Transjugular intrahepatic portosystemic shunt

(Redirected from TIPS)

Background

  • Mnimally invasive procedure performed by IR
  • Creation of a stent connection between the right hepatic vein and portal vein
  • Shunts blood flow from the portal venous system to systemic circulation
  • Decreases portal venous pressure to <12 mmHg

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

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
    • ~4 weeks after TIPS
    • Doppler sonography or angiography shows thrombus and/or occlusion
    • Treatment: anticoagulation, thrombolysis, or thrombectomy
  • TIPS stenosis
    • May present with recurrent variceal bleeding or worsening portal hypertension
    • ~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
    • <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
    • ECG, 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).

Authors:

Ross Donaldson