TIPS, or Transjugular Intrahepatic Portosystemic Shunt, is a complex medical procedure. It is mainly used in the treatment of chronic liver diseases. This method creates a pathway between the portal and hepatic veins in the liver. It is applied in cases of stomach variceal bleeding and excessive fluid accumulation in the abdomen that cannot be corrected with medical treatment.
Thus, the increased venous pressure in the liver is reduced, and bleeding is prevented. It also plays a vital role in advanced liver diseases such as cirrhosis. However, like any medical intervention, this procedure carries some risks and is carefully evaluated before being performed.
| Definition | TIPS is a minimally invasive procedure aimed at creating an artificial channel (shunt) between the portal vein and hepatic vein in the liver. This channel reduces high pressure in the liver and allows blood circulation. |
| Indications | Portal hypertension, variceal bleeding, ascites (fluid accumulation in the abdomen), hepatic encephalopathy, Budd-Chiari syndrome |
| Types of Procedures | The TIPS procedure is typically an invasive intervention performed under angiographic guidance. |
| Procedure Duration | Typically lasts between 1-3 hours. |
| Anesthesia Type | Usually general anesthesia or local anesthesia with sedation |
| Preparation | Blood tests, imaging tests (ultrasound, CT), coagulation profile evaluation, adjustment of current medications, heart evaluation, and preparation for possible liver transplantation |
| Side Effects and Risks | Infection, bleeding, shunt occlusion or narrowing, hepatic encephalopathy, liver dysfunction, complications related to anesthesia. Post-procedure, hospitalization in a gastroenterology department is mandatory. |
| Recovery Time | Patients are usually discharged within a few days; full recovery may take a few weeks. |
| Follow-Up | Regular ultrasound and Doppler examinations, liver function tests, check for patency of the TIPS shunt |
| Advantages | Minimal invasive method, reduction of complications due to portal hypertension, rapid recovery time |
| Alternative Treatments | Surgical shunt procedures, drug therapy (diuretics, beta blockers), endoscopic variceal ligation/sclerotherapy, liver transplantation |
Prof. Dr. Özgür KILIÇKESMEZ
Interventional Radiology / Interventional Neuroradiology
Reasons for Performing TIPS
- In cirrhotic patients with uncontrolled variceal bleeding, the TIPS procedure creates a shunt between two veins in the liver using a stent, reducing pressure and stopping the bleeding.
The TIPS procedure is preferred for managing complications resulting from liver tissue hardening due to cirrhosis. This procedure, performed to reduce the increased portal vein pressure in the liver, plays a key role in preventing serious health problems.
The procedure provides an effective solution for controlling complications due to portal hypertension. Especially in treatment-resistant conditions, TIPS can improve the quality of life and reduce complication risks. This procedure is recommended in the following cases:
- When variceal bleeding cannot be controlled,
- In ascites (fluid accumulation in the abdomen),
- When changes and bleeding occur in the stomach due to portal pressure,
- In cases of treatment-resistant fluid buildup (hydrothorax) between the lung membranes,
- In cases of hepatorenal syndrome, Budd-Chiari syndrome, hepatopulmonary syndrome, and obstructive liver vein diseases.
TIPS cannot be applied in cases of heart failure, severe or rapidly progressing liver failure, and encephalopathy.
Steps of the TIPS Procedure
- TIPS steps
The TIPS procedure begins from the patient’s right internal jugular vein. Initially, thin wires and catheters are used to reach the superior vena cava, which carries blood from the upper organs to the heart. Then:
- Transition is made to the right atrium of the heart.
- The inferior vena cava, which carries blood from the lower organs, is entered.
After this stage, a thin needle is inserted into the right hepatic vein, and progress is made within this vein. The vein is visualized and pressure measurements are taken. As the catheter moves toward the portal vein, a careful path is created within the liver tissue. Once the portal vein is reached:
- A connection is established between the right hepatic vein and portal vein using a thin needle and wire.
- The connection point is expanded using a balloon dilation method.
- A stent is placed at the site to ensure stability.
Finally, the procedure is re-checked, and additional measures are taken to lower portal pressure if necessary. Imaging and pressure measurements are repeated to evaluate the success of the procedure.
Potential Risks and Side Effects of TIPS
This procedure carries some risks and side effects:
- Blood accumulation in the abdominal cavity may complicate the patient’s condition.
- Injuries to the gallbladder or bile ducts may cause serious bleeding.
- Radiation used during the procedure may cause skin burns.
- Liver perfusion may be adversely affected, leading to organ dysfunction.
- Kidney failure may develop after the procedure.
- Misplacement or displacement of the stent may require re-intervention.
- The risk of death remains as the most severe complication.
- Damage to the hepatic artery may lead to serious health problems.
- Infections may develop during the post-procedure period.
- Bleeding at the entry site may require additional interventions.
- Consciousness disturbances may appear after the procedure and affect the patient’s overall condition.
These complications emphasize the need for proper risk assessment of the procedure.
Necessary Preparations Before the TIPS Procedure:
Certain precautions need to be taken before the Transjugular Intrahepatic Portosystemic Shunt procedure. The patient must be fasting for at least eight hours before the procedure. Liquids are allowed until this period ends, and afterwards, fluids are administered intravenously unless there is an emergency.
- Hemostasis tests should be done, and results must be within appropriate levels: INR, APTT, fibrinogen, platelet count.
- Tests for blood-borne diseases: HBs, HIV, and HCV.
- Kidney function should be monitored by measuring BUN and creatinine levels.
- Cardiac function evaluation
Additionally, the patient must continue their heart and blood pressure medications. If the medications are taken in the morning, they should be taken with a small amount of water. Diabetic patients should avoid taking blood sugar-lowering medications, especially metformin, 48 hours before and after the procedure.
- Antibiotics may be given before embolization procedures.
- Necessary sedatives will be administered to relax the patient before the procedure.
Finally, all necessary blood and blood products must be available for the procedure to be successful. The liver’s vascular condition should be evaluated ultrasonographically. Each of these steps is critical for the safe and effective execution of the procedure.
Post-TIPS Procedure Care
After the TIPS procedure is completed, the patient’s recovery process occurs in several stages. Initially, bleeding at the entry site is stopped by manual pressure. Once the bleeding ceases, a bandage is applied to minimize the risk of further bleeding.
Contrast media related side effects are managed by recommending a high intake of fluids. The patient’s overall health is monitored in the hospital for a few days. The following important points need attention in the post-procedure period:
- Regular measurement of right atrial pressure,
- Frequent urination with medication support to reduce heart load,
- Consultation with a doctor in case of symptoms such as coughing and shortness of breath due to the risk of pulmonary edema.
Moreover, planned ultrasound follow-ups to determine the stent condition are crucial:
- At 3rd, 6th, and 12th months after the procedure,
- Every six months after the first year.
These follow-ups are critical for evaluating the long-term success of the procedure.
Situations Where TIPS Cannot Be Applied
There are specific conditions where the procedure cannot be performed. These conditions are determined with patient safety in mind. Severe liver dysfunction is one of the primary contraindications. Alternative treatments should be considered for patients with weak liver functions.
Additionally, the procedure should not be performed in patients with active infections. Infections should be treated first. TIPS should also be avoided in the presence of pulmonary hypertension.
- Severe liver dysfunction
- Active infection
- Pulmonary hypertension
- Cancer
- Bleeding disorders
- History of allergic reactions
- Polycystic kidney disease
Each patient’s condition must be carefully evaluated, and the risks of TIPS should be considered. Especially in cancer patients, procedural risks may increase. The procedure may also be dangerous for those with bleeding disorders and a history of allergic reactions. Polycystic kidney disease patients are also not suitable candidates for this procedure. Based on these conditions, the decision to proceed with the procedure will be made according to the patient’s health status.
Effectiveness Rates of TIPS Procedure
The effectiveness rate of the procedure varies depending on several factors. The success of the procedure is primarily determined by the current health status of the liver. The patient’s overall health and response to treatment also affect success.
- Success rates generally range between 80% and 90%.
- Success rates may vary significantly from patient to patient.
- In some cases, TIPS may not provide a sufficient solution.
The patient’s individual condition plays a significant role in determining the outcome of the procedure. Therefore, the treatment approach should be personalized for each patient. Doctors aim to improve the patient’s health condition by evaluating the patient’s status and determining the most suitable treatment method. This detailed evaluation increases the chance of maximizing the success of the TIPS procedure.
Role and Timing of TIPS in Ascites Control
The TIPS procedure is used as a treatment method to control ascites. With this procedure, a visible reduction in ascites levels is achieved in most patients. The effects of the procedure vary from person to person, and the time it takes for ascites control depends on the patient’s overall health.
The decrease in ascites may not be immediately visible after the procedure, and in some cases, the effects may be observed after a few weeks or months.
- First week post-procedure: Ascites reduction is generally not observed.
- First few weeks: A reduction in ascites is observed in the majority of patients.
- After a few months: Ascites may be fully controlled.
In conclusion, the TIPS procedure provides an effective solution for patients with ascites issues. The post-procedure period should be closely monitored. The patient’s condition and the severity of ascites determine how long it will take for the treatment to take effect. Although it is difficult to predict the exact time frame for the effects, the procedure generally provides successful results.
Possibilities of Liver Transplantation After TIPS Procedure
This process is critical for determining liver function. If the recovery after the procedure does not reach the expected level, liver transplantation may become an option. In the post-procedure period, doctors carefully evaluate the patient’s overall condition and liver function. If necessary, steps for liver transplantation may be initiated.
Liver function evaluation includes:
- Liver blood flow after the procedure
- Portal pressure levels
- Overall liver health
The patient’s overall health status includes:
- Other organ functions
- Presence of complications
- General recovery process
Liver transplantation may be considered after the TIPS procedure. However, this process is determined after a series of evaluations specific to each patient. Based on the patient’s current condition and potential risks, the most appropriate treatment method is determined. Doctors’ recommendations in this process are critical for the patient’s future health status.
Effectiveness Duration of TIPS Procedure
The effectiveness duration of the TIPS procedure varies depending on several factors. The patient’s overall health condition, liver function, and portal vein pressure directly affect this duration. Additionally, the type and size of the stent used during the procedure also play an important role. Generally, the effect of this procedure lasts between two to five years.
- Health Status: The patient’s general health is a decisive factor in the success of the TIPS procedure.
- Liver Functions: A well-functioning liver provides longer-lasting benefits post-procedure.
- Portal Vein Pressure: High portal vein pressure may reduce the stent’s functionality.
- Stent Type and Size: The characteristics of the stents used can affect the longevity of the procedure.
Regular follow-ups after the procedure and rapid intervention for encountered problems extend the effectiveness of TIPS. This process is critical for controlling the progression of the disease and preventing potential complications. Therefore, the longevity of the procedure also depends on patient management and follow-up processes.
Prof. Dr. Özgür Kılıçkesmez graduated from Cerrahpaşa Medical Faculty in 1997. He completed his specialization at Istanbul Education and Research Hospital. He received training in interventional radiology and oncology in London. He founded the interventional radiology department at Istanbul Çam and Sakura City Hospital and became a professor in 2020. He holds many international awards and certificates, has over 150 scientific publications, and has been cited more than 1500 times. He is currently working at Medicana Ataköy Hospital.
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