Transjugular Intrahepatic Portosystemic Shunt (TIPS)

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TIPS Schematic

Transjugular intrahepatic portosystemic shunt (TIPS) is the creation of an endovascular shunt between the pre-sinusoidal portal venous system and the systemic circulation, thereby bypassing the intrahepatic venous pathway.

Pre-procedural evaluation and patient management

Indications/Contraindications

  • Indications - Recurrent/massive gastric or esophageal variceal bleeding, recurrent ascites, Budd Chiari syndrome, hepatic hydrothorax
  • Contraindications - Pulmonary hypertension, hepatic encephalopathy, right heart failure (>20mmHg), meld >24 in elective cases (compassionate use should be considered in unstable patients).

TIPS initial placement technique

  • R HV  - turn anterior to get to RPV
  • Middle HV - turn posterior to get to RPV
  • L HV - turn posterior to get to LPV

Techniques for easier portal vein access

  • Intravascular ultrasound (also known as intracardiac echocardiography) guided
  • Wire guided via direct percutaneous portal vein access.
  • Gore Viatorr stent - covered PTFE portion which is impermeable to bile. Length on packaging refers to the length of the covered segment as there is always a 2cm uncovered portion deployed into the portal vein.
  • Goal post-TIPS porto-systemic gradient for bleeding : <12 mmHg; for ascites: 50% decrease in portosystemic gradient

TIPS revision technique

Immediate and long-term complications

Post-procedural evaluation and patient management

  • After discharge, TIPS doppler is obtained typically 3, 6, and 12 months afterward to assess for TIPS stenosis/thrombosis and reassess need for a TIPS revision.

References

Contributing Authors

Kevin Liu