Transjugular intrahepatic portosystemic shunt (TIPSS)
Transjugular intrahepatic portosystemic shunt (TIPSS) is a minimally invasive procedure used in the management of conditions related to portal hypertension, a serious complication of liver disease. It involves the placement of a stent-like device within the liver to create a direct channel between the portal vein and the hepatic vein, bypassing the liver’s damaged areas. This innovative technique helps alleviate complications associated with increased portal pressure, such as variceal bleeding and ascites. TIPSS has proven to be a valuable intervention, offering significant relief to patients with advanced liver disorders. In this context, it’s crucial to explore the benefits, considerations, and potential outcomes associated with TIPSS as a vital aspect of comprehensive liver care.
Indications for TIPSS Procedure:
| Indication | Establishment of Diagnosis | Line of Management/Considerations | Theories/Considerations |
|---|---|---|---|
| Established Indications | |||
| Refractory Variceal Bleeding | BRTO can be considered in cases of gastric varices, from short gastric and posterior gastric veins | TIPS is considered first-line therapy if bleeding is not controlled by Endoscopic band ligation and non-selective beta-blockers | TIPS reduces portal pressure, preventing rebleeding. |
| Refractory Ascites | Unresponsive to Medical Therapy | 1. LVP with albumin infusion (8 g for every L of fluid removed above 5 L) is recommended first-line therapy for RA 2. > 3 session of LVP / month = Consider TIPSS | 1. TIPS can be considered as a bridge to liver transplantation. 2. Patient at risk of spontaneous bacterial peritonitis, hyponatremia and HRS. |
| Emerging Indications | |||
| Hepatorenal Syndrome (HRS) | Increase in S. Creat - ≥ 0.3 mg/dl within 48 hours - ≥ % 50 from baseline within 7 days. | TIPS may be considered in selected cases for improving renal function. | HRS - AKI (with acute kidney injury) HRS - non AKI is divided into -HRS - acute kidney disease: glomerular filtration rate (eGFR) is < 60 mL/min per 1.73 m2 for < 3 months and < 50% increase in serum creatinine within 3 months from last values -HRS - chronic kidney disease: eGFR is < 60 mL/min per 1.73 m2 for ≥ 3 months |
| Hepatopulmonary Syndrome (HPS) | Shortness of breath and Hypoxemia secondary to pulmonary vasodilation. | TIPS can be considered in severe, refractory cases of HPS. | TIPS may improve oxygenation by reducing intrapulmonary shunting. |
| Portal Vein Thrombosis (PVT) | Non-tumoral PVT. | 1. Anticoagulation is the primary therapy in patients without cirrhosis . 2. TIPS may be considered for select cases of chronic PVT. 3. Portal vein thrombolysis and balloon-plasty can be considered prior to TIPSS for better visualization of portal vein (transhepatic and trans-splenic approach) | 1. Ascites and Splenic vein thrombosis are independently associated with failure of anticoagulation therapy 2. Cavernoma formation - high failure rates of TIPSS |
| Budd-Chiari Syndrome (BCS) | 1. Imaging study suggestive of web or thrombosis in hepatic vein. 2. Deranged LFTs | TIPSS / DIPSS can be done for BCS to prolong the need for liver transplant. | 1. Initial management is with Anticoagulation. 2. Balloon-plasty and/or stenting of hepatic vein is successful standalone treatment in only 10% patients. |
| Special Considerations | |||
| TIPS Dysfunction | Imaging study like USG and CECT abdomen | TIPS revision techniques may be employed in cases of stent dysfunction. | Restenting, balloon-plasty, and other interventions can restore shunt function. |
Contraindications for TIPSS Procedure:
| Absolute | Relative |
|---|---|
| Primary prevention of variceal bleeding | Hepatocellular carcinoma, especially central |
| Congestive heart failure | Obstruction of all hepatic veins |
| Severe tricuspid regurgitation | Portal vein thrombosis |
| Severe pulmonary hypertension | Moderate pulmonary hypertension |
| Multiple hepatic cysts | Severe coagulopathy (international normalized ratio > 5) |
| Uncontrolled systemic infection or sepsis | Thrombocytopenia of < 20,000 cells/cm3 |
| Unrelieved biliary obstruction | Hepatic encephalopathy |
Pre-procedure Evaluation for TIPSS:
| Evaluation | Description |
|---|---|
| Liver Function Tests (CTP, MELD) | Assess baseline liver function, including bilirubin, albumin, INR, and liver enzyme levels. |
| Coagulation Profile | Evaluate clotting factors and platelet count to assess bleeding risk during the procedure. |
| Imaging Studies | Use ultrasound, CT, or MRI to visualize the liver, portal vein, and potential shunt locations. |
| Hemodynamic Assessment | Measure portal pressure gradient (PSPG) and assess severity of portal hypertension. |
| Cardiac Evaluation | Assess cardiac function, especially in patients with known cardiac issues. |
| Evaluation of Collateral Vessels | Identify any collateral vessels that may impact shunt placement and blood flow. |
Types of Stents Used in TIPS Procedures:
| Stent Type | Description |
|---|---|
| Covered Stents | Fully covered with a membrane, preventing contact between blood flow and the stent structure. |
| Uncovered Stents | Allow direct contact between blood flow and the stent, promoting endothelialization and stability. |
| Covered Viatorr® Stents | Specifically designed for TIPS procedures, combining PTFE covering with a metal stent. |
| Fluency® Stents | A type of covered stent used in TIPS, combining a polytetrafluoroethylene (PTFE) lining with a nitinol stent. |
| Stent Diameter Comparison | Considerations |
| 8-mm vs 10-mm Covered Stents | Impact on complications of PH. |
| Controlled Expansion Stents | Allows more accurate diameter control. |
Potential Complications of TIPS Procedures:
| Complication | Description |
|---|---|
| Hepatic Encephalopathy (HE) | Neurological dysfunction due to liver disease, which can be exacerbated by TIPS. |
| Shunt Stenosis or Occlusion | Narrowing or closure of the stent, leading to reduced blood flow through the shunt. |
| Portal Vein Thrombosis | Clot formation within the portal vein, potentially obstructing blood flow. |
| Hemorrhage | Bleeding, either during the procedure or post-operatively, which may require intervention. |
| Infection | Risk of infection at the insertion site or within the TIPS tract. |
| Heart Failure | Occurs rarely, usually in patients with underlying cardiac issues. |
| Biliary Complications | Injuries to the bile ducts or leakage of bile, although this is relatively uncommon. |
| Post-TIPS Liver Failure | Monitor liver function closely; consider transplant. |
| Persistence of Varices | Consider adjunctive embolization of varices. |
Follow Up Post-TIPS:
| Follow-Up Interval | Imaging/Surveillance Recommendations |
|---|---|
| 1 Month | Doppler ultrasound to assess shunt patency and flow velocities. - Normal TIPS velocity: 90-190 cm/s - Normal portal vein velocity before entering the TIPS: 30 cm/s |
| 2 Months | Repeat Doppler ultrasound for continued surveillance. |
| 6 Months | Doppler ultrasound for ongoing evaluation of shunt function. |
| 1 Year | Assess stent patency and flow velocities via Doppler ultrasound. |
| Beyond 1 Year | Doppler ultrasound every 6-12 months or as needed based on clinical symptoms. |
| Assessing Shunt Patency | Evaluate stent flow velocities, main portal vein velocity, and any significant interval changes in peak velocity. |
| Shunt Revision | Address complications like stent stenosis, occlusion, or portal vein thrombosis through techniques such as angioplasty or restenting. |
- Schindler, Philipp et al. “Shunt-Induced Hepatic Encephalopathy in TIPS: Current Approaches and Clinical Challenges.” Journal of clinical medicine vol. 9,11 3784. 23 Nov. 2020, doi:10.3390/jcm9113784
- Nardelli, Silvia et al. “Spontaneous porto-systemic shunts in liver cirrhosis: Clinical and therapeutical aspects.” World journal of gastroenterology vol. 26,15 (2020): 1726-1732. doi:10.3748/wjg.v26.i15.1726