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Transjugular Intrahepatic Portosystemic Shunt (TIPS)

Ahmad Yanis

Background

  • A TIPS procedure is done by IR to manage sequalae of portal HTN (specifically variceal bleeding and ascites)

  • A low-resistance shunt is created between an intrahepatic branch of the portal vein and the hepatic vein, allowing blood to bypass the high-resistance vessels within the fibrotic liver.

  • Ideally, creating the smallest-necessary caliber shunt is desirable. Recent studies suggest that an 8-mm-diameter PTFE-lined TIPS may be sufficient to prevent variceal rebleeding and potentially decrease the incidence of hepatic encephalopathy

Evaluation

  • Indications for TIPS

    • Variceal hemorrhage (esophageal, gastric, etc.)
      • Early “preemptive” TIPS is an urgent TIPS placement within 72 hrs (preferably within 24 hours) of initial endoscopic hemostasis in pts at high risk for rebleeding (Child-Pugh Class B with active bleeding upon insertion of endoscope or Child-Pugh Class C with recent bleeding
      • “Rescue” TIPS is placed in pts with active, uncontrolled variceal bleeding or if bleeding recurs despite maximal endoscopic and pharmacologic therapy
    • Refractory ascites (prolongs survival)
    • Other: bleeding portal hypertensive gastropathy, bleeding gastric varices, PVT recanalization, Budd-Chiari syndrome, hepatic hydrothorax

  • Contraindications to TIPS

    • Absolute contraindications
      • Primary prevention of variceal bleeding, congestive heart failure, severe tricuspid regurgitation, severe pulmonary hypertension, multiple hepatic cysts or masses, Sepsis, unrelieved biliary obstruction
    • Relative contraindications
      • Hepatic encephalopathy, hepatic tumors (especially if centrally located), thrombocytopenia, moderate pulmonary hypertension

  • Pre-procedure preparation

    • Labs: CBC, CMP, INR
    • Liver imaging to assess portal system patency and exclude liver masses
      • Ideally triple phase CT with contrast
      • In pts with renal impairment or active variceal bleeding, RUQ U/S with doppler is acceptable
    • TTE to evaluate for evidence of congestive heart failure, pulmonary hypertension, or valvular disease.
    • Antibiotic ppx with ceftriaxone 1g IV once at the time of TIPS insertion as enteric bacteria within the static portal system can enter systemic circulation
    • Patients with HE should receive rifaximin prophylaxis starting 2 weeks before procedure

Management Post-TIPS

  • Immediately following TIPS, pts are observed in the hospital overnight for complications

    • Monitor CBC and vitals closely. If hemodynamically unstable, STAT CBC and low threshold to obtain CTA A/P to evaluate for a bleeding source

  • TIPS causes a substantial increase in venous return to the heart, which can unmask cardiac dysfunction that was previously compensated for

  • Obtain RUQ U/S with Doppler to assess shunt patency 1 month of TIPS placement, or if ascites and/or variceal hemorrhage reoccur

  • If patient with a TIPS develops refractory HE, can consider TIPS revision to lessen HE symptoms

  • Clearance of ascites is not immediate post-TIPS (may take 6-12 weeks), and patients should be maintained on a sodium-restricted diet and diuretics until ascites is adequately controlled.

  • Hemodynamic Pressure Measurements and Goals

    • The HVPG refers to the difference in intravascular pressure between the portal vein and the hepatic vein. During TIPS placement, direct portal pressures are measured and used tocalculate the portosystemic pressure gradient (PSPG)
    • In patients with acute, uncontrolled esophageal variceal bleeding, the desired post-TIPS PSPG is <12 mm Hg or, If the former is not feasible, a reduction ≥50% from baseline PSPG
    • The desired PSPG for secondary prevention of gastroesophageal variceal bleeding is <12 mm Hg
    • In patients not achieving a PSPG <12 mm Hg despite dilation of the stent to a maximum 10 mm of diameter, the addition of nonselective beta-blockers (NSBBs) should be considered