Overview
Definition:
Transjugular intrahepatic portosystemic shunt (TIPS) is a minimally invasive procedure performed by interventional radiologists to create a tract between the portal vein and a hepatic vein within the liver
This reduces portal pressure, thereby controlling complications of portal hypertension
The surgical interface refers to the critical aspects relevant to surgeons, including indications, potential complications, and the role of surgical intervention in specific scenarios related to TIPS.
Epidemiology:
Portal hypertension affects millions globally, with conditions like cirrhosis being a primary driver
TIPS is indicated in a significant subset of these patients who develop refractory ascites, recurrent variceal bleeding, or hepatorenal syndrome
The incidence of TIPS procedures has steadily increased with advancements in interventional radiology.
Clinical Significance:
For surgeons, understanding TIPS is crucial as it directly impacts the management of patients with end-stage liver disease
It serves as a bridge to liver transplantation, a potential treatment for otherwise intractable complications, and can necessitate surgical intervention for its own complications or when it fails
It represents a paradigm shift from open surgical shunts to percutaneous, image-guided interventions.
Indications
Primary Indications:
Management of refractory ascites unresponsive to medical therapy
Prevention of variceal rebleeding in high-risk patients
Management of hepatorenal syndrome (HRS) as a bridge to transplantation.
Secondary Indications:
Management of hepatopulmonary syndrome (HPS) and platypnea-orthodeoxia syndrome
Relief of Budd-Chiari syndrome
Control of refractory hepatic hydrothorax.
Contraindications:
Severe hepatic encephalopathy refractory to medical management
Primary sclerosing cholangitis with dominant biliary strictures
Congenital absence of hepatic veins
Untreated severe sepsis or cholangitis
Severe pulmonary hypertension (mean PAP > 50 mmHg)
Cardiac failure.
Preoperative Preparation
Patient Evaluation:
Thorough assessment of liver function (Child-Pugh score, MELD score)
Evaluation for comorbidities, especially cardiac and pulmonary function
Detailed assessment of ascites, variceal status, and hepatic encephalopathy severity
Endoscopic evaluation for varices is mandatory.
Imaging:
Abdominal ultrasound with Doppler to assess portal vein patency and direction of flow
CT angiography or MR angiography for detailed venous anatomy and potential anatomical variations
Doppler ultrasound of the hepatic veins and IVC.
Medical Optimization:
Diuretic therapy for ascites management
Beta-blockers for variceal prophylaxis
Lactulose and/or rifaximin for hepatic encephalopathy management
Nutritional assessment and support
Prophylactic antibiotics in patients with increased risk of infection.
Procedure Overview And Surgical Relevance
Procedure Steps:
Under local anesthesia, an introducer sheath is placed in the right internal jugular vein
A guidewire is advanced into the hepatic vein
A needle is used to puncture the hepatic vein parenchyma and enter a portal venous radical
A tract is created and dilated, followed by stent-graft deployment between the hepatic vein and portal vein branches
Angiographic confirmation of shunt patency and pressure measurement are performed.
Surgical Role In Placement:
While primarily an interventional radiology procedure, surgeons are involved in the multidisciplinary team
They may be consulted for complex cases, particularly those with anatomical challenges or when surgical alternatives are considered
Surgeons manage patients pre- and post-TIPS and are involved in the care of TIPS-related complications.
Stent Graft Considerations:
The choice of stent graft material (e.g., PTFE-covered stents) is crucial to minimize endothelialization and subsequent thrombosis, thus maintaining patency
Stent diameter and length are chosen based on anatomical considerations and desired pressure reduction.
Postoperative Care And Monitoring
Immediate Postoperative Care:
Monitoring of vital signs, hematocrit, and electrolytes
Pain management
Strict fluid balance monitoring
Close observation for signs of bleeding, infection, or shunt dysfunction.
Monitoring For Dysfunction:
Regular Doppler ultrasound to assess shunt velocity and patency
Measurement of portosystemic gradient (PSG) via TIPS venography or hepatic vein pressure measurement every 6-12 months
Serial liver function tests and assessment for ascites and encephalopathy.
Medical Management Post Tips:
Continued diuretic therapy if ascites persists
Maintenance of lactulose/rifaximin for encephalopathy
Antibiotic prophylaxis may be continued in select patients
Antithrombotic therapy (e.g., aspirin) is usually initiated to maintain shunt patency.
Complications
Early Complications:
Hemorrhage (from access site or intrahepatic injury)
Shunt thrombosis or stenosis
Hepatic artery injury
Hepatic vein stenosis or thrombosis
Bile duct injury
Sepsis
Fluid overload
Worsening hepatic encephalopathy.
Late Complications:
Shunt stenosis or thrombosis (most common)
Hepatic encephalopathy (can be de novo or worsened)
Progressive liver dysfunction
Shunt infection
Shunt migration or erosion
Portal vein thrombosis.
Surgical Management Of Complications:
Surgical intervention may be required for refractory shunt dysfunction unresponsive to balloon angioplasty, for shunt thrombosis leading to re-bleeding or decompensation, or for complications like shunt erosion or infection
Surgical options include revision angioplasty, thrombectomy, shunt revision, or, in some cases, liver transplantation
Open surgical shunts are rarely considered now.
Prognosis
Factors Affecting Prognosis:
Severity of underlying liver disease (MELD score, Child-Pugh class)
Technical success and initial shunt patency
Presence and severity of hepatic encephalopathy
Development of shunt dysfunction or thrombosis
Development of infections.
Outcomes With Treatment:
Successful TIPS placement can significantly reduce portal pressure, control variceal bleeding, and improve ascites
It can improve quality of life and serve as a bridge to transplantation
However, it does not cure the underlying liver disease.
Follow Up And Transplantation Considerations:
Regular follow-up is essential to monitor shunt patency and manage complications
For patients with end-stage liver disease, TIPS can improve their status and suitability for liver transplantation
Surgeons play a key role in the transplant evaluation and peri-transplant management of these patients.
Key Points
Exam Focus:
Indications for TIPS, contraindications, and common complications
The role of TIPS in managing refractory ascites and variceal bleeding
Management of hepatic encephalopathy post-TIPS
Understanding shunt patency monitoring and when surgical intervention is needed.
Clinical Pearls:
Always consider TIPS in patients with decompensated cirrhosis and complications refractory to medical management
Aggressive management of hepatic encephalopathy is crucial post-TIPS
Early recognition of shunt dysfunction is key to preventing re-bleeding or decompensation.
Common Mistakes:
Incorrectly identifying contraindications
Failure to optimize medical management prior to TIPS
Inadequate monitoring of shunt patency
Underestimating the risk or severity of hepatic encephalopathy
Delaying surgical consultation for refractory complications.