Residency · Residency · Interventional Radiology

Transjugular Intrahepatic Portosystemic Shunt (TIPS)

Overview

TIPS creates an artificial communication between the hepatic vein and portal vein through hepatic parenchyma, lined with a stent-graft. Decompresses the portal venous system by diverting portal blood flow directly into the systemic venous circulation. Primary indications: variceal hemorrhage refractory to medical/endoscopic therapy and refractory ascites. Performed by interventional radiology via a transjugular approach under fluoroscopic and ultrasound guidance.

Indications

Variceal Hemorrhage

Acute variceal bleeding refractory to endoscopic therapy and vasoactive drugs. Secondary prophylaxis after recurrent variceal bleeding despite medical therapy (beta-blockers + band ligation). Early/preemptive TIPS (within 24-72 hours) for high-risk variceal bleeders (Child-Pugh C 10-13 or Child-Pugh B with active bleeding at endoscopy). Supported by multiple RCTs showing survival benefit.

Refractory Ascites

Ascites requiring >3 large-volume paracenteses per month despite maximal diuretic therapy. TIPS reduces portal pressure and improves renal sodium excretion. Survival benefit debated; clear quality-of-life improvement. Patient must be carefully selected (see contraindications).

Other Indications

Hepatic hydrothorax refractory to medical management. Budd-Chiari syndrome (hepatic vein thrombosis). Portal vein thrombosis (TIPS with portal vein recanalization). Hepatorenal syndrome (type 1) — TIPS as bridge to transplant. Hepatopulmonary syndrome (rare indication). Portal hypertensive gastropathy refractory to medical therapy.

Contraindications

Absolute: congestive heart failure (right-sided), severe pulmonary hypertension (mean PAP >45 mmHg), severe tricuspid regurgitation, uncontrolled sepsis, unrelieved biliary obstruction. Relative: hepatic encephalopathy (existing, poorly controlled), hepatocellular carcinoma (central, involving hepatic veins), MELD >18-20 (diminishing returns, high mortality), advanced age. Polycystic liver disease (lack of parenchymal tissue for tract).

<image>Diagram of TIPS anatomy showing the stent-graft traversing hepatic parenchyma from the right hepatic vein to the right portal vein, creating a portosystemic shunt</image>

Pre-Procedural Assessment

Laboratory and Imaging

MELD score calculation (bilirubin, INR, creatinine). Complete hepatic panel, CBC with platelets, type and screen. Echocardiogram: assess right ventricular function, pulmonary pressures, ejection fraction. Doppler ultrasound: portal vein patency, flow direction, liver size. Cross-sectional imaging (CT or MRI): hepatic vein anatomy, portal vein anatomy, HCC screening, ascites volume. Assess for portal vein thrombosis (present in 10-20% of cirrhotics).

Risk Stratification

MELD score is the strongest predictor of post-TIPS mortality. MELD >18: 30-day mortality ~30%; careful patient selection essential. Child-Pugh C patients (score >13) have very high mortality. Right heart catheterization if pulmonary hypertension suspected. Cardiac stress testing in selected patients.

Technique

Access and Approach

Right internal jugular vein access (ultrasound-guided, 10 Fr sheath). Catheter advanced through SVC → right atrium → IVC → hepatic vein (usually right hepatic vein). Hepatic venography and wedged hepatic venous pressure gradient (WHVPG) measurement. Portal pressure gradient = WHVPG - free hepatic venous pressure. Normal: 1-5 mmHg. Clinically significant portal hypertension: ≥10 mmHg. Variceal bleeding threshold: ≥12 mmHg. Goal after TIPS: <12 mmHg (ideally 8-10 mmHg).

TIPS Creation

TIPS needle set (Rosch-Uchida or Haskal set) advanced through hepatic vein catheter. Needle advanced through hepatic parenchyma toward the right portal vein. Guided by: ultrasound (intravascular or external), fluoroscopy, CO2 portography, cone-beam CT. Target: right portal vein (most common), left portal vein (if right is thrombosed). Successful portal vein access confirmed by aspiration of blood and portal venography. Portal pressure measured. Tract dilated with angioplasty balloon (8-10 mm). Covered stent-graft (Viatorr) deployed spanning from portal vein to hepatic vein/IVC junction. Viatorr stent: PTFE-covered portion within parenchymal tract, uncovered portion extending into portal vein. Standard diameters: 8 mm or 10 mm. Post-deployment portal venography and pressure measurement. Target portosystemic gradient: <12 mmHg. If gradient remains elevated: balloon dilation of stent or parallel TIPS.

Variceal Embolization

Often performed concurrently with TIPS for active variceal bleeding. Coronary (left gastric) vein and short gastric veins embolized with coils. Reduces risk of recurrent bleeding while TIPS matures and collaterals decompress. Not universally performed — some operators rely on TIPS alone to decompress varices.

<image>Fluoroscopic image showing a deployed Viatorr stent-graft during TIPS creation with portal venography confirming decompression of varices and reduced portal pressure</image>

Post-Procedural Management

Immediate Post-TIPS

Monitor for hemodynamic changes: increased cardiac preload, possible heart failure exacerbation. Doppler ultrasound within 24 hours to establish baseline TIPS velocity. Expected stent velocities: 90-190 cm/s (varies by center). Monitor for hepatic encephalopathy (30-50% of patients). Diuretic therapy adjustment for ascites patients.

TIPS Surveillance

Doppler ultrasound at 1 month, then every 3-6 months. Key surveillance parameters: Main TIPS velocity: <90 cm/s or >190 cm/s suggests dysfunction. Change in velocity >50 cm/s from baseline. Reversal of flow in intrahepatic portal branches. Venography with pressure gradient measurement if ultrasound suggests dysfunction. Covered stent-grafts (Viatorr) have dramatically reduced stenosis rates: 80-90% primary patency at 1 year vs. 30-50% with bare metal stents (historical).

TIPS Dysfunction and Revision

Causes: intimal hyperplasia at hepatic vein end, stent thrombosis, inadequate initial shunt. TIPS revision: balloon angioplasty and/or stent extension. Revision rate with Viatorr: 10-20% at 2 years. Thrombosed TIPS: mechanical thrombectomy, thrombolysis, and restenting.

Hepatic Encephalopathy After TIPS

Incidence and Risk Factors

Overt hepatic encephalopathy: 30-50% post-TIPS (most episodes within first 3 months). Risk factors: age >65, pre-existing encephalopathy, MELD >18, sarcopenia, hyponatremia, large shunt diameter. Most episodes are manageable with medical therapy.

Management

Lactulose and rifaximin (first-line). Dietary protein modification (maintain adequate protein, do not restrict excessively). If refractory: TIPS reduction (balloon-expandable stent placed within TIPS to narrow lumen). Rarely: TIPS occlusion (last resort for intractable encephalopathy).

Prevention

Use 8 mm diameter stent-graft in patients at high risk for encephalopathy. Underdilation technique: deploy 10 mm Viatorr but dilate to only 8 mm initially. Stepwise dilation if needed for persistent symptoms.

TIPS and Liver Transplant

Considerations

TIPS does not preclude liver transplantation. TIPS stent should not extend too far into the IVC (complicates transplant surgery). Ideally, the hepatic vein end of the stent-graft should be at or near the hepatic vein/IVC junction. TIPS can serve as a bridge to transplant for refractory ascites and recurrent variceal bleeding. MELD score may increase after TIPS (creatinine changes) — can affect transplant listing.

<image>Doppler ultrasound of a functioning TIPS showing normal stent velocities and hepatopetal flow in the main portal vein directed toward the shunt</image>

Complications

Early

Intraperitoneal hemorrhage (hepatic artery or portal vein injury): 1-2%. Hemobilia. Hepatic capsule puncture. Cardiac arrhythmias (wire in right atrium). Contrast reactions. Acute heart failure (volume overload from portosystemic shunting).

Late

Hepatic encephalopathy (30-50%). TIPS stenosis/occlusion (10-20% at 2 years with covered stents). Liver failure (accelerated hepatic decompensation from portal flow diversion). Hemolytic anemia (rare, from turbulent flow through stent).

Clinical Pearls

The Viatorr covered stent-graft is the standard of care — bare metal stents are obsolete for TIPS due to unacceptable stenosis rates. Preemptive TIPS within 72 hours for high-risk variceal bleeders (Child-Pugh C 10-13 or Child B with active bleeding) improves survival — do not delay for "stabilization". Always measure the portosystemic gradient before and after TIPS creation — the procedure is not complete until the gradient is <12 mmHg. Hepatic encephalopathy is the most common post-TIPS complication; counsel patients and start lactulose prophylaxis. Use an 8 mm stent in patients at high risk for encephalopathy (elderly, pre-existing encephalopathy, sarcopenia). TIPS for Budd-Chiari syndrome may require portal vein access from the IVC if hepatic veins are completely thrombosed — this is technically challenging and may require transhepatic or transcaval approaches. In transplant candidates, keep the TIPS stent as short as possible and avoid extending into the IVC. Right heart catheterization before TIPS is critical if there is any suspicion of pulmonary hypertension or right heart dysfunction — TIPS increases preload and can precipitate fatal right heart failure.

References

• Garcia-Tsao G, et al. Portal Hypertensive Bleeding in Cirrhosis: Risk Stratification, Diagnosis, and Management (AASLD Practice Guidance). Hepatology. 2017;65(1):310-335.
• Bureau C, et al. Improved Clinical Outcome Using Polytetrafluoroethylene-Coated Stents for TIPS. Gastroenterology. 2004;126(2):469-475.
• Garcia-Pagan JC, et al. Early Use of TIPS in Patients with Cirrhosis and Variceal Bleeding. N Engl J Med. 2010;362(25):2370-2379.
• Defined BR, et al. TIPS for Refractory Ascites: Individual Patient Data Meta-Analysis. Gastroenterology. 2017;152(3):480-493.
• Defined AASLD/SIR Guidelines on TIPS. Hepatology. 2019;69(3):1346-1382.
• Defined AM, et al. Viatorr Stent-Graft: Long-Term Patency and Clinical Outcomes. J Hepatol. 2020;72(3):458-466.

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