At a Glance:
1. What is portal hypertension?
4. What can one expect before a transjugular intrahepatic portosystemic shunt procedure?
5. How is the TIPS procedure done?
6. What happens after the TIPS procedure?
7. What are the benefits of transjugular intrahepatic portosystemic shunt?
8. What are the risks and complications of transjugular intrahepatic portosystemic shunt procedure?
9. What are the limitations of transjugular intrahepatic portosystemic shunt?
10. How should one choose a facility for transjugular intrahepatic portosystemic shunt procedure?
Portal hypertension is an increase in the pressure within the portal vein (the vein that carries blood from the digestive organs to the liver). This pressure build-up can cause blood to flow backward from the liver into the veins of the spleen, stomach, lower esophagus, and intestines, causing the blood vessels to become enlarged and susceptible to bleeding. The backward build-up of pressure also causes an accumulation of fluid in the chest or abdomen. Adults commonly get affected with portal hypertension due to chronic problems that lead to cirrhosis of the liver.
A shunt is an artificial connection that allows fluid to move from one part of the body to another. Transjugular intrahepatic portosystemic shunt (TIPS) is an artificially created connection between two veins in the liver. It connects the portal or hepatic portal vein that brings blood from a person’s gastrointestinal tract and the intra-abdominal organs namely gallbladder, pancreas and spleen to the hepatic vein that drains blood from the liver into the right part of the heart.
The transjugular intrahepatic portosystemic shunt (TIPS) procedure is performed using x-ray guidance by an interventional radiologist and the shunt is kept open by the placement of a tubular metal device known as a stent.
Portal hypertension: Typically, TIPS is performed in persons with increased pressure in the portal vein system, a condition known as portal hypertension. TIPS is particularly beneficial in the following complications of portal hypertension:
Budd–Chiari syndrome: Caused by a blockage of the hepatic veins that drain the liver, Budd-Chiari syndrome is an exceedingly rare condition. The presence of the syndrome is suspected if there is a classical triad of abdominal pain, ascites, and liver enlargement.
To ensure optimized treatment outcomes, an accurate diagnosis of the condition and assessment of the person for whom the procedure is indicated is essential. A preoperative evaluation is done by the treating doctor based on the following investigations and information:
Clinical history and physical examination: During the first consultation with the interventional radiologist (IR), he or she will review the person’s medical history and recommend relevant investigations.
A brief physical examination will be performed at the time of the consultation. If the IR determines that the person is a suitable candidate for the procedure, he or she will be explained the instructions to be followed before the procedure.
Before the procedure: The doctor would recommend specific preparatory instructions depending on the person’s medical status. Some of the preparatory instructions recommended are as follows:
TIPS is an image-guided, minimally invasive procedure that is performed by a radiologist who is specially trained in interventional radiology, a sub-specialty within radiology. The procedure is done in a radiology suite or occasionally in the operating room. Sometimes, the procedure may be required to be done under general anesthesia, while in some cases it can be performed under sedation and monitored anesthesia care. The procedure is performed as follows:
Once the procedure is done, the medical team monitors the person closely. The head is to be kept elevated for a few hours once a person returns from the procedure room. In most cases, since the procedure is done electively and severe complications are not experienced, a person may be allowed to go home the next day. Individuals experiencing excess bleeding are monitored in intensive care during recovery and maybe kept under observation for a longer duration in the hospital.
In the case of a non-complicated procedure, one can resume normal activities in one to two weeks.
A person may be required to undergo ultrasounds before discharge from the hospital and during follow-up after the TIPS procedure to ensure that it remains open and functions properly.
TIPS is designed and expected to produce physiological results similar to a surgical bypass or shunt without the risks associated with open surgery. Consequently, it offers the following benefits
Any medical procedure that requires the placement of an instrument like a needle or catheter inside a blood vessel is not devoid of any risks. Such risks include:
Even though they are far too less, serious complications may include:
For persons with advanced liver disease the risk of worsening of liver failure after TIPS is high, hence a TIPS may not be the best option for persons with serious liver disease and an alternative may be needed to control the symptoms. Such persons are also prone to encephalopathy i.e. alteration of the normal brain function that can lead to confusion. Encephalopathy occurs due to the accumulation of toxic substances in the bloodstream and brain that are ordinarily filtered out by the liver. TIPS may worsen encephalopathy by bypassing these toxins from the liver.
Conditions in which TIPS is contraindicated include:
Conditions in which TIPS is relatively contraindicated include:
Considering the need for sophisticated equipment, infrastructure, and considerable interventional radiology expertise, a transjugular intrahepatic portosystemic shunt procedure is recommended to be performed in specialized centers. Long term follow up to evaluate the performance of the procedure is a well-coordinated activity in such centers. The transjugular intrahepatic portosystemic shunt procedure technique requires experience and attention for performing the procedure under radiological guidance. This is one of the primary reasons that it is not performed in all centers. Very few interventional radiologists are trained to perform the procedure.
Yashoda Institute of Interventional Radiology in Hyderabad is a high-volume tertiary referral center for interventional radiology procedures like transjugular intrahepatic portosystemic shunt procedure. Our expert IRs often treat patients who are turned away by less experienced centers as being too risky or complex.
Transjugular intrahepatic portosystemic shunt (TIPS) is a minimally invasive endovenous procedure that involves the creation of a low-resistance channel between the hepatic vein and the part of the portal vein within the liver. The procedure is performed by an interventional radiologist using radiological and angiographic techniques. The patency of the channel is maintained by placing an expandable metal stent across it, thereby allowing the blood to return to the systemic circulation by bypassing the liver. The ability of TIPS to function as a surgical bypass without open surgery, reroute blood flow in the liver and reduce abnormally high blood pressure in the veins of the stomach, esophagus, bowel, and liver has led to its rapid acceptance into clinical practice.
About Author –
Dr. Suresh Giragani, Consultant Neuro & Interventional Radiologist, Yashoda Hospitals – Hyderabad
MD (Radiology), DM (Neuroradiology)
Specialized in the comprehensive and widest range of vascular interventions covering neuro interventions, hepatobiliary interventions, venous, peripheral vascular interventions and interventions in cancer care.
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