Transjugular intrahepatic porto systemic shuntPresentation Transcript
A transjugular intrahepatic portosystemic shunt
(TIPS) is a percutaneously created connection
within the liver between the portal and systemic
A TIPS is placed to reduce portal pressure in
patients with complications related to portal
This procedure has emerged as a less invasive
alternative to surgery in patients with end-stage
The goal of TIPS placement is to divert portal
blood flow into the hepatic vein, so as to reduce
the pressure gradient between portal and
Shunt patency is maintained by placing an
expandable metal stent across the intrahepatic
Acute variceal bleeding that cannot be
successfully controlled with medical treatment,
Recurrent and refractory variceal bleeding
Therapy for refractory ascites.
Portal decompression in patients with hepatic
venous outflow obstruction (Budd-Chiari
syndrome) or hepatorenal syndrome.
Initial therapy of acute variceal hemorrhage
Initial therapy to prevent initial or recurrent
Reduction of intraoperative morbidity during liver
Right-sided heart failure with increased central
Polycystic liver disease
Severe hepatic failure
Active intrahepatic or systemic infection (bacteria
can colonize the stent, causing persistent
Severe hepatic encephalopathy poorly controlled
with medical therapy
Hypervascular hepatic tumors
PV thrombosis (Although PV thrombus may make
the procedure more technically demanding, it is
not an absolute contraindication to TIPS
prophylactic broad-spectrum antibiotics.
Appropriate resuscitation with fluid and blood
Portal vein (PV) patency should be confirmed prior
to attempts at TIPS placement by Doppler
sonography, arterial portography and MRI.
In Patients with cirrhosis severe coagulopathy
should be addressed prior to procedure.
This technique is preferably done under general
After puncture of the jugular vein (most often the
right jugular vein) under sonographic guidance, a
catheter is introduced into one hepatic vein and
wedged in the liver parenchyma.
Gentle injection of dye allows the retrograde
visualization of intrahepatic portal vein branches.
CO2 can be used in patients with renal function
impairment to avoid dye nephrotoxicity.
The intrahepatic portal vein then is entered with a
modified Ross needle.
A guide wire is advanced into the main portal vein.
The tract between the hepatic and the portal vein
is dilated with an angioplasty balloon catheter (8–
10 mm) followed by stent placement to maintain
the communication between both vessels patent
Basic transjugular intrahepatic portosystemic shunt (TIPS) procedure. A
curved catheter is placed into the right hepatic vein.
A wedged hepatic venogram obtained by using the digital subtraction technique
obtained with CO2 gas demonstrates the location of the portal vein. The catheter is
wedged in a branch of the right hepatic vein.
Image demonstrates advancement of a Colapinto needle into the
right portal vein.
A TIPS (10 X 68 mm Wallstent dilated with 10 mm X 4 cm balloon) has been
placed. Note flow through the Wallstent and filling of the splenorenal shunt
Shunt surveillance:at regular 3 to 6month intervals
for Assessment of:
Size of spleen
Diameter of stent (usually 8 to 10 mm)
Configuration of stent: areas of narrowing
Extension of stent into portal + hepatic veins
Direction of flow in: extrahepatic portal vein, R + L portal
vein, SMV, splenic vein, all 3 hepatic veins, intrahepatic
IVC, paraumbilical vein, coronary vein
Peak blood flow velocity within main portal vein
Peak blood flow velocity within proximal + mid + distal
aspects of stent
1.Shunt velocity of <50 cm/sec
2.Increase or decrease in shunt
velocity of >50cm/sec compared
with initial post-procedure value
3.Hepatofugal flow in main portal
Hepatic artery pseudoaneurysm
Hemoperitoneum (due to penetration of liver
Transient bile duct dilatation (due to
(C) Stent dislodgment with embolization to right
atrium, pulmonary artery, internal jugular vein .
Follow up with duplex sonography and shunt
Early shunt occlusion <30 days: thrombosis (local
thrombolytic treatment, redilation, restenting)
Late: intimal thickening within the stent or hepatic
vein ( dilation or another stent)