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Transjugular Intrahepatic Portosystemic Shunt

  • Author: Sapna Puppala, MBBS; Chief Editor: Justin A Siegal, MD  more...
 
Updated: Jan 25, 2016
 

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.

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Indications

Accepted indications for TIPS include the following:

  • Uncontrolled variceal hemorrhage from esophageal, gastric, and intestinal varices that do not respond to endoscopic and medical management [4]
  • Refractory ascites
  • Hepatic pleural effusion (hydrothorax)

Controversial indications for TIPS include the following:

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Contraindications

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
  • Hepatopulmonary syndrome
  • Active infection
  • Tumor within the expected path of the shunt
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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]

Balloon angioplasty used to treat hyperplasia. Balloon angioplasty used to treat hyperplasia.

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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Contributor Information and Disclosures
Author

Sapna Puppala, MBBS MRCS, MRCS(Ed), FRCS(Ed), FRCR, CBCCT, EBIR, Consultant Cardiovascular Radiologist and Endovascular Specialist, Leeds Teaching Hospital, NHS Trust, UK

Sapna Puppala, MBBS is a member of the following medical societies: Royal College of Radiologists, Cardiovascular and Interventional Radiological Society of Europe

Disclosure: Nothing to disclose.

Specialty Editor Board

Mary L Windle, PharmD Adjunct Associate Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Nothing to disclose.

Laurie Scudder, DNP, NP Nurse Planner, Medscape; Senior Clinical Professor of Nursing, George Washington University

Disclosure: Nothing to disclose.

Chief Editor

Justin A Siegal, MD Radiologist, Department of Radiology, Virginia Mason Medical Center

Disclosure: Nothing to disclose.

Additional Contributors

Joseph K Lim, MD Associate Professor of Medicine, Director, Yale Viral Hepatitis Program, Section of Digestive Diseases, Yale University School of Medicine

Joseph K Lim, MD is a member of the following medical societies: American Association for the Study of Liver Diseases, American College of Gastroenterology, American College of Physicians, American Gastroenterological Association, American Society for Gastrointestinal Endoscopy

Disclosure: Nothing to disclose.

References
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  8. 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].

  9. 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].

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  12. 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].

  13. 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].

  14. 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].

  15. 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].

  16. 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].

  17. 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].

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  19. 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].

  20. 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].

  21. Clavien PA, Selzner M, Tuttle-Newhall JE, Harland RC, Suhocki P. Liver transplantation complicated by misplaced TIPS in the portal vein. Ann Surg. 1998 Mar. 227(3):440-5. [Medline]. [Full Text].

  22. 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].

  23. 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].

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Ultrasound-guided puncture.
CO2 angiography.
Pigtail for calibration.
Pre-stent portal and right atrial pressures.
Deploying of stent.
Deploying.
Poststent dilatation.
Dilatation.
Typical TIPS kit.
Artist impression of stent in situ.
Basic transjugular intrahepatic portosystemic shunt (TIPS) procedure. A curved catheter is placed into the right hepatic vein.
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.
Basic transjugular intrahepatic portosystemic shunt (TIPS) procedure. Image demonstrates advancement of a Colapinto needle into the right portal vein.
Basic transjugular intrahepatic portosystemic shunt (TIPS) procedure. Portal venogram obtained with a pigtail catheter shows filling of the coronary vein.
Basic transjugular intrahepatic portosystemic shunt (TIPS) procedure. Delayed venogram demonstrates filling of large varices.
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.
Basic transjugular intrahepatic portosystemic shunt (TIPS) procedure. Coil embolization of the splenorenal shunt has been performed.
Early transjugular intrahepatic portosystemic shunt (TIPS) thrombosis. Image obtained after placement of the initial TIPS shows good flow through the shunt.
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.
Early transjugular intrahepatic portosystemic shunt (TIPS) thrombosis. After recanalization of the shunt, a Wallgraft is placed within it.
Early transjugular intrahepatic portosystemic shunt (TIPS) thrombosis. Good flow is restored through the TIPS after placement of the Wallgraft.
A parallel transjugular intrahepatic portosystemic shunt (TIPS) required in this patient to effectively decrease the portosystemic gradient.
Hyperplasia within a transjugular intrahepatic portosystemic shunt (TIPS) several months after placement.
Balloon angioplasty used to treat hyperplasia.
Final appearance of the transjugular intrahepatic portosystemic shunt (TIPS) after balloon dilation.
 
 
 
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