TIPS Procedure Steps

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TIPS Procedure Overview

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.

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 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 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

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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

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