New Tools for TIPS

We begin by discussing Dr. Behrens portal hypertension practice. He sees patients in conjunction with hepatology and transplant surgery. The model of his clinic is the opposite of the standard practice. The specialists come to the community hospital, and their clinic gets referrals from tertiary hospitals in Chicago. This took years to build, and they received enormous pushback. This model encompasses patient-centered care because it removes many of the barriers that patients face to travel into Chicago for the workup and management plan of portal hypertension. In this clinic, they also evaluate the underlying cause of cirrhosis including more uncommon causes such as hemochromatosis, Wilson disease, and alpha 1 antitrypsin deficiency.

Next, Dr. Behrens details the typical procedure and provides tips for commonly encountered challenges during a TIPS (transjugular intrahepatic portosystemic shunt). He does all TIPS under general anesthesia. He drains ascites, then uses a multipurpose catheter to enter the hepatic vein, without a preference for which hepatic vein he is in. He uses a Launcher AL 11 1 ½ or 2 if he is having difficulty entering a hepatic vein. He then does a CO2 portogram. Next, he advances the cannula into the hepatic veins, unsheathes the cannula, then brings it back to about 2cm from the pedicle, close to the ostium of the hepatic vein. He discusses the differences in technique between the Rösch-Uchida and the Scorpion. He likes to place his stent with the proximal portion where the diaphragm crosses the right atrium and the distal part at the entry site of the portal vein. He uses a VIATORR stent, and always dilates to 8mmHg first, then re-measures pressures. His general rule for dilation is less than 12mmHg for bleeding and less than 8mmHg for ascites.

Dr. Behrens discusses follow-up for patients and post-procedure care. All patients are started on rifaximin 2 weeks prior to TIPS. If ascites drained was 4L or more, he gives 100g albumin and 20mg Lasix. He measures pressures via a right heart cath before and after the procedure. Depending on the MELD, he may send patients to the floor or home same day, while others go to the ICU. He starts all patients on lactulose and zinc 220mg BID the day of the procedure. He advises all patients against using PPIs due to the increased risk of encephalopathy. He maintains pre-procedure Lasix and spironolactone dosing for the first 3 months. At one month, patients get a TIPS US with velocities, CMP, CBC, and INR. At 3 months they get cross-sectional imaging and repeat labs. He starts managing diuretics at 3 months. After this, he sees patients every 6 months and screens for hepatocellular carcinoma.