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Transjugular Intrahepatic Portosystemic Shunt

Transjugular intrahepatic portosystemic shunt (TIPS) is a procedure in which an interventional radiologist creates a channel connecting the portal circulation with the hepatic venous circulation to treat moderate to severe portal hypertension. The newly created channel allows a portion of the portal blood flow to bypass the liver and flow directly from the portal circulation to the right heart via the hepatic veins. The TIPS procedure is a tool for treating both acute and chronic symptoms of portal hypertension such as variceal bleeding and refractory ascites. Performing the TIPS procedure can be a daunting procedure for many interventional radiologists. However, we are aiming to provide you with a solid understanding of the fundamentals, TIPS procedure steps, & techniques, to ensure the procedure is accomplished safely and efficiently.

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Ep 473 Portal Hypertension Treatment Strategies: IR & Hepatology Perspectives with Dr. Thomas Leventhal and Dr. Siobhan Flanagan

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TIPS Pre-Procedure Prep

Indications

• Prevention of variceal bleeding
• Refractory ascites
• Budd-Chiari syndrome
• Hepatic veno-occlusive disease
• Refractory hepatic hydrothorax
• Acutely bleeding gastric or esophageal varices
• Hepatorenal syndrome
• Hepatopulmonary syndrome

Contraindications

• Some physicians maintain there are no absolute contraindications to TIPS. Contraindications should be considered in the overall clinical picture
• Absolute: right-sided heart failure, encephalopathy, severe hepatic failure, uncontrolled sepsis
• Relative: biliary obstruction, malignancy, portal vein thrombosis, polycystic liver disease or liver masses.

Patient Evaluation

• Review prior imaging CT and/or US to confirm portal and hepatic vein patency
• MELD score
• Stress echo: ask Cardiologist to comment on signs of right heart failure and how patient may tolerate increased preload
• Coagulation and platelets. Give platelets if <50,000. Give FFP if INR >2.0
• Some operators do not give platelets and some reserve platelet transfusion for during the TIPS
• Important to have patient typed and cross for potential blood products
• Preprocedure antibiotics - 1 g Ancef
• Consider anesthesia support for the procedure

Transjugular Intrahepatic Portosystemic Shunt Podcasts

Listen to leading physicians discuss transjugular intrahepatic portosystemic shunt on the BackTable VI Podcast. Get tips, tricks, and expert guidance from your peers and level up your practice.

Episode #473

Portal Hypertension Treatment Strategies: IR & Hepatology Perspectives

The management of portal hypertension has drastically evolved over the years. What are the current best practices? And what’s coming next? Dr. Tom Leventhal and Dr. Siobahn Flanagan from University of Minnesota Medical School join us for an interdisciplinary discussion. Dr. Leventhal is an Associate Professor of Transplant Hepatology and Dr. Siobhan is an Associate Professor of Interventional Radiology.

Episode #455

Evolving TIPS Procedures Using New Tools & ICE

Dr. Dylan Suttle and Dr. Harris Chengazi delve into recent advancements in transjugular intrahepatic portosystemic shunt (TIPS) procedures, highlighting the significant reduction in procedural time and improvements in outcomes due to the introduction of Intracardiac Echo (ICE) and the Scorpion Portal Vein Access Series.

Episode #330

Early Days and Evolution of the TIPS Procedure

In this episode, guest host Dr. Isabel Newton interviews Dr. Richard Saxon about his innovative approach of using stent grafts for transjugular intrahepatic portosystemic shunting (TIPS), the creation of the Viatorr endoprosthesis, and medical ethics of experimental technology.

Episode #285

TIPS with ICE Guidance

In this episode, host Dr. Aparna Baheti interviews Dr. Merve Ozen, interventional radiologist, about how to integrate ICE for TIPS, including why she uses a vampire stick, her needle preference, and tips for single operators.

Episode #223

Portal Vein Recan #Recandoit

In this episode, our host Dr. Chris Beck interviews interventional radiologist Dr. Riad Salem about indications, technique, and cross-specialty collaboration in portal vein recanalization in the cirrhotic patient population.

Episode #222

New Tools for TIPS

In this episode, host Dr. Chris Beck interviews interventional radiologist Dr. George Behrens about how he built a robust multidisciplinary portal hypertension clinic in a community hospital, tips for common challenges during a TIPS, and post-TIPS management.

Episode #179

Happiness is a Warm Coil: Treating GI Bleeds

Interventional Radiologist Donald Garbett and our host Sabeen Dhand discuss their standard workups and procedural decision making for GI bleeds, including radial vs. femoral approach and preferred embolics.

Episode #160

BRTO: Beyond the Basics

Dr. Aparna Baheti talks with Dr. Saher Sabri from MedStar Georgetown University Hospital about his approach to Balloon-occluded retrograde transvenous obliteration (BRTO) for portal hypertension, including advanced tips and tricks.

Episode #127

Portal Hypertension and Ascites Management

Interventional Radiologist Christopher Beck talks with Hepatologist Parvez Mantry about the management of Portal Hypertension and Ascites, and the importance of multi-disciplinary collaborative care for these patients.

Episode #126

TIPS University Senior Year: Gunsight Technique & Splenic Closure

It's Senior Year at TIPS University with Dr. Emmett Lynskey talking us through his Gunsight technique for TIPS placement, as well as how to perform a safe closure of splenic access. Don't miss the first three parts of the series as well!

Episode #125

TIPS University Junior Year: Advanced Techniques, ICE, and Splenic Access

It's Junior Year at TIPS University with Dr. Emmett Lynskey walking through advanced techniques for TIPS, including using Intracardiac Echocardiography (ICE) for placement, as well as transsplenic access for portal reconstruction.

Episode #124

TIPS University Sophomore Year: Basic Procedure Technique

It's Sophomore Year at TIPS University with Dr. Emmett Lynskey and Dr. Christopher Beck discussing basic procedure technique for Transjugular Intrahepatic Portosystemic Shunts (TIPS).

Episode #123

TIPS University Freshman Year: Referrals and Pre-op Workup

We start our TIPS University series with Interventional Radiologist Dr. Emmett Lynskey discussing referral sources and pre-operative workup, including the importance of patient selection and MELD score.

Episode #122

History of the TIPS Procedure: An Interview with Barry Uchida

Interventional Radiologist Peder Horner talks with Barry Uchida about the early days at The Dotter Institute, with stories about working alongside Josef Rösch on developing the first TIPS sets, as well as working with other legends in the field including Charles Dotter, Fred Keller, and Julio Palmaz.

Episode #87

Deep Dive Into Ascites

Interventional Radiologist Rajeev Suri from UT Health San Antonio tells us about his clinical approach to the high-volume ascites patient, including paracentesis technique and tips, albumin regimen, and discussing the need for TIPS in some patients.

TIPS Procedure Steps

Antibiotic

• 1 g ceftriaxone (Rocephin) IV
• Vancomycin or Clindamycin for PCN allergy

Ascites

• Paracentesis prior to procedure has advantages
• Creates more favorable angle to catheterize the hepatic vein
• Liver may be less mobile for portal puncture

Different TIPS Sets

• Haskal Transjugular Liver Access Set (Cook)
• Rösch-Uchida Transjugular Liver Access Set (Cook)
• Ring Transjugular Intrahepatic Access Set (Cook)

Access

• Access right internal jugular and place sheath in right atrium
• Obtain right atrial pressure

Select Right Hepatic Vein

• MPA commonly used
• Venogram to confirm position
• If unsure if right vs middle hepatic vein position, try lateral view or US
• Arrow on the metal cannula should point posterolateral

CO2 Portogram

• Not necessary but may help to identify portal vein and bifurcation
• Can obtain with endhole catheter wedged in hepatic vein or balloon occlusion catheter
• Can also stick liver parenchyma with TIPS needle and injection into parenchyma

Portal Venous Puncture

• Advance sheath into hepatic vein over stiff wire such as an Amplatz (Boston Scientific) for more stable access
• Make pass 2-3 cm from origin of hepatic vein, can make adjustments depending on anatomy and success at this location
• Target is right portal vein 1-2 cm distal to bifurcation
• If access is too central, bifurcation may be extrahepatic which can lead to life-threatening hemorrhage
• If access too peripheral, acute angulation between hepatic and portal vein can make stent placement difficult
• Once pass is made, attach slip tip syringe half filled with dilute contrast and aspirate (without fluoroscopy) until blood return
• After blood return, fluoro and puff contrast to visualize needle tip location: portal vs hepatic vein

Catheterize Portal Vein

• Glidewire Advantage (Terumo) useful with floppy tip and stiff body
• If wire continues to advance peripherally, consider Bentson wire (Boston Scientific) which may initially advance laterally but stiff body should buckle centrally toward portal vein
• May also need angled catheter through TIPS needle if wires cannot be directed centrally
• Position wire into SMV for stable access

Portogram and Pressure Measurements

• Place marking pigtail catheter into portal vein for pressure measurements
• Obtain hepatic venous pressure measurements
• Perform portogram; can simultaneously inject sheath positioned in hepatic vein
• Evaluate: hepatic vein/IVC confluence, estimated length of stent (add 2 cm to measurement to account for projection overlap)

Place Stent

• Viatorr TIPS Endoprosthesis (Gore): polytetrafluoroethylene (PTFE) graft with distal 2 cm uncovered portion
• 2 cm uncovered portion will be in portal system, covered proximal segment will extend from parenchymal tract into hepatic vein
• Proximal landing zone: from junction of the hepatocaval confluence to 1 cm within hepatic vein
Advance sheath into portal vein
• After portal vein puncture, TIPS set can be advanced over a stiff wire into portal system, which simultaneously dilates parenchymal tract
• Alternatively, may need to predilate tract with 8 cm balloon. Waists of balloon will demarcate portal vein and hepatic vein parenchymal entry/exit points
• As balloon is deflated, can advance sheath over angioplasty balloon into portal vein
With sheath in portal vein, advance selected Viatorr stent into right portal vein
• Position sheath/stent slightly more central than the optimal landing zone
• Unsheath the uncovered, distal 2 cm of stent
• Withdraw sheath and partially uncovered stent until resistance is met - this is when uncovered stent abuts the parenchymal tract
• Unsheath remainder of stent and deploy
Dilate stent
• Carefully advance 7-12 mm balloon for angioplasty
• Start with 7 mm balloon and check pressures
• Post dilate to achieve desired pressure gradient

Portosystemic gradient
• Variceal hemorrhage: < 12 mmHg or 50% reduction from baseline
• Refractory ascites: < 8 mmHg

Final portogram
• Confirm patency of TIPS and evaluate flow to remainder of liver
• Evaluate for persistent varices for potential embolization

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TIPS Post-Procedure

Post-Procedural Care

• Close monitoring and depending on indication, may need ICU management
• If right atrial pressure is >10 mmHg following TIPS placement consider diuresis with 10-20 mg Lasix
• Monitor for encephalopathy
• Lactulose: titrate to 3 loose bowel movements/day.
• Better to give multiple dose of lactulose throughout the day (TID) rather than single dose
• Rifaximin 550 mg BID (if insurance will cover)

Complications

Minor:
• Encephalopathy (10-25%)
• Contrast induced nephropathy
• Fever
• Pulmonary edema
Major:
• Hemobilia
• Hepatic artery injury
• Stent malposition/migration
• Hemoperitoneum
• Renal failure

References

[1] Richard J, Thornburg B. New Techniques and Devices in Transjugular Intrahepatic Portosystemic Shunt Placement. Semin Intervent Radiol. 2018;35(3):206‐214. doi:10.1055/s-0038-1660800
[2] Chehab MA, Thakor AS, Tulin-Silver S, et al. Adult and Pediatric Antibiotic Prophylaxis during Vascular and IR Procedures: A Society of Interventional Radiology Practice Parameter Update Endorsed by the Cardiovascular and Interventional Radiological Society of Europe and the Canadian Association for Interventional Radiology. J Vasc Interv Radiol. 2018;29(11):1483-1501.e2. doi:10.1016/j.jvir.2018.06.007
[3] Keller FS, Farsad K, Rösch J. The Transjugular Intrahepatic Portosystemic Shunt: Technique and Instruments. Tech Vasc Interv Radiol. 2016;19(1):2‐9. doi:10.1053/j.tvir.2016.01.001
[4] Bercu ZL, Fischman AM, Kim E, et al. TIPS for refractory ascites: a 6-year single-center experience with expanded polytetrafluoroethylene-covered stent-grafts. AJR Am J Roentgenol. 2015;204(3):654‐661. doi:10.2214/AJR.14.12885[
[5] Gaba RC, Khiatani VL, Knuttinen MG, et al. Comprehensive review of TIPS technical complications and how to avoid them. AJR Am J Roentgenol. 2011;196(3):675‐685. doi:10.2214/AJR.10.4819
[6] García-Pagán JC, Caca K, Bureau C, et al. Early use of TIPS in patients with cirrhosis and variceal bleeding. N Engl J Med. 2010;362(25):2370‐2379. doi:10.1056/NEJMoa0910102
[7] Ferral H, Bilbao JI. The difficult transjugular intrahepatic portosystemic shunt: alternative techniques and "tips" to successful shunt creation. Semin Intervent Radiol. 2005;22(4):300‐308. doi:10.1055/s-2005-925556

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