Transjugular intrahepatic portosystemic shunt

Abstract

Transjugular intrahepatic portosystemic shunt (TIPS) is an established procedure for the complications of portal hypertension. The largest body of evidence for its use has been supported for recurrent or refractory variceal bleeding and refractory ascites. Its use has also been advocated for acute variceal bleed, hepatic hydrothorax, and hepatorenal syndrome. With the replacement of bare metal stents with polytetrafluoroethylene-covered stents, shunt patency has improved dramatically, thus, improving outcomes. Therefore, reassessment of its utility, management of its complications, and understanding of various TIPS techniques is important.

Keywords: Ascites; Budd-Chiari syndrome; Esophageal varices; Hepatic hydrothorax; Hepatopulmonary syndrome; Hepatorenal syndrome; Transjugular intrahepatic portosystemic shunt; Venoocclusive disease.

Figure 1. TIPS Procedure for Portal Decompression

Adapted from Bhogal HK, Sanyal AJ. Using transjugular intrahepatic portosystemic shunts for complications of cirrhosis. Clin Gastroenterol Hepatol. 2011;9(11):936-46, with permission

Figure 2

Wedged hepatic venogram using an occlusion balloon from the right hepatic vein demonstrating normal portal venous anatomy.

Figure 3

Injection of contrast confirming placement of needle in a branch of the right portal vein.

Figure 4

Simultaneous injection of contrast through a marker pigtail catheter in the portal vein and sheath in the right hepatic vein demonstrating appropriate anatomy.

Figure 5

Angioplasty balloon dilating the transhepatic tract to 8 mm prior to stent placement.

Figure 6

Completion venogram through the pigtail catheter demonstrating appropriate flow from the portal vein through the TIPS shunt into the right hepatic vein and right atrium.

Figure 7. TIPS Procedure with ‘Gunsight Technique’

A: Intravascular US has been placed in the IVC and percutaneous access into the portal system has been obtained and confirmed with an injection of contrast through the needle. B: After puncturing through loopsnares in the right portal vein and IVC from a second percutaneous access, the wire was pulled through the IVC sheath and the tract between the two sheaths is being angioplastied with a small diameter balloon. C: The wire was pulled into the portal vein and advanced into the splenic vein from above and the tract is now being dilated to 8mm. D: Completion venogram through the pigtail catheter demonstrating appropriate flow from the portal vein through the TIPS shunt into the right hepatic vein and right atrium.