Background

Transjugular intrahepatic portosystemic shunt^[1](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.^{[2, 3, 4]}TIPS, therefore, represents a first-line treatment for complications of portal hypertension, typically in patients with decompensated liver cirrhosis.

Next: Indications

Indications

Accepted indications for TIPS include the following:

Uncontrolled variceal hemorrhage from esophageal, gastric,^[5]and intestinal varices that do not respond to endoscopic and medical management^[6]
Refractory ascites
Hepatic pleural effusion (hydrothorax)

Less well accepted indications for TIPS include the following:

Bridge to transplantation and retransplantation^{[7, 8]}
Budd-Chiari syndrome
Hepatorenal syndrome (HRS)
Veno-occlusive disease (VOD)

Next: Indications

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)
Severe encephalopathy
Polycystic liver disease
Severe right-heart failure

Relative contraindications for TIPS include the following:

Portal and hepatic vein thrombosis
Pulmonary hypertension
Hepatopulmonary syndrome
Active infection
Tumor within the expected path of the shunt

Next: Indications

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 higher 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; varices tend not to bleed if 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.^{[9, 10, 11]}

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.

Balloon angioplasty used to treat hyperplasia.

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Primary patency after TIPS placement has been reported to be 66% after 1 year and 42% after 2 years. Primary-assisted patency rates at 1 and 2 years have been reported to be 83% and 79%, respectively, and secondary patency rates at 1 and 2 years have been reported to be 96% and 90%.^[9]

Reported figures for 30-day mortality have varied among centers, and nearly all centers have reported 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 who have an APACHE II score higher than 20 are at 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 to whether the procedure was performed on an emergency basis or an elective basis.^[12]In 1995, LaBerge et al reported that cumulative survival rates in patients with Child grades of A, B, and C were 75%, 68%, and 49%, respectively, at 1 year and 75%, 55%, and 43%, respectively, at 2 years.

In a retrospective study that evaluated rebleeding rate, patency, mortality, and transplant-free survival in 286 cirrhotic patients receiving TIPS implantation for variceal bleeding (bare-metal stents, n = 119; polytetrafluoroethylene [PTFE]-covered stents, n = 167; median follow-up, 821 d), Bucsics et al found that the covered stents prevented variceal rebleeding more effectively than the bare-metal stents did, by virtue of their superior patency.^[13]They recommended that only covered stents be implemented for bleeding prophylaxis when TIPS is indicated.

Periprocedure

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Colombato L. The role of transjugular intrahepatic portosystemic shunt (TIPS) in the management of portal hypertension. J Clin Gastroenterol. 2007 Nov-Dec. 41 Suppl 3:S344-51. [QxMD MEDLINE Link].
Olliff SP. Transjugular intrahepatic portosystemic shunt in the management of Budd Chiari syndrome. Eur J Gastroenterol Hepatol. 2006 Nov. 18 (11):1151-4. [QxMD MEDLINE Link].
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].
Gaba RC, Omene BO, Podczerwinski ES, Knuttinen MG, Cotler SJ, Kallwitz ER, et al. TIPS for treatment of variceal hemorrhage: clinical outcomes in 128 patients at a single institution over a 12-year period. J Vasc Interv Radiol. 2012 Feb. 23 (2):227-35. [QxMD MEDLINE Link].
King A, Masterton G, Gunson B, Olliff S, Redhead D, Mangat K, et al. A case-controlled study of the safety and efficacy of transjugular intrahepatic portosystemic shunts after liver transplantation. Liver Transpl. 2011 Jul. 17 (7):771-8. [QxMD MEDLINE Link].
Bonnel AR, Bunchorntavakul C, Rajender Reddy K. Transjugular intrahepatic portosystemic shunts in liver transplant recipients. Liver Transpl. 2014 Feb. 20 (2):130-9. [QxMD MEDLINE Link].
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].
Saugel B, Phillip V, Gaa J, Berger H, Lersch C, Schultheiss C, et al. Advanced hemodynamic monitoring before and after transjugular intrahepatic portosystemic shunt: implications for selection of patients--a prospective study. Radiology. 2012 Jan. 262 (1):343-52. [QxMD MEDLINE Link].
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].
Bucsics T, Schoder M, Diermayr M, Feldner-Busztin M, Goeschl N, Bauer D, et al. Transjugular intrahepatic portosystemic shunts (TIPS) for the prevention of variceal re-bleeding - A two decades experience. PLoS One. 2018. 13 (1):e0189414. [QxMD MEDLINE Link].
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 May. 45 (5):542-549. [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].
Smail A, Azoulay D, Castaing D. [The technique of Trans-Jugular Porto-systemic Shunt (TIPS)]. J Chir (Paris). 2004 Jan. 141 (1):21-6. [QxMD MEDLINE Link].
Partovi S, Li X, Shwaiki O, Rashwan B, Ruff C, Grozinger G, et al. Advanced portal venous access techniques for transjugular intrahepatic portosystemic shunt placement. BMJ Open Gastroenterol. 2021 Dec. 8 (1):[QxMD MEDLINE Link]. [Full Text].
Bala TM, Panda M. Cardiac perforation and tamponade: a potentially fatal complication during transjugular intrahepatic portosystemic shunt placement. South Med J. 2006 Sep. 99 (9):1000-2. [QxMD MEDLINE Link].
Li K, Cheng Y, Zhao R, Jiang H, Zhang L, Tong Y, et al. Prediction of mortality and overt hepatic encephalopathy undergoing transjugular intrahepatic portosystemic shunt: a retrospective cohort study. Abdom Radiol (NY). 2023 Nov 13. [QxMD MEDLINE Link].
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 May. 45 (5):570-577. [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].
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 Dec. 35 (12):2487-94. [QxMD MEDLINE Link].
Liang A, Brar S, Almaghrabi M, Khan MQ, Qumosani K, Teriaky A. Primary prevention of hepatic encephalopathy post-TIPS: A systematic review and meta-analysis. Medicine (Baltimore). 2023 Sep 22. 102 (38):e35266. [QxMD MEDLINE Link]. [Full Text].
Yang M, Qiu Y, Wang W. Concurrent spontaneous portosystemic shunt embolization for the prevention of overt hepatic encephalopathy after TIPS: A systematic review and meta-analysis. Dig Liver Dis. 2023 Nov 3. [QxMD MEDLINE Link].
Siddiqui M, Pillutla P. TIPS stent migration causing sinus of Valsalva rupture. BMJ Case Rep. 2023 Oct 10. 16 (10):[QxMD MEDLINE Link].
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. [QxMD MEDLINE Link].
Jahangiri Y, Kerrigan T, Li L, Prosser D, Brar A, Righetti J, et al. Risk factors for stent graft thrombosis after transjugular intrahepatic portosystemic shunt creation. Cardiovasc Diagn Ther. 2017 Dec. 7 (Suppl 3):S150-S158. [QxMD MEDLINE Link]. [Full Text].
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.

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Sections Transjugular Intrahepatic Portosystemic Shunt (TIPS)
Overview
Periprocedural Care
Technique
Media Gallery
References

Transjugular Intrahepatic Portosystemic Shunt (TIPS)

Background

Indications

Contraindications

Outcomes

References

Tables

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