transjugular intrahepatic portosystemic shunt

Transjugular intrahepatic portosystemic shunt (TIPS) is a treatment for portal hypertension in which direct communication is formed between a hepatic vein and a branch of the portal vein, thus allowing some proportion of portal flow to bypass the liver. The target portosystemic gradient after TIPS formation is <12 mmHg.

Indications

• acute variceal bleeding when pharmacologic therapy and endoscopic sclerotherapy have failed
• recurrent variceal bleeding (as a preventative procedure)
• ascites refractory to medical management in patients that require frequent drainage or do not tolerate repeated drainage
• hepatic hydrothorax that cannot be adequately managed with salt restriction and diuresis
• portal hypertensive gastropathy
• hepatorenal syndrome 
• lower gastrointestinal and stomal varices
• malignant compression of hepatic or portal veins
• Budd-Chiari syndrome of moderate level disease not responsive to anticoagulation

Contraindications

Absolute contraindications

It is arguable that there are no absolute contraindications . However, practices among interventional radiologists vary. Some generally accepted absolute contraindications are :

• severe chronic liver disease or rapidly progressive acute liver failure, as the diseased or injured liver may not tolerate the diversion of nutrient portal blood flow 
• severe encephalopathy resistant to medical management, as diversion of unfiltered blood will worsen it  
• severe right heart failure as the flow diversion from TIPS will increase pre-load  
• uncontrolled sepsis as there is a substantially increased risk of stent infection 

Relative contraindications

• right heart failure
• cavernous transformation of the portal vein
• cystic hepatic disease
• occlusive main portal vein thrombus
• polycystic kidney disease
• hepatic malignancy or hemangioma

Procedure details

Complications

Acute complications

• hemorrhage (hemoperitoneum, intrahepatic hematoma, subcapsular hematoma)
• hepatic infarction
• gallbladder puncture
• sepsis secondary to infection
• vascular access sites hematoma
• unintentional arterial access
• acute kidney injury

Long-term complications

• uncontrollable hepatic encephalopathy
• recurrence of portal hypertension with sequelae
• hepatic venous stenosis
• stent occlusion: portovenogram with re-stenting is indicated when there is recurrent bleeding and decreased Doppler flow on follow-up
• stent migration
• stent infection

* Since the introduction of PTFE (polytetrafluoroethylene) stents, stent-related complications are extremely rare .

Methods to assess patency

• color Doppler
• CT angiography
• portography with portal manometry

See: TIPS evaluation.

Factors affecting poor survival

These include :

• hyponatremia
• hyperbilirubinemia
• elevated serum ALT
• advanced liver disease
• coexisting renal insufficiency

See also

• liver and biliary interventional procedures

Siehe auch:

• Leber
• portosystemische Umgehungskreisläufe
• portale Hypertension
• Vena portae
• Aszites
• Budd-Chiari-Syndrom
• Interventionen an Leber / Gallenwegen
• TIPS-Thrombose
• problems of TIPS
• portal-hypertensive Gastropathie

und weiter:

• kavernöse Transformation Pfortader
• Fundusvarizen
• transjuguläre Leberbiopsie
• intrahepatische Shunts
• intrahepatischer portosystemischer Shunt
• TIPS revision in late TIPS failure due to venous stenosis
• problems of TIPS - Potentially dangerous portal puncture site
• splenorenaler Shunt
• transjugular intrahepatic portosystemic shunt in partially thrombosed portal vein