Transjugular Intrahepatic Portosystemic Shunt

  • The transjugular intrahepatic portosystemic shunt (TIPS) is a procedure that establishes new connections between two blood vessels in the liver(1). Patients with significant liver disorders may need this surgical operation. TIPS lower portal hypertension (high blood pressure in the portal vein) is common in cirrhotic patients(2).
  • Initially designed to treat patients with chronic variceal bleeding (gastrointestinal vein hemorrhage), the TIPS procedure is now widely used to treat other complications of this illness(3)
  • TIPS is an effective treatment for portal hypertension‘s consequences since it is less invasive and reduces portal pressure(4).
  • Interventional radiologists use imaging to establish a portal vein tunnel into the liver(5). TIPS procedure carries blood from the digestive organs to one of the hepatic veins. Hepatic veins return blood from the liver to the heart. Then a stent is put into the tube to keep it open.

What Is TIPS?

A transjugular intrahepatic portosystemic shunt (TIPS) is a passageway built inside the liver using X-ray guidance to join two veins(6). A tiny, tubular metal device generally referred to as a stent is used to keep the shunt open.

TIPS reduces the excess blood pressure in the portal vein (referred to as portal hypertension), often seen in patients with liver cirrhosis(7)

Portal hypertension increases the pressure in the portal vein system. The pressure may build up to cause blood flow backward into other organs, such as the esophagus, spleen, stomach, and intestines(8).

A TIPS stent directs blood entering the liver from the portal vein straight into the hepatic vein(9). Then, the vein empties blood from the liver to the vena cava and finally into the heart.

A specialist in gastroenterology or hepatology, in collaboration with an expert in interventional radiology, concludes that TIPS is the correct type of therapy for a patient with problems of portal hypertension(10).

Alternative Names

There are no other medical terms in TIPS. However, TIPS can be associated with cirrhosis or liver failure

Cirrhosis is a liver disease that can cause scar tissue to form(11). This condition prevents the liver from functioning properly. As the scar tissue grows, it eventually causes the liver to fail.

Studies on TIPS

The TIPS procedure, which was initially developed as rescue therapy for patients with persistent variceal bleeding has gained increasing acceptance as a treatment for various complications of this condition(12)

Variceal bleeding refers to bleeding of swollen veins (varices) situated in the gastrointestinal tract.  

The minimally invasive nature and an impressive reduction in portal pressure have made TIPS an ideal therapy for treating complications of portal hypertension(13).

In one study, the portosystemic shunt index was calculated for seven patients with no liver disease and 95 patients with different liver diseases by transrectally administered 123 I-iodoamphetamine(14)

The index was negative for patients with no liver diseases, 5.3% for those with acute hepatitis, 11.4% for chronic inactive hepatitis, and 56.6% for those with compensated liver cirrhosis.

The study suggests that the index of the portosystemic shunt is independent of the development of liver cell necrosis(15). This technique can be used to evaluate the effects of various liver diseases on the flow of the vessel.

Despite reducing the incidence of TIPS-related issues, these issues remain a significant concern(16). It has been observed that following TIPS, careful selection, and follow-up care are essential to maximizing the outcome. 

Various studies have shown that TIPS can successfully manage refractory ascites (fluid buildup in the abdominal cavity despite medical therapy) and variceal bleeding(17). TIPS effectiveness in treating patients with liver cirrhosis has also been utilized to reduce the risk of mortality and morbidity during abdominal surgery.

Additionally, TIPS has been promoted to treat acute variceal bleeds, hepatic hydrothorax, and hepatorenal syndrome(18). Shunt patency has been significantly improved by replacing bare-metal stents with polytetrafluoroethylene (PTFE) covered stents, resulting in better outcomes. 

Through overlapping, using a stent of the same diameter has to achieve the desired length of the shunt and reduce the severity of angulation(19). The use of 10- or 12-mm diameter stents is for adult patients.

After placing the stents, pressure measurements and trans-TIPS portal venography are performed. Pressure measurements are taken in the major portal vein and right atrium(20). The pressure gradient is then calculated and used to prevent a rebleeding episode.

Some experts have suggested a threshold pressure gradient value of 8 to 12 mm Hg(21). Others believe that a value of less than 12 mm Hg can provide adequate ascites control. A gradient below 5 mm Hg can increase the risk of severe hepatic encephalopathy and liver failure.

However, the primary drawbacks of TIPS include degradation of hepatic function and shunt dysfunction, necessitating periodic imaging monitoring and shunt maintenance(22)

Benefits of TIPS

TIPS is often done on individuals with liver cirrhosis(23). If patients have this disorder, the normal blood flow through the liver is obstructed by scar tissue, increasing the pressure in the portal vein.

Increased pressure in the portal vein causes the tiny veins in the gullet or stomach to grow abnormally, putting them at risk of bleeding(24). Cirrhosis also manifests as an abnormal accumulation of fluid (ascites) in the abdominal cavity.

Suppose patients have esophageal varices that bleed severely or recurrently and have not responded to conventional therapies. In that case, patients may undergo TIPS(25).

After the interventional radiologist inserts the surgical shunts, the pressure in the portal vein reduces, preventing bleeding and lowering ascites(26).

Common Uses of the Procedure

The uses of the TIPS procedure are the following(27):

  • Use this procedure to manage acute variceal bleeding that has not been controlled by usual therapy.
  • When sclerotherapy or band ligation has failed to control recurring bouts of variceal bleeding, TIPS may help.
  • While someone is awaiting liver transplantation or liver transplant, patients may be treated for variceal hemorrhage.

TIPS is also used to address the following problems of portal hypertension(28):

  • Portal gastropathy: It is a condition in which the veins in the stomach wall become engorged, resulting in excessive bleeding.
  • Severe ascites (abdominal fluid buildup) and hydrothorax (in the chest)
  • Budd-Chiari syndrome: It is caused by a blockage in one or more of the veins that return blood from the liver to the heart.

The Budd-Chiari Syndrome (BCS) is characterized by thrombosis or restriction of the hepatic venous outflow, resulting in liver damage, abdominal discomfort, and ascites(29).

Procedure

Patients need to be guided on what to expect before, during, and after the TIPS operation. 

Using imaging guidance, interventional radiologists create a tunnel through the liver to link the portal vein(30). It is the vein that transports blood from the digestive organs to the liver to one of the hepatic veins during a TIPS treatment. 

Hepatic veins are three veins that carry blood away from the liver back to the heart. Then, a stent is inserted into this tunnel to maintain the pathway’s integrity.

Equipment to Be Used

According to RadiologyInfo.org, TIPS treatment involves using a stent, X-ray or ultrasound equipment, and a balloon-tipped catheter(31).

A radiographic table, one or two x-ray tubes, and a video monitor are commonly used in TIPS examinations. 

Also, fluoroscopy is a technique that transforms x-rays into video pictures. Physicians use it to monitor and guide TIPS treatments. The x-ray equipment creates the video, and a detector hangs above the exam table.

Preparations Before the Procedure

The physician may order the following tests(32):

  • Complete blood count, electrolytes, and kidney tests
  • X-ray of the chest or electrocardiogram

Patients should adhere to the directions for when to cease eating and drinking before the treatment(33). Also, they should consult the attending physician on which medications they must take on the day of the surgery. Patients should take these medications with water.

Also, inform the physician of allergies to local anesthetic, general anesthesia, or contrast materials(34). The doctor may advise the patients to cease taking aspirin, NSAIDs, or blood thinners before the surgery.

Expectations (During Procedure)

Here is how the TIPS procedure takes place(35):

The patients will remain conscious but sedated during the surgery, guided by fluoroscopy and ultrasonography.

The interventional radiologist will use a needle to pierce the internal jugular vein on the right side of the neck and then put a vascular sheath over a wire into the inferior vena cava

To elaborate further, during the TIPS stent placement, a contrast substance will be injected into the hepatic vein to see the portal venous system(36).

A TIPS needle is then used to acquire access from the hepatic vein into the portal system (a special long needle extending from the neck into the liver)(37).

Under fluoroscopy, a stent is subsequently inserted, stretching from the portal vein to the hepatic vein. After positioning the stent correctly, the balloon is inflated to expand the stent into place.

The balloon is eventually deflated, and the catheter is withdrawn. Pressures are then monitored to establish the absence of portal hypertension. Additionally, further portal venograms are conducted to ensure adequate blood flow via the TIPS.

This treatment typically takes an hour or two to perform. However, the procedure may take several hours, depending on the intricacy of the problem and vascular architecture.

Results Interpretation

Before discharge from the hospital, patients may get an ultrasound test to evaluate the procedure’s efficacy and stent placement(38).

After completing the TIPS treatment, the interventional radiologist will inform the patients of the operation’s success.

Expectations (After Procedure)

Patients should be monitored in a hospital unit for 12 hours after TIPS insertion(39). Monitor vital signs for symptoms of intraperitoneal hemorrhage

Post-TIPS laboratory data should include a complete blood count (CBC), coagulation panel, and kidney and liver function tests. It is possible to acquire liver ultrasonography with a doppler one day following the shunt installation.

Risks

People with advanced liver disease are at increased risk of worsening their condition after TIPS(40). They may also experience encephalopathy. 

Hepatic encephalopathy has symptoms ranging from mild conditions, such as alterations in thinking, to severe ones, like coma and confusion(41)

Moreover, biliary puncture and fistula development is also an uncommon complication(42). A biliaryvascular fistula may cause hemobilia, cholangitis, sepsis, and stent infection.

Also, any operation that involves inserting a catheter into a blood artery bears some risk(43). Complications during the procedure may include malfunction of the stent, such as narrowing (stenosis) or closing (occlusion)(44).

Serious problems, which occur in less than 5% of instances, may include the following(45):

  • Full blockage and quick return of symptoms
  • Abdominal hemorrhage that may need transfusion laceration of the hepatic artery, which may result in severe liver damage or bleeding that may necessitate transfusion or immediate intervention
  • Arrhythmias of the heart or congestive heart failure
  • Skin damage caused by radiation is a relatively uncommon consequence.
  • Death (rare)

Other TIPS risks include(46):

  • TIPS failure
  • Bleeding (1% to 2 % of significant bleeds)
  • Temporary confusion/disorientation (about 5-10 %)
  • Infection of bloodstream infection
  • Contrast toxicity to the kidney function or kidney dysfunction
  • Allergic response to medication

There are many dangers associated with this procedure, including injury to the blood artery, bruising or bleeding at the puncture site, and infection(47)

Patients may be worried about how long they can live after a TIPS procedure. TIPS is a procedure that involves morbidity and mortality(48). Researchers hypothesized that the use of hemodynamic and echocardiographic measures during the TIPS procedure could help improve the stratification of patients.

The study results support that TIPS can increase right atrial pressure(49). Researchers also found several long-term factors that can predict mortality after TIPS. These include age, liver disease, and the end-stage liver disease model.

Post-TIPS Follow Up and Maintenance

Here are some tips for follow-up and maintenance(50):

  • If this is a new TIPS, patients will have to stay in the hospital for observation. However, if this is a TIPS revision, a family member or friend must drive the patient home.
  • It is necessary to restrict heavy activities after the operation. The patient must avoid straining or lifting heavy things (above 8 pounds) and avoid bumping the incision site on the neck.
  • Patients may replace the bandage the following day or within two to three days. They must change the bandage alternately or as required until the spot heals. Patients must also maintain as much moisture as possible on the spot until it heals.
  • A lump or bruise may appear at the site of an incision. It can spread over a few days, and it can cause red blood to seep into the area. If the bruise or lump gets bigger, patients must call their doctor. 

To stop the bleeding, patients should apply pressure to the area for 20 minutes. If the bleeding stops and there is no swelling or pain, they must observe the site. If the bleeding persists, then immediately calling the doctor is necessary.


  1. Transjugular intrahepatic portosystemic shunt (TIPS)
    https://www.mountsinai.org/health-library/surgery/transjugular-intrahepatic-portosystemic-shunt-tips
  2. Ibid.
  3. Transjugular intrahepatic portosystemic shunt in cirrhosis: An exhaustive critical update
    https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7545393/
  4. Ibid.
  5. Transjugular Intrahepatic Portosystemic Shunt (TIPS)
    https://www.radiologyinfo.org/en/info/tips
  6. Ibid.
  7. Ibid.
  8. Ibid.
  9. Ibid.
  10. The Transjugular Intrahepatic Portosystemic Shunt: An Update
    https://www.ajronline.org/doi/10.2214/AJR.12.9101
  11. Cirrhosis
    https://www.niddk.nih.gov/health-information/liver-disease/cirrhosis
  12. Transjugular intrahepatic portosystemic shunt in cirrhosis: An exhaustive critical update
    https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7545393/
  13. Ibid.
  14. [Estimation of portosystemic shunt by transrectally administered 123I-IMP]
    https://pubmed.ncbi.nlm.nih.gov/2388427/
  15. Ibid.
  16. Transjugular intrahepatic portosystemic shunt in cirrhosis: An exhaustive critical update
    https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7545393/
  17. Ibid.
  18. Transjugular intrahepatic portosystemic shunt in cirrhosis: An exhaustive critical update
    https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7545393/
  19. The Transjugular Intrahepatic Portosystemic Shunt: An Update
    https://www.ajronline.org/doi/10.2214/AJR.12.9101
  20. Ibid.
  21. Ibid.
  22. Ibid.
  23. Transjugular intrahepatic portosystemic shunt (TIPS)
    https://www.cirse.org/patients/ir-procedures/transjugular-intrahepatic-portosystemic-shunt-tips/
  24. Ibid.
  25. Ibid.
  26. Ibid.
  27. Transjugular Intrahepatic Portosystemic Shunt (TIPS) for Cirrhosis
    https://www.uofmhealth.org/health-library/aa87494
  28. Transjugular Intrahepatic Portosystemic Shunt (TIPS)
    https://www.radiologyinfo.org/en/info/tips
  29. TRANSJUGULAR INTRAHEPATIC PORTOSYSTEMIC SHUNT
    https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4251783/
  30. Transjugular Intrahepatic Portosystemic Shunt (TIPS)
    https://www.radiologyinfo.org/en/info/tips?google=amp
  31. Transjugular Intrahepatic Portosystemic Shunt (TIPS)
    https://www.radiologyinfo.org/en/info/tips
  32. Ibid.
  33. Ibid.
  34. Transjugular Intrahepatic Portosystemic Shunt (TIPS)
    https://www.radiologyinfo.org/en/info/tips?google=amp
  35. Ibid.
  36. Ibid.
  37. Ibid.
  38. Transjugular Intrahepatic Portosystemic Shunt (TIPS)
    https://www.radiologyinfo.org/en/info/tips
  39. TRANSJUGULAR INTRAHEPATIC PORTOSYSTEMIC SHUNT
    https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4251783/
  40. Transjugular Intrahepatic Portosystemic Shunt (TIPS)
    https://www.radiologyinfo.org/en/info/tips?google=amp
  41. Transjugular intrahepatic portosystemic shunt (TIPS)
    https://www.cirse.org/patients/ir-procedures/transjugular-intrahepatic-portosystemic-shunt-tips/
  42. TRANSJUGULAR INTRAHEPATIC PORTOSYSTEMIC SHUNT
    https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4251783/
  43. Transjugular Intrahepatic Portosystemic Shunt (TIPS)
    https://www.radiologyinfo.org/en/info/tips?google=amp
  44. Transjugular Intrahepatic Portosystemic Shunt (TIPS) for Cirrhosis
    https://www.uofmhealth.org/health-library/aa87494
  45. Transjugular Intrahepatic Portosystemic Shunt (TIPS)
    https://www.radiologyinfo.org/en/info/tips?google=amp
  46. UAB Medicine:TIPS for Patients
    https://www.uabmedicine.org/documents/142028/233977/TIPS+-+For+Patients/6adab560-10e7-43dc-b3db-15334a6ef978?version=1.0
  47. Transjugular Intrahepatic Portosystemic Shunt (TIPS)
    https://www.radiologyinfo.org/en/info/tips?google=amp
  48. Predictors of mortality after transjugular portosystemic shunt
    https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4832094/
  49. Ibid.
  50. TIPS – For Patients
    https://www.uabmedicine.org/documents/142028/233977/TIPS+-+For+Patients/6adab560-10e7-43dc-b3db-15334a6ef978?version=1.0

 

Need more?