewer MA, Hertzberg BS, Heneghan JP et-al. Transjugular intrahepatic portosystemic shunts (TIPS): effects of respiratory state and patient position on the measurement of Doppler velocities. AJR Am J Roentgenol. 2000;175 (1): 149-52. AJR Am J Roentgenol (full text) - Pubmed citation
- 2. Ferral H, Gamboa P, Postoak DW et-al. Survival after elective transjugular intrahepatic portosystemic shunt creation: prediction with model for end-stage liver disease score. Radiology. 2004;231 (1): 231-6. doi:10.1148/radiol.2311030967 - Pubmed citation
- 3. Johnson MS. Transjugular intrahepatic portosystemic shunt: accuracy of helical CT angiography in the detection of abnormalities. Radiology. 2000;215 (1): 25-6. Radiology (full text) - Pubmed citation
- 4. Kerns SR, Hawkins IF. Transjugular intrahepatic portosystemic shunt in a child with cystic fibrosis. AJR Am J Roentgenol. 1992;159 (6): 1277-8. AJR Am J Roentgenol (citation) - Pubmed citation
- 5. Yoon CJ, Chung JW, Park JH. Transjugular intrahepatic portosystemic shunt for acute variceal bleeding in patients with viral liver cirrhosis: predictors of early mortality. AJR Am J Roentgenol. 2005;185 (4): 885-9. doi:10.2214/AJR.04.0607 - Pubmed citation
- 6. Jalan R, Redhead DN, Simpson KJ et-al. Transjugular intrahepatic portosystemic stent-shunt (TIPSS): long-term follow-up. QJM. 1994;87 (9): 565-73. QJM (abstract) - Pubmed citation
- 7. Kerlan RK, LaBerge JM, Gordon RL et-al. Inadvertent catheterization of the hepatic artery during placement of transjugular intrahepatic portosystemic shunts. Radiology. 1994;193 (1): 273-6. doi:10.1148/radiology.193.1.8090907 - Pubmed citation
- 8. Pattynama PM, van Hoek B, Kool LJ. Inadvertent arteriovenous stenting during transjugular intrahepatic portosystemic shunt procedure and the importance of hepatic artery perfusion. Cardiovasc Intervent Radiol. 1995;18 (3): 192-5. Pubmed citation
- 9. Image-guided interventions. Saunders. ISBN:1455705969. Read it at Google Books - Find it at Amazon
- 10. Quality Improvement Guidelines for Transjugular Intrahepatic Portosystemic Shunts. Dariushnia, Sean R. et al. J Vasc Interv Radiol 2016; 27:1–7. doi:10.1016/j.jvir.2015.09.018 - JVIR
- 11. Kandarpa K. Handbook of Interventional Radiologic Procedures. Lippincott Williams & Wilkins. ISBN:0781768160. Read it at Google Books - Find it at Amazon
- 12. Boyer TD, Haskal ZJ. The Role of Transjugular Intrahepatic Portosystemic Shunt (TIPS) in the Management of Portal Hypertension: update 2009. Hepatology. 2010;51 (1): 306. doi:10.1002/hep.23383 - Pubmed citation
- 13. Madoff DC, Gaba RC, Weber CN et-al. Portal Venous Interventions: State of the Art. Radiology. 2016;278 (2): 333-53. doi:10.1148/radiol.2015141858 - Pubmed citation
- thyroid gland
spinal interventional procedures (general)
- epidural blood patch
- facet joint injection
- fluoroscopy-guided lumbar puncture
- sacroiliac joint injection
- spinal epidural injection
- transforaminal nerve root injection
- spinal interventional procedures (general)