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); 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 [18]
Transjugular intrahepatic portosystemic shunt (TIPS). Artist impression of stent in situ.
Patient Preparation
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. [19]
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. [20]
-
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.
