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Transjugular intrahepatic portosystemic shunt
From WikEM
Background
- Mnimally invasive procedure performed by IR
- Creation of a stent connection between the right hepatic vein and portal vein
- Shunts blood flow from the portal venous system to systemic circulation
- Decreases portal venous pressure to <12 mmHg
Indications
- Portal venous hypertension
- Refractory variceal bleeding after endoscopic (sclerotherapy or band ligation) and pharmacologic (octreotide or vasopressin) therapy
- Recurrent cirrhotic ascites that is not responsive to medical treatment and requires frequent large volume paracentesis
- Controversial indications include Budd-Chiari Syndrome, hepatorenal syndrome, hepatic hydrothorax, hepatopulmonary syndrome and bridge therapy while awaiting liver transplantation
Contraindications
- Congestive heart failure
- Tricuspid valve regurgitation
- Pulmonary hypertension
- Sepsis
- Hepatic malignancy, large masses or cysts
- Severe coagulopathy
- Biliary obstruction
Complications
- Portosystemic encephalopathy
- Most common complication
- Presents as extreme sleep disturbance, altered mental status, and coma
- Hyperammonemia
- Can be precipitated by many factors including increased protein intake, infection, gastrointestinal bleed, poor medication compliance, and dehydration
- Occurs approximately 6 weeks or more after TIPS
- Treatment is medical management – lactulose, neomycin, rifaximin, protein restriction
- TIPS thrombosis
- ~4 weeks after TIPS
- Doppler sonography or angiography shows thrombus and/or occlusion
- Treatment: anticoagulation, thrombolysis, or thrombectomy
- TIPS stenosis
- May present with recurrent variceal bleeding or worsening portal hypertension
- ~3 months to 2 years after TIPS
- Angiography is the gold standard for diagnosis
- Treatment is dilation or placement of new or additional stents
- TIPS-associated hemolysis
- Presentation includes anemia, increased bilirubin, and increased reticulocyte count
- <1-2 weeks after TIPS
- Self-limiting and resolves within 8-12 weeks
- Infection
- Fever and bacteremia
- Occurs within weeks to months after TIPS
- Doppler sonography shows vegetations or venous thrombus
- Treatment is intravenous antibiotics
- Intraperitoneal hemorrhage
- Seen primarily during the immediate post-procedure period
- Occurs due to injury to nearby vasculature during TIPS
- Rare occurrence
- Stent migration
- Stent may travel into the Inferior Vena Cava
- Most serious complication is migration into the heart
- ECG, Doppler sonography, and echocardiogram helpful for diagnosis
- Treatment is surgery or Interventional Radiology for retrieval
Outcomes
- TIPS provides salvage therapy for variceal bleeding, refractory ascites, and portal hypertension when medical therapy fails
- Despite providing improvement in portal hypertension, the procedure does not decrease overall mortality in end stage liver disease
References
- Boyer TD, Haskal ZJ. American Association for the Study of Liver Diseases. The Role of Transjugular Intrahepatic Portosystemic Shunt (TIPS) in the Management of Portal Hypertension: update 2009. Hepatology. 2010;51(1:1-16).
- Subramanian R, McCashland T. Chapter 82. Gastrointestinal Hemorrhage. In: Hall JB, Schmidt GA, Wood LH. eds. Principles of Critical Care, 3e. New York, NY: McGraw-Hill; 2005.
- Wendler C, Shoenberger JM, Mailhot T. Transjugular Intrahepatic Portosystemic Shunt (TIPS) Migration to the Heart Diagnosed by Emergency Department Ultrasound. West J Emerg Med. 2012;13(6:525-6).
