Transjugular Intrahepatic Portosystemic

What is a TIPS?

A transjugular intrahepatic portosystemic shunt (TIPS) is a tract created within the liver using x-ray guidance to connect two veins within the liver. The shunt is kept open by the placement of a small, tubular metal device commonly called a stent.

During a TIPS procedure, interventional radiologists use image guidance to make a tunnel through the liver to connect the portal vein (the vein that carries blood from the digestive organs to the liver) to one of the hepatic veins (three veins that carry blood away from the liver back to the heart). A stent is then placed in this tunnel to keep the pathway open.

Patients who typically need a TIPS have portal hypertension, meaning they have increased pressure in the portal vein system. This pressure buildup can cause blood to flow backward from the liver into the veins of the spleen, stomach, lower esophagus, and intestines, causing enlarged vessels, bleeding and the accumulation of fluid in the chest (pleural effusion) or abdomen (ascites). This condition is most commonly seen in adults, often as a result of chronic liver problems leading to cirrhosis (scarring of the liver).

There are many causes of liver failure and end stage liver disease, including alcohol-related liver disease, hepatitis, metastatic tumors, and environmental exposures to toxins. Over time, the liver can become scarred and develop cirrhosis and portal hypertension.

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How does a TIPS work?

A TIPS reroutes blood flow in the liver and reduces abnormally high blood pressure in the veins of the stomach, esophagus, bowel and liver, reducing the risk of bleeding from enlarged veins across the esophagus and stomach.

A TIPS is a pathway through the liver that connects the portal vein to a hepatic vein. A stent placed inside this pathway keeps it open and allows some of the blood that would ordinarily pass through the liver to bypass the liver entirely, reducing high blood pressure in the portal vein and the associated risk of bleeding from enlarged veins.

What are some common uses of the procedure?

A TIPS is used to treat the complications of portal hypertension, including:

Variceal bleeding, bleeding from any of the veins that normally drain the stomach, esophagus, or intestines into the liver.
Portal gastropathy, an engorgement of the veins in the wall of the stomach, which can cause severe bleeding.
Severe ascites (the accumulation of fluid in the abdomen) and/or hydrothorax (in the chest).
Budd-Chiari syndrome, a blockage in one or more veins that carry blood from the liver back to the heart.

What are the risks versus the benefits of the procedure?

Benefits

A TIPS is designed to produce the same physiological results as a surgical shunt or bypass, without the risks that accompany open surgery.
TIPS is a minimally invasive procedure that typically has a shorter recovery time than surgery.
Your TIPS should have less of an effect than open surgical bypass on future liver transplantation surgery because the abdomen has not been entered, thus there is no scar tissue formed in the abdomen.
The stent that keeps the shunt open (TIPS) is contained entirely inside the diseased liver, and is removed with it during a transplant operation.
Studies have shown that this procedure is successful in reducing variceal bleeding in more than 90 percent of patients.
No surgical incision is necessary—only a small nick in the skin that does not need stitches.

Risks

Any procedure where the skin is penetrated carries a risk of infection. The chance of infection requiring antibiotic treatment appears to be less than one in 1,000.
There is a very slight risk of an allergic reaction to the contrast material used for venograms. Also, kidney failure (temporary or permanent) due to contrast material use is a concern, particularly in patients with poor kidney function.

Any procedure that places a catheter inside a blood vessel carries certain risks. These risks include damage to the blood vessel, bruising or bleeding at the puncture site, and infection. The doctor will take precautions to mitigate these risks.

Other possible complications of the procedure include:

fever
muscle stiffness in the neck
bruising on the neck at the point of catheter insertion
delayed stenosis, or narrowing within the stent, which is less common with the current generation of stents

Serious complications, reported in fewer than five percent of cases, may include:

occlusion, or complete blockage, of the stent leading to rapid recurrence of symptoms
infection of the stent or fabric lining
abdominal bleeding that might require a transfusion
laceration of the hepatic artery, which may result in severe liver injury or bleeding that could require a transfusion or urgent intervention
heart arrhythmias or congestive heart failure
radiation injury to the skin is a rare complication (it may happen in complex and lengthy procedures requiring extended fluoroscopy use)
death (rare)

What are the limitations of TIPS?

Patients with more advanced liver disease are at greater risk for worsening liver failure after TIPS. If your liver failure is severe, a TIPS may not be the best use and a different procedure may be needed to control your symptoms. They are also at risk for encephalopathy, which is an alteration of normal brain function that can lead to confusion. This is because toxic substances in the bloodstream are ordinarily filtered out by the liver. The TIPS may cause too much of these substances to bypass the liver, so a patient who already has encephalopathy because of their liver disease may not be a good candidate for the procedure.

Encephalopathy can be treated with certain medications, a special diet or, by revising the stent, but sometimes the stent must be blocked off intentionally to solve the problem.

How is the procedure done?

The procedure is done at the hospital in the cardiac catheterization lab, also known as the “cath lab.” Your IV will be used to allow access for moderate (also known as “twilight”) sedation or general anesthesia. You will then be taken to the procedure room where you will have a team of two nurses, a radiology technician, and your interventional radiologist (an anesthesiologist will be present if you get general anesthesia). You will be connected to heart rate, blood pressure, and oxygen saturation monitors during the entire procedure. IV medication will be administered to make you comfortable (sedation). Then your interventional radiologist will administer numbing medication (local anesthetic) to the procedure site. Using ultrasound guidance) a catheter will be inserted through a vein in your neck and a small catheter will be inserted. This catheter will be maneuvered to the IVC and to the hepatic vein using real-time x-ray (fluoroscopy) guidance.

To help plan for the placement of the TIPS stent, a contrast material (dye) will be injected in the hepatic vein to identify the portal venous system. Access is then gained from the hepatic vein into the portal system using a TIPS needle (a special long needle extending from the neck into the liver). A stent is then placed extending from the portal vein into the hepatic vein. Once the stent is in the correct position, the balloon is inflated, expanding the stent into place.

The balloon is then deflated and removed along with the catheter. Additional portal venograms are performed to confirm satisfactory blood flow through the TIPS.

Pressure is applied to prevent any bleeding and the opening in the skin is covered with skin glue. No sutures are necessary.

This procedure is usually completed in an hour but may take up to several hours depending on the complexity of the condition and vascular anatomy.

What can I expect after the procedure?

You will recover after your procedure for about 1-2 hours where your procedure site, heart rate, blood pressure, and oxygen will be monitored. Your family will be able to see you soon after the procedure.

Often, symptoms are mild or controlled enough that the procedure can be done electively and patients may go home the next day. However, the amount of bleeding that can occur can sometimes be life threatening and those patients are monitored in intensive care beforehand and during recovery.

You should be able to resume your normal activities in seven to 10 days.

Follow-up ultrasounds will be performed periodically after the TIPS procedure to make sure that it remains open and functions properly.

What should I look out for?

Confusion or altered mental status may be a sign of encephalopathy. This may be because of increased toxic substances in the bloodstream that are ordinarily filtered out by the liver. The TIPS may be causing too much of these substances to bypass the liver. Be sure to contact your interventional radiologist if you feel you may be experiencing this or head to the ER if emergent.