Fidelman Et Al 2012 The Transjugular Intrahepatic Portosystemic Shunt An Update

Va s c u l a r a n d I n t e r ve n t i o n a l R a d i o l o g y • R ev i ew
Fidelman et al.
Update on Transjugular Intrahepatic Portosystemic Shunt
Vascular and Interventional Radiology

Review
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FOCUS ON:
The Transjugular Intrahepatic

Portosystemic Shunt: An Update
Nicholas Fidelman1 OBJECTIVE. The purpose of this article is to review the indications, outcomes, compli-
Sharon W. Kwan2 cations, patient selection, and technical aspects of creating a transjugular intrahepatic porto-
Jeanne M. LaBerge1 systemic shunt (TIPS).
Roy L. Gordon1 CONCLUSION. The best available evidence supports the use of TIPS in secondary pre-
Ernest J. Ring1 vention of variceal bleeding and in refractory ascites, although TIPS is also commonly used
for other indications such as Budd-Chiari syndrome, hepatic hydrothorax, and acute variceal
Robert K. Kerlan, Jr.1
hemorrhage. The TIPS procedure was revolutionized by the introduction of covered stents,
Fidelman N, Kwan SW, LaBerge JM, Gordon RL, which dramatically improved long-term shunt patency.
Ring EJ, Kerlan RK Jr
T
he transjugular intrahepatic porto- function caused by diversion of portal venous
systemic shunt (TIPS) is an estab- blood flow and shunt dysfunction, requiring
lished procedure that has proven routine imaging surveillance and shunt main-
benefit in the treatment of pa- tenance procedures. The current clinical use
tients who have complications of portal hyper- of TIPS has been influenced by a number of
tension, such as variceal bleeding and ascites. clinical trials attesting to the safety and effi-
As originally described by Rösch et al. [1] in cacy of the procedure, as well as by the intro-
1969, TIPS is a percutaneous imaging-guided duction of the model of end-stage liver disease
procedure in which a channel is constructed (MELD) scoring system for risk assessment
within the liver with the intent of reducing por- of short-term mortality in patients undergoing
tal pressure by diverting blood from the portal TIPS. Polytetrafluoroethylene (PTFE)–covered
to the systemic circulation. Gordon et al. [2] stents have been adopted during the last de-
were the first to describe the procedure in hu- cade, resulting in marked improvement of
mans. Unfortunately, durable patency could long-term shunt patency [5].
not be achieved through the tract created be- In this article, we review the common in-
tween the hepatic vein and the portal vein. dications, recommended patient selection
Keywords: complications, indications, outcomes, portal However, the deployment of a metallic stent guidelines, clinical outcomes, and expect-
hypertension, technique, transjugular intrahepatic
portosystemic shunt
bridging the hepatic parenchyma between ed complications related to the TIPS proce-
these two venous structures allowed more du- dure. Techniques for stepwise placement of
DOI:10.2214/AJR.12.9101 rable patency and marked the birth of the mod- a TIPS, as well as alternative approaches to
ern TIPS procedure [3]. The initial promise was establishing a percutaneous portosystemic
Received April 19, 2012; accepted without revision
that TIPS could provide a more effective means shunt, are described.
April 23, 2012.
of treating variceal bleeding compared with en-
1
Department of Radiology, University of California San doscopic sclerotherapy or banding, without the Indications and Outcomes
Francisco, 505 Parnassus Ave, Rm M-361, San Francisco, drawbacks of open surgery. After 20 years of Creation of a TIPS successfully reduces
CA 94143. Address correspondence to N. Fidelman clinical research, it is now known that TIPS is a the portosystemic pressure gradient in over
(Nicholas.Fidelman@ucsf.edu).
therapeutic option that can be used to treat pa- 90% of cases [6–8]. Typical indications for
2
Department of Radiology, University of Washington, tients who have complications of portal hyper- TIPS are summarized in Table 1. The stron-
Seattle, WA. tension. However, TIPS is not a replacement gest evidence of TIPS efficacy was estab-
for endoscopic therapy or surgery [4]. lished for secondary prevention of variceal
AJR 2012; 199:746–755
TIPS reduces the portosystemic pressure bleeding and treatment of refractory ascites,
0361–803X/12/1994–746 gradient by functioning as a side-to-side por- as evidenced by multiple randomized con-
tacaval shunt. The major disadvantages of the trolled trials (RCTs) and meta-analyses of
© American Roentgen Ray Society TIPS procedure are deterioration of hepatic RCTs on this topic.
746 AJR:199, October 2012

TABLE 1: Typical Indications for Transjugular Intrahepatic Portosystemic Shunt which included 390 patients, 192 of whom
Indication Best Available Level of Evidence References underwent a TIPS procedure. Findings of
the five earlier trials were summarized in a
Secondary prevention of variceal bleeding 1A 18, 19
meta-analysis by D’Amico et al. [21], which
Refractory ascites 1A 20 showed a 7.1-fold reduction in the risk of re-
Budd-Chiari syndrome 4 28, 29 currence of tense ascites after a TIPS proce-
dure (Table 3). Rates of improvement of as-
Hepatic hydrothorax 4 31–34

cites ranged from 38% to 84% after TIPS,
Hepatic venoocclusive disease 4 30
compared with 0–43% after large-volume
Hepatorenal syndromes (types 1 and 2) 2B 35 paracentesis. No significant differences in
Hepatopulmonary syndrome 4 37 survival were found by four of the RCTs [22–
Portal hypertensive gastropathy 2B 39 25]. However, two of the more recent trials
[26, 27] were able to show improved survival
Refractory acute variceal bleeding 1B 27
in the group of patients who received a TIPS.
Note—For levels of evidence, 1A = systematic review of randomized controlled trials, 1B = individual The rates of hepatic encephalopathy were
randomized control trial, 2B = individual cohort study, and 4 = case series.
2.2-fold higher in the TIPS group than in the
large-volume paracentesis group [22–27].
TABLE 2: Transjugular Intrahepatic Portosystemic Shunt (TIPS) Versus
Endoscopic Therapy in the Prevention of Rebleeding: Results From Other Indications for TIPS
Recent Meta-Analyses
Despite limited evidence, TIPS has found
Reference, Value a wider clinical use than just secondary pre-
Study Finding Burroughs and Vangeli, 2002 [19] Zheng et al., 2008 [20] vention of variceal bleeding and treatment of
No. of patients 948 883 refractory ascites. These clinical indications
include refractory acute variceal bleeding
No. of TIPS 472 440
[28], Budd-Chiari syndrome [29, 30], hepat-
No. of endoscopic therapies 476 443 ic venoocclusive disease [31], hepatic hydro-
No. of randomized controlled trials 13 12 thorax [32–35], hepatorenal syndrome [36,
Recurrent bleeding
37], and hepatopulmonary syndrome [38].
Furthermore, according to two small series,
TIPS, no. (%) 88 (18.6) 86 (19.0)
signs of portal hypertensive gastropathy have
Endoscopic therapy, no. (%) 210 (44.1) 194 (43.8) improved following a TIPS performed for
OR (95% CI) for TIPS 0.30 (0.21–0.44) 0.32 (0.24–0.43) reasons of variceal bleeding or refractory as-
Posttreatment encephalopathy
cites [39, 40].
Acute variceal bleeding—García-Pagán
TIPS, no. (%) 134 (28.4) 148 (33.6) et al. [28] randomly assigned 63 patients
Endoscopic therapy, no. (%) 83 (17.4) 86 (19.4) with cirrhosis and acute variceal bleeding
OR (95% CI) for TIPS 2.08 (1.49–2.94) 2.21 (1.61–3.03) within 24 hours after admission to receive
All-cause mortality
a TIPS (32 patients) or to receive continued
therapy using propranolol or nadolol plus en-
TIPS, no. (%) 130 (27.5) 111 (25.2) doscopic band ligation (31 patients). During
Endoscopic therapy, no. (%) 118 (24.8) 98 (22.1) a median follow-up of 16 months, rebleeding
OR (95% CI) for TIPS 1.14 (0.85–1.54) 1.17 (0.85–1.61) or failure to control bleeding occurred in 14
Note—OR = odds ratio.
patients (45%) in the pharmacotherapy plus
endoscopic therapy group, compared with
one patient (3%) in the early-TIPS group.
TIPS for Secondary Prevention of bleeding after insertion of TIPS ranged from Furthermore, actuarial survival at 1 year was
Variceal Bleeding 9% to 40.6%. Conversely, continued endo- significantly better in the TIPS group (87.5%
The strongest evidence in favor of per- scopic therapy resulted in a 20.5–60.6% rate vs 61.3%). The authors concluded that ear-
forming a TIPS procedure exists for the sec- of rebleeding. All-cause mortality rates were ly use of TIPS in patients hospitalized with
ondary prevention of variceal bleeding. A to- found to be similar between the TIPS and en- acute variceal bleeding was associated with
tal of 13 RCTs have been published on this doscopic therapy groups. However, there was significant reductions in treatment failure
topic, describing results for 948 patients, 472 a more than twofold increase in the rate of and in mortality.
of whom received a TIPS [6–18]. Recent me- development of hepatic encephalopathy after Budd-Chiari syndrome—The Budd-Chiari
ta-analyses published in 2002 [19] and 2008 a TIPS procedure [6–18]. syndrome is a rare indication for the TIPS pro-
[20] found a more than threefold decrease in cedure [29, 30]. In Budd-Chiari syndrome,
the risk of recurrent bleeding after insertion TIPS for Refractory Ascites TIPS provides better relief than surgical porta-
of a TIPS compared with various forms of A total of six RCTs have examined the role caval or mesocaval shunts by diverting blood
endoscopic therapy (Table 2). Rates of re- of TIPS in the treatment of refractory ascites, directly to the suprahepatic cava and the right
AJR:199, October 2012 747

Fidelman et al.
atrium. Because of significant inferior vena function in approximately 10% of patients with a bare-metal stent, patients with a PTFE-
cava obstruction by the enlarged caudate lobe, [20], and occasionally hepatorenal syndrome covered stent had a significantly lower rate of
surgical shunts tend to be less effective. Tech- [21], may also be observed. TIPS dysfunction (15% vs 44%), a higher rate
nically, the procedure can be quite challenging TIPS stenosis and occlusion used to be of primary patency (76% vs 36%), a lower rate
because of the absence of normal hepatic ve- quite common before wide acceptance of of clinical relapse (10% vs 29%), and were
nous structures, which necessitates entry into PTFE-covered stents (Viatorr, W. L. Gore). less likely to develop encephalopathy (33% vs
the hepatic parenchyma directly from the infe- The most common site of shunt stenosis is at 49%). On the basis of these data, a PTFE-cov-
rior vena cava. The best evidence for the use the hepatic venous end. The culprit of mid- ered stent became the standard of care device
of TIPS in the setting of Budd-Chiari syn- stent stenosis is thought to be intimal hyper- for de novo TIPS. Patients who have a bare-
drome comes from a large series from six Eu- plasia within the bare-metal stent due to con- metal stent TIPS should undergo shunt revi-
ropean centers [29], which described 124 pa- tact between traversed biliary radicles and sion with a PTFE-covered stent in the event of
tients with a median MELD score of 17. The stent lumen [42]. The incidence of stenosis shunt dysfunction [41].
main indications for TIPS were refractory as- due to hyperplasia within the stent ranged
cites (59%), liver failure (22%), and upper from 18% to 78% [41] for bare-metal stents, Patient Selection
gastrointestinal bleeding (9.5%). Despite the which led to recurrence of portal hyperten- Patients being considered for a TIPS pro-
severity of liver disease at baseline, 1- and sion complications and required frequent in- cedure should be under the care of a gastroen-
5-year liver transplant–free survival was 88% vasive procedures for reconstitution of flow. terologist or hepatologist, who, in consultation
and 78%, respectively. The authors concluded The introduction of PTFE-covered stent- with an interventional radiologist, decides
that TIPS likely leads to survival prolongation grafts led to dramatic improvement in long- that TIPS is the appropriate form of treat-
in patients with Budd-Chiari syndrome. term TIPS patency. An RCT published in ment of a patient with complications of por-
Hepatic hydrothorax—Hepatic hydrotho- 2007 [43] established a PTFE-covered stent as tal hypertension. Absolute and relative con-
rax is defined as a significant pleural effu- the preferred device for TIPS. In that study, traindications to TIPS creation are listed in
sion, usually larger than 500 mL, in a patient 80 patients were randomized to receive either Table 4. Absolute contraindications include
with cirrhosis but no primary cardiac or pul- a covered (n = 39) or a bare (n = 41) metal congestive heart failure, severe tricuspid re-
monary disease. It may affect approximately stent and were followed for 2 years after TIPS gurgitation, and severe pulmonary hyper-
5% of patients with cirrhosis [35]. The use placement. Compared with patients treated tension (mean pulmonary pressure > 45 mm
of TIPS in the setting of hepatic hydrothorax
is supported by several retrospective case se-
TABLE 3: Transjugular Intrahepatic Portosystemic Shunt (TIPS) Versus
ries describing outcomes of more than 150
High-Volume Paracentesis for Treatment of Refractory Ascites:
patients [32–35]. At least partial improve- Results From Recent Meta-Analysis (D’Amico et al., 2005 [21])
ment in clinical symptoms (dyspnea and de-
crease in frequency of thoracenteses) has Study Finding Value
been reported in 68–82% of patients, where- No. of patients 330
as complete resolution of the hydrothorax No. of TIPS 162
was observed in 57–71% of patients [32–35].
No. of high-volume paracentesis 168
Complications No. of randomized controlled trials 5

The TIPS procedure may lead to a num- Recurrent tense ascites
ber of potentially significant adverse events. TIPS, no. (%) 76 (46.9)
Technical complications sustained at the time
High-volume paracentesis, no. (%) 146 (86.9)
of TIPS placement can include transcapsular
puncture, which may occur in as many as 33% OR (95% CI) for TIPS 0.14 (0.08–0.26)
of cases. The capsular perforation leads to sig- Posttreatment encephalopathy
nificant intraperitoneal hemorrhage 1–2% of TIPS, no. (%) 75 (46.3)
the time. Clinically significant hemobilia is
also rarely observed after the procedure. The
stent can be placed too far into the inferior OR (95% CI) for TIPS 2.34 (1.41–3.87)
vena cava or even into the right atrium at the Severe posttreatment encephalopathy
cranial end or far into the main portal vein at TIPS, no. (%) 50 (30.9)
the caudal end of the shunt in up to 20% of
patients. On occasion, stents may migrate on
or shortly after placement because of catheter OR (95% CI) for TIPS 2.17 (1.21–3.67)
and balloon manipulation [41]. All-cause mortality
Diversion of portal venous flow through TIPS, no. (%) 78 (48.1)
the shunt diminishes the metabolic filtering
effect of the hepatic parenchyma, leading to
new or worsened encephalopathy in 30–46% OR (95% CI) for TIPS 0.90 (0.44–1.81)
of patients [19–21]. Deterioration of hepatic Note—OR = odds ratio.

TABLE 4: Contraindications to Placement of a Transjugular Intrahepatic clinical scenario at hand. For instance, TIPS in
Portosystemic Shunt patients with hepatocellular carcinoma and re-
Absolute Relative fractory variceal bleeding, recanalization of
occluded portal vein in patients with recur-
Primary prevention of variceal bleeding Hepatocellular carcinoma, especially central
rent variceal bleeding, and treatment of pa-
Congestive heart failure Obstruction of all hepatic veins tients with Budd-Chiari and progressive liv-
Severe tricuspid regurgitation Portal vein thrombosis er failure might justify the added risks of a
Severe pulmonary hypertension Moderate pulmonary hypertension difficult TIPS procedure. Such patients might
benefit from transfer to a center with a lot of
Multiple hepatic cysts Severe coagulopathy (international normalized ratio > 5)
experience with TIPS [41]. Patients with a
Uncontrolled systemic infection or sepsis Thrombocytopenia of < 20,000 cells/cm3 history of hepatic encephalopathy are at an
Unrelieved biliary obstruction Hepatic encephalopathy increased risk for an exacerbation of the en-
cephalopathy [44].
Hg). Relative contraindications include ana- hepatic masses, and multiple cysts. Although A number of models have been used to pre-
tomic issues that can complicate the creation a shunt can be created in these circumstanc- dict survival following TIPS [45–48]. Retro-
of the shunt or reduce the technical success, es, the difficulty and risk associated with cre- spective analyses have shown that Childs-Pugh
including portal or hepatic vein thrombosis, ating the TIPS needs to be balanced with the class C [45], variceal hemorrhage requiring
A B C
D E F
Fig. 1—Conventional transjugular intrahepatic portosystemic shunt (TIPS) creation technique.
A, Schematic diagram shows TIPS connecting right hepatic vein to right portal vein. Note that shunt extends from main portal vein to confluence of right hepatic vein and
inferior vena cava.
B, Right hepatic venogram shows course of hepatic vein.
C, Balloon occlusion transhepatic portogram using carbon dioxide shows course of portal veins.
D, Injection of iodinated contrast material through TIPS needle confirms needle position within portal vein before passage of guidewire.
E, Transhepatic portogram shows opacification of varices, transhepatic tract, and hepatic veins.
F, Portal venogram obtained after TIPS insertion shows flow through polytetrafluoroethylene-covered stent (Viatorr, W. L. Gore). Peripheral portal vein branches are no
longer opacified because of reversal of flow.

Fidelman et al.
A B C
Fig. 2—42-year-old woman with liver failure due to Budd-Chiari syndrome who received transjugular intrahepatic portosystemic shunt (TIPS).
A, Wedged hepatic venogram shows network of small collateral vessels.
B, Portal venogram shows patent portal vein.
C, Completion portal venogram shows patent TIPS.
emergent TIPS placement, serum bilirubin Preparation for TIPS receive IV hydration. Even when labora-
level greater than 3 mg/dL, alanine amino- The TIPS procedure carries with it signifi- tory parameters are within acceptable lim-
transferase level greater than 100 IU/L, and cant risks, and a clear understanding of patient- its, arrangements should be made for cross-
pre-TIPS encephalopathy unrelated to bleed- specific risks and benefits is required when de- matched blood products to be available for the
ing were associated with an increased risk of ciding whether to proceed. A detailed clinical patient in the blood bank.
post-TIPS mortality [46]. Malinchoc et al. history and physical examination are required. Recent cross-sectional imaging (ultra-
[47] introduced the Mayo Clinic risk score, Laboratory studies should be obtained within sound with Doppler or contrast-enhanced CT
comprising serum bilirubin level, interna- 24 hours of a TIPS procedure. These should or MRI) should be reviewed. If current (< 1
tional normalized ratio (INR) for prothrom- include a complete blood count, coagulation month old) liver imaging is unavailable, or if
bin time, serum creatinine level, and cause panel, and a comprehensive metabolic panel a patient had a recent deterioration in hepat-
of liver disease. A risk score greater than 1.8 including serum electrolyte levels, creatinine ic function, an urgent or emergent ultrasound
was associated with high 3-month mortality. level, and liver function tests. Significant with Doppler evaluation of hepatic vascula-
The predictive value of this risk score was thrombocytopenia (platelet count, < 50,000 ture should be obtained before the TIPS pro-
validated by subsequent studies [48, 49]. cells/mL), anemia (hematocrit, < 25%), or co- cedure to evaluate portal vein patency. An
A slight modification to the Mayo Clinic agulopathy (INR, > 1.5) should be corrected echocardiogram should be obtained in patients
score was introduced in 2001 by Kamath et by administering appropriate blood prod- with known cardiac or pulmonary disease to
al. [50], which used the same prognostic fac- ucts. Patients with renal insufficiency should exclude pulmonary arterial hypertension.
tors and became known as the MELD score.
This risk score is calculated according to the
following formula:
Risk = 9.6 × loge (creatinine, mg/dL) +

3.8 × loge (bilirubin, mg/dL) +
11.2 × loge (INR) + 6.4 × (cause of cirrhosis
[0 if alcoholic or cholestatic liver disease,
1 if otherwise]).
The MELD score was found to be superior

to the Childs-Pugh score at predicting post-
TIPS mortality [48, 50], or the Emory score
[49]. The modified MELD score, which no
longer takes into account the cause of liv-
er disease, is in wide clinical use currently. A B
A MELD score above 18 predicts a signifi-
cantly higher mortality 3 months after TIPS, Fig. 3—Conventional technique for direct intrahepatic portocaval shunt creation.
A, Schematic diagram shows needle (arrowhead) advanced through caudate lobe into main portal vein under
compared with patients with MELD scores direct intravascular ultrasound (arrows) visualization.
of 18 or less [49–51]. B, This is followed by portal vein catheterization, tract dilation, and placement of stent.

If TIPS is done for refractory ascites, a large- neuvers can be tried to advance the sheath, TIPS variceal embolization include coils and
volume paracentesis should be performed on including employment of a partially deflated cyanoacrylate, as well as sclerosants such as
the day before the scheduled TIPS procedure. angioplasty balloon, the stiff plastic tapered sodium tetradecyl sulfate.
Patients with hepatic hydrothorax may benefit sheath introducer, or the TIPS needle itself. Patients are usually admitted to a unit that
from a thoracentesis. In some difficult cases, a TIPS can be cre- can provide close monitoring for a mini-
ated by deploying an uncovered metal stent mum of 6 hours after the procedure. Labo-
Technical Aspects of TIPS Creation first, through which the TIPS sheath can ratory parameters including complete blood
Conventional Technique usually be advanced into the portal vein. In count, coagulation panel, serum creatinine
The procedure can be performed under these cases, the PTFE-covered stent is de- level, and liver function tests are checked
conscious sedation, though most practitio- ployed within the bare-metal stent. regularly. Urine output and mental status
ners currently use general anesthesia with When using PTFE-covered stents, care are tracked as well. A liver ultrasound with
endotracheal intubation for the procedure. should be taken to leave the uncovered caudal Doppler is commonly obtained on the day
Commonly used methods for creation of a portion of the stent in the portal vein, where- after the TIPS procedure to show shunt pa-
TIPS have been recently reviewed in detail as the covered portion of the stent should be tency. Flow in PTFE-covered stents is usu-
elsewhere [52]. in the parenchymal tract and in the hepatic ally difficult to detect sonographically dur-
Most practitioners prefer to create the shunt vein. The cranial end of the stent should ex- ing the first 72 hours after placement because
from the right hepatic vein approach (Fig. 1). tend to the junction of the hepatic vein and of retention of small air bubbles within the
However, portal vein access can be obtained the inferior vena cava. Overlapping stents of graft material. Adjunct diagnostic measures,
from any hepatic vein or even from the inferior the same diameter are often used to achieve such as detection of hepatopetal flow in the
vena cava in patients with complete occlusion the desired shunt length and to reduce severe main portal vein and hepatofugal flow in the
of the hepatic veins (Fig. 2). Many practitio- angulation within the shunt. A 10- or 12-mm branch portal veins, suggest TIPS patency
ners use balloon occlusion hepatic venography stent diameter is typically chosen for adult and appropriate functioning.
using carbon dioxide to show the course and patients, whereas 8-mm stents are more of-
direction of flow in the portal veins. ten used in the pediatric population. Endovascular Alternatives
Fluoroscopically guided needle passes are Once stents are deployed, trans-TIPS por- One of the technical challenges in creat-
made in the hepatic parenchyma followed by tal venography and pressure measurements ing a TIPS involves cannulation and cathe-
aspiration on the TIPS needle through a sy- in the main portal vein and the right atrium terization of an adequate portal vein branch.
ringe. A flush of blood in the syringe indicates are repeated. The post-TIPS portosystemic The reason for this challenge is the fact that
that the tip of the needle is located in a vascu- pressure gradient is calculated. A post-TIPS portal vein is not visualized on the fluoro-
lar structure. Contrast material is then injected portosystemic pressure gradient under 12 scopic images. Transhepatic portal venog-
through the needle to determine whether ac- mm Hg in patients with a history of variceal raphy helps assess the approximate course
cess to a portal vein branch has been gained. bleeding should be achieved to prevent a re- of the vein, but the 2D nature of venogra-
If the site of portal vein entry is deemed large bleeding episode [53]. A threshold portosys- phy prevents precise localization of the por-
enough and without severe angulation in the ex- temic pressure gradient value for patients re- tal vein. This inability to visualize the por-
pected course of the shunt, a 0.035-inch guide- ceiving a TIPS for refractory ascites has been tal vein often leads to multiple needle passes
wire is introduced through the needle into the a subject of some debate. Society of Inter- within the liver parenchyma that may result
portal vein. A hydrophilic-coated guidewire or ventional Radiology and American Associa- in hepatic artery, bile duct, and liver capsule
a floppy-tip nonhydrophilic guidewire can be tion for the Study of Liver Disease guidelines injuries, which in turn may have dire conse-
used; in difficult cases, a microwire and mi- [41] recommend reducing the portosystemic quences. One of the most commonly used
crocatheter combination may be helpful. pressure gradient to under 8 mm Hg, where- technical variants of a TIPS technique is the
Once transportal access to the splenic or su- as other investigators [54] suggested that a direct intrahepatic portacaval shunt (DIPS).
perior mesenteric vein with a guidewire is se- threshold value below 12 mm Hg may pro- DIPS was first described in 2001 by Peters-
cured, a 5-French catheter is introduced into vide adequate ascites control. Gradients been et al. [57]. The hallmark of the DIPS pro-
the splenic or superior mesenteric vein, and a low 5 mm Hg have been associated with an cedure is the use of the caudate lobe as the pa-
stiff guidewire is left in place. Portal venog- increase in the risk of liver failure and severe renchymal tract to create a side-to-side shunt
raphy and pressure measurement can be per- hepatic encephalopathy requiring an inter- between the inferior vena cava and the portal
formed at this point. A portosystemic pressure vention, such as TIPS reduction [55]. vein. The conventional DIPS method relies on
gradient is calculated as the pressure differ- Patients with a history of variceal bleed- direct needle guidance using an intravascular
ence between the portal vein and the right ing may benefit from selective catheteriza- ultrasound probe introduced via the femoral
atrium. The parenchymal track is then dilated tion and embolization of gastroesophageal vein approach [58]. A TIPS needle is intro-
with an angioplasty balloon to allow passage varices. A large retrospective study by Tes- duced from the jugular approach and is vis-
of the TIPS sheath into the portal vein. dal et al. [56] showed that patients who un- ualized sonographically as it passes from the
Catheterization of the portal vein with the derwent variceal embolization at the time of inferior vena cava into the portal vein (Fig. 3).
10-French TIPS sheath is required to place TIPS were significantly less likely (84% vs The remainder of the procedure is similar to
the PTFE-covered stent-graft (Viatorr, W. L. 61% at 2 years; 81% vs 53% at 4 years) to the creation of a conventional TIPS.
Gore). This step might prove to be technical- develop recurrent variceal bleeding than pa- Intravascular ultrasound skills are not re-
ly challenging because of “buckling” of the tients who had only a TIPS procedure. Em- quired to master the DIPS technique. DIPS can
sheath in the right atrium. A variety of ma- bolic materials that have been used for post- be performed using transabdominal ultrasound

Fidelman et al.
A B C
Fig. 4—Transabdominal approach for direct

intrahepatic portacaval shunt creation.
A, Needle (arrows) is advanced percutaneously into
liver under direct sonographic guidance, taking care
to traverse both major portal and hepatic venous
branches.
B, Subsequently, guidewire (arrow) is placed in
inferior vena cava, which is snared (arrowheads) from
jugular approach, thus establishing through-and-
through guidewire access.
C, Parenchymal tract is dilated.
D, Vascular sheath is advanced into portal vein
from transjugular approach. Second catheter and
guidewire (arrowheads) are used to gain access to
main portal vein.
E, Transhepatic guidewire is removed, and stent is
placed.
D E
by guiding a needle through a large intraparen- vein, decreased radiation by use of ultrasound angioplasty within the stents and the place-
chymal portal vein branch to the inferior vena during portal vein access, and decreased pro- ment of additional stents in patients to extend
cava [59]. A left lobe approach through the left cedural time [57]. Limited data suggest that cranial or caudal length of the stent [5].
portal vein is preferred in this technique be- DIPS has a high technical success rate and Hepatic encephalopathy refractory to med-
cause it avoids the intercostal approach to the long-term patency similar to that of the TIPS ical management or progressive hepatic dys-
liver right lobe. Once the inferior vena cava is procedure [60, 61]. function after TIPS placement might require
cannulated, a guidewire is advanced into the endovascular shunt reduction. A commonly
cava and is snared from the jugular approach TIPS Maintenance used technique involves shunt catheteriza-
(Fig. 4). The resulting stable through-and- Recurrence or worsening of the portal hy- tion by two parallel guidewires followed by
through guidewire access is used to introduce a pertension symptoms should prompt an ul- simultaneous deployment of two stents with-
guiding sheath from the jugular approach and trasound with Doppler to exclude TIPS ste- in the shunt (Fig. 5). One of the stents is a
dilate the parenchymal track to the portal vein. nosis. Shunt velocities 250 cm/s or higher covered endograft through which blood flow
The sheath is then advanced into the portal or 50 cm/s or less are associated with high will be conducted, whereas the second device
vein, and its location within the portal vein can (> 90%) sensitivity and specificity for shunt is a balloon-expandable bare-metal stent, the
be confirmed sonographically. A second cathe- dysfunction [62]. In addition, most hepatolo- diameter of which determines the ultimate
ter and guidewire are then manipulated into the gists order routine TIPS surveillance tests at shunt diameter. Usually, the bare-metal stent
splanchnic venous system followed by removal regular intervals using ultrasound with Dop- is placed along the cephalic aspect of the cov-
of the through-and-through guidewire and in- pler in asymptomatic patients. ered stent. This allows continued access to
troduction of a stent (Fig. 4). Patients with a suspected TIPS dysfunc- the balloon expandable stent if further reduc-
The quoted advantages of the DIPS pro- tion should undergo TIPS venography. If the tion is necessary [64, 65].
cedure are the lack of hepatic vein as shunt original TIPS was created using a bare-metal
outflow (and therefore lack of hepatic vein stent, placement of a covered stent is likely to Conclusion
stenosis), real-time imaging guidance dur- improve long-term shunt patency [63]. Oth- TIPS is an established endovascularly cre-
ing advancement of the needle into the portal er commonly used measures include balloon ated “side-to-side” portosystemic shunt used to

systemic shunt: state of the art. Semin Roentgenol

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Fig. 5—Transjugular intrahepatic portosystemic shunt (TIPS) reduction technique. ized trial comparing transjugular intrahepatic
A, Color schematic diagram shows placement of covered endograft (red) alongside balloon-expandable portosystemic stent-shunt with variceal band liga-
uncovered stent (blue) inside original TIPS (green), which results in narrowing of shunt caliber at its cephalad
tion in the prevention of rebleeding from esopha-
aspect.
B, Trans-TIPS portal venogram shows patent shunt before reduction. geal varices. Hepatology 1997; 26:1115–1122
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D, Final trans-TIPS portal venogram shows narrowing at cephalad aspects of TIPS due to presence of balloon-
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F O R YO U R I N F O R M AT I O N
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Va s c u l a r a n d I n t e r ve n t i o n a l R a d i o l o g y • R ev i ew

Vascular and Interventional Radiology

The Transjugular Intrahepatic

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750 AJR:199, October 2012

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Fig. 4—Transabdominal approach for direct

752 AJR:199, October 2012

systemic shunt: state of the art. Semin Roentgenol

sjugular intrahepatic portosystemic shunt after

AJR:199, October 2012 753

754 AJR:199, October 2012

AJR:199, October 2012 755

Journal of Gastroenterology 20:45, 16996. [Crossref]

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