TIPS Procedure and Indications

Definition and Procedure

TIPS involves an interventional radiologist or hepatologist placing a metal stent inside the liver by inserting a wire through the jugular vein in the neck, then threading and guiding it through the liver using X-ray guidance 1, 2
The procedure typically takes 90-120 minutes and is performed under general anesthesia or deep sedation 1
The stent creates a bypass that allows blood to flow directly from the portal vein to the hepatic vein, reducing portal pressure 2

TIPS is recommended for acute variceal bleeding that is unresponsive to standard treatments (endoscopic banding and drug therapy) 1, 3
TIPS is recommended for prevention of variceal rebleeding in non-emergency situations where patients have bled again despite standard endoscopic and medical therapies 1
TIPS is recommended for refractory ascites or hydrothorax where fluid accumulation persists despite other treatments like paracentesis or diuretics 1, 3
TIPS is recommended for Budd-Chiari syndrome in selected patients at specialist centers that also offer liver transplantation 1
TIPS is recommended for portal vein thrombosis in selected patients at specialized centers performing high volumes of TIPS procedures 1

Careful patient selection is critical to minimize complications, and pre-procedure evaluation includes specialized imaging of the liver and surrounding vessels 1
Pre-procedure evaluation includes liver and kidney function tests 1
Pre-procedure evaluation includes coagulation studies 1
Pre-procedure evaluation includes cardiac function assessment 1
Pre-procedure evaluation includes nutritional assessment 1
Pre-procedure evaluation includes evaluation of encephalopathy risk 1

Short-term complications occur in less than 5% of patients and include bleeding, infection, heart failure, liver failure, kidney failure, fever, and damage to blood vessels and bile ducts 1, 2
Hepatic encephalopathy affects approximately one-third of patients long-term 1

Centers performing TIPS should handle a minimum of 10 cases annually, with complex cases (thrombosed vessels or transplant recipients) reserved for centers doing at least 20 cases per year 4, 5

The role of TIPS remains unclear in "early" or "pre-emptive" TIPS within 72 hours of stabilized acute variceal bleeding 1, 6
The role of TIPS remains unclear in patients with chronic kidney disease 1
The role of TIPS remains unclear in idiopathic non-cirrhotic portal hypertension 1
The role of TIPS remains unclear in prophylactic use before non-hepatic surgery 1, 6