|Year : 2001 | Volume
| Issue : 1 | Page : 17-22
|Pictorial essay : Trans-jugular intra-hepatic porto-systemic shunt (TIPS)
TN Anuradha Rao, H Rastogi, UC Pandey
Department of Radiology, Indraprastha Apollo Hospital, New Delhi, India
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Keywords: TIPS, Cirrhosis, Portal hypertension
|How to cite this article:|
Anuradha Rao T N, Rastogi H, Pandey U C. Pictorial essay : Trans-jugular intra-hepatic porto-systemic shunt (TIPS). Indian J Radiol Imaging 2001;11:17-22
TIPS is an interventional radiologic method of creating a portosystemic shunt by percutaneous means . It is a relatively new weapon in the armamentarium of the management of portal hypertension with variceal bleeding or intractable ascites. Using needles, angioplasty balloon catheters and expandable metallic stents, a shunt is established directly inside the liver parenchyma connecting a large hepatic vein with a main portal vein branch. Depending on the diameter of the expandable stent used, the created TIPS diverts various amounts of portal blood into the systemic circulation and results in significant portal decompression, cessation of hemorrhage from esophageal varices and resolution of ascites. TIPS is not only an effective and safe alternative to shunt surgery but is life saving in cases of variceal hemorrhage.
|How to cite this URL:|
Anuradha Rao T N, Rastogi H, Pandey U C. Pictorial essay : Trans-jugular intra-hepatic porto-systemic shunt (TIPS). Indian J Radiol Imaging [serial online] 2001 [cited 2019 Aug 17];11:17-22. Available from: http://www.ijri.org/text.asp?2001/11/1/17/28303
The use of TIPS seems to be a valid alternative to surgery and has several advantages over either esophageal transection or surgical shunts. TIPS avoids a general anesthetic, laparotomy, and disruption of the hepatic venous system that may adversely affect subsequent hepatic transplantation. TIPS has been performed on patients without interfering with successful transplantation .
| Indications|| |
In patients with variceal hemorrhage and who have failed sclerotherapy, it serves as an alternative to emergency shunt surgery . It has special value in the management of variceal bleeding in patients awaiting liver transplantation, particularly in those with alcohol liver disease. TIPS not only stops bleeding without precluding a liver transplant; its effect is sufficiently long enough to acquaint patients with transplantation, and if necessary, to allow them to demonstrate compliance with an alcohol treatment program and establish an adequate support system . Other indications include mild liver disease and chronic variceal bleeding and intractable ascites , in which case it can be done on an elective basis. TIPS is used in the treatment of recurrent and refractory hepatic hydrothorax ,,. It has successfully treated chronic Budd-Chiari syndrome More Details and portal vein thrombosis ,. It has also been used in patients with portal hypertension - post adult liver transplantation . TIPS is used for the treatment of hepatorenal syndrome as it helps the kidney to regain its function. It has been successfully used in hepato-pulmonary syndrome . It improves the general condition, and hence the final outcome of liver transplantation in such patients ,.
| Patient Preparation|| |
The preliminary evaluation includes liver function test to assess the severity of impairment of liver function. Physical examination must be performed to assess the presence of encephalopathy and ascites . Paracentesis prior to TIPS is not necessary . Determination of portal vein patency prior to the procedure must be documented . Doppler ultrasound is the quickest and easiest way to identify a patent portal vein, though other non-invasive imaging modalities such as CT and MRI will also achieve the same goal. Arterial portography provides the most detailed anatomical map of the portal venous circulation, but the arterial puncture and additional contrast medium load that this involves is unnecessary for the successful conduct of TIPS in the majority of patients, except in patients with previous shunt surgery or multiple abdominal operations.
TIPS is an invasive percutaneous procedure that is performed in a suite equipped with an angiographic C-arm, DSA facility, ECG, intravascular pressure monitors and oxygen saturation measurement equipment.
The procedure can be performed under local anesthesia and conscious sedation. However, general anesthesia is preferable as the procedure is very painful.
| Venous Access|| |
The most common approach is through the right internal jugular approach. Because of the rigid needle system used, the right external, left internal or external jugular venous access routes can also be used .
After infiltrating the puncture site with 2% lignocaine and puncturing the vein a guide wire is advanced into the IVC followed by a 9F/10F vascular sheath. An angled angiographic catheter is then placed over the guide wire and the right hepatic vein is cannulated. To facilitate the procedure and ensure proper function, subsequent needle puncture is best performed through the largest available hepatic vein, namely the right hepatic vein. In case this vein is small, then the other veins are cannulated for needle access. A wedged venogram is performed with a peripherally placed hepatic vein catheter, which may identify a portion of the portal vein to facilitate subsequent puncture [Figure - 1]. A stiff guide wire is then passed through the catheter and the vascular sheath is advanced into the hepatic vein of choice. With the vascular sheath in place a rigid needle with 15-20 degrees of distal angulation is advanced over the guide wire and through the vascular sheath to enter the hepatic vein. The Colapinto needle is extremely effective in traversing hard, cirrhotic liver parenchyma to provide portal vein access.
| Portal Vein Puncture|| |
The needle tip is exposed through the end of the vascular sheath in the hepatic vein approximately 2-3 cm from IVC. The needle is advanced 3-5 cm through the liver parenchyma. The needle tip is aimed towards the expected location of either the right or left main portal vein branches, at least 2-3 cm from the main portal vein bifurcation. If the right hepatic venous approach has been employed, the needle is advanced in an anterocaudal direction towards the right portal vein [Figure - 2]. If a middle or left hepatic venous approach has been used, the needle is advanced in a direct caudal or slightly poster caudally towards the left portal vein. Previous non-invasive imaging studies, arterial portography when available or wedged hepatic venography are all useful guides to assist portal vein cannulation. If these studies are not available, a "blind" portal vein puncture is made, parallel to the upper lumber spine. Recent papers have reported the use of CO 2 in delineating the portal vein  and its superiority to contrast in outlining the portal vein .
Once satisfactory portal vein access has been achieved a guide wire is advanced into the portal venous system and the vascular sheath is forced over the needle prior to its withdrawal to facilitate needle exchange for an angiographic catheter. The catheter is advanced into the splenic vein peripherally in order to demonstrate the portal venous anatomy, visualize the varices and confirm splenic vein patency [Figure - 3]. Hemodynamic measurements are obtained in both the portal and systemic venous systems to determine the portosystemic gradient.
| Parenchymal Tract Dilation|| |
Once the preliminary venogram and pressure measurements have been obtained, the angiographic catheter is exchanged for an 8 mm diameter low profile balloon dilatation catheter. The parenchymal track between the portal and hepatic vein is dilated rapidly, solely to create a working channel for subsequent stent placement.[Figure - 4]a,b,c,. Repeat venography is useful to confirm that satisfactory intrahepatic portal access has been established without any extravasation of contrast medium.
| Stent Placement|| |
A Wallstent or Palmaz stent can be used. The Palmaz stent differs from the Wallstent in that it is a rigid, slotted tube with little elastic recoil that can be expanded to the various diameters. Its use requires placement of the vascular sheath into the portal vein to protect the stent balloon combination during deployment. Extracapsular portal vein puncture is clearly more likely with this approach.
The Wallstent on the other hand, is a flexible wire mesh, which is protected by an outer plastic sleeve and does not require advancement of the vascular sheath into the portal vein. The Wallstent can self-expand and shorten over time, therefore, the length of the stent must be sufficient to bridge the parenchymal tract and to protrude at both ends into the portal and hepatic veins [Figure - 5]. Failure to insert a sufficiently long stent to achieve these requirements may result in stent withdrawal into the liver and shunt thrombosis.
| End Points|| |
Portosystemic gradient is recalculated once the parenchymal tract is completely bridged [Figure - 6]. It should be less than 12 mm Hg to prevent variceal bleeding ,. If the gradient is above 12 mm Hg, the stent is expanded to 10 mm and the gradient is measured again. Palmaz stent can be expanded to 12 mm but the Wallstent currently available can be reached to a maximum diameter of 10 mm. In this situation, a tandem or parallel stent shunt must be created with Wallstents. Once the gradient has been lowered sufficiently repeat venography is performed to evaluate variceal and intrahepatic portal vein opacification [Figure - 7]. Upto seven days are required for reversal of esophagus-gastric variceal flow to normal hepatopetal flow. Should variceal opacification persist in patients who have undergone TIPS for acute variceal haemorrhage, embolization of the remaining varices through the shunt is recommended to avoid persistent or recurrent bleeding.
In an elective case, vital functions, liver function and neurologic status are observed for 24 hrs before the patient is discharged.
| Shunt Surveillance|| |
In the immediate post-shunt period, slight elevations in the serum bilirubin levels can occur. Resolution of ascites can take 3-4 weeks and does not occur in all patients . Doppler ultrasound remains the least invasive means of documenting shunt patency, but its ability to predict shunt failure has not been proved ,. Three points should be noted. Firstly, a baseline value for main portal vein flow velocity should be established within 24-48 hrs of TIPS completion to serve as a comparison for subsequent examination. Secondly, on follow _ up examinations, a reversal in the direction of intrahepatic portal venous flow to a pre-TIPS hepatopetal direction can be detected sonographically if shunt stenosis has occurred. Finally, Doppler sonogram can also demonstrate reversal in hepatic venous flow in cases of hepatic venous outflow stenosis. These three indicators may prove useful in predicting and identifying shunt failure and for this reason Doppler sonography should be performed at a minimum of six-months intervals following TIPS. Shunt venography, through a jugular or femoral venous approach remains the gold standard for shunt follow-up. It not only demonstrates its patency but permits measurement of the portosystemic gradient.
| Complications|| |
The most feared, immediate complication of TIPS is procedure-related hemoperitoneum. Cannulation of the portal vein in an extrahepatic location is potentially a life-threatening situation as it can lead to exsanguination. Subcapsular hematoma can occur and is self limiting. Associated pleural effusion with referred right shoulder pain may occur along with a low-grade fever.
Stent migration is usually a result of technical misadventure when tandem stents are required but are not overlapped sufficiently during their deployment.
Contrast medium nephrotoxicity is uncommon following TIPS. Septicemia may result from TIPS and is usually caused by skin pathogen. TIPS is contraindicated in patients with bacterial peritonitis.
The central venous pressure is often elevated immediately following TIPS and responds to diuretic therapy. Significant peripheral lower extremity edema with increasing ascites can occur transiently following TIPS but is usually self-limiting.
Acute hepatic failure has been described following decompressive surgery and is a potential complication of TIPS. An abrupt, continuous rise in the serum bilirubin is often the first indicator. A search for treatable causes should be made including hepatic arteriography to exclude any arterio-venous fistula that may have occurred from the TIPS procedure. It should be identified and ablated. Any inflow problem from a hepatic artery stenosis can also be identified and treated appropriately. Signs of hepatic arterial injury including pseudo-aneurysm or occlusion can be diagnosed and possibly treated. If hepatic infarction has occurred the outcome will be dictated by the amount of functional hepatic reserve present. If the etiology of hepatic failure cannot be identified and portal diversion is the assumed cause, the shunt can be occluded percutaneously or the patient can undergo urgent orthotopic liver transplantation.
Porto-systemic encephalopathy (PSE) is a well-described phenomenon following portal decompressive surgery. There is a marked variation in the propensity to develop encephalopathy following portosystemic shunting depending upon the clinical status of the patient and the type of shunt performed. Rates of post- operative encephalopathy have ranged from 6-80% ,. Preliminary data indicate the development of PSE in 5-25% of patients undergoing TIPS. The occurrence of PSE is not correlated with the loss of antegrade portal blood flow. The differences produced in portal hemodynamics by partial surgical portal decompression and TIPS, respectively, in addition to their effect on hepatic dysfunction and PSE, remain to be shown.
Acute thrombosis of successfully completed TIPS is usually a result of technical problems. If the stent material does not completely cover the hepatic parenchymal tract shunt thrombosis will occur. Acute shunt failure that results in re-bleeding following patent TIPS is the result of insufficient portal decompression. Under those circumstances, the portosystemic gradient is generally above 12 mm Hg and expansion of a rigid stent to a larger diameter or the placement of a tandem or parallel flexible stent shunt will lower the gradient and stop the bleeding.
The etiology of delayed TIPS occlusion is often unclear, but the causes are probably similar to those responsible for shunt failure due to complete occlusion. Elevation of the porto-systemic gradient with a functioning TIPS can occur in both asymptomatic patients and in those who experience recurrent complications of portal hypertension.
Narrowing of the shunt can be found within the stented parenchymal tract or hepatic venous outflow resulting in limited flow through the shunt and elevation of the portal pressure. An exuberant build up of neo-intima termed intimal hyperplasia is usually the source of shunt narrowing although organizing thrombus can play a role . It can became clinically significant as early as four months following TIPS as evidenced by the recurrence of portal hypertension and the renewed threat of variceal hemorrhage.
Re-bleeding rates following TIPS have been reported to range from 4.5% to 10% . Patient follow-up is limited however, owing to the fact that TIPS is a relatively recent technique and owing to the increasing use of hepatic transplantation.
| Mortality|| |
The operative or 30-day mortality ranges from 4% to 13% . This incidence applies to both elective and emergency shunts, as well as to patients of child's classes A, B and C. Mortality can occur from any of the complications, which may follow TIPS. These favorable early data indicate that the decision whether or not to perform TIPS in patients exhibiting the complications of portal hypertension should not be determined by the operative mortality of the procedure.
| Conclusion|| |
TIPS has been shown to be a safe and effective means of achieving portal decompression as has been determined by the world wide database in the past decade.
The indications for TIPS are expanding beyond the treatment of variceal hemorrhage to include patients with refractory ascites, hepatorenal syndrome, Budd-Chiari syndrome and hepatic hydrothorax to name a few. It serves as an effective bridge towards hepatic transplantation because it not only improves the biochemical parameters of the patient; it also minimizes the intraoperative blood loss.
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T N Anuradha Rao
Dept of Imaging and Interventional Radiology, Indraprastha Apollo Hospital, Sarita Vihar, Delhi-Mathura Road, New Delhi 110044
Source of Support: None, Conflict of Interest: None
[Figure - 1], [Figure - 2], [Figure - 3], [Figure - 4], [Figure - 5], [Figure - 6], [Figure - 7]
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