Transjugular intrahepatic portosystemic shunt or transjugular intrahepatic
portosystemic stent shunting is an artificial channel within the liver that
establishes communication between the inflow portal vein and the outflow
hepatic vein. It is used to treat portal hypertension which frequently leads to
intestinal bleeding, life-threatening esophageal bleeding and the buildup of
fluid within the abdomen. An interventional radiologist creates
the shunt using an image-guided endovascular approach, with the jugular
vein as the usual entry site. The procedure was first described by
Josef Rösch in 1969 at Oregon Health and Science University. It was first used in
a human patient by Dr. Ronald Colapinto, of the University of Toronto, in 1982,
but did not become reproducibly successful until the development of
endovascular stents in 1985. In 1988 the first successful TIPS was realized by M.
Rössle, G.M. Richter, G. Nöldge and J. Palmaz at the University of Freiburg.
The procedure has since become widely accepted as the preferred method for
treating portal hypertension that is refractory to medical therapy, replacing
the surgical portocaval shunt in that role.
Mechanism of action Portal hypertension, an important
consequence of liver disease, results in the development of significant
collateral circulation between the portal system and systemic venous
drainage. Portal venous congestion causes venous blood leaving the stomach
and intestines to be diverted along auxiliary routes of lesser resistance in
order to drain to systemic circulation. With time, the small vessels that
comprise a collateral path for porto-caval circulation become engorged
and dilated. These vessels are fragile and often hemorrhage into the GI tract..
A TIPS procedure decreases the effective vascular resistance of the liver through
the creation of an alternative pathway for portal venous circulation. By
creating a shunt from the portal vein to the hepatic vein, this intervention
allows portal blood an alternative avenue for draining into systemic
circulation. In bypassing the flow-resistant liver, the net result is
a reduced pressure drop across the liver and a decreased portal venous pressure.
Decreased portal venous pressure in turn lessens congestive pressures along veins
in the intestine so that future bleeding is less likely to occur. The reduced
pressure also makes less fluid develop, although this benefit may take weeks or
months to occur. Implantation
Transjugular intrahepatic portosystemic shunts are typically placed by an
interventional radiologist under fluoroscopic guidance. Access to the
liver is gained, as the name 'transjugular' suggests, via the
internal jugular vein in the neck. Once access to the jugular vein is confirmed,
a guidewire and introducer sheath are typically placed to facilitate the
shunt's placement. This enables the interventional radiologist to gain
access to the patient's hepatic vein by traveling from the superior vena cava
into the inferior vena cava and finally the hepatic vein. Once the catheter is
in the hepatic vein, a wedge pressure is obtained to calculate the pressure
gradient in the liver. Following this, carbon dioxide is injected to locate the
portal vein. Then, a special needle known as a Colapinto is advanced through
the liver parenchyma to connect the hepatic vein to the large portal vein,
near the center of the liver. The channel for the shunt is next created by
inflating an angioplasty balloon within the liver along the tract created by the
needle. The shunt is completed by placing a special mesh tube known as a
stent or endograft to maintain the tract between the higher-pressure portal vein
and the lower-pressure hepatic vein. After the procedure, fluoroscopic images
are made to show placement. Pressure in the portal vein and inferior vena cava
are often measured. Use in hepatorenal syndrome
TIPS has shown some promise for patients with hepatorenal syndrome.
Complications Procedural complications during a TIPS
procedure, including bleeding and direct injury to the liver, are uncommon. In
the hands of an experienced physician, operative mortality is less than 1%. On
the other hand, because TIPS reduces or eliminates first-pass clearance of
nitrogen from the gut, up to 25% of patients who undergo TIPS will
experience transient post-operative hepatic encephalopathy. In general, this
can be managed with a reduction in dietary protein and medication that
reduces the absorption of nitrogen. A less common but more difficult
complication is hepatic ischemia. Portal hypertension—the condition shared by all
TIPS patients regardless of etiology—generally causes compensatory
hypertrophy of the hepatic artery and a decreased reliance of the liver upon the
portal vein for its oxygenation. For this reason, shunting of the portal
blood away from hepatocytes is usually well tolerated. In some cases, however,
TIPS creation can cause an ischemic injury to the liver. Acute hepatic
dysfunction after TIPS may require emergent closure of the shunt.
A complication of umbilical hernia has been recently reported.
See also Distal splenorenal shunt procedure
Gastric antral vascular ectasia Interventional radiology
Portal venous system References
^ Rössle M, Richter GM, Nöldge G, Palmaz JC, Wenz W, Gerok W. "New non-operative
treatment for variceal haemorrhage". Lancet 2: 153.
doi:10.1016/s0140-6736(89)90201-8. PMID 2567908.
^ "What You Need to Know about the Transjugular Intrahepatic Portosystemic
Shunt.". Cleveland Clinic. ^ Guevara M, Rodés J. "Hepatorenal
syndrome". Int. J. Biochem. Cell Biol. 37: 22–6.
doi:10.1016/j.biocel.2004.06.007. PMID 15381144.
^ Rossle M, Piotraschke J. Transjugular intrahepatic portosystemic shunt and
hepatic encephalopathy. Dig Dis 1996; 14:12–19.
^ Mayan H, Kantor R, Rimon U, Golubev N, Heyman Z, Goshen E, Shalmon B, Weiss P.:
"Fatal liver infarction after transjugular intrahepatic portosystemic
shunt procedure." Liver, 2001;21(5):361-4.
^ Mallavarapu RK, Grimsley EW. "Incarcerated umbilical hernia after
transjugular intrahepatic portosystemic shunt procedure for refractory ascites".
Clin. Gastroenterol. Hepatol. 5: A26. doi:10.1016/j.cgh.2007.07.018. PMID
17825762. External links
RadiologyInfo: Transjugular Intrahepatic Portosystemic Shunt
Transjugular Intrahepatic Portosystemic Shunt - eMedicine.com.