What Is It?
The Transjugular Intrahepatic Portosystemic Shunt (TIPS) procedure is a medical intervention used to treat complications of portal hypertension, which is high blood pressure in the portal vein system, often due to liver cirrhosis. Portal hypertension can lead to serious complications such as variceal bleeding (bleeding from enlarged veins in the esophagus or stomach) or refractory ascites (accumulation of fluid in the abdomen).
During a TIPS procedure, an interventional radiologist creates a shunt (a small tunnel) within the liver to connect the portal vein (which carries blood from the digestive organs to the liver) to one of the hepatic veins (which carry blood from the liver back to the heart). This shunt allows blood to bypass the liver, reducing pressure in the portal vein system and thus lowering the risk of bleeding from varices and decreasing ascites.
The procedure is typically performed under local anesthesia and moderate sedation. It involves making a small incision in the jugular vein in the neck and threading a catheter through this vein down into the liver. Using X-ray guidance, the interventional radiologist then creates the shunt within the liver by puncturing the liver parenchyma (the liver tissue) and connecting the portal vein to the hepatic vein with the help of specialized stents or grafts.
TIPS is an effective procedure for managing complications of portal hypertension, but it’s not without risks. Complications can include hepatic encephalopathy (confusion or coma due to the shunting of blood away from the liver), liver failure, shunt stenosis (narrowing), or shunt thrombosis (clotting).
How Is It Treated?
Image-guided, minimally invasive procedures such as a TIPS are most often performed by a specially trained interventional radiologist in an interventional radiology suite or occasionally in the operating room. Some interventional radiologists prefer performing this procedure while the patient is under general anesthesia, while some prefer conscious sedation for their patient.
The doctor or nurse will position you on your back.
The doctor or nurse will connect you to monitors that track your heart rate, blood pressure, oxygen level, and pulse.
A nurse or technologist will insert an intravenous (IV) line into a vein in your hand or arm to administer a sedative. This procedure may use moderate sedation or general anesthesia. A breathing tube is not mandatory but may be used depending on physician and patient preference.
The nurse or technologist will sterilize the area of your body where the catheter is to be inserted. They will sterilize and cover this area with a surgical drape.
Your physician will numb an area just above your right collarbone with a local anesthetic.
The doctor will make a very small skin incision at the site.
Using ultrasound, the doctor will identify your internal jugular vein, which is situated above your collarbone, and guide a catheter, a long, thin, hollow plastic tube into the vessel.
Using real time x-ray guidance, your doctor will then guide the catheter toward the liver and into one of the hepatic veins. Pressures are measured in the hepatic vein and right heart to confirm the diagnosis of portal hypertension, and also to determine the severity of the condition. To help plan for the placement of the TIPS stent, a contrast material will be injected in the hepatic vein to identify the portal venous system. Access from the hepatic vein into the portal vein is achieved by using a TIPS needle (a special long needle extending from the neck into the liver). A stent is then placed connecting the portal vein to the hepatic vein using x-ray guidance. Once the stent is in the correct position, a balloon is inflated within the stent expanding it into place.
The balloon is then deflated and removed along with the catheter. Subsequently, pressures are measured to confirm reduction in portal vein blood pressure. Additional injections of contrast (portal venograms) may be performed to confirm satisfactory blood flow through the TIPS.
The doctor removes the catheter from the neck and applies pressure over the jugular vein to prevent any bleeding. The small incision in the skin is covered with a bandage. No sutures are necessary.
You will be admitted to the hospital following your procedure, where you will be closely observed.
This procedure is usually completed in an hour or two but may take up to several hours depending on the complexity of the condition and vascular anatomy.
How Do I Prep For The Procedure?
Tell your doctor about all the medications you take, including herbal supplements. List any allergies, especially to local anesthetic, general anesthesia, or contrast materials. Your doctor may tell you to stop taking aspirin, nonsteroidal anti-inflammatory drugs (NSAIDs) or blood thinners before your procedure.
Women should always tell their doctor and technologist if they are pregnant. Doctors will not perform many tests during pregnancy to avoid exposing the fetus to radiation. If an x-ray is necessary, the doctor will take precautions to minimize radiation exposure to the baby. See the Radiation Safety page for more information about pregnancy and x-rays.
Your doctor will likely tell you not to eat or drink anything after midnight before your procedure. Your doctor will tell you which medications you may take the morning of your procedure.
You should plan to stay overnight at the hospital for one or more days.
The nurse will give you a gown to wear during the procedure.
What Happens After The Procedure?
After the procedure, you will be monitored closely and your head will be kept elevated for a few hours after you return to your room. Often, symptoms are mild or controlled enough that the procedure can be done electively and patients may go home the next day. If your TIPS is being performed emergently for significant bleeding you will typically be monitored in intensive care beforehand and during recovery; GI bleeding from portal hypertension can be life threatening.
You should be able to resume your normal activities in seven to 10 days.
Follow-up ultrasounds will be performed frequently after the TIPS procedure to make sure that it remains open and functions properly.
Patients undergoing TIPS require careful monitoring and follow-up to manage any complications and ensure the ongoing effectiveness of the shunt.
