Transjugular Intrahepatic Portosystemic Shunt (TIPS)
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
- Evaluation for portal hypertension
- 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.