Darcy

Evaluation and Management of TIPS

Vascular and Interventional Radiology

Review
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Evaluation and Management

FOCUS ON:

of Transjugular Intrahepatic
Portosystemic Shunts
Michael Darcy 1 OBJECTIVE. The purpose of this article is to describe the evaluation of transjugular in-
trahepatic portosystemic shunts (TIPS) and the management of dysfunctional shunts.
Darcy M CONCLUSION. TIPS can become dysfunctional if stenosis develops in the shunt or the
hepatic vein above the shunt. Screening allows detection of stenoses before portal hyperten-
sive–related complications recur. Revision of stenotic shunts can be easily accomplished in
most cases. Techniques for screening and revision will be discussed.

Keywords: portal hypertension, transjugular intrahepatic
portosystemic shunts (TIPS)
DOI:10.2214/AJR.12.9060
Received April 4, 2012; accepted without revision
April 20, 2012.
1
Mallinckrodt Institute of Radiology, Washington
University School of Medicine, 510 S Kingshighway Blvd,
St. Louis, MO 63110. Address correspondence to
M. Darcy (darcym@mir.wustl.edu).
AJR 2012; 199:730–736
0361–803X/12/1994–730
© American Roentgen Ray Society
A
lthough transjugular intrahepatic
portosystemic shunts (TIPS) have
become integral to the manage-
ment of portal hypertensive–relat-
ed complications, stenosis of the shunt has been
a major problem. Originally, when TIPS were all
created with bare metal stents, the loss of prima-
ry patency was around 50% at 1 year after shunt
creation. The introduction of polytetrafluoroeth-
ylene (PTFE)–covered stents has vastly im-
proved patency but stenosis still occurs in 8–20%
of patients at 1 year after TIPS creation [1–5].
The significance of TIPS stenoses is that
they can lead to recurrent portal hypertension
and put patients at risk for reaccumulation of
ascites or further variceal hemorrhage. It is
important for interventional radiologists to
actively follow their patients with TIPS to
assess how well the shunt is functioning. The
interventional radiologists understand the
shunt better and should be able to make bet-
ter assessments regarding the function of the
TIPS and the need for revision. Furthermore,
if you place the shunt and have others follow
the patient, then your role as physician is di-
minished to that of technician.
Evaluating TIPS Function
There is no universal agreement on pro-
tocol for when or how often to screen TIPS
function. One approach is to simply wait for
symptoms of portal hypertension to recur.
This approach can be used in patients whose
TIPS were placed to treat ascites. This ap-
proach is not advisable for patients with a
history of variceal bleeding because the first
symptom suggesting a problem with the TIPS
might be a fatal recurrent hemorrhage. Even
in patients with ascites, detecting shunt prob-
lems before the patient becomes especially
symptomatic is beneficial because TIPS ve-
nography is much easier when the patient does
not have a large volume of ascites. The patient
is more comfortable and able to breathe easi-
er in a supine position when there is not much
ascites. Furthermore, massive ascites forces
the liver more cephalad, and the extra density
caused by the ascites degrades the fluoroscop-
ic image; both of these effects make the pro-
cedure more difficult.
The timing of screening has also not been
standardized and varies greatly between in-
stitutions. Our protocol has been to perform
Doppler ultrasound at 1, 3, 6, and 12 months
after TIPS creation and every 6–12 months
thereafter, depending on the patient’s clinical
status. Evaluations at other time intervals may
be triggered by any recurrence of ascites or
bleeding. Although this schedule has not been
scientifically validated, it has served us well
in our relatively large TIPS experience (1223
patients since 1991) and is similar to protocols
used by others. Through use of this protocol,
many hemodynamically significant TIPS ste-
noses have been detected and fixed before
the patients experienced recurrent hemor-
rhage. In recent years, the improved patency
of TIPS made possible by the development
of a dedicated PTFE-covered device (Via-
torr, W. L. Gore) has allowed some loosen-
ing of this schedule and even caused some
authors [6] to speculate that routine screening
may not be necessary for TIPS created with
Viatorr stents. Again, the ideal timing of fol-

730 AJR:199, October 2012


low-up screening in this era of stent-grafts has
not been scientifically determined.
Ultrasound has been the primary tool used
to screen for TIPS stenoses because it is non-
invasive, readily available, and relatively low
cost compared with other imaging modali-
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ties. However, many different ultrasound pa-
rameters have been used to assess patency,
with variable results.
Flow velocities in the TIPS represent the
primary parameter. A single velocity mea-
surement in the mid shunt has been used by
some, although the sensitivity and specificity
with this methodology were only 86% and
54%, respectively, in one study [7]. How-
ever, with careful examination of velocities
along the length of the shunt, it is often pos-
sible to identify a specific stenosis with a ma-
jor change in velocities across the stenosis.
Whereas some authors [7–9] use a drop in
shunt velocities to below 40–60 cm/s as the
criterion for calling a stenosis, it is also pos-
sible to measure significantly elevated ve-
locities (over 200 cm/s) in a jet-effect zone
just beyond the stenosis (Fig. 1). However, if
the stenosis is very close to the inferior vena
cava (IVC) within the hepatic vein, the jet ef-
fect will not be seen and the velocities will
be uniformly low within the TIPS (Fig. 2).
Thus, velocities in the shunt should range be-
tween 90 and 190 cm/s in most patent TIPS,
and peak velocities below or above this range
may indicate a stenosis [10].
Main portal vein velocity is another useful
parameter. Our group previously showed that
before TIPS the main portal velocity is usual-
ly 20 cm/s but after TIPS it typically increases
to more than 30 cm/s [11]. When a shunt gets
stenotic, the flow in the portal vein leading up
to the TIPS is diminished and the main por-
tal velocity drops often down below 30 cm/s.
Others have used higher values, such as 40
cm/s [12], but they have also reported ultra-
sound to be an inaccurate screening tool. The
direction of flow in the portal vein branch-
es should also be evaluated. In most patients
who have pre-TIPS hepatopetal flow (toward
the liver), the flow direction reverses and be-
comes hepatofugal after creation of the TIPS.
When a stenosis develops, the flow in these
branches often reverts to hepatofugal [13].
We have routinely used ultrasound with
a high degree of confidence to screen TIPS
function. In a study that compared ultrasound
criteria to venographic proof of stenosis, it was
found that no individual parameter was more
than 84% specific in predicting TIPS dysfunc-
tion. However, when an overall assessment
AJR:199, October 2012
Evaluation and Management of TIPS
was made by considering all the parameters,
the sensitivity and specificity for detecting
TIPS stenoses were 92% and 72%, respec-
tively [10]. Also in that study, it was shown
that when both main portal velocity and dis-
tal shunt velocity are abnormal, ultrasound has
100% specificity for detection of TIPS mal-
function. Furthermore, it is important to fol-
low these numbers over time because initially
after TIPS, the velocities may all be normal,
but changes in velocities and flow directions
can indicate that a stenosis has developed.
In fact, Dodd et al. [14] considered temporal
changes in velocity more sensitive than static
low-velocity parameters. Other investigators
[13, 15–18] have supported that ultrasound is
very sensitive for detecting shunt malfunction.
Unfortunately, not all investigators have
found ultrasound to be especially useful.
One prospective double-blinded study re-
ported that ultrasound predicted shunt paten-
cy in 20 of 31 shunts that proved to be oc-
cluded or stenotic [9]. However, their main
criterion for calling a stenosis was a peak
shunt velocity of < 60 cm/s, which is some-
what simplistic. Using more extensive ve-
locity criteria, another study [12] still found
concordance between ultrasound and venog-
raphy in only 53% of cases, and in their ex-
perience ultrasound rarely predicted a steno-
sis that was not already suspected on clinical
grounds. Given the variability in the report-
ed sensitivity and specificity of ultrasound,
it is important to evaluate the results at your
own institution to see how your ultrasound
readings correlate with venography and pres-
sure measurements.
The use of echo enhancers has been pro-
posed as a way of improving the accuracy of
ultrasound. In a small study of 31 TIPS, the
use of echo enhancers was found to increase
the specificity of ultrasound from 89% to
100% [19]. However, this technique has not
become common practice.
In an attempt to improve diagnostic accu-
racy, some investigators have studied using
CT to assess TIPS function. Using helical
CT, Chopra et al. [20] detected hemodynam-
ically significant stenoses with 92% sensi-
tivity and 77% specificity. Another study
that compared CT and Doppler ultrasound
showed that CT had superior sensitivity and
specificity for detecting TIPS stenoses; how-
ever, the only ultrasound criterion used to
declare TIPS abnormal was a 50% increase
or decrease in blood flow, which again is a
relatively simplistic way to use ultrasound
[21]. It is possible that surveillance of shunt
function could ultimately go in an entirely
different direction and not rely on imaging
at all. Hirasaki et al. [22] showed that wire-
less microelectromechanical pressor sensors
placed adjacent to TIPS could measure por-
tal and systemic pressures to within 2 mm
Hg of actual pressure measurements.
Currently, venography and pressure mea-
surements are the reference standards for de-
termining whether the shunt is dysfunctional
but are used only as secondary tests in many
institutions because they are more invasive
than ultrasound. Ultrasound findings indicat-
ing a significant stenosis generally trigger the
performance of venography. However, because
some ultrasound examinations are falsely neg-
ative, venography is also warranted in patients
with a negative ultrasound who have symptoms
suggestive of portal hypertension.
Managing TIPS Dysfunction
Once a stenosis is suspected, the decision
regarding what to do about it requires con-
sideration of the overall clinical status of the
patient. Be wary of treating radiologic find-
ings without the clinical context. First, the
patient’s symptoms can help with interpret-
ing the screening tests. If the TIPS procedure
was done for intractable ascites, the presence
or absence of ascites can suggest whether the
stenosis identified by ultrasound is likely to be
causing significant portal hypertension. Nev-
ertheless, if variceal bleeding was the origi-
nal presentation, then it is best not to wait for
recurrent bleeding to confirm the significance
of the ultrasound findings. The patient’s clini-
cal condition can also affect the decision to
restore shunt patency. Severe encephalopathy
or hepatic dysfunction may militate against
restoring full shunt patency because shunt
revision may increase the fraction of portal
blood flow shunted away from the liver and
may exacerbate these problems. Whether the
patient is a transplantation candidate also can
alter the decision to revise the shunt. If the pa-
tient is already on the transplantation list and
is close to receiving a new liver, then revising
the shunt may not be necessary.
Venography and shunt revision can easily
be done on an outpatient basis with minimal
sedation. The patient should receive nothing
by mouth for 6 hours before revision so that
mild sedation can be used. Although this is a
clean procedure, prophylactic antibiotics are
often used because new stents or stent-grafts
may be deployed during the revision.
The approach is almost always from the
jugular vein. A catheter with a gentle angle,
731

such as a main pulmonary artery catheter,
is often the best choice for catheterizing the
shunt, but if there in an acute angle between
the IVC and the hepatic vein (or the top of
the shunt), then a catheter with greater curve,
such as a Cobra or a Lev, may be needed.
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If the TIPS has retracted and the top end is
pointed toward the cephalad wall of the he-
patic vein, catheterizing the shunt from a jug-
ular access may be difficult. In this case, use
of a recurved catheter, such as a Simmons, or
an approach from a femoral vein can allow
the guidewire to be deflected off the cepha-
lad wall of the hepatic vein and into the TIPS.
Rarely, a hepatic vein stenosis may be so
tight or the TIPS so severely angled against
the hepatic vein wall that catheterization of
the shunt is not possible. In such cases, it is
possible with fluoroscopic guidance to direct
a 22-gauge needle transhepatically into the
bottom end of the TIPS. A 0.018-inch guide-
wire can then be advanced through this nee-
dle up across the top end of the shunt and
out into the IVC where it can be snared from
the jugular access [23]. With this through-
and-through access, it is now possible to get
a catheter across the TIPS from above.
When feeding the guidewire through the
TIPS into the portal vein, the guidewire may
pass through the interstices of the stent, re-
gardless whether the TIPS was created with a
bare metal stent or a Viatorr because the bot-
tom 2 cm of the Viatorr is not covered with
PTFE. The interstices on a Viatorr are wide
enough that a 5-French angiographic cath-
eter can pass through them over the guide-
wire. However, deploying a stent through the
interstices creates major problems because
the new stent will not easily expand if it is
constrained by the original stent. If there is
difficulty avoiding passage through the in-
terstices, using a J-tipped or a buckled-over
Bentson guidewire will facilitate passage
through the central channel of the TIPS.
Venography is then performed to look for a
stenosis of the shunt. In addition, one should
also look for secondary signs of a shunt dys-
function. These include hepatopetal flow in
the branch portal veins and reversed flow into
intrinsic routes of portal decompression, such
as the inferior mesenteric vein, splenic vein,
and left gastric vein to varices. The position
of the catheter in the portal vein is important.
If the tip is pointing into the left gastric vein,
then a high-pressure contrast injection may
force contrast material into varices that would
not normally fill. Thus, the catheter should be
positioned in the splenic vein beyond the ori-
732
Darcy
gin of major collaterals, and contrast material
should be injected by hand or with low pres-
sure. High-pressure injections can also force
contrast material into varices that might not
otherwise be filling from the portal vein.
In addition to venography, pressure mea-
surements should be taken to look for an ab-
normally high portosystemic gradient (> 12
mm Hg). Because of cardiac and respiratory
motion, it can sometimes be difficult to iden-
tify stenoses with venography alone. Thus,
if a stenosis is not readily identified on the
venogram but the pressures are elevated, a
careful pullback pressure measurement can
help identify exactly where the pressures
change. This can be accomplished by plac-
ing an end-hole catheter, such as a multipur-
pose angiographic catheter with a 0.038-inch
internal diameter into the portal vein. Then,
a 0.018-inch guidewire is placed through the
catheter, and the hub-end is sealed with a
Toughy-Borst adapter. The catheter can then
be connected to a pressure transducer and
slowly pulled back across the shunt while
maintaining access into the portal vein with
the 0.018-inch guidewire.
If the venogram does reveal a stenosis, re-
vision of the TIPS can easily be done at that
same procedure. If the patient simply has a
stenosis, angioplasty can be performed, and
this has been recommended by some as the
best first approach [24, 25]. However, in our
experience, angioplasty rarely leads to long-
term patency (Fig. 3), and this is supported
by several studies. Saxon et al. [26] report-
ed that stenting to revise stenoses often led
to durable results but that all of the steno-
ses treated with angioplasty alone recurred.
Similarly, in a recent study, stenting for shunt
revision led to significantly better patency
than angioplasty alone [27].
One question still debated is which device
is best for revising stenoses, particularly he-
patic vein stenoses. Some prefer bare metal
stents because they are less expensive, are a
little easier to use, and should not obstruct he-
patic vein blood flow. However, stenoses can
develop even in stented segments (Fig. 3), and
for this reason stent-grafts are preferred by
some to improve patency. There are limited
data on this, but Jirkovsky et al. [27] showed
that revising TIPS stenoses with a stent-graft
specifically designed for TIPS led to better
patency than did either angioplasty alone or
stenting with a bare metal stent. A small study
that used Viatorr devices for TIPS revision
showed 1- and 2-year primary patency rates of
100% and 89%, respectively [28].
Use of a stent-graft is particularly impor-
tant if one happens to be revising TIPS cre-
ated with a bare metal stent with stenosis
in the segment of stent in the parenchymal
tract. It has long been known that some ste-
noses occurring in the parenchymal tract of
a bare-metal-stent TIPS relate to communica-
tion to bile ducts torn during the process of
creating the tract [26, 29]. The bile or mucus
from these biliary communications seems to
cause more rapid formation of pseudointimal
hyperplasia. Thus, stenoses within the paren-
chymal tract of bare-metal-stent TIPS are best
revised with a stent-graft to exclude those bil-
iary communications from the TIPS lumen.
When extending the TIPS to span a hepatic
vein stenosis above the TIPS, care must be tak-
en in placing the new device. Ideally, any new
device should extend just into the IVC (Fig. 2).
If it extends too far, the top end could end up
in the right atrium. This can lead to arrhyth-
mias or even perforation of the atrium. One
case report described development of a fistula
between the right atrium and the aorta caused
by perforation from a TIPS extending into the
atrium [30]. Extension of the device too far into
the IVC can also cause complications. Hox-
worth et al. [31] described a case of IVC throm-
bosis caused by a stent-graft extending too far
into the IVC and obstructing flow. With careful
attention to technique, however, TIPS revision
is a safe outpatient procedure.
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733
 Darcy
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A B C

D E F

Fig. 1—Examinations showing detection of stenosis

by elevated velocities on Doppler ultrasound and
management of stenosis caused by incomplete stent-
grafting of parenchymal tract.
A, Venogram during initial creation of transjugular
intrahepatic portosystemic shunt (TIPS) shows
hepatic vein end of parenchymal tract.
B, Venogram after deploying Viatorr device (W. L.
Gore) shows that it was placed too low, with top end
(arrow) still within parenchymal tract.
C, Bare metal stent was deployed at top end to extend
around curve into hepatic vein.
D, Ultrasound image obtained at 3-month follow-
up shows main portal velocity (MPV) of only 23.4
cm/s, which is lower than expected and decreased
compared with 35 cm/s at 1-month follow-up.
E, Midshunt velocity during this examination is 87.1 cm/s,
which is slightly low and decreased compared with
midshunt velocity of 105 cm/s at 1-month follow-up.
F, Examination of hepatic venous end of TIPS shows
aliasing and elevated velocity of 205.1 cm/s, which,
combined with other values, indicates stenosis.
G, Venogram confirms stenosis (arrow) in portion of
parenchymal tract that was covered with bare metal stent.
H, Venogram was repeated after relining this region
with stent-graft, which lowered portosystemic
gradient from 24 to 8 mm Hg.
G H

734 AJR:199, October 2012

 Evaluation and Management of TIPS
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A B C
Fig. 2—Examinations showing low Doppler ultrasound velocities as indicator of transjugular intrahepatic
portosystemic shunts (TIPS) dysfunction and management of stenosis of uncovered segment of hepatic vein.
A, Venogram at end of TIPS creation. Top end of Viatorr (W. L. Gore) is close to but not right at hepatic vein
caval junction.
B, Ultrasound image obtained 3 months after TIPS reveals maximal velocity in TIPS of 83.7 cm/s. Other
ultrasound parameters also suggested dysfunction of TIPS.
C, Venogram shows much more hepatopetal flow into portal branches and stenosis (arrow) of short segment of
uncovered hepatic vein. Portosystemic gradient was mildly elevated at 14 mm Hg.
D, Venogram after stenting across hepatic vein stenosis shows that branch hepatic vein flow is now hepatofugal,
indicating good decompression of portal vein, and portosystemic gradient was decreased to 7 mm Hg.

Fig. 3—Series of venograms illustrating limitations

of ballon angioplasty for managing transjugular
portosystemic shunt (TIPS) stenoses.
A, Venogram shows stenosis (arrow) in distal
shunt. Portosystemic gradient was elevated. Note
hepatopetal flow in portal branches.
B, Venogram after balloon angioplasty shows
resolution of stenosis.
(Fig. 3 continues on next page)
A B

AJR:199, October 2012 735

 Darcy

Fig. 3 (continued)—Series of venograms illustrating

limitations of ballon angioplasty for managing
transjugular portosystemic shunt (TIPS) stenoses.
C, Venogram 6 months after angioplasty shows rapid
recurrence of stenosis.
D, Venogram after revising shunt by deploying stent-
graft across area of stenosis shows excellent shunt
flow and decompression of portal system.
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C D

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736 AJR:199, October 2012