Question 6

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

Not available.


Mechanism of TIPS:

  • 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


Contraindications for portal venous shunt (Boyer and Haskal, 2009)

  • 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:

    • 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.
    • Right heart failure (the venous return to the heart is increased. The RV may not be prepared for this)
    • Tricuspid endocarditis (organisms may now travel directly from the leaky gut into the systemic circulation)
    • 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.
    • Shunt infection may occur, where the shunt itself may become the source of infection. 


Ochs, Andreas, et al.New England Journal of Medicine 332.18 (1995): 1192-1197."The transjugular intrahepatic portosystemic stent–shunt procedure for refractory ascites." 

Guevara, Mónica, et al. "Transjugular intrahepatic portosystemic shunt in hepatorenal syndrome: effects on renal function and vasoactive systems."Hepatology 28.2 (1998): 416-422.

Papatheodoridis, George V., et al. "Transjugular intrahepatic portosystemic shunt compared with endoscopic treatment for prevention of variceal rebleeding: A meta‐analysis." Hepatology 30.3 (1999): 612-622.

Azoulay, D., et al. "Transjugular intrahepatic portosystemic shunt (TIPS) for severe veno-occlusive disease of the liver following bone marrow transplantation." Bone marrow transplantation 25.9 (2000).

Ganger, Daniel R., et al. "Transjugular intrahepatic portosystemic shunt (TIPS) for Budd-Chiari syndrome or portal vein thrombosis." The American journal of gastroenterology 94.3 (1999): 603-608.

Freedman, A. M., et al. "Complications of transjugular intrahepatic portosystemic shunt: a comprehensive review." Radiographics 13.6 (1993): 1185-1210.

Rösch, J., et al. "Transjugular intrahepatic portacaval shunt an experimental work." The American Journal of Surgery 121.5 (1971): 588-592.

Rössle, Martin. "TIPS: 25years later." Journal of hepatology 59.5 (2013): 1081-1093.

Colapinto, R. F., et al. "Creation of an intrahepatic portosystemic shunt with a Grüntzig balloon catheter." Canadian Medical Association Journal 126.3 (1982): 267.

Conn, Harold O. "Transjugular Intrahepatic Portal‐systemic Shunts: The State of the Art." Hepatology 17.1 (1993): 148-158.

Gülberg, Veit, et al. "Hepatic arterial buffer response in patients with advanced cirrhosis." Hepatology 35.3 (2002): 630-634.

Boyer, Thomas D., and Ziv J. Haskal. "The role of transjugular intrahepatic portosystemic shunt (TIPS) in the management of portal hypertension: update 2009." Hepatology 51.1 (2010): 306-306.

Perarnau, Jean-Marc, et al. "Feasibility and long-term evolution of TIPS in cirrhotic patients with portal thrombosis." European journal of gastroenterology & hepatology 22.9 (2010): 1093-1098.

Orloff, Marshall J. "Emergency treatment of bleeding esophageal varices in cirrhosis." Current problems in surgery3.7 (1966): 13-28.

Unger, Lukas W., et al. "The role of TIPS in the management of liver transplant candidates." United European gastroenterology journal 5.8 (2017): 1100-1107.

DeSimone, J. A., et al. "Sustained bacteremia associated with transjugular intrahepatic portosystemic shunt (TIPS)." Clinical infectious diseases 30.2 (2000): 384-386.

Bouza, Emilio, et al. "Endotipsitis: an emerging prosthetic-related infection in patients with portal hypertension." Diagnostic microbiology and infectious disease 49.2 (2004): 77-82.

Sanyal, Arun J., and K. Rajender Reddy. "Vegetative infection of transjugular intrahepatic portosystemic shunts." Gastroenterology 115.1 (1998): 110-115.