Transjugular Intrahepatic Portosystemic Shunt (TIPS)
What is TIPS?
TIPS is a side-to-side portacaval shunt that is placed by an interventional radiologist or a hepatologist usually under local anaesthesia. The purpose of a TIPS is to decompress the portal venous system and therefore prevent rebleeding from varices or stop or reduce the formation of ascites. The risk of bleeding falls significantly if the HVPG can be reduced to less than 12mmHg. The degree of reduction in HVPG to control ascites is unclear but at present a gradient of at least < 12 mm Hg has been suggested to be a reasonable goal.
Discuss the indications for TIPS?
- Control of acute variceal bleed that is refractory to medical therapy.
- TIPS is effective in the prevention of rebleeding from gastric and ectopic varices (including intestinal, stomal and anorectal varices) and is the preferred approach for the prevention of rebleeding in this group of patients.
- TIPS will decrease the need for repeated large volume paracentesis in patients with refractory cirrhotic ascites. However, given the uncertainty as to the effect of TIPS creation on survival and the increased risk of encephalopathy, TIPS should be used in those patients who are intolerant of repeated large volume paracentesis.
- TIPS may be used in the management of portal hypertensive gastropathy if there is recurrent bleeding despite the use of beta blockers.
- TIPS is effective in the control of hepatic hydrothorax but it only should be used in patients whose effusion cannot be controlled by diuretics and sodium restriction.
- TIPS may be an option in Budd-Chiari syndrome of moderate severity who have failed to respond to anticoagulation.
What tests are needed before TIPS placement?
Preceding creation of a TIPS, tests of liver and kidney function should be performed as well as cross sectional imaging of the liver to assess portal system patency and exclude liver masses. You need a pair of good kidneys in order to get rid of the excess sodium and water that will be mobilised after TIPS
What are the contraindications for TIPS?
Absolute contraindications include congestive heart failure, severe tricuspid regurgitation and severe pulmonary hypertension (mean pulmonary pressures of more than 45 mm Hg) as these patients are not candidates for a liver transplant).
Normal cardiac function is needed as after TIPS venous return is increased (almost doubles) because of increased splanchnic/portal return and may lead to cardiac failure if pre procedure cardiac function is compromised.
Discuss the complications of TIPS?
Major procedural complications (intra abdominal haemorrhage, laceration of the hepatic artery or portal vein and right heart failure) are expected in no more than 3% of cases.
Hepatic encephalopathy and TIPS dysfunction are the two complications that have limited the effectiveness of TIPS most significantly.
Other complications include infection of TIPS, sepsis and stent migration in IVC or portal vein. Haemolysis may occur following TIPS placement and appears to be due to damage to the red cells by the stent.
Discuss TIPS dysfunction?
TIPS dysfunction is defined as a loss of decompression of the portal venous system due to occlusion or stenosis of the TIPS. Recurrence of the complication of portal hypertension (bleeding or ascites) for which the TIPS was performed indicates TIPS dysfunction. Occlusion of the TIPS can either be due to thrombosis or hyperplasia of the intima. Thrombosis of the TIPS usually occurs early and can happen within 24 hours of TIPS
creation. Thrombosis of the TIPS is identified by Doppler ultrasound and patency re-established by repeat catheterization.
Documentation of patency can only be achieved with certainty by re-catheterization of the shunt. An abnormal Doppler ultrasound is predictive of occlusion or stenosis whereas a normal ultrasound does not exclude TIPS dysfunction. The recurrence of symptoms in the face of a ‘normal’ ultrasound does not eliminate the need for TIPS venography.
The development of covered stents has reduced the frequency of TIPS dysfunction.
Discuss TIPS and encephalopathy?
- TIPS is contraindicated only if the hepatic encephalopathy is uncontrollable.
- The incidence of new or worsening encephalopathy following TIPS is 20-31%.
- Encephalopathy following TIPS responds to standard therapy and only rarely (less than 5%) must the TIPS be occluded to control the encephalopathy. A TIPS also can be reduced in calibre, should excessive encephalopathy prove difficult to control and yet allow for continued portal decompression.
- It is important to note that if the encephalopathy was precipitated by variceal bleeding then prevention of rebleeding should make it less likely that the patient will have recurrent encephalopathy.
Discuss TIPS surveillance?
Doppler ultrasound should be performed at specified intervals following the procedure and on the yearly anniversary of the TIPS thereafter
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