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Transjugular Intrahepatic
Portosystemic Shunt (TIPS)

Image by Kevin Kandlbinder

Transjugular intrahepatic portosystemic shunt (TIPS) is a sophisticated interventional radiological procedure employed in the management of patients with advanced liver disease, specifically those suffering from complications related to portal hypertension. Portal hypertension arises due to increased resistance to blood flow within the portal venous system, typically occurring in the context of cirrhosis or other severe liver pathologies. The purpose of TIPS is to alleviate the elevated pressure within the portal vein by creating a shunt that diverts blood flow from the portal venous system into the hepatic venous system, thus mitigating the complications associated with portal hypertension.

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The TIPS procedure involves access to the hepatic venous system via a right sided percutaneous approach using ultrasound guidance. Meanwhile, a transjugular approach is employed to gain access to the portal venous system via the right internal jugular vein.

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Once access to both the hepatic and portal venous systems is established, a guidewire is advanced through the liver parenchyma (from the portal venous system to hepatic venous system), and a tract is created by balloon dilation. Subsequently, a stent, typically made of expanded polytetrafluoroethylene (ePTFE) or other biocompatible materials, is positioned to bridge the portal and hepatic veins, forming a conduit for blood flow diversion. This stent effectively establishes a communication route between the two venous systems, thereby reducing the portal pressure.

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The progression of the procedure is closely monitored with fluoroscopy and contrast dye injections to ensure appropriate stent placement, shunt patency, and resolution of portal hypertension. Pressure measurements within the portal venous system are routinely assessed to gauge the effectiveness of the TIPS procedure. Adjustments may be made by dilating the stent or deploying additional stents to optimize shunt flow and pressure reduction.

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TIPS is a valuable therapeutic tool in the management of complications associated with portal hypertension, including variceal bleeding, ascites, and hepatic encephalopathy. Nevertheless, it is imperative to consider potential complications, such as hepatic encephalopathy exacerbation, shunt stenosis or thrombosis, or infection, when contemplating this procedure. Thus, TIPS warrants careful patient selection and post-procedural monitoring to ensure optimal clinical outcomes in patients with advanced liver disease.

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A&I Protocol

Patient is positioned supine on the angiography table and head supported on a small, comfortable sponge with the head slightly turned to the left for transjugular access.

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  • Seldinger technique is used to gain access into the hepatic portal venous system (right side) using ultrasound guidance, and a sheath, a diagnostic catheter (e.g. 5 F Bern catheter) and 0.035" guidewire are advanced through the hepatic portal vein. Contrast injections are used to confirm position.

  • A second seldinger technique access is used to puncture transjugular, into the right internal jugular vein. Similarly, a diagnostic catheter and guidewire are advanced down the superior vena cava (SVC), and towards the IVC. Then the catheters are directed towards the portal venous system, using contrast injections to confirm position.

  • A pressure line is set up and pressures are recorded within the hepatic portal venous system (i.e. high pressures due to portal hypertension). This is useful post-shunt development.

  • A digital subtraction angiography (DSA) run is performed simultaneously at both the hepatic portal venous system (right femoral vein sheath) and the portal venous system (right internal jugular vein sheath) using contrast injection.

  • The DSA is used as a mask to demonstrate both the hepatic portal venous and portal venous system.

  • The right femoral vein sheath is exchanged to a larger French size to accommodate for the stent to be used later in the procedure.

  • The 5F catheter and a blunt tip of a guidewire (e.g. stiff guidewire) is used to puncture through the hepatic portal venous system and the liver parenchyma and into the portal venous system.

  • Once a bridge is established, the guidewire is advanced and an angioplasty balloon is dilated to form the shunt.

  • A suitable sized covered stent is measured and prepared for deployment (e.g. 10 x 59 mm Viabahn VBX balloon-expandable covered stent (W. L. Gore & Associates, Inc; Flagstaff, AZ)). Under fluoroscopic guidance, the radiopaque markers are visualised and are located in both venous systems. The balloon is dilated when in position, and thus inflating the stent.

  • A DSA run is performed from the right femoral vein sheath to check the patency of the stent and the integrity of the portosystemic shunt.

  • Pressure readings are recorded at the hepatic portal venous system end, such that the hepatic venous pressure gradient (HPVG) is less than the initial recording (e.g. Less than 12 mm Hg for variceal rebleeding, and close to 5 mm Hg).

  • After confirmation of the shunt and pressure recordings, the venous accesses are removed and pressure is applied on both the neck and right groin.

Pre-dilatation_TIPS.jpg

[Left] Angiogram showing access into the portal venous system via transjugular approach and into the hepatic portal venous system via a percutaneous liver approach. [Right] Pre-dilatation of the tract from portal venous system to hepatic portal venous system.

Angiogram of the hepatic and portal venous system in the liver. A pigtail catheter is positioned to measure the length of stent required to bridge the portal venous and hepatic portal venous systems.

Final angiogram showing the stent placement (following post-dilatation), forming the intrahepatic portosystemic shunt.

References

  1. Vizzutti F, Schepis F, Arena U, Fanelli F, Gitto S, Aspite S, et al. Transjugular intrahepatic portosystemic shunt (TIPS): current indications and strategies to improve the outcomes. Intern Emerg Med. 2020 Jan;15(1):37–48.

  2. Tripathi D, Stanley AJ, Hayes PC, Travis S, Armstrong MJ, Tsochatzis EA, et al. Transjugular intrahepatic portosystemic stent-shunt in the management of portal hypertension. Gut. 2020 Jul;69(7):1173–92.

  3. Strunk H, Marinova M. Transjugular Intrahepatic Portosystemic Shunt (TIPS): Pathophysiologic Basics, Actual Indications and Results with Review of the Literature. Rofo. 2018 Aug;190(8):701–11. 

  4. Lee HL, Lee SW. The role of transjugular intrahepatic portosystemic shunt in patients with portal hypertension: Advantages and pitfalls. Clin Mol Hepatol. 2022 Apr;28(2):121–34. 

  5. Keller FS, Farsad K, Rösch J. The Transjugular Intrahepatic Portosystemic Shunt: Technique and Instruments. Tech Vasc Interv Radiol. 2016 Mar;19(1):2–9. 
     

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