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TIPS
Nathan Saucier, MD; Suvranu Ganguli, MD
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KEY FACTS

  • Terminology

    • Preprocedure

      • Procedure

        • Post-Procedure

          • Outcomes

            TERMINOLOGY

            • Abbreviations

              • TIPS: Transjugular intrahepatic portosystemic shunt
            • Definitions

              • TIPS: Percutaneously created connection within liver between portal and systemic circulations
                • Diverts portal blood flow into hepatic vein
                  • Reduces pressure gradient between portal and systemic circulations
                  • Converts hepatofugal to hepatopetal flow
                  • Decompresses varices; treats portal hypertension and its complications
              • Portal hypertension: Increased pressure gradient between portal and hepatic veins (> 10 mm Hg)
                • Portosystemic gradient = direct portal pressure - right atrial pressure
                • Hepatic vein pressure gradient = wedged hepatic vein pressure - free hepatic vein pressure
                  • Estimate of portosystemic gradient
                • Results from chronic liver disease/cirrhosis; impaired drainage through hepatic sinusoids
                  • Causes of chronic liver disease/cirrhosis
                    • Chronic alcohol abuse
                    • Hepatitis B and C
                    • Primary and secondary biliary cirrhosis
                    • Budd-Chiari syndrome
                    • Hemochromatosis
                • Alternative venous drainage from portal to systemic veins occurs due to chronic portal pressure elevation
                  • Esophageal varices most common
                    • Seen in 40% of cirrhotic patients at diagnosis
                  • Gastric varices usually occur later in disease
                    • ~ 20% incidence
                  • Mesenteric varices also may occur
                  • Stomal varices may occur in ostomy patients
                  • Variceal hemorrhage major cause of death in portal hypertension

            PREPROCEDURE

            • Indications

              • Contraindications

                • Alternative Procedures and Therapies

                  • Pre-Procedure Imaging

                    • Getting Started

                      PROCEDURE

                      • Patient Position/Location

                        • Procedure Steps

                          • Alternative Procedures/Therapies

                            POST PROCEDURE

                            • Expected Outcome

                              • Things To Do

                                OUTCOMES

                                • Problems

                                  • Complications

                                    Selected References

                                    1. Taylor AG et al: Techniques for transjugular intrahepatic portosystemic shunt reduction and occlusion. Tech Vasc Interv Radiol. 19(1):74-81, 2016
                                    2. Fanelli F: The evolution of transjugular intrahepatic portosystemic shunt: Tips. ISRN Hepatol. 2014:762096, 2014
                                    3. Darcy M: Evaluation and management of transjugular intrahepatic portosystemic shunts. AJR Am J Roentgenol. 199(4):730-6, 2012
                                    4. Patel IJ et al: Consensus guidelines for periprocedural management of coagulation status and hemostasis risk in percutaneous image-guided interventions. J Vasc Interv Radiol. 23(6):727-36, 2012
                                    5. Gluud LL et al: Meta-analysis: isosorbide-mononitrate alone or with either beta-blockers or endoscopic therapy for the management of oesophageal varices. Aliment Pharmacol Ther. 32(7):859-71, 2010
                                    6. Kalva SP et al: Transjugular intrahepatic portosystemic shunt for acute variceal hemorrhage. Tech Vasc Interv Radiol. 12(2):92-101, 2009
                                    7. Orloff MJ et al: Portal-systemic encephalopathy in a randomized controlled trial of endoscopic sclerotherapy versus emergency portacaval shunt treatment of acutely bleeding esophageal varices in cirrhosis. Ann Surg. 250(4):598-610, 2009
                                    8. Hoppe H et al: Intravascular US-guided direct intrahepatic portocaval shunt with an expanded polytetrafluoroethylene-covered stent-graft. Radiology. 246(1):306-14, 2008
                                    9. Petersen BD et al: Direct intrahepatic portocaval shunt. Tech Vasc Interv Radiol. 11(4):230-4, 2008
                                    10. Sze DY et al: Bidirectionally adjustable TIPS reduction by parallel stent and stent-graft deployment. J Vasc Interv Radiol. 19(11):1653-8, 2008
                                    11. Tripathi D et al: Improved clinical outcome with transjugular intrahepatic portosystemic stent-shunt utilizing polytetrafluoroethylene-covered stents. Eur J Gastroenterol Hepatol. 18(3):225-32, 2006
                                    12. Boyer TD et al: American Association for the Study of Liver Diseases Practice Guidelines: the role of transjugular intrahepatic portosystemic shunt creation in the management of portal hypertension. J Vasc Interv Radiol. 16(5):615-29, 2005
                                    13. Montgomery A et al: MELD score as a predictor of early death in patients undergoing elective transjugular intrahepatic portosystemic shunt (TIPS) procedures. Cardiovasc Intervent Radiol. 28(3):307-12, 2005
                                    14. Russo MW et al: Transjugular intrahepatic portosystemic shunt for refractory ascites: an analysis of the literature on efficacy, morbidity, and mortality. Am J Gastroenterol. 98(11):2521-7, 2003
                                    15. Kanterman RY et al: Doppler sonography findings associated with transjugular intrahepatic portosystemic shunt malfunction. AJR Am J Roentgenol. 168(2):467-72, 1997
                                    16. LaBerge JM et al: Two-year outcome following transjugular intrahepatic portosystemic shunt for variceal bleeding: results in 90 patients. Gastroenterology. 108(4):1143-51, 1995
                                    17. LaBerge JM et al: Histopathologic study of stenotic and occluded transjugular intrahepatic portosystemic shunts. J Vasc Interv Radiol. 4(6):779-86, 1993
                                    18. Rösch J et al: Transjugular portal venography and radiologic portacaval shunt: an experimental study. Radiology. 92(5):1112-4, 1969
                                    Related Anatomy
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                                    Related Differential Diagnoses
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                                    References
                                    Tables

                                    Tables

                                    KEY FACTS

                                    • Terminology

                                      • Preprocedure

                                        • Procedure

                                          • Post-Procedure

                                            • Outcomes

                                              TERMINOLOGY

                                              • Abbreviations

                                                • TIPS: Transjugular intrahepatic portosystemic shunt
                                              • Definitions

                                                • TIPS: Percutaneously created connection within liver between portal and systemic circulations
                                                  • Diverts portal blood flow into hepatic vein
                                                    • Reduces pressure gradient between portal and systemic circulations
                                                    • Converts hepatofugal to hepatopetal flow
                                                    • Decompresses varices; treats portal hypertension and its complications
                                                • Portal hypertension: Increased pressure gradient between portal and hepatic veins (> 10 mm Hg)
                                                  • Portosystemic gradient = direct portal pressure - right atrial pressure
                                                  • Hepatic vein pressure gradient = wedged hepatic vein pressure - free hepatic vein pressure
                                                    • Estimate of portosystemic gradient
                                                  • Results from chronic liver disease/cirrhosis; impaired drainage through hepatic sinusoids
                                                    • Causes of chronic liver disease/cirrhosis
                                                      • Chronic alcohol abuse
                                                      • Hepatitis B and C
                                                      • Primary and secondary biliary cirrhosis
                                                      • Budd-Chiari syndrome
                                                      • Hemochromatosis
                                                  • Alternative venous drainage from portal to systemic veins occurs due to chronic portal pressure elevation
                                                    • Esophageal varices most common
                                                      • Seen in 40% of cirrhotic patients at diagnosis
                                                    • Gastric varices usually occur later in disease
                                                      • ~ 20% incidence
                                                    • Mesenteric varices also may occur
                                                    • Stomal varices may occur in ostomy patients
                                                    • Variceal hemorrhage major cause of death in portal hypertension

                                              PREPROCEDURE

                                              • Indications

                                                • Contraindications

                                                  • Alternative Procedures and Therapies

                                                    • Pre-Procedure Imaging

                                                      • Getting Started

                                                        PROCEDURE

                                                        • Patient Position/Location

                                                          • Procedure Steps

                                                            • Alternative Procedures/Therapies

                                                              POST PROCEDURE

                                                              • Expected Outcome

                                                                • Things To Do

                                                                  OUTCOMES

                                                                  • Problems

                                                                    • Complications

                                                                      Selected References

                                                                      1. Taylor AG et al: Techniques for transjugular intrahepatic portosystemic shunt reduction and occlusion. Tech Vasc Interv Radiol. 19(1):74-81, 2016
                                                                      2. Fanelli F: The evolution of transjugular intrahepatic portosystemic shunt: Tips. ISRN Hepatol. 2014:762096, 2014
                                                                      3. Darcy M: Evaluation and management of transjugular intrahepatic portosystemic shunts. AJR Am J Roentgenol. 199(4):730-6, 2012
                                                                      4. Patel IJ et al: Consensus guidelines for periprocedural management of coagulation status and hemostasis risk in percutaneous image-guided interventions. J Vasc Interv Radiol. 23(6):727-36, 2012
                                                                      5. Gluud LL et al: Meta-analysis: isosorbide-mononitrate alone or with either beta-blockers or endoscopic therapy for the management of oesophageal varices. Aliment Pharmacol Ther. 32(7):859-71, 2010
                                                                      6. Kalva SP et al: Transjugular intrahepatic portosystemic shunt for acute variceal hemorrhage. Tech Vasc Interv Radiol. 12(2):92-101, 2009
                                                                      7. Orloff MJ et al: Portal-systemic encephalopathy in a randomized controlled trial of endoscopic sclerotherapy versus emergency portacaval shunt treatment of acutely bleeding esophageal varices in cirrhosis. Ann Surg. 250(4):598-610, 2009
                                                                      8. Hoppe H et al: Intravascular US-guided direct intrahepatic portocaval shunt with an expanded polytetrafluoroethylene-covered stent-graft. Radiology. 246(1):306-14, 2008
                                                                      9. Petersen BD et al: Direct intrahepatic portocaval shunt. Tech Vasc Interv Radiol. 11(4):230-4, 2008
                                                                      10. Sze DY et al: Bidirectionally adjustable TIPS reduction by parallel stent and stent-graft deployment. J Vasc Interv Radiol. 19(11):1653-8, 2008
                                                                      11. Tripathi D et al: Improved clinical outcome with transjugular intrahepatic portosystemic stent-shunt utilizing polytetrafluoroethylene-covered stents. Eur J Gastroenterol Hepatol. 18(3):225-32, 2006
                                                                      12. Boyer TD et al: American Association for the Study of Liver Diseases Practice Guidelines: the role of transjugular intrahepatic portosystemic shunt creation in the management of portal hypertension. J Vasc Interv Radiol. 16(5):615-29, 2005
                                                                      13. Montgomery A et al: MELD score as a predictor of early death in patients undergoing elective transjugular intrahepatic portosystemic shunt (TIPS) procedures. Cardiovasc Intervent Radiol. 28(3):307-12, 2005
                                                                      14. Russo MW et al: Transjugular intrahepatic portosystemic shunt for refractory ascites: an analysis of the literature on efficacy, morbidity, and mortality. Am J Gastroenterol. 98(11):2521-7, 2003
                                                                      15. Kanterman RY et al: Doppler sonography findings associated with transjugular intrahepatic portosystemic shunt malfunction. AJR Am J Roentgenol. 168(2):467-72, 1997
                                                                      16. LaBerge JM et al: Two-year outcome following transjugular intrahepatic portosystemic shunt for variceal bleeding: results in 90 patients. Gastroenterology. 108(4):1143-51, 1995
                                                                      17. LaBerge JM et al: Histopathologic study of stenotic and occluded transjugular intrahepatic portosystemic shunts. J Vasc Interv Radiol. 4(6):779-86, 1993
                                                                      18. Rösch J et al: Transjugular portal venography and radiologic portacaval shunt: an experimental study. Radiology. 92(5):1112-4, 1969