Transjugular Intrahepatic Portosystemic Shunt (TIPS)

Transjugular intrahepatic portosystemic shunt (also known as TIPS) is a radiologic approach that is used to create a portosystemic shunt percutaneously, where the hepatic vein and the main portal vein are connected. It is used in patients with portal hypertension for managing variceal bleeding in the stomach or esophagus, or both. This technique is more suitable for adults than for young children.

Through needles, a balloon catheter and a metal stent called a shunt is placed inside the liver connecting the two veins. This can divert the large amount of blood flow from the portal vein directly into the systemic circulation. TIPS is an effective and life-saving approach to control hemorrhage in varices.

History of TIPS

The introduction of TIPS is dated back to the 1960s. Rosch and his colleagues were the first people who studied portal venography through a transjugular method in 1968. Later, subsequent experiments on animals were conducted with tract dilation dilators and balloons.

In 1982, Colapinto and co-workers presented the first human balloon-dilated transjugular portosystemic shunt (TPS). In 1988, a stent made of metal was used in TIPS for human clinical application by Goetz Richter.

Applications of TIPS

TIPS serves as an alternative treatment method in many cases, especially in patients for whom sclerotherapy treatment is unsuccessful.TIPS is capable to stop bleeding without the need for liver transplantation. Also, in patients with portal hypertension, the procedure is effective even during post-transplantation of liver.

TIPS is also done on a selective basis when other indications such as mild liver sickness, chronic variceal blood loss, and intractable ascites are exhibited.

Other diseases that can be effectively treated using this procedure are portal vein thrombosis, Budd–Chiari syndrome, hepatopulmonary syndrome, and hepatorenal syndrome.

Benefits of TIPS

• Compared with open surgery, TIPS has some advantages in the treatment results. It has relatively less risk than surgery. It is designed to make similar physiological results as the bypass or surgical shunt.
• It is a less invasive procedure, requires only a short time to recover, and reduces the period of stay in the hospital.
• If a patient undergoes liver transplantation in the future, TIPS has fewer effects on it as open surgery is not required and so no scars appear on the abdomen. It requires only a small cut on the neck and, therefore, stitches are not necessary.
• The other advantage of TIPS is that it can be removed at the time of liver transplantation as it is located completely inside the diseased liver.
• TIPS enhances blood filtration in the kidney and excretion of urine by increasing sodium excretion in the urine (natriuresis). It also helps in decreasing the activity of plasma rennin, aldosterone, and noradrenaline levels. This in turn assists in improving the function of the kidney that has changed due to cirrhosis.

Risks of TIPS

Some of the risks or complications of using TIPS include:

• Increase in body temperature
• Infection in the cut region (has a high risk of occurrence) may require antibiotic treatment.
• Bleeding and bruising at the incision site
• Stiffness of the neck muscle
• Blood vessel damage
• Chances of allergic reaction (even though it is less probable) to the contrast material used in venograms, which is used to image the blood flow in the veins.

TIPS may in rarer cases cause some problems due to stent blockage and infection in the stent. Also, there is a chance for the blood vessels in the liver to tear, belly bleeding, arrhythmias, and other heart-related disorders.

Limitations of TIPS

This process also has some limitations, for instance, patients having very advanced liver disease might not be capable of undergoing this procedure because it might make the liver condition worse after implanting the stent. Also, it will not help if the person has failure of liver function.

TIPS might even lead to encephalopathy, which is the condition where the brain does not function normally and results in confusion. This is due to the presence of toxic materials in the bloodstream. Normally, these toxins are to be filtered by the liver, but due to the bypassing of the blood from the liver by TIPS, this filtering may not happen, and the unfiltered blood might reach the brain.

In children, TIPS is not so favorable and is extremely rarely used, if at all. It can be carried out in children before liver transplant procedure if they have ascites or bleeding in the varices that are treatment resistive to conventional methods. This process in children depends upon their physiology and their medical conditions.

The prognosis of this treatment depends upon the time of stent implantation. The radiologist will inform the patient about the right way of the procedure to provide the best result. According to recent studies, around 80–90% of patients with portal hypertension are successively treated using TIPS.