Transjugular Intrahepatic Portosystemic Shunt

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

Accepted indications for TIPS include the following:

Controversial indications for TIPS include the following:

Absolute contraindications for TIPS include the following:

Relative contraindications for TIPS include the following:

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 of more 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 when 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. ^{[7, 8, 9, 10]}

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. 

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 are reported to be 83% and 79%, respectively, and secondary patency rates at 1 and 2 years are reported to be 96% and 90%. ^[8]

Reported figures for 30-day mortality vary among centers, and nearly all centers report 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 with an APACHE II score higher than 20 have a 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. ^[11] 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 (119 bare-metal stents and 167 polytetrafluoroethylene [PTFE]-covered stents) at a median follow-up of 821 days, 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. ^[12] They recommended that only covered stents should be implemented for bleeding prophylaxis when TIPS is indicated.

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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. [Medline].

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. [Medline].

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. [Medline].

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. [Medline].

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. [Medline].

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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. [Medline].

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 Jan 22. [Medline].

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. [Medline].

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. [Medline].

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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. [Medline].

Jalan R, Elton RA, Redhead DN, Finlayson ND, Hayes PC. Analysis of prognostic variables in the prediction of mortality, shunt failure, variceal rebleeding and encephalopathy following the transjugular intrahepatic portosystemic stent-shunt for variceal haemorrhage. J Hepatol. 1995 Aug. 23 (2):123-8. [Medline].

Clavien PA, Selzner M, Tuttle-Newhall JE, Harland RC, Suhocki P. Liver transplantation complicated by misplaced TIPS in the portal vein. Ann Surg. 1998 Mar. 227 (3):440-5. [Medline]. [Full Text].

Gschwantler M, Gebauer A, Vavrik J, Madani B, Rohrmoser M, Schrutka-Kölbl C, et al. Acute and chronic complications after implantation of a transjugular intrahepatic portosystemic shunt–a prospective study in 53 patients. Z Gastroenterol. 1997 Nov. 35 (11):999-1005. [Medline].

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. [Medline].

Freedman AM, Sanyal AJ, Tisnado J, Cole PE, Shiffman ML, Luketic VA, et al. Complications of transjugular intrahepatic portosystemic shunt: a comprehensive review. Radiographics. 1993 Nov. 13 (6):1185-210. [Medline].

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. [Medline]. [Full Text].

Spiliopoulos S, Kamarinos NV, 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 Jan 29. [Medline].

Pereira K, Baker R, Salsamendi J, Doshi M, Kably I, Bhatia S. An Approach to Endovascular and Percutaneous Management of Transjugular Intrahepatic Portosystemic Shunt (TIPS) Dysfunction: A Pictorial Essay and Clinical Practice Algorithm. Cardiovasc Intervent Radiol. 2016 May. 39 (5):639-651. [Medline].

Sapna Puppala, MBBS, MRCS, MRCS(Edin), FRCS(Edin), FRCR, CBCCT, EBIR Consultant Cardiovascular Radiologist and Endovascular Specialist, Leeds Teaching Hospital, NHS Trust, UK

Sapna Puppala, MBBS, MRCS, MRCS(Edin), FRCS(Edin), FRCR, CBCCT, EBIR is a member of the following medical societies: Royal College of Radiologists, Cardiovascular and Interventional Radiological Society of Europe

Disclosure: Nothing to disclose.

Mary L Windle, PharmD Adjunct Associate Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Nothing to disclose.

Laurie Scudder, DNP, NP Nurse Planner, Medscape; Senior Clinical Professor of Nursing, George Washington University

Disclosure: Nothing to disclose.

Justin A Siegal, MD Radiologist, Department of Radiology, Virginia Mason Medical Center

Disclosure: Nothing to disclose.

Joseph K Lim, MD Associate Professor of Medicine, Director, Yale Viral Hepatitis Program, Section of Digestive Diseases, Yale University School of Medicine

Joseph K Lim, MD is a member of the following medical societies: American Association for the Study of Liver Diseases, American College of Gastroenterology, American College of Physicians, American Gastroenterological Association, American Society for Gastrointestinal Endoscopy

Disclosure: Nothing to disclose.

Transjugular Intrahepatic Portosystemic Shunt

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