Question 16

Outline the mechanism of action and list the indications, contraindications and complications of the TIPSS procedure (Transjugular intrahepatic portosystemic shunt).

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College answer

Mechanism of action:

Percutaneous formation of a tract between hepatic vein and intrahepatic segment of portal vein. Blood is shunted away from portal circulation to systemic circulation, thereby reducing portal pressure.

Indications:              (20% Marks)

  • Uncontrolled variceal bleeding
  • Refractory ascites
  • Hepatic pleural effusion
  • Also consider in: bridge to transplant
  • Budd Chiari (may need a DIPS- shunt from IVC to portal vein)
  • HRS
  • Hepatic veno occlusive disease
  • Hepatic hydrothorax

Contraindications      (1 mark/point to max 4 points)            (30% marks)

  • Severe progressive liver failure with imminent death
  • Severe encephalopathy
  • Severe Right or congestive heart failure ( increases preload)
  • Polycystic liver disease
  • Caution in: portal vein thrombosis
  • Pulmonary hypertension/tricuspid regurg
  • Hepatopulmonary syndrome
  • Active infection
  • Tumor in shunt pathway

Complications:         (50% marks)


  • Technical failure
  • Trauma to heart/liver
  • Bleeding haemoperitoneum
  • Bile leak
  • Stent Migration

Post insertion:

  • Encephalopathy
  • Stenosis/obstruction of shunt (uncommon with modern stents)
  • Portal or hepatic vein thrombosis
  • Acute liver ischamia
  • Infection: peritonitis, endotipsitis
  • Heart failure
  • Deterioration in hepatic function

Examiners Comments:

Candidates responses lacked specific details.


In short, the rationale for a TIPS can be summarised as follows:

  • Portal hypertension causes the majority of the morbidity from chronic liver disease
  • This is due to raised portal pressure
  • TIPS decompresses the portal circulation by allowing it to empty into the comparatively lower central venous circulation
  • Ergo, TIPs should relieve the majority of the morbidity from chronic liver disease

Indications for TIPS include:

Contraindications (from Boyer and Haskal, 2009) include

  • Absolute contraindications:
    • Moderate to severe pulmonary hypertension
    • Congestive heart failure
    • Multiple hepatic cysts
    • Uncontrolled sepsis
    • Uncontrolled biliary obstruction
    • Total portal vein thrombosis (in the absence of any patent intrahepatic branches)
  • Relative contraindications:
    • A MELD score above 18
    • Central hepatocellular carcinoma
    • Portal vein thrombosis (in the absence of an experienced operator)
    • Hepatic vein thrombosis
    • Severe coagulopathy or thrombocytopenia

Technical complications of TIPS procedure:

  • Vascular access complications
  • Hepatic damage (through-and-through puncture): risk of intraperitoneal haemorrhage is 1-2%
  • Haemobilia (damage to the biliary tree)
  • Shunt stenosis or thrombosis (it happens in up to 70%)
  • Shunt migration
  • Hepatic vein stenosis (this can sabotage a future transplant)

Complications from portal venous shunt:

  • Worsening hepatic encephalopathy
  • Shunt thrombosis or portal vein thrombosis (7-10%). If there is already a portal vein thrombosis, this risk appears to increase somewhat (Perarnau et al, 2010) - which probably reflects the overall prothrombotic diathesis.
  • Bilirubin rise: the diseased liver doesn't even get a chance to metabolise it
  • Ischaemic hepatitis: the liver gets much of its oxygen from the portal vein, and even in spite of the hepatic arterial buffer response there is a risk of ischaemic hepatitis.
  • Haemolysis (due to the direct shearing effect of being in contact with the shunt)
  • "Unmasked" cardiomyopathy: the TIPS returns splanchnic blood to the heart and acts as a volume challenge, and if there was pre-existing cardiomyopathy, it may be dramatically revealed in this manner.
  • Tricuspid endocarditis (organisms may now travel directly from the leaky gut into the systemic circulation)
  • Shunt infection may occur, where the shunt may become the source of infection. The term "edotipsitis" is supposed to reflect the fact that persistent bacteraemia resembles bacterial endocarditis. 


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