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TIPS (Transjugular intrahepatic portosystemic shunt) for Portal Hypertension

  • Posted on- Apr 18, 2018
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A transjugular intrahepatic portosystemic shunt (TIPS) is a way created inside the liver using x-ray guidance to connect two veins within the liver. The shunt is kept open by the placement of a small, tubular metal device commonly called a stent.


During a TIPS procedure, interventional radiologists use image guidance to make a tunnel through the liver to connect the portal vein (the vein that carries blood from the digestive organs to the liver) to one of the hepatic veins (three veins that carry blood away from the liver back to the heart). A stent is then placed in this tunnel to keep the pathway open.


Patients who typically need TIPS have portal hypertension, meaning they have increased pressure in the portal vein system. This pressure buildup can cause blood to flow backward from the liver into the veins of the spleen, stomach, lower esophagus, and intestines, causing enlarged vessels, bleeding and the accumulation of fluid in the chest or abdomen.


This condition is most commonly seen in adults, often as a result of chronic liver problems leading to cirrhosis (scarring of the liver). Portal hypertension can also occur in children, although children are much less likely to require TIPS.


What are some common uses of the procedure?


TIPS procedure is used to treat the complications of portal hypertension, including:

  • variceal bleeding, bleeding from any of the veins that normally drain the stomach, esophagus, or intestines into the liver.
  • Portal gastropathy, an engorgement of the veins in the wall of the stomach, which can cause severe bleeding.
  • Severe ascites (the accumulation of fluid in the abdomen) and/or hydrothorax (in the chest).
  • Budd-Chiari syndrome, a blockage in one or more veins that carry blood from the liver back to the heart.


What does the equipment look like?


In TIPS procedure, x-ray or ultrasound equipment, a stent, and a balloon-tipped catheter are used.


The equipment typically used for this examination consists of a radiographic table, one or two x-ray tubes and a television-like monitor that is located in the examining room. Fluoroscopy, which converts x-rays into video images, is used to watch and guide the progress of the procedure. The video is produced by the x-ray machine and a detector that is suspended over a table on which the patient lies.


Ultrasound scanners consist of a console containing a computer, a video display screen and a transducer that is used to do the scanning. The transducer is a small hand-held device that resembles a microphone, attached to the scanner by a cord.


The transducer sends out inaudible high-frequency sound waves into the body and then listens for the returning echoes from the tissues in the body. The principles are similar to sonar used by boats and submarines.


The ultrasound image is immediately visible on a video display screen that looks like a computer or television monitor. The image is created based on the amplitude (loudness), frequency (pitch) and time it takes for the ultrasound signal to return from the area of the patient being examined to the transducer (the device used to examine the patient), as well as the type of body structure and composition of body tissue through which the sound travels. A small amount of gel is put on the skin to allow the sound waves to travel back and forth from the transducer.


How does the TIPS procedure work?


A TIPS procedure reroutes blood flow in the liver and reduces abnormally high blood pressure in the veins of the stomach, esophagus, bowel and liver, reducing the risk of bleeding from enlarged veins across the esophagus and stomach.


A TIPS procedure involves creating a pathway through the liver that connects the portal vein (the vein that carries blood from the digestive organs to the liver) to a hepatic vein (one of three veins that carry blood from the liver to the heart).


A stent placed inside this pathway keeps it open and allows some of the blood that would ordinarily pass through the liver to bypass the liver entirely, reducing high blood pressure in the portal vein and the associated risk of bleeding from enlarged veins.


How is the TIPS procedure performed?


Image-guided, minimally invasive procedures such as TIPS are most often performed by a specially trained interventional radiologist in an interventional radiology suite or occasionally in the operating room.


Some interventional radiologists prefer performing this procedure while the patient is under general anesthesia, while some prefer conscious sedation for their patient. The advantage of general anesthesia is that the patient will not feel anything.


What will anyone experience during and after the TIPS procedure?

  • Devices to monitor the patient’s heart rate and blood pressure will be attached to his body.
  • The patient will feel a slight pin prick when the needle is inserted into his vein for the intravenous line (IV) and when the local anesthetic is injected. The arteries have no sensation. Most of the sensation is at the skin incision site which is numbed using a local anesthetic.
  • If the patient receives a general anesthetic, he will be unconscious for the entire procedure, and he will be monitored by an anesthesiologist.
  • If the case is done with sedation, the intravenous (IV) sedative will make the patient feel relaxed and sleepy. He may or may not remain awake, depending on how deeply the patient is sedated.
  • When the needle is advanced through the liver and the pathway is expanded by the balloon, the patient may experience discomfort. If the patient feels pain, he should inform his physician he may be given extra intravenous medications.
  • As the contrast material passes through the patient’s body, he may get a warm feeling.
  • After the procedure, the patient will be monitored closely and your head will be kept elevated for a few hours after you return to his room.  However, the amount of bleeding that can occur can sometimes be life-threatening and those patients are monitored in intensive care beforehand and during recovery.
  • The patient should be able to resume his normal activities in seven to 10 days.

Follow-up ultrasounds will be performed frequently after the TIPS procedure to make sure that it remains open and functions properly.


What are the benefits vs. risks?


Benefits

  • A TIPS procedure is designed to produce the same physiological results as a surgical shunt or bypass, without the risks that accompany open surgery.
  • TIPS procedure is a minimally invasive procedure that typically has a shorter recovery time than surgery.
  • The stent that keeps the shunt open (TIPS) is contained entirely inside the diseased liver and is removed with it during a transplant operation.
  • Studies have shown that this procedure is successful in reducing variceal bleeding in more than 90 percent of patients.
  • No surgical incision is needed—only a small nick in the skin that does not have to be stitched closed.


Risks

  • Any procedure where the skin is penetrated carries a risk of infection. The chance of infection requiring antibiotic treatment appears to be less than one in 1,000.
  • There is a very slight risk of an allergic reaction to the contrast material used for venograms. Also, kidney failure (temporary or permanent) due to the contrast material used is a concern, particularly in patients with poor kidney function.
  • Any procedure that involves placement of a catheter inside a blood vessel carries certain risks. These risks include damage to the blood vessel, bruising or bleeding at the puncture site, and infection.

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