Transjugular intrahepatic porto systemic shunt

2. A transjugular intrahepatic portosystemic shunt
(TIPS) is a percutaneously created connection
within the liver between the portal and systemic
circulations.

4. A TIPS is placed to reduce portal pressure in
patients with complications related to portal
hypertension.

5. This procedure has emerged as a less invasive
alternative to surgery in patients with end-stage
liver disease.

6. The goal of TIPS placement is to divert portal
blood flow into the hepatic vein, so as to reduce
the pressure gradient between portal and
systemic circulations.
Shunt patency is maintained by placing an
expandable metal stent across the intrahepatic
tract.

7. Acute variceal bleeding that cannot be
successfully controlled with medical treatment,
including sclerotherapy.
Recurrent and refractory variceal bleeding

8. Therapy for refractory ascites.
Portal decompression in patients with hepatic
venous outflow obstruction (Budd-Chiari
syndrome) or hepatorenal syndrome.

9. Initial therapy of acute variceal hemorrhage
Initial therapy to prevent initial or recurrent
variceal hemorrhage
Reduction of intraoperative morbidity during liver
transplantation.

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

12. Active intrahepatic or systemic infection (bacteria
can colonize the stent, causing persistent
infection)
Severe hepatic encephalopathy poorly controlled
with medical therapy

13. Hypervascular hepatic tumors
PV thrombosis (Although PV thrombus may make
the procedure more technically demanding, it is
not an absolute contraindication to TIPS
placement.)

14. prophylactic broad-spectrum antibiotics.
Appropriate resuscitation with fluid and blood
products.
 Portal vein (PV) patency should be confirmed prior
to attempts at TIPS placement by Doppler
sonography, arterial portography and MRI.

15. In Patients with cirrhosis severe coagulopathy
should be addressed prior to procedure.

19. This technique is preferably done under general
anesthesia
 After puncture of the jugular vein (most often the
right jugular vein) under sonographic guidance, a
catheter is introduced into one hepatic vein and
wedged in the liver parenchyma.

20. Gentle injection of dye allows the retrograde
visualization of intrahepatic portal vein branches.
CO2 can be used in patients with renal function
impairment to avoid dye nephrotoxicity.

21. The intrahepatic portal vein then is entered with a
modified Ross needle.
A guide wire is advanced into the main portal vein.

22. The tract between the hepatic and the portal vein
is dilated with an angioplasty balloon catheter (8–
10 mm) followed by stent placement to maintain
the communication between both vessels patent

23. Basic transjugular intrahepatic portosystemic shunt (TIPS) procedure. A
curved catheter is placed into the right hepatic vein.

24. A wedged hepatic venogram obtained by using the digital subtraction technique
obtained with CO2 gas demonstrates the location of the portal vein. The catheter is
wedged in a branch of the right hepatic vein.

25. Image demonstrates advancement of a Colapinto needle into the
right portal vein.

26. A TIPS (10 X 68 mm Wallstent dilated with 10 mm X 4 cm balloon) has been
placed. Note flow through the Wallstent and filling of the splenorenal shunt

28. Shunt surveillance:at regular 3 to 6month intervals
for Assessment of:
MORPHOLOGY
Ascites
Portosystemic collaterals
Size of spleen
Diameter of stent (usually 8 to 10 mm)
Configuration of stent: areas of narrowing
Extension of stent into portal + hepatic veins

29. HEMODYNAMICS
Direction of flow in: extrahepatic portal vein, R + L portal
vein, SMV, splenic vein, all 3 hepatic veins, intrahepatic
IVC, paraumbilical vein, coronary vein
Peak blood flow velocity within main portal vein
Peak blood flow velocity within proximal + mid + distal
aspects of stent

31. 1.Shunt velocity of <50 cm/sec
2.Increase or decrease in shunt
velocity of >50cm/sec compared
with initial post-procedure value
3.Hepatofugal flow in main portal
vein

32. COMPLICATIONS
(A) Obstruction to flow
Shunt obstruction (38%)
Hepatic vein stenosis

33. (B)Trauma
(a)Vascular injury
Hepatic artery pseudoaneurysm
Arterioportal fistula
Intrahepatic/subcapsular hematoma
Hemoperitoneum (due to penetration of liver
capsule)

34. (b)Biliary injury
Transient bile duct dilatation (due to
hemobilia)
Bile collection
(C) Stent dislodgment with embolization to right
atrium, pulmonary artery, internal jugular vein .

36. Follow up with duplex sonography and shunt
angiography
Early shunt occlusion <30 days: thrombosis (local
thrombolytic treatment, redilation, restenting)
Late: intimal thickening within the stent or hepatic
vein ( dilation or another stent)

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