Procedure Guide

TIPS Procedure Steps

Transjugular intrahepatic portosystemic shunt (TIPS) is a procedure in which an interventional radiologist creates a channel connecting the portal circulation with the hepatic venous circulation to treat moderate to severe portal hypertension. The newly created channel allows a portion of the portal blood flow to bypass the liver and flow directly from the portal circulation to the right heart via the hepatic veins. The TIPS procedure is a tool for treating both acute and chronic symptoms of portal hypertension such as variceal bleeding and refractory ascites. Performing the TIPS procedure can be a daunting procedure for many interventional radiologists. However, we are aiming to provide you with a solid understanding of the fundamentals, TIPS procedure steps, & techniques, to ensure the procedure is accomplished safely and efficiently.

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

TIPS Pre-Procedure Prep

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

TIPS Podcasts

Ep. 127

Portal Hypertension and Ascites Management

Interventional Radiologist Christopher Beck talks with Hepatologist Parvez Mantry about the management of Portal Hypertension and Ascites, and the importance of multi-disciplinary collaborative care for these patients.

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Ep. 126

TIPS University Senior Year: Gunsight Technique & Splenic Closure

It's Senior Year at TIPS University with Dr. Emmett Lynskey talking us through his Gunsight technique for TIPS placement, as well as how to perform a safe closure of splenic access.

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Ep. 125

TIPS University Junior Year: Advanced Techniques, ICE, and Splenic Access

Dr. Emmett Lynskey walks through advanced techniques for TIPS, including using Intracardiac Echocardiography (ICE) for placement, as well as transsplenic access for portal reconstruction.

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Ep. 124

TIPS University Sophomore Year: Basic Procedure Technique

It's Sophomore Year at TIPS University with Dr. Emmett Lynskey and Dr. Christopher Beck discussing basic procedure technique for Transjugular Intrahepatic Portosystemic Shunts (TIPS).

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TIPS Procedure Steps

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)

Access

• 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

TIPS Articles

Tools and Technical Tips for TIPS

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

Stiff Glide Wire for TIPS

Patient Selection for a TIPS Procedure

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

Catheter placement for transjugular intrahepatic portosystemic shunt

TIPS Post-Procedure

Post-Procedural 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

TIPS Demos

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.

TIPS Tools

Child-Pugh Score Calculator

The Child-Pugh Score calculator can be used to quickly assess the severity of cirrhosis, life expectancy, and risk of perioperative abdominal surgery mortality in patients with liver disease. To use this tool, you will need bilirubin, albumin, prothrombin time (INR), ascites, and encephalopathy grade. Each of these measures have corresponding categories in the Child-Pugh Score calculator that give 1, 2, or 3 points. After inputting your values, the calculator will provide the severity of cirrhosis based on Child-Pugh class, life expectancy, and abdominal surgery perioperative mortality rate.

Child-Pugh Score Calculator on BackTable

MELD Calculator

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

MELD Calculator on BackTable

Related Content

No related content.

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Podcast

TIPS University Freshman Year: Referrals and Pre-op Workup

TIPS University Freshman Year: Referrals and Pre-op Workup BackTable Podcast Guest Dr. Emmett Lynskey
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Podcast

Deep Dive Into Ascites

Deep Dive Into Ascites BackTable Podcast Guest Dr. Rajeev Suri
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Practice Tool

MELD Calculator

MELD Calculator on BackTable
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Demo Video

Transjugular Intrahepatic Portosystemic Shunt (TIPS)

Join The Discussion

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

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.