TIPSS Procedure (Transjugular Intrahepatic Portosystemic Shunt)

Indications

• Refractory variceal hemorrhage (esophageal/gastric) - most common
• Refractory ascites
• Budd-Chiari syndrome
• Hepatic hydrothorax
• Secondary prevention of variceal re-bleeding

Contraindications

• Congestive heart failure / tricuspid regurgitation
• Moderate-to-severe pulmonary hypertension
• Advanced hepatic encephalopathy
• Portal vein or hepatic vein thrombosis/occlusion
• Active liver cancer

Pre-Procedure Preparation

1. Patient optimization
   • Platelet count >60,000/mm³ and INR <1.5 recommended (not always essential in emergencies)
   • Hemoglobin transfusion target 7-9 g/dL; correct coagulopathy with FFP/platelets if needed
   • Prophylactic broad-spectrum antibiotics (e.g., 1 g ceftriaxone IV)
   • NPO at least 8 hours before
2. Anesthesia choice
   • Local anesthesia + sedation (most common for elective)
   • General anesthesia (preferred for patients with significant ascites, recent variceal hemorrhage, or inability to tolerate supine positioning)
3. Optional: Paracentesis prior to procedure
   • Draining ascites creates a more favorable angle to catheterize the hepatic vein and stabilizes the liver for portal puncture

Step-by-Step Procedure

Step 1 - Venous Access (Right Internal Jugular Vein)

• A small incision is made in the right side of the neck
• The right internal jugular vein is accessed under ultrasound guidance
• A sheath is placed and advanced into the right atrium
• Right atrial pressure is measured as a baseline

Step 2 - Cannulation of the Hepatic Vein

• A catheter (commonly a multipurpose angled/MPA catheter) is advanced from the jugular vein, through the superior vena cava and right atrium, down the inferior vena cava, into a hepatic venous branch (preferably the right hepatic vein)
• A venogram is performed to confirm position (contrast injected to confirm right vs. middle hepatic vein using lateral view or ultrasound if needed)
• Hepatic venous pressure gradient (HVPG) / wedge pressure is measured to quantify portal hypertension

Step 3 - Localization of the Portal Vein

• Carbon dioxide or dilute contrast is injected to locate the portal vein via indirect portography
• Ultrasound guidance may also be used to visualize the portal vein target
• The intrahepatic anatomy is mapped; the right portal vein is the usual target

Step 4 - Transhepatic Portal Vein Puncture

• A special needle (Rösch-Uchida or Colapinto needle) housed within the catheter system is advanced from the hepatic vein through the liver parenchyma toward the portal vein
• The needle passes from the hepatic vein into an intrahepatic branch of the portal vein
• After each pass, the needle is aspirated (without fluoroscopy) until blood returns, then fluoroscopy is used to confirm portal (vs. hepatic) vein position by injecting a small puff of contrast
• This is the most technically challenging step; success rate is >95% with an experienced operator

Step 5 - Wire Placement and Portal Vein Catheterization

• A guidewire (e.g., Glidewire Advantage - Terumo) is advanced through the needle into the portal vein and positioned in the superior mesenteric vein (SMV) for stable access
• An angled catheter may be needed if the wire cannot be directed centrally

Step 6 - Portogram and Pressure Measurement

• A pigtail catheter is placed in the portal vein
• Portal vein pressure is measured
• A portogram is performed (contrast injection) to:
  • Visualize the full portal venous system
  • Identify gastroesophageal collaterals and varices
  • Measure the length of stent required (add ~2 cm to fluoroscopic measurement to account for projection overlap)
  • Evaluate hepatic vein/IVC confluence for optimal stent landing zone

Step 7 - Tract Dilation

• The needle track through the hepatic parenchyma is dilated using an angioplasty balloon advanced over the guidewire
• Initial dilation creates the channel that will accommodate the stent

Step 8 - Stent Placement

• A covered metallic stent-graft is deployed across the tract
  • The device of choice today is the Viatorr TIPS Endoprosthesis (Gore) - a PTFE-covered stent with:
    • A 2 cm uncovered (bare) distal portion that anchors in the portal vein
    • A covered proximal portion that lines the parenchymal tract and extends into the hepatic vein (reducing intimal hyperplasia and improving patency vs. bare stents)
  • The proximal landing zone extends from the hepatocaval confluence to ~1 cm within the hepatic vein

Step 9 - Stent Balloon Dilation (Post-Deployment)

• The stent is dilated with a 7-12 mm balloon to the desired diameter
• Start with a 7 mm balloon and check pressures; post-dilate to achieve target gradient

Step 10 - Pressure Measurement and Endpoint Confirmation

• Portosystemic gradient is re-measured:
  • Variceal hemorrhage target: portacaval gradient <12 mmHg (or ≥50% reduction from baseline)
  • Refractory ascites target: gradient <8 mmHg
• The balloon is deflated and removed

Step 11 - Final Portogram

• A final contrast injection is performed to:
  • Confirm TIPS patency and adequate blood flow through the shunt
  • Evaluate remaining hepatic portal flow
  • Assess for persistent varices - if present, embolization may be performed at the same sitting

Step 12 - Catheter Removal and Closure

• The catheter and sheath are removed from the jugular vein
• Pressure is applied over the puncture site to prevent bleeding
• A small bandage is placed; no sutures are required

Duration

Post-Procedure Monitoring

• Admitted to hospital overnight; closely observed for bleeding
• Head of bed elevated
• Monitor for early complications: intra-abdominal hemorrhage (1-2%), hemobilia, contrast nephropathy
• Monitor for late complications: hepatic encephalopathy (25-30%), shunt stenosis/thrombosis (requires re-dilation or re-stenting), heart failure from increased venous return, hemolytic anemia

Fluoroscopic images of TIPS creation: (A) Portogram showing portal venous system and gastroesophageal collaterals; (B) Stent placed bridging hepatic and portal vein, balloon inflating; (C) Stent deployed with balloon dilation of the parenchymal tract; (D) Final result showing patent shunt.

• Sleisenger and Fordtran's Gastrointestinal and Liver Disease, Chapter 92 - [TIPS section textbook]
• Schwartz's Principles of Surgery, 11th Ed. - Transjugular Intrahepatic Portosystemic Shunt section
• Miller's Anesthesia, 10th Ed. - TIPS procedure overview
• BackTable VI - TIPS Procedure Steps & Technique (updated Sep 2025)
• RadiologyInfo.org - TIPS

• Asking a follow-up question about the TIPSS procedure?
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TIPSS (Transjugular Intrahepatic Portosystemic Shunt) - Complete Overview

What is TIPSS?

Indications

Contraindications

• Congestive heart failure
• Severe tricuspid regurgitation
• Moderate-to-severe pulmonary hypertension
• Unrelieved biliary obstruction

• Advanced hepatic encephalopathy (TIPSS worsens it)
• Portal vein or hepatic vein thrombosis/occlusion
• Liver cancer (hepatocellular carcinoma)
• Severe coagulopathy / thrombocytopenia
• Active systemic infection / sepsis

Procedure Steps (Summary)

Hemodynamic Goals

• Variceal bleeding: Portosystemic gradient <12 mmHg or ≥50% reduction from baseline
• Refractory ascites: Portosystemic gradient <8 mmHg

Stent Used

• Distal 2 cm: bare/uncovered - anchors in portal vein
• Proximal covered portion: PTFE-lined - lines parenchymal tract and hepatic vein
• Covered stents significantly reduce intimal hyperplasia and improve long-term patency vs. bare metal stents

Complications

Procedure-Related (immediate)

• Intra-abdominal hemorrhage (1-2%)
• Haemobilia (bleeding into biliary tree)
• Haemothorax / haemopericardium
• Contrast-induced nephropathy
• Air embolism

Early (within 30 days)

• Shunt thrombosis / stenosis
• Accelerated hepatic encephalopathy (most common - 25-30%)
• Heart failure from sudden increase in venous return
• Fever / sepsis
• Acute liver failure

Late (after 30 days)

• Shunt dysfunction - stenosis requiring re-dilation or re-stenting
• Chronic encephalopathy
• Haemolytic anaemia
• Progressive liver failure

Post-Procedure Care

• Overnight hospital admission with close monitoring
• Monitor for bleeding, encephalopathy, renal function
• Head of bed elevated
• Doppler ultrasound at 1 month, 3 months, then every 6 months to check shunt patency
• Patients with encephalopathy managed with lactulose + rifaximin
• TIPSS does not affect eligibility for subsequent liver transplantation

Key Facts to Remember

• Success rate: >95% by experienced operator
• Controls variceal bleeding in >90% of cases refractory to medical treatment
• HVPG should be <12 mmHg post-procedure
• Duration: typically 1-2 hours
• Anesthesia: sedation (elective) or GA (emergency/significant ascites)
• Does not preclude future liver transplantation