Transjugular Intrahepatic Portosystemic Shunt (TIPS)

Medications and endoscopic treatments are tried first, but if they cannot control the problem, the next step is either a surgical bypass or a radiological shunt called a TIPS.TIPS stands for T ransjugular (the route to the liver, which is via the internal jugular vein), I ntrahepatic (the shunt is entirely inside the liver), P orto-systemic (it connects the portal, or intestinal, circulation with the systemic circulation) and S hunt (meaning a bypass conduit).

A TIPS is performed in the radiology laboratory by an interventional radiologist. The procedure is done using intravenous sedation or general anesthesia, depending on your level of illness. Often, symptoms are mild or controlled enough that the procedure can done electively and patients may go home the next day. However, the amount of bleeding that can occur can sometimes be life threatening and those patients are monitored in intensive care beforehand and during recovery.

What are some common uses of the procedure?

variceal bleeding (bleeding from any of the veins that normally drain the stomach, esophagus, or intestines into the liver),
portal gastropathy (engorgement of the veins in the wall of the stomach, which can also cause severe bleeding),
ascites (the accumulation of high-protein fluid in the chest or abdomen), or
Budd-Chiari syndrome (a blockage of one or more hepatic veins, which carry blood from the liver back toward the heart).

How should I prepare for the procedure?

If you are not already admitted to the hospital, you will be staying at least overnight, and perhaps longer. You should bring an overnight bag with toiletries and personal items. You will be instructed not to eat or drink anything after midnight the night before your procedure. You will be contacted in advance to make sure that it is safe to continue to take your daily medications. Certain medications, such as blood thinners, will need to be discontinued several days or more in advance.

What does the equipment look like?

The procedure is done with an x-ray camera for guidance, which is also known as a fluoroscope. A portable ultrasound unit is usually used at the start of the procedure to get access to the vein situated above your collarbone, which is called the internal jugular vein. The procedure requires sterile conditions, so a large drape is placed over the working area like a tent, which is open to one side for air and visibility, usually the left. The nursing or anesthesia equipment is located near the head of the operating table and the physicians are typically working over your right shoulder.

How does the procedure work?

The interventional radiologist will be working inside the liver, to connect a portal vein branch to one of the hepatic vein branches. The conduit is made up of a metal sleeve, which is called a stent, and a fabric lining, which is usually made of GORE-TEX®. The TIPS is designed to be permanent and will be monitored by periodic ultrasound examinations to make sure that it remains open and functions properly. The procedure ordinarily takes an hour or two to complete, depending on whether abdominal fluid needs to be drained beforehand and whether there are varices that continue to fill after the shunt has been placed, which sometimes must be blocked off in order to prevent re-bleeding.

How is the procedure performed?

You will be very heavily sedated or completely asleep during the procedure. After numbing the skin above the right collarbone, ultrasound is used to guide entry into the internal jugular vein and a small plastic tube called a catheter is guided with the fluoroscope into the liver and out into one of the hepatic veins. X-ray contrast material is injected and pictures of the veins are taken, as well as pressure measurements, for planning the TIPS shunt. A needle is then guided through the catheter to create the pathway for the shunt. The tract is dilated with a balloon and the conduit is placed.

What will I experience during the procedure?

An intravenous line (IV) will be inserted in your arm beforehand to deliver fluids and medication during your procedure. You will be connected to monitors that track your heart rate, blood pressure, and pulse during the procedure. If you receive general anesthesia , you will not be aware of anything from the time you go to sleep until you wake up afterward. If general anesthesia is not felt to be necessary, you will be very heavily sedated, but may periodically be aware that something is happening, just as you might during a dental procedure, although you will often drift off to sleep for most of the procedure. The steps where the needle is advanced through the liver and the tract is dilated can be uncomfortable, so extra intravenous medications will be given at those points to maximize your comfort. If you are feeling anything that hurts, please inform the radiologist. You will be monitored closely after the procedure. The head of your bed will be kept elevated for a few hours after you return to your room.

Who interprets the results and how do I get them?

Your procedure will be performed by an interventional radiologist. This is a radiologic subspecialist that has received specialized training to perform TIPS and other complex procedures. He or she will discuss the risks and benefits with you beforehand and will explain the procedure in detail. He or she will be responsible for following up with you after your procedure and will oversee your periodic ultrasound examinations to monitor TIPS function in the years to come. Occasionally your TIPS may need a “tune-up,” and again it will be the interventional radiologist who will do any future interventions on your TIPS.

What are the benefits vs. risks?

Benefits

A transjugular intrahepatic portosystemic shunt produces the same physiological results that a surgical shunt or bypass is designed to do, 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 than open surgical bypass on future liver transplantation surgery, because the abdomen has not been entered.
The TIPS conduit is contained entirely inside the diseased liver, and is removed with it during the transplant operation.
Studies have shown that this procedure is successful in reducing variceal bleeding in more than 90 percent of patients.

Risks

Fever,
Muscle stiffness in the neck,
Bruising on the neck at the point of catheter insertion, or
Delayed stenosis (narrowing of the shunt), which is less common with the current generation of GORE-TEX-lined shunts.

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

Occlusion, or complete blockage, of the TIPS and rapid recurrence of symptoms,
Infection of the TIPS 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 might require a transfusion or urgent intervention,
Heart arrhythmias or congestive heart failure, or
Death (extremely rare).

What are the limitations of TIPS?

Patients with more advanced liver disease are at greater risk for worsening liver failure after TIPS. They are also at risk for encephalopathy, which is an alteration of normal brain function that can lead to confusion. This is because toxic substances in the bloodstream are ordinarily filtered out by the liver. The TIPS may cause too much of these substances to bypass the liver, so a patient who already has encephalopathy because of their liver disease may not be a good candidate for the procedure. Encephalopathy can be treated with certain medications, a special diet or, by revising the shunt, but sometimes the shunt must be blocked off intentionally to solve the problem.