TIPS 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 Procedure 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