Transjugular intrahepatic portosystemic shunt (TIPS or TIPSS) is an artificial channel within the

liver The liver is a major metabolic organ (anatomy), organ exclusively found in vertebrates, which performs many essential biological Function (biology), functions such as detoxification of the organism, and the Protein biosynthesis, synthesis of var ...

that establishes communication between the inflow

portal vein The portal vein or hepatic portal vein (HPV) is a blood vessel that carries blood from the gastrointestinal tract, gallbladder, pancreas and spleen to the liver. This blood contains nutrients and toxins extracted from digested contents. Approxima ...

and the outflow hepatic vein. It is used to treat portal hypertension (which is often due to liver cirrhosis) which frequently leads to intestinal bleeding, life-threatening esophageal bleeding ( esophageal varices) and the buildup of fluid within the abdomen ( ascites). An interventional radiologist creates the shunt using an image-guided endovascular (via the

blood vessel Blood vessels are the tubular structures of a circulatory system that transport blood throughout many Animal, animals’ bodies. Blood vessels transport blood cells, nutrients, and oxygen to most of the Tissue (biology), tissues of a Body (bi ...

s) approach, with the jugular vein as the usual entry site.

History

The procedure was first described by Josef Rösch in 1969 while working as a research fellow with Charles Dotter, the "Father of Interventional Radiology," at Oregon Health and Science University. Dr. Rösch became a visiting professor at the

University of California, Los Angeles The University of California, Los Angeles (UCLA) is a public university, public Land-grant university, land-grant research university in Los Angeles, California, United States. Its academic roots were established in 1881 as a normal school the ...

, where he made an accidental entry into the peripheral portal venous branch while attempting a diagnostic transjugular cholangiogram on a canine model that became the first TIPS. They began researching how to maintain the shunts by experimenting with Teflon tubes and silicone-covered spring coils; the primary challenge was to find a material that could remain open (patent) and not clot(thrombose). It was first used in a human patient by Dr. Ronald Colapinto of the

University of Toronto The University of Toronto (UToronto or U of T) is a public university, public research university whose main campus is located on the grounds that surround Queen's Park (Toronto), Queen's Park in Toronto, Ontario, Canada. It was founded by ...

in 1982, who created the first human balloon dilated TIPS, but did not become reproducibly successful until the development of self-expanding bare endovascular stents in 1985. In 1988 the first successful TIPS was realized by M. Rössle, G.M. Richter, G. Nöldge and J. Palmaz at the

University of Freiburg The University of Freiburg (colloquially ), officially the Albert Ludwig University of Freiburg (), is a public university, public research university located in Freiburg im Breisgau, Baden-Württemberg, Germany. The university was founded in 1 ...

. The American Association for the Study of Liver Disease established practice guidelines for "role of TIPS in the management of portal hypertension" in 2005 and added Budd-Chiari syndrome as an additional indication in 2009. The procedure has since become widely accepted as the preferred method for treating portal hypertension that is refractory to medical therapy, replacing the surgical portacaval shunt in that role.

Indications and Contraindications

TIPS is a life-saving procedure in bleeding from esophageal or gastric varices. A randomized study showed that the survival is better if the procedure is done within 72 hours after bleeding.

Indications

TIPS is indicated for patients with severe

liver disease Liver disease, or hepatic disease, is any of many diseases of the liver. If long-lasting it is termed chronic liver disease. Although the diseases differ in detail, liver diseases often have features in common. Liver diseases File:Ground gla ...

causing ascites that keeps recurring and does not respond to other treatment (refractory ascites), recurrent buildup of fluid around the lungs (refractory hepatic hydrothorax), hepatorenal syndrome, hepatopulmonary syndrome, Budd-Chiari syndrome, and is a secondary form of prevention for life-threatening bleeding from dilated veins in the esophagus or stomach ( esophageal varices or gastric varices).

Contraindications

Absolute contraindications for TIPS include

congestive heart failure Heart failure (HF), also known as congestive heart failure (CHF), is a syndrome caused by an impairment in the heart's ability to fill with and pump blood. Although symptoms vary based on which side of the heart is affected, HF typically pr ...

pulmonary hypertension Pulmonary hypertension (PH or PHTN) is a condition of increased blood pressure in the pulmonary artery, arteries of the lungs. Symptoms include dypsnea, shortness of breath, Syncope (medicine), fainting, tiredness, chest pain, pedal edema, swell ...

, severe infection (

sepsis Sepsis is a potentially life-threatening condition that arises when the body's response to infection causes injury to its own tissues and organs. This initial stage of sepsis is followed by suppression of the immune system. Common signs and s ...

), presence of blockage of the

bile duct A bile duct is any of a number of long tube-like structures that carry bile, and is present in most vertebrates. The bile duct is separated into three main parts: the fundus (superior), the body (middle), and the neck (inferior). Bile is requ ...

system (biliary obstruction), and presence of extensive hepatic cysts. TIPS should not be used as primary prevention of variceal hemorrhage, for example, when a patient is actively bleeding from esophageal or gastric varices. Patients should be hemodynamically stabilized before performing a TIPS procedure. Other relative contraindications for TIPS include presence of liver cancer, portal vein or hepatic vein thrombosis or other occlusion, severe bleeding disorders or low platelet count (coagulopathy), and advanced

hepatic encephalopathy Hepatic encephalopathy (HE) is an altered level of consciousness as a result of liver failure. Its onset may be gradual or sudden. Other symptoms may include movement problems, changes in mood, or changes in personality. In the advanced stag ...

. TIPS may worsen hepatic encephalopathy. There is some debate on whether TIPS can be done concurrently with mechanical thrombectomy (removal of a blood clot) for patients with active portal venous thrombosis. It is suggested that simultaneous treatment can restore portal vein flow with good patency (>84%) 1 year after the procedure.

Complications

Severe procedural complications during a TIPS procedure, including catastrophic bleeding or direct liver injury, are relatively uncommon. In the hands of an experienced physician, operative mortality is less than 1%. On the other hand, up to 25% of patients who undergo TIPS will experience transient post-operative

caused by increased porto-systemic passage of nitrogen from the gut. A less common, but more serious complication, is hepatic ischemia causing acute liver failure. While healthy livers are predominantly oxygenated by portal blood supply, long-standing portal hypertension results in compensatory hypertrophy of and increased reliance on the hepatic artery for oxygenation. Thus, in people with advanced liver disease the shunting of portal blood away from hepatocytes is usually well tolerated. However, in some cases suddenly shunting portal blood flow away from the liver may result in acute liver failure secondary to hepatic ischemia. Acute hepatic dysfunction after TIPS may require emergent closure of the shunt. A rare but serious complication is persistent TIPS infection, also known as endotipsitis. Lastly, the TIPS may become blocked by a blood clot or in-growth of endothelial cells and no longer function. This has been significantly reduced with the use of

polytetrafluoroethylene Polytetrafluoroethylene (PTFE) is a synthetic fluoropolymer of tetrafluoroethylene, and has numerous applications because it is chemically inert. The commonly known brand name of PTFE-based composition is Teflon by Chemours, a corporate spin-of ...

(PTFE)–covered stents.

Mechanism of action

Portal hypertension, an important consequence of liver disease, results in the development of significant collateral circulation between the portal system and systemic venous drainage (porto-caval circulation). Portal venous congestion causes venous blood leaving the stomach and intestines to be diverted along auxiliary routes of lesser resistance in order to drain to systemic circulation. With time, the small vessels that comprise a collateral path for porto-caval circulation become engorged and dilated. These vessels are fragile and often hemorrhage into the GI tract. (''See esophageal, gastric, rectal varices''). A TIPS procedure decreases the effective vascular resistance of the liver through the creation of an alternative pathway for portal venous circulation. By creating a shunt from the portal vein to the hepatic vein, this intervention allows portal blood an alternative avenue for draining into systemic circulation. In bypassing the flow-resistant liver, the net result is a reduced pressure drop across the liver and a decreased portal venous pressure. Decreased portal venous pressure in turn lessens congestive pressures along veins in the intestine so that future bleeding is less likely to occur. The reduced pressure also makes less fluid develop, although this benefit may take weeks or months to occur.

Implantation

Transjugular intrahepatic portosystemic shunts are typically placed by an interventional radiologist under fluoroscopic guidance. Access to the liver is gained, as the name 'transjugular' suggests, via the

internal jugular vein The internal jugular vein is a paired jugular vein that collects blood from the brain and the superficial parts of the face and neck. This vein runs in the carotid sheath with the common carotid artery and vagus nerve. It begins in the posteri ...

in the

neck The neck is the part of the body in many vertebrates that connects the head to the torso. It supports the weight of the head and protects the nerves that transmit sensory and motor information between the brain and the rest of the body. Addition ...

. Once access to the jugular vein is confirmed, a guidewire and introducer sheath are typically placed to facilitate the shunt's placement. This enables the interventional radiologist to gain access to the patient's hepatic vein by traveling from the

superior vena cava The superior vena cava (SVC) is the superior of the two venae cavae, the great venous trunks that return deoxygenated blood from the systemic circulation to the right atrium of the heart. It is a large-diameter (24 mm) short length vei ...

into the

inferior vena cava The inferior vena cava is a large vein that carries the deoxygenated blood from the lower and middle body into the right atrium of the heart. It is formed by the joining of the right and the left common iliac veins, usually at the level of the ...

and finally the hepatic vein. Once the catheter is in the hepatic vein, a wedge pressure is obtained to calculate the pressure gradient in the liver. Following this, carbon dioxide is injected to locate the portal vein. Then, a special needle known as a Colapinto or Rösch-Uchida is advanced through the liver parenchyma to connect the hepatic vein to the large

, near the center of the liver. The channel for the shunt is next created by inflating an angioplasty balloon within the liver along the tract created by the needle. The shunt is completed by placing a special mesh tube known as a stent or endograft to maintain the tract between the higher-pressure portal vein and the lower-pressure hepatic vein. After the procedure, fluoroscopic images are made to show placement. Pressure in the portal vein and inferior vena cava are often measured as the dynamic changes in the portal pressure system can help predict mortality after TIPS.

TIPS with Intracardiac Echocardiography

TIPS can also be done with intracardiac echocardiography (ICE) guidance to assist in cases where there is challenging anatomy or presence of portal vein thrombosis. Benefits to using ICE include reduced procedure time, reduced anesthesia time, reduced radiation exposure from

fluoroscopy Fluoroscopy (), informally referred to as "fluoro", is an imaging technique that uses X-rays to obtain real-time moving images of the interior of an object. In its primary application of medical imaging, a fluoroscope () allows a surgeon to see t ...

, reduced contrast agent use, and reduced risk of puncture outside of the liver. This can also assist in cases where there may be relative contraindications to the procedure such as presence of hepatic cysts. In the variation of the TIPS procedure with ICE, a second puncture site in the right jugular vein or the right common femoral vein is used to insert the ICE catheter. The ICE is advanced to the level of the inferior vena cava and right atrial junction and into the intrahepatic IVC to visualize the hepatic vein and the target portal venous branch. The probe is then rotated to identify the TIPS needle and help the primary operator aim for the portal venous branch.

Stents in TIPS

In order to keep the new pathway open between the portal vein and hepatic vein, stents are used in TIPS. Covered stents are preferred as they may help improve overall survival compared to bare stents. A smaller 8mm stent is preferred over a larger 10mm covered stent due to reduced risk of bleeding, higher efficacy, and lower hepatic encephalopathy rates. If an 8mm stent clots, you can repeat TIPS and replace it with a larger stent.

References

External links

RadiologyInfo: Transjugular Intrahepatic Portosystemic Shunt (TIPS)

Transjugular Intrahepatic Portosystemic Shunt
- eMedicine.com. {{Authority control Accessory digestive gland surgery Hepatology Implants (medicine) Vascular surgery Interventional radiology