Transjugular Intrahepatic Portosystemic Shunt (TIPS)

Catie Gray

Background

  • Low resistant shunt between a portal vein branch and a hepatic vein placed by IR 
  • Bypasses fibrotic liver → reduced portal pressure→ treats complications of portal HTN (mainly variceal bleeding and refractory ascites) 
  • Using the smallest effective stent (≈8 mm PTFE-lined) help balance efficacy with low risk of hepatic encephalopathy (HE)

Indications for TIPS

  • Variceal hemorrhage (esophageal, gastric, etc.) 
    • Early (pre-emptive) TIPS: within 72 hrs (ideally <24 hrs) after endoscopic control in highrisk patients 
    • Child-Pugh B with active bleeding 
    • Child-Pugh C with recent bleeding 
    • Rescue TIPS: persistent or recurrent bleeding despite maximal endoscopic + pharmacologic therapy 
  • Refractory ascites (survival benefit) 
  • Other: bleeding portal hypertensive gastropathy, bleeding gastric varices, PVT recanalization, Budd-Chiari syndrome, hepatic hydrothorax

Contraindications for TIPS

  • Absolute contraindications: primary prevention of variceal bleeding, congestive heart failure, severe tricuspid regurgitation, severe pulmonary hypertension, multiple hepatic cysts or masses, sepsis, unrelieved biliary obstruction
  • Relative contraindications: Hepatic encephalopathy, hepatic tumors (especially if centrally located), thrombocytopenia (<20k), moderate pulmonary hypertension

Pre-procedure Preparation

  • Labs: CBC, CMP, INR 
  • Liver imaging to assess portal system patency and exclude liver masses 
    • Preferred: triple phase CT with contrast 
    • If renal dysfunction/active bleed: RUQ US w/ doppler
  • TTE to assess cardiac function, pulmonary HTN, valvular disease 
  • Antibiotic prophylaxis: ceftriaxone 1 g IV at time of procedure 
  • HE prophylaxis (high-risk): rifaximin starting ~2 weeks before and continued ≥6 months (would check to ensure covered by insurance prior to prescribing. If not covered or issues, can consider lactulose if not already on it)

Management post-TIPS

  • Observe overnight, monitor vitals and CBC 
    • Hemodynamic instability → STAT CBC ± CTA A/P (rule out bleeding) 
    • Increased venous return can unmask cardiac dysfunction 
    • RUQ US with Doppler at ~1 month (or earlier if recurrent ascites/bleeding) to confirm patency 
    • Refractory HE → consider TIPS reduction/revision 
    • Ascites improvement is delayed (6–12 weeks) → continue sodium restriction and diuretics until controlled.

Hemodynamic pressure measurements and goals 

  • Portal decompression is assessed by the portosystemic pressure gradient (PSPG) 
  • Target for pt with acute variceal bleeding: PSPG <12 mm Hg or ≥50% reduction 
    • If achieved, can stop NSBB therapy. 
  • Secondary prophylaxis: aim for PSPG <12 mm Hg 
  • If PSPG remains >12 mm Hg despite dilation to 10 mm → consider adding nonselective betablocker
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