The Transjugular Intrahepatic Portosystemic Shunt (TIPS) is a specialized medical procedure used to manage severe complications of advanced liver disease. This non-surgical intervention is performed by interventional radiologists using imaging guidance to create an artificial pathway, or shunt, within the liver. The procedure redirects blood flow to reduce dangerously high pressure in the veins of the digestive system. TIPS is an effective treatment option when standard medical therapies are no longer sufficient to control life-threatening complications.
Defining the Procedure and Its Purpose
The primary problem the TIPS procedure addresses is portal hypertension, an abnormal elevation of blood pressure within the portal vein system. This system drains blood from the digestive tract, spleen, and pancreas directly into the liver. In patients with conditions like cirrhosis, the liver becomes stiff and scarred, creating significant resistance to this incoming blood flow.
This resistance causes blood to back up, leading to a substantial increase in pressure throughout the portal venous network. The TIPS shunt creates a new, direct channel inside the liver connecting the high-pressure portal vein to one of the lower-pressure hepatic veins, which drain into the main circulation. This internal bypass allows a portion of the portal blood to flow directly into the systemic circulation, effectively decompressing the portal system. This mechanical reduction in pressure alleviates the complications of portal hypertension.
Specific Medical Conditions Requiring TIPS
The TIPS procedure is reserved for patients whose symptoms of portal hypertension are severe and unresponsive to first-line medical treatments. The most common indication is refractory variceal bleeding, which involves hemorrhaging from enlarged, fragile veins, typically in the esophagus or stomach. These varices form when the body attempts to find alternate routes for blocked portal blood flow, and the high pressure causes them to rupture.
Another significant indication is refractory ascites, the accumulation of fluid in the abdominal cavity that does not improve with standard management, such as a low-sodium diet and diuretic medications. The high pressure in the portal system forces fluid to leak out of the veins and into the abdomen. TIPS may also be used for less common conditions, including hepatic hydrothorax, where fluid accumulates around the lungs, and certain cases of Budd-Chiari syndrome, which involves blockages in the hepatic veins.
How the Shunt is Created
The creation of the TIPS shunt is a minimally invasive, image-guided process performed in an interventional radiology suite. The procedure begins with placing a thin needle into the internal jugular vein, located in the side of the neck. This vein serves as the access point, allowing the radiologist to navigate the body’s vascular network without a major surgical incision.
Using fluoroscopic X-ray guidance, a catheter and guidewire are advanced from the jugular vein, through the superior vena cava, and into one of the hepatic veins inside the liver. Once the catheter is stabilized, a specialized needle punctures the liver tissue, creating a tract that connects the hepatic vein to a branch of the portal vein. This connection establishes the desired internal bypass route.
The newly created tract is then widened using a small balloon catheter to achieve the target diameter for blood flow. Finally, a covered, expandable metal stent is deployed to line this tract and keep the channel permanently open. The covered nature of the modern stent helps prevent the shunt from narrowing or closing over time. Once the stent is in place, the interventional radiologist measures the pressure gradient to confirm adequate pressure reduction before completing the procedure.
Post-Procedure Care and Potential Complications
Following the TIPS procedure, patients require close monitoring, often in an intensive care or step-down unit, to manage immediate changes in blood pressure and organ function. Long-term management includes routine follow-up with a hepatologist and interventional radiologist to ensure the shunt remains open and functional. Doppler ultrasound imaging is a standard non-invasive tool used to regularly check the flow velocity and patency of the stent, typically within the first few days and at scheduled intervals.
The most significant and common complication following TIPS is the development or worsening of Hepatic Encephalopathy (HE), which occurs in 20% to 50% of patients. HE is a neurological disorder caused by the bypass of portal blood around the liver. Since the liver is the body’s main filter, diverting blood means toxins, primarily ammonia, are not adequately cleared and travel to the brain, causing symptoms like confusion, disorientation, and lethargy.
Medical management for post-TIPS HE centers on medications that lower the body’s toxin burden. Lactulose is a synthetic sugar that decreases ammonia production and absorption in the gut, while the antibiotic rifaximin reduces the gut bacteria that produce ammonia. If HE is severe and persistent, it may necessitate a procedure to reduce the shunt’s diameter or, in rare cases, occlude it entirely. Patients are also advised to maintain a low-sodium diet to manage fluid balance and prevent the recurrence of ascites.