TRANSJUGULAR INTRAHEPATIC PORTO-SYSTEMIC SHUNT (TIPS)

Percutaneously created connection within the liver between the portal and systemic circulations

Placed to reduce portal pressure in patients with complications related to portal hypertension

Less invasive alternative to surgery in patients with end-stage liver disease.

Mainstay of nonsurgical treatment of PHT due to cirrhosis.

Highly effective as salvage therapy in high-risk patient with active variceal hemorrhage with failed endosopic scleropathy.

Goal – To reduce portal vein-hepatic vein gradient to ≤12mm Hg.

INDICATIONS :

1)Accepted indications -

A) Acute variceal bleeding that cannot be successfully controlled with medical treatment, including sclerotherapy

B) Recurrent and refractory variceal bleeding or recurrent variceal bleeding in patients who cannot tolerate conventional medical treatment, including sclerotherapy and pharmacologic therapy.

2) Unproven but promising indications -

A) Therapy for refractory ascites

B) Portal decompression in patients with hepatic venous outflow obstruction (Budd-Chiari syndrome), hepatic hydrothorax, or hepatorenal syndrome

3) Unproven uses -

A) Initial therapy of acute variceal hemorrhage

B) Reduction of intraoperative morbidity during liver transplantation

CONTRAINDICATIONS

1) Absolute contraindications ----

Right-sided heart failure with increased central venous pressure Polycystic liver disease Severe hepatic failure

2) Relative Contraindications-

Active intrahepatic or systemic infection Severe hepatic encephalopathy Hypervascular hepatic tumors PV thrombosis

PATIENT PREPARATION :

Prophylactic broad-spectrum antibiotics

Appropriate resuscitation with fluid and blood products prior to the procedure

Confirmation of PV patency by ---

1) Doppler sonography

2) arterial portography via the splenic or superior mesenteric artery

3) In the presence of reversed intrahepatic portal flow, the PV may not fill during arterial portography, than Magnetic resonance venography may have a promising role in assessing PV patency prior to TIPS

If platelet counts are less than 50,000 mm3 – administration of platlet

an international normalized ratio (INR) of greater than 2.0.= give FFP

Commercially available sets ----

a) Colapinto transjugular and biopsy set --16-gauge Colapinto puncture needle.

b) Rosch-Uchida transjugular liver access set

c) Angiodynamics TIPS set

d) Ring transjugular intrahepatic access set

APPROACH---

Right internal jugular- preferred becoz it provides direct straight line needle access to liver

Other- external jugular

left internal jugular

femoral v.

Procedure –

Initially, placement of 9F hemostatic sheath advanced into right atrium.

Recording of atrial pressure

Sheath is threaded into IVC

5F diagnostic catheter passed through sheath & advanced to liver

Balloon catheters introduced via the internal jugular vein can be passed down the superior and inferior vena cava into the hepatic veins(Usually right hepatic v; if blocked, than middle or left hepatic v. If all are blocked or stenosed, than creation of TRANSCAVAL INTRAHEPATIC PORTOSYSTEMIC SHUNT)

WEDGED CONTRAST VENOGRAPHY– to attempt to visualize intrahepatic portal vein - Typically, a 50-mL manual injection of CO2 is given which usually demonstrates the location of the main PV, as well as that of the left and right branches.

Now diagnostic catheter exchanged for COLAPINTO needle (length- 50 cm, 16 G,curved needle with 45 cm long teflon sheath).

Under radiological guidance, puncture across an appropriate strip of liver tissue can be achieved into a dilated portal branch. Balloon rupture and dilatation of this tissue 'window' can then be performed with relative safety, since the surrounding liver tissue provides some degree of support to the damaged tissue. Deployment of metallic stent within the shunt tract

Types of metallic shunts-----

Palmez Gianturco

Wallstent Strecker

Postplacement venography - pressures are measured to confirm adequate stent positioning, good flow through the TIPS, and reduction in the portosystemic gradient

COMPLICATIONS

Related to the puncture site

pneumothorax,

vessel or tissue injury

arteriovenous fistula formation

Placement of the catheter in the right atrium

cardiac dysrrhythmias

During the creation of the intrahepatic tract

Injury to the hepatic artery or bile ducts

Capsular tears result in life-threatening hemorrhage when they occur in association with a hepatic artery puncture

Portal venous puncture

After a newly placed TIPS

New onset or worsened encephalopathy

Predisposing factors -

preprocedural hepatic encephalopathy

Child class C cirrhosis

Large diameter and degree of portosystemic gradient reduction

Shunt stenosis and occlusion

Early shunt thrombosis (often within 24 h) is usually believed to be secondary to extension of the intrahepatic tract across a bile duct

And treated with balloon dilation of the stent. The use of covered (polytetrafluoroethylene [PTFE], polyester) stents

Deterioration of the patient's hemodynamic status Due to increases in cardiac output and central venous and pulmonary wedge pressures can result in acute pulmonary edema and congestive heart failure

ADVANCED TIPS TECHNIQUES

If standard portal venous access fails ---

to percutaneously place a transhepatic Chiba (Cook) needle, which can be used as a target under fluoroscopy to advance the Colapinto needle

Alternatively, puncture of a patent umbilical vein

If direct PV and right atrial pressures (measured to determine the portosystemic gradient) show a less-than-expected gradient, a competitive shunt (spontaneous splenorenal or large varices) should be excluded by advancing the catheter into the splenic or mesenteric vein and injecting bolus of contrast agent with digital imaging

If competitive shunt is present then Competitive shunts can be selectively embolized with coils

If no competitive shunt is found and if the gradient is less than 12 mm Hg, TIPS is not indicated

CLINICAL IMAGING FOLLOW-UP

patients undergo a baseline Doppler study within 24 hours of the procedure to document functional parameters

Doppler criteria for high sensitivity and specificity of shunt function

Surveillance ultrasonography is recommended at 3 and 6 months after the procedure and twice yearly thereafter

CAUSES FOR SHUNT FAILURE

1) Technical failure due to an anatomic situation that prevents acceptable portal venous puncture

2) Late stenosis and occlusion due to pseudointimal hyperplasia within the stent

more commonly, intimal hyperplasia within the hepatic vein.

TIPSS Malfunction

Direct signs

No flow – consistent with shunt occlusion or thrombosis.

Low-velocity flow – especially at portal venous end of shunt.

Change in peak shunt velocity – increase or decrease from baseline of 50cm/s.

Reversal of flow in hepatic vein.

Hepatopetal intrahepatic portal venous flow

Secondary signs

Reappearances of varices

Reaccumulation of ascites

Reappearance of recanalized paraumbilical vein

10% risk of encephalopathy

Shunt stenosis in 50% cases by 6 months ----- narrowing progresses with time