Transjugular Intrahepatic Portosystemic Shunt Technique

Updated: Jan 25, 2016
  • Author: Sapna Puppala, MBBS, MRCS, MRCS(Edin), FRCS(Edin), FRCR, CBCCT, EBIR; Chief Editor: Justin A Siegal, MD  more...
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Technique

Creation of Transjugular Intrahepatic Portosystemic Shunt

Transjugular intrahepatic portosystemic shunt (TIPS) creation proceeds as follows. [14, 15, 7]

Preparation

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. [16] (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. [17]

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.

Procedure

If the patient has ascites with significant volume, perform paracentesis first. Clean the skin on the neck with chlorhexidine or povidone-iodine solution. Use ultrasonographic guidance to choose a point on the skin above the vein.

Make a small (≤1 cm) horizontal skin incision. Using ultrasonographic guidance and a micropuncture or an 18-gauge access needle, puncture the anterior wall of the vein, and enter the vein (see the video below). Aspirate venous blood to confirm the needle position.

Ultrasound-guided puncture.

Advance the 0.035-in. guide wire, and insert the accompanying 5-French sheath over the wire. Use a curved catheter and Terumo hydrophilic wire to access the right hepatic vein. Wedge the catheter in the hepatic vein. Obtain wedged hepatic and inferior vena cava (IVC)/right atrial pressure measurements, and calculate the gradient.

Perform portal angiography (if available), using medical CO2 (see the image below). Because the catheter is wedged, an indirect portogram along with a hepatic venogram can be obtained. Use the images to confirm the patency of both veins. [15] Use the image as a fluoroscopic fade/roadmap, or mark the portal vein and hepatic veins on screen. Either way, lock the table in position.

CO2 angiography. CO2 angiography.

Insert an Amplatz wire, and then exchange the Cobra-2 catheter and 5-French sheath for the 10-French sheath with dilator. Remove the dilator, and introduce the inner sheath, loaded together with the metal stiffener. Insert the system up to 1 cm from the point of intersection of the two veins.

Remove the wire, and insert the catheter with the needle. Turn the system, using the metal arrow on the stiffener anteriorly (on the assumption of placement in the right hepatic vein), and advance the needle with the catheter in an anteroinferior direction parallel to the spine, aiming for the portal vein. Start the throw approximately 2 cm from the confluence of the right hepatic vein and the IVC. The right portal vein is typically accessed 0.5-1.5 vertebral body widths lateral to the spine between T10 and T12.

Remove the needle, and attach a small syringe with 1 mL of contrast to the catheter. Aspirate while gently withdrawing. A loss of resistance is felt when in the portal vein. Confirm by aspiration and then injection of contrast.

Once in the portal vein, insert a Terumo Glidewire. Advance the wire into the superior mesenteric vein or the splenic vein, and advance the catheter.

Obtain portal and central pressure measurements to confirm the gradient.

Exchange the Terumo wire for an 180-cm Amplatz wire. Perform angioplasty of the tract (with a 6- or 8-mm balloon). Advance a 10-French sheath into the portal vein; replacing the dilator is likely to be helpful.

Exchange the catheter for a calibrated pigtail catheter (see the first image below). Perform a double-flush angiogram via both the pigtail and the side arm of the sheath (with the inner metal stiffener removed and sheath pulled back into the hepatic vein) to obtain images of hepatic and portal veins (see the second image below). Use these images to calculate the length of stent required. Measure from the portal vein to the confluence of the hepatic vein and the IVC. To correctly size a Viatorr stent, add 1-2 cm to the measured length.

Pigtail for calibration. Pigtail for calibration.
Pre-stent portal and right atrial pressures. Pre-stent portal and right atrial pressures.

Reinsert the Amplatz wire, and advance the sheath back into the portal vein. Remove the pigtail catheter. Insert the stent over the wire into position; be careful to keep the Viatorr stent confined by the packaging sheath until it is fully introduced into the 10-French sheath, and do not advance the stent beyond the sheath tip in the portal vein. Sheath and stent should extend approximately 3 cm into the portal vein.

Withdraw the outer TIPS sheath, and then deploy the stent as per its prescribed mechanism. With the Viatorr, an upstream 2-cm-long uncovered segment is deployed by withdrawing the sheath (see the images below). Positioning may be fine-tuned at this point to achieve the goal of placing the uncovered portion in the portal vein and the covered portion in the tract/hepatic vein. Undersizing the initial tract angioplasty may help give a tactile sense of the junction of the portal vein and the tract.

Deploying of stent. Deploying of stent.
Deploying. Deploying.

Perform a portogram to assess flow through stent and any waisting. Measure pressures to ensure a typical goal portohepatic gradient of less than 12 mm Hg. If necessary, dilate the stent with an 8-mm balloon. If the stent does not reach the confluence of the hepatic vein and the IVC, it may be extended with an additional uncovered stent. The images below depict poststent dilatation.

Poststent dilatation. Poststent dilatation.
Dilatation. Dilatation.

Pearls

Always perform Doppler ultrasonography to assess the portal vein before starting the TIPS procedure to confirm that the portal vein is not thrombosed.

If the middle hepatic vein is used, remember to rotate the TIPS sheath and stiffener posteriorly because the middle portal vein lies posterior and inferior to the hepatic vein.

To confirm entry into portal vein, inject contrast material. Contrast flowing toward the right atrium indicates hepatic vein location. Static contrast likely indicates biliary system location. Contrast flowing to liver periphery can indicate location in the hepatic artery or portal vein; however, the portal radicals are larger in size.

If insertion is unsuccessful, pull the catheter back into the sheath, reinsert the needle, and try again.

When using Amplatz wires, always keep the tip of the wire under control. If the wire tip is not properly controlled, it can easily perforate the liver or the mesentery.

If covered shunt patency is difficult to assess on follow-up Doppler ultrasonography, CT may be performed.

Next:

Complications

Immediate complications of TIPS placement include the following:

  • Inability to place stent
  • Bleeding (hemoperitoneum; 3%)
  • Trauma to liver and heart [18, 8]
  • Stent infection [11]
  • Bile leak and peritonitis
  • Encephalopathy (15%) - This may be amenable to medical therapy [19] ; if it is severe, the shunt may have to be narrowed or embolized [20]
  • Heart failure
  • Stent thrombosis
  • Death (1%)
  • Stent malposition [21]
  • Nephropathy

Delayed complications of TIPS placement include the following [22, 23, 24] :

  • Encephalopathy [23, 24]
  • In-stent stenosis - Greater than 50% stenosis is seen in 25% of TIPS cases; this can be addressed with angioplasty
  • Stent thrombosis
  • Stent occlusion
  • Hemolytic anemia
  • Severe hyperbilirubinemia
  • Radiation injury

Various endovascular and percutaneous approaches to managing TIPS dysfunction have been described. [25]

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