Transjugular intrahepatic portosystemic shunt (TIPS or TIPSS) is an artificial channel within the liver that establishes communication between the inflow portal vein and the outflow hepatic vein. It is used to treat portal hypertension (which is often due to liver cirrhosis) which frequently leads to intestinal bleeding, life-threatening esophageal bleeding (esophageal varices) and the buildup of fluid within the abdomen (ascites). An interventional radiologist creates the shunt using an image-guided endovascular (via the blood vessels) approach, with the jugular vein as the usual entry site.
History The procedure was first described by Josef Rösch in 1969 while working as a research fellow with Charles Dotter, the "Father of Interventional Radiology," at Oregon Health and Science University. Dr. Rösch became a visiting professor at the University of California, Los Angeles, where he made an accidental entry into the peripheral portal venous branch while attempting a diagnostic transjugular cholangiogram on a canine model that became the first TIPS. They began researching how to maintain the shunts by experimenting with Teflon tubes and silicone-covered spring coils; the primary challenge was to find a material that could remain open (patent) and not clot(thrombose). It was first used in a human patient by Dr. Ronald Colapinto of the University of Toronto in 1982, who created the first human balloon dilated TIPS, but did not become reproducibly successful until the development of self-expanding bare endovascular stents in 1985. In 1988 the first successful TIPS was realized by M. Rössle, G.M. Richter, G. Nöldge and J. Palmaz at the University of Freiburg. The American Association for the Study of Liver Disease established practice guidelines for "role of TIPS in the management of portal hypertension" in 2005 and added Budd-Chiari syndrome as an additional indication in 2009. The procedure has since become widely accepted as the preferred method for treating portal hypertension that is refractory to medical therapy, replacing the surgical portacaval shunt in that role.
Indications and Contraindications TIPS is a life-saving procedure in bleeding from esophageal or gastric varices. A randomized study showed that the survival is better if the procedure is done within 72 hours after bleeding.
Indications TIPS is indicated for patients with severe liver disease causing ascites that keeps recurring and does not respond to other treatment (refractory ascites), recurrent buildup of fluid around the lungs (refractory hepatic hydrothorax), hepatorenal syndrome, hepatopulmonary syndrome, Budd-Chiari syndrome, and is a secondary form of prevention for life-threatening bleeding from dilated veins in the esophagus or stomach (esophageal varices or gastric varices).
Contraindications Absolute contraindications for TIPS include congestive heart failure, pulmonary hypertension, severe infection (sepsis), presence of blockage of the bile duct system (biliary obstruction), and presence of extensive hepatic cysts. TIPS should not be used as primary prevention of variceal hemorrhage, for example, when a patient is actively bleeding from esophageal or gastric varices. Patients should be hemodynamically stabilized before performing a TIPS procedure. Other relative contraindications for TIPS include presence of liver cancer, portal vein or hepatic vein thrombosis or other occlusion, severe bleeding disorders or low platelet count (coagulopathy), and advanced hepatic encephalopathy. TIPS may worsen hepatic encephalopathy. There is some debate on whether TIPS can be done concurrently with mechanical thrombectomy (removal of a blood clot) for patients with active portal venous thrombosis. It is suggested that simultaneous treatment can restore portal vein flow with good patency (>84%) 1 year after the procedure.
Complications Severe procedural complications during a TIPS procedure, including catastrophic bleeding or direct liver injury, are relatively uncommon. In the hands of an experienced physician, operative mortality is less than 1%. On the other hand, up to 25% of patients who undergo TIPS will experience transient post-operative hepatic encephalopathy caused by increased porto-systemic passage of nitrogen from the gut. A less common, but more serious complication, is hepatic ischemia causing acute liver failure. While healthy livers are predominantly oxygenated by portal blood supply, long-standing portal hypertension results in compensatory hypertrophy of and increased reliance on the hepatic artery for oxygenation. Thus, in people with advanced liver disease the shunting of portal blood away from hepatocytes is usually well tolerated. However, in some cases suddenly shunting portal blood flow away from the liver may result in acute liver failure secondary to hepatic ischemia. Acute hepatic dysfunction after TIPS may require emergent closure of the shunt. A rare but serious complication is persistent TIPS infection, also known as endotipsitis. Lastly, the TIPS may become blocked by a blood clot or in-growth of endothelial cells and no longer function. This has been significantly reduced with the use of polytetrafluoroethylene (PTFE)–covered stents.
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