Portal Hypertension · IR Playbook

Transjugular Intrahepatic Portosystemic Shunt Creation (TIPS)

TIPS is the percutaneous creation of a stent-graft-lined channel between a hepatic vein and an intrahepatic portal vein branch, decompressing the portal system into the systemic circulation. The mechanism is diversion of portal inflow through a low-resistance conduit, which lowers the portosystemic pressure gradient and therefore variceal wall tension and ascites formation; the same diversion bypasses hepatocyte perfusion and first-pass metabolism, which is why hepatic encephalopathy and hepatic decompensation are the dominant complications rather than incidental ones. With PTFE-covered stent-grafts, primary patency at 1 year is approximately 80-90% and rebleeding rates are markedly lower than with bare stents. Post-TIPS overt hepatic encephalopathy occurs in roughly 20-45% of patients depending on selection.

Learning objectives

• Select patients for elective, preemptive and salvage TIPS using bleeding risk, ascites refractoriness, liver reserve and cardiac assessment.
• Identify the hepatic vein and portal vein anatomy that determines puncture direction, and recognise variants that mandate a change of approach.
• Size and position the stent-graft so that the covered portion spans the parenchymal tract without extending into the main portal vein or the IVC.
• Recognise the haemodynamic endpoint by direct gradient measurement and adjust shunt calibre accordingly.
• Recognise and manage intraprocedural capsular perforation, biliary injury and post-procedural hepatic encephalopathy or shunt dysfunction.

Indications

• Secondary prophylaxis of variceal haemorrhage after failure of combined endoscopic and pharmacological therapy.
• Preemptive (early) TIPS within 72 hours in high-risk patients with acute variceal haemorrhage, notably Child-Pugh C below 14 points or Child-Pugh B with active bleeding at endoscopy.
• Salvage TIPS for acute variceal haemorrhage uncontrolled by endoscopic and pharmacological measures or by balloon tamponade.
• Refractory or recidivant ascites in appropriately selected patients with preserved cardiac and cognitive function.
• Refractory hepatic hydrothorax.
• Bleeding from ectopic or gastric fundal varices, and gastric antral or portal hypertensive gastropathy bleeding refractory to medical therapy.
• Budd-Chiari syndrome with failure of anticoagulation and medical therapy.
• Portal vein thrombosis in cirrhosis where recanalisation is required to enable transplantation or to control complications.
• Portal decompression before major abdominal surgery in selected patients with clinically significant portal hypertension.

Absolute contraindications

• Severe right or left heart failure and severe pulmonary arterial hypertension.
• Severe uncorrected tricuspid regurgitation.
• Uncontrolled systemic or biliary sepsis.
• Multiple diffuse hepatic cysts or diffuse tumour precluding a safe parenchymal tract.

Relative contraindications

• Persistent overt hepatic encephalopathy despite therapy.
• Very advanced liver failure, for example MELD above 18-20 or bilirubin above 3 mg/dL in the elective setting, where post-TIPS liver failure risk is high.
• Extensive portal vein thrombosis with cavernoma.
• Hepatocellular carcinoma, particularly centrally located tumours along the intended tract.
• Uncorrectable severe coagulopathy or profound thrombocytopenia.
• Biliary obstruction, which increases the risk of shunt infection and biliary-shunt fistula.

Equipment

• Ultrasound machine with vascular probe for jugular access and optional transabdominal needle guidance
• 18 G access needle, 0.035 inch J wire, 10 Fr long vascular sheath with haemostatic valve
• 5 Fr multipurpose or Cobra catheter for hepatic vein selection
• Dedicated TIPS set with a curved metal cannula and 16 G Colapinto-type or Rosch-Uchida needle system
• CO2 delivery system for wedged portography
• 0.035 inch hydrophilic guidewire and stiff exchange wire, 260 cm
• 5 Fr pigtail catheter or marker pigtail for portal venography and tract measurement
• 8-12 mm high-pressure angioplasty balloons, 4-8 cm length
• PTFE-covered TIPS stent-graft, 8 or 10 mm diameter, covered lengths 5-8 cm with a 2 cm uncovered portal segment
• Pressure transducer and manifold for right atrial, hepatic vein and portal vein pressure measurement
• Microcatheter, coils and sclerosant or glue for adjunctive variceal embolisation

Procedure steps

1. Position supine with the head turned left and the neck extended. Under ultrasound guidance puncture the right internal jugular vein and place a 10 Fr long sheath over a stiff wire into the IVC. Ultrasound guidance is used rather than landmark puncture because carotid puncture in a coagulopathic patient is difficult to compress.
2. Advance a catheter to the right atrium and record pressure with the transducer zeroed at the mid-axillary line. This value is the systemic reference used later to calculate the portosystemic gradient, so it must be recorded before any volume shifts occur.
3. Catheterise the right hepatic vein with a multipurpose or Cobra catheter and hydrophilic wire and perform a hepatic venogram in a shallow left anterior oblique projection. Confirm you are in the true right hepatic vein and not an accessory vein by its cranial insertion into the IVC and its lateral course, and note the vein calibre and angle, which determine whether the standard anterior throw is feasible.Pearl: A wedged hepatic venogram or free venogram in two projections confirms which vein you occupy before you commit to a puncture direction.
4. Wedge a balloon occlusion or end-hole catheter peripherally in the hepatic vein and hand-inject CO2 briskly to opacify the portal branches retrogradely, acquiring at frame rates that capture the transient portal filling. Watch for the position of the portal bifurcation and its distance and direction from the hepatic vein; if the portal vein does not opacify, reposition more peripherally rather than increasing injection force.Pearl: CO2 rather than iodinated contrast is used because it crosses the sinusoids readily and opacifies the portal vein without a nephrotoxic load.
5. Advance the curved metal cannula of the TIPS set over the wire into the right hepatic vein, positioning its tip 1-2 cm from the IVC confluence, and rotate the curve anteriorly. A puncture taken too close to the ostium risks an extrahepatic course into the IVC or the retroperitoneum; a puncture taken too peripherally lengthens the tract and may not reach the portal vein.
6. With the cannula rotated anteriorly (or posteriorly if working from the middle hepatic vein), advance the 16 G needle 3-5 cm in a firm single throw toward the mapped target, then withdraw slowly under gentle aspiration. Free blood return with dark, non-pulsatile flow suggests portal entry; confirm with a small hand injection of contrast showing hepatopetal portal branches, and abandon that pass immediately if you see biliary radicles, arterial pulsation or a parenchymal blush.Pearl: Suspend respiration in the same phase for mapping and for the throw, so that the target has not moved between the roadmap and the puncture.
7. Advance a hydrophilic wire deep into the splenic or superior mesenteric vein and exchange for a pigtail catheter. Perform portal venography to define the exact portal entry site, opacify varices, and measure the distance from portal entry to hepatic vein along the tract using a marker catheter — this measurement determines the covered stent length you will need.
8. Record direct portal vein pressure and subtract the right atrial pressure to obtain the baseline portosystemic gradient. This is the reference against which the technical endpoint is judged; a gradient that is unexpectedly low should prompt you to question whether you are truly in the portal vein.
9. Exchange for a stiff 260 cm wire, advance a 6-8 mm balloon across the parenchymal tract and dilate to create a waist-free channel and to define the tract limits fluoroscopically. The residual waists mark the hepatic vein and portal vein entry points, which is how you plan the covered segment landing zones.
10. Deploy the dedicated PTFE-covered endoprosthesis so that the 2 cm uncovered segment lies within the portal vein and the covered portion spans the entire parenchymal tract to the hepatic vein-IVC junction without protruding into the IVC or the main portal vein. Watch the portal-end marker during unsheathing and adjust before full release, because a covered segment left short of the portal entry exposes bare parenchyma and predicts early tract stenosis.Pearl: Extension into the right atrium or across the hepatic vein ostium compromises future transplant hepatectomy and should be avoided in transplant candidates.
11. Dilate the stent to 8 mm initially, repeat portography and remeasure the portosystemic gradient. If the gradient remains above target, dilate further toward 10 mm; if it falls excessively in a patient at high encephalopathy risk, accept an underdilated 8 mm shunt rather than a fully expanded one.Pearl: Underdilating an 8 mm covered stent-graft is a controlled way to titrate decompression while retaining the option to dilate further at a later session.
12. If varices remain opacified on the completion portogram despite an adequate gradient, catheterise the feeding vein with a microcatheter and embolise with coils, with or without a sclerosant or glue. Persistent filling indicates that decompression alone has not removed the bleeding risk from that channel.
13. Perform a final portogram and shunt venogram to document flow direction and stent position, remove the sheath and achieve haemostasis at the jugular site with manual compression.

Complications

• Intraperitoneal haemorrhage
• Hepatic encephalopathy
• Acute-on-chronic liver failure
• Shunt dysfunction
• Haemobilia and biliary-shunt fistula
• Hepatic artery injury or arterioportal fistula
• Cardiac decompensation and pulmonary oedema
• Shunt infection (endotipsitis)
• Contrast-induced or hepatorenal acute kidney injury

Exam pearls

• The right portal vein lies anterior and caudal to the right hepatic vein, which is why the transjugular needle is thrown anteriorly from a right hepatic vein origin; from the middle hepatic vein the throw is reversed to posterior.
• The post-shunt haemodynamic target differs by indication: below 12 mmHg for variceal haemorrhage, but only a 20-50% reduction from baseline for refractory ascites, because over-decompression causes encephalopathy and liver failure.
• Wedged CO2 portography is preferred over iodinated contrast for portal mapping because CO2 crosses the sinusoids readily and avoids a nephrotoxic contrast load in patients who often have hepatorenal physiology.
• PTFE-covered TIPS endoprostheses carry a 2 cm uncovered portal segment; the covered portion must span the entire parenchymal tract, and leaving bare tract at either end predicts early stenosis.
• Hepatic encephalopathy after TIPS peaks in the first month, and refractory cases are managed by shunt reduction with a constrained or reducing stent rather than by outright occlusion.
• Severe right heart failure, severe pulmonary hypertension and uncontrolled sepsis are absolute contraindications to TIPS, because the shunt acutely increases preload and becomes an infected foreign body respectively.

Viva questions

You are working from the middle hepatic vein rather than the right. Which way do you throw the needle, and why?

Posteriorly and to the right, because the portal branches lie posterior to the middle hepatic vein, the reverse of their relationship to the right hepatic vein. Throwing anteriorly from the middle hepatic vein drives the needle out through the anterior liver surface into the peritoneum.

Your post-TIPS gradient is 6 mmHg in a 68-year-old with refractory ascites and a past episode of encephalopathy. Are you satisfied?

No — this is over-decompression for an ascites indication in a high-risk patient. The target is a 20-50% reduction from baseline, not the sub-12 mmHg target used for variceal bleeding, because excessive portal diversion in an elderly patient with prior encephalopathy predicts disabling encephalopathy and hepatic insufficiency.

During a needle pass you aspirate bile. What do you do, and what are you now worried about downstream?

Abandon that tract and select a different puncture plane rather than dilating it. A biliary communication within a stented tract creates a biliary-shunt fistula, causing haemobilia and early shunt thrombosis because bile is strongly thrombogenic.

Why is the stent-graft covered, and why is the portal 2 cm left bare?

The PTFE covering excludes the parenchymal tract from bile ingress and from pseudointimal hyperplasia, which is what raised 1-year primary patency to around 80-90% compared with bare stents. The uncovered portal segment anchors the device in the portal vein without covering and occluding contralateral portal branches.

A patient with refractory ascites has severe tricuspid regurgitation on echocardiography. Defend your decision.

I would not proceed. The shunt abruptly increases venous return and right-sided preload, and a right heart that cannot accommodate it decompensates into pulmonary oedema and low-output failure. Severe right heart disease is an absolute contraindication rather than a caution.

Six months after TIPS, ascites recurs but Doppler ultrasound reports a patent shunt. Next step?

Proceed to shunt venography with direct portosystemic gradient measurement. Doppler is a screening test that misses stenoses within covered stents, and clinical recurrence of the index complication is itself an indication for venography irrespective of the ultrasound result.

Which patients with acute variceal bleeding get preemptive TIPS rather than TIPS after endoscopic failure?

High-risk bleeders — Child-Pugh C below 14 points, or Child-Pugh B with active bleeding at endoscopy — treated within 72 hours, ideally 24 hours. In this group early shunting improves both bleeding control and survival compared with waiting for endoscopic and pharmacological therapy to fail.

Your patient has a large spontaneous splenorenal shunt on CT. How does that change your plan?

It competes with the TIPS for portal flow, so the shunt may fail to decompress varices adequately and the patient is at higher risk of refractory encephalopathy. I would plan for possible concurrent or subsequent embolisation of the splenorenal shunt and counsel the patient specifically about encephalopathy.

References