TIPS (Shunt): Transjugular Intrahepatic Portosystemic ...

Transjugular Intrahepatic Portosystemic Shunt (TIPS) is a shunt or a bypass use to connect two veins within the liver with the use of x-ray by interventional radiology. This tract is what we call a Transjugular Intrahepatic Portosytemic Shunt or simply abbreviated as TIPS. See the “yellow” tract on the picture to your left.

When is TIPS procedure indicated?

TIPS is indicated to treat patients with portal hypertension (variceal bleeding, portal hypertension gastropathy and severe ascites) and in some cases in Budd-Chiari Syndrome.

How to prepare for my TIPS procedure?

The night prior to your procedure, do not eat any food or drink any liquid. However, you may be allowed to drink clear liquids to help you on the day of the TIPS procedure. It is well advised to take your morning medication as instructed by your physician and to stay in the hospital for 24 hrs for observation after the procedure.

How is the procedure performed?

This procedure will be performed by an interventional radiologist that will use an image guided approach to create an artificial tunnel within the liver to connect the portal vein to the hepatic vein. A stent is then placed to keep the pathway open.  The TIPS procedure can be performed under general anesthesia to avoid you feeling any pain that they could possibly feel while the procedure is being carried out.

You will be positioned on your back, connecting you to monitors where your blood pressure, pulse and heart rate will all be traced while the TIPS procedure is being conducted. Prior to the TIPS procedure itself, you will be prepared by the nurses by having an intravenous or IV inserted. The specific area of your body where the catheter will be inserted will be shaved, sterilized and covered with a surgical drape preparing you for the start of the procedure. The upper part of your right collarbone will be numbed with a local anaesthetic before a small cut is made in the skin at the site.  With the use of ultrasound, the specialist will identify the patient’s internal jugular vein and guide a catheter into the vessel towards the liver and into the hepatic vein. To confirm the diagnosis of portal hypertension and its severity, pressure is also  measured within the right side of the heart and in the hepatic vein. A contrast material will be injected into the hepatic vein to help place the TIPS stent and to identify the portal venous system. An entry is then gained from the hepatic vein into the portal system using a TIPS needle. The stent will be placed under the fluoroscopy extending from the portal vein into the hepatic vein. Once the stent is properly placed, the balloon is inflated, expanding the stent into place. The skin will then be covered with a bandage leaving you with no need for sutures. Close follow up observations are needed after your operation which will be conducted within the hospital.

What are the complications of TIPS?

There are two major complications from TIPS procedure:

• Hepatic encephalopathy or confusion- This is a condition were you have altered mental status which it is believed to be due to toxic products from the intestines (ammonia). This ammonia is normally removed from the blood by the liver. When TIPS is performed, the TIPS will allow toxin-containing blood with ammonia to bypass your liver. This may affects your brain in a way that may cause confusion or even comma. Different treatments can be use to treat this condition.
• Heart failure- This is due to the increase in the amount of blood returning to your heart through the shunt or TIPS. The heart may be unable to return blood fast enough back to your body and it may cause heart failure. If you have history of heart failure notify your doctor before having the procedure.

Other Procedures

A transjugular intrahepatic portosystemic shunt (TIPS) procedure is a treatment method used to lower portal hypertension, or excessive pressure in your portal vein.

This vein is responsible for carrying blood from your abdomen to your liver. Excess pressure can lead to significant bleeding and fluid buildup in your abdomen, which is known as ascites.

Keep reading to find out more about the TIPS procedure, including why you might need it, how doctors perform it, and potential side effects that could result from this procedure.

What is a TIPS procedure?

A TIPS procedure involves creating a shunt between your portal vein and your hepatic vein by placing a stent. Here are each of the three parts of the procedure:

• Shunt: Something that re-routes or re-directs flow from its normal pathway.
• Portal vein: The vein that transports blood from your gastrointestinal system, gallbladder, pancreas, and spleen on the way to your liver.
• Hepatic vein: The veins (usually three) that return blood that doesn’t have oxygen from your liver back to your heart.

A specialist known as an interventional radiologist will perform the procedure, typically in a specialized operating suite known as an interventional radiology suite. During this time, an interventional radiologist will use X-ray guidance to place the shunt.

Who qualifies for a TIPS procedure in the liver?

Those who need a TIPS procedure are usually moderately to severely ill.

Examples of conditions and acute occurrences that may warrant a TIPS procedure include:

• Budd-Chiari syndrome: A rare disorder that affects the ability of blood to leave the liver, which causes significant portal hypertension.
• Hepatopulmonary syndrome: A syndrome that occurs in people with significant liver disease that affects the abilities of their lungs to work well.
• Hepatorenal syndrome: A condition where a person experiences significant liver failure that also affects the way their kidneys work.
• Portal hypertensive gastropathy: Bleeding in the stomach and stomach lining due to portal hypertension.
• Refractory ascites: Ascites (severe swelling in the abdomen) that won’t respond to traditional treatments.
• Refractory hepatic hydrothorax: Severe pleural effusion (fluid buildup outside the lungs) that’s a result of significant liver disease.
• Variceal hemorrhage: A condition that causes veins in the esophagus or stomach to bleed profusely.

As you can likely tell from these indications, the liver is an important receiver and transporter of blood in your body. When your liver doesn’t work well, its poor function can impact multiple organ systems and cause symptoms that can become indicators for the TIPS procedure.

Pros and cons

Doctors will usually perform a TIPS procedure after other first-line treatments have failed. For example, doctors may try to lower ascites by draining the excess fluid or variceal fluid by banding or stopping bleeding in your esophagus. If these fail, a doctor may recommend a TIPS procedure.

As with any procedure, the TIPS procedure isn’t without side effects. Those who need the procedure are often very sick, which can increase the risk for side effects. A doctor should thoroughly explain the pros, cons, and risks of the procedure.

Pros

• It quickly and effectively lowers portal venous pressure.
• It improves renal perfusion, lowers ascites, and can help to reverse hepatorenal syndrome.
• It has a low incidence of postprocedure side effects and 30-day mortality rates.

Cons

• People who undergo a TIPS procedure have a 10% higher rate of encephalopathy (brain disturbances that can cause confusion and affected memory) compared with those who don’t undergo the procedure.
• People who undergo a TIPS procedure are at increased risk of right heart failure due to excessive pressures that can back up to the right heart.

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How is a TIPS procedure done?

Doctors perform the TIPS procedure under general anesthesia (where you’re completely asleep and unaware) or under conscious sedation. While the approaches may vary based on the person, the following are some of the basic steps for a TIPS procedure:

• An interventional radiologist will cannulate (access) your right internal jugular vein.
• The radiologist will advance the catheter down to your right hepatic vein.
• A doctor will use ultrasound guidance to identify your portal veins.
• After identifying the portal veins, the surgeon will place a stent that extends to where your hepatic vein and inferior vena cava meet.
• A doctor may also have to embolize (destroy with heat) other bleeding areas in your body.
• The doctor will measure pressures in the portal veins as well as the right atrium of your heart to ensure the shunt is working appropriately. They’ll also measure the velocity of blood flow via ultrasound to ensure the blood is flowing through the shunt appropriately.
• Your doctor will remove the catheters, and you’ll be taken to the postanesthesia recovery unit, where healthcare professionals will closely observe you.

The TIPS procedure usually takes between 1 and 2 hours.

However, if your case is very complicated, the procedure may take longer.

Is the TIPS procedure safe?

Some people shouldn’t undergo a TIPS procedure. People who absolutely shouldn’t undergo a TIPS procedure include those with:

• bile duct obstruction
• liver cysts that impair the ability to advance or place a stent
• right heart failure
• sepsis or severe systemic infection
• severe pulmonary hypertension

The fatality rate for a TIPS procedure is less than 1%, and the 30-day mortality rate is less than 3%. This means that after 30 days, 97% of people who underwent the procedure are alive.

The most common causes of death from the TIPS procedure are organ failure and hemobilia, or bleeding within the biliary system.

What can you expect after a TIPS procedure?

You’ll likely remain in a hospital for at least 24 hours after a TIPS procedure. This allows medical staff to monitor your blood pressure, heart rate, circulation, and urine output. Your doctor will monitor other blood tests that indicate how well your heart and liver are working and make sure you aren’t experiencing any internal bleeding.

Before you’re allowed to go home, your doctor will perform an ultrasound of your abdomen to identify how well blood is flowing in the portal vein and ensure the stent is working appropriately.

Outlook

A TIPS procedure doesn’t cure the underlying disorders that lead to ascites and bleeding. As a result, doctors don’t consider it 100% effective.

Often, those undergoing a TIPS procedure may be on the list for a liver transplant, which could correct the underlying disorder(s).

The outcome for people with portal hypertension is poor. Survival rates and outlook for people after undergoing the TIPS procedure depend upon why they needed the TIPS procedure and their overall health. People who undergo the TIPS procedure due to ascites usually have a better outlook than those who have bleeding varices.

Frequently asked questions

The following are some commonly asked questions after a TIPS procedure.

Is there a special diet after a TIPS procedure?

Your doctor may advise you as to a healthy post-TIPS procedure diet. Examples of interventions include a low-protein diet and low-sodium diet. Immediately following the procedure, your doctor may recommend eating no more than 20 grams of protein a day for 3 days to lower the risks for postoperative side effects.

Will I need a liver transplant after a TIPS procedure?

Over time, the TIPS procedure can lower your liver’s functioning. The effect is likely due to less blood flow to your liver. The underlying reasons you needed a TIPS procedure and undergoing the TIPS procedure itself may be indications for a liver transplant. However, there are many factors that impact if you need a liver transplant. You should discuss if you’re a candidate given your age and overall health.

What is the life expectancy after a TIPS procedure in the liver?

A TIPS procedure can lower a person’s mortality compared with no intervention. Those who don’t undergo TIPS procedures but may be candidates have a mortality rate of 40% compared with those who undergo TIPS procedures, whose mortality rate is between 20% and 35%.

Takeaway

A TIPS procedure can lower portal hypertension without requiring significant, open surgery. Because the procedure doesn’t correct the underlying issues of liver dysfunction, you may require further treatments to improve your liver health following the procedure. A doctor should carefully explain the risks and benefits of the procedure to you before undergoing it.