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Transjugular Intrahepatic Portosystemic Shunt (TIPS)

Pakinam Mekki

Background

  • A Transjugular Intrahepatic Portosystemic Shunt or TIPS procedure is done by interventional radiology to manage sequelae of portal hypertension (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

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: portal hypertensive gastropathy, 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

Last update: 2022-06-21 11:08:42