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Gastrointestinal (GI) System ORGAN SYSTEMS

Transjugular intrahepatic portosystemic shunt (TIPS)

Percutaneous image-guided procedure in which a tract or conduit is constructed within the liver between the systemic venous system and portal system with an intent for portal decompression

Percutaneous image-guided procedure in which a tract or conduit is constructed within the liver between the systemic venous system and portal system with an intent for portal decompression

TIPS Procedure for Portal Decompression | Bhogal HK, Sanyal AJ. Using transjugular intrahepatic portosystemic shunts for complications of cirrhosis. Clin Gastroenterol Hepatol. 2011;9(11):936-46,

Procedure

The shunt itself is created by placing a stent between the portal vein and the hepatic vein. The resultant shunting of portal venous flow to the systemic circulation helps reduce the portosystemic gradient and alleviate bleeding and ascites without changing the extrahepatic anatomy.

The most common conduit is between the right hepatic vein (HV) and the right portal vein (PV).

Schemes of a transjugular intrahepatic portosystemic shunt (TIPS) (A) and a direct intrahepatic portosystemic shunt (DIPS) (B). A, TIPS (original procedure) is created by stenting between the right (Rt.) branch of the portal vein (PV) and the Rt. hepatic vein (HV). B, DIPS is a modified TIPS procedure in which direct stent insertion is carried out from the inferior vena cava (IVC) into the PV through the caudate lobe under intravascular ultrasound (IVUS) guidance. | Kawahara, Y., Tanaka, Y., Isoi, N., Hatanaka, K., Yamada, K., Yamamoto, M., Okamura, T., Kaji, T., Sakamoto, T., Saitoh, D. and Ikeuchi, H. (2017), Direct intrahepatic portocaval shunt for refractory hepatic hydrothorax: a case report. Acute Med Surg, 4: 306-310. https://doi.org/10.1002/ams2.257

Clinical indications

  • Refractory variceal hemorrhage
  • Refractory ascites
  • Hepatorenal syndrome (types 1 and 2)
  • Portal hypertensive gastropathy
  • Hepatic hydrothorax
  • Hepatopulmonary syndrome
  • Budd-Chiari syndrome
  • Hepatic Veno-occlusive disease
Fluoroscopy and angiography in a 64-year-old man with refractory pleural effusion caused by portal hypertension. Imaging was carried out during the direct intrahepatic portosystemic shunt procedure. Fluoroscopy image during angiogram showing a guide wire (GW) and 4-Fr catheter penetrating from the inferior vena cava (IVC) to the portal vein (PV) through the caudal lobe of the liver. This was a direct portosystemic shunt to the IVC that corresponded to the segment between the two arrowheads. A, Digital subtraction angiogram showing portosystemic shunt flow circulating from the PV (white arrow) to the IVC (black arrow), which corresponds to a segment between the two arrowheads. B, A high-magnification view of the fluoroscopic image showing the replacement of a nitinol stent (E-LuminexxR, Bard Peripheral Vascular, Tempe, AZ, USA; diameter, 10 mm; length, 60 mm) between the PV and IVC. An intravascular ultrasound (IVUS) probe was inserted from the right femoral vein to the IVC for real-time needle guidance. The white and black arrows indicate the PV and IVC, respectively. C, Vertical sector image created by the IVUS probe showing detailed, real-time visualization, which facilitates needle puncture from the IVC to the PV. CBD, common biliary duct; GB, gall bladder; HA, hepatic artery; SV, splenic vein. | Kawahara, Y., Tanaka, Y., Isoi, N., Hatanaka, K., Yamada, K., Yamamoto, M., Okamura, T., Kaji, T., Sakamoto, T., Saitoh, D. and Ikeuchi, H. (2017), Direct intrahepatic portocaval shunt for refractory hepatic hydrothorax: a case report. Acute Med Surg, 4: 306-310. https://doi.org/10.1002/ams2.257

Contraindications

Relative contraindicationsAbsolute contraindications
Hepatocellular Carcinoma, especially centrally locatedPrimary prevention of variceal bleeding
Obstruction of all hepatic veinsCongestive heart failure
Portal vein thrombosisSevere tricuspid regurgitation
Moderate pulmonary hypertensionSevere pulmonary hypertension
Severe coagulopathy (international normalized ration >5)Multiple hepatic cysts
Thrombocytopenia of <20,000 cells/cm3Uncontrolled systemic infection or sepsis
Hepatic encephalopathyUnrelieved biliary obstruction

Scoring systems

Child–Turcotte–Pugh (CTP):

Originally developed to evaluate the risk of portocaval shunt procedures performed for portal hypertension. It is also useful
in predicting the surgical risks of other intra-abdominal operations performed in cirrhotic patients.
The Child-Turcotte-Pugh (CTP) classification system utilizes two clinical parameters (encephalopathy and ascites) and three laboratory values (bilirubin, albumin, and prothrombin time). Patients are classified as class A, B, or C based on their total points. | Pugh RN, Murray-Lyon IM, Dawson JL, Pietroni MC, Williams R. Transection of the oesophagus for bleeding oesophageal varices. Br J Surg. 1973;60:646-9.

Modified Model for End-Stage Liver Disease score (MELD):

For predicting post-TIPS survival; superior to CPT score and Emory score
Model for End-Stage Liver Disease (MELD) Score Calculator The calculation for MELD score is complex as shown in this formula. Calculation of MELD score should be performed with a MELD calculator, and many MELD calculators are available as a free online resource. Abbreviations: MELD = Model for End-Stage Liver Disease | Source: Malinchoc M, Kamath PS, Gordon FD, Peine CJ, Rank J, ter Borg PC. A model to predict poor survival in patients undergoing transjugular intrahepatic portosystemic shunts. Hepatology. 2000;31:864-71.

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