Transjugular Intrahepatic Portosystemic Shunt

Transjugular Intrahepatic Portosystemic Shunt

FINAL (2)-150.png
BackTABLEfinal-2tone_edited.png

© 2020 by Backtable. All rights reserved.

Disclaimer: The Materials available on BackTable.com are for informational and educational purposes only and are not a substitute for the professional judgment of a healthcare professional in diagnosing and treating patients.

Pre-Procedure

Indications:
• Prevention of variceal bleeding
• Refractory ascites
• Budd-Chiari syndrome
• Hepatic veno-occlusive disease
• Refractory hepatic hydrothorax
• Acutely bleeding gastric or esophageal varices
• Hepatorenal syndrome
• Hepatopulmonary syndrome

Contraindications:
• Some physicians maintain there are no absolute contraindications to TIPS. Contraindications should be considered in the overall clinical picture
• Absolute: right-sided heart failure, encephalopathy, severe hepatic failure, uncontrolled sepsis
• Relative: biliary obstruction, malignancy, portal vein thrombosis, polycystic liver disease or liver masses.

Patient Evaluation:
• Review prior imaging CT and/or US to confirm portal and hepatic vein patency
• MELD score
• Stress echo: ask Cardiologist to comment on signs of right heart failure and how patient may tolerate increased preload
• Coagulation and platelets. Give platelets if <50,000. Give FFP if INR >2.0
• Some operators do not give platelets and some reserve platelet transfusion for during the TIPS
• Important to have patient typed and cross for potential blood products
• Preprocedure antibiotics - 1 g Ancef
• Consider anesthesia support for the procedure.

Procedure

Antibiotic:
• 1 g ceftriaxone (Rocephin) IV
• Vancomycin or Clindamycin for PCN allergy

Ascites:
• Paracentesis prior to procedure has advantages
• Creates more favorable angle to catheterize the hepatic vein
• Liver may be less mobile for portal puncture

Different TIPS sets:
• Haskal Transjugular Liver Access Set (Cook)
• Rösch-Uchida Transjugular Liver Access Set (Cook)
• Ring Transjugular Intrahepatic Access Set (Cook)

Steps of procedure:

Access right internal jugular and place sheath in right atrium
• Obtain right atrial pressure

Select right hepatic vein
• MPA commonly used
• Venogram to confirm position
• If unsure if right vs middle hepatic vein position, try lateral view or US
• Arrow on the metal cannula should point posterolateral

CO2 portogram
• Not necessary but may help to identify portal vein and bifurcation
• Can obtain with endhole catheter wedged in hepatic vein or balloon occlusion catheter
• Can also stick liver parenchyma with TIPS needle and injection into parenchyma

Portal venous puncture
• Advance sheath into hepatic vein over stiff wire such as an Amplatz (Boston Scientific) for more stable access
• Make pass 2-3 cm from origin of hepatic vein, can make adjustments depending on anatomy and success at this location
• Target is right portal vein 1-2 cm distal to bifurcation
• If access is too central, bifurcation may be extrahepatic which can lead to life-threatening hemorrhage
• If access too peripheral, acute angulation between hepatic and portal vein can make stent placement difficult
• Once pass is made, attach slip tip syringe half filled with dilute contrast and aspirate (without fluoroscopy) until blood return
• After blood return, fluoro and puff contrast to visualize needle tip location: portal vs hepatic vein

Catheterize portal vein
• Glidewire Advantage (Terumo) useful with floppy tip and stiff body
• If wire continues to advance peripherally, consider Bentson wire (Boston Scientific) which may initially advance laterally but stiff body should buckle centrally toward portal vein
• May also need angled catheter through TIPS needle if wires cannot be directed centrally
• Position wire into SMV for stable access

Portogram and pressure measurements
• Place marking pigtail catheter into portal vein for pressure measurements
• Obtain hepatic venous pressure measurements
• Perform portogram; can simultaneously inject sheath positioned in hepatic vein
• Evaluate: hepatic vein/IVC confluence, estimated length of stent (add 2 cm to measurement to account for projection overlap)

Place stent
• Viatorr TIPS Endoprosthesis (Gore): polytetrafluoroethylene (PTFE) graft with distal 2 cm uncovered portion
• 2 cm uncovered portion will be in portal system, covered proximal segment will extend from parenchymal tract into hepatic vein
• Proximal landing zone: from junction of the hepatocaval confluence to 1 cm within hepatic vein
Advance sheath into portal vein
• After portal vein puncture, TIPS set can be advanced over a stiff wire into portal system, which simultaneously dilates parenchymal tract
• Alternatively, may need to predilate tract with 8 cm balloon. Waists of balloon will demarcate portal vein and hepatic vein parenchymal entry/exit points
• As balloon is deflated, can advance sheath over angioplasty balloon into portal vein
With sheath in portal vein, advance selected Viatorr stent into right portal vein
• Position sheath/stent slightly more central than the optimal landing zone
• Unsheath the uncovered, distal 2 cm of stent
• Withdraw sheath and partially uncovered stent until resistance is met - this is when uncovered stent abuts the parenchymal tract
• Unsheath remainder of stent and deploy
Dilate stent
• Carefully advance 7-12 mm balloon for angioplasty
• Start with 7 mm balloon and check pressures
• Post dilate to achieve desired pressure gradient

Portosystemic gradient
• Variceal hemorrhage: < 12 mmHg or 50% reduction from baseline
• Refractory ascites: < 8 mmHg

Final portogram
• Confirm patency of TIPS and evaluate flow to remainder of liver
• Evaluate for persistent varices for potential embolization

Post-Procedure

Postprocedural care:
• Close monitoring and depending on indication, may need ICU management
• If right atrial pressure is >10 mmHg following TIPS placement consider diuresis with 10-20 mg Lasix
• Monitor for encephalopathy
• Lactulose: titrate to 3 loose bowel movements/day.
• Better to give multiple dose of lactulose throughout the day (TID) rather than single dose
• Rifaximin 550 mg BID (if insurance will cover)

Complications:
Minor
• Encephalopathy (10-25%)
• Contrast induced nephropathy
• Fever
• Pulmonary edema
Major
• Hemobilia
• Hepatic artery injury
• Stent malposition/migration
• Hemoperitoneum
• Renal failure

Related Procedures

No related procedures.

Step-by-step guidance on how to perform Transjugular Liver Biopsy. Review tools, techniques, pearls, and pitfalls on the BackTable Web App.
 

References

[1] RiChard J, Thornburg B. New Techniques and Devices in Transjugular Intrahepatic Portosystemic Shunt Placement. Semin Intervent Radiol. 2018;35(3):206‐214. doi:10.1055/s-0038-1660800
[2] Chehab MA, Thakor AS, Tulin-Silver S, et al. Adult and Pediatric Antibiotic Prophylaxis during Vascular and IR Procedures: A Society of Interventional Radiology Practice Parameter Update Endorsed by the Cardiovascular and Interventional Radiological Society of Europe and the Canadian Association for Interventional Radiology. J Vasc Interv Radiol. 2018;29(11):1483-1501.e2. doi:10.1016/j.jvir.2018.06.007
[3] Keller FS, Farsad K, Rösch J. The Transjugular Intrahepatic Portosystemic Shunt: Technique and Instruments. Tech Vasc Interv Radiol. 2016;19(1):2‐9. doi:10.1053/j.tvir.2016.01.001
[4] Bercu ZL, Fischman AM, Kim E, et al. TIPS for refractory ascites: a 6-year single-center experience with expanded polytetrafluoroethylene-covered stent-grafts. AJR Am J Roentgenol. 2015;204(3):654‐661. doi:10.2214/AJR.14.12885[
[5] Gaba RC, Khiatani VL, Knuttinen MG, et al. Comprehensive review of TIPS technical complications and how to avoid them. AJR Am J Roentgenol. 2011;196(3):675‐685. doi:10.2214/AJR.10.4819
[6] García-Pagán JC, Caca K, Bureau C, et al. Early use of TIPS in patients with cirrhosis and variceal bleeding. N Engl J Med. 2010;362(25):2370‐2379. doi:10.1056/NEJMoa0910102
[7] Ferral H, Bilbao JI. The difficult transjugular intrahepatic portosystemic shunt: alternative techniques and "tips" to successful shunt creation. Semin Intervent Radiol. 2005;22(4):300‐308. doi:10.1055/s-2005-925556

Join The Discussion

 

Demos

Demos are not yet available for this procedure.

Please check back soon.

TIPS by Dr. Robert Gish

A mini lecture by Dr. Bob Gish on TIPSS, also known as transjugular intrahepatic portosystemic shunt or transjugular intrahepatic portosystemic stent shunting. During this procedure, a shunt is created using an image-guided endovascular approach with the jugular vein as the entry site.

Transjugular Intrahepatic Portosystemic Shunt (TIPS)

Overview and demo of TIPS treatment for select patients with portal hypertension.

 

Tools

Tools are not yet available for this procedure.

Please check back soon.

MELD Calculator

MELD Calculator on BackTable

Model for End-Stage Liver Disease. Stratifies severity of end-stage liver disease, for transplant planning.

 

Literature

Literature is not yet available for this procedure.

Please check back soon.

Seminars in Interventional Radiology (Jun 2015)

Transjugular Intrahepatic Portosystemic Shunt-Related Complications and Practical Solutions

This article provides an overview of the spectrum of periprocedural and delayed complications related to the performance of TIPS and offers the reader pearls for both avoiding and managing those complications.

New England Journal of Medicine (Jun 2010)

Early Use of TIPS in Patients with Cirrhosis and Variceal Bleeding

Cirrhosis patients hospitalized for acute variceal bleeding and at high risk for treatment failure benefit from early use of TIPS.

American Journal of Roentgenology (Mar 2011)

Comprehensive Review of TIPS: Technical Complications and How to Avoid Them

The goal of this article is to describe potential technical complications related to transjugular intrahepatic portosystemic shunts (TIPS) placement and to discuss strategies to avoid and manage complications if they arise.

 

Podcasts

Podcasts are not yet available for this procedure.

Please check back soon.

TIPS Procedure Techniques Podcast with Dr. Peter Bream

Dr. Peter Bream

Dr. Peder Horner

East Coast "McBreamy" and "Western Peder" discuss their Colapinto vs. Uchida needle preference, advantages of the ICE catheter, and other pearls and pitfalls for the TIPS Procedure.

&

 

Blog Articles

Blog articles are not yet available for this procedure.

Please check back soon.

bt-procedure-feed-arterial-revasculariza

Patient Selection for a TIPS Procedure

Transjugular intrahepatic portosystemic shunt (TIPS) practices, patient selection, TIPS alternatives, and adjunctive therapy.

bt-procedure-feed-arterial-revasculariza

Tools and Technical Tips for TIPS

Imaging work-up prior to elective TIPS procedure, preferred tools for executing TIPS, and TIPS technique.