Introduction
Cirrhosis is a disorder that is usually connected with portal hypertension, which is a serious condition. This disease develops as a consequence of increased resistance inside the liver as well as increased blood flow within the splanchnic area, which ultimately leads to a state of hyperdynamic circulation. The transjugular intrahepatic portosystemic shunt, also known as TIPS, is a therapeutic method that has gained widespread acceptance as a means of controlling a variety of problems that are linked with portal hypertension.
What Is Liver Transjugular Intrahepatic Portosystemic Shunt?
The transjugular intrahepatic portosystemic shunt, also known as (TIPS) technique, is a percutaneous image-guided intervention that involves the development of a channel or conduit within the liver, with the goal of attaining portal decompression. This connection between the systemic venous system and the portal system is necessary in order to carry out the procedure. The right hepatic vein (HV) and the right portal vein (PV) are the most common locations for the predominant conduit to be found. The use of bare metal stents was initially what was required in order to achieve patency in the vessel.
Since the development of stents coated in polytetrafluoroethylene (PTFE) in recent years, patency rates have considerably increased, making these stents the superior option over bare metal stents. Among these problems are bleeding esophageal varices, refractory cirrhotic ascites, hepatic hydrothorax, and syndromes of the hepatorenal and hepatopulmonary systems. In addition, TIPS has been found to be effective in the treatment of Budd-Chiari syndrome as well as veno-occlusive illness in a growing number of patients. Despite the vast number of possible uses, however, the only ones that have been successfully treated are refractory acute variceal bleeding and therapy for refractory cirrhotic ascites.
What Are the Factors That Necessitate the Implementation of a Transjugular Intrahepatic Portosystemic Shunt (TIPS) In an Individual?
The following are the two primary reasons why a person could require a TIPS:
1. Ascites- The fluid accumulation in the abdominal cavity that cannot be controlled by reducing the amount of sodium in one's diet or taking diuretics (often known as "water pills").
- Ascites can sometimes pass through the diaphragm muscle that separates one of the lungs and the belly to fill the area around the lung, most commonly the right lung.
- This condition is known as hepatic hydrothorax, and TIPS is frequently helpful in treating it as well. If the fluid accumulation can be managed by restricting the amount of sodium in the diet and taking diuretics, then there is no need to consider TIPS.
2. Varices- Varices are enlarged veins, most commonly found in the esophagus.
- Bleeding from varices that cannot be controlled with endoscopic treatment, such as ligation with a rubber band, might occur.
- Rubber band ligation is a more challenging treatment option for bleeding varices that are located in the stomach, rectum, or elsewhere; hence, a TIPS is frequently required in these kinds of scenarios.
What Is the Mechanism Employed for Implementing the Procedure?
- An interventional radiologist will be the one to carry out this surgery; they will make use of an image-guided method in order to construct a synthetic tunnel within the liver in order to establish a connection between the portal vein and the hepatic vein.
- After that, a stent is inserted to maintain the open passageway.
- It is possible to carry out the TIPS operation under general anesthesia, which will numb the patient completely and shield them from any pain that they could experience while the procedure is being carried out.
- During the TIPS process, the patient will be asked to lie on the back so that blood pressure, pulse, and heart rate may be monitored.
- While the surgery is being performed, it is connected to a series of monitors.
- The nurses will prepare for the TIPS operation by inserting an intravenous catheter or IV into one of your veins before beginning the procedure itself. In order to get you ready for the beginning of the surgery, the part of the body that will have the catheter inserted into it will be shaved, then sterilized, and then a surgical drape will be placed over it.
- Before making a small cut in the skin at the location, an upper portion of the collarbone will be numbed with a local anesthetic.
- The cut will be made at the site, the internal jugular vein of the patient will be located with the use of ultrasound, and the specialist will then insert a catheter into the vessel in order to direct it towards the liver and into the hepatic vein.
- In addition, pressure is measured on the right side of the heart as well as in the hepatic vein in order to confirm the diagnosis of portal hypertension and to determine the severity of the condition.
- The TIPS stent will be placed with the assistance of a contrast substance that will be put into the hepatic vein.
- It will identify the portal venous system; a TIPS needle is inserted into the hepatic vein in order to get access to the portal system.
- Under the guidance of the fluoroscopy, the stent will be positioned so that it runs from the portal vein into the hepatic vein.
- After the stent has been properly positioned, the balloon will then be inflated, which will cause the stent to expand into its new location.
- The affected area of the skin will be bandaged, and you won't require any stitches for the wound. Following the operation, you will be required to have careful follow-up observations, which will be carried out within the hospital.
What Are the Potential Risks and Dangers Connected With a Transjugular Intrahepatic Portosystemic Shunt (TIPS)?
Since the liver's primary job is to filter out toxins from the blood, including ammonia and other toxins taken up from the colon, when a TIPS is inserted, the blood that enters the liver is not filtered as well.
- Increases in ammonia and other toxic levels in the blood can lead to unconsciousness, confusion, and disorientation.
- Ingesting lactulose facilitates the removal of toxins from the colon, whereas Rifaximin lessens the number of toxins generated within the colon; these are occasionally required following a TIPS.
- A TIPS might not be the best course of action for someone who is currently taking those drugs because there are no other choices for treatment in the event that hepatic encephalopathy develops following a TIPS.
- A rupture of the bile ducts, bleeding from the liver into the abdomen, infection, and liver infarction, a condition in which part of the liver dies due to a lack of blood flow, are additional dangers associated with having a TIPS.
- It is important to carefully assess the possible advantages of a TIPS against the potential risks before deciding to implement one.
What Are the Primary Factors Contributing to an Individual’s Ineligibility for a Transjugular Intrahepatic Portosystemic Shunt (TIPS) Procedure?
There are many primary factors that typically discourage the placement of a transjugular intrahepatic portosystemic shunt (TIPS).
- The liver's impaired functionality is such that Transjugular Intrahepatic Portosystemic Shunt (TIPS) procedures have the potential to exacerbate liver failure.
- Typically, an international normalized ratio (INR) exceeding 2.0 or a total bilirubin level surpassing 3 to 5 mg/dl is indicative of an unfavorable prognosis.
- When the Model for End-Stage Liver Disease (MELD) score surpasses 15, the Transjugular Intrahepatic Portosystemic Shunt (TIPS) procedure carries an elevated risk. Typically, if the MELD score exceeds 18 to 20, TIPS is not performed unless it becomes imperative to manage variceal hemorrhage in an emergency situation and the individual is actively listed for liver transplantation.
- The right ventricle of the heart, responsible for pumping blood to the lungs, may exhibit insufficient strength to accommodate the augmented blood flow resulting from the Transjugular Intrahepatic Portosystemic Shunt (TIPS) procedure.
- This insufficiency may be exacerbated if there is pre-existing severe hypertension in the pulmonary circulation since the heightened flow from TIPS can impose a significant strain on the heart.
- The determination of this is typically made through the utilization of an echocardiography prior to the insertion of a transjugular intrahepatic portosystemic shunt (TIPS).
- Portal vein thrombosis is a condition characterized by the obstruction of the portal vein due to the presence of a blood clot.
- The occurrence of hepatocellular carcinoma or other malignancies in the hepatic organ.
- The Transjugular Intrahepatic Portosystemic Shunt (TIPS) procedure is typically not recommended for the management of major varices in the esophagus or stomach in cases when there has been no prior occurrence of bleeding.
Conclusion
TIPS has emerged as a useful tool for managing portal hypertension-related problems. Patients who arrive with hepatic hydrothorax, hepatorenal syndrome, or an abrupt variceal bleed might be better after TIPS implantation. Long-term patency has significantly improved with the use of coated stents, further supporting early use. Unfortunately, there are sometimes issues with TIPS insertion; HE is among the most frequent ones. Carefully choosing the patients and paying close attention to the final portosystemic gradient are two potential solutions to this. Lastly, TIPS may become more involved in the treatment of patients with portal hypertension issues in the future because of new and improved procedures.
