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Interventional Radiology
Procedures
Venous, Portal, and Lymphatic Procedures
Portal Venous Interventions
TIPS
TIPS
Brandt C. Wible, MD; Nathan Saucier, MD; Suvranu Ganguli, MD
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KEY FACTS

  • Terminology

    • Preprocedure

      • Procedure

        • Post Procedure

          • Outcomes

            TERMINOLOGY

            • Abbreviations

              • Transjugular intrahepatic portosystemic shunt (TIPS)

            • Definitions

              • TIPS: Percutaneously created connection within liver between portal & systemic circulations
                • Diverts portal blood flow into hepatic vein
                  • Reduces pressure gradient between portal & systemic circulations
                  • Converts hepatofugal to hepatopetal flow
                  • Decompresses varices; treats portal hypertension & its complications
              • Portal hypertension: ↑ pressure gradient between portal & hepatic veins (> 10 mm Hg)
                • Hepatic vein pressure gradient (HVPG) = wedged hepatic vein pressure - free hepatic vein pressure
                  • Estimate of portosystemic gradient (direct portal pressure - right atrial pressure)
                • Clinically significant portal hypertension can lead to
                  • Gastroesophageal varices & portosystemic collaterals
                    • Esophageal varices: 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
                  • Hepatic decompensation [ascites, hepatic encephalopathy (HE)]
                • Complications of portal hypertension
                  • Bleeding
                    • From ruptured varix, repeat bleeding common
                    • Hemorrhage can be massive & uncontrollable
                  • Ascites
                    • ↑ risk of spontaneous bacterial peritonitis (SBP)
                    • ↑ risk of hepatorenal syndrome (HRS)
                  • Portal vein thrombosis (PVT)
                • Results from chronic liver disease/cirrhosis & impaired drainage through hepatic sinusoids
                  • Causes include chronic alcohol abuse, hepatitis B & C, primary & secondary biliary cirrhosis, Budd-Chiari syndrome, hemochromatosis

            PREPROCEDURE

            • Indications

              • Contraindications

                • Preprocedure Imaging

                  • Alternative Procedures & Therapies

                    • Getting Started

                      PROCEDURE

                      • Patient Position/Location

                        • Procedure Steps

                          • Alternative Procedures/Therapies

                            POST PROCEDURE

                            • Things to Do

                              OUTCOMES

                              • Problems

                                • Complications

                                  • Expected Outcomes

                                    Selected References

                                    1. Rêgo HMC et al: Transjugular intrahepatic portosystemic shunt with transhepatic portal vein puncture guided by ultrasound: a technical alternative. Eur J Gastroenterol Hepatol. 34(1):112-6, 2022
                                    2. Alqadi MM et al: Transjugular intrahepatic portosystemic shunt creation for treatment of gastric varices: systematic literature review and meta-analysis of clinical outcomes. Cardiovasc Intervent Radiol. 44(8):1231-9, 2021
                                    3. Chen X et al: Effect of transjugular intrahepatic portosystemic shunt on transarterial chemoembolization for hepatocellular carcinoma: a systematic review and meta-analysis. Diagn Interv Radiol. 27(5):671-6, 2021
                                    4. Huang Z et al: Efficacy and safety of transjugular intrahepatic portosystemic shunt (TIPS) created using covered stents of different diameters: a systematic review and meta-analysis. Diagn Interv Imaging. 102(5):279-85, 2021
                                    5. García-Pagán JC et al: Where does TIPS fit in the management of patients with cirrhosis? JHEP Rep. 2(4):100122, 2020
                                    6. Wang ZW et al: Comparison of the effects of TIPS versus BRTO on bleeding gastric varices: a meta-analysis. Can J Gastroenterol Hepatol. 2020:5143013, 2020
                                    7. Manatsathit W et al: Performance of ultrasound for detection of transjugular intrahepatic portosystemic shunt dysfunction: a meta-analysis. Abdom Radiol (NY). 44(7):2392-402, 2019
                                    8. Brand M et al: Surgical portosystemic shunts versus transjugular intrahepatic portosystemic shunt for variceal haemorrhage in people with cirrhosis. Cochrane Database Syst Rev. 10:CD001023, 2018
                                    9. Kwan SW et al: Cost-effectiveness of transjugular intrahepatic portosystemic shunt versus large-volume paracentesis in refractory ascites: results of a Markov model incorporating individual patient-level meta-analysis and nationally representative cost data. J Vasc Interv Radiol. 29(12):1705-12, 2018
                                    10. Ferral H et al: Post-transjugular intrahepatic portosystemic shunt follow-up and management in the VIATORR era. Tech Vasc Interv Radiol. 19(1):82-8, 2016
                                    11. Taylor AG et al: Techniques for transjugular intrahepatic portosystemic shunt reduction and occlusion. Tech Vasc Interv Radiol. 19(1):74-81, 2016
                                    12. Fanelli F: The evolution of transjugular intrahepatic portosystemic shunt: Tips. ISRN Hepatol. 2014:762096, 2014
                                    13. Darcy M: Evaluation and management of transjugular intrahepatic portosystemic shunts. AJR Am J Roentgenol. 199(4):730-6, 2012
                                    14. 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
                                    15. 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
                                    16. Kalva SP et al: Transjugular intrahepatic portosystemic shunt for acute variceal hemorrhage. Tech Vasc Interv Radiol. 12(2):92-101, 2009
                                    17. 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
                                    18. Hoppe H et al: Intravascular US-guided direct intrahepatic portocaval shunt with an expanded polytetrafluoroethylene-covered stent-graft. Radiology. 246(1):306-14, 2008
                                    19. Petersen BD et al: Direct intrahepatic portocaval shunt. Tech Vasc Interv Radiol. 11(4):230-4, 2008
                                    20. Sze DY et al: Bidirectionally adjustable TIPS reduction by parallel stent and stent-graft deployment. J Vasc Interv Radiol. 19(11):1653-8, 2008
                                    21. 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
                                    22. 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
                                    23. 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
                                    24. 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
                                    25. Kanterman RY et al: Doppler sonography findings associated with transjugular intrahepatic portosystemic shunt malfunction. AJR Am J Roentgenol. 168(2):467-72, 1997
                                    26. 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
                                    27. LaBerge JM et al: Histopathologic study of stenotic and occluded transjugular intrahepatic portosystemic shunts. J Vasc Interv Radiol. 4(6):779-86, 1993
                                    28. 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

                                                • Transjugular intrahepatic portosystemic shunt (TIPS)

                                              • Definitions

                                                • TIPS: Percutaneously created connection within liver between portal & systemic circulations
                                                  • Diverts portal blood flow into hepatic vein
                                                    • Reduces pressure gradient between portal & systemic circulations
                                                    • Converts hepatofugal to hepatopetal flow
                                                    • Decompresses varices; treats portal hypertension & its complications
                                                • Portal hypertension: ↑ pressure gradient between portal & hepatic veins (> 10 mm Hg)
                                                  • Hepatic vein pressure gradient (HVPG) = wedged hepatic vein pressure - free hepatic vein pressure
                                                    • Estimate of portosystemic gradient (direct portal pressure - right atrial pressure)
                                                  • Clinically significant portal hypertension can lead to
                                                    • Gastroesophageal varices & portosystemic collaterals
                                                      • Esophageal varices: 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
                                                    • Hepatic decompensation [ascites, hepatic encephalopathy (HE)]
                                                  • Complications of portal hypertension
                                                    • Bleeding
                                                      • From ruptured varix, repeat bleeding common
                                                      • Hemorrhage can be massive & uncontrollable
                                                    • Ascites
                                                      • ↑ risk of spontaneous bacterial peritonitis (SBP)
                                                      • ↑ risk of hepatorenal syndrome (HRS)
                                                    • Portal vein thrombosis (PVT)
                                                  • Results from chronic liver disease/cirrhosis & impaired drainage through hepatic sinusoids
                                                    • Causes include chronic alcohol abuse, hepatitis B & C, primary & secondary biliary cirrhosis, Budd-Chiari syndrome, hemochromatosis

                                              PREPROCEDURE

                                              • Indications

                                                • Contraindications

                                                  • Preprocedure Imaging

                                                    • Alternative Procedures & Therapies

                                                      • Getting Started

                                                        PROCEDURE

                                                        • Patient Position/Location

                                                          • Procedure Steps

                                                            • Alternative Procedures/Therapies

                                                              POST PROCEDURE

                                                              • Things to Do

                                                                OUTCOMES

                                                                • Problems

                                                                  • Complications

                                                                    • Expected Outcomes

                                                                      Selected References

                                                                      1. Rêgo HMC et al: Transjugular intrahepatic portosystemic shunt with transhepatic portal vein puncture guided by ultrasound: a technical alternative. Eur J Gastroenterol Hepatol. 34(1):112-6, 2022
                                                                      2. Alqadi MM et al: Transjugular intrahepatic portosystemic shunt creation for treatment of gastric varices: systematic literature review and meta-analysis of clinical outcomes. Cardiovasc Intervent Radiol. 44(8):1231-9, 2021
                                                                      3. Chen X et al: Effect of transjugular intrahepatic portosystemic shunt on transarterial chemoembolization for hepatocellular carcinoma: a systematic review and meta-analysis. Diagn Interv Radiol. 27(5):671-6, 2021
                                                                      4. Huang Z et al: Efficacy and safety of transjugular intrahepatic portosystemic shunt (TIPS) created using covered stents of different diameters: a systematic review and meta-analysis. Diagn Interv Imaging. 102(5):279-85, 2021
                                                                      5. García-Pagán JC et al: Where does TIPS fit in the management of patients with cirrhosis? JHEP Rep. 2(4):100122, 2020
                                                                      6. Wang ZW et al: Comparison of the effects of TIPS versus BRTO on bleeding gastric varices: a meta-analysis. Can J Gastroenterol Hepatol. 2020:5143013, 2020
                                                                      7. Manatsathit W et al: Performance of ultrasound for detection of transjugular intrahepatic portosystemic shunt dysfunction: a meta-analysis. Abdom Radiol (NY). 44(7):2392-402, 2019
                                                                      8. Brand M et al: Surgical portosystemic shunts versus transjugular intrahepatic portosystemic shunt for variceal haemorrhage in people with cirrhosis. Cochrane Database Syst Rev. 10:CD001023, 2018
                                                                      9. Kwan SW et al: Cost-effectiveness of transjugular intrahepatic portosystemic shunt versus large-volume paracentesis in refractory ascites: results of a Markov model incorporating individual patient-level meta-analysis and nationally representative cost data. J Vasc Interv Radiol. 29(12):1705-12, 2018
                                                                      10. Ferral H et al: Post-transjugular intrahepatic portosystemic shunt follow-up and management in the VIATORR era. Tech Vasc Interv Radiol. 19(1):82-8, 2016
                                                                      11. Taylor AG et al: Techniques for transjugular intrahepatic portosystemic shunt reduction and occlusion. Tech Vasc Interv Radiol. 19(1):74-81, 2016
                                                                      12. Fanelli F: The evolution of transjugular intrahepatic portosystemic shunt: Tips. ISRN Hepatol. 2014:762096, 2014
                                                                      13. Darcy M: Evaluation and management of transjugular intrahepatic portosystemic shunts. AJR Am J Roentgenol. 199(4):730-6, 2012
                                                                      14. 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
                                                                      15. 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
                                                                      16. Kalva SP et al: Transjugular intrahepatic portosystemic shunt for acute variceal hemorrhage. Tech Vasc Interv Radiol. 12(2):92-101, 2009
                                                                      17. 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
                                                                      18. Hoppe H et al: Intravascular US-guided direct intrahepatic portocaval shunt with an expanded polytetrafluoroethylene-covered stent-graft. Radiology. 246(1):306-14, 2008
                                                                      19. Petersen BD et al: Direct intrahepatic portocaval shunt. Tech Vasc Interv Radiol. 11(4):230-4, 2008
                                                                      20. Sze DY et al: Bidirectionally adjustable TIPS reduction by parallel stent and stent-graft deployment. J Vasc Interv Radiol. 19(11):1653-8, 2008
                                                                      21. 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
                                                                      22. 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
                                                                      23. 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
                                                                      24. 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
                                                                      25. Kanterman RY et al: Doppler sonography findings associated with transjugular intrahepatic portosystemic shunt malfunction. AJR Am J Roentgenol. 168(2):467-72, 1997
                                                                      26. 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
                                                                      27. LaBerge JM et al: Histopathologic study of stenotic and occluded transjugular intrahepatic portosystemic shunts. J Vasc Interv Radiol. 4(6):779-86, 1993
                                                                      28. Rösch J et al: Transjugular portal venography and radiologic portacaval shunt: an experimental study. Radiology. 92(5):1112-4, 1969