Preprocedural Planning

Planning for transjugular intrahepatic portosystemic shunt (TIPS) creation includes the following:

Review preprocedural vascular ultrasound studies or computed tomography (CT) scans of the abdomen to confirm the patency of the portal vein and assess for anatomic limitations
Determine the Model for End-stage Liver Disease (MELD) score; this helps predict TIPS mortality, which is higher with a MELD score of 18 or above ^[14] (see the MELD Score for End-Stage Liver Disease calculator); addition of sodium assessment to the MELD score may further enhance prediction of TIPS mortality ^[15]
Obtain informed consent
Ensure that the patient has no contrast allergy, has a platelet count higher than 50,000/μL, and has a relatively normal international normalized ratio (INR)
Consider broad-spectrum antibiotic prophylaxis

Equipment

Equipment used for TIPS creation includes the following:

Good ultrasound machine with linear-array probe
Fluoroscopy
Chlorhexidine or povidone-iodine solution for skin disinfection
Heparinized saline (1000-2000 U heparin in 1000 mL of 0.9% NaCl)
Basic angiography set
Sheath, 5 French, and curved catheter
Guide wires - Terumo Glidewire (0.035 in.) and exchange-length Amplatz wire (0.035 in.)
Pressure transducer
TIPS kit (Cook Medical, Bloomington, IN; see the first image below) - Sheath, 10 French, 40 cm; guide catheter, 51 cm, with metal stiffener; portal venous access needle, 60 cm
Medical CO ₂ and its kit ^[16](if available)
Angioplasty balloons, typically 8 mm × 40 mm
Covered stent ^[17]- Gore Viatorr (WL Gore, Flagstaff, AZ) or another brand, such as Wallgraft (Boston Scientific, Natick, MA) or BeGraft ^[18](Bentley, Hechingen, Germany); the advantage of the Gore Viatorr is the design, which consists of a distal 2-cm-long unlined segment that is deployed in the portal vein and therefore gives better anchorage without obstructing the flow and allows for nutrient portal perfusion (see the second image below)
Bare stents may be used, if needed, to extend to the right atrium ^[19]

Transjugular intrahepatic portosystemic shunt (TIPS). Typical equipment kit.

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Transjugular intrahepatic portosystemic shunt (TIPS). Artist impression of stent in situ.

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There has been debate regarding the optimal stent diameter for TIPS. In a meta-analysis comparing 8-mm stents with 10-mm stents, Huang et found that 10-mm stents yielded a lower TIPS dysfunction rate; however, they also noted that in Asian studies, the rate of postoperative hepatic encephalopathy was lower with 8-mm stents than with 10-mm stents, suggesting that the former may be recommended for Asian patients.^[20]

Anesthesia

General anesthesia is usually required for pediatric patients and is preferred in many institutions for adults as well. Procedural sedation may be used, depending on local practices. Midazolam with fentanyl citrate is a reasonable combination for achieving procedural sedation. Local anesthesia is achieved with approximately 5 mL of lidocaine 1% at the jugular puncture site.

Positioning

Position the patient supine, with the neck turned away from the side of vein puncture. Avoid pillows unless they are needed.

Monitoring & Follow-up

The high frequency of shunt stenosis warrants close surveillance with Doppler ultrasonography (US) or portography. Patients undergo a baseline Doppler US study within 24 hours of the procedure to document functional parameters, including the direction of portal vein flow and flow velocities throughout the shunt and within the hepatic vein. Although TIPS venography with direct portal and right atrial pressure measurements is the criterion standard for stent assessment, high sensitivity and specificity for shunt function has been reported with certain Doppler criteria, as follows:

Absent flow
Low peak shunt velocity (< 50 to 90 cm/s)
High peak shunt velocity (190 cm/s)
Low mean portal vein velocity (< 30 cm/s)
Return of antegrade flow in the intrahepatic portal veins
Significant change in shunt velocity (>50 cm/s) as compared with the immediate postprocedural result

In the acute phase, the stent can thrombose. To treat this, the stent can be lysed, or mechanical thrombectomy can be performed. If later in-stent stenosis occurs, perform angioplasty or insert another stent, as required.

Postprocedural follow-up for TIPS placement is important to ensure patency. Post-TIPS Doppler US may be performed at 24 hours, 3 months, 6 months, and 12 months and annually thereafter.

A study by Young et al in patients who underwent TIPS placement for refractory ascites suggested that clinical surveillance for symptom relapse was as sensitive as US in this setting and significantly more specific.^[21]

Contrast-enhanced US (CEUS) at a high mechanical index has been suggested as an alternative for follow-up after TIPS placement to detect postprocedural abnormalities.^[22]

Technique

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Angermayr B. Transjugular intrahepatic portosystemic shunt--current status in 2011. Acta Gastroenterol Belg. 2011 Dec. 74 (4):553-9. [QxMD MEDLINE Link].
Yu Q, Liu C, Raissi D. Balloon-occluded Retrograde Transvenous Obliteration Versus Transjugular Intrahepatic Portosystemic Shunt for Gastric Varices: A Meta-Analysis. J Clin Gastroenterol. 2021 Feb 1. 55 (2):147-158. [QxMD MEDLINE Link].
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Tripathi D, Helmy A, Macbeth K, Balata S, Lui HF, Stanley AJ, 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. [QxMD MEDLINE Link].
Gaba RC, Khiatani VL, Knuttinen MG, Omene BO, Carrillo TC, Bui JT, et al. Comprehensive review of TIPS technical complications and how to avoid them. AJR Am J Roentgenol. 2011 Mar. 196 (3):675-85. [QxMD MEDLINE Link].
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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. [QxMD MEDLINE Link].
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Feyssa E, Ortiz J, Grewal K, Azhar A, Parsikia A, Tufail 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. [QxMD MEDLINE Link].
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. [QxMD MEDLINE Link].
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. [QxMD MEDLINE Link].
Triantafyllou T, Aggarwal P, Gupta E, Svetanoff WJ, Bhirud DP, Singhal S. Polytetrafluoroethylene-Covered Stent Graft Versus Bare Stent in Transjugular Intrahepatic Portosystemic Shunt: Systematic Review and Meta-Analysis. J Laparoendosc Adv Surg Tech A. 2018 Jul. 28 (7):867-879. [QxMD MEDLINE Link].
Schultheiss M, Bettinger D, Sturm L, Schmidt A, Backhus J, Waidmann O, et al. Comparison of the Covered Self-Expandable Viatorr CX Stent with the Covered Balloon-Expandable BeGraft Peripheral Stent for Transjugular Intrahepatic Portosystemic Shunt (TIPS) Creation: a Single-Centre Retrospective Study in Patients with Variceal Bleeding. Cardiovasc Intervent Radiol. 2022 Jan 12. [QxMD MEDLINE Link].
Clark W, Golkar F, Luberice K, Toomey P, Paul H, Marcadis A, 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. [QxMD MEDLINE Link].
Huang PC, Zhao M, Wei YY, Xia FF, Li H. Transjugular intrahepatic portosystemic shunt: a meta-analysis of 8 mm versus 10 mm stents. Wideochir Inne Tech Maloinwazyjne. 2021 Dec. 16 (4):623-632. [QxMD MEDLINE Link]. [Full Text].
Young S, Scanlon P, Sherestha P, Golzarian J, Sanghvi T. Duplex Ultrasound Versus Clinical Surveillance in the Prediction of TIPS Malfunction Placed for Refractory Ascites: Is Ultrasound Surveillance Useful?. Cardiovasc Intervent Radiol. 2017 Dec. 40 (12):1861-1865. [QxMD MEDLINE Link].
Gao X, Wang HH, Zhang YZ, Liu XB, Qin XC. Contrast-enhanced ultrasound at high mechanical index: a new method for transjugular intrahepatic portosystemic shunt follow-up. Clin Radiol. 2020 Apr. 75 (4):302-307. [QxMD MEDLINE Link].
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Li X, Partovi S, Coronado WM, Gadani S, Martin C, Thompson D, et al. Hepatic Encephalopathy After TIPS Placement: Predictive Factors, Prevention Strategies, and Management. Cardiovasc Intervent Radiol. 2022 Jan 3. [QxMD MEDLINE Link].
Greco L, Chegai F, Pensabene MC, De Corato L, Pampana E, Lenci I, et al. Early detection of hepatic encephalopathy after transjugular intrahepatic portsystemic shunt using multiparametric magnetic resonance with spectroscopy. Eur J Radiol Open. 2019. 6:350-357. [QxMD MEDLINE Link].
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Spiliopoulos S, Vasiniotis Kamarinos N, Konstantos C, Palialexis K, Reppas L, Tsitskari M, et al. Recanalization of Occluded Transjugular Intrahepatic Portosystemic Shunts Using the Rösch-Uchida Stiffening Cannula. Cardiovasc Intervent Radiol. 2018 May. 41 (5):799-803. [QxMD MEDLINE Link].
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Media Gallery

Transjugular intrahepatic portosystemic shunt (TIPS). Ultrasound-guided puncture.
Transjugular intrahepatic portosystemic shunt (TIPS). CO2 angiography.
Transjugular intrahepatic portosystemic shunt (TIPS). Pigtail for calibration.
Transjugular intrahepatic portosystemic shunt (TIPS). Prestent portal and right atrial pressures.
Transjugular intrahepatic portosystemic shunt (TIPS). Deploying of stent.
Transjugular intrahepatic portosystemic shunt (TIPS). Deploying.
Transjugular intrahepatic portosystemic shunt (TIPS). Poststent dilatation.
Transjugular intrahepatic portosystemic shunt (TIPS). Dilatation post stenting.
Transjugular intrahepatic portosystemic shunt (TIPS). Typical equipment kit.
Transjugular intrahepatic portosystemic shunt (TIPS). Artist impression of stent in situ.
Transjugular intrahepatic portosystemic shunt (TIPS). Basic procedure. Curved catheter is placed into right hepatic vein.
Transjugular intrahepatic portosystemic shunt (TIPS). Basic procedure. Wedged hepatic venogram obtained by using digital subtraction technique obtained with CO2 gas demonstrates location of portal vein. Catheter is wedged in branch of right hepatic vein.
Transjugular intrahepatic portosystemic shunt (TIPS). Basic procedure. Image demonstrates advancement of Colapinto needle into right portal vein.
Transjugular intrahepatic portosystemic shunt (TIPS). Basic procedure. Portal venogram obtained with pigtail catheter shows filling of coronary vein.
Transjugular intrahepatic portosystemic shunt (TIPS). Basic procedure. Delayed venogram demonstrates filling of large varices.
Transjugular intrahepatic portosystemic shunt (TIPS). Basic procedure. TIPS (10 X 68 mm Wallstent dilated with 10 mm X 4 cm balloon) has been placed. Note flow through Wallstent and filling of splenorenal shunt. Intrahepatic portal flow became reversed after TIPS placement.
Transjugular intrahepatic portosystemic shunt (TIPS). Basic procedure. Coil embolization of splenorenal shunt has been performed.
Early transjugular intrahepatic portosystemic shunt (TIPS) thrombosis. Image obtained after placement of initial TIPS shows good flow through shunt.
Early transjugular intrahepatic portosystemic shunt (TIPS) thrombosis. Sonogram obtained on day after shunt placement demonstrates thrombosis. Catheter was placed through thrombosed TIPS without any difficulty. Note absence of flow through shunt and hepatopetal portal flow.
Early transjugular intrahepatic portosystemic shunt (TIPS) thrombosis. After recanalization of shunt, Wallgraft is placed within it.
Early transjugular intrahepatic portosystemic shunt (TIPS) thrombosis. Good flow is restored through TIPS after placement of Wallgraft.
Parallel transjugular intrahepatic portosystemic shunt (TIPS) required in this patient to effectively decrease portosystemic gradient.
Hyperplasia within transjugular intrahepatic portosystemic shunt (TIPS) several months after placement.
Balloon angioplasty used to treat hyperplasia.
Final appearance of transjugular intrahepatic portosystemic shunt (TIPS) after balloon dilation.