Transjugular Intrahepatic Portosystemic Shunt (TIPS)

Patients with cirrhosis can develop major complications such as ascites and variceal bleeding, related to portal hypertension.

A transjugular intrahepatic portosystemic shunt (TIPS) can be an effective means to decrease portal hypertension, by shunting some of the blood flow from the portal venous system into the hepatic venous system, via a stent.

Placement of a TIPS is a highly specialized interventional procedure, and should only be considered after consultation with a liver specialist.

See the ALTA consensus guidelines (PMID 34274511) for an in-depth review of TIPS in portal hypertension.

-For elective TIPS for ascites, a staged approach to TIPS creation is suggested – starting at 8 mm and then progressively dilating the stent q 6 weekly to 9 mm and 10 mm if required to optimize the clinical response.

Step 1:

Evaluate the indication for TIPS

Common Indications:

Bleeding related to portal hypertension
Refractory ascites/hydrothorax

Step 2:

Consider potential contraindications and risk for complications

Contraindications:

Severe Congestive Heart Failure
Severe untreated valvular heart disease
Moderate to Severe Pulmonary Hypertension
Refractory overt Hepatic encephalopathy
Active infection
Hepatocellular Carcinoma (location dependant)
Unrelieved Biliary Obstruction
Multiple Hepatic Cysts that preclude stent creation

Risk Factors Associated with Post-TIPS Complications:

Complication	Risk Factor
Liver Failure	Advanced Liver Disease (MELD >18) Cardiovascular disease
Encephalopathy	Prior Encephalopathy Wider diameter TIPS Sarcopenia Hyponatremia Age>65
Cardiac Decompensation	Aortic stenosis Diastolic dysfunction Prolonged QTc interval Elevated BNP
Mortality	Child Pugh C Urgent indication (variceal bleed) Bilirubin >50 umol/L Child Pugh score >13, or MELD score >30 and lactate >12 mmol/L (PMID 34018627) Pre-insertion consult by an interventional radiologist should be considered in all circumstances, but especially these

Step 3:

Perform pre-TIPS investigations

Echocardiogram
Liver Ultrasound Doppler: Evaluate liver vasculature, rule out hepatocellular carcinoma. In most cases CT may be required pre-TIPS insertion.
Labs: TBili, INR, Cr, CBC, BNP

Step 4:

Provide pre-placement patient counselling

Patients will require short post-procedure hospital admission
Risk of hepatic encephalopathy (30-45%). Treat using standard hepatic encephalopathy therapy. For patients who do not respond to standard therapy – consideration should be given to narrowing or blocking the TIPS. This decision will be based on the severity of symptoms and the potential impact on the patient’s quality of life
It can take weeks for symptoms like ascites to resolve so patients may require alternate therapy (such paracentesis for ascites) in the initial period post-TIPS
Liver failure is rare but can occur, particularly if there is advanced liver dysfunction pre-procedure.
Immediate procedural complications (vascular injury, pneumothorax, hepatic injury) are discussed in detail by diagnostic imaging.

Step 5:

Info for liver specialists to arrange the TIPS procedure

Edmonton

Send referral to interventional radiology for “TIPS insertion”
Provide patient instructions regarding admission and pre procedure labs
Ensure admission is coordinated, including notification of admitting physician and completion of admission orders.

Step 6:

Post-procedure follow-up

Routine monitoring:

Item	Rationale	Frequency
Labs	Monitor for worsening liver & renal function, electrolyte abnormalities, hemolytic anemia	Day 1, Week 4, 8 & 12, then based on patient clinical status
Symptom assessment •Encephalopathy	Common complication post TIPS	Day 1, Week 4, 8 & 12, then based on patient clinical status.
•Ascites/hydrothorax	Monitor response to TIPS Evaluate potential to taper off diuretics as TIPS improves volume management
•Edema, shortness of breath	Monitor for cardiac decompensation
•Blood pressure and heart rate	Evaluate need to discontinue beta blocker used for variceal bleed prophylaxis (might need to continue if PPG post TIPS is > 12 mmHg)
•GI bleeding	Monitor response to TIPS
Ultrasound Doppler	Detect TIPS stenosis	Month 1-3, 6, and then every 6 months along with routine screening ultrasound performed for hepatocellular carcinoma screening.

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