Transjugular intrahepatic portosystemic shunt (TIPS) is a procedure that creates a connection between the hepatic vein and a branch of the portal vein to allow portal blood flow to bypass the liver and lower portal hypertension. TIPS is indicated for acute variceal bleeding unresponsive to other treatments, recurrent variceal bleeding, refractory ascites, and other complications of portal hypertension. The procedure involves accessing the hepatic vein via the jugular vein, puncturing the liver to access a portal vein branch, dilating the tract, and placing a stent to form the shunt. The goal is to reduce the portosystemic gradient to less than 12 mmHg to relieve portal hypertension.

1. TRANSJUGULAR
INTRAHEPATIC
PORTOSYSTEMIC
SHUNT (TIPS)
INTERVENTIONAL
RADIOLOGY
Endovascular Expert , Jaipur
Dr Nikhil Bansal
MBBS,MD,PGDHHM,FIPM
,FVIR

3.  Transjugular intrahepatic portosystemic
shunt (TIPS) is a treatment for portal
hypertension in which direct communication is
formed between a hepatic vein and a branch
of the portal vein, thus allowing some
proportion of portal flow to bypass the liver.
The target portosystemic gradient after TIPS
formation is <12 mmHg.

4.  Indications
 acute variceal bleeding when pharmacologic therapy and endoscopic
sclerotherapy have failed 12
 recurrent variceal bleeding (as a preventative procedure)
 ascites refractory to medical management in patients that require frequent
drainage or do not tolerate repeated drainage 12
 hepatic hydrothorax that cannot be adequately managed with salt
restriction and diuresis 12
 portal hypertensive gastropathy
 hepatorenal syndrome
 lower gastrointestinal and stomal varices
 malignant compression of hepatic or portal veins
 Budd-Chiari syndrome of moderate level disease not responsive to
anticoagulation

5. Contraindications
 Absolute contraindications
 It is arguable that there are no absolute contraindications 10. However, practices
among interventional radiologists vary. Some generally accepted absolute
contraindications are 11:
 severe chronic liver disease or rapidly progressive acute liver failure, as the diseased
or injured liver may not tolerate the diversion of nutrient portal blood flow
 severe encephalopathy resistant to medical management, as diversion of unfiltered
blood will worsen it
 severe right heart failure as the flow diversion from TIPS will increase pre-load
 uncontrolled sepsis as there is a substantially increased risk of stent infection
 Relative contraindications
 right heart failure
 cavernous transformation of the portal vein
 cystic hepatic disease
 occlusive main portal vein thrombus
 polycystic kidney disease
 hepatic malignancy or hemangioma

6. Procedure details
 ultrasound-guided vascular access gained typically via the right internal jugular vein (other approaches are
possible if this is contraindicated) with a vascular sheath inserted into the right atrium for initial pressure
measurement
 an angiographic catheter is advanced into a chosen hepatic vein (typically the right hepatic vein), and hepatic
venography is performed
 curved TIPS puncture needle is advanced into the hepatic vein with its surrounding sheath
 for the typical case of right-hepatic-vein to right-portal-vein branch stent, the TIPS puncture needle is rotated
anteriorly and advanced inferiorly through the liver parenchyma to the anticipated location of the portal vein
branch
 portal venogram is performed with contrast injected through the TIPS puncture needle to confirm portal vein
cannulation
 guidewire is advanced through the needle and manipulated into the splenic or mesenteric vein to ensure portal
vein access is not lost as the liver will be moving craniocaudally with respiration
 angiographic catheter is advanced into the portal vein for portal pressure measurement, and venography can be
repeated to visualize varices
 the tract created through the liver parenchyma is dilated using a balloon catheter
 vascular sheath is advanced through the tract and 2 cm into the portal vein branch
 stent is deployed over the sheath.
 portal pressures are measured to assess if the desired reduction in portosystemic gradient is achieved (stent
dilation is possible immediately and in the future to increase flow diversion)
 venography can be repeated to confirm variceal bleeding has ceased with portal pressure reduction