Transjugular Intrahepatic Portosystemic Shunt (TIPS)

Transjugular Intrahepatic Portosystemic Shunt or TIPS is a procedure that uses imaging guidance to create a connection between two large veins in the liver, the portal vein and the hepatic vein. This helps blood bypass the abnormal liver so that it can return to the heart more easily. A small metal device called a stent is placed to keep the connection open. TIPS is performed to reduce the risk of internal bleeding from the stomach and esophagus in patients with cirrhosis. TIPS may also reduce the accumulation of fluid in the abdomen or lungs.

Tell your doctor if there's a possibility you are pregnant and discuss any recent illnesses, medical conditions, allergies and medications you're taking. You may be advised to stop taking aspirin, nonsteroidal anti-inflammatory drugs (NSAIDs) or blood thinners several days prior to your procedure. You will likely be instructed to not eat or drink anything after midnight the night before your procedure. Your doctor will tell you which medication to take the morning of the procedure. Leave jewelry and valuables at home. Wear loose, comfortable clothing. You will be asked to wear a gown. Plan to stay overnight at the hospital for one or more days after the procedure.

What is a Transjugular Intrahepatic Portosystemic Shunt (TIPS)?

A transjugular intrahepatic portosystemic shunt (TIPS) is a tract created to connect two veins within the liver. The procedure typically uses x-ray and ultrasound guidance. The TIPS is kept open by a small, tubular metal device commonly called a stent.

During a TIPS procedure, interventional radiologists use image guidance to make a tunnel through the liver to connect the portal vein (the vein that carries blood from the digestive organs to the liver) to one of the hepatic veins (the veins that carry blood out of the liver back to the heart). A stent is then placed in this tunnel to keep the pathway open.

Patients who typically need a TIPS have portal hypertension, meaning they have increased pressure in the portal vein system. This pressure buildup can cause blood to flow backward from the liver into the veins of the spleen, stomach, lower esophagus, and intestines, causing enlarged vessels, bleeding and the accumulation of fluid in the chest or abdomen. This condition is most commonly seen in adults, often as a result of chronic liver problems leading to cirrhosis (scarring of the liver). Portal hypertension can also occur in children, although children are much less likely to require a TIPS.

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What are some common uses of the procedure?

A TIPS is used to treat the complications of portal hypertension, including:

• variceal bleeding, bleeding from enlarged veins that normally drain the stomach, esophagus, or intestines into the liver.
• portal gastropathy, an engorgement of the veins in the wall of the stomach, which can cause severe bleeding.
• severe ascites (the accumulation of fluid in the abdomen) and/or hydrothorax (in the chest).
• Budd-Chiari syndrome, a blockage in one or more veins that carry blood from the liver back to the heart.

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How should I prepare?

Tell your doctor about all the medications you take, including herbal supplements. List any allergies, especially to local anesthetic, general anesthesia, or contrast materials. Your doctor may tell you to stop taking aspirin, nonsteroidal anti-inflammatory drugs (NSAIDs) or blood thinners before your procedure.

Women should always tell their doctor and technologist if they are pregnant. Doctors will not perform many tests during pregnancy to avoid exposing the fetus to radiation. If an x-ray is necessary, the doctor will take precautions to minimize radiation exposure to the baby. See the Radiation Safety page for more information about pregnancy and x-rays.

Your doctor will likely tell you not to eat or drink anything after midnight before your procedure. Your doctor will tell you which medications you may take the morning of your procedure.

You should plan to stay overnight at the hospital for one or more days.

The nurse will give you a gown to wear during the procedure.

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What does the equipment look like?

In this procedure, x-ray and/or ultrasound equipment, a stent, and a balloon-tipped catheter are used.

This exam typically uses a radiographic table, one or two x-ray tubes, and a video monitor. Fluoroscopy converts x-rays into video images. Doctors use it to watch and guide procedures. The x-ray machine and a detector suspended over the exam table produce the video.

Ultrasound machines consist of a computer console, video monitor and an attached transducer. The transducer is a small hand-held device that resembles a microphone. Some exams may use different transducers (with different capabilities) during a single exam. The transducer sends out inaudible, high-frequency sound waves into the body and listens for the returning echoes. The same principles apply to sonar used by boats and submarines.

The technologist applies a small amount of gel to the area under examination and places the transducer there. The gel allows sound waves to travel back and forth between the transducer and the area under examination. The ultrasound image is immediately visible on a video monitor. The computer creates the image based on the loudness (amplitude), pitch (frequency), and time it takes for the ultrasound signal to return to the transducer. It also considers what type of body structure and/or tissue the sound is traveling through.

A catheter is a long, thin plastic tube that is considerably smaller than a "pencil lead." It is about 1/8 inch in diameter.

The stent used in this procedure is a small wire mesh tube often covered with fabric.

This procedure may use other equipment, including an intravenous line (IV), ultrasound machine and devices that monitor your heart beat and blood pressure.

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How does the procedure work?

A TIPS reroutes blood flow in the liver and reduces abnormally high blood pressure in the veins of the stomach, esophagus, bowel and liver, reducing the risk of bleeding from enlarged veins.

A TIPS procedure involves creating a pathway through the liver that connects the portal vein (the vein that carries blood from the digestive organs to the liver) to a hepatic vein (one of three veins that carry blood from the liver to the heart).

A stent placed inside this pathway keeps it open and allows some of the blood that would ordinarily pass through the liver to bypass the liver entirely, reducing high blood pressure in the portal vein and the associated risk of bleeding from enlarged veins.

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How is the procedure performed?

Image-guided, minimally invasive procedures such as a TIPS are most often performed by a specially trained interventional radiologist in an interventional radiology suite or occasionally in the operating room. Some interventional radiologists prefer performing this procedure while the patient is under general anesthesia, while some prefer conscious sedation for their patient.

The doctor or nurse will position you on your back.

The doctor or nurse will connect you to monitors that track your heart rate, blood pressure, oxygen level, and pulse.

A nurse or technologist will insert an intravenous (IV) line into a vein in your hand or arm to administer a sedative. This procedure may use moderate sedation or general anesthesia. A breathing tube is not mandatory but may be used depending on physician and patient preference.

The nurse or technologist will sterilize the area of your body where the catheter is to be inserted. They will sterilize and cover this area with a surgical drape.

Your physician will numb an area just above your right collarbone with a local anesthetic.

The doctor will make a very small skin incision at the site.

Using ultrasound, the doctor will identify your internal jugular vein, which is situated above your collarbone, and guide a catheter, a long, thin, hollow plastic tube into the vessel.

Using real time x-ray guidance, your doctor will then guide the catheter toward the liver and into one of the hepatic veins. Pressures are measured in the hepatic vein and right heart to confirm the diagnosis of portal hypertension, and also to determine the severity of the condition. To help plan for the placement of the TIPS stent, a contrast material will be injected in the hepatic vein to identify the portal venous system. Access from the hepatic vein into the portal vein is achieved by using a TIPS needle (a special long needle extending from the neck into the liver). A stent is then placed connecting the portal vein to the hepatic vein using x-ray guidance. Once the stent is in the correct position, a balloon is inflated within the stent expanding it into place.

The balloon is then deflated and removed along with the catheter. Subsequently, pressures are measured to confirm reduction in portal vein blood pressure. Additional injections of contrast (portal venograms) may be performed to confirm satisfactory blood flow through the TIPS.

The doctor removes the catheter from the neck and applies pressure over the jugular vein to prevent any bleeding. The small incision in the skin is covered with a bandage. No sutures are necessary.

You will be admitted to the hospital following your procedure, where you will be closely observed.

This procedure is usually completed in an hour or two but may take up to several hours depending on the complexity of the condition and vascular anatomy.

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What will I experience during and after the procedure?

The doctor or nurse will attach devices to your body to monitor your heart rate and blood pressure.

You will feel a slight pinch when the nurse inserts the needle into your vein for the IV line and when they inject the local anesthetic. Most of the sensation is at the skin incision site. The doctor will numb this area using local anesthetic. You may feel pressure when the doctor inserts the catheter into the vein or artery. However, you will not feel serious discomfort.

If you receive a general anesthetic, you will be unconscious for the entire procedure. An anesthesiologist will monitor your condition.

If the procedure uses conscious sedation, you will feel relaxed, sleepy, and comfortable. You may or may not remain awake, depending on how deeply you are sedated.

When the needle is advanced through the liver and the pathway is expanded by the balloon, you may experience discomfort. If you feel pain, you should inform your physician; you may be given extra intravenous medications.

As the contrast material passes through your body, you may feel warm. This will quickly pass.

After the procedure, you will be monitored closely and your head will be kept elevated for a few hours after you return to your room. Often, symptoms are mild or controlled enough that the procedure can be done electively and patients may go home the next day. If your TIPS is being performed emergently for significant bleeding you will typically be monitored in intensive care beforehand and during recovery; GI bleeding from portal hypertension can be life threatening.

You should be able to resume your normal activities in seven to 10 days.

Follow-up ultrasounds will be performed frequently after the TIPS procedure to make sure that it remains open and functions properly.

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Who interprets the results and how do I get them?

Prior to leaving the hospital, you may have an ultrasound exam to determine the effectiveness of the procedure and placement of the stent.

After the procedure is complete, the interventional radiologist will tell you whether the procedure was a success.

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What are the benefits vs. risks?

Benefits

• A TIPS is designed to produce the same physiological results as a surgical shunt or bypass, without the risks that accompany open surgery.
• TIPS is a minimally invasive procedure that typically has a shorter recovery time than surgery.
• Your TIPS should have less of an effect on candidacy for future liver transplantation versus open surgical bypass because the abdomen has not been entered which can form scar tissue making future transplantation more difficult.
• The stent that keeps the shunt open (TIPS) is contained entirely inside the diseased liver, and is removed with it during a transplant operation.
• Studies have shown that this procedure is successful in reducing variceal bleeding in more than 90 percent of patients.
• No large surgical incision is necessary—only a small nick in the skin that does not need stitches.

Risks

• Any procedure that penetrates the skin carries a risk of infection. The chance of infection requiring antibiotic treatment appears to be less than one in 1,000.
• There is a very slight risk of an allergic reaction to the contrast material used for venograms. Also, kidney failure (temporary or permanent) due to contrast material use is a concern, particularly in patients with poor kidney function.
• Any procedure that places a catheter inside a blood vessel carries certain risks. These risks include damage to the blood vessel, bruising or bleeding at the puncture site, and infection. Interventional radiologists are specifically trained to perform the procedure in such a way as to reduce these risks to as low a level as possible and will take precautions to mitigate these risks.

Other possible side effects/complications of the procedure include:

• fever
• muscle stiffness in the neck
• bruising on the neck at the point of catheter insertion
• delayed stenosis, or narrowing within the stent

Serious complications, reported in fewer than five percent of cases, may include:

• occlusion, or complete blockage, of the stent and rapid recurrence of symptoms
• infection of the stent or fabric lining
• abdominal bleeding that might require a transfusion
• laceration of the hepatic artery, which may result in severe liver injury or bleeding that could require a transfusion or urgent intervention
• heart arrhythmias or congestive heart failure
• radiation injury to the skin is a rare complication (it may happen in complex and lengthy procedures requiring extended fluoroscopy use)
• death (rare)

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What are the limitations of TIPS?

Patients with more advanced liver disease are at greater risk for worsening liver failure after TIPS. If your liver failure is severe, a TIPS may not be recommended and a different procedure may be needed to control your symptoms. Patients with severe liver disease are also at risk for encephalopathy, which is an alteration of normal brain function that can lead to confusion due to buildup of toxic substances in the bloodstream ordinarily removed by the liver. Encephalopathy can be treated with certain medications, a special diet, or by revising the TIPS. In some cases the stent must be blocked off intentionally to solve this problem.

Although extremely rare, children may also require a TIPS procedure. TIPS in children are more likely to be performed before liver transplant in those with ascites or variceal bleeding resistant to traditional medical treatments. The greatest difference in performing TIPS in children is their tremendous variability in size, physiology, and medical diseases. This can result in significant challenges in creating the TIPS.

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Additional Information and Resources

Society of Interventional Radiology (SIR): Liver Disease

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Despite improvements in the surgical techniques, anesthesia and intensive care, abdominal surgery in patients with cirrhosis remains a challenge. Transjugular intrahepatic portosystemic shunt (TIPS) has been used to manage complications of portal hypertension. Preoperative TIPS (prophylactic) can theoretically improve outcomes in this population. Seven original studies were identified with 24 patients who underwent prophylactic TIPS before abdominal surgery. No perioperative mortality or major abdominal bleeding attributable to portal hypertension was reported for this cohort. One patient had poor wound healing post surgery (4.2%), one had right heart failure (4.2%), and five developed hepatic encephalopathy (20.8%) post surgery. More evidence is needed to optimize the timing of surgery post TIPS and the selection of an appropriate stent size to further decrease the associated morbidity. Overall, the decision for prophylactic TIPS placement for cirrhotic patients undergoing abdominal surgery needs individualization to allow its safe use with concomitant improvement in perioperative morbidity.

Transjugular intrahepatic portosystemic shunt (TIPS) has been used to manage complications of portal hypertension, including bleeding esophageal varix, refractory ascites and hepatic hydrothorax [ 4 ]. Preoperative TIPS can theoretically improve outcomes in patients with cirrhosis and portal hypertension undergoing abdominal surgery by decompressing the varices and resolution of ascites, thus decreasing bleeding (perioperative), improving wound healing, and minimizing the infection risk.

By virtue of the pathophysiology of cirrhosis, in addition to the contribution from its etiologic agent (hepatitis B/C, alcohol, autoimmune), the cirrhotic patient is at risk for encephalopathy, ascites (infections and poor wound healing), increased pressures in portal circulation (bleeding), renal dysfunction (hepatorenal syndrome), cardiac dysfunction (high cardiac output leading to cirrhotic cardiomyopathy), electrolyte disturbances (hyponatremia), respiratory issues (portopulmonary hypertension, hepatic hydrothorax, hepatopulmonary syndrome), malnutrition (poor wound healing), and poor tolerance to stress (surgery). One or more of these factors are together responsible for poor surgical outcomes in this population. Abdominal surgery in patients with cirrhosis is associated with higher rates of morbidity and mortality [ 1 ]. Despite improvements in the surgical techniques, anesthesia and intensive care, major abdominal surgery in patients with cirrhosis remains a challenge. The mortality can be as high as 50% in emergent cases [ 2 ]. The mortality and morbidity risk correlates with the Child-Turcotte-Pugh (CTP) class of cirrhosis [ 3 ]. Consequently, abdominal surgery may be contraindicated in some patients with cirrhosis and portal hypertension who would otherwise have been candidates for potentially curative surgical procedures.

An extensive English literature search was performed, using PubMed and Google Scholar, to identify the peer-reviewed original and review articles published up to December 2016, using the following keywords: prophylactic transjugular intrahepatic portosystemic shunt, cirrhosis, abdominal surgery. Only human studies were included. To identify additional studies, the reference lists of pertinent studies were searched manually. Studies reporting abdominal surgery in cirrhotic patients with TIPS, but placed for indications other than surgery itself, were excluded. After applying the exclusion criteria, the search yielded only eight single-center studies. The indications, procedural details, success rates, clinical outcomes, complications and limitations of each individual study were studied. Descriptive statistics (percentages, means, median, range) were calculated for each outcome (success, failure, complications) and the same were used to interpret the composite data.

Results

A total of 8 original studies were identified. These included two case reports from the UK [5] and Italy [6], three case series from the USA [7], Spain [8] and France [9], and three retrospective studies from the USA [10,11] and Canada [12]. A retrospective study from the USA described 25 patients with cirrhosis undergoing abdominal or cardiothoracic surgeries [10]. However, only 4 patients who had prophylactic TIPS before planned abdominal surgery were included [10]. Another retrospective study from the USA described 7 patients who had a TIPS procedure before surgery with the intent to minimize perioperative complications [11]. The retrospective study from Canada compared the clinical outcomes of patients with cirrhosis who underwent TIPS before abdominal surgery with those of the group without TIPS [12]. In this study, only 13 patients had elective TIPS placed before planned abdominal surgery [12]. Data were not reported separately for these 13 patients; hence, we have mentioned the results in the table but have not combined them with those of other studies in order to maintain uniformity in our inclusion and exclusion criteria for this review article.

The results from each individual study are summarized in .

Patient characteristics

These studies were small, with the number of subjects undergoing preoperative TIPS varying between 1 and 18 [5-12]. Only one study had more than 10 subjects [12]. A total of 43 patients across all studies had preoperative TIPS. Thirty-one patients were male and 12 were female. Age for the study cohort varied from as young as 41 years [5] to as old as 80 years [6].

The etiology of liver cirrhosis was alcohol in 47.6% (10/21) of patients, hepatitis C in 28.6% (6/21), a combination of alcohol and hepatitis C in 9.5% (2/21), primary biliary cirrhosis in 9.5% (2/21), and cryptogenic in 4.8% (1/21) of patients [5-9,11]. Vinet et al reported 61.1% (11/18) of patients to have a non-alcohol etiology without any further specification [12]. The severity of liver cirrhosis was described using CTP in 7 studies [5-11]. Of 25 patients, 48.0% (12/25) had CTP class A, 36.0% (9/25) had CTP class B and 16.0% (4/25) patients had CTP class C disease [5-11]. Vinet et al reported a mean CTP score of 7.7 (6-10) for the patients undergoing TIPS and 6.2 (5-9) for the control group [12]. All patients from each study had one or more signs of portal hypertension: ascites [7-12], esophageal varices [5-11], gastric varices [9,10], or gastrointestinal bleeding [5-11].

The baseline patient characteristics from each individual study are summarized in .

Table 2

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Overall, our study results are reflective of wide heterogeneity in the selected patients considered for elective pre-surgery TIPS, which points to the lack of uniform criteria. We believe that there is a selection bias in all reported studies towards patients expected to do well with or without TIPS followed by surgery. Current guidelines of the American Association for the Study of Liver Diseases suggest caution in placing TIPS in patients with a Model for End-Stage Liver Disease score >15-18 or total bilirubin >4.0 mg/dL [13]. Other absolute contraindications include severe pulmonary hypertension, congestive heart failure, and uncontrolled sepsis. Relative contraindications include anatomical challenges for TIPS placement, coagulopathy and prior episodes of encephalopathy. A multidisciplinary approach should be used, taking into consideration the center’s experience, surgeon’s expertise and hepatologist’s input to allow patient recruitment for TIPS before the planned major abdominal surgery to be safe overall in this high-risk population subgroup.

Timing of TIPS

The time period between TIPS placement and abdominal surgery was variable and ranged from 1 week [8] to a mean of 2.9 months [9]. Although the hepatic venous pressure reduces immediately after TIPS placement, new hemodynamic equilibrium and its clinical effects take time [14].

Currently, there is no consensus about the optimal timing of surgery after TIPS placement. There are a number of factors that need to be considered, including the type and urgency of abdominal surgery, local expertise, availability of TIPS, and resolution of ascites and varices.

Indication and type of planned surgery

The most frequent indication for surgery was cancer potentially resectable [5-12]. Surgery would have been the treatment of choice in these patients in the absence of cirrhosis and portal hypertension. These patients underwent a large variety of abdominal surgical procedures, including cholecystectomy [10], umbilical herniorhaphy [10], gastrectomy [5,6,8,11,12], sigmoidectomy [7,8,11], colectomy [8,10-12], nephrectomy [7,11,12], small bowel resection [12], bilateral salpingo-oophorectomy [11], oophorectomy [11], total abdominal hysterectomy [11], pancreato-duodenectomy [8,12] and exploratory laparotomy [11]. The indication and the type of surgery across all individual studies are given in .

Pre- and post-TIPS hepatovenous portal gradient (HVPG)

Generally, an HVPG of less than 12 mmHg is targeted for TIPS to be effective. The HVPG was reduced to a range between 6 mmHg and 14 mmHg in the included studies [5-12]. Gil et al reported a patient who had a pre TIPS HVPG of 28 mmHg and a post TIPS HVPG of 6 mmHg [8]. This patient had the largest change in HVPG (22 mmHg) among the reported patients. The patient developed right cardiac insufficiency. There is a lack of data to allow an accurate prediction of post-TIPS pressure gradient based on the size of shunt. It is unknown whether TIPS of different sizes should be individualized depending on pre-TIPS pressure gradient, patient’s cardiovascular status, body mass index, type of hepatic decompensation and severity of liver disease. Pre- and post-TIPS HVPG values across individual studies have been summarized in .

Table 3

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The timing of pressure measurement after TIPS placement is also important. In the studies included, the HVPG was measured at the time of TIPS placement; however, it may not be indicative of portal pressures at the time of surgery. A recent study compared portal pressure gradient (PPG) at different times after TIPS placement [15]. The immediate PPG (immediately after TIPS placement) differed significantly from the early PPG (measured after 24 h); however, there was no significant difference between proportion of patients with early PPG vs. late PPG (measured at 1 month) for values of <12 mmHg.

Outcome (morbidity)

Perioperative bleeding

Minor bleeding. This was defined as ≤2 units of red blood cells (RBCs) in the perioperative period. It is more likely to be the result of the surgery itself and less likely to be the result of portal hypertension.

No bleeding was reported in the cases described by Norton et al and Liverani et al [5,6]. Grubel et al reported two patients (2/2, both CTP C) who each had a transfusion of 2 units of RBCs and 2 units of fresh frozen plasma [7]. In the study by Gil et al, none of the subjects (0/3) required intraoperative transfusion, though one patient (CTP B) did require 2 units of RBCs in the postoperative period because of hematemesis [8]. In another study, two patients (2/6, both CTP A) received intraoperative transfusion and one patient (1/6, CTP C) required 2 units of RBCs in the postoperative period because of intra-abdominal bleeding [9]. Schlenker et al reported the requirement of 1 unit of RBCs for one patient and 2 units for another patient of 7 study patients (2/7, both CTP A) [11]. Of eight patients with minor bleeding, four were CTP A, one was CTP B and three were CTP C class.

Major bleeding. This was defined as the need for >2 units of RBCs in the perioperative period. This amount of bleeding is more likely to be attributable to persistent portal hypertension. None of the patients (0/20) from studies had major abdominal bleeding in the perioperative post-surgery period [5-9,11].

Vinet et al reported that the number of transfusions and the total quantity needed were lower for patients with TIPS compared to those without TIPS undergoing abdominal surgery [12]. Six of 18 patients in the TIPS group required 1 to 4 units of RBCs, whereas 7 of 17 patients in control group required between 2 and 4 units [12]. The authors did not report data specifically for patents with prophylactic TIPS.

Wound healing

Ascites can potentially delay wound healing and may even increase the risk for peritonitis and wound infection. TIPS placement seems to lower the risk of these complications. Among the studies evaluated [5-11], Schlenker et al reported two patients, one with new ascites and wound infection (related to portal hypertension) and the other developing a fecal fistula with localized peritonitis post surgery (unrelated to portal hypertension) [11]. Both of these patients improved with antibiotics and drainage. In composite, only one (CTP-A) of 24 patients (4.2%) had trouble with wound healing post surgery.

Encephalopathy

TIPS placement can potentially worsen hepatic encephalopathy secondary to shunting of blood with toxins to the brain. In our study cohort [5-11], a total of 5 patients (5/24) were reported to develop hepatic encephalopathy post surgery [8,10,11]. Two of these patients had changes in portosystemic gradient (PSG) of 22 mmHg [8] and 13 mmHg [11] post TIPS, whereas the data for the other three patients [10,11] were not available. Currently, we lack prediction models for the expected change in PSG with different sizes of shunt. In addition, other factors, such as the pre-TIPS severity of liver disease, also play a role. Of 5 patients with hepatic encephalopathy, 2 were CTP A, 2 were CTP B, and one was CTP C class [8,10,11]. Careful evaluation of each individual patient with cirrhosis is essential to determine the safety of TIPS for these patients.

Cardiac complications

Cardiac complications post TIPS are in most cases seen in patients who have a pre-existing cardiovascular disease that worsens post TIPS as a result of volume overload. In our cohort [5-11], one patient (1/24) (CTP A) developed right-heart failure post TIPS [8]. As explained above, this was likely due to an inadvertent decrease in PSG post TIPS and the patient consequently underwent a repeat procedure with a smaller stent size. None of the other studies reported this complication [5-7,9-11]. The remainder of the complications secondary to surgery (unrelated to portal hypertension) are summarized in .

Composite portal hypertension-related morbidity (complication) events for our study cohort were 8 among 12 CTP A class patients, 3 among 8 CTP B class patients, and 4 among 4 CTP C class patients. All of these, as mentioned above, were successfully managed conservatively with zero mortality.

Outcome (mortality)

Zero mortality was observed in patients with TIPS in the perioperative period following abdominal surgery [5-11]. Two deaths from liver failure at 5 weeks [9] and 14 months [11] in CTP C and CTP B class patients, respectively, were reported. Mortality from non–liver-related causes has been summarized in .