Transjugular intrahepatic portosystemic shunt

Background

• TIPS is a minimally invasive procedure that is performed by Interventional Radiology
• Involves the creation of a stent connection between the right hepatic vein and portal vein
• Results in shunting of blood flow from the portal venous system to systemic circulation
• Decreases portal venous pressure to < 12 mm Hg

Indications

• Portal venous hypertension
• Refractory variceal bleeding after endoscopic (sclerotherapy or band ligation) and pharmacologic (octreotide or vasopressin) therapy
• Recurrent cirrhotic ascites that is not responsive to medical treatment and requires frequent large volume paracentesis
• Controversial indications include Budd-Chiari Syndrome, hepatorenal syndrome, hepatic hydrothorax, hepatopulmonary syndrome and bridge therapy while awaiting liver transplantation

Contraindications

• Congestive heart failure
• Tricuspid valve regurgitation
• Pulmonary hypertension
• Sepsis
• Hepatic malignancy, large masses or cysts
• Severe coagulopathy
• Biliary obstruction

Complications

• Portosystemic encephalopathy
  • Most common complication
  • Presents as extreme sleep disturbance, altered mental status, and coma
  • Hyperammonemia
  • Can be precipitated by many factors including increased protein intake, infection, gastrointestinal bleed, poor medication compliance, and dehydration
  • Occurs approximately 6 weeks or more after TIPS
  • Treatment is medical management – lactulose, neomycin, rifaximin, protein restriction

• TIPS thrombosis
  • Occurs approximately 4 weeks after TIPS
  • Doppler sonography or angiography shows thrombus and/or occlusion
  • Treatment includes anticoagulation, thrombolysis, or thrombectomy

• TIPS stenosis
  • May present with recurrent variceal bleeding or worsening portal hypertension
  • Occurs approximately 3 months to 2 years after TIPS
  • Angiography is the gold standard for diagnosis
  • Treatment is dilation or placement of new or additional stents

• TIPS-associated hemolysis
  • Presentation includes anemia, increased bilirubin, and increased reticulocyte count
  • Occurs within 1-2 weeks after TIPS
  • Self-limiting and resolves within 8-12 weeks

• Infection
  • Fever and bacteremia
  • Occurs within weeks to months after TIPS
  • Doppler sonography shows vegetations or venous thrombus
  • Treatment is intravenous antibiotics

• Intraperitoneal hemorrhage
  • Seen primarily during the immediate post-procedure period
  • Occurs due to injury to nearby vasculature during TIPS
  • Rare occurrence

• Stent migration
  • Stent may travel into the Inferior Vena Cava
  • Most serious complication is migration into the heart
  • EKG, doppler sonography, and echocardiogram helpful for diagnosis
  • Treatment is surgery or Interventional Radiology for retrieval

Outcomes

• TIPS provides salvage therapy for variceal bleeding, refractory ascites, and portal hypertension when medical therapy fails
• Despite providing improvement in portal hypertension, the procedure does not decrease overall mortality in end stage liver disease

References

• Boyer TD, Haskal ZJ. American Association for the Study of Liver Diseases. The Role of Transjugular Intrahepatic Portosystemic Shunt (TIPS) in the Management of Portal Hypertension: update 2009. Hepatology. 2010;51(1):1-16.
• Subramanian R, McCashland T. Chapter 82. Gastrointestinal Hemorrhage. In: Hall JB, Schmidt GA, Wood LH. eds. Principles of Critical Care, 3e. New York, NY: McGraw-Hill; 2005.
• Wendler C, Shoenberger JM, Mailhot T. Transjugular Intrahepatic Portosystemic Shunt (TIPS) Migration to the Heart Diagnosed by Emergency Department Ultrasound. West J Emerg Med. 2012;13(6):525-6.