Transjugular Intrahepatic Portosystemic Shunt, commonly known as the TIPS procedure, is an X-ray-guided procedure mainly performed in patients with portal hypertension.
The main aim of the TIPS procedure is to bypass the hepatic circulation to decrease the blood pressure in the portal system and relieve the signs and symptoms of portal hypertension in patients with liver diseases.
The TIPS procedure is not a surgical procedure. An interventional radiologist performs it in a hospital setting.
Transjugular Intrahepatic Portosystemic Shunt (TIPS)
Ascites, Portal hypertension, Variceal bleeding
Benefits of the Surgery
Good prognosis, Safer than surgery, Low chances of developing complications
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What is a Transjugular Intrahepatic Portosystemic Shunt (TIPS)?
The portosystemic shunt connects two veins in the liver to bypass circulation. This shunt is created with the help of a stent in the liver via the jugular vein. Hence, this procedure is known as the 'Transjugular intrahepatic portosystemic shunt (TIPS).'
The TIPS procedure is performed to relieve high blood pressure by bypassing the circulation in the liver. A stent is placed in the TIPS procedure connecting the portal veins with the hepatic veins. This allows the natural movement of blood from the portal to the hepatic vein and ultimately into the vena cava.
Due to this alternate route, the blood does not enter the liver and is directly transferred to the heart for further circulation to the entire body.
Anatomy and Physiology of LiverA transjugular intrahepatic portosystemic shunt is created in the liver.
The liver is the second largest organ in the body, weighing around 1.5 kg. It is present just below the diaphragm and lower ribs on the right side of the abdomen.
The liver's primary function is to digest food and eliminate toxic substances from the body.
The liver consists of two portal veins carrying blood from the gastrointestinal tract to the liver. This blood takes up all nutrients from the food consumed into the liver.
The blood that goes into the liver via the portal veins enters the sinusoids.
The blood that enters the liver via the portal veins is then transported to the right and left hepatic veins. These hepatic veins carry the blood from the liver to the vena cava and are ultimately drained to the right side of the heart.
Conditions treated with TIPS procedure
The most common TIPS procedure indications are as follows:
- Ascites (accumulation of fluid in the abdomen)
TIPS is indicated in ascites which are not controlled with the help of diuretics (water pills) and dietary restriction of sodium. It is also indicated in hepatic pleural effusion (hydrothorax), where the ascitic fluid buildup is so much that it enters the thorax.
- Portal hypertension
TIPS procedure creates a shunt between the portal and the hepatic veins. This allows the natural movement of blood from the hepatic veins into the heart via the vena cava, thus helping to decrease the blood pressure in the portal system.
- Variceal bleeding
Varices are enlarged veins that are typically in the oesophagus. Variceal bleeding that cannot be managed with endoscopic therapy, like rubber band ligation, benefits from this procedure and is a standard TIPS procedure indication.
TIPS is frequently performed because bleeding varices in the stomach, rectum, or elsewhere are more challenging to treat with rubber band ligation.
- Budd Chiari syndrome
- Post-liver transplantation
- Hepatorenal syndrome (HRS)
- Veno-occlusive disease (VOD)
Who needs the TIPS procedure?
The suitable candidates for the TIPS procedure are as follows:
- Good liver function
Candidates must have good liver function to be able to undergo the TIPS procedure.
Typically, a total bilirubin level above 3 to 5 mg/dl and an International normalised ratio (INR) above 2.0 indicates bad outcomes.
TIPS is generally not performed if the Model for End-Stage Liver disease (MELD) score is more than 18–20 unless it is urgently required to control bleeding from varices and the patient is on the waiting list for the liver transplant. A TIPS has a higher risk once the MELD score is above 15, and it is generally avoided if the MELD score is more than 15–20.
- Surgeries or medical management fails.
TIPS are preferred in patients having varices when they can't be treated with endoscopic rubber band ligation or medical management.
- No pre-existing liver conditions
TIPS is not recommended in patients with pre-existing liver conditions such as portal vein thrombosis and liver cancer. Patients must also not have severe hypertension in the lung circulation or unbled oesophagal or stomach varices.
The TIPS procedure can't be performed in patients with pre-existing cardiovascular disease or hepatic encephalopathy.
How is TIPS performed?
An interventional radiologist performs a TIPS procedure under heavy sedation or general anaesthesia. The entire process takes between 2 to 3 hours.
Steps of the TIPS procedure:
- The patient is made to lie in a supine position with the neck turned towards the opposite side of the vein puncture.
- An IV line will be established into a vein to administer a sedative by the nurse or anesthesiologist.
- The pulse, blood pressure, oxygen saturation, and heart rate will be monitored.
- The area where the catheter will be sterilised, cleaned, and covered with a surgical drape by the nurse.
- The patient will be given sedatives or general anaesthetic agents. The doctor will use a local anaesthetic to numb the skin immediately above the right collarbone. 5 mL of 1% lidocaine will be applied to the site of the jugular puncture for local anaesthesia. A combination of midazolam and fentanyl citrate can be used to achieve sedation.
- The radiologist will make a tiny skin incision at this location.
- The radiologist will insert a thin hollow needle into the jugular vein on the right side of the neck.
- With the help of X-Ray guided vision, a wire will then be passed through the needle into the jugular vein, ultimately leading to the hepatic veins.
- A catheter is then inserted through the hepatic veins.
- To confirm the presence of portal hypertension and to assess its severity, pressures in the right heart and hepatic vein shall be monitored.
- After inserting the catheter, the radiologist will insert a wire into the portal vein with the help of ultrasound-guided vision.
- Alternatively, another needle will be inserted in the artery of the groin region. This is done to inject the dye into the arterial system to ensure that the TIPS is appropriately placed.
- After this, a channel is created and expanded.
- A stent is inserted from the portal vein and then into the hepatic vein using fluoroscopy. The balloon is inflated, and the stent is expanded into place once it has been placed precisely.
- The catheter is then removed, followed by the deflation of the balloon.
- Pressures are then monitored to confirm the decrease in portal hypertension. Further portal venograms are also carried out to verify that the blood flow through the TIPS is sufficient.
- This stent is permanently left within the liver.
- Following the procedure, a small bandage is applied to the neck region. In most cases, there are no stitches.
What to expect before and on the day of the TIPS procedure?
TIPS procedure generally requires the patient to stay in the hospital for a few days, depending on his or her health condition. To prepare for the day of surgery, the patient must consider the following things:
Before the TIPS procedure
- The patient must tell the doctor about all the vitamins, herbs, and medicines, including over-the-counter medications such as aspirin, that he or she takes.
- The patient must ask the doctor if taking blood thinners is safe before the surgery.
- The patient must also confirm if any other type of medication needs to be avoided.
- The patient must follow all the instructions given by the doctor.
- The doctor will recommend getting a CT scan and an echocardiogram done before the procedure to see if the patient is fit for the procedure.
- The patient will be required to meet the anaesthesia doctor to discuss any allergies, specifically to contrast dyes. The patient will be asked if he/ she is on any blood thinning medication or is pregnant.
- The doctor will run some blood tests on the patient. The patient must have a platelet count higher than 50,000/μL and a relatively normal international normalised ratio (INR).
- The patient is advised not to eat or drink anything for at least six hours before the TIPS procedure.
On the day of the TIPS procedure
- The patient must keep the following things in mind on the day of the TIPS procedure.
- The patient must report for the procedure well in advance on the day of the TIPS procedure.
- The patient will be asked to sign the consent form before the surgery.
- The patient is made to change into a hospital gown.
- The patient shall be asked to remove all metal jewellery and prostheses and change into a gown to prepare for the procedure.
- The doctor will prescribe medication for the patient to take on the day of the TIPS procedure.
- The patient shall be allowed to take some fluids before the procedure.
- The healthcare providers monitor the patient’s vitals throughout the surgery.
- The patient will be taken to the treatment room where the procedure will be performed.
What to expect after the TIPS procedure?
The following things can be expected after the TIPS procedure:
The recovery process at the hospital
- The patient is shifted to the recovery room after the procedure and is kept there for 24- 48 hours under observation. During observation in the TIPS procedure recovery phase, the patient's vitals are monitored until the anaesthetic effects wear off.
- The bleeding parameters of the patient are kept in check.
- The patient will be advised to keep the head end slightly elevated.
- The doctor will perform an ultrasound of the liver to check if the stent is working properly.
- Patients usually experience no pain after the procedure.
- If everything is alright, the patient will be discharged home, usually on the next day of the TIPS procedure, with water pills.
- The doctor will also precribe antibiotics to reduce the risk of infection.
Recovery process/expectation after hospital discharge
- Instructions provided by the doctor must follow at home.
- It takes around 6 months to notice the full effects of the TIPS procedure.
- The patient may feel pain for several days. The doctor will prescribe medications, including opioids, non-steroidal anti-inflammatory drugs (NSAIDs), and local anaesthetics for pain management and relief.
- One may go back to performing their daily activities within 7 to 10 days of the TIPS procedure.
- Regular TIPS monitoring with the help of ultrasound scans is mandatory to check if the stent is working properly.
- Most people with the TIPS procedure recover quickly.
First follow-up appointment
- The patient is expected to come for the first follow-up after three months or as suggested by the doctor to check if the stent is working properly.
- Post-TIPS Doppler US may be performed at six months, 12 months and annually after that.
- The doctor might also change the medication or advise the patient to continue with the previous medication for some more time, depending on the condition and recovery of the surgical area.
- The patient will also be informed regarding future visits to examine if the implant is in place and functioning properly.
Benefits of the TIPS procedure
TIPS procedure is a safe and effective procedure. Below are the TIPS procedure benefits:
- Has a good prognosis.
- Safer than surgery since it does not involve any cutting or stitches.
- Patients recover well and may return to their daily routine within a week.
- Patients can be discharged the next day.
- Low chances of developing complications.
- Prevent the stage of liver transplantation in some patients.
Risks and complications of the TIPS procedure
The TIPS procedure carries certain risks and complications with it. The primary difficulties associated with the TIPS procedure are:
- Hepatic Encephalopathy
- This complication occurs due to the accumulation of ammonia in the body. The liver normally removes ammonia.
- In patients with the TIPS procedure, the circulation in the liver is bypassed, leading to the accumulation of ammonia that is toxic to the body. It affects the brain leading to altered mental status or even coma.
- Heart failure
- The TIPS procedure increases the amount of blood returning to the heart through TIPS. This increases the heart's workload and makes it difficult for the blood to get pumped to the whole body, leading to heart failure.
- TIPS occlusion
- The shunt in the TIPS procedure can become occluded or blocked due to the formation of blood clots or excessive scar tissue in the liver. This can occur within a few days, weeks or even years after the TIPS procedure.
- This complication can be caught on periodical ultrasounds that are needed to evaluate the functioning of the TIPS procedure. Risk factors for TIPS occlusion are older age, lower body mass index (BMI), and higher post-TIPS portosystemic gradients.
- One should seek immediate medical care from an interventional radiologist if it becomes fully blocked.
- Severe and progressive liver damage
- Patients with severe liver damage are at an increased risk of developing complications with TIPS. The severity of liver damage is assessed by scoring the health status of the liver with the help of a scoring system called the Child-Pugh scoring system.
- According to the Child-Pugh score, scores A and B result in better outcomes than scores C. The doctor will assess the condition and suggest the right treatment.
- Technical failure
This can happen in some patients as it might be impossible to place the stent.
- Damage to blood vessels
Since a needle or wire is inserted into the blood vessel, there is a risk of puncturing the blood vessels while doing so.
Bruises are formed at the sides where the needles were inserted, for example, in the neck or the groin. It usually subsides in a day or two
- Worsening of kidney function
The kidney function may deteriorate after a TIPS procedure, but this is usually reversible.
- Bleeding in the abdomen
Bleeding may occur from the blood vessels within or outside the liver. However, this is quite rare. A blood transfusion may be required for severe abdominal bleeding.
The patient may be required to stay for an extra duration in the hospital so that the complications are managed and treated appropriately.
When is consultation with the doctor needed?The patient must consult the doctor immediately if they experience the following:
- Altered mental status
- Shortness of breath
- Fatigue or weakness
- Irregular or rapid heartbeat
Risks of the delayed TIPS procedureDelayed TIPS procedure can lead to severe complications of ascites, variceal bleeding and other conditions. If not treated on time with the TIPS procedure, these conditions may lead to life-threatening situations, and the person may die.
Hence it is crucial to get the TIPS procedure done when the doctor indicates it.
Cost of the TIPS procedure
The cost of the TIPS procedure ranges from INR 1,70,000 to 4,00,000. The cost of the TIPS procedure widely depends upon a lot of factors. This includes:
- The patient’s age
- The condition, its stage, progression, and treatment plan
- The type of rooms you choose in the hospital for your stay
- The duration of hospital stay
Frequently Asked Questions on Tips Procedure
What are some Myths vs Facts regarding TIPS?
- Myth: The stent placed in the TIPS procedure is replaced periodically.
Fact: The stent placed in TIPS procedure is permanent. Its diameter can be decreased if blood flow through the TIPS is more than expected and obstructs the rest of the liver, but it cannot be removed. This is commonly known as a TIPS revision.
- Myth: TIPS procedure is very risky.
Fact: TIPS procedure is a safe procedure with low risk of developing complications.
- Myth: TIPS procedure is performed by a surgeon.
Fact: TIPS procedure is performed by an interventional radiologist.
- Myth: TIPS procedure is an extensive, long-lasting surgical procedure.
Fact: TIPS procedure is a minimally invasive procedure that lasts for two to three hours.
- Myth: TIPS procedure is very painful.
Fact: TIPS procedure is not painful since it's performed under general anaesthesia; however, pain at the site of inserting the needles is felt that is normally mild and goes away within a few days.
What is a TIPS procedure?
How long can you live with the TIPS procedure?
Who is a candidate for a TIPS procedure?
- Good liver function
- No pre-existing liver conditions such as portal vein thrombosis and liver cancer.
- No severe hypertension in the lung circulation or unbled oesophagal or stomach varices
- No effect of surgeries or medical management
- Pre-existing cardiovascular disease or hepatic encephalopathy.
Who is not a candidate for the TIPS procedure?
- Severe hypertension or right heart failure
- Portal vein thrombosis
- Liver cancer
- Esophageal or stomach varices if they've never bled
When is TIPS indicated?
- Portal hypertension
- Variceal bleeding
- Budd Chiari syndrome
- Post liver transplantation
- Hepatorenal syndrome (HRS)
- Veno-occlusive disease (VOD)
Where is a TIPS usually placed, and why?
What are the side effects of the TIPS procedure?
- Infections, bruising
- Damage to the blood vessels
- Hepatic encephalopathy
- Allergic reaction to the contrast dyes
- Heart failure
- Occlusion of blood vessels
- Stiff, sore or bruised neck