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Transjugular intrahepatic portosystemic shunts (TIPS)

Home Gastrointestinal Transjugular intrahepatic portosystemic shunts (TIPS)

TIPS is an interventional radiologic procedure to create a shunt from the portal vein to a hepatic vein in order to decrease portal hypertension. Intravascular access is obtained, most frequently from the internal jugular vein, and a tract is created between the two venous systems. A metal expandable stent is then deployed to maintain patency.

Indications

  • Most commonly done to treat complications of portal hypertension (variceal bleeding, particularly secondary prevention of esophageal variceal bleeding, and refractory ascites)
  • Other indications include:
    • Hepatic hydrothorax
    • Hepatorenal syndrome
    • Budd-Chiari syndrome
    • Hepatic sinusoidal obstruction syndrome

Contraindications

  • Heart failure
  • Tricuspid regurgitation
  • Pulmonary hypertension
  • Sepsis
  • Severe liver failure
  • Hepatic encephalopathy
  • Hepatic cysts
  • Unrelieved biliary obstruction

Complications

  • Thrombosis (of portal vein, hepatic vein, or in-stent thrombosis)
  • Hyperbilirubinemia
  • Hemobilia
  • Hemoperitoneum
  • Hepatic infarction
  • Stent stenosis
  • Hepatic encephalopathy
  • Radiation skin burn
  • Renal failure potentially leading to dialysis

Work-up

    • Multi-disciplinary approach – usually involving a hepatologist or gastroenterologist.
    • Model for End-stage Liver Disease (MELD) score: looks at lab data (sodium, bilirubin, creatinine, INR) to predict a patient’s three month mortality risk
    • Lab work: CBC, CMP, PT/INR, aPTT
      • If platelets <50,000 or INR >1.5, patient will need blood products or reversal prior to TIPS
    • Imaging: Liver ultrasound to assess portal vein patency. If patient has a known cardiac history or known pulmonary hypertension, an echocardiogram should be done pre-procedure.
    • If a patient has recurrent ascites or hydrothorax, a paracentesis or thoracentesis may need to be performed 24-48 hours prior to TIPS.
  • Other Treatment Options

    • Medical management:
      • Ascites: sodium restriction, diuretics (particularly spironolactone and furosemide), paracentesis
      • Variceal bleeding: non-selective beta-blockers, octreotide
    • Procedural interventions:
      • Endoscopic ligation, cauterization, or banding: role in treating variceal bleeding
      • Balloon-occluded retrograde obliteration (BRTO): can be used to treat refractory gastric variceal bleeding and refractory hepatic encephalopathy.
      • Plug-assisted retrograde trans venous obliteration: can also be used to treat gastric varices and hepatic encephalopathy
      • Coil-assisted retrograde trans venous obliteration: can also be used to treat gastric varices and hepatic encephalopathy

     

     

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