• Transjugular intrahepatic portosystemic shunt (TIPS) is a percutaneous procedure that involves the creation of a tract between the portal vein and hepatic vein, under fluoroscopic guidance. It is performed to treat portal hypertension.
• Portal hypertension. Esophageal varices develop at a hepatic venous pressure gradient (HVPG) of at least 10 mm Hg. Blood is diverted from the high pressure of the cirrhotic and fibrotic liver to the spleen, intestines, and stomach (creates abnormal varices). The development of ascites or variceal bleeding usually begins at 12 mm Hg.
• Prior to the procedure, the patency of the portal vein is verified by ultrasound or angiography. The right internal jugular vein is accessed via needle aspiration and ultrasound guidance. The percutaneous tract is dilated and a large bore sheath is inserted into the right atrium. The right atrial pressure is measured.
• A smaller catheter is then passed through the sheath (superior vena cavaright atriuminferior vena cava) and into the hepatic vein. A wedged hepatic venograph is performed, and retrograde flow of the contrast agent through the liver into the portal system provides an image of the portal vein and its branches. Iodinated contrast agents provide excellent image resolution but carry a risk of liver parenchymal injury (high viscosity) as well as anaphylaxis or renal toxicity. Carbon dioxide is often preferred as a contrast agent for its low viscosity and ease of diffusion through the sinusoids into the portal venous system.
• Under guidance from the venogram images, a needle is passed within the liver parenchyma into the portal vein and direct portal vein pressures are measured. The pressure gradient between the portal vein and the right atrium is calculated (portosystemic pressure gradient).
• Specialized balloon dilators are passed over the portal vein needle to create a tract through the liver parenchyma; a large bore sheath and stent are then advanced into the portal vein. The sheath is retracted and the stent is deployed.
• Postdeployment, the stent is balloon angioplastied to an 8 mm diameter, initially, because too much portal vein flow bypassing the liver increases the risk of encephalopathy and can worsen liver function. The portosystemic pressure gradient is measured; if the reduction is <12 mm Hg in patients with variceal bleeding or <8 mm Hg in patients with ascites, then a 10 mm balloon is used to dilate the shunt further.
• A post-insertion venography is performed to confirm adequate stent positioning and good flow through the newly created shunt.
• Preexisting varices may also be embolized at this time.
• Indications. Primary indications include secondary prevention of variceal bleeding and refractory cirrhotic ascites. TIPS may be potentially beneficial in refractory, acutely bleeding varices, refractory hepatic hydrothorax, hepatorenal syndrome (HRS), failed anticoagulation in moderate Budd–Chiari syndrome, prevention of rebleeding from gastric and ectopic varices, and rebleeding after medical management in portal hypertensive gastropathy.
• Absolute contraindications include primary prevention of variceal bleeding, congestive heart failure (CHF), severe pulmonary hypertension, multiple hepatic cysts, uncontrolled systemic infection, and unrelieved biliary obstruction.

Supine, arms tucked

• Right internal jugular access
• Ultrasound guidance

1–4 hours

Minimal, but can potentially be massive from vessel injury combined with coagulopathy

1–2 days

• Fluoroscopy, Doppler ultrasonography
• Special needle sets, angioplasty balloons, endovascular stent grafts, CO₂ injection apparatus.
• Embolic agents may be required

Incidence

Not available

Prevalence

15,000 TIPS were performed from its first report in the 1980s till the year 2000.

<3% major procedural complications

Immediate mortality from intraabdominal hemorrhage or right heart failure is 1.7%.

History

• Advanced liver disease.
• Model for end-stage liver disease (MELD) formula for risk stratification utilizes INR, bilirubin, and creatinine levels.
  • Best outcome with MELD score <14.
  • TIPS may be performed as a salvage treatment for active bleeding with a MELD score >24.
  • Carefully weigh risk of hepatic decompensation with the benefit of TIPS for a MELD score between 15 and 25.

Signs/Physical Exam

Hypoxemia, clubbing, cyanosis, encephalopathy, ascites, bruises, jaundice

Labs/Studies

• CBC
• Coagulation studies
• Liver function tests
• Kidney function and electrolytes
• Type and Crossmatch blood
• Cardiac echocardiogram to rule out CHF, portopulmonary hypertension, right-to-left shunt
• Liver imaging for portal vein thrombosis, hepatic mass.

• Cautious use of benzodiazepines
• Correct coagulopathies
• Correct electrolytes, can cause arrhythmias

• Blood transfusion
• Possible invasive monitoring lines
• Postoperative ventilator support

First-generation cephalosporins against skin flora

• Deep sedation may be utilized
• General anesthesia should be considered in patients with a difficult airway, high risk of bleeding, aspiration, encephalopathy, anxiety, or inability to stay still. Also preferred if compromised pulmonary status from hepatopulmonary syndrome or ascites.

• Standard ASA monitors
• Invasive lines are determined by the patient's comorbidities.
• Adequate IV access should be attained in the event that large volume resuscitation is required.

If general anesthesia, intubation is preferred due to the limited access to the head (and increased risk for aspiration if active gastrointestinal bleeding or ascites).

• Volatile agents: Isoflurane, sevoflurane and desflurane have the least effect on hepatic blood flow.
• Neuromuscular blockade. Organ independent elimination of atracurium and cisatracurium
• Opioids. The half-life is prolonged in liver disease.
• Volume. Patients are intravascularly volume depleted (functionally hypovolemic) while being total body water overloaded. Judicious volume replacement with colloids, blood products, or crystalloids should be administered as appropriate.
• If performed under monitored anesthesia care, judicious use of sedatives is recommended. Either propofol or dexmedetomidine may be used for maintenance of sedation. Dexmedetomidine has some analgesic effect and causes minimal respiratory depression. It may cause significant hypotension in intravascularly depleted patients, but this side effect is probably negated after diversion of portal blood into the systemic circulation.

Standard extubation criteria. Patients should be fully awake.