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
Â
Â
- Medical management:
