Transjugular intrahepatic portosystemic shunts (TIPS)

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.