Background
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.
Indications
Accepted indications for TIPS include the following:
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Uncontrolled variceal hemorrhage from esophageal, gastric, and intestinal varices that do not respond to endoscopic and medical management [4]
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Refractory ascites
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Hepatic pleural effusion (hydrothorax)
Controversial indications for TIPS include the following:
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Hepatorenal syndrome (HRS)
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Veno-occlusive disease (VOD)
Contraindications
Absolute contraindications for TIPS include the following:
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Severe and progressive liver failure (on the basis of the Child-Pugh score; scores A and B have a better outcome than score C)
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Severe encephalopathy
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Polycystic liver disease
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Severe right-heart failure
Relative contraindications for TIPS include the following:
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Portal and hepatic vein thrombosis
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Hepatopulmonary syndrome
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Active infection
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Tumor within the expected path of the shunt
Outcomes
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%. [8]
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. [11] 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.
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Ultrasound-guided puncture.
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CO2 angiography.
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Pigtail for calibration.
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Pre-stent portal and right atrial pressures.
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Deploying of stent.
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Deploying.
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Poststent dilatation.
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Dilatation.
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Typical TIPS kit.
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Artist impression of stent in situ.
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Basic transjugular intrahepatic portosystemic shunt (TIPS) procedure. A curved catheter is placed into the right hepatic vein.
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Basic transjugular intrahepatic portosystemic shunt (TIPS) procedure. 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.
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Basic transjugular intrahepatic portosystemic shunt (TIPS) procedure. Image demonstrates advancement of a Colapinto needle into the right portal vein.
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Basic transjugular intrahepatic portosystemic shunt (TIPS) procedure. Portal venogram obtained with a pigtail catheter shows filling of the coronary vein.
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Basic transjugular intrahepatic portosystemic shunt (TIPS) procedure. Delayed venogram demonstrates filling of large varices.
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Basic transjugular intrahepatic portosystemic shunt (TIPS) procedure. 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. The intrahepatic portal flow became reversed after TIPS placement.
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Basic transjugular intrahepatic portosystemic shunt (TIPS) procedure. Coil embolization of the splenorenal shunt has been performed.
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Early transjugular intrahepatic portosystemic shunt (TIPS) thrombosis. Image obtained after placement of the initial TIPS shows good flow through the shunt.
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Early transjugular intrahepatic portosystemic shunt (TIPS) thrombosis. Sonogram obtained the day after shunt placement demonstrates thrombosis. The catheter was placed through the thrombosed TIPS without any difficulty. Note the absence of flow through the shunt and the hepatopetal portal flow.
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Early transjugular intrahepatic portosystemic shunt (TIPS) thrombosis. After recanalization of the shunt, a Wallgraft is placed within it.
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Early transjugular intrahepatic portosystemic shunt (TIPS) thrombosis. Good flow is restored through the TIPS after placement of the Wallgraft.
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A parallel transjugular intrahepatic portosystemic shunt (TIPS) required in this patient to effectively decrease the portosystemic gradient.
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Hyperplasia within a transjugular intrahepatic portosystemic shunt (TIPS) several months after placement.
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Balloon angioplasty used to treat hyperplasia.
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Final appearance of the transjugular intrahepatic portosystemic shunt (TIPS) after balloon dilation.
