Transjugular Intrahepatic Portosystemic Shunt
- Author: Sapna Puppala, MBBS; Chief Editor: Justin A Siegal, MD more...
Transjugular intrahepatic portosystemic shunt (TIPS) creation is the percutaneous formation of a tract between the hepatic vein and the intrahepatic segment of the portal vein in order to reduce the portal venous pressure. The blood is shunted away from the liver parenchymal sinusoids, thus reducing the portal pressure.[1, 2, 3] TIPS, therefore, represents a first-line treatment for complications of portal hypertension, typically in patients with decompensated liver cirrhosis.
Accepted indications for TIPS include the following:
Hepatic pleural effusion (hydrothorax)
Controversial indications for TIPS include the following:
Absolute contraindications for TIPS include the following:
Severe and progressive liver failure (on the basis of the Child-Pugh score; scores A and B have a better outcome than score C)
Polycystic liver disease
Severe right-heart failure
Relative contraindications for TIPS include the following:
Portal and hepatic vein thrombosis
Tumor within the expected path of the shunt
The technical success of TIPS placement is related to the experience and skill of the interventional radiologist. Data from three large centers (University of California, San Francisco; University of Pennsylvania; and the Freiberg group) demonstrated technical success rates of more than 90%.
Successful TIPS placement results in a portosystemic gradient of less than 12 mm Hg and immediate control of variceal-related bleeding. A target portosystemic gradient of 12 mm Hg is used as varices tend not to bleed when the gradient is less than 12 mm Hg. When technical failure occurs, it is usually due to an anatomic situation that prevents acceptable portal venous puncture. Significant reduction in ascites usually occurs within 1 month of the procedure, and this is estimated to occur in 50-90% of cases.[7, 8, 9, 10]
Late stenosis and occlusion are usually related to pseudointimal hyperplasia within the stent or, more commonly, intimal hyperplasia within the hepatic vein. In most cases, the stenotic stent can be crossed with a guide wire and recanalized with balloon dilation (see the image below) or repeat stent placement to improve long-term patency rates. Primary patency after TIPS placement has been reported to be 66% and 42% after 1 and 2 years. Primary-assisted patency rates at 1 and 2 years are reported to be 83% and 79%, respectively, and secondary patency rates at 1 and 2 years are reported to be 96% and 90%.
Reported figures for 30-day mortality vary among centers, and nearly all centers report few or no deaths directly related to the procedure itself. Early mortality has been shown to be related to the Acute Physiology and Chronic Health Evaluation (APACHE) II score. Patients with severe systemic disease with an APACHE II score higher than 20 have a greater risk for early mortality, compared with others.
Patients with active bleeding during the procedure also have increased early mortality. The 30-day mortality is in the range of 3-30%; the variation within this range is related to the preprocedural Child classification and whether the procedure was performed on an emergency basis or an elective basis. In 1995, LaBerge et al reported that cumulative survival rates in patients with Child grades of A, B, and C, respectively, were 75%, 68%, and 49% at 1 year and 75%, 55%, and 43% at 2 years.
Colombato L. The role of transjugular intrahepatic portosystemic shunt (TIPS) in the management of portal hypertension. J Clin Gastroenterol. 2007 Nov-Dec. 41 Suppl 3:S344-51. [Medline].
Olliff SP. Transjugular intrahepatic portosystemic shunt in the management of Budd Chiari syndrome. Eur J Gastroenterol Hepatol. 2006 Nov. 18(11):1151-4. [Medline].
Angermayr B. Transjugular intrahepatic portosystemic shunt--current status in 2011. Acta Gastroenterol Belg. 2011 Dec. 74(4):553-9. [Medline].
Gaba RC, Omene BO, Podczerwinski ES, et al. TIPS for treatment of variceal hemorrhage: clinical outcomes in 128 patients at a single institution over a 12-year period. J Vasc Interv Radiol. 2012 Feb. 23(2):227-35. [Medline].
King A, Masterton G, Gunson B, et al. A case-controlled study of the safety and efficacy of transjugular intrahepatic portosystemic shunts after liver transplantation. Liver Transpl. 2011 Jul. 17(7):771-8. [Medline].
Bonnel AR, Bunchorntavakul C, Rajender Reddy K. Transjugular intrahepatic portosystemic shunts in liver transplant recipients. Liver Transpl. 2013 Oct 18. [Medline].
Kauffmann GW, Richter GM. Transjugular intrahepatic portosystemic stent-shunt (TIPSS): technique and indications. Eur Radiol. 1999. 9(4):685-92. [Medline].
Tripathi D, Helmy A, Macbeth K, et al. Ten years' follow-up of 472 patients following transjugular intrahepatic portosystemic stent-shunt insertion at a single centre. Eur J Gastroenterol Hepatol. 2004 Jan. 16(1):9-18. [Medline].
Gaba RC, Khiatani VL, Knuttinen MG, et al. Comprehensive review of TIPS technical complications and how to avoid them. AJR Am J Roentgenol. 2011 Mar. 196(3):675-85. [Medline].
Saugel B, Phillip V, Gaa J, et al. Advanced hemodynamic monitoring before and after transjugular intrahepatic portosystemic shunt: implications for selection of patients--a prospective study. Radiology. 2012 Jan. 262(1):343-52. [Medline].
Armstrong PK, MacLeod C. Infection of transjugular intrahepatic portosystemic shunt devices: three cases and a review of the literature. Clin Infect Dis. 2003 Feb 15. 36(4):407-12. [Medline].
Maleux G, Nevens F, Heye S, Verslype C, Marchal G. The use of carbon dioxide wedged hepatic venography to identify the portal vein: comparison with direct catheter portography with iodinated contrast medium and analysis of predictive factors influencing level of opacification. J Vasc Interv Radiol. 2006 Nov. 17(11 Pt 1):1771-9. [Medline].
Clark W, Golkar F, Luberice K, et al. Uncovering the truth about covered stents: is there a difference between covered versus uncovered stents with transjugular intrahepatic portosystemic shunts?. Am J Surg. 2011 Nov. 202(5):561-4. [Medline].
Smail A, Azoulay D, Castaing D. [The technique of Trans-Jugular Porto-systemic Shunt (TIPS)]. J Chir (Paris). 2004 Jan. 141(1):21-6. [Medline].
Martinez-Cuesta A, Elduayen B, Vivas I, Delgado C, Gonzalez-Crespo I, Bilbao JI. CO(2) wedged hepatic venography: technical considerations and comparison with direct and indirect portography with iodinated contrast. Abdom Imaging. 2000 Nov-Dec. 25(6):576-82. [Medline].
Feyssa E, Ortiz J, Grewal K, et al. MELD score less than 15 predicts prolonged survival after transjugular intrahepatic portosystemic shunt for refractory ascites after liver transplantation. Transplantation. 2011 Apr 15. 91(7):786-92. [Medline].
Ahmed R, Santhanam P, Rayyan Y. MELD-Na as a prognostic indicator of 30- and 90-day mortality in patients with end-stage liver disease after creation of transjugular intrahepatic portosystemic shunt. Eur J Gastroenterol Hepatol. 2015 Oct. 27 (10):1226-7. [Medline].
Bala TM, Panda M. Cardiac perforation and tamponade: a potentially fatal complication during transjugular intrahepatic portosystemic shunt placement. South Med J. 2006 Sep. 99(9):1000-2. [Medline].
Pereira K, Carrion AF, Martin P, Vaheesan K, Salsamendi J, Doshi M, et al. Current diagnosis and management of post-transjugular intrahepatic portosystemic shunt refractory hepatic encephalopathy. Liver Int. 2015 Sep 1. [Medline].
Jalan R, Elton RA, Redhead DN, Finlayson ND, Hayes PC. Analysis of prognostic variables in the prediction of mortality, shunt failure, variceal rebleeding and encephalopathy following the transjugular intrahepatic portosystemic stent-shunt for variceal haemorrhage. J Hepatol. 1995 Aug. 23(2):123-8. [Medline].
Gschwantler M, Gebauer A, Vavrik J, et al. Acute and chronic complications after implantation of a transjugular intrahepatic portosystemic shunt--a prospective study in 53 patients. Z Gastroenterol. 1997 Nov. 35(11):999-1005. [Medline].
Masson S, Mardini HA, Rose JD, Record CO. Hepatic encephalopathy after transjugular intrahepatic portosystemic shunt insertion: a decade of experience. QJM. 2008 Jun. 101(6):493-501. [Medline].
Freedman AM, Sanyal AJ, Tisnado J, Coleet al. Complications of transjugular intrahepatic portosystemic shunt: a comprehensive review. Radiographics. 1993 Nov. 13(6):1185-210. [Medline].
Pereira K, Baker R, Salsamendi J, Doshi M, Kably I, Bhatia S. An Approach to Endovascular and Percutaneous Management of Transjugular Intrahepatic Portosystemic Shunt (TIPS) Dysfunction: A Pictorial Essay and Clinical Practice Algorithm. Cardiovasc Intervent Radiol. 2015 Nov 24. [Medline].