Sagar Rathod Dr.P.

Gharde
Pratikshit Raghuwanshi
Dr.D.D Wagh
 A transjugular intrahepatic portosystemic shunt (TIPS) is a
percutaneously created connection within the liver between the
portal and systemic circulations.
Transjugular intrahepatic portosystemic shunt, or TIPS, is a
procedure used to decompress the portal system resulting from
portal hypertension.
TIPS involve creation of low resistance channel between the
hepatic vein and the intrahepatic portion of the portal vein using
the angiographic technique.
Usually the right branch of the portal vein is made use of while
carrying out this procedure.
The tract is kept patent by deployment of an expandable metallic
stent , thereby blood to return from systemic circulation.
A TIPS is placed to reduce portal pressure in patients
with complications related to portal hypertension.
This procedure has emerged as a less invasive
alternative to surgery in patients with end-stage
liver disease.
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 systemic
circulations.
Shunt patency is maintained by placing an
expandable metal stent across the intrahepatic
tract.
 HISTORY
The technique was inadvertently discovered during a transjugular cholangiography
procedure around 1969.
Interventional radiologist Josef Rösch is known to be the creator of TIPS.
In early 1980s Colapinto created the first human balloon dilated TIPS.
In late 1980s Richeter developed the first human Palmaz stent TIPS.
Early 1990 , human usage of bare metallic stent in TIPS was on rise .
The first clinical application of TIPSS using expandable metal stents was in 1988 by Martin
Rossle and Joerg Richter and colleagues from Freiburg who used Palmaz stents in a 9 mm
channel
In 2001 the procedure endpoint was defined as PSG < 12 mmhg.
In early 2000s e-PTFE usage in human has started .
CAUSES OF PORTAL HYPERTENSION
INDICATIONS AND CONTRAINDICATIONS FOR
TIPSS
 VARICEAL BLEEDING
Portal hypertension can cause varices along the entire gastrointestinal tract , including
the small bowel and colon (hemorrhoids).

Mortality from acute variceal bleeding is approx. 33% in patients with cirrhosis.

Initial management of Variceal bleeding is medical therapy and/or endoscopic

management but rebleeding has been noted in more than 50% of patients. In such
conditions TIPS has played a very important role in the management of the same .
There has been seen to be reduced rebleeding rates and less mortality , indirectly
leading to better survival rates.

Currently, the primary indication for TIPS is to control portal variceal bleeding
refractory to medical and endoscopic management; however, there is evidence
supporting the early use of TIPS in selected patients with advanced cirrhosis (Child-
Pugh class B and C) and acute esophageal variceal bleeding (early TIPS).
 ASCITES

Cirrhosis most commonly gives rise to ascites.

Besides impeding lifestyle , ascites also can pose risk for developing bacterial
peritonitis , renal failure and also has been seen to increase mortality .

Initial management of ascites is sodium restriction and administration of loop diuretics

(furosemide) and aldosterone antagonists (spironolactone). In advanced stages , ascites
becomes refractory to medical management and TIPS may be indicated.

TIPS has shown to be very effective in eliminating ascites .

TIPS may not show results right away due to root cause being hemodynamic/hormonal ,
initially additional paracentesis may be required in relieving ascites .

Randomized controlled trials, meta-analyses, and systematic reviews of the literature

have demonstrated that TIPS significantly improves transplant-free survival compared
with repeated paracentesis.
 HEPATIC HYDROTHORAX
Hepatic hydrothorax is defined as the accumulation of at least 500 mL of pleural fluid
in a patient with cirrhosis without cardiopulmonary disease.

It occurs in less than 10% of patients with cirrhosis as peritoneal fluid permeates via
small diaphragmatic communications. As with ascites resulting from portal
hypertension, initial management is sodium restriction and diuretics.

In nonresponsive patients, TIPS will eliminate hydrothorax in most and decrease the
frequency of thoracentesis in the rest.
 HEPATORENAL SYNDROME
Hepatorenal syndrome portends a poor prognosis for the cirrhotic patient because it
generally occurs during the late stages of cirrhosis.

Two distinct forms of hepatorenal syndrome (HRS) have been identified: type 1,
which is rapidly progressing, and type 2, which evolves slowly.

Type 1 is precipitated by an event that incites acute-on- chronic liver failure, an

exaggerated systemic inflammatory response, and kidney dysfunction as part of
broader multiorgan failure. Targeting the precipitating event is the hallmark of
treatment for type 1.

Type 2 results in large part from a reduction in effective arterial blood volume created
by shift of fluid from the intravascular compartment to the extravascular
compartment (i.e., ascites).

Studies suggest that reduction of post-TIPS can improve renal function in type 2
HRS.
 BUDD-CHIARI SYNDROME
It is caused by mechanical obstruction of the hepatic venous outflow and gradually
results in cirrhosis and postal hypertension.

Treatment for fulminant form of budd-chiari syndrome is liver transplantation.

TIPS has proven to be a valuable tool to bridge such patients to transplantation.

In fulminant form of Budd-chiari syndrome , anticoagulation is first line therapy.

When anticoagulation fails , TIPS is a reasonable and accepted next step or Direct
Intrahepatic Posrtosystemic shunt (DIPS) , if access to hepatic veins is completely
occluded.
-Prophylactic broad-spectrum antibiotics.
-Appropriate resuscitation with fluid and blood products.
-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.

- a pre-TIPS echocardiogram can non-invasively
evaluate cardiac function and can exclude any
evidence of right heart failure.
- This technique is preferably done under
general anesthesia
- 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.
- Access is maintained with a long, large
vascular sheath positioned in the
intrahepatic inferior vena cava to allow
multiple catheter-wire exchanges Right hepatic venogram performed via a selective

without recrossing the right atrium

catheter (white arrow).The tip of the internal
jugular sheath (black arrow) is below the
diaphragm to avoid catheter/wire manipulations in
the right atrium.
 DIAGNOSTIC ASSESSMENT
- One of the contraindications to TIPS is an elevated
right heart pressure. Ensuring the right atrial pressure
is not severely elevated is mandatory before shunting
the portal venous blood to an already overburdened
right heart. Right atrial pressures below 15 mm Hg are
generally safe, whereas pressures above 20 mm Hg
predispose the patient to acute right heart failure.
- 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.
 SHUNT PLACEMENT
- Next step in TIPS is cannulation of right portal vein via
right hepatic vein.
- A curved metallic sheath is advanced via the pre existing
guide wire and the angle adjusted accordingly so as to direct
it toward portal vein (postal vein being antero-inferior to the
hepatic vein).
- The sheath is progressed further and confirmation is done
by aspiration of blood and contrast injection confirms tip to
be in portal vein .
- The use of ultrasound guidance during TIPS with
intracardiac echocardiography is a new technique that may
improve the technical success of portal vein access,
decreasing procedure time and complications.
 SHUNT PLACEMENT
- Once it is confirmed that the tip of the needle is in the right
portal vein, an exchange length hydrophilic wire is passed
distally through the main portal vein into the superior
mesenteric vein or splenic vein for security .
- In patients with severe cirrhosis , due to severe fibrosis
small calibre (4-6 mm) balloon is used to predilate the
fibrotic patch.
- The stent is advanced through the larger sheath, which
keeps it constrained and in position. The sheath is pulled
back into the right atrium, uncovering the stent. The distal 2
cm of the stent is uncovered and flares out on withdrawal of
the sheath. The rest of the stent is deployed once it is in the
appropriate position .
 SHUNT EVALUATION
- Usually, a 10-mm diameter stent is used and initially balloon-
dilated up to 8 mm in diameter. The direct portal pressure is
measured again and, if it is not satisfactory, a 10-mm balloon is
used to open the stent to capacity. The smaller the stent
diameter, the less the chance for encephalopathy post procedure.
- A final portal venogram is performed to document flow and
lack of variceal filling.
Procedure video
 BUDD-CHIARI SYNDROME
In this case due to hepatic vein being thrombosed , the
usual steps for the TIPS can not be followed .

In such cases inferior vena cava-to-portal vein TIPS

through the caudate lobe, a so-called DIPS can be
done to facilitate poral pressure control.
 Parallel TIPS
Rarely, despite a previous TIPS, the patient’s symptoms may
not be completely alleviated. If portal hypertension and
variceal bleeding are a persistent problem despite a TIPS, or if
the first TIPS thromboses, a second TIPS may be placed using
the other hepatic and portal veins.
Transumbilical or Direct Portal Access
> When access into the portal vein is challenging because of anatomy, there
are two options.
- First, access into the umbilical vein, which is usually dilated, provides a
conduit into the left portal vein. A catheter there allows opacification of the
portal venous system, which provides a better target for TIPS.
- Second, access through a naturally occurring portosystemic shunt, such as
a splenorenal shunt, can sometimes be used to gain access to the portal
circulation.
- When the umbilical vein is not accessible and a natural portosystemic
shunt does not exist, direct percutaneous access into the right or left portal
vein can allow for contrast opacification and targeting.
 TIPS Reversal/Revision
Occasionally, a TIPS reversal or revision is necessary. Limited liver
reserve and/or over shunting may result in liver failure or intractable
encephalopathy. In such cases, the interventionalist has the option to
decrease the shunting or shut down the TIPS altogether.

Several maneuvers exist to reduce shunting, including placing a stent

within the TIPS, or two stents side by side, or even a “waisted” (hourglass-
like) stent. If these interventions are not possible or are inadequate, then
the entire TIPS can be shut down.
 DIPS
- DIPS is a recently developing modification to the TIPS procedure.
- Using intravascular ultrasound guidance, DIPS has been shown to decrease
radiation dose and procedural time compared to TIPS.
- DIPS uses the caudate lobe as a parenchymal tract to create a side- to-side
portocaval shunt, which alleviates the difficulties presented by significant hepatic
vein stenoses.
- Portal access is accomplished by advancing a 21-gauge trocar needle through the
caudate lobe into the main portal vein. After the inner trocar is removed, a
guidewire (0.018-inch) can be advanced, followed by a 5Fr catheter.
- The needle and guidewire can then be removed, after which a 0.035-inch stiff
guidewire can be advanced into the portal vein. Following portal vein access, a
shunt can be created using a PTFE-covered stent graft .In recent studies, DIPS
creation was usually successful in entire patient cohorts and has produced higher
patency and real- time imaging compared with TIPS. In some interventional
radiology practices, DIPS has replaced TIPS as default procedure, especially in
patients with occluded TIPS, challenging anatomy, calcification of the portal vein, or
portal vein thrombosis resulting from hepatocellular carcinoma.
 DIPS

(A) Frontal unsubtracted hepatic venogram in a patient with Budd-Chiari syndrome. Hepatic venogram shows the spider-like
appearance (arrow) of multiple small collateral draining veins. (B) Repeat unsubtracted portal venogram after placement of a direct
intrahepatic portocaval shunt extending from the inferior vena cava to the right portal vein.
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:
 MORPHOLOGY
Ascites

Portosystemic collaterals

Size of spleen

Diameter of stent (usually 8 to 10 mm)

Configuration of stent: areas of narrowing

Extension of stent into portal + hepatic veins

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
vein
 COMPLICATIONS
(A) Obstruction to flow
Shunt obstruction (38%)

Hepatic vein stenosis

(B)Trauma
(a)Vascular injury
Hepatic artery pseudoaneurysm

Arterioportal fistula

Intrahepatic/subcapsular hematoma

Hemoperitoneum (due to penetration of liver

capsule)
 (b)Biliary injury

Transient bile duct dilatation (due to hemobilia)

Bile collection

(C) Stent dislodgment with embolization to right

atrium, pulmonary artery, internal jugular vein .
COMPLICATIONS
 CLINICAL RESPONSE TO TIPS
- TIPS is the most effective option for treating gastroesophageal variceal bleeding.
- Rebleeding rate after TIPS placement is 4% per year, the lowest among all
treatment options, including endoscopic management.
- TIPS is reserved after failure of endoscopic management only because of the
greater risks associated with it, particularly encephalopathy. Cessation of bleeding
is evident almost immediately after TIPS creation.
- TIPS has also been shown to be very effective in treating ascites, and it reduces
the risk of ascites by 50%–80% over the life of the patient.
- TIPS has also shown to improve survival and transplant- free survival compared
with other treatment options.
- Resolution of ascites may take up to 4 weeks after TIPS placement.
- TIPS improves renal function in 62% of patients with hepatorenal syndrome.
 Follow up with duplex sonography and shunt
angiography
 Early shunt occlusion <30 days: thrombosis (local
thrombolytic treatment, redilation, restenting)
 Late: intimal thickening within the stent or hepatic
vein ( dilation or another stent)
THANK
YOU