transjugular intrahepatic porto systemic shunt

A transjugular intrahepatic portosystemic shunt (TIPS) is a percutaneously created connection within the liver between the portal and systemic circulations.

A TIPS is placed to reduce portal pressure in patients with complications related to portal hypertension.

This procedure has emerged as a less invasive alternative to surgery in patients with end-stage liver disease.

The goal of TIPS placement is to divert

portal blood flow into the hepatic vein, so as to reduce the pressure gradient between portal and systemic circulations.

Shunt patency is maintained by placing an expandable metal stent across the intrahepatic tract.

Acute variceal bleeding that cannot be successfully controlled with medical treatment, including sclerotherapy.

Recurrent and refractory variceal bleeding

Therapy for refractory ascites. Portal decompression in patients with

hepatic venous outflow obstruction (Budd-Chiari syndrome) or hepatorenal syndrome.

Initial therapy of acute variceal hemorrhage Initial therapy to prevent initial or recurrent

variceal hemorrhage Reduction of intraoperative morbidity

during liver transplantation.

Right-sided heart failure with increased

central venous pressure Polycystic liver disease Severe hepatic failure

Active intrahepatic or systemic infection

(bacteria can colonize the stent, causing persistent infection)

Severe hepatic encephalopathy poorly controlled with medical therapy

Hypervascular hepatic tumors PV thrombosis (Although PV thrombus may

make the procedure more technically demanding, it is not an absolute contraindication to TIPS placement.)

prophylactic broad-spectrum antibiotics. Appropriate resuscitation with fluid and blood

products. Portal vein (PV) patency should be confirmed

prior to attempts at TIPS placement by Doppler sonography, arterial portography and MRI.

In Patients with cirrhosis severe coagulopathy should be addressed prior to procedure.

This technique is preferably done under general anesthesia

After puncture of the jugular vein (most often the right jugular vein) under sonographic guidance, a catheter is introduced into one hepatic vein and wedged in the liver parenchyma.

Gentle injection of dye allows the retrograde visualization of intrahepatic portal vein branches.

CO2 can be used in patients with renal function impairment to avoid dye nephrotoxicity.

The intrahepatic portal vein then is entered with a modified Ross needle.

A guide wire is advanced into the main portal vein.

The tract between the hepatic and the portal vein is dilated with an angioplasty balloon catheter (8–10 mm) followed by stent placement to maintain the communication between both vessels patent

Basic transjugular intrahepatic portosystemic shunt (TIPS) procedure. A curved catheter is placed into the right hepatic vein.

A wedged hepatic venogram obtained by using the digital subtraction technique obtained with CO2 gas demonstrates the location of the portal vein. The catheter is wedged in a branch of the right hepatic vein.

Image demonstrates advancement of a Colapinto needle into the right portal vein.

A TIPS (10 X 68 mm Wallstent dilated with 10 mm X 4 cm balloon) has been placed. Note flow through the Wallstent and filling of the splenorenal shunt

Shunt surveillance:at regular 3 to 6month intervals for Assessment of:

MORPHOLOGYAscitesPortosystemic collateralsSize of spleenDiameter of stent (usually 8 to 10 mm)Configuration of stent: areas of narrowingExtension of stent into portal + hepatic veins

HEMODYNAMICSDirection of flow in: extrahepatic portal vein, R +

L portal vein, SMV, splenic vein, all 3 hepatic veins, intrahepatic IVC, paraumbilical vein, coronary vein

Peak blood flow velocity within main portal veinPeak blood flow velocity within proximal + mid +

distal aspects of stent

1. Shunt velocity of <50 cm/sec 2. Increase or decrease in shunt

velocity of >50cm/sec compared with initial post-procedure value

3. Hepatofugal flow in main portal vein

COMPLICATIONS (A) Obstruction to flow

Shunt obstruction (38%) Hepatic vein stenosis

(B)Trauma (a)Vascular injury Hepatic artery pseudoaneurysm Arterioportal fistula Intrahepatic/subcapsular hematoma Hemoperitoneum (due to penetration

of liver capsule)

(b)Biliary injury Transient bile duct dilatation (due to

hemobilia) Bile collection

(C) Stent dislodgment with embolization to right atrium, pulmonary artery, internal jugular vein .

Follow up with duplex sonography and shunt angiography

Early shunt occlusion <30 days: thrombosis (local thrombolytic treatment, redilation, restenting)

Late: intimal thickening within the stent or hepatic vein ( dilation or another stent)

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