Interventional Radiology

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Identify this procedure. What are the indications for performing it?
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Transjugular Intrahepatic Portosystemic Shunt (TIPS)

  • Established Indications: Portal hypertension with variceal bleeding that has failed endoscopic treatment. Refractory ascites
  • Tips is intended to decrease portal vein pressures in patients with portal hypertension by creating a conduit for blood to bypass the hepatic parenchyma and enter the systemic circulation
  • General Principles: Confirm portal vein patency prior to procedure (US, CT, or angiography) preprocedure paracentesis may be helpful. Right internal jugular vein is the preferred access vessel
  • Goal of procedure: Portal-systemic gradient of 10 mm Hg (ideal is 10 mm, any less and shunt may not remain patent, any more and not adequately therapeutic), decompression of varices
  • Contraindications: Polycystic liver dz, hepatic failure, severe right-sided failure, severe hepatic encephalopathy, severe portal vein thrombosis, active infection, larger liver hypervascular tumor
  • Results: Patency is 50% at 1 year. Recurrent bleeding in 10%

Technique

  • Right IJV approach
  • Obtain wedged hepatic pressure and venogram
  • Create tract from right hepatic vein to the portal vein (16 gauge needle)
  • Advance catheter over wire into portal venous system
  • Obtain portal venogram
  • Measure portal pressures
  • Dilate tract with PTA balloon (8 mm)
  • Deploy metallic stent (Palmaz or Wallstent)
  • Dilate stent until gradient < 10 mm HG
  • Coil embolization of varices is optional

Complications:

  • Hepatic Encephalopathy
  • Bleeding
  • Shunt Thrombosis or Stenosis
  • Right Heart Failure
  • Renal Failure

Signs of Malfunction

  • No flow
  • Low velocity flow (<50-60 cm="" sec="" at="" portal="" venous="" end="" of="" shunt="" span="">
  • Reversal of flow in hepatic vein away from IVC
  • Hepatopedal flow in intrahepatic portal vein
  • Reaccumulation of ascites; recanalized umbilical veins
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