1. TIPS Made Easy: A Procedure Review
Fabbricatore Aldo, Cea-Pereira Sonia
Interventional Radiology
Hospital Xeral Cies
Vigo, Spain

2. Learning Objectives
To present a review on TIPS (Transjugular Intrahepatic Portosystemic Shunt): Indications, contraindications, technique and complications

3. Transjugular Intrahepatic Portosystemic Shunt (TIPS)
Definition It is an interventional radiologic procedure that creates a low-resistance channel between a normal branch of the portal vein and a main hepatic vein to decompress the splanchnic venous system in patient with portal hypertension 1
Luca et al. TIPS for prevention of recurrent bleeding in patients with cirrhosis: Meta-analysis of randomized clinical trial. Radiology 1999 August; 212 (2):

4. TIPS Right Suprahepatic vein Portal vein Dr. Casal Spleen Left Kidney
Sistema porta
Left Kidney
Right Kidney
Inferior Mesenteric Vein
Dr. Casal
Superior Mesenteric Vein

5. Success and complication rates should be monitored.
The decision to perform a TIPS, should be reached by a team: Gastroenterologist / hepatologist, interventional radiologist and transplant physician where appropriate.
TIPS should only be place by experience interventional radiologist or specially trained physicians.
Success and complication rates should be monitored.
Boyer TD, Haskal ZJ. The role of transjugular intrahepatic portosystemic shunt in the management of portal hypertension. Hepatology 2005 Feb; 41 (2):
Boyer TD, Haskal ZJ.. Hepatology 2005 Feb; 41 (2):

6. TIPS Advantage: Technical success rate around 95%
Inferior morbi-mortality compare to surgery.
Transplant:
It respects the hepatic hilium
It is extracted with the liver (does not requires a surgery)
Technical success rate around 95%
Control of bleeding achieved in 91-97% of cases
Ascites control improved in 60-85% of cases
Preprocedure survival should be estimated
MELD, CHILD-PUGH, APACHE II or bilirrubin 3

7. GOAL Variceal bleeding: Refractory Ascites:
Reduction in venous portal gradient to less than 12 mmHg
Refractory Ascites:
Reduction in venous portal gradient to at less 8 mmHg

8. Indications
Acute variceal bleeding that cannot be successfully controlled with medical treatment (including sclerothepapy).
Recurrent or refractory variceal bleeding in patients who cannot tolerate conventional medical treatment.
Refractory ascites.
Control of hepatic hydrothorax.
Budd-Chiari syndrome (moderate disease).

9. Contraindication Absolute: Relative:
Primary prevention of variceal bleeding
Severe hepatic encephalopathy poorly controlled with medical therapy
Right-sided heart failure with increased central venous pressure
Hypervascular hepatic tumors
Polycystic liver disease
Portal vein thrombosis
Severe hepatic failure
Severe coagulopathy
Uncontrolled intrahepatic or
systemic infection
Hazkal et all. Quality Improvement Guidelines for Transjugular Intrahepatic Portosystemic Shunt. J Vasc Interv Radiol 2003; 14:S265–S270
Hazkal et al. J Vasc Interv Radiol 2003; 14:S265–S270

10. Pre-TIPS Evaluation Cross-sectional imaging of the liver: US, CT or MR
Assess portal system pattency.
Exclude liver masses
Lab Work: Previous 24 hours
Liver function Complete blood count
Renal function Serum Electrolytes
General anesthesia or conscious sedation

11. Equipment TIPS Set: Angioplasty Balloons: 8x40mm
40cm long 10-Fr sheath
10-Fr angle introducer with metal stiffner
47cm 5-Fr straight catheter with central sharp inch trocar.
Angioplasty Balloons: 8x40mm
Stent: Viatorr, 10mm diameter. (lengths 5 to 8 cm)
Invasive pressure measuring transducer

12. TIPS: Technique Step by Step
Catheterization of the hepatic veins and hepatic venography.
Pressure measurement (free and wedge)
Passage of a long, curve transjugular needle from the chosen hepatic vein through the liver parenchyma into de intrahepatic branch of the portal vein.
Balloon dilation of the liver track.
Deployment of the stent
Angiographic and hemodynamic assessment of pressure reduction

13. TIPS: Technique
1.- Right Jugular access is obtain and a 5-Fr multipurpose catheter is placed into the right hepatic vein.
2.- Suprahepatic Flebography
3.- Advancement of needle into the portal vein.

14. TIPS 4.- Catheter and guidewire in portal system 5.- Portography
6.- Graduated marking catheter
(determine the length of the stent)

15. TIPS 7.- Balloon dilation of the 8.- Stent being deploy
parenchyma track.
8.- Stent being deploy

16. 8.- Prosthesis fully deployed and control flebography

17. Post-TIPS Evaluation
Doppler ultrasound should be perform before hospital discharge, at 3 months and every 6 months.
Important parameters:
Flow velocity :
Proximal and distal end of shunt ( cm/s)
Portal veins
Flow direction (hepatofugal)
Assess for collaterals
If clinical or imaging evidence of malfunction:
TIPS venography and invasive pressure measurement.

18. Complications Intraprocedure Complication around 7%
Major Complication 3%
Minor Complication 4%
Periprocedural complication 10-15%
Intraprocedure Mortality 0-2%
Depends on severity of liver disease
Childs-Pugh C 30 days mortality of 90%

19. TIPS Complications Major complications Minor complication:
Hemoperitoneum
Gallbladder puncture
Stent malposition
Radiation skin burn
Hepatic Infarction
Hepatic artery injury
Death
Minor complication:
Transient contrast-induce renal failure
Encephalopathy
Fever
Transient pulmonary edema
Entry site hematoma
Hazkal et al. J Vasc Interv Radiol 2003; 14:S265–S270

20. TIPS Complications Puncture of biliary tree Transcapsular pucture
Puncture of biliary tree and air bubbles in common bile duct

21. Stenosis

22. Conclusions
TIPS is a safe and successful technique developed to treat complications of portal hypertension with a low incidence of major complications in which patient selection and timing to perform the procedure are critical to obtain a good clinical outcome.
TIPS should not be considered as primary therapy for any complication of portal hypertension

23. Reference
Luca et al. TIPS for prevention of recurrent bleeding in patients with cirrhosis: Meta-analysis of randomized clinical trial. Radiology August; 212 (2):
Boyer TD, Haskal ZJ. The role of transjugular intrahepatic portosystemic shunt in the management of portal hypertension. Hepatology 2005 Feb; 41 (2):
Mauro et al. Image-Guided Interventions. Expert Radiology. 1st Edition. Saunders. Pennsylvania, USA p
Hazkal et al. Quality Improvement Guidelines for Transjugular Intrahepatic Portosystemic Shunt. J Vasc Interv Radiol 2003; 14:S265– S270
Waldman D, Patel N and Saad W. Interventional Radiology Secrets. 1st Edition. Hanley&Belfus. USA p